Case Report: A liver metastasis 24 years after resection of a very low-risk jejunal gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, with recurrence risk primarily determined by tumor size, mitotic index, site, and genetic profile. While most recurrences occur within 5 years post-resection, late recurrences (>10 years) are rare, posing diagnostic and therapeutic challenges. We report a unique case of hepatic metastasis from a jejunal GIST 24 years after initial curative resection of a very low-risk tumor (1.5 cm, ≤5 mitoses/50 HPF). The patient underwent jejunal GIST resection in November 2000, no KIT/PDGFRA mutational testing or adjuvant therapy was performed at the time. He remained recurrence-free for 24 years based on periodic abdominal imaging. In June 2024, abdominal ultrasound revealed a liver nodule (2.9×1.8 cm), confirmed by MRI/CT as a suspicious hepatic lesion. Laparoscopic right-sided complex hepatectomy was performed, and histopathology with immunohistochemistry (DOG1+/CD117+) and molecular testing (KIT exon 11 deletion) confirmed metastatic GIST. Adjuvant imatinib (400 mg/day) was initiated, with no recurrence at 18-month follow-up. This case challenges the assumption that very low-risk GISTs confer negligible long-term risk, highlighting their potential for extremely delayed metastasis. It underscores the need for lifelong vigilance, even in low-risk patients, and emphasizes the critical roles of advanced imaging, immunohistochemistry, and molecular diagnostics in diagnosing late metastases. Individualized follow-up strategies and consideration of long-term surveillance for selected low-risk GISTs warrant reevaluation in the era of molecular-targeted therapy.