A 61-year-old male was referred to the emergency department by his general practitioner in April 2010 for investigation of loose bowel motions and an episode of black stool.
The patient had a history of insulin-dependent type II diabetes mellitus, hypertension, ischaemic heart disease with two previous ischaemic events, obstructive sleep apnoea, depression, schizophrenia and a previous incisional hernia repair.
On examination, he was morbidly obese (BMI 45) and was noted to have marked hepatomegaly.
This was not associated with any recent weight loss, haematemesis, jaundice or abdominal pain.
The patient denied previous blood transfusions, usage of intravenous drugs and did not drink alcohol.
A faecal occult blood test was negative, and the patient’s last colonoscopy 2 years prior was unremarkable.
He was referred to our tertiary centre for further management after an ultrasound scan (USS) displayed an ovoid mass of mixed echogenicity arising from the liver, measuring 12 × 9 cm.
A computed tomography (CT) scan confirmed a malignant appearing, pedunculated lesion attached to segment IV (Fig.1).
A subsequent magnetic resonance imaging (MRI) confirmed that on T2 weighted imaging (WI), the lesion was isointense to the liver peripherally with central branching hyperintensities (Fig.2a) which corresponded to the hypointensities seen on T1WI (Fig.2b).
Enhancement of the lesion was noted in arterial phase (Fig.3a), during portal venous phase (Fig.3b) and at 2 min (Fig.3c), with some central areas of non-enhancement.
The lesion becomes slightly hypointense on delayed images at 10 (Fig.3d) and 20 min compared to the surrounding liver.
Laboratory investigations revealed a mildly elevated gamma-glutamyl transpeptidase of 137 IU/L (normal 5–50 IU/L).
Hepatitis screen, alpha-fetoprotein, carcinoembryonic antigen and cancer antigen 19–9 were all unremarkable.
The patient underwent a subsegmental resection of the 15 cm segment IVb mass in June 2010.
There was severe hepatic steatosis, but no cirrhosis.
The patient was discharged postoperative day seven without complications.
Pathology of the resection specimen confirmed SFTL.
The specimen displayed a pale tan nodular appearance with a firm and rubbery cut surface.
Histological examination revealed fascicles of spindle cells in storiform arrangement with a pushing margin.
There was evidence of extracellular collagen deposition, areas of myxoid stroma and branching vessels with hyalinisation.
The specimen displayed a high mitotic rate of up to 9 per 10 high-power fields (HPF) with no necrotic or haemorrhagic features.
Immunohistochemistry showed positive staining for CD34, CD99 and BCL-2.
The tumour was negative for c-Kit, CD31, SMA, desmin, cytokeratins (AE1/AE3, MNF116 and Cam 5.2), EMA and S100.
The margins were clear.
The non-neoplastic remainder of the liver displayed pericellular fibrosis indicative of steatohepatitis.
The patient was followed-up regularly every 4 to 6 months with CT scans by the local general practitioner who liaised with the consultant surgeon.
There were two episodes of re-admissions for further investigation of recurrent right upper quadrant pain between 2011 and 2013.
Multiple MRI scans performed during this period revealed expected postsurgical changes with no tumour recurrence.
However, in May 2016, the patient presented to his local emergency department with progressively worsening right upper quadrant pain and increasing dyspnoea with an oxygen demand.
CT of his chest, abdomen and pelvis revealed extensive tumour recurrence adjacent to the previous resection site (Fig.4).
In addition, there was a clinically significant right-sided pleural effusion and a pleural mass at the right lung base measuring 3.8 cm (Fig.5).
Pleurocentesis was performed, draining 1400 ml of serosanguineous fluid.
Cytology was negative for malignant cells.
The case was discussed extensively in a multi-disciplinary setting, and it was decided given the patient’s two sites of disease and significant perioperative risk that he was not a candidate for radical reoperation.
There were also no suitable chemo- or radiotherapeutic therapies available.
The patient was subsequently referred to the palliative team for management of his symptoms and discharged back to the community.
He was still alive 1 month after discharge.