Invasion of the cardiovascular system in childhood malignant hepatic tumors

PURPOSE

To evaluate the utility of transthoracic echocardiography for the early detection of subclinical cardiac metastasis in childhood malignant hepatic tumors.

PATIENTS AND METHODS

From April 1995 until February 2000, 12 consecutive children with malignant hepatic tumor were enrolled in this study. To determine the degree of invasion of the cardiovascular system, transthoracic echocardiography was performed for all patients at the time of initial diagnosis and also at subsequent follow-up investigations every 6 months until the patient was deemed to be disease-free, or until the patient died.

RESULTS

There were seven patients diagnosed with hepatocellular carcinoma (six boys, one girl) and five patients diagnosed with hepatoblastoma (three boys, two girls). Most tumors were multiple (7/12) and involved both lobes of the liver (7/12). Inferior vena cava thrombi were observed in four patients. Three patients exhibited intracardiac tumor metastasis, and lung metastasis was noted in four patients. Lung metastasis was significantly more common in children with cardiovascular involvement (4/4) compared with those without (0/8). The ages of the patient, levels of alpha-fetoprotein, and types of tumor did not differ between the two groups.

CONCLUSIONS

Echocardiography may be useful for the early detection of cardiovascular metastases of malignant hepatic tumors in children; this was the case for 33% of the patients in this series. The frequent occurrence of cardiovascular tumor involvement and the high degree of association between lung metastasis and cardiovascular involvement observed in this small series suggest that transthoracic echocardiography should be studied prospectively in a large series of children with hepatic tumors.

Pretreatment prognostic factors and treatment results in children with hepatoblastoma: a report from the German Cooperative Pediatric Liver Tumor Study HB 94

BACKGROUND

In the past 20 years, a dramatic improvement in the prognosis of patients with hepatoblastoma (HB) has been achieved by combining surgery with chemotherapy in several national and international trials. A worldwide, unsolved problem remains the treatment of patients with advanced or metastatic HB.

METHODS

The German Cooperative Pediatric Liver Tumor Study HB 94 was a prospective, multicenter, single-arm study. The study ran from January 1994 to December 1998. The protocol assessed the efficiency of chemotherapy consisting of cisplatin, ifosfamide, and doxorubicin (CDDP/IFO/DOXO) and/or etoposide and carboplatin (VP16/CARBO). The prognostic significance of the surgical strategy, pretreatment factors, and tumor characteristics for disease free survival (DFS) were analyzed.

RESULTS

Sixty-nine children with HB were treated in the HB 94 study. The median follow-up of survivors was 58 months (range, 32-93 months). Fifty-three of 69 patients (77%) remained alive, and 16 of 69 patients (23%) died. Long-term DFS was as follows: 26 of 27 patients had Stage I HB, 3 of 3 patients had Stage II HB, 19 of 25 patients had Stage III HB, and 5 of 14 patients had Stage IV. A complete resection of the primary tumor was achieved in 54 of 63 patients (86%). Six children (8%) had no surgical treatment. Twenty-two tumors were resected primarily, and 41 children underwent surgery after initial chemotherapy. Two children underwent liver transplantation. There was no perioperative death. Forty-eight children received primary chemotherapy with CDDP/IFO/DOXO. Forty-one of 48 children achieved partial remission after CDDP/IFO/DOXO. Eighteen children with advanced or recurrent HB underwent VP16/CARBO chemotherapy, with a response achieved by 12 children. The relevant pretreatment prognostic factors were growth pattern of the liver tumor (P = 0.0135), vascular tumor invasion (P = 0.0039), occurrence of distant metastases (P = 0.0001), initial alpha-fetoprotein level (P = 0.0034), and surgical radicality (P < 0.0001).

CONCLUSIONS

The current results underline the necessity of preoperative chemotherapy in all children with HB. Complete tumor resection is one of the main prognostic factors.

Hepatoblastoma in a child of extremely low birth weight

Hepatoblastoma is a rare childhood embryonal malignancy. Recent reports suggested a linkage between premature birth and later development of hepatoblastoma. In August 2000, we encountered a 24-month-old boy with extremely low birth weight who developed hepatoblastoma with an unfavorable histology. His birth weight was only 584 g. Radiological evaluation of the liver revealed a hypoattenuated tumor occupying the left lobe. His initial serum alpha-fetoprotein level was 4032 ng/mL. The patient underwent successful left hepatectomy. The histological examination showed that the tumor, weighing 210 g, was a hepatoblastoma of epithelial type in two different patterns. One was composed purely of fetal type of tumor cells, whereas another was made up of embryonal type of cells in a macrotrabecular pattern. Four courses of adjuvant chemotherapy were given after surgery and were well tolerated. The patient remained in clinical remission 18 months after diagnosis.

Preoperative chemoembolization for unresectable hepatoblastoma

Complete surgical resection offers the only chance for cure in patients with hepatoblastoma (HB). Patients with unresectable lesions are given preoperative chemotherapy in an attempt to create a resectable lesion. We present a case of an 11-month-old with an unresectable stage III HB unresponsive to systemic chemotherapy. Transfemoral hepatic-artery chemoembolization resulted in a surgically resectable tumor. The patient underwent a right trisegmentectomy with complete resection of the tumor and remains tumor-free 24 months postoperatively. Salvage chemoembolization can be an effective preoperative modality to convert an unresectable tumor into a resectable one.

Glutathione-S-transferase-pi expression regulates sensitivity to glutathione-doxorubicin conjugate

We have reported that glutathione-doxorubicin conjugate (GSH-DXR) exhibited potent cytotoxicity against tumor cells and inhibited glutathione-S-transferase (GST) enzyme activity. In order to determine whether or not the expression of GST-pi lowered the cytotoxicity of GSH-DXR, cytocidal activity of the conjugate was examined using tumor cells in which the level of GST-pi expression was regulated by transfecting GST-pi cDNA in the correct or reverse direction and comparing with that of DXR. Enhancement of GST-pi expression by transfecting GST-pi sense cDNA into human hepatoblastoma HepG2 cells in which GST-pi expression was extremely low caused an increase in GST activity from 0.26 to 55.0 nmol/mg/min and a marked reduction in transfectant sensitivity to GSH-DXR to 1/120 (0.15-18 nM IC50) although the sensitivity to DXR was slightly decreased to 1/2.6 (380-990 nM IC50). By contrast, a high GST-pi-expressing human colon cancer cell line, HT29, showed a decrease in GST enzyme activity from 72.0 to 45.9 nmol/mg/min after transfecting GST-pi antisense cDNA and a marked improvement in transfectant sensitivity to GSH-DXR was observed (28-2.9 nM IC50) compared with the transfectant sensitivity to DXR (1020-320 nM IC50). Additionally, the expression of GST-pi in HepG2 cells caused a decrease in GSH-DXR-induced activation of caspase-3, which was an apoptotic marker, whereas the suppression of GST-pi in HT29 cells showed an increase in caspase-3 activation. These results suggested that the cytocidal efficacy of GSH-DXR, but not that of DXR, was controlled by the level of GST-pi expression in the cells.

Liver-targeted gene transfer into a human hepatoblastoma cell line and in vivo by sterylglucoside-containing cationic liposomes

We investigated the transfection efficiency of beta-sitosterol beta-D-glucoside (Sit-G)-containing liposome/DNA complex (Sit-G-liposome/DNA complex) for liver targeting. The Sit-G-liposome/DNA complex was composed of Tfx-20 reagent (Tfx), ie synthetic cationic lipid [N,N,N',N'-tetramethyl-N,N'-bis(2-hydroxyethyl)-2,3-di(oleoyloxy)-1,4-butanediammonium iodide] with L-dioleoylphosphatidylethanolamine (DOPE), 3 beta[N-(N',N'-dimethylaminoethane)-carbamoyl]cholesterol (DC-Chol) and Sit-G with plasmid DNA. The in vitro studies were performed in HepG2 cells in serum-containing medium and the in vivo studies were carried out in the mice following intravenous injection. The Sit-G-liposome produced a Sit-G-liposome/DNA complex of relatively small size (100--250 nm). Transfection efficiency of the luciferase marker gene by Sit-G-liposome/DNA complex was increased in the presence of 10% serum in vitro, and was selectively high in the mouse liver reaching expression values up to an average of 14.9 pg luciferase/mg tissue protein, compared with Tfx/DNA complex, which showed approximately three-fold higher gene expression than Sit-G-liposome/DNA complex in vitro. High in vitro transfection efficiency by Sit-G-liposome/DNA complex seemed to be possible even with large lipid precipitates, whereas high in vivo activity seemed to be related to small and dispersed complexes. The interaction of liposome/DNA complexes with serum may be a key point to predict the in vivo efficiency of a liposome vector.

Successfully resected hepatoblastoma in a young adult with chronic hepatitis B: report of a case

Hepatoblastoma usually occurs in children, but a few cases have also been reported in adults. We report the unusual case of hepatoblastoma in an 18-year-old adult with chronic hepatitis B. He visited a local hospital with right upper abdominal pain. Abdominal ultrasound showed a large mass in the right lobe of his liver. He was referred to our hospital and admitted for further examination. At admission, liver function tests gave slightly elevated results (aspartate aminotransferase (AST) 103 IU/l, alanine aminotransferase (ALT) 63 IU/l). A test for hepatitis virus revealed that he was a hepatitis B surface antigen (HBsAg) carrier and had experienced seroconversion. His alpha-fetoprotein (AFP) was elevated to 1 548 000 IU/ml. Abdominal ultrasound showed a 109 x 96 x 80-mm mass with mosaic pattern in the right lobe of the liver and right portal vein thrombus. Abdominal computed tomography (CT) demonstrated a large low-density mass occupying the right lobe, with some high-density parts that showed calcification. From these results, we diagnosed hepatoblastoma in a young adult. A right lobectomy was performed. Pathological examination showed a highly differentiated hepatoblastoma. Adjuvant chemotherapy was performed with cisplatin and pirarubicin. The patient has been well and free of recurrence for 12 months, and his AFP level remains almost normal.

Surgical resection and chemotherapy improve survival rate for patients with hepatoblastoma

BACKGROUND

The authors reviewed retrospectively their experience in 30 children with hepatoblastoma (HB). Despite an increased trend in the incidence of HB during the last 2 decades, an encouraging cure rate has been achieved with complete resection of the tumor and chemotherapy before or after surgery with cisplatin plus doxorubicin (Adriamycin) or cisplatin plus vincristine plus 5-Fluorouracil.

RESULTS

There were 10 female and 20 male patients. For the period from 1963 to 1980 there were 8 patients, and for the period from 1981 to 1998 there were 22 patients. Their mean age at surgery was 16 months (range, 3.5 months to 5.5 years). Tumors were localized to the right lobe in 10 (42%), to the left lobe in 7 (29%), and in both lobes in 7 (29%) of the resected patients. Tumors were greater than 10 cm in size in 16 (67%) of these patients. Twenty-four patients (80%), underwent liver resection before or after chemotherapy. One patient (3%) with an unresectable tumor received chemotherapy and a liver transplant. In 5 patients (17%) the hepatic involvement was too extensive for resection. The types of resection performed were right lobectomy in 7, left lobectomy in 6, right trisegmentectomy in 8, left trisegmentectomy in 2, and middle hepatectomy in 1. The overall survival rate for 35 years of the study was 60% (18 of 30). With the association of surgery and chemotherapy (1981 through 1998) survival rate is 82% (14 of 17). Overall median follow-up in our study is 8 years (range, 2.5 to 24 years).

CONCLUSIONS

There has been a dramatic improvement in the results of treatment of hepatoblastoma. Formerly, only 25% to 30% of patients were cured, whereas today, with combination of chemotherapy and surgery, 75% to 80% may be cured.

Childhood cancers: hepatoblastoma

Hepatoblastoma is the most common primary liver tumor in children, accounting for just over 1% of pediatric cancers. The etiology is unknown, but it has been associated with Beckwith-Weidemann syndrome, familial adenomatosis polypi, and low birth weight. The primary treatment is surgical resection, however, chemotherapy plays an important role by increasing the number of tumors that are resectable. The prognosis for patients with resectable tumors is fairly good, however, the outcome for those with nonresectable or recurrent disease is poor.

Hepatic tumors in children

Although they account for only 1% to 4% of solid tumors in children, hepatic tumors and pseudotumors offer a diagnostic challenge to the clinician seeing only an occasional case. Metastatic lesions such as neuroblastoma, Wilms' tumor, and lymphoma are the most common neoplasm seen in the liver, but 10 distinct primary tumors and pseudotumors of the liver occur with some regularity, and a few others may be seen rarely, including leiomyosarcoma, rhabdoid tumor, and endodermal sinus tumor. Five of these neoplasms--hepatoblastoma, infantile hemangio-endothelioma, mesenchymal hamartoma, undifferentiated embryonal sarcoma, and embryonal rhabdomyosarcoma of the biliary tree--occur only in children and are the major focus of the article.

Therapy associated changes in childhood tumors

Contemporary treatment regimens for the common solid tumors of childhood have led to increased numbers of post-treatment pathologic specimens from survivors. Current therapeutic strategies for childhood cancers in North America require an accurate pathologic diagnosis and stratify patients based on combinations of clinical, biological, and pathologic features. In several tumor systems, the pathologic response to therapy also modifies the treatment regimen. Accurate pathologic interpretation of such specimens is critical in providing useful prognostic information for therapeutic decisions. Standardized handling of post-therapy pathologic specimens, appropriate use of molecular and genetic studies, consideration of the differential diagnoses, and assessment of the potential biologic significance of therapy-induced pathologic changes are, therefore, critical for patient management and determination of treatment protocols.

Pulmonary lipiodol embolism during transcatheter arterial chemoembolization for hepatoblastoma under general anaesthesia

We present a case of pulmonary embolism that occurred during the injection of lipiodol during transcatheter arterial chemoembolization under general anaesthesia. A 7-year-old child suffering from a large hepatoblastoma was admitted for arterial chemoembolization and carcinostatic administration. Pulmonary embolism due to lipiodol during arterial chemoembolization was evident by a sudden fall in oxyhaemoglobin saturation from 100 to 90%. This was associated with a spread of lipiodol into both lungs, particularly the middle lung zones and detected by chest fluoroscopy. Arterial blood gases returned to normal values 1 day later but pulmonary infiltration persisted for 7 days before final clearance. Pulmonary embolism caused by lipiodol during arterial chemoembolization is infrequent, but such a complication could prove fatal. Understanding the risk of pulmonary embolism in patients receiving lipiodol, during and after arterial chemoembolization, and late onset pulmonary injury is important and a close follow-up for several days after arterial chemoembolization is advisable.

Intrahepatic chemoembolization in unresectable pediatric liver malignancies

OBJECTIVE

To determine the effectiveness of a new multidisciplinary approach using neoadjuvant intrahepatic chemoembolization (IHCE) and liver transplant (OLTx) in patients with unresectable hepatic tumors who have failed systemic chemotherapy.

MATERIALS AND METHODS

From November 1989 to April 1998, 14 children (2-15 years old) were treated with 50 courses of intra-arterial chemotherapy. Baseline and post-treatment contrast-enhanced CT and alpha-fetoprotein levels were performed. Seven had hepatoblastoma, and 7 had hepatocellular carcinoma (1 fibrolamellar variant). All patients had subselective hepatic angiography and infusion of cisplatin and/or adriamycin (36 courses were followed by gelfoam embolization). The procedure was repeated every 3-4 weeks based on hepatic function and patency of the hepatic artery.

RESULTS

Six of 14 children received orthotopic liver transplants (31 courses of IHC). Pretransplant, 3 of 6 showed a significant decrease in alpha-fetoprotein, while only 1 demonstrated a significant further reduction in tumor size). Three of 6 patients are disease free at this time. Three of 6 patients died of metastatic tumor 6, 38, and 58 months, respectively post-transplant. One of 14 is currently undergoing treatment, has demonstrated a positive response, and is awaiting OLTx. Three of 14 withdrew from the program and died. Four of 14 patients developed an increase in tumor size, developed metastatic disease, and were not transplant candidates. Two hepatic arteries thrombosed, and one child had a small sealed-off gastric ulcer as complications of intrahepatic chemoembolization.

CONCLUSION

The results of intrahepatic chemoembolization are promising and suggest that some children who do not respond to systemic therapy can be eventually cured by a combination of intrahepatic chemoembolization orthotopic liver transplant. Alpha-fetoprotein and cross-sectional imaging appear to be complementary in evaluating tumor response. IHCE does not appear to convert an anatomically unresectable lesion to a candidate for partial hepatectomy.

Liver tumors

Liver tumors in children are rare, potentially complex, and encompass a broad spectrum of disease processes. Any age group may be affected, including the fetus. Most present with abdominal distension and/or a mass. Accurate preoperative diagnosis is usually possible using a combination of ultrasound scanning and cross-sectional imaging techniques (CT and/or MR), supplemented by liver biopsy and measurement of tumor markers. The most common benign tumors are hemangiomas, but mesenchymal hamartoma, focal nodular hyperplasia, and adenoma also are found. In Western countries, hepatoblastoma is the most common primary malignant liver tumor; disease-free survival is now possible in more than 80% of affected patients because of advances in combination chemotherapy, improved techniques of surgical resection, and the selective use of liver transplantation. In contrast, there has been less progress in the management of hepatocellular cancer, which still poses many therapeutic challenges.

Treatment options for other hepatic malignancies

1. Resection rates for cholangiocarcinoma (unrelated to primary sclerosing cholangitis) have increased to 54% to 79%, and the subsequent 5-year survival rates are 24% to 31%. 2. Multimodality approaches involving various combinations of chemotherapy, irradiation, and surgery increasingly are being used to treat cholangiocarcinoma. 3. The role of liver transplantation in the management of cholangiocarcinoma is limited by the perception that it is inappropriate to use scarce organs when 5-year survival rates are 25%. 4. Liver transplantation is an important intervention in patients with tumors that remain unresectable after chemotherapy. The role of liver transplantation in patients with extrahepatic disease that responds to chemotherapy is controversial. Careful timing of surgery is required to avoid secondary drug resistance. 5. Liver transplantation has been successfully applied to a range of rare hepatic malignancies, but small numbers preclude strong recommendations on the appropriateness of this practice.

Transplantation for liver and biliary cancer

The early survival of patients transplanted for liver and biliary cancer is excellent, but the overall mid- to long-term survival is poor. In an era of severe donor organ shortage, it is not justified to allocate donor liver to patients with a suboptimal outcome. Patients with non-resectable hepatocellular carcinoma in a non-cirrhotic liver should not be assigned to liver transplantation. Although patients with the fibrolamellar variant have a somewhat better outlook, they are still likely to recur, and the young age of many of these patients is likely to overwhelm any rational approach. The results of transplantation for early-stage hepatocellular carcinoma in a cirrhotic liver are similar to those achieved with benign disease. The inclusion of such cases as a group is justified, but attempts should be made to resect tumors whenever possible and to not assign the entire group to transplantation as the first and only option. The value of pre- and postoperative adjuvant therapy for this group is still under debate, but the present waiting period is so long that some form of therapy to slow growth and prevent dissemination of tumor cells is probably required. The results following transplantation for cholangiocarcinoma can only be regarded as dismal, and the diagnosis of cholangiocarcinoma is a contraindication for the procedure. Liver transplantation has a definite place in the treatment of epithelioid hemangioendothelioma and unresectable chemo-responsive hepatoblastoma when confined to the liver, and in a limited number of metastatic neuroendocrine tumors.

Sialoblastoma and hepatoblastoma in a neonate

We report a case of salivary gland neoplasm and associated hepatoblastoma. The sialoblastoma was diagnosed by prenatal sonography; however, the hepatoblastoma was imaged post-operatively. Prior knowledge could have prevented a subsequent operation, including the additional risks of repeat anesthesia. We suggest that if a sialoblastoma is in the differential diagnosis, then additional imaging may be indicated because of the possibility of associated lesions.

Childhood tumors

Pediatric solid tumors represent a distinct set of malignancies of embryonal origin whose incidence peaks in the first years of life. Specific genetic anomalies with pathogenic significance, which have helped to define the diagnosis better and to improve the prognosis of children with these tumors, recently have been discovered. Survival of children with solid tumors also has improved significantly because of effective multidisciplinary care, which, in this case, always involves chemotherapy and surgery. These favorable results require that children with these diseases are referred and treated at institutions that have multidisciplinary teams and the infrastructure and expertise for caring for these children. Diagnostic and therapeutic principles for the most common childhood solid tumors are discussed in this article, with an emphasis on surgical procedures.

Feasibility and toxicity of chemoembolization for children with liver tumors

PURPOSE

To determine the feasibility, toxicity, and efficacy of hepatic arterial chemoembolization (HACE) in pediatric patients with refractory primary malignancies of the liver.

PATIENTS AND METHODS

Six patients with hepatoblastoma (HB), three with hepatocellular carcinoma (HCC), and two with undifferentiated sarcoma of the liver were treated with HACE every 2 to 4 weeks until their tumors became surgically resectable or they showed signs of disease progression. All but one newly diagnosed patient with HCC had previously received systemic chemotherapy.

RESULTS

All patients with HB and HCC responded to HACE, as measured by imaging studies and alpha-fetoprotein levels. Surgical resection (complete or microscopic residual disease) was feasible in five of 11 patients, and three patients remain alive with no evidence of disease. Elevated liver transaminase and bilirubin levels were seen after each one of the 46 courses of HACE. Other toxicities included fever, pain, nausea, vomiting, and transient coagulopathy.

CONCLUSION

HACE is feasible, well tolerated, and effective in inducing surgical resectability of primary hepatic tumors in children.

Successful transumbilical embolization of congenitally ruptured hepatoblastoma

To avoid a high-risk operation on a moribund neonate with a ruptured hepatic tumor, transumbilical embolization of the bleeding tumor was attempted in a 2-day-old neonate. A 3F microferret catheter was advanced through the right umbilical artery. After identifying the left hepatic artery feeding the bleeding tumor, Gelfoam (Upjohn, Kalamazoo, MI) particles were injected. Bleeding was successfully controlled. The infant was able to tolerate enteral feeding when stable. Seventeen days after embolization, elective left hepatic lobectomy was performed. Histological examination showed a fetal epithelial type hepatoblastoma. The baby is 13 months old now and is receiving chemotherapy.

[Multidisciplinary management of malignant hepatic tumors in children: a recent national experience]

BACKGROUND

Malignant hepatic tumors (Mht) are rare in children. Among them hepatoblastoma (HB) is the most common.

AIM

To report the results of the multidisciplinary management in 6 consecutive children: five HB and one metastatic Wilms tumor (MWT).

PATIENTS AND METHODS

The mean age of patients was 42 months. All HB patients had elevated serum alfafetoprotein (median 150,000 ng/ml). All patients received preoperative chemotherapy: HB patients received carboplatin/doxorubicin alternating with cisplatin, and the MWT patient, vincristine alone. Surgery included two formal right and two formal left hepatectomies, one extensive central resection with partial left segmentectomy, and one lateral segmentectomy. Extracorporeal circulation was used in the child with atrial involvement. All patients received postoperative chemotherapy.

RESULTS

All tumors had variable regresion on preoperative chemotherapy. Complete resection with negative margins was achieved in all patients. The degree of tumor necrosis on histology ranged from 60% to 90%. Alfafetoprotein levels fell to under 10 ng/ml in all HB cases, one to three months after surgery. All patients survive free of disease at a median follow up of 19 months.

CONCLUSION

A multidisciplinary approach including the well timed used of chemotherapy and surgery is highly effective in the management of pediatric malignant tumors.

Thrombotic microangiopathy associated with reactivation of human herpesvirus-6 following high-dose chemotherapy with autologous bone marrow transplantation in young children

Thrombotic microangiopathy (TMA) is a serious complication of BMT. Several factors are important in the etiology of TMA, such as cyclosporin A, GVHD, irradiation, intensive conditioning chemotherapy and infection, which cause damage to vascular endothelial cells leading to activation of these cells. We describe two young children with TMA following high-dose chemotherapy with autologous BMT. Development of TMA was accompanied by reactivation of HHV-6, which was identified by both an increase in the copy number of HHV-6 DNA in the peripheral blood and a significant increase in antibody titers to HHV-6. Thus, it was suggested that reactivation of HHV-6 together with high-dose chemotherapy played an important role in the pathogenesis of TMA in these patients. Since HHV-6 is known to infect vascular endothelial cells, and CMV which is virologically closely related to HHV-6, has been reported to be a pathogen that causes TMA, infection with HHV-6 of vascular endothelial cells may induce TMA via damage and activation of these cells.