CLINICAL STUDIES Transjugular liver biopsy in patients with di¡use liver disease: comparison of three cores with one or two cores for accurate histological interpretation E. Cholongitas 1 , A. Quaglia 2,3 , D. Samonakis 1 , M. Mela 1 , D. Patch 1 , A. P. Dhillon 2 , T. R. Fanshawe 4 and A. K. Burroughs 1 1 Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, UK 2 Department of Histopathology, Royal Free Hospital, London, UK 3 Institute of Liver Studies, King’s College Hospital, London, UK 4 Department of Public Health and Primary Care, Centre for Applied Medical Statistics, University of Cambridge, Cambridge, UK Keywordslength – liver biopsy – percutaneous liver biopsy – portal tract – transjugular liver biopsy – size of liver biopsy Correspondence Andrew K. Burroughs, Liver Transplantation and Hepatobililary Medicine, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK. Tel.: 10044 20 74726229 Fax: 10044 20 74726226 e-mail: Andrew.Burroughs@royalfree.nhs.uk Received 3 August 2006 accepted 22 January 2007 DOI:10.1111/j.1478-3231.2007.01496.x Abstract Background: Transjugular liver biopsy (TJLB) can be performed to obtain more than two cores safely. This advantage has not been evaluated in terms of diagnostic accuracy or grading/staging evaluation. Aim: To evaluate whether three separate cores of TJLB provide more histological information compared with two or one cores. Methods: Twenty-three patients, who had three separate passes, with each core Z7mm in length using a 19G Tru-cut needle, were evaluated. Each TJLB was blindly coded; the pathologist randomly assessed: (a) each core separately covering the other two, (b) two cores simultaneously covering the third and (c) the three cores together for diagnostic yield, inflammation and fibrosis. Results: The mean TJLB length was 32  5.5mm. In 12 one-core (52%) and 18 2-core (78%) assessments, diagnosis (mainly cirrhosis) was made correctly in each core. The within-patient standard deviations for one-core vs two-core assessment were similar for grading (0.42 and 0.47, respectively), but higher for staging (0.39 and 0.15, respectively). Staging was underestimated in assessing one-core and less for two cores compared to three cores. Conclusion: Three non-fragmented cores (each core Z7mm in length) of TJLB can be considered a minimum requirement for histological assessment, giving better reproducibility in diagnosis as well as for inflammation and fibrosis. Liver biopsy (LB) remains an important tool in the diagnostic and therapeutic decision-making process in patients with acute and chronic liver disease (1). However, LB is an invasive procedure and it is now increasingly being emphasized that it should be per- formed only if it can offer significant diagnostic or prognostic information (2). Although it is assumed that LB is reasonably representative of the whole liver, it is estimated that LB represents approximately only 1/50000 of the total liver mass (3). As a result, there are limitations that must be appreciated in LB interpreta- tion of diffuse liver disease, such as the optimal size of a liver specimen (3, 4), the impact of intra- and inter- observer variation (5, 6) and sampling error in clinical practice (7–10). Several studies have stressed the sampling error with respect to using a percutaneous or laparoscopic ap- proach to obtain liver specimens (7–14). The majority of these studies showed that at least two concomitant samples are necessary for reliable histological inter- pretation. Although recent studies have shown that the unreliability of LB is attributable to an insufficient size of the liver samples [a LB should be Z20–25mm long and/or containing Z11 complete portal tracts (CPT)] (15, 16), on reviewing the literature, we found that the mean length and CPT of percutaneous LB (PLB) were suboptimal: 17.7  5.8 and 7.5  3.4mm, respectively (17). These data confirm that more than one pass with a PLB would be required to obtain an optimal biopsy. However, this would increase the risk of major and minor complications and potentially increase the costs (18–20). Transjugular liver biopsy (TJLB) is considered an alternative and safe method to obtain liver samples in high-risk patients (1, 3, 21, 22). TJLB are usually performed in an interventional radiology room with Liver International (2007) 646 c  2007 The Authors. Journal compilation c  2007 Blackwell Munksgaard Liver International ISSN 1478-3223