An unusual case of high alpha-fetoprotein level and liver masses.

A 60-year-old man was admitted to our institution because of abdominal ultrasound and CT scan evidence of several solid liver masses associated with significantly increased alpha-fetoprotein level (1800 ng/ml; normal value <15). Unintended weight loss, anorexia and weakness occurred in the previous 4 months. He denied alcohol abuse and liver diseases. His medical history was unremarkable except for duodenal ulcer diagnosed by barium enema 15 years before and treated with H-2 antagonists. Laboratory tests revealed increased serum levels of gamma-glutamyltransferase, alkaline phosphatase and carcinoembryonic antigen. The patient was negative for hepatitis B surface antigen and antibody, and hepatitis C antibody. Alpha-fetoprotein level was 17,000 ng/ml. Testicular neoplasms were excluded by means of clinical and ultrasound examination. Upper endoscopy showed an ulcer at the incisura angularis, covered with fibrin at the base and infiltrating deep into the mucosal layer. Histology showed cords of polygonal cells with large nuclei and prominent nucleoli resembling moderately differentiated hepatocellular carcinoma. Immunohistochemistry showed widespread intense positivity in the hepatoid areas. Hepatoid adenocarcinoma of the stomach with multiple liver metastases was diagnosed. Our clinical case has two intriguing aspects: the rarity of alpha-fetoprotein-producing gastric carcinoma (only 80 cases described so far) and the differential diagnosis with liver masses associated with a high level of alpha-fetoprotein. Indeed, the radiologic characteristics of hepatocarcinoma in the setting of non-cirrhotic livers have yet to be defined, and multiple liver metastases can be difficult to distinguish from multifocal HCC.