# Liver biopsy quality criteria to exclude cirrhosis in case of suspicion of porto-sinusoidal vascular disorder

## TL;DR

The study determines the minimum liver biopsy length and staining method needed to rule out cirrhosis when diagnosing porto-sinusoidal vascular disorder.

## Contribution

The study provides evidence-based criteria for liver biopsy length and staining to exclude cirrhosis in porto-sinusoidal vascular disorder diagnosis.

## Key findings

- A 15 mm biopsy with a 10 mm fragment is sufficient to exclude cirrhosis in PSVD.
- Picrosirius red staining performs slightly better than Masson’s trichrome for this purpose.
- Percutaneous biopsies have higher sensitivity than transjugular biopsies for cirrhosis exclusion.

## Abstract

Baveno VII guidelines based porto-sinusoidal vascular disorder (PSVD) diagnosis on a liver biopsy excluding cirrhosis. However, evidence-based quality criteria for liver biopsy are lacking. This study aimed to determine biopsy length and staining appropriate to rule out cirrhosis.

Liver explants from 12 patients with cirrhosis and 12 with PSVD were selected. Slides were stained with Picrosirius red or Masson’s trichrome. A total of 36,000 virtual liver biopsies were randomly generated, including different biopsy widths (572 and 1,000 μm corresponding to transjugular and percutaneous biopsies, respectively) and lengths (5 mm, 10 mm, 15 mm, 20 mm, 25 mm; fragmented 5 + 10 mm and 5 + 5 + 5 mm). Biopsies were assessed by an expert pathologist for the presence or absence of cirrhosis.

Overall sensitivity of percutaneous biopsies for the diagnosis of cirrhosis was 85%, higher with Picrosirius red (86%) than with Masson’s trichrome (83%) (p <0.001). Sensitivity increased with the length of percutaneous biopsies, reaching a plateau from 15 mm (88%). Sensitivity was significantly higher for percutaneous (89%) than for transjugular biopsies (84%) (p <0.001). A plateau was also observed from 15 mm for transjugular biopsies. Fragmented biopsies with at least one 10-mm-long fragment (5 + 10 mm) had similar sensitivity as 15-mm-long biopsies. Diagnostic accuracy was lower in case of Laennec A cirrhosis, HBV-associated disease, or incomplete septal fibrosis. Validation by a second pathologist gave similar results.

For the diagnosis of PSVD, the minimum length of liver biopsy to exclude cirrhosis was 15 mm with at least one fragment of 10 mm. Picrosirius red had a better performance than Masson's trichrome staining. The transjugular route showed lower sensitivity, but provides additional information.

This study shows that, for the diagnosis of porto-sinusoidal vascular disorder, the minimum length of liver biopsy to exclude cirrhosis is 15 mm, with a minimum fragment of 10 mm. Picrosirius red had a slightly better performance than Masson's trichrome staining. Future guidelines might consider that a ≥15-mm-long biopsy, with a fragment ≥10 mm, is sufficient to rule out cirrhosis in case of suspicion of porto-sinusoidal vascular disorder with signs of portal hypertension.

Image 1

•Liver biopsies to rule out cirrhosis in PSVD should be ≥15 mm long with a ≥10 mm tissue fragment.•Picrosirius red staining performs slightly better than Masson’s trichrome to exclude cirrhosis.•Percutaneous biopsies better exclude cirrhosis as they are wider than transjugular samples.•Transjugular biopsy provides additional data on hepatic pressure gradient and vein-to-vein collaterals.•Distinguishing incomplete septal cirrrhosis from LaennecA cirrhosis is difficult; repeat biopsy might be needed.

Liver biopsies to rule out cirrhosis in PSVD should be ≥15 mm long with a ≥10 mm tissue fragment.

Picrosirius red staining performs slightly better than Masson’s trichrome to exclude cirrhosis.

Percutaneous biopsies better exclude cirrhosis as they are wider than transjugular samples.

Transjugular biopsy provides additional data on hepatic pressure gradient and vein-to-vein collaterals.

Distinguishing incomplete septal cirrrhosis from LaennecA cirrhosis is difficult; repeat biopsy might be needed.