2165 Endoscopic Ultrasound-Guided Fine-Needle Biopsy (FNB) of a Liver Lesion Demonstrating Metastatic Esophageal Adenocarcinoma

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INTRODUCTION: The role of biopsy in determining the etiology of hepatic lesions is crucial in determining pathology and potential therapy. Liver biopsies are often accomplished with the aid of interventional radiology with a percutaneous approach. However, there are instances when a percutaneous approach is not feasible. Here, we present a patient who underwent an endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) of a left lobe hepatic lesion which demonstrated metastatic esophageal adenocarcinoma. CASE DESCRIPTION/METHODS: A 76 year-old man with a history of esophageal adenocarcinoma, who previously underwent treatment with neoadjuvant chemoradiation and surgical resection 3 years earlier, was found on routine surveillance CT imaging to have a lesion within the left lobe of his liver. He subsequently underwent a PET CT that demonstrated this lesion to be FDG avid without any other evidence of FDG avidity (Figure 1). Interventional radiology was initially consulted for liver biopsy, however due to a poor window for access this could not be performed. He subsequently was referred for an EUS-guided FNB. EUS demonstrated a round to oval shaped, irregular mass within the left lobe of the liver. The mass was hypoechoic and heterogeneous with central spiculation. The mass measured 43 mm by 33 mm in maximal cross-sectional diameter. Color Doppler imaging was used prior to needle puncture to confirm a lack of significant vascular structures within the needle path. Fine needle aspiration for cytology was performed. Three passes were made with a 22-gauge FNB needle (Acquire™ 22ga) using a trans-gastric approach (1 pass for cytology touch prep, and 2 core biopsy samples for surgical pathology) (Figure 2). Preliminary rapid on-site cytological evaluation (ROSE) was suspicious for malignancy, with final specimen demonstrating adenocarcinoma. Surgical pathology from the core biopsy was reviewed and a diagnosis of metastatic adenocarcinoma, moderately differentiated, morphologically compatible with esophageal adenocarcinoma was rendered (Figure 3). DISCUSSION: This case demonstrates the utility and feasibility of an EUS-guided liver biopsy when a percutaneous approach is not possible to help make a diagnosis and direct therapy.