Title : Endoscopic ultrasound-guided fine-needle biopsy of a caudate-lobe cholangiocarcinoma with complex vascular anatomy: A case report
Abstract:
Background: Caudate-lobe lesions can be difficult to sample percutaneously because of their deep location and close relationship to the inferior vena cava (IVC), portal vein and hepatic veins. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) may provide a shorter, real-time, Doppler-guided route to selected Segment I lesions.
Case presentation: An 82-year-old woman undergoing investigation for a possible bowel malignancy was found incidentally to have a 2.5-cm lesion in hepatic Segment I. MRI demonstrated an ill-defined mass with arterial enhancement, washout and restricted diffusion. Serum CA19-9 was markedly elevated at 926 U/mL, whereas alpha-fetoprotein was 2 ng/mL. Interval triple-phase CT showed enlargement to 3.0 × 2.5 cm, extension across Segments I, V and VII, broad contact with the IVC, portal-vein trifurcation, contact with the main portal vein and thrombus in the right posterior portal-vein branch. The patient did not wish to undergo surgical resection. Following multidisciplinary review, a percutaneous approach was considered technically unfavourable and EUS-FNB was selected. Transgastric EUS demonstrated a hypoechoic solid lesion, and two biopsy passes were performed without an immediate complication. Histology showed adenocarcinoma with no morphological features of hepatocellular carcinoma. In the context of the imaging and biochemical findings, the multidisciplinary team considered the overall diagnosis to be intrahepatic cholangiocarcinoma with metastatic disease and referred the patient for palliative oncology assessment.
Conclusion: This case illustrates how EUS-FNB can provide clinically useful tissue from a caudate-lobe lesion when a percutaneous route is judged unfavourable. Its main value was its contribution to a patient-centred change in management. Larger prospective studies are needed to define patient selection, comparative safety and strategies that reliably obtain sufficient tissue for molecular profiling.
