Volume 69 - 2006 - Fasc.2 - Symposium
Management of small hepatocellular carcinoma
In the last years the incidence of hepatocellular carcinoma (HCC) is rising in cirrhotic patients worldwide. Due the impor- tance of early and definite diagnosis of HCC, any nodular lesion detected in patients with chronic liver disease should be con- sidered as suspicious for HCC.
The screening and surveillance programs in patients with liver diseases have increased the number of small HCC detected at an early stage, when the therapeutic options available are able to pro- vide benefit. The introduction of new imaging techniques has improved the accuracy of characterizing these nodules. According to the EASL recommendations, contrast-enhanced computed tomography (CT), contrast enhanced ultrasound (US) and magnetic resonance (MR) with different MR-contrast agents are currently used to characterize liver lesions. Imaging guided biopsy is recommended for small nodules or in lesions without typical fea- tures (arterial hypervascularization) in at least two imaging tech- niques. Frequently the differential diagnosis of small nodules is complicated by discordant vascularity and recent studies have also demonstrated the presence of small hypovascular HCC at perfu- sional US and helical CT. At present, different treatment options can be offered to patients with diagnosis of small HCC at an early stage ; percutaneous techniques, surgical resection and liver trans- plantation can provide benefit in properly selected patients.
This review describes some critical points regarding the detec- tion, diagnosis and therapeutic management of small nodules of HCC in cirrhotic patients. (Acta gastroenterol. belg., 2006, 69, 230- 235).
Management of small focal liver lesions in a cirrhotic liver : Discussion
Any cirrhotic patient is at risk for the development of hepatocellular carcinoma (HCC), but especially patients with viral hepatitis B and C, alcoholic liver disease, and hemochromatosis. More recently, it has become appar- ent that obese patients and patients with diabetes (NASH) have an increased risk for HCC. It is also clear that male patients have a 2 to 3 ?? higher risk for devel- oping HCC. Older patients (in Europe > 50 years) carry a higher risk as well, but this is probably only reflection of the duration of the disease. A slight elevation of a-FP remains a risk factor for HCC in the next years.
Epistemology of Evidence Based Medicine
Clinically relevant attitudes and guidelines issued by a rational evidence based medicine (EBM) approach integrate individual clinical expertise with the best available external clinical evidence from systematic research. However, many physicians, while consid- ering the ultraliberal world they are practising in and fearing that the primary goal of managed care in a market environment is reducing cost in order to make profit or decrease spending, remain suspicious of this kind of tentative protocol driven medicine when applied to medical and surgical practice. If physicians want to develop a health policy agenda that emphasises patient care issues above providers' or payers' interests, they should share a common semantics (i.e. understand the words and the numbers), enhance education programmes, improve continuing objective assessment of the way medicine and surgery are performed, face moral issues raised by innovation, and assume an increased leadership role in sound critical evaluation of non-validated new techniques. They should no longer consider EBM as a weapon turned against the medical profession, but rather see it as a tool that may provide some answers to chronically unresolved questions in the evolving art of Medicine and Surgery. (Acta gastroenterol. belg., 2006, 69, 238-246).
