CASE HISTORY
An 83-year-old male patient was admitted to our hospital in March 2022,
presenting with complaints of tumor recurrence. On physical examination,
distention of the abdomen was observed, and multiple palpable lumps
measuring approximately 10x10 cm were found in the abdomen. The patient
has no personal or family history of hypertension, diabetes, or other
relevant medical conditions. On abdominal computed tomography (CT) with
contrast, the patient was diagnosed with recurrent stromal tumor with
hepatic subcapsular mass opacity with uneven enhancement and multiple
metastases in the abdomen and pelvis, and progressed earlier (Figure
1A-C). The preoperative hemoglobin was 101.0g/L, and the glycochain
antigen 125 was 95.96U/ml. No significant abnormalities were observed.
The patient’s past medical history is complex, and the details of his
diagnosis and treatment process are summarized in Table 1. Nine years
ago, in May 2013, the patient visited the hospital due to experiencing
lower abdominal pain. During the physical examination, a large mass was
detected in the right lower abdomen. Subsequently, the patient underwent
surgery to remove the small intestinal mass. The postoperative pathology
revealed a small intestinal stromal tumor with focal ischemic necrosis.
measuring 28.0×20.0×7.0 cm, and more than 5 nuclear fissions were
observed in 50 high-power fields (HPFs). Immunohistochemical analysis
indicated positive results for CD117, SMA, calpin, actin, and Vim, while
bcl-2, S-100, EMA, CD34, CD57, CD99, and ki-67 showed negative results.
Based on the NSH risk classification of stromal tumors, the patient was
classified as high risk. Following the surgery, the patient underwent a
conventional dose of imatinib anti-tumor therapy. One year later
(October 2014), a CT follow-up revealed the presence of a new lesion in
the left liver (Figure 2A). The lesion appeared as a round, low-density
shadow and measured approximately 1.4 × 1.1 cm. At that time, the
patient was diagnosed with GIST metastasis and continued to receive
imatinib treatment. Three years later (November 2016), another CT
follow-up showed a significant increase in the size of the left liver
lesion (Figure 2B), measuring 4.4 × 3.7 cm, enhanced by
contrast-enhanced scan. MRI was performed to further clarify the nature
of the lesion, and the lesion was not significantly enhanced on
contrast-enhanced scan, and the GIST metastase in the left lobe of the
liver were considered (Figure 2C). Surgical treatment was recommended
(Figure 2D), and surprisingly, the postoperative pathological diagnosis
revealed primary moderately differentiated hepatocellular carcinoma
(HCC) of the left liver (Figure 3A), accompanied by focal hemorrhagic
necrosis, rather than GIST liver metastases. After the surgery, imatinib
treatment was discontinued due to physical reasons. A follow-up CT
performed in August 2018 revealed the presence of new lesions under the
liver capsule (Figure 2E). GIST metastasis was considered, and imatinib
anti-tumor treatment was resumed. The follow-up CT scan in November 2021
showed multiple metastases under the liver capsule and in the pelvis
(Figure 2F). Due to the inadequate control effect of imatinib, the
patient was switched to a conventional-dose second-generation TKI,
sunitinib, for antineoplastic therapy (Figure 1D).