Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Liver biopsy processing & stains
      
We helped organize the outpatient, convenient, comfort-controlled radiologist-performed liver biopsy program at Lexington Medical Center in about 1993.We will ideally have percutaneous core biopsies done by the radiologist with ultrasound localization. Until about 2009, one core was placed in formalin so as to duplicate classical morphology, and another in a mercury-based fixative (M2) for maximal enhancement of cytohistology; now, we only use formalin. Each core is step-cut at 6 or more levels so that the chance of finding micro-focal disease is amplified. A pre-biopsy CBC smear is reviewed in order to detect such things as atypical lymphocytosis of CMV infection, RBC burr cell formation of liver disease, RBC leptomacrocytes of chronic liver disease, and hairy lymphocytes of hairy cell leukemia (to mention a few). Also, at the time of blood drawing to check against bleeding problems prior to biopsy, we draw a tube of blood to check current liver function tests (LFTs) and to reserve the left-over serum in case other tests (especially serological antibody tests) are needed (patient will not have to return). Then 3 special stains are performed routinely (and others can be ordered when desired):
  • iron stain:
    1. positivity:
      • blue granular: hemosiderin iron.
      • blue blush or haze: ferritin.
    2. periportal hepatocytic staining is suggestive of genetic hemochromatosis.
    3. secondary siderosis tends only in RES cells.
    4. a mixed pattern in insulin-resistance-associated hepatic iron overload (IR-HIO) syndrome (AJCP 116:253, 8/01)...metabolic syndrome.
  • trichrome stain:
    1. main use: to assess any fibrosis and the patterns and stage (blue-stained fibrous).
    2. enhance search for Mallory bodies (red to grey-"void" stained) [L10-13705].
    3. enhance visibility of small vessicle steatosis.
    4. enhance search for portal biliary ductule (should see one in at least 80% of portal areas & suspect ductopenia if not4).
    5. HBV ground-glass cytoplasmic alteration is easier to see with this stain than with H&E. [LMC-04-1928].
    6. lipidotic, swollen Ito cells stand out as clear voids and can be seen at low to medium power [LMC-03-5757] & may indicate hypervitaminosis A and/or activation to a point of being fibrogenic.
    7. enhance search for megamitochondria (stain red)[LMC-01-6118] which reflect alcoholism or acute fatty liver of pregnancy1; usually round & red & d-PAS neg. but can be needles3.
  • d-PAS stain:
    1. detect alpha-1 antitrypsin deficiency (large, positive, periportal intra-hepatocytic globules 1-40 microns diameter...an RBC is about 6 microns).
    2. some alpha-1 antitrypsin globules show up in in alcoholic disease1.
    3. some globules in alpha-1 antichymotrypsin deficiency cases rarely show up positively.
    4. H&E neg. hyalin globules centrally in some cases of chronic passive congestion.
    5. evidence of hepatocyte injury in past 6 months:
      • sinusoidal lining cells containing fine, positive granules which subsequently "migrate" to,
      • portal macrophages containing fine, positive granules.
    6. detect giant hepatocytic intracellular lysosomes.
    7. enhance search for portal biliary ductule basement membrane profile even if devoid of epithelials (should see one in at least 80% of portal areas & suspect ductopenia if not4).
    8. helps find Poulsen lymphoid lesion with biliary ductule in center by enhancement of ductule basement membrane. [LMC-01-5531].
    9. slight aid in differential diagnosis of pigments (lipofuscin is slightly positive).
    10. can help discern accurately whether any portal polys are peribiliary vs. intrabiliary [LMC-01-5269].
    11. can detect fungi.
  • Routine H&E stain:
    1. clear-vacuole stellate Ito cells in lobule...if prominent, may indicate hypervitaminosis A.
    2. lipofuscin is a brownish finely granular pigment increasingly present with age, concentrating around the bile cannaliculus and more centrilobular.
    3. Dubin-Johnson coarse brownish pigment tends centrilobular.
  • PAS stain5:
    1. diffuse & even strong positive marking of glycocen indicates "healthy" cytoplasmic energy stores of carbohydrate (glycogen) in hepatocytes. A patchy decrease or worse indicates depletion of energy stores, a likely sign of "injury".
    2. steatosis of either mild levels or as a microvesicular pattern being unveiled as clear voids in the intensely red/fuscia-staining cytoplasm [L09-9114; L10-12181].
    3. the reactive proliferation of biliary cells at the hepatobiliary interface may be better appreciated with this stain because the biliary cells are PAS negative.
    4. plasma cells may "light up" in a background of lymphocytes with their PAS and/or d-PAS positive staining.
  • reticulin stain:
    1. hepatoportal sclerosis [HPS] causing idiopathic portal hypertension only shows increased reticulin "fibrosis" of sinusoids, especially early.
    2. looking for early phases of sinusoidal reticulin fibrosis (as in some cases of idiopathic myelofibrosis [L11-12010]) causing idiopathic portal hypertension.
    3. to evaluate for evidence of post-hepatitic areas of collapse as well as evidence of the abnormal pattern in well-differentiated hepatoma.
  • AFB stain:
    1. this marks lipofuscin weakly positive & Dubin-Johnson not at all.
    2. marks acid fast organisms.
  • Copper stains (orcein for metalloprotein & rhodanine for metal):
    1. the accumulation tends to be (1) in periportal hepatocytes and (2) in an eccentric paranuclear concentration.
    2. may be not-definitely pathologically present in babies up to about 9 months.
    3. deposits said to be birefringent.
    4. accumulates in Wilson's disease & chronic obstructive biliary disease.
    5. copper quantitative analysis is best way to discern less-than-striking increases.
  • IHC for ubiquitin: the condensed cytokeratins become "ubiquinated" with other proteins & are marked by this IHC marker [L10-13705]; it marks Mallory bodies.
  • IHC for ck7: marks biliary differentiation as opposed to hepatocytic.
  • IHC for ck8: marks Mallory hyaline from granule & granule clusters to rope-like deposits to larger deposits (see with toxicity, such as alcoholic & medicinal [amiodarone]); also marks both biliary epithelium and ck8 expressing hepatocytes at the operiphery of cirrhotic nodules (L13-10520).
References:

  1. Ludwig & Batts, Practical Liver Biopsy Interpretation 2nd Ed., 1998 (EBS's office)
  2. Scheuer PJ, et. al. Pathology of the Liver, 4th Ed. [text], 2002. (EBS)
  3. Frank Mitros' liver web site
  4. Mozaic Pathology pathologist (or other experts) tips by phone, fax, letter, or e-mail.
  5. special-interest expertise of our own team (MJS).
(posted 2001; latest addition 20 August 2013)

 
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