Reiterative Radiofrequency Ablation in the Management of Pediatric Patients with Hepatoblastoma Metastases to the Lung, Liver, or Bone

Surgical management in hepatoblastoma: points to take

Hepatoblastoma is the most common primary malignant paediatric liver tumour and surgery remains the cornerstone of its management. The aim of this article is to present the principles of surgical treatment of hepatoblastoma. All aspects of surgery in hepatoblastoma are discussed, from biopsy, through conventional and laparoscopic liver resections, to extreme resection with adjacent structures, staged hepatectomy and transplantation.

Percutaneous ablation of malignant and locally aggressive solid tumors in pediatric patients

Image-guided percutaneous ablation is an accepted treatment modality for common adult cancers. Unfortunately, its use in patients younger than 18 years is rare. This retrospective review presents our series of pediatric patients treated with ablation at our institution. From January 2002 to December 2021, a total of 14 patients (17 lesions) younger than 18 years were treated with percutaneous image-guided ablation. Estimated overall survival at 5 years was 58%; median survival of this group was not reached. Estimated local tumor progression-free survival at 5 years was 62%. One major complication was recorded.

Bone metastases in hepatoblastoma, an unusual presentation. Case report and review of the literature

Primary liver tumors are rare in childhood. Hepatoblastoma is the most prevalent and has a variable clinical presentation. The initial approach requires clinical suspicion, histopathological confirmation, and measurement of AFP levels, in addition to PRETEXT staging by abdominal computed tomography. PET-CT is useful in metastatic disease for diagnosis and evaluation of therapeutic response. Pulmonary metastases at the time of diagnosis are frequent, while bone metastases are rare. We present the case of an infant with a history of metastatic hepatoblastoma, multiple relapses, and poor response to multimodal management. The patient had bone metastases demonstrated by PET-CT imaging.

Treatment optimization for recurrent hepatoblastoma: retrospective study from a hepatoblastoma cohort in Southern China

PURPOSE

The present study aimed to explore the clinical characteristics and optimal treatments of RHB patients.

METHODS

We retrospectively collected 42 RHB cases and 161 primary HB (PHB) cases. Clinical characteristics were compared between RHB and PHB patients. The risk factors related to overall survival (OS) and progression-free survival (PFS) in RHB patients were explored by COX regression analysis. Patients were further divided into curable and refractory subgroup by treatments. Propensity score match (PSM) analysis was performed to match recurrent curable patients from 145 curable PHB patients from the same cohort. PFS was further compared between 34 pairs of primary and recurrent curative HB patients.

RESULTS

Recurrence treatment and number of relapsed tumors were significantly related with both OS and PFS of RHB patients (p < 0.05). Chemotherapy regimen alteration was also risk factor of PFS for RHB (HR = 4.26; 95% CI = 1.54-11.78; p = 0.005). RHB patients underwent curable treatment had better prognosis, compared with recurrent refractory subgroup (p < 0.001). Matched curable PHB patients demonstrated no significant difference of 3-year PFS with curable RHB patients (p = 0.540).

CONCLUSION

Curable RHB patients might get benefit from surgery or ablation with similar prognosis with primary curable HB patients.

Percutaneous thermal ablation versus open liver resection for recurrent hepatoblastoma: a retrospective study

BACKGROUND

The survival of children with recurrent hepatoblastoma (RHB) is still unsatisfactory and the treatment for relapsed patients is challenging.

PURPOSE

To compare short-term results between open liver resection (OLR) and percutaneous thermal ablation (TA) in the treatment of RHB and provide evidence to support the treatment options for such patients.

METHODS

A retrospective data of 21 patients with RHB in two Chinese centers were analyzed from January 2013 to May 2019. The baseline indicators and clinical effect of the two groups of children were compared.

RESULTS

There was no statistical difference in baseline indicators between the two groups of children, and complete remission (CR) was achieved after comprehensive treatment. The median follow-up time was 30 months (IQR 38.5 months) in the TA group, and 23 months (IQR 21.7 months) in OLR group (p = .57). The 2-year OS rates were 92.3% in the percutaneous TA group and 87.5% in the OLR group (p = .68, HR = 1.6, 95% confidence interval [CI]: 0.2-12.4). The 2-year EFS rates were 66.7%, in the TA group and 50.0% in the OLR group (p = .51, HR = 0.6, 95% CI: 0.2-2.6). Compared with the OLR group, TA group had shorter operation time (3.5 ± 1.8 vs. 0.5 ± 0.1, p < .001) and postoperative hospitalization time (11.8 ± 3.0 vs. 9.5 ± 6.8 d, p = .045). No major complications occurred in both groups.

CONCLUSIONS

Ultrasound-guided percutaneous TA for RHB is a safe and effect treatment option for children. It has comparable effect with surgery within 2 years after treatment. Particularly, due to its minimally invasive advantage, it needs shorter operation and hospitalization time. Percutaneous ablation may be an alternative minimally invasive treatment for RHB children.

Incomplete thermal ablation-induced up-regulation of transcription factor nuclear receptor subfamily 2, group F, member 6 (NR2F6) contributes to the rapid progression of residual liver tumor in hepatoblastoma

Hepatoblastoma is a kind of extreme malignancy frequently diagnosed in children. Although surgical resection is considered as the first-line treatment for hepatoblastoma, a relatively large population of patients have lost the preferred opportunity for surgery. Administration of locoregional ablation enables local tumor control but with the deficiency of insufficient ablation, residual tumor, and rapid progression. In this study, we integrated 219 hepatoblastoma and 121 non-cancer liver tissues to evaluate the expression of NR2F6, from which a higher NR2F6 level was found in hepatoblastoma compared with non-cancer livers with a standard mean difference (SMD) of 1.04 (95% CI: 0.79, 1.29). The overexpression of NR2F6 also appeared to be an efficient indicator in distinguishing hepatoblastoma tissues from non-cancer liver tissues from the indication of a summarized AUC of 0.90, with a pooled sensitivity of 0.76 and a pooled specificity of 0.89. Interestingly, nude mouse xenografts provided direct evidence that overexpressed NR2F6 was also detected in residual tumor compared to untreated hepatoblastoma. Chromatin immunoprecipitation-binding data in HepG2 cells and transcriptome analysis of HepG2 xenografts were combined to identify target genes regulated by NR2F6. We finally selected 150 novel target genes of NR2F6 in residual tumor of incomplete ablation, and these genes appeared to be associated with the biological regulation of lipid metabolism-related pathway. Accordingly, targeting NR2F6 holds a therapeutic promise in treating residual recurrent hepatoblastoma after incomplete ablation.

A retrospective study of clinical features and outcome in patients with refractory or recurrent hepatoblastoma: A single institution experience

BACKGROUND

Hepatoblastoma (HB) is the most common childhood primary hepatic malignancy. The overall survival rate in patients with HB has reached more than 80% over the past decades. The poor prognostic and high-risk HB have been defined, but the treatment and cure of refractory or relapsed HB is still an arduous task.

METHODS

The complete records of HB in patients under the age of 18 at the MacKay Memorial Hospital between 1990 and 2019 were examined.

RESULTS

The treatment results for 11 patients with refractory or relapsed HB are presented. The multi-modality treatment records were reviewed and the clinical characteristics associated with poor outcome included multifocal lesions, low α-fetoprotein, great vessel invasion and metastases. Delayed liver tumor surgery was carried out in eight cases. The median duration of follow-up for the 11 patients was 48.6 months (range 1.9 to 316.8 months). The 5-year and 10-year overall survival rate were 62.3% ± 15% (SE) and 49.9% ± 16.4% (SE), respectively. Most treatment-related toxicities were tolerable. The major concern during long term follow-up was irreversible high-frequency hearing loss.

CONCLUSION

Patients with refractory/relapsed HB are still a thorny issue and more research is needed to improve the outcome.

Stereotactic radiofrequency ablation of a variety of liver masses in children

BACKGROUND AND AIMS

Surgical resection is currently the cornerstone of liver tumor treatment in children. In adults radiofrequency ablation (RFA) is an established minimally invasive treatment option for small focal liver tumors. Multiprobe stereotactic RFA (SRFA) with intraoperative image fusion to confirm ablation margins allows treatment for large lesions. We describe our experience with SRFA in children with liver masses.

METHODS

SRFA was performed in 10 patients with a median age of 14 years (range 0.5-17.0 years) suffering from liver adenoma (n = 3), hepatocellular carcinoma (n = 1), hepatoblastoma (n = 2), myofibroblastic tumor (n = 1), hepatic metastases of extrahepatic tumors (n = 2) and infiltrative hepatic cysts associated with alveolar echinococcosis (n = 1). Overall, 15 lesions with a mean lesion size of 2.6 cm (range 0.7-9.5 cm) were treated in 11 sessions.

RESULTS

The technical success rate was 100%, as was the survival rate. No transient adverse effects higher than grade II (Clavien and Dindo) were encountered after interventions. The median hospital stay was 5 d (range 2-33 d). In two patients who subsequently underwent transplant hepatectomy complete ablation was histologically confirmed. Follow-up imaging studies (median 55 months, range 18-129 months) revealed no local or distant recurrence of disease in any patient.

CONCLUSIONS

SRFA is an effective minimal-invasive treatment option in pediatric patients with liver tumors of different etiologies.

Results of redo pulmonary metastasectomy

Repeat surgical resection (redo) for pulmonary metastases is a questionable, albeit intriguing topic. We performed an extensive review of the literature, to specifically analyze results of redo pulmonary metastasectomies. We reviewed a total of 3,523 papers. Among these, 2,019 were excluded for redundancy and 1,105 because they were not completely retrievable. Out of 399 eligible papers, 183 had missing information or missing abstract, while 96 lacked data on survival. A total of 120 papers dated from 1991 onwards were finally included. Data regarding mortality, major morbidity, prognostic factors and long-term survivals of the first redo pulmonary metastasectomies were retrieved and analyzed. Homogeneity of data was affected by the lack of guidelines for redo pulmonary metastasectomy and the risks of bias when comparing different studies has to be considered. According to the histology sub-types, redo metastasectomies papers were grouped as: colorectal (n=42), sarcomas (n=36), others (n=20) and all histologies (n=22); the total number of patients was 3,015. Data about chemotherapy were reported in half of the papers, whereas targeted or immunotherapy in 9. None of these associated therapies, except chemotherapy in two records, did significantly modify outcomes. Disease-free interval before the redo procedure was the prevailing prognostic factor and nearly all papers showed a significant correlation between patients’ comorbidities and prognosis. No perioperative mortality was reported, while perioperative major morbidity was overall quite low. Where available, overall survival after the first redo metastasectomy ranged from 10 to 72 months, with a 5-years survival of approximately 50%. The site of first recurrence after the redo procedure was mainly lung. Despite the data retrievable from literature are heterogeneous and confounding, we can state that redo lung metastasectomy is worthwhile when the lesions are resectable and the perioperative risk is low. At present, there are no “non-surgical” therapeutic options to replace redo pulmonary metastasectomies.

Radiofrequency Ablation for Cervical Metastatic Lymph Nodes in Children and Adolescents With Papillary Thyroid Carcinoma: A Preliminary Study

OBJECTIVE

To evaluate the safety and efficacy of radiofrequency ablation (RFA) for metastatic lymph nodes (LNs) in children and adolescents with papillary Thyroid Carcinoma (PTC).

MATERIALS AND METHODS

From December 2014 to March 2018, 10 metastatic LNs(mean volume 0.30 ± 0.38 ml, range 0.06-1.23ml) in 5 children and adolescents (3 females, 2 males; mean age 15.60 ± 2.97 years, range 12-19 years) with PTC treated by RFA were evaluated in this study. The mean number of surgical procedures performed before RFA was 1.2 (range 1-2) and the mean number of treated metastatic LNs per patient was 2 (rang 1-3). RFA was performed with an 18-gauge bipolar RF applicator under local anesthesia. Follow-up consisted of US and serum thyroglobulin (Tg) level at 1, 3, 6, 12 months and every 12 months thereafter.

RESULTS

All the patients were well tolerant to RFA procedure and no procedure-related complications occurred. During a mean follow-up time of 52.00 ± 21.44 months, the initial volume of LNs was 0.30 ± 0.38 ml, which significantly decreased to 0.01 ± 0.03 ml (P = 0.005) with a mean VRR of 99.28 ± 2.27%. A total of 9 metastatic LNs (90.00%) completely disappeared. After RFA, 2 patients developed newly metastases. One patient had additional RFA. The other one with multiple LN metastases underwent total thyroidectomy with central neck dissection.

CONCLUSION

As a less invasive and effective technique, RFA may provide another alternative to the existing therapeutic modalities for cervical metastatic LNs in children and adolescents with PTC.

Potential therapies for residual hepatoblastoma following incomplete ablation treatment in a nude mouse subcutaneous xenograft model based on lncRNA and mRNA expression profiles

Tumor recurrence following radiofrequency ablation (RFA) treatment in liver cancer is an important factor affecting patient prognosis. Furthermore, the biological role of long non‑coding RNAs (lncRNAs) in residual hepatoblastoma (HB) tissues after RFA remains largely unknown. By using microarray technology, this study investigated the expression of lncRNAs and mRNAs among four pairs of HB tissues (incomplete ablation treatment and no treatment) in a nude mouse subcutaneous xenograft model. Subsequently, bioinformatics analysis was used to understand the functions and pathways of the identified mRNAs. Finally, a connectivity map (CMap) analysis was conducted to identify potential therapeutic strategies for residual HB tissues. Compared with the untreated nude mouse subcutaneous xenograft model, in the experimental group, a significant difference in the expression of 740 lncRNAs and 663 mRNAs was detected. Subsequently, bioinformatics analysis revealed that the differentially expressed mRNAs were significantly enriched in pathways associated with antigen processing, the presentation of endogenous antigens, the regulation of cellular metabolic processes, MAPK signaling and cell cycle regulation. Additionally, six compounds (valproic acid, metformin, tanespimycin, wortmannin, fulvestrant and MK‑886) were identified by CMap analysis as potential therapeutic agents for the treatment of residual HB tissues. These findings provide a novel insight into the pathogenesis of residual HB and potential therapeutic strategies for aggressive tumor recurrence following RFA treatment in patients with HB.

Technology and precision therapy delivery in childhood cancer

PURPOSE OF REVIEW

The purpose of this review is to describe current advances in pediatric precision therapy through innovations in technology and engineering. A multimodal approach of chemotherapy, surgery and/or radiation therapy has improved survival outcomes for pediatric cancer but with significant early and late toxicities. The pediatric population is particularly vulnerable given their age during treatment. Advances in precision interventions discussed include image guidance, ablation techniques, radiation therapy and novel drug delivery mechanisms that offer the potential for more targeted approach approaches with improved efficacy while limiting acute and late toxicities.

RECENT FINDINGS

Image-guidance provides improved treatment planning, real time monitoring and targeting when combined with ablative techniques and radiation therapy. Advances in drug delivery including radioisotopes, nanoparticles and antibody drug conjugates have shown benefit in adult malignancies with increasing use in pediatrics. These therapies alone and combined may lead to augmented local antitumor effect while sparing systemic exposure and potentially limiting early and late toxicities.

SUMMARY

Pediatric cancer medicine often requires a multimodal approach, each with early and late toxicities. Precision interventions and therapies offer promise for more targeted approaches in treating pediatric malignancies and require further investigation to determine long-term benefit.

How Do Synchronous Lung Metastases Influence the Surgical Management of Children with Hepatoblastoma? An Update and Systematic Review of the Literature

Approximately 20% of children with hepatoblastoma (HB) have metastatic disease at diagnosis, most frequently in the lungs. In children with HB, lung metastatic disease is associated with poorer prognosis. Its treatment has been approached with a variety of methods that integrate chemotherapy and surgical resection. The timing and feasibility of complete extirpation of lung metastases, by chemotherapy and/or metastasectomy, is crucial for the surgical treatment of the primary liver tumor, which can vary from major hepatic resections to liver transplantation (LT). In children with unresectable HB, which can be surgically treated only by LT, the persistence of unresectable metastases after neoadjuvant chemotherapy excludes the possibility of recurring to LT with consequent negative impact on patients' outcomes. Due to limited evidence and experience, there is no consensus amongst oncologists and surgeons across institutions regarding the surgical treatment for HB with synchronous metastatic lung disease. This narrative review aimed to update the current management of pulmonary metastasis in children with HB and to define its role in the decision-making strategy for the surgical approach to primary liver tumours.