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.

Effectiveness of preoperative transarterial chemoembolization in presumed inoperable hepatoblastoma

PURPOSE

To evaluate the effectiveness and therapeutic role of preoperative transarterial chemoembolization (TACE) of hepatoblastoma.

MATERIALS AND METHODS

Four patients (one boy, three girls) with unresectable hepatoblastoma were treated twice with preoperative TACE in an effort to improve the surgical and clinical outcome. The patients ranged in age from 8 to 27 months (mean, 15 months). The first TACE was performed superselectively in tumor feeding arteries. The second TACE was performed 3 weeks later. Surgical hepatic resection was performed 1 month after the second TACE. Contrast-enhanced computed tomography (CT) was used to evaluate changes in size, volume, internal texture, and margin of the masses. The toxicity of the chemotherapeutic drugs was evaluated by blood chemistry analysis (AST/ALT, alpha-FP) performed before and after TACE, and after surgery.

RESULTS

TACE allowed subsequent surgical resection in all four patients, who remained disease free 16-52 months after operation. There were no major problems related to TACE. There was no chemotherapeutic agent toxicity from TACE. The average largest diameters and volumes of the tumors decreased by 31% (8.3 to 5.6 cm) and 69% (317 to 93 cm2), respectively.

CONCLUSION

TACE provided subsequent successful surgical resection and good long-term results in all four patients. The hepatoblastomas were initially considered inoperable because of extensive hepatic involvement and indistinct margins.

Transcatheter arterial chemoembolization in the treatment of hepatoblastoma

BACKGROUND

The prognosis of hepatoblastoma is poor unless the tumor is completely resected. Various types of chemotherapy have been developed to increase its resectability. Recently, transcatheter arterial chemoembolization (TACE) has been developed for the treatment of unresectable adult hepatoma with favorable results. The authors applied this procedure to hepatoblastoma in infants and children.

METHODS

TACE was performed in eight hepatoblastoma cases. After an intraarterial catheter was inserted into the main feeding artery of the tumor, injection of adriamycin or THP-adriamycin (20 to 30 mg/m2) dispersed in lipiodol and cisplatin (40 to 60 mg/m2) followed by embolization using Gelfoam pieces was performed. Effects of TACE were evaluated according to shrinkage of tumor mass on imaging examinations, alpha-fetoprotein (AFP) levels, and pathological findings of the surgical specimens 4 weeks after TACE.

RESULTS

A marked reduction in tumor size associated with a decrease in AFP level occurred 1 month after the treatment. Tumor shrinkage ranged from 0.9% to 45.0% with a mean value of 25.8%. AFP levels decreased by 0.2% to 11.9% with a mean level of 4.6% from initial levels. In addition, there was no marked chemotherapeutic agent-induced toxicity noted during the observation period. Resection of the tumors was performed safely after TACE in all cases. Pathological examination showed massive necrosis in the surgical specimens, and the mean percentage of necrotic area within the tumor was 71.1%. Two patients died of extensive lung metastasis 2 months and 3 years after the operation, respectively. The remaining six were doing well and free of disease at a mean follow-up period of 50 months.

CONCLUSION

TACE is an effective, safe, and useful method for the initial treatment of hepatoblastoma.

Hepatic neoplasms in childhood - a clinicopathologic study

Primary hepatic tumours are rare in childhood. We observed nine cases between 1976 and 1995, of which eight were hepatoblastomas and one a mesenchymal hamartoma. A male-to-female ratio of 2:1 was noted; 78% of the cases occurred in children below 2 years of age. Five hepatoblastomas were of the pure epithelial type; mesenchymal components encountered in the mixed type were cartilage, bone, and spindle sarcomatous cells.

Thirty-eight years experience of malignant hepatic tumors in infants and childhood

A description is given of therapeutic experiences with 39 cases of malignant liver tumors in infancy and childhood during the past 38 years. Of these patients, 9 not undergoing hepatic resection all died, while 18 (60%) of 30 patients treated by hepatic resection survived. When only patients with hepatoblastoma are considered, 14 of 24 patients are alive, although 3 of them had local recurrence and had lung metastasis. Among patients with other types of liver tumor, those with hepatocellular carcinomas (2 cases) and vascular neoplasms all died in a short period of time, whereas 2 with yolk sac tumor and one with metabolic pancreatic tumor are alive despite of tumor recurrence. In summary, the results of surgical treatment of malignant liver tumors in infancy and childhood, which formerly were poor, have been improved remarkably, which we owe mainly to: 1) advances in diagnostic imaging techniques (e.g., angiography, ultrasonography, CT and MRI) permitting early diagnosis, localization of tumor, visualization of the coursing of major vessels (particularly, hepatic artery & vein) and more accurate definition of resectability, 2) technical improvement of hepatic resection and 3) progress of chemotherapy mainly with cisplatin and adriamycin.

Hepatoblastoma in children: a review

The past 25 years have seen a dramatic improvement in results of treatment of children with HBL; formerly, < 25% were cured, and today, 65 to 75% may be cured. New, active agents are still needed, and the late effects of therapy, especially on the heart and kidneys, remain a concern. Nevertheless, it is clear that treatment of HBL is indeed "a bit of a success story" (42).

[Treatment of malignant liver tumors in children: evaluation and prospects]

Rather discouraging in the past, treatment of malignant tumors in children allows today a 75% cure rate for hepatoblastoma. Complete surgical resection remains the ongoing basis of the treatment, but the main advances are due to more efficient chemotherapy protocols using cisplatin, to an improvement in imaging procedures, to modern techniques of anesthaesia, to aggressive surgery and treatment of metastases, and finally to liver transplantation when the extension of the tumor precludes total resection in the absence of metastasis. The management of children with malignant tumors should be performed in selected centres participating in collaborative protocols, therefore providing the best oncological and surgical standards and the possibility of liver transplantation if necessary.

Hepatoblastoma in adult age: a report of two cases

Hepatoblastoma in adults is a rare malignancy that presents in the epithelial or mixed epithelial-mesenchymal variants. We report two cases, the former representing the epithelial and the latter the mixed type. A 21 year-old woman with epigastric pain had abdominal ultrasound and CT scans showing a large hepatic mass. A right trisegmentectomy was performed. The first and second recurrences were treated by resection. The third recurrence was treated by hepatic transarterial chemo-embolization, systemic chemotherapy and 19 percutaneous alcohol injections. A careful follow up by abdominal ultrasound and CT scans was able to detect the recurrence at an early stage. The patient is well at 151 months. A 39 year-old man with epigastric pain and dyspepsia had upper-GI series and abdominal CT scan showing a left hepatic mass involving the stomach. Liver resection and Billroth II hemigastrectomy were performed. A recurrence involving the left hepatic lobe, the spleen and the remaining stomach occurred 15 months later and the patient died from multi organ failure. Surgery is the treatment of choice of hepatoblastoma in adults. Recurrences can also be treated aggressively by surgical resections if no extrahepatic organs are involved. Other therapeutic modalities can be attempted whenever surgery is not possible.

Surgery for hepatoblastoma in children

The survival of children with hepatoblastoma, the most common malignant tumor of the liver in children, has improved dramatically over the past 20 years. This progress has been made with advances in surgical technique and improved chemotherapy, primarily with adriamycin and cisplatin. Despite these advances, those patients who present with advanced disease have unsatisfactory survival. Continued refinement of liver surgery and chemotherapy, as well as the use of new techniques such as chemoembolization, immunotherapy, and molecular biology, should lead to improved survival in patients with advanced disease.

Solid tumours in newborns and infants

Thirty two cases of solid tumours in newborns and infants were observed by the authors over a 15 year period. The most common type of tumours were soft tissue tumours (n = 8), neuroblastomas (n = 7), nephroblastomas (n = 5) and germ cell tumours (n = 5). Other types of embryonal tumours such as retinoblastoma and hepatoblastoma were observed in four children and non-Hodgkin's lymphomas in three children. Of 25 children followed up 18 survived. Five children died of their tumours and two children died of causes unrelated to their basic disease. Analysis of the fate of the patients and the effect of the therapy is made. It is concluded that malignant tumours prevail in infancy (90.6% of all cases). The percentage of patients treated successfully with insignificant risk for consequences from radiotherapy and chemotherapy is also high (72%).

Favorable outcome in children with Beckwith-Wiedemann syndrome and intraabdominal malignant tumors

Children with Beckwith-Wiedemann syndrome (BWS) have an increased risk of developing Wilms' tumors, hepatoblastomas, and adrenal tumors. This study evaluates disease-free survival in children with BWS and intraabdominal tumors. Sixteen tumors occurred in 13 children with BWS (8 boys, 5 girls). Diagnoses included Wilms' tumor (10) (2 bilateral, 20%), hepatoblastoma (2), bladder rhabdomyosarcoma (1), and adrenal cortical tumor (1). In the 10 children with Wilms' tumor, the average age at diagnosis was 3.5 years (range, 7 months to 5 years). Nine of 10 had initial tumor resection, chemotherapy, and radiation therapy (when indicated). One child with bilateral disease had tumor biopsy, chemotherapy, and partial nephrectomy. Tumors were classified as stage I (5), stage II (2), stage IV (1) and stage V (2), all with favorable histology. Disease-free survival rate was 100% with median follow-up of 9 years (range, 4 to 22 years). One patient had a left adrenal tumor detected during screening sonography 11 years after Wilms' tumor resection. Two infants with advanced-stage hepatoblastoma responded to chemotherapy, allowing subsequent complete hepatic resection. Both tumors had unfavorable histology. Both completed postoperative chemotherapy and have no evidence of disease (NED) with normal alpha-fetoprotein levels at 21 and 12 months, respectively, after tumor detection. One patient with stage III (group 3) bladder rhabdomyosarcoma underwent partial cystectomy following chemoradiation and is alive (NED) after 20 months. Children with BWS should be screened at regular intervals (every 3 to 6 months) for renal, adrenal, and hepatic tumors. The exact duration of screening is not yet determined.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatoblastoma: actual therapeutic strategies. A case report

Starting from a case report of a six-month-old boy with a hepatoblastoma, we discuss this topic. New virologic and cytogenetic findings in hepatoma are mentioned in the chapter "epidemiology". In "diagnosis" we focus on history, physical examination, echography, conventional RX, the role of CT-scan of abdomen and thorax, of fine needle aspiration, arteriography and magnetic resonance. In "therapy" we emphasize the new therapeutical means: chemotherapy, orthotopic liver transplantation, resection of pulmonary metastases, as well as radiotherapy and immunotargeting chemotherapy. We conclude that surgery still is the cornerstone of treatment, but the new therapeutical means create hopeful perspectives in outcome.

Prolonged survival following multiple thoracotomies for metastatic hepatoblastoma

A 14-month-old boy presented with hepatoblastoma, which was completely excised. He had pulmonary metastases, diagnosed 1 year later, treated with chemotherapy followed by resection at age 2 1/2 years. At the age of 3 1/2 years a further metastasis was shown on CT scan and this was resected. Two further metastses were resected at ages 4 1/2 and 5 1/2 years. At age 9 1/2 he had a further isolated pulmonary metastasis resected and is again disease-free more than 30 months from the last thoracotomy. Prolonged survival following metastatic hepatoblastoma can be achieved with repeated thoracotomies, especially if the first recurrence is more than 6 months from diagnosis and the number of metastases is small. Follow-up examinations should be both radiological and with serum alpha fetaprotein (S alpha FP).

Clinico-pathological criteria with prognostic relevance in hepatoblastoma

We investigated clinical data and histological specimens of 46 patients with a hepatoblastoma (HB) for prognostic criteria. Disease-free survival (DFS) of 23 patients treated in the German Cooperative Study HB-89 (1988-1990) was 83%, in contrast to 40% in 10 children with other chemotherapy regimes (1977-1987) and 38% in 13 with only a tumour resection (P = 0.005). Tumour residence after resection (R category) correlated significantly with probability of DFS (P = 0.0001). This was also the case for pT status, according to the pTNM classification for liver carcinoma (P = 0.0007), involvement of one or both liver lobes (P = 0.004), multiplicity of tumour nodes (P = 0.001), vascular invasion (P = 0.0006) and expression of nucleolar organiser regions as an indicator for proliferation activity of tumour cells (P = 0.05). Patients' age and histopathological subtypes could only indicate outcome, while tumour size and serum alpha-fetoprotein values were not significantly related to prognosis. In multivariate analysis, pT status and R categories remained significant. These should be applied in all cooperative trials on HB.

Management of hepatic epithelial malignancy in childhood and adolescence

This review addresses the management of epithelial liver tumors of childhood and adolescence (hepatoblastoma and hepatocellular carcinoma), which constitute approximately 90% of primary liver malignancy in this age group. The epidemiology, pathology, clinical presentation, and diagnosis are given in order to appreciate differences in biological behavior of these two neoplasms and the need for a distinct therapeutic approach to each. The multidisciplinary treatment of hepatoblastoma has become increasingly refined and long-term survival can be expected in approximately 80% of patients. Where survival once depended solely on complete surgical resection, it is now also possible in patients with initially unresectable tumors due to effective cytoreductive chemotherapy. The problem of systemic relapse following complete surgical resection has been reduced although not eliminated by adjuvant chemotherapy programs. To date, the biological behavior of hepatocellular carcinoma prohibits complete resection in the majority of children and chemotherapy has not been effective. Early detection, development of new agents and techniques such as monoclonal antibodies and total hepatectomy with autologous transplantation in selected cases may offer hope for the future.