University Pathologists - Staging and Grading - Liver

CHRONIC VIRAL HEPATITIS - ACTIVITY GRADING AND FIBROSIS STAGING

Batts Scheme | Scheuer Scheme | Metavir Scoring System

LAËNNEC CIRRHOSIS SCORING SYSTEM

NASH STAGING AND GRADING

Brunt scoring system | Nonalcoholic Steatohepatitis Activity Score

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CHRONIC VIRAL HEPATITIS - ACTIVITY GRADING AND FIBROSIS STAGING - Batts Scheme

GRADING OF DISEASE ACTIVITY IN CHRONIC VIRAL HEPATITIS

Semiquantitative	Activity	Piecemeal Necrosis	Lobular necrosis and inflammation
0	Portal inflammation only	None	None
1	Minimal	Minimal, patchy	Minimal, occasional spotty necrosis
2	Mild	Mild; involves some or all portal tracts	Mild with focal hepatocellular necrosis
3	Moderate	Moderate; involves all portal tracts	Moderate hepatocellular necrosis; noticeable degenerative changes
4	Severe	Bridging fibrosis	Severe with prominent diffuse hepatocellular damage

STAGING OF CHRONIC VIRAL HEPATITIS

Semiquantitative	Descriptive	Criteria
0	No fibrosis	Normal connective tissue
1	Portal fibrosis	Fibrous portal expansion
2	Periportal fibrosis	Periportal or rare portal-portal septa
3	Septal fibrosis	Fibrous septa with architectural distortion; no obvious cirrhotic nodules
4	Cirrhosis	Cirrhotic nodules; broad collagen bands

REFERENCE

Batts KP and Ludwig J. Chronic Hepatitis: An update on terminology and reporting. Am J Surg Pathol 1995;19(12):1409-1417.

 

CHRONIC VIRAL HEPATITIS - ACTIVITY GRADING AND FIBROSIS STAGING - Scheuer Scheme

SCORING NECROINFLAMMATORY ACTIVITY IN CHRONIC HEPATITIS

Grade	Portal/periportal activity	Lobular activity
0	None, minimal	None
1	Portal inflammation	Inflammation but no necrosis
2	Mild piecemeal necrosis	Focal necrosis of acidophilic bodies
3	Moderate piecemeal necrosis	Severe focal damage
4	Severe piecemeal necrosis	Diffuse damage including bridging necrosis

SCORING FIBROSIS AND CIRRHOSIS

Stage	Fibrosis - criteria
0	None
1	Enlarged, fibrotic portal tracts
2	Periportal or portal-portal septa with intact architecture
3	Fibrosis with architectural distortion but no obvious cirrhosis
4	Probable or definite cirrhosis

REFERENCE

Scheuer PJ. Classification of chronic viral hepatitis: a need for reassessment. J Hepatol 1991;13:372-374

 

CHRONIC VIRAL HEPATITIS - ACTIVITY GRADING AND FIBROSIS STAGING - Metavir Scoring System

METAVIR HISTOLOGIC ACTIVITY SCORE

Activity score (A)	Piecemeal necrosis (PMN)	Lobular necrosis (LN)
A=0	PMN=0	LN=0
A=1	PMN=0 PMN=1	LN=1 LN=0,1
A=2	PMN=0 PMN=1 PMN=2	LN=2 LN=2 LN=0,1
A=3	PMN=2 or PMN=3	LN=2 LN=0,1,2

HISTOLOGIC ACTIVITY CRITERIA

Histologic feature	Score	Criteria
Piecemeal necrosis	0	No
	1	Mild - focal alteration of the periportal plate in some portal tracts
	2	Moderate - diffuse alteration of the periportal plate in some tracts or focal lesions around all portal tracts
	3	Severe - diffuse alteration of the periportal plate in all portal tracts
Lobular necrosis	0	No or mild - less than one necroinflammatory focus per lobule
	1	Moderate - at least one necroinflammatory focus per lobule
	2	Severe - several necroinflammatory foci per lobule, or confluent or bridging necrosis
Portal inflammation	0	No
	1	Mild - presence of mononuclear aggregates in some portal tracts
	2	Moderate - mononuclear aggregates in all portal tracts
	3	Severe - large and dense mononuclear aggregates in all portal tracts
Bridging necrosis	YES	Necroinflammatory foci linking 2 portal tracts or a portal tract with a terminal hepatic venule
	NO

METAVIR FIBROSIS SCORE

Score	Criteria
F0	Portal inflammation
F1	Portal fibrosis without septa
F2	Portal fibrosis with rare septa
F3	Numerous septa without cirrhosis
F4	Cirrhosis

 

LAËNNEC CIRRHOSIS SCORING SYSTEM

Grade	Semiquantitative	Histologic Criteria
4A	Mild	Market septation with rounded contours or visible nodules; most septa are thin
4B	Moderate	At least 2 broad septa; < half biopsy length composed of minute nodules
4C	Severe	At least one very broad septum; >half of biopsy length composed of minute nodules

REFERENCE

Kutami R, et al. The Laennec grading system for assessment of hepatic fibrosis: validation by correlation with wedged hepatic vein pressure and clinical features. Hepatology 2000;32:407A

 

NASH STAGING AND GRADING - Brunt scoring system, 1999

NONALCOHOLIC STEATOHEPATITIS GRADING

Grade	Semiquant.	Steatosis	Ballooning	Lobular inflammation	Portal inflammation
1	Mild	<33 %, usually macro	Rare, zone 3	Rare acute and occasional chronic	None or mild
2	Moderate	Any degree, usually mixed	Obvious, zone 3	PMNs associated with ballooned hepatocytes	Mild to moderate
3	Severe	>66%, panacinar	Marked, predominantly zone 3	Frequent acute and chronic	Mild to moderate

NONALCOHOLIC STEATOHEPATITIS STAGING

Stage	Histologic criteria
1	Zone 3 perivenular perisinusoidal/pericellular fibrosis, focal or extensive
2	As above with focal or extensive periportal fibrosis
3	Bridging fibrosis, focal or extensive
4	Cirrhosis

REFERENCE

Brunt EM, et al. Nonalcoholic steatohepatitis: A proposal for grading and staging the histologic lesions. Am J Gastroenterol 1999;94;2467-74.

 

NASH STAGING AND GRADING - Nonalcoholic Steatohepatitis Clinical Research Network scoring system (Nonalcoholic Steatohepatitis Activity Score - NAS), 2005

ACTIVITY SCORE

Histologic feature	Grade	Description
Steatosis	0	<5%
	1	5-33%
	2	33-66%
	3	>66%
Lobular inflammation	0	None
	1	<2 foci/200x field
	2	2-4 foci/200x field
	3	>4 foci/200x field
Ballooning	0	None
	1	Few balloon cells
	2	Many cells/ prominent ballooning

NAS > 5 = NASH, NAS<2 = no evidence of NASH, NAS 3-4 = borderline/possible.

FIBROSIS STAGING

Stage	Histologic criteria
1	Zone 3 perivenular perisinusoidal/pericellular fibrosis, focal or extensive · 1A - delicate perisinusoidal fibrosis · 1B - dense perisinusoidal fibrosis · 1C - portal-only fibrosis
2	As above with focal or extensive periportal fibrosis
3	Bridging fibrosis, focal or extensive
4	Cirrhosis

REFERENCE

Kleiner DE, et al. Design and validation of histologic scoring system for nonalcoholic fatty liver disease. Hepatology 2005;41:1313-21.

 

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