Biopsy in chronic liver disease: proposal for a shared path between clinicians and pathologists

Abstract

Introduction: Liver biopsy is fundamental for characterizing chronic liver disease. Effective communication between specialists during the diagnostic process is crucial. This project aims to outline a diagnostic path shared by clinicians and pathologists, and to propose practical solutions at different stages of the diagnostic work-up, from clinical suspicion to the histology report in patients with chronic liver diseases.

Methods: A panel of experts, within the methodological framework of lean management, joined two rounds of discussion sharing their professional experiences. They reached an agreement on the essential phases and actions of the diagnostic process, and built a shared diagnostic workflow.

Results: The panel agreed on the importance of a standardized form to be filled with all relevant clinical and laboratory data to ensure the flow of information between the clinician and the pathologist. Further decisions were reached on the following practical issues: the advantage of performing liver biopsies in dedicated centers, the need for homogeneous procedures, and the minimum quality standards in all phases, including reporting. Finally, the panel agreed on the usefulness of digital pathology to exchange observations and opinions and to create a territorial network to discuss challenging cases.

Conclusion: Sharing a diagnostic path between the pathologist and the clinician can be a powerful tool to improve both the timing and accuracy of the histology report.

Keywords: Chronic liver diseases; diagnostic pathway; lean management; liver biopsy.

Figure 1.

Definition of adequacy and quality criteria for the biopsy.

Figure 2.

Minimum sample preparation standard. PAS, Periodic Acid-Schiff; PAS-D, PAS Diastase stain.

Figure 3.

Required stains. (A) H&E staining demonstrates moderate portal nodular inflammation that spares the biliary duct, along with interface hepatitis and hemosiderin overload in the cytoplasm of hepatocytes in a patient with beta-thalassemia (original magnification: 20x). (B) The reticulum stain highlights a preserved lobular architecture and reticulin network, showing slight regenerative features of the hepatocytes in what appears to be an almost normal liver biopsy (original magnification: 10x). (C) PAS stain highlights the glycogen content of normal hepatocytes (original magnification:20x). (D) PAS/D stain. After treatment with diastase glycogen is not detected in the hepatocytes (original magnification: 20x). (E) Perls stain displays coarse hemosiderin granules in both periportal hepatocytes and portal macrophages in a Beta-Thalassemia patient (original magnification:20x). (F) CK7 staining reveals damage to the central duct, ductular reaction, and loss of Heiring channels in an overlap variant AIH-PBC (original magnification:20x). (G) Trichrome stain highlights the size of the portal tract with the portal vein, artery and bile duct (original magnification: 10x).