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University of Athens Medical School Athens, Greece
"LAIKON" General Hospital Athens, Greece
We read with interest the article of Chen et al. [1] in the October 2002 issue of the American Journal of Roentgenology. The authors emphasize the fact that, after treatment with imatinib mesylate, hepatic metastases of gastrointestinal stromal tumors (GISTs) appear with near-cystic components and well-defined borders on contrast-enhanced CT. They also mention that before treatment the metastases were poorly defined, heterogeneous, and peripherally enhanced, with density of 30–60 H (mean ± SD, 43 ± 12 H).
Apart from the clinical significance of these radiologic changes, it is vital to realize that metastatic GIST is often impossible to differentiate from cysticlike metastases of various origins solely on the basis of CT appearance [2]. Furthermore, in countries with high prevalence of amebiasis, the amebic abscess must be excluded [3].
We present a patient with low-grade fever, weight loss, left-quadrant pain, and a history of amebiasis, whose CT findings are shown in Figure 4. Tests for amebiasis had negative findings. Supporting the possible diagnosis of amebic abscess, paracentesis produced an "anchovy sauce" liquid with no evidence of malignancy. An ineffective trial of metronidazole and subsequently an extensive workup for neoplasia was required to reach the correct diagnosis of metastatic stomach GIST. After several months of therapy, the patient is doing fairly well and shows clinical signs of improvement. CT appearance of the metastases became more cystic, with well-defined borders similar to those of true cysts.
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In conclusion, liver metastases of GIST may be a difficult radiologic diagnosis. Both clinicians and radiologists must cooperate to exclude more benign lesions before malignancy is diagnosed [4].
References
Wake Forest University School of Medicine Winston-Salem, NC 21757-1088
We appreciate the comments of Drs. Zonios et al. regarding our recent article, "Cystic Changes in Hepatic Metastases from Gastrointestinal Stromal Tumors (GISTs) Treated with Gleevec (Imatinib Mesylate)" [1]. We agree that it is impossible to differentiate metastatic GIST from cysticlike metastases of various causes solely on the basis of their CT appearance. We also agree that the amebic abscess must be excluded in patients from countries with a high prevalence of amebiasis.
Our focus in this article [1] was the CT findings in patients with known hepatic metastases from GIST who were treated with Gleevec. We expect that there will be a long list of differential diagnoses for hepatic near-cystic lesions shown on CT.
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