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Diagnosis and Treatment of Hepatocellular Carcinoma
  1. P JOHNSON  

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    Diagnosis and Treatment of Hepatocellular Carcinoma.Edited by Livraghi T, Makuuchi M, Buscarini L. (Pp 454; illustrated; price not given.) London: Greenwich Medical Media, 1997. ISBN 1-900151-308.

    Very early in my career I told a senior colleague that I was interested in trying to treat patients with hepatocellular carcinoma (HCC). “Oh, that is easy,” he replied, “Give them a bottle of whiskey and send them home!” In those days HCC was seldom even diagnosed during life let alone treated. Gut readers, many of whom will have been brought up on single authored textbooks of gastroenterology, may be dismayed to find that treatment and diagnosis of HCC can now fill an entire book of more than 400 pages. That this task requires more than 60 authors will compound their dismay. Indeed, it is probably the size of the book that tells the main story. There is no consensus on how best to diagnose, screen for, or treat this tumour, with the result that each diagnostic approach, and each of the numerous treatment options, is described individually by their own proponents.

    This is not to imply that HCC is not worthy of such detailed examination. In high incidence areas HCC management will occupy very considerable resources. For example, about a quarter of all beds in this author’s wards will be taken up by patients with HCC. In the West, the implication of the rate at which HCC develops among the increasing number of patients who are carriers of the hepatitis C virus (HCV) is only just sinking in. Decisions on whether or not to screen them all, and then what to do when the tumour is found, will have major resource implications for gastroenterologists and hepatologists. As noted above, gastroenterologists in the past have sought refuge in (justified) therapeutic nihilism. Now, however, it is clear that long term survival following resection can be achieved and long term results following liver transplantation are very impressive.

    Within this volume the reader will be able to find information on all aspects of the diagnosis and management of HCC. The book is comprised of 32 chapters arranged in five sections: basic aspects, clinical aspects, diagnosis, treatment and fibrolamellar HCC with an international, though predominantly Italian and Japanese authorship. The individual chapters are perhaps best read as a series of good reviews on the various topics rather than constituting a coherent text book. This is because in several instances—for example, in the chapter on chemoembolisation, the authors tend to recount their own, single institution experience without reference to randomised controlled trials when these are done elsewhere.

    There are some areas where tighter editing would have helped clarity and accuracy. For example, under the heading of “Besides therapies” we are told that “non-randomized trials (of tamoxifen) supplied contradictory results regarding the value of its use ...” But of the five references supplied to support this contention, three were, in fact, clearly randomised and at least two of these suggested that tamoxifen did increase survival.

    Gut readers will find a good analysis (Cottone and D’Antoni), but no easy answers, as to how often and by what means to screen their high risk patients. Whether screening will help the individual or the community remains unclear. Italian authors are pessimistic, Japanese more positive. Perhaps they are both correct in relation to the tumour as seen within their own countries. The authors’ conclusion that, “The lack of evidence that early detection translates into improved clinical outcome strengthens the concept that the primary goal in the battle against HCC should focus on the prevention of cirrhosis by vaccinating against hepatitis, by minimizing the risk of hepatitis C and decreasing the risk of alcoholism”, is probably correct but likely to be of little solace to current carriers of hepatitis B or C.

    With regard to an overall approach to therapy, individual units will find a great deal of information in this well produced and lavishly illustrated book. They will, however, have to sift the data very carefully to develop approaches suitable for their own institutions. The editors conclude, under the heading “Therapeutic guidelines”: “To sum up, the possible combinations (of treatments) are many and it is not easy to lay down strict rules for the management of patients whose HCC is not advanced ... the most opportune treatment has to be decided in the light of each individual patient’s characteristics, evaluating every variable, and the expertise available at each centre and the resources of the national health services”.

    It seems that HCC is not a single entity but rather several different types. Each may need its own approach, both in relation to different geographical areas of the world and to different aetiologies. This makes the task of editors wishing to give an overall view of HCC extremely difficult, but Livraghi, Makuuchi and Buscarini have, by and large, succeeded.

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