Biopsy vs Fibroscan - MRI Liver Cyst

[Pete]

During my recent screening for a clinical trial conducted by Abbvie, one of the tests was a fibroscan.   The test was conducted by the Hepatologist.  Median score was 9.0.  My doctor said, "Congratulations!, that represents stage 2 fibrosis, you don't have cirrhosis."

The clinician followed up with, "According to the AbbVie trial guidelines, you'll only need 12 weeks of TX instead of 24".

To which I asked? " Why does this result conflict with 2 prior biopsies?"  I reminded them that the 2003 and 2006 biopsy score was Stage 3 fibrosis with "signs of early bridging fibrosis".  I'll add that it was the 2 prior biopsy reports that led this medical team to conclude that I had likely advanced to cirrhosis by this time. 

I was told by the doctor that a biopsy only samples a very small portion of the liver and that the results can be misleading.  I've read that fibroscan results may also be subject to potential inaccuracies.   Abbvie will use the fibroscan stage 2 result to determine length of tx. Hence 12 weeks of Viekira Pak/Solvaldi with Riba

I should be pleased with this new result, but I am skeptical in regards to the accuracy of the fibroscan. Could 2 previous biopsy results both be in error? One can only hope in the instance.

You may recall I was UND at 8 & 12 weeks with Harvoni, but failed to achieve SVR. I've always felt that 24 weeks of Harvoni would had been the ticket.  So now another 12 week regime? 

If I fail to achieve SVR after 12 weeks of this cocktail, (6 different DAA's) I could end up with an extremely virulent strain of the virus.  In fact there is a disclaimer in the consent form that speaks to this as a possibility.

I'm wondering if I should reject 12 weeks of anything based on my 12 week Harvoni experience. 

This may all be a moot point anyway.  A 4 cm complex liver cyst was noted my MRI last week.  That finding may disqualify me from participating in the trial.  The cyst is not new and was fist discovered late in 2014. It actually reduced in size 3.4 to 1.6 cm during Harvoni TX completed in June of 2016. 

This new development will undoubtedly open a new chapter for me.  I suspect they'll recommend removal of the cyst for closer examination.  Maybe I should call a timeout on treatment for now?

Sorry for the long post. Stay tuned...

Pete



 

[gnatcatcher]

Pete, I'm sorry you have to deal with the need for a second treatment and possible cyst removal. As for accuracy of various liver stiffness measurement (LSM) methods, your doctor is correct about biopsy's limitations. From what I've read, FibroScan and the various blood methods (e.g., FibroSure) also have their limitations. Here is an article about the FibroScan's limitations:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4071883/
Conclusions:
"FibroScan failure and poorly reliable LSM are uncommon. The most important determinants of poorly reliable results are older age, obesity, higher liver stiffness and the operator, the latter emphasizing the need for adequate training."

In doing some reading, I see that cysts can be removed either laparoscopically or through open surgery. If the latter, I presume they can assess LSM at the same time.

If you do call a timeout on treatment, a new trial will probably be coming around the bend shortly. But this does sound like a good time for a second opinion.

Best wishes,

Gnatty

[Pete]

My hepatologist has referred me to a surgeon. Appt is 2 weeks out. Still no word whether or not I can participate in the Abbvie trial. 

Gettin' pretty uptight here...

Pete

[gnatcatcher]

. . . sending peaceful thoughts to you . . .

[beto]

Hey Pete,

Pulling for you...so sorry for your troubles.  I have experience with one of the newer fibro scans (fibroscan touch 502).  Here is a review of of the newer devices. 

http://onlinelibrary.wiley.com/doi/10.1002/cld.407/pdf

[Else]

Hi Pete,
Gnatty made a good point that another trial opportunity is likely right around the corner.  I would try to take one thing at a time.  If the cyst grew from 1.6 cm to 4 cm it would seem prudent to take a closer look at it.

I only wish the appt. with your surgeon was in 2 days not 2 weeks.  I wish I could share the secrets of mastering the waiting game with ease or calm.  But not my strong suit.  I'm wishing you peace as well.  Keep us posted.

[Pete]

About that increase from 1.6 to 4.cm.  I wondering if the 1.6 was mis-read or a typo in the record.  I say that because 6 months prior to the 1.6 measurement, it was cited as 3.4 cm.  Just seems odd it would shrink 50% in 6 mos and then double in size over the next 6 mos.  My Doctor suspects that my liver was on the mend for a brief period during the Harvoni tx and the cyst was shrinking in mass as a result. 

I'll try to learn what Fibroscan device my clinic is using.  I should have checked... didn't think of it.   

Thanks everyone for your kind words and consideration.  I feel I have friends here.

Best to all,
Pete

[HEPful Guy]

Liver biopsies are extremely accurate because it does look at the actual tissue. They can be misleading since it only represent the spot in the liver that the tissue was taken. So part of your liver could be F3 while other parts could be F4, or F2. Fibroscans typically provide a great general consensus of your entire liver but may not show your highest fibrosis scoring. For example you have F2 on fibroscan because 95% of your liver could be F2 staging. The biopsy has a chance of being taken from the 5% of your liver that has F3 staging.

Even with F3 staging, you would only need 12 weeks of viekira pak. Before you start any additional therapies you should have a NS3/4A genosure and a NS5A genosure done to test for cross resistance. From my experience, patients who have had treatment with Harvoni have a good chance for cross-resistance with Viekira Pak. Depending on what the genosure says, it should help dictate what your next treatment option would be.  The most logical next therapy option would be Sovaldi + Daklinza or now Zepatier if there is any cross-resistance.

[Pete]

I requested the testing for RAV in Nov '15,  Results indicated:

HCV Ns5A
Daclatasvir - Resistance not predicted
Ledipasvir - Resistance Predicted
Ombitasvir - Resistance Not predicted
     
Ns3 
Boceprevir Resistance not predicted
Paritaprevir Resistance not predicted
Simeprevir Resistance Predicted

Your perspective on Fibrosis staging, (biopsy vs fibroscan) is encouraging. 

Regards,
Pete

[dragonslayer]

Liver biopsies are supposed to be  accurate through all the stages of fibrosis, whereas Fibroscan is supposedly strong at the low and high ends of staging, but weak in the middle.

Pick your poison!