At the time of hospital admission, the patient was a 63-year-old male and showed fever as the main clinical manifestation. His body temperature fluctuated in the range of 37.5 C-38 C. The patient did not have jaundice, the abdomen was flat and soft, and showed no tenderness or rebound pain. The liver and spleen were not palpable under the ribs, and no mobile dullness was identified. The patient did not have a history of chronic diseases such as hypertension and diabetes, a history of infectious diseases including hepatitis B and tuberculosis, or a family history of tumors.
Blood routine tests showed increased levels of white blood cells (11.14 x 109/L). The blood biochemical examination revealed that alanine aminotransferase (37 U/L) and aspartate transferase (18 U/L) were within the normal range. We noted a decrease in the total protein content (62.8 g/L) and the white ball ratio (1.0); however, the C-reactive protein (215.70 mg/L) levels had increased abnormally. Immune screening detected no hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. Through the tumor marker screening, we determined that carcinoembryonic antigen (CEA) (1.24 ng/ml), alpha-fetoprotein (AFP) (4.47 ng/ml), prostate-specific antigen (2.98 ng/ml), carbohydrate antigen 19-9 (CA19-9) (6.32 IU/ml), and carbohydrate antigen 15-3 (CA15-3) (18.10 IU/ml) were within the normal range.
The patient underwent a physical examination at the local hospital. Ultrasound examination of the liver, gallbladder, pancreas, and spleen showed the presence of space-occupying lesions in the left lobe of the liver. Computed tomography (CT) of the upper abdomen indicated a liver abscess and multiple lymphadenopathies in the abdominal cavity. However, a subsequent (1 week later) ultrasound-guided percutaneous liver biopsy revealed a malignant tumor in the left lobe of the liver.
To receive further treatment for liver tumors, the patient was admitted to the Department of Hepatobiliary Surgery at our hospital. The Color Doppler ultrasound (hepatobiliary, pancreatic, spleen, and portal vein) showed that the left outer lobe of the liver had a mixed echo of 103 x 112 x 110 cm. The tumor was mainly hypoechoic with an irregular shape and clear boundaries. The internal echo was uneven, the color revealed the presence of dots of blood flow signals in and around the tumor, and no abnormality in the portal vein was noted. Irregular masses of long T1 (Figure 1A) and long T2 (Figure 1B) abnormal signals in the space between the liver and the stomach were detected through magnetic resonance imaging (MRI) of the tumor (plain scan + enhanced + functional imaging). In the images, the tumor size was approximately 9.5 x 8.3 cm, the circular short T1 and long T2 signals can be clearly visualized, and the tumor has a well-defined boundary. However, the lesion and the left lobe of the liver appear to be unclearly decomposed. Diffusion-weighted imaging (DWI) (Figure 1C) shows a strong signal, and the enhancement (Figures 1D-F) indicates progressive heterogeneous enhancement. Irregular thickening of the stomach wall was noted on the side of the corresponding lesser curvature of the fundus. The gallbladder was not enlarged, and its wall did not appear to be thickened. No dilation was observed in the intrahepatic and extrahepatic bile ducts and we noted no obvious filling defect in the main portal vein and its branches. We did not identify any abnormalities in the pancreas and spleen morphology or any obvious signal indicating irregularity. In the imaging range, multiple small lymph nodes could be identified in the retroperitoneum. Chest x-ray and CT images showed no abnormalities in the lungs, the heart, or the diaphragm. We used an electronic gastroscope and determined the presence of a submucosal bulge with a diameter of approximately 0.8 cm in the fornix and the greater curvature of the stomach. The surface of the protuberance was smooth, tough to touch with the biopsy forceps, and appeared to be inactive. This observation suggested that there were multiple SMTs within the protuberance. In the lesser curvature of the stomach near the corner, we noted that there was a sheet-like shallow erosion with smooth mucosa flushing in color; however, no ulcer or bleeding was observed. Pathologic examination of the biopsy revealed chronic superficial gastritis of the mucosa, which was severe, active, and locally accompanied by ulcers and Helicobacter pylori (HP) infection.
The patient was febrile and showed no characteristic clinical presentation. Results of laboratory tests, including tumor markers, were unremarkable. A combination of imaging findings and liver puncture results of the patient in the local hospital assisted us in determining that the patient had a malignant tumor in the left lobe of the liver, accompanied by greater curvature GST, without obvious metastatic lesions. Owing to the fact that only a small amount of pathological tissue was acquired through the liver puncture, the nature of the tumor required further elucidation via postoperative pathologic analysis. HCC, ICC, HSC, and other properties are not excluded. We performed left hepatic lobectomy combined with partial gastrectomy (wedge resection) with the patient's and his family's consent. We intraoperatively identified a mass of ~10 cm in diameter in the left lobe of the liver, with off-white color and hard texture. The tumor had appeared to have broken through the liver capsule, the visceral surface densely adhered to the lesser curvature of the stomach, and enlarged lymph nodes were palpable in the suspensory ligament of the hepatoduodenum. Intraoperative biopsies were performed and all three enlarged lymph nodes tested negative upon pathologic examination. Two superficial tumors were observed on the greater curvature of the stomach wall. The right liver was normal in size and soft to the touch. The size of the gallbladder was approximately 7 x 4 x 3 cm. No tumor metastatic nodules were detected in the omentum, diaphragm, jejunum, or pelvis. Intraoperative examination revealed that the liver tumor had invaded the left gastric artery, which was removed from the root. The operation was relatively successful, lasted for approximately 6 h, and the bleeding volume was approximately 200 ml.
The postoperative specimens were subjected to pathological examination and immunohistochemistry (IHC). The liver tumor tissue specimen was diagnosed as a high-grade pleomorphic malignant tumor of the left lateral lobe of the liver with necrosis. The immunological markers were as follows: CK (+) (Figure 2B), Vim (-), CD117 (-), Dog-1 (-), CD34 (-), SMA (-), Ki-67 (+, ~60%), GPC-3 (-), and Hepar-1 (-). Additionally, the tissue specimen was sent to another hospital for consultation, and the IHC results showed AE1/AE3 (+) (Figure 2C), P16 (-), CDK4 (+), MDM2 (-), Desmin (-), Myogenin (-), and MyoD1 (-). Molecular detection: MDM2 gene status (-), no amplification. According to the outcomes of IHC analysis, a sarcomatoid carcinoma (SC) with a length of 10 cm, and a negative cut-off edge of the liver section was considered. The gastric tissue specimen was diagnosed as representing spindle cell proliferative disease, combined with immunological markers in line with low-risk GST, featuring 2 pieces with a length of 1.0-1.5 cm. The relevant immunohistochemical markers were as follows: Vim (+), CD117 (+) (Figure 2E), CD34 (+), Dog-1 (+) (Figure 2F), Ki-67 (+, ~5%), SMA (-), S-100 (-).
The patient recovered favorably and was discharged from our hospital on postoperative day 8. No adjuvant therapy was administered or prescribed. The patient was followed up in the outpatient clinic 1 month after discharge, and he presented no obvious symptoms or discomfort. The blood routine test and biochemical profile showed no abnormalities, and AFP (10.5 ng/ml) had no significant increase compared with the first measurement (4.47 ng/ml). The hepatobiliary, pancreatic and splenic ultrasound showed no obvious space-occupying lesions.
However, 3 months later, the patient presented with persistent pain in the upper left abdomen, which worsened paroxysmally. Imaging examinations revealed the presence of an irregular and substantial mass in the area between the greater curvature of the stomach and the omental sac (Figure 3A), and the enhanced CT scan showed uneven enhancement. The patient underwent gastric tumor resection with partial resection of the transverse colon. The tumor was 53 x 78 x 100 mm in size, gray in color, and showed internal necrosis (Figures 3B,C). Results of postoperative pathology and IHC tests confirmed that the tumor in the stomach had metastasized from the HSC. The patient recovered well after the operation. Four months after the second operation, the patient died from multiple metastases to other sites.