S4510 Feasibility and Safety of Peroral Biopsies of an Inferior Cavoatrial Tumor

Introduction: Inferior cavoatrial (ICA) tumors are located at the junction between the inferior vena cava (IVC) and the right atrium. Due to the complex anatomy, these tumors are difficult to obtain biopsies. We present a case of an ICA tumor that was successfully and safely biopsied per orem. To our knowledge, this is the first report of such maneuver in the medical history. Case Description/Methods: The patient is a 63-year-old man with a history of atrial fibrillation on anticoagulation presenting with 2 weeks of worsening scrotal swelling to the size of a soccer ball, severe pedal edema and abdominal distension. A scrotal ultrasound showed significant scrotal fluid and normal testes. Computed tomography (CT) demonstrated a lobulated soft-tissue mass measuring 8.1 × 6.5 × 5.1 cm at the junction between the IVC and the right atrium, moderate right pleural effusion, moderate ascites and anasarca. Gastroenterology was consulted for trans-esophageal biopsies. Diffuse moderate gastritis was found on esophagogastroduodenoscopy. Linear endoscopic ultrasound demonstrated an irregular, heterogeneous mass at the inferior cavoatrial junction measuring 80 × 65 × 50 mm with poorly-defined endosonographic borders. One enlarged lymph node was visualized in the middle paraesophageal mediastinum (level 8M), measuring 30 × 25 mm in diameter. The lymph node was oval, heterogeneous and had well-defined margins. Fine needle biopsies of the mass and the lymph node were performed using a trans-esophageal approach. Three passes were made with a 25-gauge biopsy needle with color Doppler imaging. Visible cores of tissue were obtained. Preliminary cytologic examination and touch preps were performed. The patient tolerated the procedures well with no complications. Both the tumor and the lymph node were positive for malignant germ cells. The lesion was determined to be an extra-gonadal germ cell tumor with lymph node metastasis. Oncology was consulted. The patient was scheduled to have a port placement followed by chemotherapy. He was discharged in stable condition after 7 days of hospitalization. Discussion: ICA tumors are extremely rare, with only a few case reports in the medical literature. These tumors can cause IVC syndrome with lower extremity edema, scrotal swelling, ascites, and anasarca. Diagnostic evaluation typically includes CT and magnetic resonance imaging followed by biopsies taken through a trans-venous approach. Our case report highlights the feasibility and safety of obtaining peroral biopsies through the trans-esophageal approach, demonstrating its utility in the diagnosis of ICA tumors.