In Reply The patient in our case was noted to have intussusception of the small bowel on the single-phase CT scan. Enteric malignancies are a well-recognized etiology for intussusceptions in adult patients. Given the concomitant, innumerable liver lesions, there was initial concern for metastatic disease from an enteric malignancy. Thus, triple-phase CT enterography was pursued to evaluate for a primary malignancy involving the small bowel. Hypothetically, if liver biopsy had been performed first and the pathology had revealed neuroendocrine tumor cells, subsequent imaging would still have been needed to identify the primary neuroendocrine tumor. Therefore, performance of a biopsy of the liver lesion before triple-phase imaging, as suggested by Dr Ellis, would not have led to an overall change in the care or clinical course of this patient. Yet we do agree that liver biopsy of the metastatic lesions would have been an alternative approach to obtaining a pathologic diagnosis in this particular case. However, the purpose of the article was not to define the proper means of tissue acquisition but rather to inform readers of the importance of tissue sampling before treatment and to educate them on the routine use of endoscopic ultrasound-guided biopsy for pancreatic masses.
