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Fleming AM, Murphy AJ, Sarvode Mothi S, Interiano RB, Loh A, McCarville ME, Abramson Z, Mansfield SA, Abdelhafeez H, Davidoff AM, Gosain A, Gartrell JA, Furman WL, Langham MR. Aggressive Pursuit of No Evidence of Disease Status in Hepatoblastoma Improves Survival: An Observational Study. J Pediatr Surg 2023; 58:1081-1087. [PMID: 36906486 PMCID: PMC10198831 DOI: 10.1016/j.jpedsurg.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND The utility of repeated surgical interventions in hepatoblastoma to achieve no evidence of disease (NED) is not well-defined. We examined the effect of aggressive pursuit of NED status on event-free (EFS) and overall survival (OS) in hepatoblastoma with subgroup analysis of high-risk patients. METHODS Hospital records were queried for patients with hepatoblastoma from 2005 to 2021. Primary outcomes were OS and EFS stratified by risk and NED status. Group comparisons were performed using univariate analysis and simple logistic regression. Survival differences were compared with log-rank tests. RESULTS Fifty consecutive patients with hepatoblastoma were treated. Forty-one (82%) were rendered NED. NED was inversely correlated with 5-year mortality (OR 0.006; CI 0.001-0.056; P < .01). Ten-year OS (P < .01) and EFS (P < .01) were improved by achieving NED. Ten-year OS was similar between 24 high-risk and 26 not high-risk patients when NED was attained (P = .83). Fourteen high-risk patients underwent a median of 2.5 pulmonary metastasectomies, 7 for unilateral disease, and 7 for bilateral, with a median of 4.5 nodules resected. Five high-risk patients relapsed, and three were salvaged. CONCLUSIONS NED status is necessary for survival in hepatoblastoma. Repeated pulmonary metastasectomy and/or complex local control strategies to obtain NED can achieve long-term survival in high-risk patients. LEVEL OF EVIDENCE Level III - Treatment Study - Retrospective Comparative Study.
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Affiliation(s)
- Andrew M Fleming
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA.
| | - Andrew J Murphy
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA; Le Bonheur Children's Hospital, Department of Surgery, Memphis, TN, USA.
| | - Suraj Sarvode Mothi
- St. Jude Children's Research Hospital, Department of Biostatistics, Memphis, TN, USA
| | - Rodrigo B Interiano
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA; Le Bonheur Children's Hospital, Department of Surgery, Memphis, TN, USA
| | - Amos Loh
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA
| | - Mary E McCarville
- St. Jude Children's Research Hospital, Department of Diagnostic Imaging, Memphis, TN, USA
| | - Zachary Abramson
- St. Jude Children's Research Hospital, Department of Diagnostic Imaging, Memphis, TN, USA
| | - Sara A Mansfield
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA; Le Bonheur Children's Hospital, Department of Surgery, Memphis, TN, USA
| | - Hafeez Abdelhafeez
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA
| | - Andrew M Davidoff
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA
| | - Ankush Gosain
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA; Le Bonheur Children's Hospital, Department of Surgery, Memphis, TN, USA
| | - Jessica A Gartrell
- St. Jude Children's Research Hospital, Department of Oncology, Memphis, TN, USA
| | - Wayne L Furman
- St. Jude Children's Research Hospital, Department of Oncology, Memphis, TN, USA
| | - Max R Langham
- St. Jude Children's Research Hospital, Department of Surgery, Memphis, TN, USA; The University of Tennessee Health Science Center, Department of Surgery, Memphis, TN, USA; Le Bonheur Children's Hospital, Department of Surgery, Memphis, TN, USA
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Yu W, Liu X, Li J, Xi Z, Jin J, Huang H, Ge Y, Xia Q. A single-center retrospective analysis of childhood hepatoblastoma in China. Gland Surg 2020; 9:1502-1512. [PMID: 33224825 DOI: 10.21037/gs-20-710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to investigate the critical factors associated with prognosis for children with hepatoblastoma (HB) in mainland China combined with the aspect of health economics and management. Methods This study retrospectively reviewed children with HB in Renji Hospital Affiliated to the Shanghai Jiao Tong University School of Medicine from January 2013 to December 2019. Descriptive analysis was used to describe the essential characteristics. Kaplan-Meier method and Cox proportional hazard models were used to estimate the survival rate and prognosis factors. Results For the 87 children with HB, the average survival was 2,002.8 days (95% CI: 1,798.7-2,206.9 days), the 1- and 5-year survival rates were 87.7% and 78.9%, respectively. Undergoing surgery and sex were independent prognostic factors of childhood HB. Children with HB undergoing hepatectomy (HR: 0.039) or liver transplantation (HR: 0.142) had a better prognosis, while boys were associated with a poorer prognosis (HR: 3.614). The average medical expenses for childhood HB were 40,217.5±3,862.0 CNY and liver transplantation cost more than hepatectomy. Conclusions The results had a comparable survival rate with other studies globally. Surgical therapy and sex are associated with the prognosis of children with HB. The economic burden of childhood HB deserves to be further explored.
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Affiliation(s)
- Wenya Yu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Liu
- Department of Respiratory Disease, The 903rd Hospital of PLA, Hangzhou, China
| | - Jingquan Li
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhifeng Xi
- Department of Liver Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Jin
- Department of Liver Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongting Huang
- Department of Liver Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Ge
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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de Freitas Paganoti G, Tannuri ACA, Dantas Marques AC, Torres RR, Mendes Gibelli NE, Tannuri U. Extensive Hepatectomy as an Alternative to Liver Transplant in Advanced Hepatoblastoma: A New Protocol Used in a Pediatric Liver Transplantation Center. Transplant Proc 2019; 51:1605-1610. [PMID: 31155201 DOI: 10.1016/j.transproceed.2019.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Surgery is a key factor in the treatment of hepatoblastoma, but choosing between an aggressive resection and liver transplant may be an extremely difficult task. The aim of this study was to describe the outcomes of patients with advanced hepatoblastoma: pretreatment extent of disease (PRETEXT)/post-treatment extent of disease (POST-TEXT) III and IV undergoing aggressive resections or living donor liver transplant in cases involving the entire liver. Based on this experience, a new protocol for the treatment of these patients was proposed. METHODS A retrospective study included patients with advanced hepatoblastoma (POST-TEXT III and IV) who were referred for a liver transplant from 2010 to 2017. RESULTS A total of 24 children were included: 13 (54.2%) were male, with a median age at diagnosis of 42 months (range, 15-120 months), and a history of prematurity was identified in 20.8% of the patients. Ten cases (41.7%) were staged as PRETEXT/POST-TEXT III, and 12 cases (50.0%) were staged as PRETEXT/POST-TEXT IV. Two patients were referred after posthepatectomy recurrence. Five patients underwent a liver transplant, with recurrence and death in 2 patients (40.0%) within a mean period of 6 months. In the extensive hepatectomy group, there was recurrence in 6 patients (31.6%), with disease-free outcomes and overall survival in 63.2% and 94.7% of patients, respectively. CONCLUSION In cases of advanced hepatoblastoma, an extensive surgical approach is a valuable option. The fact that the team was fully prepared to proceed with living donor liver transplant allowed the surgeon to be more aggressive and to switch to transplantation when resection was not possible.
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Affiliation(s)
- G de Freitas Paganoti
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - A C A Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - A C Dantas Marques
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - R R Torres
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - N E Mendes Gibelli
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - U Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Ramos-Gonzalez G, LaQuaglia M, O'Neill AF, Elisofon S, Zurakowski D, Kim HB, Vakili K. Long-term outcomes of liver transplantation for hepatoblastoma: A single-center 14-year experience. Pediatr Transplant 2018; 22:e13250. [PMID: 29888545 DOI: 10.1111/petr.13250] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 12/25/2022]
Abstract
HB is the most common primary liver tumor in children. Complete tumor excision, either by partial resection or by total hepatectomy and liver transplantation, in combination with chemotherapy provides the best chance for cure. We performed a retrospective analysis of patients who underwent liver transplantation for HB and herein present our 14-year single-institution experience. Twenty-five patients underwent liver transplantation for HB at a median age of 26 months (IQR: 15-44). Graft survival was 96%, 87%, and 80% at 1, 3, and 5 years, respectively. There were four patient deaths, three of them due to disease recurrence within the first year post-transplant. Ten-year overall survival was 84%. Three recipients initially presented with pulmonary metastases and underwent resection of metastatic disease, of which two are alive at 3.9 years. Of three patients who underwent salvage transplants, two are alive at 1.5 years after transplant. Non-survivors were associated with lower median alpha fetoprotein value at presentation compared to survivors (21 707 vs 343 214; P = .04). In conclusion, the overall long-term outcome of primary liver transplantation for HB is excellent. Tumor recurrence was the highest contributor to mortality. Even patients with completely treated pulmonary metastases prior to transplant demonstrated a favorable survival.
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Affiliation(s)
| | | | - Allison F O'Neill
- Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Scott Elisofon
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Singh Y, Braeuning A, Schmid A, Pichler BJ, Schwarz M. Selective poisoning of Ctnnb1-mutated hepatoma cells in mouse liver tumors by a single application of acetaminophen. Arch Toxicol 2013; 87:1595-607. [DOI: 10.1007/s00204-013-1030-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/25/2013] [Indexed: 01/26/2023]
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Pediatric malignancies: neuroblastoma, Wilm's tumor, hepatoblastoma, rhabdomyosarcoma, and sacroccygeal teratoma. Surg Clin North Am 2012; 92:745-67, x. [PMID: 22595719 DOI: 10.1016/j.suc.2012.03.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Common pediatric malignancies are reviewed: neuroblastoma, Wilms tumor, hepatoblastoma, rhabdomyosarcoma, and sacrococcygeal teratoma. Elements of presentation, diagnosis, staging, treatment, and longterm prognosis are discussed, with particular attention to surgical management.
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8
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Di Benedetto F, Di Sandro S, D'Amico G, De Santis M, Gerunda GE. Role of chemoembolization as a rescue treatment for recurrence of resected hepatoblastoma in adult patients. Surg Innov 2011; 18:136-40. [PMID: 21247961 DOI: 10.1177/1553350610393990] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Hepatoblastoma is the most common malignant liver tumor in children, but it is extremely rare in adults. MATERIALS AND METHODS A 33-year-old man was admitted with nausea, vomiting, weight loss, and right upper quadrant pain. A preoperative magnetic resonance imaging showed a nodular hepatic lesion infiltrating the lesser curvature of the stomach. A left hepatectomy and a subtotal gastrectomy were performed. The histological diagnosis was hepatoblastoma. A recurrence in the right lobe was seen. RESULTS Three cycles of transcatheter arterial chemoembolization (TACE) were performed 40, 70, and 130 days after surgery. No sign of recurrence was present at the time of the second chemoembolization. CONCLUSION The TACE was well tolerated by the patient and controlled the recurrence. The patient survived 11 months after recurrence of disease and died 1 year after the liver resection. The use of TACE to treat the hepatic recurrence was never described.
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Lautz TB, Ben-Ami T, Tantemsapya N, Gosiengfiao Y, Superina RA. Successful nontransplant resection of POST-TEXT III and IV hepatoblastoma. Cancer 2010; 117:1976-83. [PMID: 21509775 DOI: 10.1002/cncr.25722] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 09/20/2010] [Accepted: 09/21/2010] [Indexed: 01/19/2023]
Abstract
BACKGROUND Liver transplantation is increasingly advocated as primary surgical therapy for children with hepatoblastoma involving 3 or 4 sectors of the liver after neoadjuvant chemotherapy. This study evaluated the results of nontransplant hepatectomy in children who might otherwise have been considered for liver transplantation. METHODS All children who underwent resection at a single institution from 1998 to 2009 for POST-TEXT IV or centrally located POST-TEXT III hepatoblastoma after neoadjuvant chemotherapy were reviewed. RESULTS Fourteen children (7 boys) with a median age of 8 months at diagnosis met study criteria. Pulmonary metastases in 3 patients were resected in 2 and resolved with chemotherapy in 1 patient. Preoperative grouping after neoadjuvant chemotherapy was POST-TEXT IV in 3 patients and POST-TEXT III in 11 patients. Thirteen of 14 (93%) children who underwent aggressive resection despite being potential candidates for primary transplantation were alive and tumor-free with a median follow-up of 57 months. Observed survival rates at 1, 2, and 5 years were 93%, 91%, and 88% respectively. Event-free survival rates at 1, 2, and 5 years were 93%, 91%, and 75%, respectively. CONCLUSIONS Excellent survival (93%) was obtained with aggressive resection in children with POST-TEXT III and IV hepatoblastoma meeting criteria for transplant referral. The 1 death occurred in a patient with unfavorable small cell histology. These children should be managed at institutions experienced in both advanced pediatric hepatobiliary surgery and transplantation. Operative exploration was frequently required to ultimately determine which tumors can be resected and which require transplantation.
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Affiliation(s)
- Timothy B Lautz
- Department of Surgery, Children's Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, Illinois 60614, USA
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10
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Malek MM, Shah SR, Atri P, Paredes JL, DiCicco LA, Sindhi R, Soltys KA, Mazariegos GV, Kane TD. Review of outcomes of primary liver cancers in children: our institutional experience with resection and transplantation. Surgery 2010; 148:778-82; discussion 782-4. [PMID: 20728194 DOI: 10.1016/j.surg.2010.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 07/12/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Operative intervention plays an important role in the management of primary liver cancers in children. Recent improvements in diagnostic modalities, pre- and postoperative chemotherapy, and operative technique have all led to improved survival in these patients. Both hepatic resection and orthotopic liver transplantation are effective operations for pediatric liver tumors; which intervention is pursued is based on preoperative extent of disease. This is a review of our institution's experience with operative management of pediatric liver cancer over an 18-year period. METHODS A retrospective chart review from 1990 to 2007 identified patients who were ≤18 years old who underwent operative intervention for primary liver cancer. Demographics, type of operation, intraoperative details, pre- and postoperative management, as well as outcomes were recorded for all patients. RESULTS Fifty-four patients underwent 57 operations for primary liver cancer, 30 of whom underwent resection; the remaining 27 underwent orthotopic liver transplantation. The mean age at diagnosis was 41 months. Twenty patients had stage 1 or 2 disease and 34 patients had stage 3 or 4 disease. Forty-eight (89%) patients received preoperative chemotherapy. Postoperative chemotherapy was given to 92% of patients. Mean overall and intensive care unit duration of stay were 18 and 6 days, respectively. About 45% of patients had a postoperative complication, including hepatic artery thrombosis (n = 8), line sepsis (n = 6), mild acute rejection (n = 3), biliary stricture (n = 2), pneumothorax (n = 2), incarcerated omentum (n = 1), Horner's syndrome (n = 1), and urosepsis (n = 1). Only 6 patients had a recurrence of their cancer, 5 after liver resection, 3 of whom later received a transplant. There was only 1 recurrence after liver transplantation. There was 1 perioperative mortality from cardiac arrest. Overall survival was 93%. CONCLUSION Operative intervention plays a critical role in the management of primary liver cancer in the pediatric population. Neoadjuvant chemotherapy can be given if the tumor seems unresectable at diagnosis. If chemotherapy is unable to sufficiently downstage the tumor, orthotopic liver transplantation becomes the patient's best option. Our institution has had considerable experience with both resection and liver transplantation in the treatment of pediatric primary liver cancer, with good long-term outcomes.
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Affiliation(s)
- Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center, Children's Hospital of UPMC, Pittsburgh, PA 15224, USA
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Heifetz SA, French M, Correa M, Grosfeld JL. Hepatoblastoma: The Indiana Experience with Preoperative Chemotherapy for Inoperable Tumors; Clinicopathological Considerations. ACTA ACUST UNITED AC 2010. [DOI: 10.1080/15513819709168750] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Meyers RL, Rowland JR, Krailo M, Chen Z, Katzenstein HM, Malogolowkin MH. Predictive power of pretreatment prognostic factors in children with hepatoblastoma: a report from the Children's Oncology Group. Pediatr Blood Cancer 2009; 53:1016-22. [PMID: 19588519 PMCID: PMC4408767 DOI: 10.1002/pbc.22088] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND PRETEXT is used to stratify risk in children with hepatoblastoma by the Liver Tumor Strategy Group (SIOPEL) of the International Society of Pediatric Oncology (SIOP). A recent analysis excluding patients that did not survive neoadjuvant chemotherapy, concluded that PRETEXT was superior to Children's Oncology Group (COG) stage for predicting survival. Puzzled by this result, we made a similar comparison of PRETEXT and COG stage. This time, however, we include all patients, and we compare predictive value at diagnosis, instead of after neoadjuvant chemotherapy. METHODS Hepatoblastoma patients in INT-0098 were retrospectively reviewed for PRETEXT and other potential prognostic factors including pathologic subtype, and alpha-fetoprotein (AFP). RESULTS Five-year overall survival by PRETEXT was 88.9%, 84.5%, 71.6%, and 30.9%, for PRETEXT I, II, III, and IV, respectively. The 5-year overall survival rates by COG stage were 100%, 97.5%, 100%, 70.2%, and 39.3% for Stage I pure fetal histology (PFH), Stage I unfavorable histology (UH = not PFH), Stage II, Stage III, and Stage IV, respectively. PRETEXT added significant additional prognostic information within the COG Stage III, but not COG Stage IV. Additional prognostic factors statistically significant for an increased risk of death were small-cell-undifferentiated (SCU) histologic subtype and AFP < 100 at diagnosis. CONCLUSIONS PRETEXT, COG stage, SCU histology, and AFP < 100, as assessed at diagnosis, are important determinants of survival that will allow us to better develop common international criteria for risk stratification. Common risk stratification is an essential prerequisite to establish effective cooperation across the ocean in this field of rare tumors.
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Affiliation(s)
- Rebecka L. Meyers
- Division of Pediatric Surgery, University of Utah, Primary Children’s Medical Center
| | - Jon R. Rowland
- Division of Pediatric Pathology, Oakland Children’s Hospital
| | - Mark Krailo
- Keck School of Medicine, University of Southern California, Los Angeles, CA Cure Search, Children’s Oncology Group, Arcadia, California
| | - Zhengjia Chen
- Keck School of Medicine, University of Southern California, Los Angeles, CA Cure Search, Children’s Oncology Group, Arcadia, California
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Browne M, Sher D, Grant D, Deluca E, Alonso E, Whitington PF, Superina RA. Survival after liver transplantation for hepatoblastoma: a 2-center experience. J Pediatr Surg 2008; 43:1973-81. [PMID: 18970927 DOI: 10.1016/j.jpedsurg.2008.05.031] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Revised: 05/16/2008] [Accepted: 05/20/2008] [Indexed: 11/30/2022]
Abstract
PURPOSE Complete resection with adjuvant chemotherapy is the accepted treatment for hepatoblastoma. The aim of this study is to evaluate our results of liver transplantation (LT) for tumors still unresectable after adequate chemotherapy. METHODS All patients transplanted for hepatoblastoma from 2 institutions between 1990 and 2004 were included. Variables reviewed to determine impact on survival included the following: previous tumor resection, metastatic disease at diagnosis, microscopic vascular invasion, alpha-fetoprotein (AFP) levels at diagnosis and at transplant, tumor histology, and administration of posttransplantation chemotherapy. Effectiveness of pretransplantation chemotherapy was defined as a drop of more than 99% in peak AFP levels. RESULTS Fourteen patients were transplanted: 9 boys and 5 girls (age range, 18 months-13 years; mean age, 57 +/- 48 months). Patients were transplanted a mean of 4 +/- 1 months after diagnosis. Overall survival was 71% (10/14) with a mean follow-up of 46 months. All deaths were secondary to recurrent tumor. Of 10 patients who underwent a primary LT, 9 survived compared to only 1 of 4 transplanted for unresectable tumor recurrence after primary resection (90% vs 25%; P = .02). Decline in peak AFP of more than 99% was also associated with better survival (100% vs 56%; P = .08). Similarly, patients who received posttransplantation chemotherapy had 100% survival compared with 56% without chemotherapy (P = .08). Other variables had little effect on survival. CONCLUSIONS Liver transplantation is a successful treatment option for children with unresectable hepatoblastoma with a 90% survival rate for primary transplantation. Rescue LT for recurrent hepatoblastoma after previous resection has a poor survival outcome and should be considered a relative contraindication. Posttransplantation chemotherapy improves survival. A prospective multicenter collaboration to validate these findings with a larger patient population is necessary. Until that time, patients who receive rescue transplants should receive posttransplantation chemotherapy.
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Affiliation(s)
- Marybeth Browne
- Department of Surgery, Children's Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL 60614, USA
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Szavay PO, Luithle T, Warmann SW, Geerlings H, Ure BM, Fuchs J. Impact of pedicle clamping in pediatric liver resection. Surg Oncol 2008; 17:17-22. [PMID: 17855078 DOI: 10.1016/j.suronc.2007.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 07/17/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vascular clamping techniques are commonly used but so far the impact on pediatric liver surgery has not been investigated. The purpose of this study was to analyze pedicle clamping during pediatric liver resection in terms of hepato-cellular injury and blood loss. METHODS Sixty-seven children undergoing liver resection were analyzed retrospectively. Vascular clamping was used in 28 cases (PC group), in 39 the resection was performed without clamping (NPC group). Major hepatectomies (resection of more than three segments) were carried out in 88%, minor hepatectomies (resection of three and less segments) in 12% of patients. Twenty-six children underwent extended liver resection. Patient data, liver function tests (LFTs) and blood loss were analyzed statistically. RESULTS There were no significant differences in patient preoperative and postoperative data and LFTs between the groups. Within the NPC group the amount of administered fresh frozen plasma (FFP) in total and per kilogram (FFP/kg) was significantly higher (p=0.023 and 0.028) than in the PC group. For patients with extended liver resection, operation times were significantly longer (p=0.016) in the group without vascular clamping (NPCext). In the NPCext group significantly more children required packed red cells, FFP and FFP/kg. LFTs showed no significant differences in all children regardless of vascular clamping. CONCLUSIONS For children undergoing liver resection, vascular clamping offers a blood saving surgical technique. Postoperative LFTs were not statistically different, regardless of vascular clamping. Pedicle clamping proved to be a safe method, not associated with an increase in perioperative complications.
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Affiliation(s)
- Philipp O Szavay
- Department of Pediatric Surgery, Children's Hospital, University of Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany.
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Pham TH, Iqbal CW, Grams JM, Zarroug AE, Wall JCH, Ishitani MB, Nagorney DM, Moir C. Outcomes of primary liver cancer in children: an appraisal of experience. J Pediatr Surg 2007; 42:834-9. [PMID: 17502194 DOI: 10.1016/j.jpedsurg.2006.12.065] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Hepatoblastoma (HB) and hepatocellular carcinoma (HCC) are the most common primary liver cancers in children. Recent advances in management of pediatric liver cancer have improved disease-specific survival (DSS). This is a review of our experience with childhood liver malignancy over the past 3 decades. MATERIALS AND METHODS A retrospective chart review from 1975 to 2005 identified patients who were 18 years old or younger with a histologically confirmed diagnosis of primary liver cancer. Patients were staged according to the Children's Cancer Group and Pediatric Oncology Group (CCG/POG) system. Patients were followed up prospectively through clinic visits and mail correspondence. Standard statistical methods were used for comparison, risk, and survival analyses. RESULTS Fifty-two patients were confirmed to have primary liver cancers, where 24 (46%) patients had HB, 22 (42%) had HCC, 3 (6%) had sarcomas, and 3 (6%) had other histologies. Mean ages at presentation for HB and HCC were 3.2 and 13.1 years old, respectively. The most common presentations were abdominal mass (67%) and pain (40%). Most patients underwent major liver resection (n = 45, 87%), including: lobectomy (n = 25, 48%), and trisegmentectomy (n = 11, 21%). Three patients underwent liver transplantation (n = 3, 6%) for advanced local disease. Forty-five (87%) received primary or neoadjuvant and/or adjuvant chemotherapy. Patients had the following CCG/POG stages: I (n = 31, 60%), II (n = 6, 11.5%), III (n = 9, 17%), and IV (n = 6, 11.5%). Complete gross resection (stage I and II) was achieved in 37 (71%) patients. The perioperative mortality and morbidity rates were 0% and 29%, respectively. Patients with complete resection had significantly better 5-year DSS and median survival compared with incomplete gross resection: 62% vs 9% and 216 vs 18 months, P < .001. Patients treated during the period 1995-2005 had better 5-year DSS and median survival compared with those treated during 1975-1994: 68% vs 32% and 117 vs 27 months, P = .032. All 3 patients who underwent transplantation for conventionally unresectable disease are alive without disease recurrence (follow-up period, 1-15 years). CONCLUSION Complete resection of the pediatric primary liver tumors remains the cornerstone of treatment to achieve cure. Major liver resection can be performed with minimal perioperative mortality and morbidity. Patients with HB appeared to have better survival compared with patients with HCC, and there was significant improvement in the DSS of children treated in the recent decade. Liver transplantation in conjunction with chemotherapy may have an increasing role in the management of locally advanced primary liver cancers.
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Affiliation(s)
- Tuan H Pham
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Casas-Melley AT, Malatack J, Consolini D, Mann K, Raab C, Flynn L, Woolfrey P, Menendez J, Dunn SP. Successful liver transplant for unresectable hepatoblastoma. J Pediatr Surg 2007; 42:184-7. [PMID: 17208562 DOI: 10.1016/j.jpedsurg.2006.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of children with stage III and IV hepatoblastoma has shown little improvement with 5-year survival rates of 64% and 25%, respectively (J Clin Oncol 2000;18:2665-75). A timely and organized treatment program including preoperative chemotherapy combined with living donor liver transplantation and postoperative chemotherapy has been used seeking improved long-term survival in stage III and IV cases. METHODS A retrospective review of 8 patients with stage III and IV hepatoblastoma unresectable by conventional resection were treated with complete hepatectomy and transplantation. Approval was obtained from our institutional review board. RESULTS Since August of 2001, we have treated 6 patients with stage III hepatoblastoma and 2 patients with initial stage IV hepatoblastoma. These patients (age, 23 months-9 years) had all received extensive chemotherapy or prior resections. After chemotherapy, none had gross tumor documented outside of the liver at time of transplantation. All underwent hepatectomy including vena cava resection, in selected cases, with living donor orthotopic liver transplantation. All patients had at least 2 cycles of postoperative chemotherapy. Of 8 patients, 6 are alive and well with normalized alpha-fetoprotein levels. There were 2 late deaths from recurrent disease. Length of follow-up ranged from 7 to 53 months. CONCLUSION Complete hepatectomy with living donor liver transplantation provides optimal surgical treatment in unresectable stage III and initial stage IV disease confined to the liver at resection. This series indicates that children tolerate complete hepatectomy, transplantation, and postoperative chemotherapy well. Referral to a transplant center during the first 3 cycles of chemotherapy appears to offers the best opportunity for long-term survival.
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Affiliation(s)
- Adela T Casas-Melley
- Division of Solid Organ Transplant, AI duPont Hospital for Children, PO Box 269, Wilmington, DE 19899, USA.
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17
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Hepatoblastoma: transplantation for unresectable disease. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000244653.90414.7b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Saenz NC. Pediatric Hepatic Tumors. Surg Oncol 2006. [DOI: 10.1007/0-387-21701-0_57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ekinci S, Karnak I, Tanyel FC, Senocak ME, Kutluk T, Büyükpamukçu M, Büyükpamukçu N. Hepatic lobectomies in children: experience of a center in the light of changing management of malignant liver tumors. Pediatr Surg Int 2006; 22:228-32. [PMID: 16395609 DOI: 10.1007/s00383-005-1608-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2005] [Indexed: 11/26/2022]
Abstract
Hepatic resection is the main treatment modality for hepatic tumors in childhood. Advances in diagnostic technique, preoperative preparation, surgical technique, and postoperative management increased the success rate. The aim of this study is to report our experience in hepatic lobectomy, which is relatively rare procedure in childhood. Medical records of 25 patients who underwent hepatic lobectomy between January 1977 and June 2002 were reviewed retrospectively. Age, gender, diagnosis, physical examination findings, results of preoperative laboratory investigations, radiological examination, resectability criteria, preoperative biopsies, chemotherapies, radiotherapies, postoperative pathological results, incisions, operation technique, intraoperative transfusions, drains used, antibiotic prophylaxes, and intraoperative and postoperative complications were evaluated for all patients. Out of 25 patients with hepatic tumor seven patients with hepatoblastoma and four patients with hepatocellular carcinoma were given 5.7 +/- 0.3 cycles of chemotherapy before the operation. Right lobectomy (n = 12), left lobectomy (n = 5), extended left lobectomy (n = 4), and extended right lobectomy (n = 3) and right lobectomy with enucleation of two masses from left lobe (n = 1) were performed. Intraoperative blood transfusion of 30.7+/-6.0 ml/kg body weight was necessary. Pathological examination of resected tumors revealed hepatoblastoma (n=11), mesenchymal hamartoma (n = 5), hepatocellular carcinoma (n = 4), hemangioendothelioma (n=1), malignant mesenchymal tumor (n = 1), hemangioma (n = 1), cyst adenoma (n = 1), and metastasis of cellular mesoblastic nephroma (n = 1). Patients were observed in the intensive care unit for 3.4 +/- 0.3 days. Postoperative complications were sepsis (n = 1), disseminated intravascular coagulation (n = 2), fever (n = 3), jaundice (n = 3), intraabdominal abscess (n = 3), ileus (n = 2), and subdiaphragmatic abscess with pleural effusion (n = 1). Hepatic lobectomy is a major operation, which is feasible yielding curative results in children. Safe hepatic resections with acceptable blood loss can be performed by a technique relying on good anatomic dissection and surgical control.
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Affiliation(s)
- Saniye Ekinci
- Department of Pediatric Surgery, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
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Schnater JM, Kuijper CF, Zsiros J, Heij HA, Aronson DC. Pre-operative diagnostic biopsy and surgery in paediatric liver tumours--the Amsterdam experience. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2005; 31:1160-5. [PMID: 16157464 DOI: 10.1016/j.ejso.2005.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Revised: 07/18/2005] [Accepted: 07/28/2005] [Indexed: 11/15/2022]
Abstract
AIM To report 24 years of pre-treatment biopsy and surgical experience in primary liver tumours in children. METHODS Between 1979 and 2003, 53 children presented with a primary liver tumour of whom 48 who underwent surgical resection were evaluated (two died, two were unresectable, and one was transplanted). Biopsy data, per- and post-operative complications, mortality, and survival were retrospectively reviewed. RESULTS Benign tumours were diagnosed in eight patients. Surgical resection for a malignant tumour was performed in 40 patients (26 hepatoblastomas (HB), eight hepatocellular carcinomas (HCC) (four had fibrolamellar HCC), three rhabdomyosarcomas (RMS), one neuroblastoma, one non-hodgkin lymphoma (NHL), and one teratoma). Primary resection was performed in one HB, and four HCCs. The cumulative survival without evidence of disease was 73% for HB (median 7 years) and 88% for HCC (median 3.5 years). CONCLUSION The treatment results are comparable with those of larger international series except for HCC. The existing diagnostic pitfalls in differentiating between the various liver malignancies justify the use of a diagnostic biopsy.
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Affiliation(s)
- J M Schnater
- Pediatric Surgical Centre, Emma Children's Hospital AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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21
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Bajpai M, Pal K, Agarwala S, Seth T, Gupta AK. Midterm results with hepatectomy after preoperative chemotherapy in hepatoblastoma. Pediatr Surg Int 2005; 21:364-8. [PMID: 15838617 DOI: 10.1007/s00383-005-1381-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2005] [Indexed: 10/25/2022]
Abstract
We evaluated the results of surgical treatment for hepatoblastoma in infants and children after intensive preoperative chemotherapy, with special reference to histology and extent of liver involvement. The clinical features of 10 children with hepatoblastoma were reviewed regarding response to neoadjuvant chemotherapy, histological subtypes, extent of hepatectomy, operative complications, and prognosis. Response to chemotherapy was measured by volumetric assessment of tumour size by computed tomography scan. Cisplatin and Adriamycin (PLADO regime) up to three cycles markedly reduced the tumour volume on computed tomography (mean regression rate 65.9%); alpha-foetoprotein (AFP) levels also decreased from an initial mean of 16,116.4 ng/ml to 2,050.9 ng/ml. Five patients underwent right hepatectomy, two had right trisegmentectomy, two had left hepatectomy, and one had left trisegmentectomy. Histopathology of resected specimens revealed foetal histology in four patients, poorly differentiated (anaplastic) subtype in three, and mixed histology with mesenchymal components and osteoid formation in three. There was 100% resectability including six unresectable tumours (prechemotherapy). Moreover, hepatic resection tended to be less invasive in patients whose tumours had been much reduced after preoperative chemotherapy. Preoperative administration of cisplatin and Adriamycin reduces the tumour size significantly so that a safe radical hepatectomy can be performed. It also allows early administration of postoperative chemotherapy. Although overall good results were obtained with the current protocol, we also document our experience of unfavourable outcomes in patients with bilobar tumours (despite trisegmentectomy), patients with tumours showing poor response to neoadjuvant chemotherapy, and patients with anaplastic histology. Overall, at a 60-month follow-up we report an 80% survival rate by a combined approach.
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Affiliation(s)
- Minu Bajpai
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, 110029, India.
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22
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The current management of hepatoblastoma: a combination of chemotherapy, conventional resection, and liver transplantation. J Pediatr 2005; 146:204-11. [PMID: 15689909 DOI: 10.1016/j.jpeds.2004.09.011] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To review our experience in the management of children who present with hepatoblastoma. STUDY DESIGN Thirty patients treated for hepatoblastoma at a single institution were reviewed. RESULTS Ten patients presented with stage I to stage II disease and underwent resection. Seventeen presented with stage III disease; two underwent initial resection of which one required rescue transplantation. The remaining 15 underwent biopsies, which were followed by chemotherapy. Nine patients had a reduction in tumor size and underwent conventional resection. One required rescue transplantation for residual disease. Five patients underwent primary transplantation for unresectable disease. One patient expired during chemotherapy. Three patients presented with stage IV disease and underwent biopsies, which were followed by chemotherapy. One patient responded but required "rescue" transplantation after conventional resection. Seven patients underwent aggressive conventional resection (trisegmentectomy or central liver resection); three had positive surgical margins and underwent transplantation. One developed recurrent disease. Five-year survival was 82.5% +/- 7.1%. There was no operative mortality during surgical therapy. All transplant recipients were tumor free, but one died from lymphoma 7 years post-transplant. CONCLUSION Chemotherapy may reduce tumor size, allowing for conventional resection. If aggressive resection is necessary or bi-lobar disease persists, primary transplantation is recommended.
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Abstract
Primary hepatic neoplasms in children are relatively infrequent, accounting for between 0.5 and 2.0% of all pediatric neoplasms. They are a diverse group of epithelial and mesenchymal tumors whose incidence can vary considerably with patient age. They are clinically relevant tumors however as two thirds of them are malignant. The therapy of these tumors has evolved over time and it currently involves a combination of surgery, adjuvant and neoadjuvant chemotherapy and possible transplantation.
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Affiliation(s)
- Sukru Emre
- Recanati/Miller Transplantation Institute, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
BACKGROUND Many patients with hepatoblastoma present with unresectable disease. Neoadjuvant therapy has improved resectability rates to as high as 70% to 90%. Despite this improvement, many patients will be left with tumors that are of borderline resectability. The authors hypothesize that favorable outcomes may be achieved even with resection margins less than 1 cm thus sparing the need for liver transplantation. METHODS Between January 1981 and March 2003, 23 patients age less than 16 years with a diagnosis of hepatoblastoma undergoing surgical resection were identified. The clinical characteristics, pathologic resection margins, and survival status were reviewed. RESULTS Eighteen (78%) of the patients were alive with no evidence of recurrence at last follow-up. Thirteen (56.5%) had > or =1 cm resection margins, whereas 10 (43.5%) had resection margins less than 1 cm. Eleven (47.8%) presented with PRETEXT III tumors. There was no significant difference in survival rate between resection margins less than 1 cm and > or =1 cm (P =.13; 95% CI 0.91 to 2.61). Thirteen patients (56.5%) presented with synchronous pulmonary metastatic disease, where survival was significantly worse (P =.04; 95% CI 1.10 to 2.50). Subgroup analysis confirmed that margins less than 1 cm did not significantly affect survival after controlling for pulmonary metastatic disease (P =.56; 95% CI 0.71 to 3.61). CONCLUSIONS Surgical resection with margins less than 1 cm are associated with survival that is equivalent to resection with margins > or =1 cm. Our findings suggest it is preferable to preserve key structures with a small resection margin and therefore spare the need for liver transplantation in patients with advanced hepatoblastoma.
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Affiliation(s)
- Bryan J Dicken
- Department of Surgery, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Otte JB, Pritchard J, Aronson DC, Brown J, Czauderna P, Maibach R, Perilongo G, Shafford E, Plaschkes J. Liver transplantation for hepatoblastoma: results from the International Society of Pediatric Oncology (SIOP) study SIOPEL-1 and review of the world experience. Pediatr Blood Cancer 2004; 42:74-83. [PMID: 14752798 DOI: 10.1002/pbc.10376] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND For hepatoblastoma (HB) that remains unresectable by partial hepatectomy after chemotherapy, total hepatectomy with orthotopic liver transplantation (LTX) has been advocated as the best treatment option. The role of LTX in the overall management of HB is still, however, unclear. PROCEDURE The results of LTX from the first study of HB by the International Society of Pediatric Oncology, SIOPEL-1, were analyzed. In addition, the world experience of LTX for HB was extensively reviewed. Twelve patients in the SIOPEL-1 study underwent a LTX. Median (range) follow-up at Dec. 31, 2001 was 117 months (52-125) since LTX. RESULTS Overall survival at 10 years post-LTX was 85% for the seven children who received a "primary LTX" and 40% for the 5 children who underwent a "rescue LTX" after previous partial hepatectomy. In the world experience (147 cases), the overall survival rate at 6 year post-LTX was 82% for 106 patients who received a "primary LTX" and 30% for 41 patients who underwent a "rescue LTX." Multivariate analysis of patients undergoing primary LTX showed that only macroscopic venous invasion had a significant impact (P-value: 0.045 with a hazard ratio of 2.96) on overall survival. CONCLUSIONS Orthotopic LTX has added a new dimension to the treatment of HB unresectable by partial hepatectomy. Because of the rarity of the disease and to optimize results, children with extensive HB should be treated in centers with surgical expertise in pediatric major liver resection and LTX, in close collaboration with pediatric oncologists, radiologists, and histopathologists.
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Affiliation(s)
- J B Otte
- Department of Pediatric Surgery and Liver Transplantation, Université Catholique de Louvain, Cliniques Saint-Luc, Brussels, Belgium.
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Cillo U, Ciarleglio FA, Bassanello M, Brolese A, Vitale A, Boccagni P, Zanus G, Zancan L, D'Antiga L, Dall'igna P, Montin U, Gringeri E, Carraro A, Cappuzzo G, Violi P, Baldessin M, Bridda A, D'Amico DF, Perilongo G. Liver transplantation for the management of hepatoblastoma. Transplant Proc 2003; 35:2983-5. [PMID: 14697956 DOI: 10.1016/j.transproceed.2003.10.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Hepatoblastoma (HEP) is the most frequent liver malignancy occurring in childhood. Surgical resection currently represents the gold standard for treatment. In patients with initially unresectable tumors, chemotherapy may induce remarkable reductions in size. In nonresponder patients, liver transplantation (OLTx) may offer a chance of cure. MATERIALS AND METHODS From 1990 to 2003, a total of 400 OLTx (31 pediatric transplants) have been performed at Padua University. Seven patients (4 males and 3 females) underwent OLTx for hepatoblastoma. All patients presented with bilobar liver involvement and had received chemotherapy according to the SIOPEL-1. In all patients preoperative staging was negative for extrahepatic involvement. RESULTS The mean age of the pts was 8.2 years (range 6.4 months to 34 years). Mean follow-up after OLTx was 41.4 months (median 36, range 3 to 108 months). Actuarial patient survival rates after OLTx for hepatoblastoma are 83.3%, 83.3%, and 56% at 1, 3, and 5 years, respectively. Five of seven subjects with HEP are alive after transplant at 3, 12, 36, 65, and 108 months. Two patients died owing to recurrent disease after 6 and 60 months, respectively, from transplantation. Another subject, primarily treated with surgical resection, shows HEP recurrence at 40 months after OLTx. The remaining 4 patients are alive and well at a mean follow-up of 28 months (median 24, range 3 to 65 months). CONCLUSIONS Liver transplantation may represent a valid therapeutic option for patients with unresectable HEP, but it is contraindicated in cases of recurrence following previous resection surgery. Neo-adjuvant chemotherapy is of paramount importance to obtain good long-term results.
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Affiliation(s)
- U Cillo
- Clinica Chirurgica 1 and Liver Transplantation Unit, P.G. Cevese Department of Surgical and Gastroenterological Sciences, Padua University, Via Giustiniani 2, Padua 35128, Italy
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Warmann S, Göhring G, Teichmann B, Geerlings H, Fuchs J. MDR1 modulators improve the chemotherapy response of human hepatoblastoma to doxorubicin in vitro. J Pediatr Surg 2002; 37:1579-84. [PMID: 12407543 DOI: 10.1053/jpsu.2002.36188] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE P-glycoprotein, a membrane efflux pump encoded by the MDR1 gene, plays an important role in the development of multidrug resistance in human hepatoblastoma (HB). Chemosensitizers antagonize the efflux action of P-glycoprotein. This study investigates the effects of 3 chemosensitizers (the cyclosporin analogue SDZ PSC 833 (PSC 833), the acridone carboxamide derivative GG 918, and verapamil) on the chemotherapy of HB in vitro. METHODS The doxorubicin (DOXO) concentration that produces 50% growth inhibition (IC50) in a HB cell line was determined and additional effects of PSC 833, GG 918, and verapamil were investigated in a cytotoxicity assay. The MDR1 gene expression after treatment was determined in a semiquantitative reverse transcription polymerase chain reaction approach. RESULTS The IC50 of DOXO is 2.5 microg/mL, 0.61 microg/mL for DOXO + PSC 833, 1.17 microg/mL for DOXO + verapamil, and 1.47 microg/mL for DOXO + GG 918. In combination with DOXO, cell growth was inhibited 4.1-fold by PSC 833, 2.1-fold by verapamil, and 1.9-fold by GG 918. The MDR1 gene expression was enhanced significantly in all treated cells, with and without modulator. CONCLUSIONS MDR1 modulators significantly improve the response of HB to DOXO in vitro. The combination of anticancer agents and MDR1 modulators might be a possible contribution to overcome multidrug resistance in HB.
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Affiliation(s)
- Steven Warmann
- Department of Pediatric Surgery, University of Tübingen, Germany
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Srinivasan P, McCall J, Pritchard J, Dhawan A, Baker A, Vergani GM, Muiesan P, Rela M, David Heaton N. Orthotopic liver transplantation for unresectable hepatoblastoma. Transplantation 2002; 74:652-5. [PMID: 12352881 DOI: 10.1097/00007890-200209150-00011] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The outcome of treatment for advanced hepatoblastoma has recently improved after the introduction of preoperative or pre- and postoperative cisplatin-containing chemotherapy combined with complete surgical excision. The role of liver transplantation in a population of patients who have received this regimen has not been clearly defined. METHODS Orthotopic liver transplantation (OLT) was performed in 13 children, aged 5 months to 11 years (median 27 months), who were assessed with unresectable hepatoblastoma, and whose pretreatment extent-of-disease was based on radiologic findings of group III (n=11) and group IV (n=2). One child with a multifocal tumor showed pulmonary metastases at presentation, but, according to radiologic studies, the deposits resolved with chemotherapy before liver transplantation. One other child showed exophytic extension of the primary tumor infiltrating the porta hepatis and body of the pancreas. All 13 patients received preoperative chemotherapy to reduce the size of the primary tumor(s) and to treat metastatic spread. RESULTS Twelve children underwent elective OLT; all are alive and show normal graft function at a mean follow-up of 33 months (range 1-108). One child shows evidence of recurrent disease in the form of pulmonary metastases. One child underwent emergency OLT for acute liver failure after (incomplete) extended right hepatectomy and died from respiratory failure, with no evidence of recurrent tumor 3 weeks posttransplant. CONCLUSIONS Liver transplantation is an effective treatment for unresectable unifocal or multifocal hepatoblastoma confined to the liver. A multidisciplinary approach to the management of hepatoblastoma, with thoughtful collaboration between pediatric oncologists, hepatologists, and liver surgeons, is essential.
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Affiliation(s)
- Parthi Srinivasan
- Liver Transplant Surgical Service, Institute of Liver Studies, London, UK
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Katzenstein HM, London WB, Douglass EC, Reynolds M, Plaschkes J, Finegold MJ, Bowman LC. Treatment of unresectable and metastatic hepatoblastoma: a pediatric oncology group phase II study. J Clin Oncol 2002; 20:3438-44. [PMID: 12177104 DOI: 10.1200/jco.2002.07.400] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To estimate the disease-response rate, proportion of patients whose tumors can be made resectable, event-free survival (EFS), and toxicity in children with unresectable or metastatic hepatoblastoma (HB) after sequential treatment with the following: (1) carboplatin (CARBO); (2) CARBO, vincristine, and fluorouracil (CARBO-VCR-5-FU); and (3) high-dose cisplatin and etoposide (HDDP-ETOP). PATIENTS AND METHODS Thirty-three assessable patients with stage III (n = 22) and stage IV (n = 11) HB were treated sequentially with one course of CARBO (700 mg/m(2)), followed by three courses of CARBO (700 mg/m(2)), day 0; 5-FU (1,000 mg/m(2)/d), by continuous infusion days 0 to 2; and VCR (1.5 mg/m(2)), days 0, 7, and 14. After that therapy, patients whose tumors were resectable underwent surgery and then received two additional courses of CARBO-VCR-5-FU. Children whose tumors remained unresectable after CARBO-VCR-5-FU or who demonstrated no response or progressive disease during this therapy received two courses of HDDP (40 mg/m(2)/d), days 1 to 5; and ETOP (100 mg/m(2)/d), days 2 to 4. RESULTS Five-year EFS estimates were 59% +/- 11% for stage III disease (n = 22) and 27% +/- 16% for stage IV disease (n = 11), respectively (P =.037). Twenty-seven (82%) of 33 patients had at least a partial response to chemotherapy; 18 (55%) of 33 responded to CARBO; 24 (80%) of 30 responded to CARBO and CARBO-VCR-5-FU; and nine (75%) of 12 responded to HDDP-ETOP. Surgical resection was achieved in 19 (58%) of 33 patients, including 15 (68%) of 22 stage III patients and four (36%) of 11 stage IV patients. Five-year EFS for patients whose tumors were completely resected was 79% +/- 10%. CONCLUSION Patients treated sequentially with CARBO, CARBO-VCR-5-FU, and HDDP-ETOP had response rates and EFS comparable to other therapeutic regimens. This regimen is effective in treating localized, unresectable HB and potentially has less toxicity than other regimens. Novel approaches are needed for patients with metastatic disease.
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Affiliation(s)
- Howard M Katzenstein
- Department of Pediatrics and Surgery, Northwestern University and Children's Memorial Hospital, Chicago, IL, USA.
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Fuchs J, Rydzynski J, Von Schweinitz D, Bode U, Hecker H, Weinel P, Bürger D, Harms D, Erttmann R, Oldhafer K, Mildenberger H. Pretreatment prognostic factors and treatment results in children with hepatoblastoma: a report from the German Cooperative Pediatric Liver Tumor Study HB 94. Cancer 2002; 95:172-82. [PMID: 12115331 DOI: 10.1002/cncr.10632] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Jörg Fuchs
- Department of Pediatric Surgery, University of Tuebingen, Tuebingen, Germany.
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31
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Affiliation(s)
- M Reynolds
- Children's Memorial Hospital, Chicago, IL, USA
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Schnater JM, Aronson DC, Plaschkes J, Perilongo G, Brown J, Otte JB, Brugieres L, Czauderna P, MacKinlay G, Vos A. Surgical view of the treatment of patients with hepatoblastoma: results from the first prospective trial of the International Society of Pediatric Oncology Liver Tumor Study Group. Cancer 2002. [PMID: 11920482 DOI: 10.1002/cncr.10282] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Surgical resection is the cornerstone of treatment for patients with hepatoblastoma (HB). The Society of Pediatric Oncology Liver Tumor Study Group launched its first prospective trial (SIOPEL-1) with the intention to treat all patients with preoperative chemotherapy and delayed surgical resection. The objective of this article was to assess the assumed surgical advantages of primary chemotherapy. METHODS Between 1990 and 1994, 154 patients age < 16 years with HB were registered on SIOPEL-1. The pretreatment extent of disease was assessed, and, after undergoing biopsy, patients were treated with cisplatin 80 mg/m(2) intravenously over 24 hours and doxorubicin 60 mg/m(2) intravenously over 48 hours by continuous infusion (PLADO). Generally, tumors were resected after four of a total of six courses of PLADO. RESULTS One hundred twenty eight patients underwent surgical resection (13 patients underwent primary surgery, and 115 patients underwent delayed surgery after PLADO). A pretreatment surgical biopsy was performed in 96 of 128 patients (75%). Biopsy complications occurred in 7 of 96 patients (7%). Twenty-two patients showed pulmonary metastases at the time of diagnosis, and 7 patients underwent thoracotomy. Operative morbidity and mortality were 18% and 5%, respectively. Complete macroscopic surgical resection was achieved in 106 patients (92%), including 6 patients who underwent orthotopic liver transplantation. The actuarial 5-year event free survival (EFS) rate for all 154 patients in the study was 66%, and the overall survival (OS) rate was 75%. For the 115 patients who were included in the surgical analysis that followed the exact protocol, the EFS and OS rates were 75% and 85%, respectively. CONCLUSIONS Biopsy is a safe procedure and should be performed routinely. Preoperative chemotherapy seems to make tumor resection easier. Reresection of a positive resection margin does not necessarily have to be performed, because postoperative chemotherapy showed good results. Resection of lung metastases can be curative if there is local control of the primary tumor; however, results showed that the patient's prognosis was worse. Surgical morbidity or mortality rates were not necessarily higher in large multicenter studies. More importantly, countries of lesser economic status also can contribute effectively to these trials.
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Affiliation(s)
- J Marco Schnater
- Pediatric Surgical Center Amsterdam (EKZ-AMC/VUmc), Amsterdam, The Netherlands
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Chan KL, Fan ST, Tam PKH, Chiang AKS, Chan GCF, Ha SY. Management of spontaneously ruptured hepatoblastoma in infancy. MEDICAL AND PEDIATRIC ONCOLOGY 2002; 38:137-8. [PMID: 11813186 DOI: 10.1002/mpo.1292] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- K L Chan
- Center of Study of Liver Disease, Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong, SAR, China.
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Pimpalwar AP, Sharif K, Ramani P, Stevens M, Grundy R, Morland B, Lloyd C, Kelly DA, Buckles JA, de Ville De Goyet J. Strategy for hepatoblastoma management: Transplant versus nontransplant surgery. J Pediatr Surg 2002; 37:240-5. [PMID: 11819207 DOI: 10.1053/jpsu.2002.30264] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Liver transplantation now is proposed for managing selected hepatoblastoma cases. Indications are not yet well defined. METHODS The case records of 34 children with hepatoblastoma treated over a period of 10 years (1991 to 2000) were reviewed retrospectively. RESULTS All patients benefited from preoperative chemotherapy. Twenty patients underwent major hepatic resections. Twelve patients, in absence of residual metastasis, underwent liver transplant because the tumour remained unresectable after chemotherapy. Two patients who presented with recurrence after a right hepatectomy, benefited from transplant as a second option. Two other patients did not undergo surgery because of widespread disease or resistance to chemotherapy. Disease-free survival rates were 95% after surgical resection, 100% when primary transplant was performed in patients with good response to chemotherapy, 60% after transplantation in patients with poor response to chemotherapy, 50% in patients with transplant as second option, and 0% in patients not undergoing surgery. CONCLUSIONS Transplantation is a potentially curative option for unresectable hepatoblastoma when chemosensitive (decrease in alpha-fetoprotein and decrease in tumour size). In this context, also favourable cases with good response but difficult resections with doubtful margins of resection may best be proposed for primary transplantation. Patients with recurrent or resistant disease are not good candidates.
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Chardot C, Saint Martin C, Gilles A, Brichard B, Janssen M, Sokal E, Clapuyt P, Lerut J, Reding R, Otte JB. Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma. Transplantation 2002; 73:90-2. [PMID: 11792985 DOI: 10.1097/00007890-200201150-00017] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In most cases of total hepatectomy (TH) required for hepatoblastoma (HB), the retrohepatic inferior vena cava (IVC) has to be removed with the native liver for complete tumor excision. Because the liver graft procured by living donation has no IVC, a reconstruction of the recipient IVC is needed. We report our experience with living-related liver transplantation (LRLT) and IVC replacement in such cases. METHODS Between May 1998 and December 1999, four children underwent TH, including IVC and LRLT with IVC replacement for otherwise irresectable HB after chemotherapy (SIOPEL 2 and 3 protocols). IVC reconstruction used an allogenic iliac vein procured from a cadaveric donor (bank graft) in two cases and an internal jugular vein procured from the donor parent in two cases. Median age and weight at surgery were 17 months (range 10-60) and 9.6 kg (range 8.3-17.9). RESULTS In the living donors, there were two complications of the procurement: one intra-abdominal biliary collection and one subcutaneous abscess. In all four children, complete excision of the tumor could be achieved without any intra-operative complication. One patient died 5 months after LRLT due to lung metastases. Three patients were alive and well with no evidence of tumor recurrence 13-24 months after surgery. Reconstructed IVC was patent in two patients, and asymptomatic thrombosis occurred 2 years after operation in one patient. CONCLUSION Total hepatectomy including the retrohepatic IVC is not a technical obstacle to LRLT. Therefore, scheduled surgery, at the best time after chemotherapy, can be considered in all patients with otherwise irresectable HBs.
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Affiliation(s)
- Christophe Chardot
- Centre Hospitalier Universitaire de Bicêtre, 78 rue du Général Leclerc, F-94275 Le Kremlin Bicetre, France.
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36
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Warmann SW, Fuchs J, Wilkens L, Gratz KF, von Schweinitz D, Mildenberger H. Successful therapy of subcutaneously growing human hepatoblastoma xenografts with topotecan. MEDICAL AND PEDIATRIC ONCOLOGY 2001; 37:449-54. [PMID: 11745873 DOI: 10.1002/mpo.1228] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Human hepatoblastoma is an infrequent liver tumor in children. Although many hepatoblastomas can be treated adequately with well-defined treatment regimens, problems still persist with advanced and non-resectable tumors; in these cases, an effective chemotherapy is necessary to improve the patients' prognosis. This underlines the need for alternative anti-tumor agents in the treatment of human hepatoblastoma. The aim of this study was to investigate the therapeutic effects of topotecan, a water-soluble camptothecin analog (topoisomerase-I-antagonist), in an in vivo model of three human hepatoblastomas xenografted subcutaneously into nude mice. PROCEDURE Hepatoblastoma cell suspensions from three children were transplanted subcutaneously into nude mice NMRI (nu/nu). Treatment with topotecan was initiated when the tumors reached a volume between 50 and 80 mm(3). A dose of 6.6 mg/kg of topotecan were given intraperitoneally every 4 days on four occasions. The tumor volume development and alpha-fetoprotein alterations were measured and statistically analyzed. After the treatment, the tumors were investigated histologically and by immunohistochemistry. RESULTS There was a significant reduction of tumor growth in all treated tumor xenografts vs. untreated control groups (mean relative volume 3.1 vs. 47.4; P = 0,0015-0,0079). Serum alpha-fetoprotein levels were reduced in all three cell lines, in two of them significantly (mean 44,535 kU/l vs. 228,883 kU/l; P = 0.005-0.246). Histologically, the tumor necrosis rates were higher and immunohistochemistry showed lower proliferation activities in the treated tumor xenografts vs. the control groups. CONCLUSION The data show that topotecan is an effective agent in the treatment of human hepatoblastoma xenografts. From these results, treatment with topotecan appears to be a promising alternative in the pre- and postoperative therapy of patients suffering from human hepatoblastoma
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Affiliation(s)
- S W Warmann
- Department of Pediatric Surgery, Medical School Hannover, Carl-Neuberg-Str.1, 30625 Hannover, Germany.
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37
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Ahn SI, Seo JM, Shin SH, Hong KC, Kim SJ, Lee KY, Hur YS, Kim SK, Hwang TS, Woo ZH. Hepatocellular carcinoma with lung metastasis in a 9-year-old-boy. J Pediatr Surg 2001; 36:1599-601. [PMID: 11584420 DOI: 10.1053/jpsu.2001.27068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hepatocellular carcinoma (HCC) remains chemoresistant and, therefore, the principal treatment of HCC is surgical resection. After a 9-year-old boy with huge HCC with lung metastasis received the 5 cycles of chemotherapy (cisplatin and Adriamycin), the lung metastasis had been resolved completely and the size of HCC in liver had decreased. Right hepatic trisegmentectomy was performed, and then the additional 3 cycles of chemotherapy was given. Currently, the patient shows no recurrence of HCC 42 months after surgical extirpation.
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Affiliation(s)
- S I Ahn
- Department of Surgery, Inha University Hospital, Inchon, Korea
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Abstract
Most tumors of the liver in children are malignant. Benign tumors occur most often in infants, are usually vascular, and seldom require surgery. Hepatoblastoma and hepatocellular carcinoma are the most common malignant tumors. Hepatoblastoma affects younger children and hepatocellular carcinoma affects older children and adolescents. Treatment consists of surgical resection before or after chemotherapy, and long-term survival is impossible without resection. Survival rate exceeds 80% in children with hepatoblastoma. Children with hepatocellular carcinoma and other more unusual malignant tumors do not do as well. Current treatment plans are described for both benign and malignant tumors of the liver.
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Affiliation(s)
- M Reynolds
- Northwestern University Medical School and the Department of Pediatric Surgery, Children's Memorial Hospital, Chicago, IL 60614, USA
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Carceller A, Blanchard H, Champagne J, St-Vil D, Bensoussan AL. Surgical resection and chemotherapy improve survival rate for patients with hepatoblastoma. J Pediatr Surg 2001; 36:755-9. [PMID: 11329582 DOI: 10.1053/jpsu.2001.22953] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- A Carceller
- Division of Pediatrics, General Surgery, and Hemato-Oncology, Ste-Justine Hospital, Montreal, Quebec, Canada
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40
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Affiliation(s)
- R P Scott
- Department of Surgery, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.
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Abstract
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.
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Affiliation(s)
- R W Strong
- Department of Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
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Matsusaka S, Nakasho K, Terada N, Sugihara A, Tsujimura T, Takanashi T, Uematsu K, Okamoto E, Toyosaka A. Inhibition by an angiogenesis inhibitor, TNP-470, of the growth of a human hepatoblastoma heterotransplanted into nude mice. J Pediatr Surg 2000; 35:1198-204. [PMID: 10945693 DOI: 10.1053/jpsu.2000.8726] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The effect of TNP-470, an angiogenesis inhibitor, on the growth of a hepatoblastoma transplanted into nude mice was examined. METHODS A hepatoblastoma obtained from a 3-year-old girl was serially transplanted into nude mice subcutaneously, and the transplant tumors of the seventh and eighth generations were used for experiments. Expression of various markers in the tumors was examined immunohistochemically. TNP-470 was injected subcutaneously every other day into tumor-bearing mice from 3 weeks after tumor transplantation. The proliferation of tumor cells and endothelial cells was estimated by means of the bromodeoxyuridine labeling index. RESULTS The original hepatoblastoma showed the histology of the epithelial type, consisting of both the fetal and embryonal subtypes and was positively stained with anti-alpha-fetoprotein (AFP), anti-cytokeratin-19 and polyclonal anticarcinoembryonic antigen antibodies, and an antihuman hepatocyte antibody (hepatocyte paraffin 1). The transplant tumors consisted of solid nests of tumor cells with numerous vascular lakes of various sizes, and showed positive staining with all antibodies that reacted positively with the original hepatoblastoma. Injections of TNP-470 at the doses of 15 mg and 30 mg/kg body weight suppressed the tumor growth and the increase in the serum level of AFP dose dependently. Injections of TNP-470 also suppressed the proliferation of tumor cells and endothelial cells in the tumors. CONCLUSIONS Hepatoblastomas maintained in nude mice retained the immunohistochemical characteristics of the original hepatoblastoma, and TNP-470 suppressed the growth of hepatoblastomas transplanted into nude mice. TNP-470 may be worth investigating further as to its usefulness as a therapy for hepatoblastomas.
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Affiliation(s)
- S Matsusaka
- First Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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Ma SK, Cheung AN, Choy C, Chan GC, Ha SY, Ching LM, Wan TS, Chan LC. Cytogenetic characterization of childhood hepatoblastoma. CANCER GENETICS AND CYTOGENETICS 2000; 119:32-6. [PMID: 10812168 DOI: 10.1016/s0165-4608(99)00203-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We describe the cytogenetic abnormalities in two cases of childhood hepatoblastoma. The first case was of fetal histology with squamous metaplasia, and cytogenetic study showed an add(5)(q31). Although an association between hepatoblastoma and familial adenomatous polyposis is recognized, the breakpoint in this case is distal to 5q21 and most probably does not involve the APC gene at that location. The second case was of macrotrabecular histology, and cytogenetic study showed an unbalanced translocation in the form of der(4)t(1;4)(q12;q34) in a hyperdiploid clone. Including our case, der(4)t(1;4)(q12;q34) has been recognized in four cases of hepatoblastoma, and it may be the first recurrent translocation in this tumor. Understanding the molecular mechanism and clinical significance of this translocation awaits analysis of more cases.
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Affiliation(s)
- S K Ma
- Department of Pathology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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44
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Affiliation(s)
- N A Dower
- Department of Pediatrics, University of Alberta, Walter C. MacKenzie Health Sciences Centre, Edmonton, Alberta, Canada T6G 2R7
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Dower NA, Smith LJ, Lees G, Kneteman N, Idikio H, Emond J, Rosenthal P. Experience with aggressive therapy in three children with unresectable malignant liver tumors. MEDICAL AND PEDIATRIC ONCOLOGY 2000; 34:132-5. [PMID: 10657875 DOI: 10.1002/(sici)1096-911x(200002)34:2<132::aid-mpo11>3.0.co;2-h] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Children with malignant liver tumors often present with unresectable disease but need not be considered incurable. The advent of effective chemotherapy makes aggressive management feasible, as our experience with three such patients demonstrates. Procedure and Results One child with an unresectable undifferentiated sarcoma of the liver and two others with unresectable primary hepatoblastoma and lung metastases were treated with initial chemotherapy, followed by aggressive surgical management. Treatment with chemotherapy followed by hepatectomy and liver transplantation (cadaveric or live donor) in two children has resulted in disease-free survivals of 79 and 38 months. The third patient is alive and well 24 months following chemotherapy and aggressive resection of the primary and 12 metastatic lesions. CONCLUSIONS Initial chemotherapy for unresectable liver tumors with or without metastases is supported by the review of the literature. Consideration of orthotopic liver transplantation (OLT) from cadaveric or living related donor is warranted when the malignancy is demonstrably chemosensitive, independent of initial staging. Aggressive resection of primary and metastatic disease may be called for in selected cases.
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Affiliation(s)
- N A Dower
- Department of Pediatrics, University of Alberta, Walter C. MacKenzie Health Sciences Center, Edmonton, Alberta, Canada
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Fuchs J, Gratz KF, Habild G, Gielow P, von Schweinitz D, Baum RP. Immunoscintigraphy of xenotransplanted hepatoblastoma with iodine 131-labeled anti-alpha-fetoprotein monoclonal antibody. J Pediatr Surg 1999; 34:1378-84. [PMID: 10507433 DOI: 10.1016/s0022-3468(99)90015-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Hepatoblastoma (HB) is the most common primary malignant liver tumor affecting infants and young children. The alpha-fetoprotein level is elevated in 95% of all children with hepatoblastoma. Therefore, it is of interest to assess targeting of the HB marker alpha-fetoprotein by antibody imaging. In this pilot study, the authors investigated the radioimmunoscintigraphy of xenotransplanted HB in nude mice utilizing an anti-alpha-fetoprotein antibody. METHODS HB cell suspensions from tumors of 3 children were transplanted subcutaneously into nude mice NMRI (nu/nu). A total of 200 microg of intact anti-alpha-fetoprotein antibody was injected intravenously into 8 animals from each HB. Before injection, the monoclonal antibody was labeled with iodine (I) 131 (specific activity of 75 MBq/mg, labeling yield of 95%) using the conventional iodogen method. Planar scintigraphic images of anesthetized mice in posterior views were acquired with a gamma camera immediately after injection, and after 1, 2, 3, 7, and 14 days. The biodistribution data were obtained by killing and dissecting animals, and the activity in the tissues was measured in a gamma counter. The alpha-fetoprotein levels in the animals' sera were recorded 15 days after imaging and were compared with the control group. RESULTS A total of 66% of the hepatoblastomas could be detected by scintigraphy. Within 24 hours, the mean specific tumor uptake in nude mice hepatoblastomas with a volume of over 1,000 mm3, was 14% per injected dose (+/-3.9%). The biological half-life of the labeled antibody complex in the tumor was 3.86 (+/-0.84) days. Thyroid uptake of free I-131 was 2.85% per injected dose (+/-1.5%) reflecting the deiodination of the labeled antibody complex. CONCLUSIONS The results show the possibility of imaging xenotransplanted hepatoblastoma with 131I-labeled anti-alpha-fetoprotein and may, in the future, determine tumor recurrence and extension, and thereby improve the prognosis of advanced HBs.
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Affiliation(s)
- J Fuchs
- Department of Pediatric Surgery, Medical School Hannover, Germany
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47
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Al-Qabandi W, Jenkinson HC, Buckels JA, Mayer AD, McKiernan P, Morland B, John P, Kelly D. Orthotopic liver transplantation for unresectable hepatoblastoma: a single center's experience. J Pediatr Surg 1999; 34:1261-4. [PMID: 10466608 DOI: 10.1016/s0022-3468(99)90164-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE Complete surgical resection after chemotherapy is the definitive treatment for hepatoblastoma. However, orthotopic liver transplantation (OLT) is now accepted as a treatment modality for patients with unresectable tumours. The aim of this study was to review a single center's experience of OLT for unresectable hepatoblastoma. METHODS A retrospective review of 8 patients with unresectable hepatoblastoma who were referred for liver transplantation was conducted. RESULTS The patients assessed had an age range of 5 to 105 months at presentation; median, 24 months, (5 boys; 3 girls). Two patients have familial adenomatous polyposis, and one has right hemihypertrophy. All 8 patients had received standard chemotherapy according to SIOP (International Society of Pediatric Oncology) protocols. Extrahepatic metastases were found in 3 patients at diagnosis, but none had detectable metastases at the time of OLT. Four patients continued chemotherapy while awaiting OLT. Three patients received whole grafts, and 5 received reduced grafts. The median follow-up period was 22 months (range, 2 to 78 months). Five patients are alive and well, although 1 patient had a second OLT for biliary cirrhosis secondary to biliary stricture at 6 years. Three patients died: one 26 days post OLT of sepsis and two of disease recurrence at 22 months and 70 months posttransplant. The actuarial survival rate is 88% and 65% at 1 and 5 years, respectively, whereas the overall survival rate is 62.5%. CONCLUSION OLT for unresectable hepatoblastoma without extra hepatic metastases is highly successful with a low recurrence rate.
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Affiliation(s)
- W Al-Qabandi
- Department of Oncology, The Birmingham Children's Hospital NHS Trust, England
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48
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Abstract
An infant or child who presents with a large intrahepatic mass will most likely have a malignant tumor. In children, benign tumors constitute only 30% of liver tumors and most are vascular in origin. Treatment of benign vascular tumors is conservative and seldom surgical. Hepatoblastoma is the most common malignant tumor followed by hepatocellular carcinoma. Treatment of malignant tumors is based on a combination of surgery and chemotherapy. Children with hepatic malignancies that can be resected have an excellent prognosis. Other rare benign and malignant tumors of the liver do occur and surgery plays a critical role in management.
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Affiliation(s)
- M Reynolds
- Northwestern University Medical School and Children's Memorial Hospital, Chicago, Illinois.
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49
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Fuchs J, Habild G, Leuschner I, Schweinitz DV, Haindl J, Knop E. Paclitaxel: an effective antineoplastic agent in the treatment of xenotransplanted hepatoblastoma. MEDICAL AND PEDIATRIC ONCOLOGY 1999; 32:209-15. [PMID: 10064189 DOI: 10.1002/(sici)1096-911x(199903)32:3<209::aid-mpo8>3.0.co;2-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hepatoblastoma is an uncommon liver tumor of infancy and early childhood. Though most patients with nonmetastatic hepatoblastomas can be cured by defining surgical strategies and chemotherapy regimes, new drugs are needed for children with advanced hepatoblastomas. The activity of paclitaxel as a new antineoplastic agent with limited experience in pediatric oncology was studied in a xenograft model. PROCEDURE Hepatoblastoma cell suspensions from three children were transplanted subcutaneously into nude mice NMRI (nu/nu). One of the primary tumors was an embryonal multifocal hepatoblastoma, whereas the other tumors were embryonal/fetal hepatoblastomas localized on a liver lobe. After 4 weeks, xenografted tumor sizes reached 50-100 mm3. The xenografted tumors resembled their originals histologically and produced high levels of alpha-fetoprotein. The efficiency of paclitaxel at equitoxic doses was analyzed. RESULTS Paclitaxel produced an effect in all three hepatoblastomas. There was a significant reduction of tumor volume (P < 0.001) and alpha-fetoprotein levels after chemotherapy (P < 0.0001). The proliferation activity of the tumor cells corresponded with these results. Histologically, after treatment with paclitaxel the tumor regression was 35%-49%. The mechanism of paclitaxel action could be demonstrated by light microscopy immunohistochemistry and electron microscopy. CONCLUSIONS The preliminary results in phase I trials of solid tumors in children and the results of this study suggest that paclitaxel in phase II studies can now be entertained for patients with hepatoblastoma.
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Affiliation(s)
- J Fuchs
- Department of Pediatric Surgery, Medical School Hannover, Germany.
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Fuchs J, Wenderoth M, von Schweinitz D, Haindl J, Leuschner I. Comparative activity of cisplatin, ifosfamide, doxorubicin, carboplatin, and etoposide in heterotransplanted hepatoblastoma. Cancer 1998; 83:2400-7. [PMID: 9840541 DOI: 10.1002/(sici)1097-0142(19981201)83:11<2400::aid-cncr21>3.0.co;2-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hepatoblastoma is the most common primary malignant liver tumor affecting infants and young children. Recent clinical experience with advanced hepatoblastoma shows that a reliable in vivo model to study the tumor's response to drugs is needed urgently. METHODS Hepatoblastoma cell suspensions from three children were transplanted subcutaneously into NMRI nude mice (nu/nu). One of the primary tumors was a embryonal multifocal hepatoblastoma, whereas the other tumors were embryonal/fetal hepatoblastomas localized to one liver lobe. The xenograft tumors resembled their original tumors histologically and produced high levels of alpha-fetoprotein. The mice who received the tumors were given ifosfamide, cisplatin, doxorubicin, carboplatin, and etoposide as single agents. Thereafter, the tumor growth rate and alpha-fetoprotein levels in the animal sera were measured before and after chemotherapy and compared with the control group. After chemotherapy, the tumors were studied by conventional histology. RESULTS The tumors in the nude mice derived from the multifocal hepatoblastoma reacted minimally against four of the five cytotoxic agents, whereas cisplatin reduced the tumor volume significantly. There was a marked reduction in tumor volume in the other tumors after application of cisplatin and doxorubicin, respectively. The tumors displayed a moderate reduction in size after treatment with ifosfamide, etoposide, and carboplatin. The responses to the different cytostatic agents also corresponded with serum alpha-fetoprotein levels and mitotic rates in the tumor cells. CONCLUSIONS To the authors' knowledge, this is the first time an in vivo model for analyzing the effects of chemotherapy on hepatoblastoma has been established. The animal model may be suited for the evaluation of new drugs for the treatment of hepatoblastoma and for the investigation of multidrug resistance mechanisms in hepatoblastoma.
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Affiliation(s)
- J Fuchs
- Department of Pediatric Surgery, Medical School Hannover, Germany
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