Markedly elevated alpha-fetoprotein leading to the diagnosis of high-grade endometrial carcinoma during hepatocellular carcinoma surveillance

Background Alpha-fetoprotein (AFP) is widely used for hepatocellular carcinoma surveillance in patients with chronic liver disease. AFP is rarely elevated in endometrial cancer but may be a useful marker of aggressive histologic variants. Case A 70-year-old woman with autoimmune hepatitis–associated cirrhosis undergoing hepatocellular carcinoma (HCC) surveillance developed a rapid rise in AFP from 5 ng/mL to greater than 13,000 ng/mL. Liver imaging revealed no evidence of HCC. Positron-emission tomography (PET) demonstrated focal uptake in the uterus. Pelvic magnetic resonance imaging identified a deeply invasive endometrial mass. Hysteroscopic biopsy revealed high-grade endometrial carcinoma. The patient subsequently underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) with pathology demonstrating a stage IB high-grade endometrial carcinoma with extensive somatic-type glandular yolk sac / fetal-type differentiation and minor carcinosarcoma component (<5%). Serum AFP steadily and rapidly decreased after surgery. Conclusion This case highlights the importance of considering extrahepatic sources of AFP elevation and demonstrates an unusual presentation of endometrial carcinoma detected during HCC surveillance.