Correspondence

Alpha-Fetoprotein in Early Hepatocellular Carcinoma

Establishing whether the patient has developed HCC in the setting of cirrhosis is essential, because it has a great impact on determining whether resection can be performed. Liver function should be evaluated by clinical examination, laboratory testing, and cross-sectional imaging.14 Measurement of the transjugular hepatic venous pressure gradient, to estimate the degree of portal hypertension, can aid in the choice of treatment modality because it may provide a contraindication to resection surgery.15

The calls for abandoning the monitoring of alpha-fetoprotein levels may be premature,32 especially given the already low rates of surveillance of hepatocellular carcinoma in community practice. In North American studies, the combined measurement of alpha-fetoprotein and other biomarkers, such as des-gamma-carboxyprothrombin or lectin-bound alpha-fetoprotein, was shown to provide only a limited additional benefit as compared with the measurement of alpha-fetoprotein alone and thus cannot be recommended.30,33,34 Computed tomography (CT) and magnetic resonance imaging (MRI) are not generally recommended for hepatocellular carcinoma surveillance (as distinct from diagnosis and staging); their sensitivity, specificity, and positive and negative predictive values for this purpose are unknown, and their use is associated with high cost as well as possible harm (e.g., radiation, allergic reaction to contrast medium, nephrotoxicity with CT, and nephrogenic fibrosing dermopathy from the use of gadolinium with MRI in patients with renal insufficiency).