TABLE 3.

Considerations regarding liver biopsy in liver injury associated with checkpoint inhibitors

Benefits	Limitations
Diagnosis confirmation	Specificity of findings
Findings can strengthen diagnosis if uncertain or atypical presentation or labs (lobular inflammation, endotheliitis, granulomas, and apoptosis)	No pathognomonic histological findings for ILICI
Prognosis	Periprocedural risk
Eosinophils and granulomas have better outcomes	1%–2% risk of severe bleeding/hospitalization
Severe necrosis and fibrosis have poorer outcomes	30% require analgesics
Identify pre-existing liver disease	Logistics
Metabolic-associated liver disease in 10%–20% of general US population	Scheduling Delay in corticosteroids
Alternative etiology and management	Clinical impact
Malignant infiltration of the liver will worsen with immunosuppression	< 10% have an alternative etiology
Opportunistic viral infection (HSV, CMV) will worsen with immunosuppression	> 80% of Grade 2–4 patients rapidly respond to corticosteroids
Cholestatic patients may have small duct sclerosing cholangitis only seen on biopsy	—

Abbreviations: CMV, cytomegalovirus; HSV, herpes simplex virus; ILICI, immune-mediated liver injury from checkpoint inhibitor.