Elevated Alpha-Fetoprotein Level: A Dilemma

Abstract

To the Editor: This letter is in regard to the article, “Hepatoid esophageal carcinoma: a rare cause of elevated alpha fetoprotein” published in Journal of Gastrointestinal Cancer by Atiq et al. [1]. We share our experience in managing a patient who presented with esophageal cancer, liver metastasis, and elevated alpha-fetoprotein (AFP). A 51-year-old Caucasian male presented in the emergency room with increasing difficulty swallowing, pain in his right upper quadrant, and stating that he had lost 20 lbs over the last 2 months. He was also complaining of nausea, food sticking in his lower chest, and spitting up after eating. The patient’s history was positive for gastroesophageal reflux disease, smoking for 40 pack-years and alcoholism, which he quit 20 years ago, and a family history of esophageal cancer. He denies any constipation, diarrhea, melena, or bleeding from the rectum. His pertinent physical examination was negative for enlarged liver, ascites, or swollen testicles. A computed tomography (CT) was done in the emergency room, which showed at least two dozens of variably sized liver metastases. His complete blood count, comprehensive metabolic panel, and viral hepatitis panel were nonsignificant/negative. His serum AFP level was 24,430 ng/mL, and carcinoembryonic antigen was 7.5 ng/mL. CT scan of the chest was negative. His esophagogastroduodenoscopy was positive for a large fungating lower esophageal mass. Esophageal biopsy showed poorly differentiated adenocarcinoma with areas of signet ring cells (Fig. 1). Periodic acid-Schiff (PAS) and mucin stains were positive. The tumor cells were strongly positive with Ber-EP4 and p53 immunostains and weakly positive for Her2/NEU. CK5/6, AFP, HCG, and TTF-1 immunostains were negative. Rare tumor cells were positive for HepPar-1. There was a high proliferative fraction of greater than 75%, as assessed by Ki-67, indicative of probably biologically aggressive behavior. Due to elevated AFP, liver biopsy was done, which showed tumor to be positive with CK20, CDX2, MOC31, and Mucicarmine (Fig. 2). It was negative with stains including CK7, TTF-1, chromogranin, synaptophysis, and CK5/6.