Impact of liver biopsy size on histological evaluation of chronic viral hepatitis: the smaller the sample, the milder the disease
Introduction
The main purpose of a liver biopsy taken in patients with chronic viral hepatitis is to grade and stage the disease of the liver [1], [2], [3]. Grading reflects necroinflammatory activity and integrates the severity of different histological elementary lesions, while staging represents the extent of fibrosis: both have prognostic and therapeutic implications [3], [4], [5]. In practice, grading and staging are done using standardized semi-quantitative scoring systems, which express each elementary lesion as a numerical value [6], [7], [8].
While several studies have focused on the relevance of intra- and inter-observer variation in estimating the grade and stage of chronic viral hepatitis [7], [9], [10], a blameworthy lack of attention has been focused on how biopsy size affects the reliability of the assessment. The few studies on the relationship between sample size and accuracy of histological evaluation are all dated and none of them applied the current semi-quantitative scoring systems [11], [12], [13], [14].
A satisfactory length of liver biopsy was reported to range from 1 to 4 cm [15] and a sample 1.5 cm long and/or containing 4/6 portal tracts has been considered acceptable [16]. In chronic viral hepatitis, however, the diagnostic information obtainable by examining different lengths and/or diameters of the same biopsy has never been addressed.
The aim of the present study was to establish the impact of liver biopsy size on the assessment of the necroinflammatory activity and extent of fibrosis in cases of chronic viral hepatitis.
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Materials and methods
The material used in this study was selected from 355 consecutive percutaneous liver biopsies taken between 1995 and 1999 at the Liver unit of Seriate Hospital. All biopsies were obtained from patients affected by chronic viral hepatitis (types B, C or D) using a 16 G disposable Menghini-type needle (Surecut®, TSK Laboratory, Akasaka, Japan), which produces a core sample 1.4 mm in diameter. Cases with other concomitant active viral infection (i.e. human immunodeficiency virus (HIV),
Impact of specimen length on grading and staging
Table 1 shows the impact of different specimen lengths on the number of portal tracts and on the grade and stage recorded. As expected, the number of complete and incomplete portal tracts dropped significantly when the specimen was shortened from the original ≥3 to 1 cm (P<0.001).
The reduction in length led to an underestimation of grade and stage. The shorter the specimen, the higher the rate of mild grades, which increased from 49.7% in ≥3 cm specimens to 60.2% in 1.5 cm and 86.6% in 1 cm
Discussion
The results of this study provide the first evidence of a significant relationship between biopsy size and histological grading and staging of chronic viral hepatitis. Basically, we evaluated the impact of reducing the length and width of a liver specimen on the score for necroinflammatory lesions and fibrosis. For our purposes, we chose three lengths: long (≥3 cm), short (1 cm) and the referenced ‘standard’ size (1.5 cm) and two widths: standard (1.4 mm) and thin (1 mm).
Our data demonstrate
Acknowledgements
The authors who took part in this study have never had any relationship with the manufacturers of the materials involved and received no funding from said manufacturers to carry out their research.
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Present address: Medical Division, Policlinico San Pietro, Bergamo, Italy.