Re: Dig.#96/Biopsy Grading/Staging

[Guest guest]

Dear alley,

I believe 'grade' applies to inflammation, 'stage' to both fibrosis and

cirrohsis. There is more than one system used to grade/stage biopsies.

Nomenclature, grading, staging of liver biopsies

A recommendation to replace the old terminology for chronic active and

chronic persistent hepatitis (Popper, 1971; Rev International Group, 1968)

is now becoming widely accepted for a variety of reasons (Gerber, 1992;

Ludwig, 1993; Scheuer, 1986). The new nomenclature would use " chronic

hepatitis " with the addition of a grading of activity of the hepatitis based

on the degree of inflammation and necrosis and the stage of fibrosis. The

terminology will also include the etiologic agent or cause, if known

(International Working Party, 1994).

Several grading and staging systems have been proposed that use a variety of

scores (Bedossa, et al, 1994; Desmet, 1994; Ishak, et al, 1995; Ludwig,

1993; Scheuer, 1991). Many of these systems have been modified from Knodell,

1981. Examples of a simple and a somewhat more complex system are given.

System adapted from Ludwig, 1993

Portal and Lobular Inflammatory Activity

0 None or minimal portal inflammation, no necrosis

1 Portal inflammation (chronic persistent hepatitis) without necrosis

and/or lobular inflammation without evidence of necrosis.

2 Mild limiting plate necrosis (mild chronic active

hepatitis) and/or focal lobular necrosis.

3 Moderate limiting plate necrosis (moderate CAH) and/or

severe focal cell damage

4 Severe limiting plate necrosis (severe CAH) and/or

bridging necrosis.

Fibrosis

Stg 1 No fibrosis or confined to enlarged portal zones

Stg 2 Periportal or portal-portal septa but intact architecture

Stg 3 Septal- fibrosis with architectural distortion; no obvious

cirrhosis

Stg 4 Probable or definite cirrhosis

System adapted from Ishak, et al, 1995

Necroinflammatory Scores

Score Pathology

A. Periportal or periseptal interface hepatitis

(piecemeal necrosis)

0 Absent

1 Mild (focal, few portal areas)

2 Mild/moderate (focal, most portal areas)

3 Moderate around less than 50% of tracts or septa)

4 Severe (continuous around more than 50% of tracts or

septa)

B. Confluent necrosis

0 Absent

1 Focal confluent necrosis

2 Zone 3 necrosis in some areas

3 Zone 3 necrosis in most areas

4 Zone 3 necrosis, plus occasional

portal-central (P-C) bridging

5 Zone 3 necrosis, plus multiple P-C bridging

6 Panacinar or multiacinar necrosis

C. Focal (spotty) lytic necrosis, apoptosis and focal inflammation

0 Absent

1 One focus or less per 1Ox objective (ob)

2 Two to four foci per 10x ob

3 Five to ten foci per 10x ob

4 More than ten foci per 10x ob

D. Portal inflammation

0 None

1 Mild, some or all portal areas

2 Moderate, some or all portal areas

3 Moderate/marked, all portal areas

4 Marked, all portal areas

Architectural Changes, Fibrosis/Cirrhosis

0 No fibrosis

1 Fibrous expansion of some portal areas,

with or without short fibrous septa

2 Fibrous expansion of most portal areas,

with or without short fibrous septa

3 Fibrous expansion of most portal areas with

occasional portal to portal (P-P) bridging

4 Fibrous expansion of portal areas with

marked bridging (P-P as well as P-C)

5 Marked bridging (P-P and/or P-C) with

occasional nodules (incomplete cirrhosis)

6 Cirrhosis, probable or definite

______________________________________________________

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[Guest guest]

Dear alley,

I believe 'grade' applies to inflammation, 'stage' to both fibrosis and

cirrohsis. There is more than one system used to grade/stage biopsies.

Nomenclature, grading, staging of liver biopsies

A recommendation to replace the old terminology for chronic active and

chronic persistent hepatitis (Popper, 1971; Rev International Group, 1968)

is now becoming widely accepted for a variety of reasons (Gerber, 1992;

Ludwig, 1993; Scheuer, 1986). The new nomenclature would use " chronic

hepatitis " with the addition of a grading of activity of the hepatitis based

on the degree of inflammation and necrosis and the stage of fibrosis. The

terminology will also include the etiologic agent or cause, if known

(International Working Party, 1994).

Several grading and staging systems have been proposed that use a variety of

scores (Bedossa, et al, 1994; Desmet, 1994; Ishak, et al, 1995; Ludwig,

1993; Scheuer, 1991). Many of these systems have been modified from Knodell,

1981. Examples of a simple and a somewhat more complex system are given.

System adapted from Ludwig, 1993

Portal and Lobular Inflammatory Activity

0 None or minimal portal inflammation, no necrosis

1 Portal inflammation (chronic persistent hepatitis) without necrosis

and/or lobular inflammation without evidence of necrosis.

2 Mild limiting plate necrosis (mild chronic active

hepatitis) and/or focal lobular necrosis.

3 Moderate limiting plate necrosis (moderate CAH) and/or

severe focal cell damage

4 Severe limiting plate necrosis (severe CAH) and/or

bridging necrosis.

Fibrosis

Stg 1 No fibrosis or confined to enlarged portal zones

Stg 2 Periportal or portal-portal septa but intact architecture

Stg 3 Septal- fibrosis with architectural distortion; no obvious

cirrhosis

Stg 4 Probable or definite cirrhosis

System adapted from Ishak, et al, 1995

Necroinflammatory Scores

Score Pathology

A. Periportal or periseptal interface hepatitis

(piecemeal necrosis)

0 Absent

1 Mild (focal, few portal areas)

2 Mild/moderate (focal, most portal areas)

3 Moderate around less than 50% of tracts or septa)

4 Severe (continuous around more than 50% of tracts or

septa)

B. Confluent necrosis

0 Absent

1 Focal confluent necrosis

2 Zone 3 necrosis in some areas

3 Zone 3 necrosis in most areas

4 Zone 3 necrosis, plus occasional

portal-central (P-C) bridging

5 Zone 3 necrosis, plus multiple P-C bridging

6 Panacinar or multiacinar necrosis

C. Focal (spotty) lytic necrosis, apoptosis and focal inflammation

0 Absent

1 One focus or less per 1Ox objective (ob)

2 Two to four foci per 10x ob

3 Five to ten foci per 10x ob

4 More than ten foci per 10x ob

D. Portal inflammation

0 None

1 Mild, some or all portal areas

2 Moderate, some or all portal areas

3 Moderate/marked, all portal areas

4 Marked, all portal areas

Architectural Changes, Fibrosis/Cirrhosis

0 No fibrosis

1 Fibrous expansion of some portal areas,

with or without short fibrous septa

2 Fibrous expansion of most portal areas,

with or without short fibrous septa

3 Fibrous expansion of most portal areas with

occasional portal to portal (P-P) bridging

4 Fibrous expansion of portal areas with

marked bridging (P-P as well as P-C)

5 Marked bridging (P-P and/or P-C) with

occasional nodules (incomplete cirrhosis)

6 Cirrhosis, probable or definite

______________________________________________________

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