Pathology Associates Of Lexington, P.A.

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. One core is placed in formalin so as to duplicate classical morphology, and another in a mercury-based fixative (M2) for maximal enhancement of cytohistology. 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 antibody tests) are needed (patient will not have to return). Then 3 special stains are performed:

iron stain positivity:
1. positivity:
  - blue granular: hemosiderin iron.
  - blue blush or haze: ferritin.
2. periportal hepatocytic staining suggestive of hemochromatosis.
3. secondary siderosis in RES cells.
4. a mixed pattern in insulin resistance-associated hepatic iron overload (IR-HIO) syndrome (AJCP 116:253, 8/01).
trichrome stain:
1. to assess any fibrosis and the patterns and stage (blue).
2. enhance search for Mallory bodies.
3. enhance search for portal biliary ductule (should see one in at least 80% of portal areas & suspect ductopenia if not⁴.
4. HBV ground-glass cytoplasmic alteration is easier to see with this stain than with H&E. [LMC-04-1928].
5. lipidotic Ito cells stand out as clear voids and can be seen at low to medium power [LMC-03-5757] may indicate hypervitaminosis A.
6. enhance search for megamitochondria (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 about 6).
2. some alpha-1 antitrypsin globules 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 (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. [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].
Routine H&E stain:
1. clear-vacuole stellate Ito cells in lobule...if prominent, may indicate hypervitaminosis A.

References:

Ludwig & Batts, Practical Liver Biopsy Interpretation 2nd Ed., 1998 (EBS's office)
Scheuer PJ, et. al. Pathology of the Liver, 4th Ed. [text], 2002. (EBS)
Frank Mitros' liver web site
Mozaic Pathology pathologist (or other experts) tips by phone, fax, letter, or e-mail.

(posted 2001; latest addition 17 March 2004)