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Can reference images improve interobserver agreement in reporting liver fibrosis?
  1. Alyn L German1,
  2. Kenneth Fleming2,
  3. Philip Kaye3,
  4. Susan Davies4,
  5. Robert Goldin5,
  6. Stefan G Hubscher6,
  7. Dina Tiniakos7,8,
  8. Angus McGregor9,
  9. Judith I Wyatt1
  1. 1 Department of Histopathology, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK
  2. 2 Green Templeton College, Oxford University, Oxford, UK
  3. 3 Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
  4. 4 Department of Pathology, Cambridge University Hospitals NHS Trust, Cambridge, UK
  5. 5 Centre for Pathology, Imperial College, London, UK
  6. 6 Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  7. 7 Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle, UK
  8. 8 Department of Histopathology, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
  9. 9 Department of Histopathology, University Hospitals of Leicester NHS Trust, Leicester, UK
  1. Correspondence to Dr Alyn L German, Department of Histopathology, St James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK; alyn.german{at}


Staging of fibrosis in medical liver biopsies has inherent interobserver variability. There are a number of disease-specific scoring systems available. While recognising the importance of these scoring systems, there is scope to consider how concordance amongst histopathologists could be improved using a generic fibrosis staging system.

Using virtual slides, we approached both specialist liver histopathologists and general histopathologists from the UK to assess the degree of fibrosis against a proposed four-tiered reporting system. Example reference images were then produced and distributed to the same responders who were asked to rate a second set of slides to assess if the use of reference images improved concordance between pathologists.

The use of reference images eliminated spread across three categories (from 15% to 0%). Overall, agreement was already good; our study showed an improved agreement amongst all participants for percentage agreement (67.79% to 70.08%) and interobserver agreement improved (Fleiss’ Kappa 0.55 to 0.59).

  • liver disease
  • fibrosis
  • histopathology
  • liver

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  • Handling editor Runjan Chetty.

  • Contributors JIW and KF: initial concept for project. JIW, KF, PK, RG, SD, SGH, DT and AM: contributed to the development of the project and part one participants. PK: provided slides for assessment. JIW, KF and ALG: recruited participants. ALG and JIW: coordinated virtual slides, data collection and distribution and authored the manuscript. PK, KF, SD, RG, SGH, DT and AM: reviewed and edited the manuscript. ALG, JIW, KF, PK, RG, SD, SGH, DT and AM: responded to reviewer comments and revised manuscript.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Provenance and peer review Not commissioned; externally peer reviewed.