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Hepatocellular carcinoma (HCC) is a slowly growing tumor, whose natural history is not completely known. Since the
hepatocarcinogenetic process may evolve for years in a stepwise fashion from premalignant to overt HCC, detection of
early, better treatable tumors is made possible by surveillance of patients at risk. A 6-month interval surveillance with
ultrasound is considered cost-effective, generally leading to the identification of a single < 3 cm tumor in 50-70% of
the patients at risk. For greater than 2 cm tumors, demonstration of arterial hypervascularization of the node by sonovue
US, triphasic spiral CT or MRI is diagnostic for HCC. The diagnosis of a less than 2 cm in diameter tumor may be
more difficult due to the risk of false negative diagnoses with contrast imaging technique (50% of the cases) caused by
immature arterial vascularization of the small nodules. Prognosis largely depends on the evolutionary stage at which HCC
is detected, i.e. a size and number of HCC nodes, vascular invasiveness and degree of liver impairment. The multinodular
pattern of HCC, representing one third of all early cancers, heralds poor prognosis, especially for patients not fitting
the Milan criteria for liver transplantation. The best prognosis is for a single, less than 5 cm node in compensated
cirrhosis without vascular invasion, since this tumor is amenable to both liver transplantation and hepatic resection
which may confer long-term survival. Better survivals of cirrhotic patients with a recently identified tumors reflect the
application of accurate criteria for tumor staging and stringent criteria for curative treatments. However, ageing of the
patients, deterioration of liver function during surveillance, occurrence of multinodular tumors and limited access to liver
transplantation may hamper surveillance programs effectiveness.
