A 70-year-old woman with 10 years of markedly elevated alpha-fetoprotein measurements.

The incidence of hepatocellular carcinoma (HCC) is growing dramatically in the Western world. It is currently the fifth most common cancer worldwide, and the third most common cause of death from cancer. Studies clearly demonstrate that surveillance programs can increase the proportion of HCCs that are detected at an early stage, and improved therapeutic modalities, applied to early stage HCCs, improve cure rates and duration of survival in noncurable cases. What constitutes appropriate surveillance remains an unresolved issue. Measurements of serum alpha-fetoprotein and imaging, especially with ultrasound, are the most widely used elements in surveillance programs. The authors present a 70-year-old woman with chronic hepatitis C in whom elevated alpha-fetoprotein levels were first detected 10 years ago, reaching levels of >700 ng/mL. Frequent imaging studies by ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) have found only one lesion, which does not have radiographic features strongly suggestive of HCC. This lesion has been seen only intermittently, and when seen has shown no growth over an 8-year period. Segmental ablation did not alter the serum alpha-fetoprotein levels. The authors believe the patient does not have HCC. Alpha-fetoprotein as a screening test for HCC is known to lead to false-negative results. This case, and a review of the literature, emphasize that it is also subject to false-positives. In addition, interpretation of borderline imaging studies such as occurred in this case often causes controversy among the physicians involved. This case illustrates yet again the deficiencies of alpha-fetoprotein as a surveillance tool for HCC. It also highlights the need for more emphasis on developing new and improved tools for HCC surveillance if improved therapeutic modalities are to be exploited to the fullest.