Management of Elevated AFP and DHEA

Initial Diagnostic Workup

The National Comprehensive Cancer Network recommends measuring serum β-hCG and LDH immediately alongside AFP, as germ cell tumors frequently produce multiple markers and β-hCG elevation occurs in 40% of advanced nonseminomatous germ cell tumors 1, 2
The National Comprehensive Cancer Network suggests obtaining liver function tests (ALT, AST, bilirubin, alkaline phosphatase) as hepatitis, cirrhosis, and hepatocellular carcinoma commonly elevate AFP 3, 4
The National Comprehensive Cancer Network recommends checking hepatitis panel (HBsAg, hepatitis B surface antibody, HBcAb, HCV antibodies) since chronic viral hepatitis is a major risk factor for HCC 3

The National Comprehensive Cancer Network states that cancer-associated AFP shows a consistent rising pattern, and serial measurements demonstrating progressive increases strongly suggest malignancy 1
The National Comprehensive Cancer Network notes that AFP >400 ng/mL is highly specific for malignancy but only occurs in 18% of HCC patients; 46% of HCC patients have normal AFP levels <20 ng/mL 3
The National Comprehensive Cancer Network indicates that pure seminoma never produces AFP, and significantly elevated AFP in a patient with "pure seminoma" histology indicates mixed germ cell tumor with nonseminomatous elements 2, 1

The National Comprehensive Cancer Network recommends excluding nonseminomatous germ cell tumor, as AFP elevation occurs in 10-20% of stage I and 40-60% of advanced disease 1
The National Comprehensive Cancer Network suggests excluding hepatocellular carcinoma, as elevated AFP with liver mass has high positive predictive value 3, 4

The National Comprehensive Cancer Network describes the classic HCC enhancement pattern as arterial hyperenhancement with washout on portal venous or delayed phases on multiphasic CT or MRI 3, 4

The National Comprehensive Cancer Network recommends not delaying orchiectomy for marker results in males with testicular mass 1
The National Comprehensive Cancer Network suggests measuring pre-orchiectomy markers for interpreting post-orchiectomy levels and staging 1
The National Comprehensive Cancer Network recommends discussing adrenal masses in a multidisciplinary expert meeting for all lesions except homogeneous masses with HU ≤10, and open adrenalectomy is recommended when malignancy is suspected 5

The National Comprehensive Cancer Network recommends measuring AFP, β-hCG, LDH before each treatment cycle if germ cell tumor diagnosed 1
The National Comprehensive Cancer Network suggests post-treatment surveillance every 2-4 months in the first year, every 3-4 months in the second year, annually for at least 10 years 1
The National Comprehensive Cancer Network indicates that postoperative corticosteroid supplementation is required after adrenalectomy until recovery of the hypothalamus-pituitary-adrenal axis 5