A 58-year-old man with a history of chronic liver disease secondary to hepatitis C infection comes to the office due to progressive fatigue and abdominal discomfort. He has no other medical conditions, and a recent colonoscopy was normal. Physical examination shows ascites and jaundice. Ultrasonography of the abdomen reveals a solid mass within the liver parenchyma. Surgical resection of the liver lesion is performed. Microscopy reveals large cells with prominent nucleoli arranged in thickened plates as shown below. Which of the following serum markers would be most useful for monitoring this patient for disease recurrence?

Question

A 58-year-old man with a history of chronic liver disease secondary to hepatitis C infection comes to the office due to progressive fatigue and abdominal discomfort.  He has no other medical conditions, and a recent colonoscopy was normal.  Physical examination shows ascites and jaundice.  Ultrasonography of the abdomen reveals a solid mass within the liver parenchyma.  Surgical resection of the liver lesion is performed.  Microscopy reveals large cells with prominent nucleoli arranged in thickened plates as shown below.  Which of the following serum markers would be most useful for monitoring this patient for disease recurrence?

Quizplus · Accepted Answer

11ec160b_394e_320b_9249_6d868b6be220_MD0001_00 Hepatocellular carcinoma (HCC) occurs in up to 25% of patients with chronic hepatitis C virus (HCV). HCV increases hepatocyte turnover and generates local proinflammatory cytokines, which causes hepatocyte damage and fibrosis. Over time, damaged hepatocytes can proliferate into dysplastic nodules and undergo malignant transformation into HCC. Suspicion for HCC is often raised when patients with chronic HCV develop worsened underlying cirrhotic symptoms such as fatigue, ascites, variceal bleeding, abdominal discomfort, or jaundice. Abdominal imaging will show a liver mass; biopsy usually reveals abnormal thickened plates, solid sheets, or gland-like structures of malignant hepatocytes with a variable degree of cytologic atypia (eg, pleomorphism, high nuclear-to-cytoplasmic ratio). Serum alpha-fetoprotein (AFP) level is often used to aid diagnosis and screen for disease recurrence following treatment. AFP is a glycoprotein produced by the fetal liver and yolk sac during gestation. Although levels of AFP are often mildly or moderately elevated in patients with chronic liver disease, dramatic elevations or sudden rises in AFP should prompt an investigation for HCC. AFP levels do not correlate with the size or stage of the tumor and are not elevated in all cases of HCC. (Choice A) 5-Hydroxyindoleacetic acid is the major breakdown product of serotonin. Elevated urine levels are seen in carcinoid tumors and certain neuroendocrine tumors. (Choice C) CA 125 is a serum marker associated with ovarian cancer. It may also be elevated in other malignancies (eg, endometrial) and certain benign conditions (eg, endometriosis). (Choice D) CA 19-9 is primarily used as a marker for pancreatic cancer or other tumors of the biliary tract. (Choice E) Carcinoembryonic antigen is a serum marker that is primarily used to monitor response to treatment in patients with colorectal cancer. This patient's clinical features (ie, chronic hepatitis C, negative colonoscopy) are consistent with HCC rather than colorectal cancer. (Choice F) Human chorionic gonadotropin is elevated in choriocarcinoma and may also be elevated in germ cell tumors (eg, testicular). However, it is most commonly used as a marker for pregnancy. Educational objective: Alpha-fetoprotein is a serum tumor marker that is often moderately elevated in patients with chronic viral hepatitis. However, it can be strikingly elevated in those with hepatocellular carcinoma, and a sudden rise can be a sign that a patient with chronic liver disease is harboring hepatocellular carcinoma.

A 58-Year-Old Man with a History of Chronic Liver Disease