Tumor rupture in hepatoblastoma: A high risk factor?

Recent advances in surgical strategies and liver transplantation for hepatoblastoma

Hepatoblastoma (HB) is the most common malignant liver tumor in children. Although the development of treatment strategies with advances in chemotherapy has greatly improved the prognosis of HB, surgical resection and liver transplantation still play a vital role in the treatment of HB. In recent years, technological innovations have led to the development of new surgical approaches for HB. In this review, we describe the latest research on the surgical management of HB, including new imaging technologies, minimally invasive approaches, and the application of associating liver partition portal vein ligation for staged hepatectomy. We also discuss the current role of liver transplantation, use of ante-situm or ex-situ liver resection with auto-transplantation, and management of metastatic HB.

Clinical risk factors for patients with ruptured hepatoblastoma in children: a retrospective study from a single center in China

OBJECTIVE

Hepatoblastoma (HB) tumor rupture is a high-risk criterion in the International Childhood Liver Tumors Strategy Group (SIOPEL) 3/4 protocol. However, the causes and risk factors for HB rupture are still unknown, and whether tumor rupture is an independent risk factor for HB prognosis is still controversial. The purpose of this study was to retrospectively analyze the clinical characteristics of children with HB tumor rupture and to search for clinical risk factors to conduct early prediction and intervention.

METHODS

We conducted a retrospective study of 27 patients with HB rupture between July 2009 and July 2019. To further identify the risk factors for HB rupture, we included 97 nonruptured HB patients from January 2013 to January 2019. We searched for potentially useful characteristics for HB rupture by univariate and multivariate logistic regression analyses.

RESULTS

There were 27 patients with HB rupture, with the median age of 31 (12, 69) months. Nineteen cases (70.37%) were spontaneous tumor rupture, 1 case (3.70%) was posttraumatic rupture, 2 cases (7.41%) were tumor rupture after the biopsy, and 5 cases (18.52%) were tumor rupture after chemotherapy. After the tumor rupture, 4 patients died of hemorrhagic shock and multiple organ dysfunction syndrome (MODS), 4 patients refused further therapy and were discharged against medical advice, and the remaining 19 patients were stable after emergency treatment. After the treatment, 14 patients survived without disease, 2 patients died, and 3 patients were lost to follow-up. The median follow-up was 48 (33, 60) months, the 3-year overall survival (OS) was 54.7%. Compared with the non-tumor rupture group by multivariate logistic regression analysis, it was found that the maximum diameter of the primary tumor > 13.4 cm, and vascular invasion were independent risk factors for tumor rupture.

CONCLUSION

HB rupture is rare, but it seriously threatens the life and health of children. In the acute phase of tumor rupture, surgery, rescue chemotherapy, transcatheter arterial embolization (TAE) and other supportive care can be adopted. Large tumors and vascular invasion are risk factors for HB rupture.

LEVEL OF EVIDENCE

Level IV.

Management of acute intra-abdominal hemorrhage in ruptured hepatoblastoma with transarterial embolization using calibrated gelfoam particles

This brief report aims to evaluate the treatment outcome of transarterial embolization in ruptured hepatoblastoma complicated with acute intra-abdominal hemorrhage. Three children (mean age 6 years) with high-risk hepatoblastoma presented with rupture and acute intra-abdominal hemorrhage. In addition to aggressive fluid resuscitation and blood product support, super-selective embolization of the arteries with active bleeding or pseudoaneurysm was performed using calibrated gelfoam particles, with a technical success rate of 100%. Hemodynamic status and hemoglobin level were normalized in all patients within 2 days postembolization. The 30-day survival rate was 100%. No major complication was detected apart from mild elevation of alanine transaminase.

Emergencies in paediatric hepatology

The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.

Imaging findings of spontaneous intraabdominal hemorrhage: neoplastic and non-neoplastic causes

Contrary to traumatic and iatrogenic intraabdominal hemorrhages, spontaneous intraabdominal hemorrhage is a challenging clinical situation. A variety of neoplastic and non-neoplastic conditions may cause spontaneous intraabdominal bleeding. Imaging findings vary depending on the source of bleeding and the underlying cause. In this article, we aim to increase the awareness of imagers to the most common causes of spontaneous intraabdominal hemorrhage by using representative cases.

Retrospective Analysis of Pediatric Hepatoblastoma With Tumor Rupture: Experience From a Single Center

PURPOSE

Hepatoblastoma (HB) tumor rupture is currently considered as a high-risk factor in some risk stratification systems. This study aimed to investigate the value of HB tumor rupture in predicting the poor prognosis.

METHODS

The clinical data from children with high-risk HB or HB tumor rupture at our institution from October 2008 to 2017 were retrospectively reviewed and analyzed.

RESULTS

Together, 34 children with high-risk HB or HB tumor rupture were retrospected, including 25 in the high-risk group and nine in tumor rupture group. The 3-year overall survival (OS) rate in tumor rupture group was significantly higher than that of the high-risk group (100 vs. 64%, p = 0.0427). In tumor rupture group, seven (77.8%) of nine patients had a hemoglobin level ≤ 8 g/L and 3 of them (33.3%) had ≤ 6 g/L at the time of diagnosis. Peritoneal perfusion with interleukin-2 was implemented for each patient. At the end of the treatment, seven (77.8%) of nine patients achieved complete response (CR). No patient died at the last follow-up.

CONCLUSIONS

HB tumor rupture might not be predictive of poor prognosis with the risk of peritoneal dissemination/relapse, in which peritoneal perfusion with interleukin-2 could play a role.