Gastric Hepatoid Carcinoma Presenting Initially as GIST on CT Scan

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A 67-year-old male smoker with history of atrial fibrillation status post-ablation and multiple cardioversions, COPD, and diabetes presented with shortness of breath. Work-up with chest x-ray showed left lower lobe infiltrate. His chest computer tomography (CT) scan showed left lower lobe infiltrate and chronic inflammatory changes at the lung bases. There was also an incidental finding of a 10×12 cm left upper quadrant heterogeneous mass with continuity with the stomach and no definite continuity with pancreas, considered likely to be GIST (Figure 1). The patient had no symptoms of nausea, vomiting, abdominal fullness, or earlier satiety. His last colonoscopy was about 3 years prior where 3 benign polyps were removed. He never had an esophagogastroduodenoscopy. The CT scan was consistent with GIST tumor, and so elective surgical resection was planned after he recovered from his pneumonia and had cardiac clearance. He underwent partial gastrectomy and partial resection of the diaphragm because the tumor had invaded part of the left diaphragm. The specimen's gross margin was negative for malignancy. The final pathology revealed carcinoma with hepatocellular features that was attached to the serosa of the stomach (Figure 2). Immunohistochemical stainings were positive for AFP and hepatocellular markers CK8/18 and HepPar A (Figures 3A, A,3B).3B). Contrast CT scan of abdomen and pelvis with venous phase did not show any liver mass. Therefore, the tumor was considered to be a hepatoid carcinoma. His recovery was complicated by multiple events. He had pneumonia and then a small spontaneous pneumothorax that managed conservatively with observation and oxygen. He also slipped into persistent atrial fibrillation that required repeat cardioversion. His postoperative ileus was also short-lived. Eventually he improved and was able to tolerate a regular diet before discharge.