AFP > 9000 without demonstrable HCC

History A 51 y/o white male, who was diagnosed with hereditary hemochromatosis in 1996 There is a history of diabetes, loss of libido, and a bronze hyperpigmentation There was a history of excessive alcohol usage

History Initially, he was treated with weekly phlebotomy. In 3/01, routine screening test with serum AFP revealed a value of 600 ng/ml. Extensive work-up was performed, which included: 1) Abdominal MRI 2) PET scan 3) Testicular ultrasound.

History Repeat serum AFP levels obtained at three month intervals revealed: 1) 1,800 ng/ml 2) 9,030 ng/ml. Subsequently, he was referred for further evaluation.

Physical Examination HEENT: Sclera anicteric Neck: No JVD CVS: Regular rhythm, normal S1.S2, No murmurs appreciated ABD: Hepatomegaly of 18 cm, No shifting dullness EXT: No edema of lower extremities Skin: Bronze pigmentation

Laboratory data WBC 5.6/ul. Albumin 4.0 g/dl. Hb 15.5 g/dl. AST 64 U/L. Platelets 181/ul. ALT 47 U/L. Creatinine 1.1 g/dl. INR 1.22 MELD 5

Figure – 1 (CT scan of 10/11/01)

Chest CT scan and a bone scan were negative for metastatic lesions.

Figure – 2 (laparoscopy was performed in November 2001)

Figure –3 (Liver biopsy of 11/5/01)

Due to the elevated serum level of AFP and the abnormal appearing abdominal CT scan, the decision was made to list the patient for transplantation with a back-up

He underwent cadaveric liver transplantation on 6/11/02 Gross examination of the liver and abdomen did not reveal evidence of hepatocellular carcinoma

Figure – 4 (Explant 6/11/02).

Repeat serum AFP level in 7/02 was 3.3 ng/ml After nine month follow-up, the patient is doing well. Serial abdominal imaging with serial serum AFP levels have been negative for hepatocellular carcinoma