# Situation: A 55-year-old man with chronic hepatitis B and compensated cirrhosis is followed up at the Rural Health Unit (RHU). At today's visit, his findings are: Liver ultrasound 4 months ago: no focal lesion Alpha-fetoprotein: 6 ng/mL 4 months ago; 38 ng/mL today (normal below 10) General condition: feels well; weight stable What should the nurse do?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 55-year-old man with chronic hepatitis B and compensated cirrhosis is followed up at the Rural Health Unit (RHU).

At today's visit, his findings are:
Liver ultrasound 4 months ago: no focal lesion
Alpha-fetoprotein: 6 ng/mL 4 months ago; 38 ng/mL today (normal below 10)
General condition: feels well; weight stable
What should the nurse do?

## 보기

1. Refer him now for liver imaging because the marker is rising **✔ 정답**
2. Keep his next ultrasound on schedule in 2 months
3. Repeat the marker in 6 months to see if it is still high
4. Tell him the marker confirms liver cancer and refer for treatment

**정답: 1**

## 해설

People with cirrhosis have surveillance ultrasound, with or without alpha-fetoprotein, every 6 months. A rising alpha-fetoprotein is a warning sign of hepatocellular carcinoma that should not wait for the next routine scan. A tumor marker alone does not diagnose cancer, so the next step is prompt imaging rather than a diagnosis.

## 심화 해설

Clinical context

A 55-year-old man with chronic hepatitis B and compensated cirrhosis is in a surveillance program. His ultrasound 4 months ago showed no focal lesion, and his alpha-fetoprotein was 6 ng/mL at that time. Today the AFP has risen to 38 ng/mL, which is above the normal threshold of 10 ng/mL. He feels well and his weight is stable, so there are no clinical symptoms pointing to overt decompensation or advanced tumor burden.

Why the correct action is prompt imaging

In cirrhosis, the purpose of surveillance is to detect hepatocellular carcinoma at an early stage, when curative treatment is still possible. The standard interval is 6 months for ultrasound, with or without AFP [2]. However, a rising AFP during the surveillance interval is a red flag that should trigger immediate diagnostic imaging rather than waiting for the next scheduled scan. The change from 6 ng/mL to 38 ng/mL represents a meaningful upward trajectory, not a borderline fluctuation.

Tumor marker alone does not diagnose cancer

An elevated or rising AFP supports suspicion but is not confirmatory. The next step is contrast-enhanced liver imaging—such as multiphase CT or MRI—to look for a focal lesion that would establish the diagnosis. The nurse should not tell the patient that the marker confirms liver cancer, because AFP can rise for reasons other than HCC, and the diagnosis requires imaging findings. The role of the nurse at the RHU is to recognize the warning sign and facilitate timely referral.

Why the other options are not appropriate

Keeping the next ultrasound on schedule in 2 months would delay evaluation of a concerning change. Repeating AFP in 6 months would also postpone diagnosis and potentially allow tumor progression. Telling the patient that the marker confirms liver cancer is both inaccurate and harmful, because it jumps to a diagnosis without imaging and without the appropriate diagnostic workup.

What the evidence adds about AFP trajectories

Longitudinal AFP patterns before HCC diagnosis are not uniform. Some patients show a rising trajectory, while others do not . This means that a single normal AFP value does not rule out HCC, but a clearly rising AFP in a high-risk patient is a strong signal to investigate further. The patient’s pattern here—low normal AFP followed by a marked rise—fits the rising trajectory that warrants immediate imaging.

Surveillance and early detection

Biannual ultrasound with or without AFP is recommended for high-risk patients, including those with cirrhosis from chronic hepatitis B [2]. Surveillance is intended to identify early-stage tumors that can be treated with curative intent. When surveillance is performed regularly, patients are more likely to be diagnosed at an earlier stage and to receive curative therapy . However, surveillance only works if abnormal findings are acted on promptly. Key point! A rising AFP during surveillance is not a reason to repeat the marker later; it is a reason to obtain diagnostic imaging now.

Diagnostic accuracy considerations

Surveillance tests—including AFP and ultrasound—are evaluated for their ability to detect early-stage HCC in cirrhosis . No single biomarker is perfectly accurate, which is why imaging is needed to confirm or exclude a focal lesion. Watch out! Do not equate an elevated AFP with a cancer diagnosis. The correct nursing action is to refer for prompt liver imaging, not to diagnose or reassure based on the marker alone.References (research sources)

- [2]Hepatocellular carcinoma surveillance in Europe: challenges and lessons from global practice.Research articleQurashi M, Buti M, Lai-Hung Wong G, Qureshi H, Kudo M, Tanwandee T, Chen CJ, Abdelaziz AO, AbdAllah M, Howell J, Hebditch V, Singal AG, Jepsen P, Sharma R. (2026) · DOI: 10.1016/j.lanepe.2026.101852

## 임상 시나리오

Rising AFP in Cirrhosis: Act PromptlyDo not wait for the next routine scan
In cirrhosis, surveillance ultrasound with or without alpha-fetoprotein is done every 6 months. A rising AFP during the interval is a red flag for hepatocellular carcinoma and requires prompt imaging, not observation.

An AFP rise from 6 ng/mL to 38 ng/mL is a meaningful upward trajectory. The next step is contrast-enhanced liver imaging, such as multiphase CT or MRI, to look for a focal lesion.

CautionA tumor marker alone does not diagnose cancer. Do not tell the patient that AFP confirms liver cancer; the diagnosis requires imaging findings.

## 핵심 개념

- **alpha-fetoprotein** — A tumor marker that, when rising in cirrhosis, raises suspicion for hepatocellular carcinoma but does not confirm the diagnosis.
- **hepatocellular carcinoma** — Primary liver cancer for which patients with cirrhosis undergo surveillance every 6 months with ultrasound with or without AFP.
- **cirrhosis surveillance** — Regular screening for HCC in patients with cirrhosis, typically every 6 months, to detect early-stage disease.
- **compensated cirrhosis** — Cirrhosis without complications such as ascites, variceal bleeding, or encephalopathy; the patient may feel well.
- **multiphase CT or MRI** — Contrast-enhanced imaging used to diagnose HCC when a rising AFP or suspicious finding is present.

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