(Special thanks to my GI attending, Dr. Jessica Tracht, for this useful information)
(Pictures/examples coming soon)
Grading and staging hepatitic C virus (HCV) used to be a big part of liver pathology. However, treatment with Harvoni is now available which can cure patients with certain HCV genotypes, lessening the need for HCV liver biopsies to be evaluated. But we still get them and you will likely see them in private practice.
How to approach a liver biopsy for Hep C:
Always get a complete clinical history:
Has the patient been treated?
Have they achieved sustained viral response (SVR)? (SVR means an HCV is nondetectable on viral quant 24 weeks after treatment).
What is their HCV viral quant?
Special Stains used to workup any medical liver biopsy:
Grading & Staging (Scheuer system)
Our institution uses the Scheuer grading and staging system for these. It is broken down into a portal grade, a lobular grade, and a stage (fibrosis). Always put these in your write up for HCV for both biopsies and explants, even if they have SVR.
Scheuer Portal Grade:
i.e. How much portal inflammation is there?:
- GRADE 0: NONE TO MINIMAL PORTAL INFLAMMATION
- GRADE 1: MILD PORTAL INFLAMMATION
- GRADE 2: PORTAL INFLAMMATION WITH MILD INTERFACE ACTIVITY
- GRADE 3: PORTAL INFLAMMATION WITH MODERATE INTERFACE ACTIVITY
- GRADE 4: PORTAL INFLAMMATION WITH SEVERE INTERFACE ACTIVITY
Scheuer Lobular Grade:
i.e. How much inflammation is in the lobules?
- GRADE 0: NO LOBULAR INFLAMMATION
- GRADE 1: MILD LOBULAR INFLAMMATION
- GRADE 2: LOBULAR INFLAMMATION WITH ACIDOPHIL BODY FORMATION
- GRADE 3: LOBULAR INFLAMMATION WITH SEVERE FOCAL CELL DAMAGE
- GRADE 4: LOBULAR INFLAMMATION WITH BRIDGING NECROSIS
i.e. Is there fibrosis? How bad/what pattern? Is there cirrhosis?
- STAGE 0: NO APPRECIABLE FIBROSIS
- STAGE 1:PORTAL FIBROSIS
- STAGE 2:PORTAL FIBROSIS WITH PERIPORTAL OR PORTAL-PORTAL SEPTA, BUT INTACT ARCHITECTURE
- STAGE 3:PORTAL AND BRIDGING FIBROSIS WITH ARCHITECTURAL DISTORTION
- STAGE 4:PROBABLE OR DEFINITE CIRRHOSIS
Example Sign Out
Liver, native, core biopsy:
Mild to moderate portal inflammation with mild interface activity and no significant lobular activity, consistent with the history of viral hepatitis C infection.
No significant fibrosis.
The specimen consists of three adequate core liver biopsies with 17 portal tracts available for evaluation. Most, but not all, portal tracts contain a mild to moderate chronic inflammatory infiltrate composed predominantly of lymphocytes with rare plasma cells. There is patchy interface activity (Scheuer portal grade 1 of 4). The interlobular bile ducts appear to be intact, but there is focal duct injury and ductitis (Poulsen lesion). There is minimal lobular inflammation with no definite apoptotic bodies noted (Scheuer lobular grade 0-1 of 4). There is no necrosis, steatosis, or cholestasis. A trichrome stains highlights focally increased portal fibrosis. An iron stain is negative. No PAS+ globules are noted on PAS-D stain.
The findings of this biopsy are consistent with the clinical history of viral hepatitis C infection with mild activity (grade 1 of 4) and minimal fibrosis (Scheuer stage 0-1 of 4).