Grading and staging of chronic hepatitis: a trap for the unwary

[Guest guest]

Grading and staging of chronic hepatitis: a trap for the unwary

J Scheuer, 16 March 2001

For twenty years or so, the pathological changes in liver biopsies from

patients with chronic hepatitis have increasingly been allotted numbers.

Many different methods for this kind of scoring are available. The first to

be widely used was devised by Knodell and colleagues [1] for assessment of

biopsies from asymptomatic patients. An updated version of this was

published by Ishak et al. [2]. There are also more complex systems,

generating a wider range of numbers [3], and simpler systems [4;5] which

are less time-consuming to apply.

Grading and staging are mainly used to assess patients before hepatitis

therapy, to help decide on the likely response to therapy, to monitor new

treatments, and to study the natural history of the disease. Some

pathologists incorporate grading and staging scores into routine reports.

There are two common and important pitfalls for the unwary. In the first

place, all these systems are subject to intra-observer variation. That is

to say, one pathologist assessing the same biopsy on two occasions will not

necessarily come up with exactly the same numbers.

Inter-observer variation is even greater. The problem is usually greater

for grading of inflammation and hepatocellular damage than for staging of

fibrosis and structural changes, and is also greater with complex scoring

systems than with simple ones [6]. It follows that use of scoring in

routine reporting is of doubtful value, and simply adds to the increasing

pressure of work to which histopathologists are subjected.

Secondly, grading and staging, while conventionally generating numbers, are

not measurements, and the process is subjective rather than objective. This

might have been more clearly understood if letters rather than numbers had

been used for the various grades and stages in the first place. A grade of

2 for a particular feature, say, interface hepatitis, is not exactly half

way between 1 and 3; it is merely, in the opinion of the pathologist doing

the grading, more than 1 and less than 3. It follows that the numbers

generated must not be manipulated as if they were exact measurements. In my

opinion they should not be added together or averaged. A glance at the

relevant literature shows that the grading and staging scores are widely

misunderstood and misused.

References

Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz N, Kiernan TW,

Wollman J. Formulation and application of a numerical scoring system for

assessing histological activity in asymptomatic chronic active hepatitis.

Hepatology 1981; 1:431-5.

Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H,

Desmet V, Korb G, MacSween RNM, MJ, Portmann BG, Poulsen H,

Scheuer PJ, Schmid M, Thaler H. Histological grading and staging of chronic

hepatitis. J Hepatol 1995; 22:696-9.

Bedossa P, Bioulac-Sage P, Callard P, Chevallier M, Degott C, Deugnier Y,

Fabre M, Reynés M, Voigt J-J, Zafrani ES. Intraobserver and interobserver

variations in liver biopsy interpretation in patients with chronic

hepatitis C. Hepatology 1994; 20:15-20.

Scheuer PJ. Classification of chronic viral hepatitis: a need for

reassessment. J Hepatol 1991; 13:372-4.

Bedossa P, Poynard T, The METAVIR cooperative study group. An algorithm for

the grading of activity in chronic hepatitis C. Hepatology 1996; 24:289-93.

Goldin RD, Goldin JG, Burt AD, Dhillon P, Hubscher S, Wyatt J, Patel N.

Intra-observer and inter-observer variation in the histopathological

assessment of chronic viral hepatitis. J Hepatol 1996; 25(5):649-54.

SourceURL:

http://www.gastrohep.com/

[Guest guest]

Grading and staging of chronic hepatitis: a trap for the unwary

J Scheuer, 16 March 2001

For twenty years or so, the pathological changes in liver biopsies from

patients with chronic hepatitis have increasingly been allotted numbers.

Many different methods for this kind of scoring are available. The first to

be widely used was devised by Knodell and colleagues [1] for assessment of

biopsies from asymptomatic patients. An updated version of this was

published by Ishak et al. [2]. There are also more complex systems,

generating a wider range of numbers [3], and simpler systems [4;5] which

are less time-consuming to apply.

Grading and staging are mainly used to assess patients before hepatitis

therapy, to help decide on the likely response to therapy, to monitor new

treatments, and to study the natural history of the disease. Some

pathologists incorporate grading and staging scores into routine reports.

There are two common and important pitfalls for the unwary. In the first

place, all these systems are subject to intra-observer variation. That is

to say, one pathologist assessing the same biopsy on two occasions will not

necessarily come up with exactly the same numbers.

Inter-observer variation is even greater. The problem is usually greater

for grading of inflammation and hepatocellular damage than for staging of

fibrosis and structural changes, and is also greater with complex scoring

systems than with simple ones [6]. It follows that use of scoring in

routine reporting is of doubtful value, and simply adds to the increasing

pressure of work to which histopathologists are subjected.

Secondly, grading and staging, while conventionally generating numbers, are

not measurements, and the process is subjective rather than objective. This

might have been more clearly understood if letters rather than numbers had

been used for the various grades and stages in the first place. A grade of

2 for a particular feature, say, interface hepatitis, is not exactly half

way between 1 and 3; it is merely, in the opinion of the pathologist doing

the grading, more than 1 and less than 3. It follows that the numbers

generated must not be manipulated as if they were exact measurements. In my

opinion they should not be added together or averaged. A glance at the

relevant literature shows that the grading and staging scores are widely

misunderstood and misused.

References

Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz N, Kiernan TW,

Wollman J. Formulation and application of a numerical scoring system for

assessing histological activity in asymptomatic chronic active hepatitis.

Hepatology 1981; 1:431-5.

Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H,

Desmet V, Korb G, MacSween RNM, MJ, Portmann BG, Poulsen H,

Scheuer PJ, Schmid M, Thaler H. Histological grading and staging of chronic

hepatitis. J Hepatol 1995; 22:696-9.

Bedossa P, Bioulac-Sage P, Callard P, Chevallier M, Degott C, Deugnier Y,

Fabre M, Reynés M, Voigt J-J, Zafrani ES. Intraobserver and interobserver

variations in liver biopsy interpretation in patients with chronic

hepatitis C. Hepatology 1994; 20:15-20.

Scheuer PJ. Classification of chronic viral hepatitis: a need for

reassessment. J Hepatol 1991; 13:372-4.

Bedossa P, Poynard T, The METAVIR cooperative study group. An algorithm for

the grading of activity in chronic hepatitis C. Hepatology 1996; 24:289-93.

Goldin RD, Goldin JG, Burt AD, Dhillon P, Hubscher S, Wyatt J, Patel N.

Intra-observer and inter-observer variation in the histopathological

assessment of chronic viral hepatitis. J Hepatol 1996; 25(5):649-54.

SourceURL:

http://www.gastrohep.com/

[Guest guest]

Grading and staging of chronic hepatitis: a trap for the unwary

J Scheuer, 16 March 2001

For twenty years or so, the pathological changes in liver biopsies from

patients with chronic hepatitis have increasingly been allotted numbers.

Many different methods for this kind of scoring are available. The first to

be widely used was devised by Knodell and colleagues [1] for assessment of

biopsies from asymptomatic patients. An updated version of this was

published by Ishak et al. [2]. There are also more complex systems,

generating a wider range of numbers [3], and simpler systems [4;5] which

are less time-consuming to apply.

Grading and staging are mainly used to assess patients before hepatitis

therapy, to help decide on the likely response to therapy, to monitor new

treatments, and to study the natural history of the disease. Some

pathologists incorporate grading and staging scores into routine reports.

There are two common and important pitfalls for the unwary. In the first

place, all these systems are subject to intra-observer variation. That is

to say, one pathologist assessing the same biopsy on two occasions will not

necessarily come up with exactly the same numbers.

Inter-observer variation is even greater. The problem is usually greater

for grading of inflammation and hepatocellular damage than for staging of

fibrosis and structural changes, and is also greater with complex scoring

systems than with simple ones [6]. It follows that use of scoring in

routine reporting is of doubtful value, and simply adds to the increasing

pressure of work to which histopathologists are subjected.

Secondly, grading and staging, while conventionally generating numbers, are

not measurements, and the process is subjective rather than objective. This

might have been more clearly understood if letters rather than numbers had

been used for the various grades and stages in the first place. A grade of

2 for a particular feature, say, interface hepatitis, is not exactly half

way between 1 and 3; it is merely, in the opinion of the pathologist doing

the grading, more than 1 and less than 3. It follows that the numbers

generated must not be manipulated as if they were exact measurements. In my

opinion they should not be added together or averaged. A glance at the

relevant literature shows that the grading and staging scores are widely

misunderstood and misused.

References

Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz N, Kiernan TW,

Wollman J. Formulation and application of a numerical scoring system for

assessing histological activity in asymptomatic chronic active hepatitis.

Hepatology 1981; 1:431-5.

Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H,

Desmet V, Korb G, MacSween RNM, MJ, Portmann BG, Poulsen H,

Scheuer PJ, Schmid M, Thaler H. Histological grading and staging of chronic

hepatitis. J Hepatol 1995; 22:696-9.

Bedossa P, Bioulac-Sage P, Callard P, Chevallier M, Degott C, Deugnier Y,

Fabre M, Reynés M, Voigt J-J, Zafrani ES. Intraobserver and interobserver

variations in liver biopsy interpretation in patients with chronic

hepatitis C. Hepatology 1994; 20:15-20.

Scheuer PJ. Classification of chronic viral hepatitis: a need for

reassessment. J Hepatol 1991; 13:372-4.

Bedossa P, Poynard T, The METAVIR cooperative study group. An algorithm for

the grading of activity in chronic hepatitis C. Hepatology 1996; 24:289-93.

Goldin RD, Goldin JG, Burt AD, Dhillon P, Hubscher S, Wyatt J, Patel N.

Intra-observer and inter-observer variation in the histopathological

assessment of chronic viral hepatitis. J Hepatol 1996; 25(5):649-54.

SourceURL:

http://www.gastrohep.com/

[Guest guest]

Grading and staging of chronic hepatitis: a trap for the unwary

J Scheuer, 16 March 2001

For twenty years or so, the pathological changes in liver biopsies from

patients with chronic hepatitis have increasingly been allotted numbers.

Many different methods for this kind of scoring are available. The first to

be widely used was devised by Knodell and colleagues [1] for assessment of

biopsies from asymptomatic patients. An updated version of this was

published by Ishak et al. [2]. There are also more complex systems,

generating a wider range of numbers [3], and simpler systems [4;5] which

are less time-consuming to apply.

Grading and staging are mainly used to assess patients before hepatitis

therapy, to help decide on the likely response to therapy, to monitor new

treatments, and to study the natural history of the disease. Some

pathologists incorporate grading and staging scores into routine reports.

There are two common and important pitfalls for the unwary. In the first

place, all these systems are subject to intra-observer variation. That is

to say, one pathologist assessing the same biopsy on two occasions will not

necessarily come up with exactly the same numbers.

Inter-observer variation is even greater. The problem is usually greater

for grading of inflammation and hepatocellular damage than for staging of

fibrosis and structural changes, and is also greater with complex scoring

systems than with simple ones [6]. It follows that use of scoring in

routine reporting is of doubtful value, and simply adds to the increasing

pressure of work to which histopathologists are subjected.

Secondly, grading and staging, while conventionally generating numbers, are

not measurements, and the process is subjective rather than objective. This

might have been more clearly understood if letters rather than numbers had

been used for the various grades and stages in the first place. A grade of

2 for a particular feature, say, interface hepatitis, is not exactly half

way between 1 and 3; it is merely, in the opinion of the pathologist doing

the grading, more than 1 and less than 3. It follows that the numbers

generated must not be manipulated as if they were exact measurements. In my

opinion they should not be added together or averaged. A glance at the

relevant literature shows that the grading and staging scores are widely

misunderstood and misused.

References

Knodell RG, Ishak KG, Black WC, Chen TS, Craig R, Kaplowitz N, Kiernan TW,

Wollman J. Formulation and application of a numerical scoring system for

assessing histological activity in asymptomatic chronic active hepatitis.

Hepatology 1981; 1:431-5.

Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H,

Desmet V, Korb G, MacSween RNM, MJ, Portmann BG, Poulsen H,

Scheuer PJ, Schmid M, Thaler H. Histological grading and staging of chronic

hepatitis. J Hepatol 1995; 22:696-9.

Bedossa P, Bioulac-Sage P, Callard P, Chevallier M, Degott C, Deugnier Y,

Fabre M, Reynés M, Voigt J-J, Zafrani ES. Intraobserver and interobserver

variations in liver biopsy interpretation in patients with chronic

hepatitis C. Hepatology 1994; 20:15-20.

Scheuer PJ. Classification of chronic viral hepatitis: a need for

reassessment. J Hepatol 1991; 13:372-4.

Bedossa P, Poynard T, The METAVIR cooperative study group. An algorithm for

the grading of activity in chronic hepatitis C. Hepatology 1996; 24:289-93.

Goldin RD, Goldin JG, Burt AD, Dhillon P, Hubscher S, Wyatt J, Patel N.

Intra-observer and inter-observer variation in the histopathological

assessment of chronic viral hepatitis. J Hepatol 1996; 25(5):649-54.

SourceURL:

http://www.gastrohep.com/