Chronic hepatitis B virus carriers A fetoprotein suddenly increased, not liver cancer, but... Case learning

Alpha-fetoprotein (AFP) is associated with primary liver cancer, gastric tumors, lung cancer, etc.
, and can occur in a variety of clinical situations
.
This article reports a case of a sudden increase in AFP in a chronic hepatitis B virus carrier, and his cause is relatively rare.
.
.

Case Data The
patient, a 31-year-old male with a history of diabetes mellitus and viral hepatitis B, was admitted to hospital
with epigastric pain, steatorrhea, and elevated AFP.
There is a history of excessive drinking for more than a decade
.
2 years ago, due to bloating in another hospital, CT showed pancreatic enlargement, followed by endoscopic ultrasound-guided fine needle puncture (EUS-FNA), diagnosed with chronic pancreatitis
.
Since then, although the patient's symptoms have been relieved after drug therapy (including pancreatic enzyme preparations and prokinetic agents), he has lost 25 kg
.

Physical examination: epigastric tenderness
.
Laboratory abnormal indicators: white blood cell count (11.
01 × 109/L), erythrocyte sedimentation rate (120 mm/h), alkaline phosphatase (163 U/L; Reference values, 45-125 U/L), γ-glutamine transpeptidase (223 U/L; Reference values, 10-60 U/L), CEA (9.
32 ng/mL; Reference values, 0-5.
00 ng/mL), AFP (3473 ng/mL; Reference value, 0-20 ng/mL).

CA19-9（21.
70 U/mL； Reference values, 0-34.
00 U/mL) and IgG4 (0.
263 g/L, reference value, 0.
030-2.
100 g/L) are normal
.

Plain abdominal scanning/contrast CT shows: diffuse pancreatic enlargement, low density, focal crude calcification, capsule signs (Figure 1a
).
PET shows an increase in the uptake of 18F-FDP at the head and hook (Figure 1b
).

Ultrasound endoscopy in Figure 1
shows a low echo mass at the head of the pancreas, which is punctured with a fine needle (Figure 2a-d
).

Figure 2
How should it be diagnosed?
Analytical diagnosis
is based on the patient's symptoms and medical history (male, alcohol consumption, viral hepatitis, and significant elevation of AFP), with an initial focus on screening for hepatocellular carcinoma (HCC
).
However, CT and PET show no significant abnormalities in the liver, but suggest suspected pancreatic tumors and chronic pancreatitis (Figures 1a and b
).
Although the patient's IgG4 level is normal, a differential diagnosis
of autoimmune pancreatitis is considered based on the "dachshund-like" appearance and capsule signs of the pancreas shown by CT.

Further evaluation
was carried out by EUS-FNA.
Ultrasonography shows a 4.
5 × 4.
2 cm low echo mass at the pancreatic head, with unclear boundaries, uneven internal echo, and diffuse scattered calcification (Figure 2a
).
Cytology shows that tumor cells are relatively consistent in morphology and size, but moderately enlarged, and the nucleus is "pretzel-shaped", which is characteristic of pancreatic neuroendocrine tumors (Figure 2b
).
Histopathological results show glandular inhomogeneity and irregular enlargement of the nucleus (Figure 2c
).
Immunohistochemical staining (IHS) found abnormal cells to be positive for CK7, Hep-par 1 (Figure 2d), and negative for chromogranin A, synapsin, or CD56
.

After multidisciplinary discussion, the final diagnosis was determined by histology and IHS as pancreatic ductal adenocarcinoma (PDAC
).

Discussion AFP
is often used as a biomarker for HCC, yolk cysts, gonadal tumors, and certain types of gastric cancer
.
There have also been clinical reports of elevated AFP due to pancreatic tumors, usually hepatoid and acinar cell carcinoma
.
Elevated AFP caused by PDAC is rare
.
One possible explanation for pancreatic cancer causing an increase in AFP is the activation of liver genes within the pancreas during carcinogenesis
.
Histopathology and immunohistochemistry may be critical
for a definitive diagnosis.
Post-treatment AFP levels can be used as an indicator
to monitor treatment response and relapse.


References: 1.
CHANG Binxia, XIN Shaojie.
Research Progress on A-fetoprotein and Its Clinical Application[J].
World Journal of Chinese Digestion, 2010,18(06):576-580.
2.
Lin BS, Su P, Li Z.
Gastrointestinal: Pitfalls of an abruptly elevated alpha-fetoprotein in a chronic hepatitis B carrier.
J Gastroenterol Hepatol.
2022 Sep 20.
doi: 10.
1111/jgh.
15989.