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EUS Trucut biopsy liver parenchyma acquisition and yield are comparable to that of a transjugular liver biopsy
LETTERS TO THE EDITOR EUS Trucut biopsy liver parenchyma acquisition and yield are comparable to that of a transjugular liver biopsy To the Editor:
most patients. However, this approach could be considered whenever EUS is otherwise indicated for another pathologic process, and when the percutaneous or transjugular approaches fail or are contraindicated, as was the case for each of the patients in our reported experience.
We read with interest the article by DeWitt et al,1 which was accompanied by the editorial by Manning and Afdhal.2 Manning and Afdhal2 suggest that, based on the findings of DeWitt et al,1 liver EUS-guided Trucut biopsy (EUS-TCB) specimens are inadequate and that an alternative liver biopsy route is preferred to avoid unnecessary repeat biopsy. Our initial experience has led us to an alternate conclusion. We previously reported such initial experience in patients with unconfirmed parenchymal liver disease and showed that we could obtain diagnostic tissue specimens by using EUS-TCB, allowing diagnosis of various hepatic parenchymal disorders.3 The number of complete portal tracts (CPTs) is considered to be the best parameter for comparing liver biopsy tools and routes of tissue acquisition.4,5 A liver biopsy, when performed to evaluate most forms of hepatic parenchymal disease, is viewed as adequate when the tissue acquired, regardless of the number of biopsy specimens taken, provides an aggregate core R 15 mm in length and contains R 5 CPTs.6,7 A percutaneous Menghini cutting needle (14 gauge) may obtain 6 CPTs per linear cm of tissue, and a 19-gauge Trucut transjugular biopsy specimen, when R 28 mm in length, contains R 11 CPTs (approximately 0.4 CPTs per mm).8,9 The tissue specimen length and number of CPTs obtained is similar for percutaneous and transjugular routes.9,10 In our study of 9 patients, a median of 2 TCBs (range 1-3) were performed, obtaining an aggregate mean tissue core length of 16.9 mm (range 8-28 mm), thus yielding a median of 7 CPTs (range 5-8) per patient. For the group as a whole, 18 TCB passes were performed, yielding 152 mm of tissue, equating to 8.4 mm of tissue per pass. Contained within these specimens, 63 CPTs were found, resulting in approximately 0.4 portal tracts per mm of tissue acquired. This equates with transjugular liver biopsy pathological evaluation and satisfies accepted criteria for sample adequacy. Sufficient tissue was obtained via EUS-TCB to allow histopathologic diagnosis in all 9 patients, with the findings of final diagnosis of mild steatosis (n = 4), cryptogenic cirrhosis (n = 2), chronic ductopenic biliary tract disease (n = 1), portal fibrosis with ductular proliferation (n = 1), or alcoholic bridging fibrosis with 3þ hemosiderosis. Our preliminary experience demonstrates that the tissue obtained via EUS-TCB is adequate to allow histologic diagnosis of benign parenchymal liver disease after a limited number of passes. Understandably, it is not practical or cost effective to routinely obtain a liver biopsy via EUS for
Drs Gleeson and Levy review their previously published experience with EUS-guided Trucut biopsy (EUS-TCB) of the liver by using the technique described in our article.1 The authors are to be congratulated for demonstrating an improved specimen yield compared to those we obtained. However, it is important to emphasize that their study was retrospective and involved only 9 patients. This is in contrast to our prospective study,2 which enrolled 21 patients. Based on the collective published work of 30 patients from both reports, it seems premature to conclude whether EUS-
1046 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 5 : 2009
www.giejournal.org
Ferga C. Gleeson Michael J. Levy, MD Division of Gastroenterology and Hepatology Fiterman Centre for Digestive Diseases Mayo Clinic College of Medicine Rochester, Minnesota, USA REFERENCES 1. Dewitt J, McGreevy K, Cummings O, et al. Initial experience with EUS-guided Tru-cut biopsy of benign liver disease. Gastrointest Endosc 2009;69:535-42. 2. Manning DS, Afdhal NH. EUS-guided liver biopsy: a procedure looking for an indication. Gastrointest Endosc 2009;69:543-5. 3. Gleeson FC, Clayton AC, Zhang L, et al. Adequacy of endoscopic ultrasound core needle biopsy specimen of nonmalignant hepatic parenchymal disease. Clin Gastroenterol Hepatol 2008;6:1437-40. 4. Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001;344: 495-500. 5. Bedossa P, Dargere D, Paradis V. Sampling variability of liver fibrosis in chronic hepatitis C. Hepatology 2003;38:1449-57. 6. Hølund B, Poulsen H, Schlichting P. Reproducibility of liver biopsy diagnosis in relation to the size of the specimen. Scand J Gastroenterol 1980;15:329-35. 7. Schlichting P, Hølund B, Poulsen H. Liver biopsy in chronic aggressive hepatitis: diagnostic reproducibility in relation to size of specimen. Scand J Gastroenterol 1983;18:27-32. 8. Crawford AR, Lin XZ, Crawford JM. The normal adult human liver biopsy: a quantitative reference standard. Hepatology 1998;28:323-31. 9. Cholongitas E, Quaglia A, Samonakis D, et al. Transjugular liver biopsy: how good is it for accurate histological interpretation? Gut 2006;55: 1789-94. 10. Kalambokis G, Manousou P, Vibhakorn S, et al. Transjugular liver biopsy-indications, adequacy, quality of specimens, and complicationsd a systematic review. J Hepatol 2007;47:284-94. doi:10.1016/j.gie.2009.03.030
Response:
most patients. However, this approach could be considered whenever EUS is otherwise indicated for another pathologic process, and when the percutaneous or transjugular approaches fail or are contraindicated, as was the case for each of the patients in our reported experience.
We read with interest the article by DeWitt et al,1 which was accompanied by the editorial by Manning and Afdhal.2 Manning and Afdhal2 suggest that, based on the findings of DeWitt et al,1 liver EUS-guided Trucut biopsy (EUS-TCB) specimens are inadequate and that an alternative liver biopsy route is preferred to avoid unnecessary repeat biopsy. Our initial experience has led us to an alternate conclusion. We previously reported such initial experience in patients with unconfirmed parenchymal liver disease and showed that we could obtain diagnostic tissue specimens by using EUS-TCB, allowing diagnosis of various hepatic parenchymal disorders.3 The number of complete portal tracts (CPTs) is considered to be the best parameter for comparing liver biopsy tools and routes of tissue acquisition.4,5 A liver biopsy, when performed to evaluate most forms of hepatic parenchymal disease, is viewed as adequate when the tissue acquired, regardless of the number of biopsy specimens taken, provides an aggregate core R 15 mm in length and contains R 5 CPTs.6,7 A percutaneous Menghini cutting needle (14 gauge) may obtain 6 CPTs per linear cm of tissue, and a 19-gauge Trucut transjugular biopsy specimen, when R 28 mm in length, contains R 11 CPTs (approximately 0.4 CPTs per mm).8,9 The tissue specimen length and number of CPTs obtained is similar for percutaneous and transjugular routes.9,10 In our study of 9 patients, a median of 2 TCBs (range 1-3) were performed, obtaining an aggregate mean tissue core length of 16.9 mm (range 8-28 mm), thus yielding a median of 7 CPTs (range 5-8) per patient. For the group as a whole, 18 TCB passes were performed, yielding 152 mm of tissue, equating to 8.4 mm of tissue per pass. Contained within these specimens, 63 CPTs were found, resulting in approximately 0.4 portal tracts per mm of tissue acquired. This equates with transjugular liver biopsy pathological evaluation and satisfies accepted criteria for sample adequacy. Sufficient tissue was obtained via EUS-TCB to allow histopathologic diagnosis in all 9 patients, with the findings of final diagnosis of mild steatosis (n = 4), cryptogenic cirrhosis (n = 2), chronic ductopenic biliary tract disease (n = 1), portal fibrosis with ductular proliferation (n = 1), or alcoholic bridging fibrosis with 3þ hemosiderosis. Our preliminary experience demonstrates that the tissue obtained via EUS-TCB is adequate to allow histologic diagnosis of benign parenchymal liver disease after a limited number of passes. Understandably, it is not practical or cost effective to routinely obtain a liver biopsy via EUS for
Drs Gleeson and Levy review their previously published experience with EUS-guided Trucut biopsy (EUS-TCB) of the liver by using the technique described in our article.1 The authors are to be congratulated for demonstrating an improved specimen yield compared to those we obtained. However, it is important to emphasize that their study was retrospective and involved only 9 patients. This is in contrast to our prospective study,2 which enrolled 21 patients. Based on the collective published work of 30 patients from both reports, it seems premature to conclude whether EUS-
1046 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 5 : 2009
www.giejournal.org
Ferga C. Gleeson Michael J. Levy, MD Division of Gastroenterology and Hepatology Fiterman Centre for Digestive Diseases Mayo Clinic College of Medicine Rochester, Minnesota, USA REFERENCES 1. Dewitt J, McGreevy K, Cummings O, et al. Initial experience with EUS-guided Tru-cut biopsy of benign liver disease. Gastrointest Endosc 2009;69:535-42. 2. Manning DS, Afdhal NH. EUS-guided liver biopsy: a procedure looking for an indication. Gastrointest Endosc 2009;69:543-5. 3. Gleeson FC, Clayton AC, Zhang L, et al. Adequacy of endoscopic ultrasound core needle biopsy specimen of nonmalignant hepatic parenchymal disease. Clin Gastroenterol Hepatol 2008;6:1437-40. 4. Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001;344: 495-500. 5. Bedossa P, Dargere D, Paradis V. Sampling variability of liver fibrosis in chronic hepatitis C. Hepatology 2003;38:1449-57. 6. Hølund B, Poulsen H, Schlichting P. Reproducibility of liver biopsy diagnosis in relation to the size of the specimen. Scand J Gastroenterol 1980;15:329-35. 7. Schlichting P, Hølund B, Poulsen H. Liver biopsy in chronic aggressive hepatitis: diagnostic reproducibility in relation to size of specimen. Scand J Gastroenterol 1983;18:27-32. 8. Crawford AR, Lin XZ, Crawford JM. The normal adult human liver biopsy: a quantitative reference standard. Hepatology 1998;28:323-31. 9. Cholongitas E, Quaglia A, Samonakis D, et al. Transjugular liver biopsy: how good is it for accurate histological interpretation? Gut 2006;55: 1789-94. 10. Kalambokis G, Manousou P, Vibhakorn S, et al. Transjugular liver biopsy-indications, adequacy, quality of specimens, and complicationsd a systematic review. J Hepatol 2007;47:284-94. doi:10.1016/j.gie.2009.03.030
Response: