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    Liver biopsy

    Background

    Needle biopsies are commonly used to evaluate liver disease which encompasses non-neoplastic and neoplastic conditions. Ideally a needle biopsy should be 20mm long, 1.4mm in diameter and contain eleven portal tracts, particularly for the assessment of viral hepatitis4,5, but this is rarely possible clinically.1,6 Therefore cores 10mm long containing six portal tracts are considered the minimum for adequacy.1,3


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    If no clinical notes are provided, contact the supervising Pathologist or requesting clinician to determine whether the biopsies should be processed as investigation of diffuse (non-tumour) disease or a liver lesion.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Copper analysis
    • Iron analysis
    • Cytogenetics
    • Flow cytometry
    • Electron microscopy
    • Microbiology
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    Biopsies of liver will frequently require special stains and/or immunohistochemistry. Ensure adequate fixation.

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Procedure

    Record as stated by the clinician.

    • Liver core biopsy
    • Liver wedge biopsy
    • Other, specify

    Pathology indicated

    • Diffuse disease (liver special stains required)
    • Focal lesion (immunohistochemistry may be required)

    Specimen integrity

    • Number of core(s)
    • Fragmented, number of pieces received

    Cirrhotic liver may result in fragmented cores.2

    Specimen size (mm)

    Record the specimen dimensions:

    Core biopsy

    Each core and/or fragment in two dimensions:

    • Diameter
    • Length

    Wedge biopsy

    In three dimensions:

    • Length along free edge
    • Depth into liver parenchyma (from free edge to apex of wedge)
    • Thickness (from one capsular surface to the other at the widest point)

    Colour

    • Yellow
    • Brown
    • White
    • Green

    Liver is usually red-brown in colour, so white tissue may indicate capsular tissue or the presence of tumour.2


    Dissection

    No dissection required.

    Serially slice (“bread loaf” style) at right angles to the capsule running from free edge to apex at 3-4mm intervals.

    Paint the surgical margin with ink and serially slice ("bread-loaf" style) at right angles to the capsule running from free edge to apex& at 3-4mm intervals. Photograph the relevant slices.


    Internal Inspection

    Not required.


    Processing

    Submit all tissue directly into cassettes for processing.

    Cassette sponges (or similar) are required to prevent loss of tissue during processing. Ensure adequate fixation; although liver biopsies can be processed rapidly on a same day cycle, it is preferable for processing to occur over a routine cycle.

    Submit representative tissue for processing (small “left over” corners can be omitted).

    • Submit any focal abnormality.
    • Nominate one block for the panel of special stains.

    Submit representative sections of:

    • Tumour
    • Overlying capsule
    • Closest margins
    • Non-lesional liver
    • Any other abnormal areas

    In the setting of definite or suspected chronic liver disease, nominate one block for the panel of special stains.

    Standard protocols for sectioning and staining of liver core biopsies should be established in the laboratory. Different protocols are required for investigating diffuse disease and focal lesions (see examples below). Care should be taken to conserve tissue in case ancillary studies are required.

    Example protocols

    Core biopsy

    Diffuse disease:

    • Several (2 or 3) H&E levels
    • A panel of special stains on the intervening ribbon/s
    • Departments will have their preferences but a typical panel may include; a reticulin stain, a connective tissue stain, an iron stain, an orcien stain, periodic acid-Schiff’s (PAS) and PAS diastase (PAS-D).
    • A ribbon or unstained sections should be retained in case further stains are required.

    Focal lesions:

    • Several (2 or 3) H&E levels
    • A panel of special stains is not necessarily required and can be requested later if needed.
    • The intervening ribbon/s or unstained sections should be retained in case the special stain panel or an immunohistochemistry panel is required.

    Wedge biopsy

    Diffuse disease:

    • One H&E level on each block
    • A panel of special stains on one selected block
    • Departments will have their preferences but a typical panel may include; a reticulin stain, a connective tissue stain, an iron stain, an orcein stain, PAS and PAS-D.

    Focal lesions:

    • One H&E level on each block(s)
    • A panel of special stains is not necessarily required and can be requested later if needed.

    Record details of each cassette.

    An illustrated block key similar to the one below may be useful.

    Block allocation key

    Cassette id Site No. of pieces
    A Liver  
     

    Acknowledgements

    A/Prof Bastiaan de Boer for his contribution in reviewing and editing this protocol.


    References

    1. Wyatt J, Hübscher S and Bellamy C. Tissue pathways for liver biopsies for the investigation of medical disease and for focal lesions, The Royal College of Pathologists, London, 2014.
    2. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    3. Colloredo G, Guido M, Sonzogni A and Leandro G. Impact of liver biopsy size on histological evaluation of chronic viral hepatitis: the smaller the sample, the milder the disease. J Hepatol 2003;39(2):239-244.
    4. Bedossa P, Dargere D and Paradis V. Sampling variability of liver fibrosis in chronic hepatitis C. Hepatology 2003;38(6):1449-1457.
    5. Cholongitas E, Senzolo M, Standish R, Marelli L, Quaglia A, Patch D, Dhillon AP and Burroughs AK. A systematic review of the quality of liver biopsy specimens. Am J Clin Pathol 2006;125(5):710-721.

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      Liver biopsy

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      22-Mar-2019
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