Undifferentiated (embryonal) sarcoma of the liver in childhood. Successful combined-modality therapy in four patients

Clinicopathologic features, prognostic factors, and outcomes of visceral sarcomas: A retrospective 12-year single-center study

Background

Visceral sarcomas are a rare form of soft tissue sarcoma. This study aimed to evaluate the survival and prognostic factors and effective treatments for visceral sarcomas.

Methods

All patients with visceral sarcoma referred to our center between January 2010 and December 2021 were retrospectively analyzed. The Kaplan-Meier method and a log-rank test were used for survival analysis.

Results

A total of 53 patients with visceral sarcoma were analyzed in this study with the median age at diagnosis of 57 (range, 24-77) years. Among them, 37 (69.8%) and 16 (30.2%) patients had localized and metastatic diseases at the initial presentation, respectively, and 44 patients underwent surgical resection. The median follow-up, event-free survival (EFS) and overall survival (OS) were 63.0 (range, 2-130), 42.0 months (95% confidence interval [CI] 10.879-73.121) and 45.0 months (95% CI 9.938-80.062), respectively. The 5-year EFS and OS rates were 44% and 46%, respectively. Univariate analysis of prognostic indicators illustrated that metastasis at presentation, surgery, surgical margin and the types of surgery were significantly associated with OS and EFS. In this study, combined chemotherapy or radiotherapy had no effects on EFS and OS.

Conclusion

Primary visceral sarcoma is an uncommon and aggressive malignant tumor with a higher rate of local recurrence. In the largest cohort of visceral sarcomas in China to date, we identified metastases at presentation, surgery, surgical margin, and the types of surgery as independent predictors of survival. The combination of chemotherapy and radiotherapy did not affect survival.

Undifferentiated embryonal sarcoma of the liver in adults: Retrospective analysis of a case series and systematic review

Adult undifferentiated embryonal sarcoma of the liver (UESL) is an aggressive malignant tumor. As UESL is rare, the literature predominantly includes case reports, with a limited number of small case series. The aim of the present study was to investigate the presentation, treatment modalities and outcomes of this rare tumor. The present study includes a case series of adult UESL and a systematic review. A single-institution case series of adult UESL were retrospectively analyzed, and a systematic review of adult UESL was performed by searching MEDLINE, Web of Science, EMBASE, the Google Scholar database and the Cochrane Library. For all identified adult UESL cases, the demographic variables, treatments and survival were analyzed. Three female adult patients with UESL (median age, 21 years) were successfully treated by complete tumor resection, with or without adjuvant chemotherapy, at Beijing Tsinghua Changgung Hospital between 2015 and 2018. Of these patients, two are currently alive (follow-up, 9 and 41 months), and one died after pulmonary recurrence 17 months post-diagnosis. The present systematic review identified 108 cases of adult UESL. Among all 111 analyzed cases, the median overall and disease-free survival rates were as follows: 1-year, 72 and 67%; 3-year, 56 and 40%; and 5-year, 47 and 35%, respectively. Treatment strategies combining complete tumor resection and chemotherapy promoted improved overall and disease free survival time compared with radical tumor resection alone. The present analysis included one of the largest case series of UESL in adults, and is the first such study to present survival rates. The results of the present study confirmed that survival was improved by treatment strategies combining complete tumor resection and chemotherapy.

Long-term survival outcomes of undifferentiated embryonal sarcoma of the liver: a pooled analysis of 308 patients

BACKGROUND

Treatment of undifferentiated embryonal sarcoma of the liver (UESL) is a great clinical challenge due to its rarity. This study aims to examine the long-term survival of UESL patients after treatment using different therapeutic modalities.

METHODS

A pooled analysis of individual data was performed on all UESL patients obtained from literature search (n = 307) and our institution (n = 1).

RESULTS

The 5-year overall survival rate of the 308 patients was 65.8%, 70% for partial hepatectomy group (n = 271), 78.9% for liver transplantation group (n = 14) and 6.6% for nonsurgical treatment group (n = 23). For patients receiving partial hepatectomy, paediatric patients, radical resection and combined chemotherapy were independent predictors for improved survival.

CONCLUSION

Radical hepatectomy combined chemotherapy should be considered as the preferred treatment option for USEL. Liver transplantation appears to be a reasonable alternative for unresectable disease.

Characteristics and outcomes in children with undifferentiated embryonal sarcoma of the liver: A report from the National Cancer Database

OBJECTIVE

To examine patient characteristics and outcomes in children with undifferentiated embryonal sarcoma of the liver (UESL) using a multi-institutional database.

SUMMARY BACKGROUND DATA

UESL is a rare disease (incidence is one per million). Therefore, the current literature is mostly limited to small case series.

METHODS

The National Cancer Database was queried for primary UESL diagnosed between 1998 and 2012.

RESULTS

A total of 103 patients (<18 years) were identified. The 5-year overall survival of the entire group was 86%. The best outcomes were seen in children who had tumors smaller than 15 cm and were able to undergo surgical resection with or without chemotherapy. Margin status did not appear to significantly affect survival. The most common type of resection was hemihepatectomy (37%), followed by sectionectomy (10%) and trisectionectomy (10%). Orthotopic liver transplant was performed in 10 children, all of whom survived to 5 years.

CONCLUSION

Surgical resection with or without chemotherapy should be the mainstay of treatment in children with UESL, and is associated with very favorable outcomes. Negative surgical margins were not associated with improved survival. Orthotopic liver transplantation may be a viable method of attaining local control in tumors, which would otherwise be unresectable.

Adult Embryonal Sarcoma of the Liver: Management of a Massive Liver Tumor

Undifferentiated embryonal sarcomas of the liver are extremely rare cases in adults. We report the case of a 30-year-old male who presented with early satiety and abdominal pain due to a massive tumor originating from the left liver and occupying the entire epigastrium. The patient underwent bland embolization in an attempt to decrease the size of the tumor. He then underwent a formal left hepatectomy with resection of liver segments 2, 3, and 4. Extrahepatic inflow control of the portal vein and hepatic artery was performed prior to parenchymal transection. No Pringle maneuver was required. Pathology analysis showed a 45 cm tumor consistent with an undifferentiated embryonal sarcoma and negative microscopic margins. The epidemiology, treatment, and prognosis of this unusual cancer presentation are reviewed.

Undifferentiated Embryonal Sarcoma of the Liver (UESL): A Single-Center Experience and Review of the Literature

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare and aggressive pediatric malignancy. The purpose of this study was to review the clinical, radiologic, and pathologic features and outcome of children with UESL at our institution, in the United Network of Organ Sharing database and to review the existing literature to define the state of the art for children with UESL. Six children were diagnosed with UESL at the Texas Children's Cancer Center between 1993 and 2014, 12 children underwent liver transplantation registered in the United Network of Organ Sharing database, and 198 children with UESL were described in 23 case series during 1978 to 2014. Patients were treated with multimodal treatment approaches including primary surgical resection, neoadjuvant and/or adjuvant chemotherapy, and liver transplantation resulting in overall survival reported between 20% and 100% with significant improvement over the recent years. We show that complete tumor removal remains the key element of treatment and our single-institutional experience and data in the published literature suggest that combination chemotherapy with ifosfamide and doxorubicin to facilitate complete surgical resection is an effective approach to cure children with UESL.

Embryonal sarcoma of the liver

PURPOSE

Embryonal sarcoma accounts for 6 % of liver tumors. This study reviews its features and the results of treatment in a referral center.

METHODS

We retrospectively reviewed liver tumors treated between 1995 and 2011. PRETEXT staging and biopsy were used to tailor chemotherapy according to SIOP protocols. Radical surgery was performed when possible. Complications and cumulative survival were the outcome endpoints.

RESULTS

Six out of 156 primary liver tumors (four males and two females) were sarcomas. The mean age at diagnosis was 81 ± 8.5 months. The most frequent finding was abdominal mass. Alfa-fetoprotein was normal. Imaging depicted heterogeneous tumors with septa, necrosis, and hemorrhagic areas. The diagnosis was ascertained by biopsy. Three tumors were located in the right lobe (PRETEXT II): two were bilobar (PRETEXT III) and one was in the left lobe (PRETEXT I). Two children had metastases at diagnosis and high-risk chemotherapy (vincristine, carboplatin, epirubicin) was administered with poor response. They died without operation 4 and 10 months later. Four patients with local disease underwent typical liver resections after chemotherapy (iphosphamide, vincristine, actinomycin D, and doxorrubicin). Overall actuarial survival at 70 months was 66.6 %.

CONCLUSIONS

Extended and metastatic embryonal sarcoma do poorly whereas localized tumors amenable to complete surgical removal after chemotherapy can cure.

Treatment of undifferentiated embryonal sarcoma of the liver in children--single center experience

BACKGROUND

Undifferentiated embryonal sarcoma of the liver (UESL) represents less than 5% of all malignant hepatic tumors in childhood. It is considered an aggressive neoplasm with an unfavorable prognosis. The aim of this paper is to present a single center experience in the treatment of children with UESL.

MATERIALS AND METHODS

Ten children with UESL were treated between 1981 and 2012. Age at diagnosis ranged from 4 months to 17 years (median age, 6 years and 9 months). Surgery after neoadjuvant chemotherapy (CHT) was performed in 7 patients, and in 3 patients primary surgery was done. Adjuvant chemotherapy was administered in all 10 patients (CYVADIC, CAV, CAV/ETIF/IF+ADM, CDDP/PLADO). Right hemihepatectomy was performed in 1 patient, extended right hemihepatectomy in 6, and partial resection of the right lobe (segments V-VI, segment V) in 2 patients. One patient with unresectable tumor affecting both lobes was listed for liver transplantation (LTx).

RESULTS

Follow-up from diagnosis ranged from 50 to 222 months (mean 138 months). Among 9 patients treated with partial liver resection, distant metastases/local recurrence was not observed in any, and disease-free survival in this group is 100% (9 patients alive). The patient that underwent liver transplantation died of multiorgan failure 4 months postoperatively. However, this patient was misdiagnosed as having hepatoblastoma (HBL) and received PLADO chemotherapy. The overall survival rate is 90%.

CONCLUSION

Excellent results with long-term survival can be achieved in children with UESL with conventional therapy, including a combination of neoadjuvant and adjuvant chemotherapy and surgery, even in large extensively growing tumors.

Soft tissue tumors of uncertain origin

Many soft tissue tumors of childhood lack obvious differentiation toward a defined mesenchymal tissue type or have a phenotype that does not correspond to any defined normal tissue. These challenging tumors are currently regarded as neoplasms of uncertain differentiation. Nonetheless, there have been great strides in the understanding of their pathologic and genetic features and biologic underpinnings. The application of new genetic information to the pathologic diagnosis among this group of tumors is an emerging area in diagnostic pediatric pathology. This article reviews the clinicopathologic features of tumors of uncertain and/or miscellaneous origin, with an emphasis on the unique aspects of these neoplasms in children and adolescents, use of diagnostic adjuncts, and differential diagnosis.

A long-term survival case of adult undifferentiated embryonal sarcoma of liver

Undifferentiated embryonal sarcoma of the liver (USEL) is a rare malignant hepatic tumor with a poor prognosis that is usually observed in children (aged 6 to10 years) and rarely seen in adults. We present a case of USEL in a 27-year-old woman with no previous history of the disease. Laboratory tests performed on admission showed that the patient had mildly elevated levels of aspartate aminotransferase, alanine transaminase, alkaline phosphatase, lactate dehydrogenase, and γ-glutamyl transpeptidase. The levels of viral hepatitis and tumor serum markers were all within normal limits. Computed tomography showed a large mass involving the right lobe and the medial segment of the liver. Right trisectionectomy was performed. Microscopically, the tumor was composed of pleomorphic and polynuclear dyskaryotic cells in a myxoid stroma with focal eosinophilic globules and no clear differentiation to muscle. Histological diagnosis showed undifferentiated embryonal sarcoma. Adjuvant therapy with cisplatin, vincristine, doxorubicin, cyclophosphamide, and actinomycin D was initiated. We administered a high dose of etoposide to extract the patient’s peripheral blood stem cells and performed radiation therapy and peripheral blood stem cell transplantation. At 5-year follow-up, the patient was alive without any evidence of recurrence. Here, we describe the clinical and histopathological features of USEL as well as the therapeutic options for USEL in adults with this disease.

Undifferentiated sarcoma of the liver: a single institution experience using a uniform treatment approach

Undifferentiated (embryonal) sarcoma of the liver is a rare malignant tumor, most commonly seen in children aged 6 to 10 years. Previously believed to carry a poor prognosis, more recent reports indicate that treatment regimens combining surgical resection and adjuvant chemotherapy can yield long-term, disease-free survival. In this study, we review 5 pediatric patients with undifferentiated sarcoma of the liver treated with a uniform approach of resection followed by adjuvant chemotherapy and radiation when indicated. All 5 patients are disease free in their first remission at a median of 53 months.

Undifferentiated sarcoma of the liver: a rare pediatric tumor

Undifferentiated embryonal sarcoma of the liver (UESL) is an uncommon hepatic tumor of mesenchymal origin recognized as a unique clinicopathologic entity since 1978. UESL has historically been considered an aggressive neoplasm with an unfavorable prognosis. Survival has improved using recent multimodal approaches, designed for patients with soft tissue sarcomas at other sites. Several small series have reported survival of up to 70% of children. We report a case of a 12-year-old boy from the United Arab Emirates who relapsed after complete surgical resection and was then successfully treated with re-resection followed by chemotherapy and radiotherapy. With a follow-up of 5 years, he is well and asymptomatic, and is leading a healthy life. This case emphasizes the fact that these poorly prognostic tumors may benefit from post-surgery chemotherapy. This case illustrates the improved survival of UESL patients following the multimodality therapy with a relatively long follow-up. This is the first case of UESL reported in this region of the world.

Liver transplant for relapsed undifferentiated embryonal sarcoma in a young child

Undifferentiated embryonal sarcoma of the liver is a rare hepatic malignancy of childhood with a historically poor prognosis. Recent improvements in outcomes have been reported in small numbers of cases with the use of combination therapy involving aggressive surgical resection and chemotherapy. Complete surgical resection is frequently difficult to achieve when the location of the tumor is along the margins of the major hepatic vessels (portal vein, hepatic vein, and hepatic artery). Here we report a case of undifferentiated embryonal sarcoma of the liver that recurred along surgical hepatic vein margins in a 9-year-old boy who subsequently underwent orthotopic liver transplantation from a cadaveric donor. The patient has been in continuous clinical remission for the last 5 years.

Undifferentiated embryonal sarcoma of the liver: case report and literature survey

Undifferentiated embryonal sarcoma (UES) of the liver was first identified as an independent clinicopathologic type of sarcoma in 1978. It is an uncommon hepatic tumor, of mesenchymal origin, usually observed in children, and cases in adults are rare: to our best knowledge, reports of only 51 cases have been published in the past 50 years. We present a case of UES of the liver in a previously healthy 22 year-old woman, admitted to our hospital due to a palpable mass in the right upper abdomen. On admission, laboratory studies showed mildly elevated aspartate aminotransferase, alkaline phosphatase, and gamma-GPT. Hepatitis and tumor markers were negative. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) showed a large mass involving the right lobe and the medial segment of the liver, with compression of the bile duct. Right trisectionectomy with bile duct resection and reconstruction was performed. Microscopically, the tumor was composed of pleomorphic spindle cells in a myxoid stroma with focal staining of S-100 by immunohistochemistry. The histologic diagnosis was UES. Adjuvant therapy with vincristine, actinomycin-D, and cyclophosphamide was performed, and at 14 months of follow-up, the patient is alive without any evidence of recurrence. The clinical and histopathological features, as well as the therapeutic choices for adult UES, are described for this patient and in the literature of the past 50 years.

Childhood undifferentiated embryonal liver sarcoma: clinical features and immunohistochemistry analysis

PURPOSE

The aim of the study was to report on 3 cases of childhood undifferentiated embryonal liver sarcoma (UELS) and to highlight the clinical features, laboratory findings, diagnosis, and management of this rare disease.

METHODS

The patients' age, sex, clinical features, laboratory findings, pathologic results, and therapy were reviewed. Immunohistochemistry analysis was performed on the resected mass sections.

RESULTS

In this study, 2 cases were female (aged 8 and 12 years) and 1 was male (aged 9 years). The causes of hospitalization were mainly abdominal pain, mass, or fever. An elevated erythrocyte sedimentation rate was noted in 2 available cases, and alpha fetoprotein (AFP) was within the normal range. Imaging findings indicated a well-defined heterogeneous large mass in the right lobe. Histopathologic evaluation of the mass confirmed the diagnosis of UELS. Immunohistochemical staining showed that vimentin and CD68 antigen were positive in all samples, whereas desmin was positive in one sample. Surgery with chemotherapy was performed in 2 cases.

CONCLUSION

The diagnosis of UELS depends mainly on the pathologic findings. Undifferentiated embryonal liver sarcoma should be included in the differential diagnosis of mass in the liver, especially with well-defined heterogeneous imaging findings and normal AFP. Diagnosis and management should be made early as UELS is a potentially treatable tumor.

Undifferentiated embryonal sarcoma of the liver in adults

BACKGROUND

Undifferentiated embryonal sarcoma of the liver (UESL), a rare tumor that predominantly affects children, generally has been considered an aggressive neoplasm with an unfavorable prognosis. More recent reports have indicated that modern multimodal treatment and supportive care improve the survival of children with UESL. Data regarding the treatment and survival of adults have not been reviewed comprehensively, and only a few adult patients with UESL have been reported in the literature.

METHODS

The authors analyzed demographics, treatment, and actuarial survival of all reported cases of UESL in patients aged >or=15 years (n = 67 patients). In addition, 1 case is presented of a patient with UESL who was treated successfully at the authors' institution.

RESULTS

The median survival of all patients with UESL who were analyzed was 29 months. Patients who underwent complete tumor resection followed by adjuvant chemotherapy survived over a median follow-up of 28.5 months and had significantly better survival compared with patients who underwent surgical treatment alone. Patients who underwent an incomplete tumor resection had a tendency toward poorer outcomes.

CONCLUSIONS

To the authors' knowledge, this is the first report to demonstrate a significant effect on survival for adjuvant chemotherapy after complete surgical resection of UESL in adults. The role of neoadjuvant chemotherapy was not evaluated in this study. In the case study presented herein, combined therapy with surgery and chemotherapy led to a complete, sustained remission that has lasted for >6 years to date.

Salvage surgery following downstaging of unresectable hepatocellular carcinoma--a strategy to increase resectability

BACKGROUND

Surgical resection with complete extirpation of the tumor gives the best chance of a cure for patients with hepatocellular carcinoma (HCC). However, the resectability of HCC at the time of diagnosis is low (10-30%). This article reviews the use of salvage surgery following tumor downstaging to treat unresectable HCC.

MATERIALS AND METHODS

A Medline search was undertaken from 1966 to 2005 to identify articles using the keywords "liver neoplasm," "hepatocellular carcinoma," "tumor downstaging," and "unresectable." Additional papers were identified by a manual search of the references from the key articles.

RESULTS

Eight to eighteen percent of patients with unresectable HCC responded well enough to the initial palliative treatment to downstage HCC to allow salvage surgical resection. The reported five-year survival rate after salvage surgery following tumor downstaging varied from 24.9 to 57%.

CONCLUSIONS

Although it is still unknown whether the outcome of salvage surgery following tumor downstaging is comparable to those of resectable tumors after primary resection, one clear message is that salvage surgery following tumor downstaging gives good long-term results and the possibility of a cure in a proportion of patients with unresectable HCC. The role of salvage surgery after tumor downstaging in improving disease-free and overall survival in patients with unresectable HCC should be investigated further by prospective randomized controlled trials.

Undifferentiated embryonal sarcoma of the liver successfully treated with chemotherapy and liver resection

Undifferentiated embryonal sarcoma is the third most common malignant tumor of the liver in children, accounting for 13% of hepatic malignancies in this age group. It has been considered an aggressive neoplasm with very poor prognosis until the late 1980s, when long-term survivors were reported after multiagent chemotherapy followed by resection. We, herein, report two pediatric cases of undifferentiated embryonal sarcoma treated successfully with surgical resection after neoadjuvant chemotherapy based on therapy used in childhood soft tissue sarcomas and in childhood hepatic malignancies. The first patient also had a concurrent cerebellar tumor (pilocytic astrocytoma), for which he first underwent craniotomy and resection, delaying the liver tumor resection by 10 weeks. They are alive and tumor free at 48 months (case no. 1) and 18 months (case no. 2) following neoadjuvant chemotherapy and liver resection.

Undifferentiated (embryonal) sarcoma of the liver (USL): MRI findings including dynamic gadolinium enhancement

We report the MR appearance of undifferentiated (embryonal) sarcoma of the liver (USL) in a 13-year-old female who presented with a 1-year history of intermittent abdominal pain, weight loss, and fatigue. The tumor was a large, solitary, well-defined focal mass lesion with multiple cystic spaces, septations, and substantial central necrosis.

Clinical outcomes of surgical resections for primary liver sarcoma in adults: results from a single centre

BACKGROUND

Primary hepatic sarcoma is a rare tumour with a poor prognosis.

METHODS

From 1997 to 2002 eight patients had liver resection for primary sarcoma of the liver at our institution. The clinical characteristics, imaging findings, surgical procedures, adjuvant therapy and outcome were retrospectively reviewed. There were two patients each with angiosarcoma (AS), leiomyosarcoma (LMS), and undifferentiated embryonal sarcoma (UES), one patient with epithelioid hemangioendothelioma (EHE) and one patient with malignant peripheral nerve sheath sarcoma (PNSS).

RESULTS

The most common presenting symptoms were right upper quadrant pain and fever. Typical imaging findings were a heterogenous mass with poorly defined margins, pseudocapsule and aberrant vasculature. Preoperative diagnosis of a primary liver sarcoma was made in 7/8 cases, either by fine needle aspiration (n = 5) or angiography (n = 2). Five right hepatectomies and three trisegmentectomies were performed. An R (0) resection was possible in three cases. Two patients developed complications and there was one death. Adjuvant chemoradiotherapy was administered to 5/7 patients. Systemic chemotherapy led to tumour regression in both patients with UES which enabled a second hepatic resection.

CONCLUSIONS

The majority of patients with primary liver sarcoma present with right upper quadrant pain, fever and a liver mass. Differentiating the rare primary liver sarcoma from the much more common hepatocellular carcinoma (HCC) may aid in planning therapy. Patients with resectable tumours should be referred for surgery. Liver resection combined with adjuvant chemotherapy are the mainstays of treatment for UES in the adult.

Undifferentiated (embryonal) sarcoma of the liver: combination treatment by surgery and chemotherapy

BACKGROUND/PURPOSE

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare malignancy found in older children, and the most appropriate treatment strategy has been controversial. The authors report the tumor's clinical characteristics and the results of management in 6 children and recommend the best treatment plans based on these findings.

METHODS

Six USL pathologically verified at Seoul National University Children's Hospital between 1990 and 2000 were reviewed retrospectively.

RESULTS

The mean age at diagnosis of USL was 10.3 years (range, 7 to 13 years). There were 2 girls and 4 boys; 5 of 6 children presented with large abdominal mass, one with weight loss. Tumors ranged in size from 8.5 x 9.0 cm to 15.0 x 15.0 cm. Location of the tumor varied from right lobe in 4 to left lobe in one, and both lobes in one. Three children underwent primary complete resection without preoperative chemotherapy. Partial resection of the tumor was done in one child because of encasing inferior vena cava and hepatic vein. However, complete resection was possible at second-look operation after chemotherapy. Two children underwent complete resection after chemotherapy. Preoperative chemotherapy allowed successful resection of 3 USL, which were initially considered unresectable. Postoperative recovery for all children was uneventful. Chemotherapy according to the the Third Intergroup Rhabdomyosarcoma Study (IRS III) was administered to all except one child who refused further postoperative chemotherapy after having had severe complications during the first cycle of chemotherapy. One child with partial resection died of sepsis at 22 months after diagnosis during postoperative chemotherapy after complete surgical removal of the tumor. Five children are alive without recurrence at 40, 45, 48, 60, and 122 months, respectively, after diagnosis.

CONCLUSION

The combined therapy of surgery and chemotherapy in USL can improve the prognosis.

Undifferentiated sarcoma of the liver in childhood: a curable disease

BACKGROUND

Undifferentiated (embryonal) sarcoma of the liver (UESL) is a rare childhood hepatic tumor, and it is generally considered an aggressive neoplasm with an unfavorable prognosis.

METHODS

The Soft Tissue Sarcoma Italian and German Cooperative Groups enrolled 17 children with UESL in studies conducted between 1979 and 1995. They were treated using the same multimodal approach as for patients with sarcomas including conservative surgery at diagnosis, multiagent chemotherapy, and second-look operation in cases of residual disease. Radiotherapy was occasionally used (2 of 17 patients).

RESULTS

Twelve patients are alive with follow-up ranging from 2.4 to 20 years. Eight underwent complete tumor resection either at diagnosis or after preoperative chemotherapy, and all are currently alive. After initial chemotherapy tumor reduction was evident in six of nine evaluable cases. Overall three patients died of disease and one of a surgical complication. One child died in second complete remission for a non-disease-related cause.

CONCLUSIONS

The current prognosis of UESL no longer should be regarded as poor. Modern multimodal treatment and supportive therapy have improved survival.

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.

Undifferentiated embryonal sarcoma of the liver: results of clinical management in one center

PURPOSE

This study was undertaken to review the authors' clinical experience with undifferentiated embryonal sarcoma of the liver (UES) in children, focusing on the clinical presentation and results of treatment.

METHODS

A retrospective analysis of all children who have undergone treatment for UES during the 15-year period from 1984 through 1998 was performed.

RESULTS

Seven patients (4 boys and 3 girls) ranging in age from 20 months to 12 years at the time of diagnosis were identified. All presented with large abdominal masses and normal liver function test results. All underwent complete tumor resection; trisegmentectomy was required in 4 of these cases. All patients received postoperative chemotherapy. Two patients suffered tumor recurrence at 12 and 29 months; both of these patients died of their disease. Another patient died of complications related to chemotherapy. The other 4 patients are alive with no evidence of disease after 19 to 150 months' follow-up.

CONCLUSIONS

Undifferentiated embryonal sarcoma of the liver presents as a large hepatic tumor. Operative resection is difficult, but combined with adjuvant chemotherapy offers the best hope for cure.

Undifferentiated (embryonal) sarcoma of the liver: fine-needle aspiration cytology and preoperative chemotherapy as an approach to diagnosis and initial treatment. A case report

The present report describes the case of a 9-year-old girl with an undifferentiated (embryonal) sarcoma of the liver diagnosed by fine-needle aspiration cytology (FNAC). The smears revealed pleomorphic cells, some with cytoplasmic vacuoles and eosinophilic inclusions, as well as spindle cells and myxoid tissue, cytologic features which appear to be distinctive from any other malignant tumor of the liver. Preoperative chemotherapy was then given using a protocol for high-grade soft-tissue sarcomas (MMT95 953 branch B, SIOP). This scheme induced very good response allowing complete surgery 8 months after diagnosis. The patient is alive and well 11 months after surgery. The combined FNAC-preoperative chemotherapy approach may prove useful for this highly malignant tumor.

Hepatic malignancies in childhood and adolescence (hepatoblastoma, hepatocellular carcinoma, and embryonal sarcoma)

Hepatoblastoma is the most common malignant liver tumor of childhood. Clinical trials have demonstrated its responsiveness to chemotherapy, especially with platinum-based chemotherapeutic agents. In patients with completely resected tumors, recurrent disease is effectively controlled by adjuvant chemotherapy. In patients with initially unresectable tumors, chemotherapy can induce tumor shrinkage sufficient to allow complete extirpation of tumor and also to prevent recurrent disease. The child with tumor resistant to primary therapy or with recurrent disease presents a special problem requiring individualized and innovative therapies, including consideration of orthotopic liver transplant. Hepatocellular carcinoma in children and adolescents carries a much poorer prognosis compared to hepatoblastoma. Complete resection of tumor offers the only hope of cure, but these tumors are unfortunately resistant or partially resistant to conventional doses of chemotherapy. A number of innovative treatment strategies have been employed, but optimal treatment remains elusive. Transplant for tumor localized to the liver may offer the only hope of cure. Embryonal (undifferentiated) sarcoma of the liver is a rare tumor that has not been studied prospectively in any clinical trial. Small published series indicate that it can be responsive to chemotherapy, and cure may be possible.

Primary multilocular cystic undifferentiated (embryonal) sarcoma of the liver in childhood resembling hydatid cyst of the liver

Undifferentiated (embryonal) sarcoma (UES) is a very rare primary malignant tumour of the liver; typically presenting in later childhood. This tumour usually appears on CT and ultrasound as a predominantly solid mass with or without cystic areas. We report a case of primary UES which had a multilocular cystic appearance resembling a hydatid cyst on imaging.

Partial nephrectomy in well-responding stage I Wilms' tumors: report of three cases

We report on 3 of 21 stage I Wilms' tumor patients with tumor volumes of 190, 890, and 1300 mL, respectively, who responded dramatically to preoperative chemotherapy according to the Austrian/Hungarian Wilms' Tumor Study 89 by tumor volume reductions to 20%, 23%, and 13%, respectively. Radical resection of the tumors with renal preservation was achieved in all patients. Postoperative studies did not show any functional deficit in the preserved kidney. The patients have been in complete remission for 26, 33, and 60 months, respectively. Our preliminary results indicate that tumor resection should be feasible in patients with good responding stage I Wilms' tumors.