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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