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).