How would you approach a patient with newly diagnosed hepatocellular carcinoma with very high AFP (>100,000) but no clear radiographic evidence of metastatic disease?

This is a challenging situation. Oftentimes, these patients have significant vascular involvement of their tumor. AFP has been shown to correlate with survival and those with markedly elevated (>100,000) have a very poor prognosis (REACH, REACH2, Zhu et al., PMID 33531690).

If a patient has known HCC but confined to the liver, it is critical to carefully evaluate for metastatic disease by CT, MRI, or less commonly PET.

These patients are often recommended systemic therapy, assuming some measurab...

Elevated AFP levels are indicative of high tumor aggressivity, and microvascular invasion (MVI). (Fan et al., PMID 23321029) Post-treatment AFP response may serve as a non-invasive tool to monitor treatment efficacy and can predict the survival of HCC patients who were treated with liver transplant, hepatectomy, or RFA.

However, there have been several different definitions of post treatment response in the literature: while some studies defined post-treatment AFP response as >50%/≥50% reduction...