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JAMA Clinical Challenge
January 1/8, 2019

A Patient With an Elevated α-Fetoprotein Level and Liver Masses

Author Affiliations
  • 1University of Illinois at Chicago
  • 2Northwestern University, Chicago, Illinois
  • 3University of Chicago Medicine, Chicago, Illinois
JAMA. 2019;321(1):97-98. doi:10.1001/jama.2018.18435

A 55-year-old man with no significant medical history presented with several weeks of malaise and a 6.8-kg weight loss associated with poor appetite. He reported no fevers, night sweats, abdominal pain, emesis, and diarrhea. Physical examination revealed a thin habitus; no palmar erythema, spider angiomas, or gynecomastia were observed. Laboratory tests showed normal complete blood cell count and chemistry panel findings. Hepatic panel showed an elevated alkaline phosphatase level (209 U/L; upper limit of normal [ULN], 150 U/L [3.49 μkat/L; ULN, 2.5 μkat/L]), normal total bilirubin level (0.4 mg/dL [6.84 μmol/L]), elevated alanine aminotransferase level (41 U/L; ULN, 35 U/L [0.68 μkat/L; ULN, 0.58 μkat/L]), and normal aspartate aminotransferase level (27 U/L [0.45 μkat/L]). A single-phase computed tomography (CT) scan of the abdomen revealed multiple hypoattenuating masses with rim enhancement throughout the liver, intussusception of the small bowel, and normal liver contour with no signs of portal hypertension (Figure 1, left). α-Fetoprotein (AFP) level was elevated (1252 ng/mL; ULN, 9 ng/mL); levels of carbohydrate antigen 19-9 (<2 U/mL) and carcinoembryonic antigen (2.8 ng/mL) were normal. A triple-phase CT scan was obtained to further evaluate the small bowel, which revealed no small bowel abnormalities but instead demonstrated a 3.3 × 2.8-cm heterogeneously enhancing pancreatic tail mass not seen on the previous single-phase CT (Figure 1, right).