Pancreatic Cancer with Liver Lesions Diagnosed by a Single EUS-FNA

Abstract

Purpose: Introduction: In the EUS evaluation of pancreatic masses, portions of the left and right lobes of the liver can be seen in the EUS field of view. Published case series have demonstrated that EUS guided transgastric FNA of liver lesions is safe, with a high diagnostic yield. Providing cytologic confirmation of metastatic liver disease at the time of the initial EUS can prevent the need for additional imaging studies or procedures, such as PET CT or percutaneous liver biopsies. We report a case of a pancreatic mass with a suggestion of metastatic spread to the liver, in which both lesions were confirmed to be adenocarcinoma, by simultaneous FNA of both the pancreatic mass and liver lesion, in one EUS procedure. Case Description: A 71-year-old female presented with epigastric pain radiating to the back, and unexplained weight loss. A CT scan of the abdomen showed a mass in the pancreatic neck, as well as low density liver lesions in both the right and left hepatic lobes. The patient was then sent for an EUS, which confirmed the presence of a hypoechoic density in the pancreatic neck. EUS guided FNA was done into the mass and a cytologic diagnosis was made of adenocarcinoma. During the EUS, the left hepatic lobe was visualized, revealing several localized, rounded heterogenous lesions, the largest being 1 cm. Changing to a new 22 gauge needle, FNA was then performed with three passes through the gastric wall and into the largest liver lesion, again yielding a cytologic diagnosis of adenocarcinoma. There was no evidence of bleeding following the transgastric hepatic FNA, and the patient was discharged home without incident. The findings provided cytologic confirmation of a primary pancreatic cancer with documented metastasis to the liver. Based on the proven liver lesion, the patient was deemed inoperable and referred to a pancreatic oncologist, and started treatment with Gemcitabine chemotherapy. Conclusion: Previously published case series have demonstrated that EUS guided transgastric FNA of liver lesions is safe and can be done at the same time as the initial EUS. This case report adds to our knowledge that liver lesions should be looked for during an EUS of the pancreas, and if found, can be safely sampled by transgastric FNA, precluding the need for any additional studies to verify metastatic disease.Figure