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- Mon Aug 16, 2010 4:24 am
To Whom It May Concern
My Father is suffering from Hepatitis C disease since 1995. He is doing really well and regularly undergo checkups which include various blood tests and Endoscopy. His recent test of AFP revealed levels of 298.4, due to which the doctor advised us to undergo a CT SCAN.
The CT SCAN detailed that a HEPATOMA of 2 x 2 cm in the segment VI of the liver was diagnosed.
Our Gastro doctor advised us to undergo a surgery called RFA. We got admitted to the hospital which later discharged us on the report of the Radiologist that the Tumor could not be seen on the Ultrasound machine due to which the surgery can't be performed.
We were later advised to travel to Singapore for the procedure.
Just recently before attempting surgery in Singapore, we visited a well known Cancer Hospital and were advised to undergo a few tests as well as a MRI Scan with Contrast.
The MRI Report has got me really confused as it showed that there were no signs of HEPATOMA but a HEMANGIOMA. Gastro Doctors at the Cancer hospital termed my father out of danger and sent us back home.
Later on consulting our Gastro Doctor in my hometown, the doctor was of the opinion that there is a Hepatoma as the AFP shows.
Kindly help as we are really confused.
| Dr.M.Aroon kamath
- Tue Aug 17, 2010 6:44 am
To begin with, let me try to explain the reason for some of the difficulties experienced in interpreting α-Fetoprotein (AFP) levels.
In adults, levels over 500 nanograms/milliliter of AFP are seen in the following situations:
- Hepatocellular carcinoma(HCC),
- Germ cell tumors of ovary and testis, and
- liver metastasis due to primary malignancies elsewhere.
Not every person with increased AFP test results can be presumed to have cancer or will develop liver cancer. AFP concentrations can be elevated, and fluctuate, in individuals with chronic hepatitis and cirrhosis. When the AFP concentrations of individuals with chronic liver disease change from ‘moderately’ elevated to ‘greatly’ elevated, their risk of developing liver cancer increases. AFP levels can increase temporarily in conditions causing liver injury and regeneration, and moderate elevations can be seen with a variety of conditions including some other cancers (gastric, pancreatic and biliary tract cancers).
The “high dose hook effect” is an artefact of tumor marker immunoassay kits, that results in reported value of a tumor marker to be falsely low, when the actual level is in fact, high. An undetected hook effect may cause delayed recognition of a tumor. A suspected hook effect can be confirmed by analyzing serial dilutions. If the hook effect is absent, then, reported quantities of tumor marker in a serial dilution should be proportional to the dilution.
Hereditary persistence of alpha-fetoprotein (HPAFP): an autosomal dominantly inherited condition, should be considered in both children and adults with unexplained and persistent elevation of AFP. This can be easily confirmed by analyzing AFP levels in the other members of the family.
Fibrolamellar variant of HCC: this is one variant which presents differently. It is more common in women and has a better prognosis. Less than 10% of patients with fibrolamellar carcinoma (FLC) have AFP levels > 200 ng/mL.
<10-20% of cases of FLC are associated with hepatitis B viral infection, and is rarely associated with hepatitis C viral infection.
The important of this condition (in the context of your father’s case) lies in the fact that it has some imaging features in common with hemangiomas and focal nodular hyperplasia and at times may be difficult to diagnose based on imaging.
A relatively new test, called AFP-L3% (one of the AFP variants), is sometimes used to compare the amount of total AFP to the amount of AFP-L3. The AFP-L3% test is not yet widely used in the U.S, but has gained wider acceptance in other countries such as Japan. The main use of this test is to help determine the risk of developing HCC, especially in those individuals with chronic liver disease. When total AFP and AFP-L3% are significantly elevated, then risk for such a person of having, or developing hepatocellular carcinoma in the next year or two is higher.
Thus, in your father’s case, several possibilities must be entertained, such as
- that he in fact has a hemangioma and has an elevated AFP level due to hepatitis C,
- that he in fact has a hemangioma and has a raised AFP level due HPAFP,
- that a firolamellar variant of HCC has been mistaken for a hemangioma (although it is more common in women and rarely associated with hepatitis C), or
- hypervascular metastasis from tumors such as neuroendocrine carcinoma, melanoma or renal cell carcinoma.
It is indeed an unfortunate situation to be in. What could be done next is hard to recommend.
One approach may be to have the AFP levels repeated after a few months. total AFP and AFP-L3% may be checked. MRI should also be repeated after a few months. RBC-tagged technetium-99m scintigraphy may be useful to confirm a hemangioma (sensitivity better for larger lesions).
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