Endoscopic Ultrasound (EUS) in the Diagnosis of Metastatic Uterine Cancer to the Liver: A Case Report

Abstract

Purpose: The clinical utility of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) in diagnosing primary and metastatic liver lesions and pelvic tumors has not been well defined. We present a case of metastatic uterine cancer diagnosed by EUS-FNA of a liver lesion and transrectal EUS-FNA of the primary uterine mass in a single session. A 45-year-old caucasian female with a history of cirrhosis and hepatitis C presented with 4 months' weight loss and non-specific abdominal pain. CT scan of the chest, abdomen and pelvis showed a 14-cm heterogenous mass in the pelvis with possible central necrosis, a 7.4-cm liver mass with celiac and mediastinal and left hilar lymphadenopathy. She denied any history of vaginal bleeding or other gynecological symptoms. Personal and family history was negative for gastrointestinal disease or malignancy. Exam was only significant for a mildly distended abdomen. Labs were grossly normal except for an elevated CEA of 58. CA 125 was 15 (normal). Alpha fetoprotein was normal. An upper and lower EUS was done. Upper EUS findings: The pancreas was normal. Two malignant appearing lymph nodes in the celiac region, the largest measuring 23 x 32 mm in diameter were seen. The nodes were irregular, hypoechoic, characterized by hyperechoic foci and well defined margins. A 55 x 61 mm hypoechoic round mass arising from the left lobe of the liver was also seen. FNA of both these lesions was performed with a 25 gauge ultrasound biopsy needle (Beacon Endoscopic, Newton, MA) using a transgastric approach. Lower EUS findings: A large 71 x 83 mm hypoechoic and heterogenous perirectal mass was identified originating from the uterus. FNA biopsy of lesion performed. Pathology for all the above biopsies were positive for a poorly differentiated adenocarcinoma staining for pancytokeratin, cytokeratin 7 and CDX2. This was consistent with metastatic uterine cancer. Conclusion: Our case clearly demonstrates the safety and accuracy of EUS in the diagnosis of metastatic liver lesions from a primary pelvic tumor in a single session. EUS provides very good imaging of the left lobe of the liver and a significant portion of the right lobe of the liver. Percutaneous biopsies under CT or ultrasound guidance have several limitations. A single-session EUS overcomes these limitations and is a useful and complementary imaging technique in the assessment of pelvic pathology as well as metastatic colorectal cancer. The major advantage of EUS is the possibility of performing ultrasound-guided biopsies of primary and metastatic lesions in a single session.