Raised alpha fetoprotein in cirrhotic liver with colorectal liver metastasis mimicking hepatocellular carcinoma: case report and review of literature

OBJECTIVES: To highlight the diagnostic challenges posed by alpha-fetoprotein (AFP)-producing colorectal adenocarcinoma presenting with liver metastases in a cirrhotic background, which may closely mimic hepatocellular carcinoma (HCC). CASE PRESENTATION: A 58-year-old man with chronic hepatitis B and cirrhosis, previously treated for rectosigmoid adenocarcinoma, presented with progressive abdominal fullness and markedly elevated AFP (315 KIU/L). Imaging showed multiple arterially enhancing hepatic lesions with washout, highly suggestive of HCC in a cirrhotic liver. Given the patient's history and risk factors, the initial diagnostic impression favored HCC. However, core biopsy of a liver lesion revealed poorly differentiated adenocarcinoma consistent with colorectal origin (CK20 positive, CK7 patchy positive, CDX2 negative). Surgical resection was contraindicated due to severe aortic stenosis and prior chemotherapy toxicity. The patient received palliative systemic therapy but developed hepatic decompensation and died of progressive disease. A literature review identified only a few reports of AFP-producing colorectal cancers, most presenting with advanced disease and poor outcomes, with cirrhotic background being exceptionally rare. CONCLUSIONS: AFP-producing colorectal adenocarcinoma with liver metastases can masquerade as HCC, particularly in patients with underlying liver disease. This case underscores the need for histological confirmation of atypical hepatic lesions to avoid misdiagnosis. Awareness of this rare entity and careful clinical reasoning are crucial to guide appropriate management and highlight pitfalls in diagnostic practice.