Multifactorial Contributors to Diagnostic Delay in a High-Risk Patient with Hepatocellular Carcinoma: A Case Report with Clinical Lessons.

BACKGROUND: Patients at high risk for primary liver cancer (PLC) are recommended to undergo PLC surveillance at least every six months. Alpha-fetoprotein (AFP) is a commonly used biomarker; however, approximately 15-30% of PLC cases remain AFP-negative throughout their course. Therefore, surveillance in high-risk populations should be based on liver imaging. Any newly detected or progressive lesion should be further characterized by contrast-enhanced computed tomography (CT), contrast-enhanced magnetic resonance imaging (MRI), or contrast-enhanced ultrasound, following guideline-based classification and follow-up recommendations.

CASE PRESENTATION: This case details a 45-year-old Chinese male with hepatitis B virus (HBV) infection, type 2 diabetes mellitus, and a family history of PLC. As a high-risk individual for PLC, he did not undergo regular PLC surveillance for three years. During opportunistic encounters for acute myocardial infarction and abdominal pain, the attending specialists failed to appreciate the progression of liver imaging findings. In addition, the COVID-19 pandemic may have further aggravated pre-existing difficulties with follow-up and access to care, contributing to a delayed diagnosis of PLC.

CONCLUSION: This case illustrates how a combination of physician-related, patient-related, and social-environmental factors contributed to surveillance failure and diagnostic delay in a high-risk patient with PLC. It reflects on why guideline-recommended interventions were not implemented at each healthcare encounter, how to correctly interpret AFP, and how to improve adherence to surveillance among high-risk populations for PLC. The insights from this case aim to inform systematic improvements in PLC monitoring for patients with chronic HBV infection.