A Case Report on Alpha-Fetoprotein-Positive Colorectal Cancer

Alpha-fetoprotein (AFP) is commonly produced by hepatocellular carcinoma and yolk sac tumors, while AFP in colorectal cancer (CRC) is a rare association. We report a case of a patient with primary AFP-producing CRC, which was successfully treated with surgery and adjuvant chemotherapy. This case highlighted the importance of recognizing a case of AFP-producing CRC.  This case report discussed a 59-year-old male who had a history of hepatitis B infection, with two months of intermittent fresh per rectal bleeding. Given his previous burden of hepatitis B infection, and the serum AFP level on admission was high (212.6 ng/mL), this raised suspicions of possible hepatocellular carcinoma. Therefore, a triphasic computed tomography of the liver was performed, which revealed an incidental hepatic flexure lesion with no involvement of the liver. Subsequent colonoscopy revealed a large friable tumor obstructing the whole lumen of the proximal transverse colon. He then underwent an emergency extended right hemicolectomy. Histopathological examination showed a Duke C mucinous adenocarcinoma (T3N2b), with a satisfactory resected margin. Immunohistochemical analysis indicated that the tumor exhibited positivity for MLH1/MSH2/MSH6/PMS2 (+++) and human epidermal growth factor receptor 2 (HER2), and notably, it also stained positive for AFP. The postoperative period was uneventful, and serum AFP level eventually normalized. The patient completed eight cycles (four months) of adjuvant chemotherapy with capecitabine and oxaliplatin (CAPOX) regimen. A follow-up CT scan and colonoscopy showed no evidence of local or distant recurrence after 12 months of surveillance. AFP may be useful for not only hepatocellular carcinoma but also CRC. In particular, this case report has fully demonstrated the unexpected incidence and emphasized the importance of early recognition and appropriate treatment to prevent potential oversights in the diagnosis of CRC.

A Practical Tool for Risk Management in Clinical Laboratories

Risk management constitutes an essential component of the Quality Management System (QMS) of medical laboratories. The international medical laboratory standard for quality and competence, International Standards Organization (ISO) 15189, in its 2012 version, specified risk management for the first time. Since then, there has been much focus on this subject. We authors aimed to develop a practical tool for risk management in a clinical laboratory that contains five major cyclical steps: risk identification, quantification, prioritization, mitigation, and surveillance. The method for risk identification was based on a questionnaire that was formulated by evaluating five major components of laboratory processes, namely i) Specimen, ii) Test system, iii) Reagent, iv) Environment, and v) Testing. All risks that would be identified using the questionnaire can be quantified by calculating the risk priority number (RPN) using the tool, failure modes, and effects analysis (FMEA). Based on the calculated RPN, identified risks then shall be prioritized and mitigated. Based on our collective laboratory management experience, we authors also enlisted and scheduled a few process-specific quality assurances (QA) activities. The listed QA activities intend to monitor new risk emergence and re-emergence of those previously mitigated ones. We authors believe that templates of risk identification, risk quantification, and risk surveillance presented in this article will serve as ready references for supervisors of clinical laboratories.