1
|
Ishikawa Y, Saito R, Murakami K, Fujio A, Miyazawa K, Sasaki K, Matsumura M, Mitsugashira H, Degawa K, Kobayashi Y, Muto R, Tokodai K, Furukawa T, Unno M, Kamei T. Small Intestinal Adenocarcinoma Arising at the Anastomotic Site after Kasai Operation for Biliary Atresia: A Case Report and Literature Review. TOHOKU J EXP MED 2023; 261:267-272. [PMID: 37766552 DOI: 10.1620/tjem.2023.j080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Biliary atresia is an obliterative cholangiopathy of unknown etiology. Hepatic portoenterostomy, in which obliterated extrahepatic bile ducts are resected and bile flow is restored, known as Kasai operation, is performed within 3 months after birth. While this operation enhances long-term survival of patients, the occurrence of primary malignant hepatic tumors has been increasing. We report a case of small intestinal adenocarcinoma arising at the anastomotic site after Kasai operation. A 49-year-old man, who underwent Kasai operation for biliary atresia when he was 2 months old, experienced rapidly progressive jaundice and liver dysfunction. Deceased-donor liver transplantation was performed for liver failure. Macroscopically, there was a white-yellow tumor located at the anastomotic site of hepatic portoenterostomy of the resected liver. Pathological examination revealed a well-differentiated adenocarcinoma with some Paneth cells in the neoplastic lesion. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) but positive for cytokeratin 20 (CK20) and a homeobox domain-containing transcription factor (CDX2). Mucin expression in tumor cells was negative for mucin 1 (MUC1) and mucin 6 (MUC6) and positive for mucin 2 (MUC2) and mucin 5AC (MUC5AC). The pathological diagnosis was small intestinal adenocarcinoma originating from the jejunum. The patient was discharged 48 days after the operation. The patient had not experienced recurrence at 10 months after the operation. This is the first report of small intestinal adenocarcinoma arising at the anastomotic site after Kasai operation for biliary atresia. Special care should be taken for the patients after Kasai operation with acute progressive jaundice and liver dysfunction because there is a possibility of malignancy in their native liver.
Collapse
Affiliation(s)
- Yuki Ishikawa
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Ryusuke Saito
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Keigo Murakami
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine
| | - Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Koji Miyazawa
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Kengo Sasaki
- Department of Surgery, Tohoku University Graduate School of Medicine
| | | | | | - Kazuki Degawa
- Department of Surgery, Tohoku University Graduate School of Medicine
| | | | - Ryo Muto
- Department of Surgery, National Hospital Organization Mito Medical Center
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine
| |
Collapse
|
2
|
Calinescu AM, Rougemont AL, Anooshiravani M, Rock NM, McLin VA, Wildhaber BE. Features of Nodules in Explants of Children Undergoing Liver Transplantation for Biliary Atresia. J Clin Med 2022; 11:jcm11061578. [PMID: 35329903 PMCID: PMC8950310 DOI: 10.3390/jcm11061578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 12/07/2022] Open
Abstract
(1) Background: In patients with biliary atresia (BA) liver nodules can be identified either by pre-transplant imaging or on the explant. This study aimed to (i) analyze the histopathology of liver nodules, and (ii) to correlate histopathology with pretransplant radiological features. (2) Methods: Retrospective analysis of liver nodules in explants of BA patients transplanted in our center (2000−2021). Correlations with pretransplant radiological characteristics, patient age at liver transplantation (LT), time from Kasai hepatoportoenterostomy (KPE) to LT, age at KPE and draining KPE. (3) Results: Of the 63 BA-patients included in the analysis, 27/63 (43%) had nodules on explants. A majority were benign macroregenerative nodules. Premalignant (low-grade and high-grade dysplastic) and malignant (hepatocellular carcinoma) nodules were identified in 6/63 and 2/63 patients, respectively. On pretransplant imaging, only 13/63 (21%) patients had liver nodules, none meeting radiological criteria for malignancy. The occurrence of liver nodules correlated with patient age at LT (p < 0.001), time KPE-LT (p < 0.001) and draining KPE (p = 0.006). (4) Conclusion: In BA patients, pretransplant imaging did not correlate with the presence of liver nodules in explants. Liver nodules were frequent in explanted livers, whereby 25% of explants harboured malignant/pre-malignant nodules, emphasizing the need for careful surveillance in BA children whose clinical course may require LT.
Collapse
Affiliation(s)
- Ana M. Calinescu
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.-L.R.); (M.A.); (N.M.R.); (V.A.M.); (B.E.W.)
- Division of Child and Adolescent Surgery, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
- Correspondence: ; Tel.: +41-22-372-4662
| | - Anne-Laure Rougemont
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.-L.R.); (M.A.); (N.M.R.); (V.A.M.); (B.E.W.)
- Division of Clinical Pathology, Diagnostic Department, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| | - Mehrak Anooshiravani
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.-L.R.); (M.A.); (N.M.R.); (V.A.M.); (B.E.W.)
- Unit of Pediatric Radiology, Diagnostic Department, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| | - Nathalie M. Rock
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.-L.R.); (M.A.); (N.M.R.); (V.A.M.); (B.E.W.)
- Gastroenterology, Hepatology and Nutrition Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| | - Valerie A. McLin
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.-L.R.); (M.A.); (N.M.R.); (V.A.M.); (B.E.W.)
- Gastroenterology, Hepatology and Nutrition Unit, Division of Pediatric Specialties, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| | - Barbara E. Wildhaber
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (A.-L.R.); (M.A.); (N.M.R.); (V.A.M.); (B.E.W.)
- Division of Child and Adolescent Surgery, Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| |
Collapse
|
3
|
Hepatocellular carcinoma in the native liver of a 38-year-old female patient with biliary atresia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
4
|
Yoon H, Jeon T, Yoo SY, Kim J, Eo H, Lee SK, Kim J. Hepatic tumours in children with biliary atresia: Single-centre experience in 13 cases and review of the literature. Clin Radiol 2014; 69:e113-9. [DOI: 10.1016/j.crad.2013.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/22/2013] [Accepted: 10/23/2013] [Indexed: 01/09/2023]
|
5
|
Abstract
BACKGROUND Liver transplantation for biliary atresia is indicated whenever a Kasai portoenterostomy is considered unfeasible. However, the timing of liver transplantation in biliary atresia has not been precisely defined. Excessive shortening of hepatocellular telomeres may occur in patients with biliary atresia, and therefore, telomere length could be a predictor of hepatocellular reserve capacity. METHODS Hepatic tissues were obtained from 20 patients with biliary atresia who underwent LT and 10 age-matched autopsied individuals (mean age, 1.7 and 1.2 years, respectively). Telomere lengths were measured by Southern blotting and quantitative fluorescence in situ hybridization using the normalized telomere-centromere ratio. The correlation between the normalized telomere-centromere ratio for the hepatocytes in biliary atresia and the pediatric end-stage liver disease score was analyzed. RESULTS The median terminal restriction fragment length of the hepatic tissues in biliary atresia was not significantly different from that of the control (p = 0.425), whereas the median normalized telomere-centromere ratio of hepatocytes in biliary atresia was significantly smaller than that of the control (p < 0.001). Regression analysis demonstrated a negative correlation of the normalized telomere-centromere ratio with the pediatric end-stage liver disease score in biliary atresia (p < 0.001). CONCLUSIONS Telomere length analysis using quantitative fluorescence in situ hybridization could be an objective indicator of hepatocellular reserve capacity in patients with biliary atresia, and excessive telomere shortening supports the early implementation of liver transplantation.
Collapse
|
6
|
Hadžić N, Quaglia A, Portmann B, Paramalingam S, Heaton ND, Rela M, Mieli-Vergani G, Davenport M. Hepatocellular carcinoma in biliary atresia: King's College Hospital experience. J Pediatr 2011; 159:617-22.e1. [PMID: 21489554 DOI: 10.1016/j.jpeds.2011.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 02/01/2011] [Accepted: 03/02/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To establish risks for development of hepatocellular carcinoma (HCC) in children with biliary atresia (BA), the most common chronic liver disease of childhood. STUDY DESIGN In our tertiary referral center database we have identified children with BA who had development of or have been incidentally found to have HCC. Their demographic, clinical, radiologic, and histologic features were analyzed. RESULTS Between 1990 and 2008, 387 infants were diagnosed with BA at our center. Of these, three (0.8 %) who underwent operation at a median age of 68 (range 66 to 71) days had development of a histologically proven HCC detected at a median age of 2.1 (range 1.8 to 4.9) years. Another two, referred later, were diagnosed with HCC on their liver explants at ages 1.1 and 17.75 years, respectively. Overall, two had elevated serum levels of alpha-fetoprotein. All five children underwent successful liver transplantation at a median age of 2.1 years (range 1.1 to 17.75) and remain well after a median of 2.5 (range 2 to 5.7) years. CONCLUSION HCC develops in a small percentage of children with BA. Serum alpha-fetoprotein levels and ultrasound screening are helpful but not absolute markers of the malignant change. In the absence of the extrahepatic involvement, liver transplantation represents an effective treatment.
Collapse
Affiliation(s)
- Nedim Hadžić
- Paediatric Liver Centre, King's College Hospital, Denmark Hill, London, United Kingdom.
| | | | | | | | | | | | | | | |
Collapse
|
7
|
Miraglia R, Caruso S, Maruzzelli L, Spada M, Riva S, Sciveres M, Luca A. MDCT, MR and interventional radiology in biliary atresia candidates for liver transplantation. World J Radiol 2011; 3:215-23. [PMID: 22007284 PMCID: PMC3194042 DOI: 10.4329/wjr.v3.i9.215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 07/18/2011] [Accepted: 07/25/2011] [Indexed: 02/06/2023] Open
Abstract
The multi-detector computed tomography (MDCT) scan and magnetic resonance (MR) of the abdomen play a key role in the work-up to liver transplantation (LT) by identifying congenital anomalies or cirrhosis-related modifications, conditions that can require changes in surgical technique. Moreover, the MDCT and MR scans allow identification of cirrhotic liver hepatic masses, extrahepatic porto-systemic shunts, eventual thrombosis of portal system and radiological signs of portal hypertension associated with biliary atresia (BA). The aim of this paper is to review MDCT, MR imaging and interventional radiology procedures performed to evaluate morphological changes and degree of portal hypertension in pediatric patients with end-stage liver disease secondary to BA, who are candidates for LT. Advances in the field of MR, MDCT and in percutaneous minimally invasive techniques have increased the importance of radiology in the management of pediatric patients with BA who are candidates for LT.
Collapse
|
8
|
Abstract
Kasai portoenterostomy (PE) increases the survival for children with biliary atresia (BA) and consequently postpones subsequential liver transplantation. All long-term survivors, however, develop complications of biliary cirrhosis. We report a case of hepatocellular carcinoma (HCC) in a 19-year-old male patient with BA and Kasai PE. The preoperative abdominal ultrasound and magnetic resonance imaging showed a large hepatic mass (diameter 10 cm). The serum alpha-fetoprotein level was within normal range. Pathologic findings of the mass, after orthotopic liver transplantation, demonstrated a well-differentiated HCC (T1N0M0). HCC is a rare complication of BA, but will intensively impair the survival. Therefore, clinicians should be alert to the development of HCC in this very young patient group. Repeated sequential magnetic resonance imaging of the native liver in patients with Kasai PE is necessary to monitor possible malignant transformation of liver nodules that may potentially develop as a result of chronic cholestatic liver disease.
Collapse
|
9
|
Affiliation(s)
- Benjamin L Shneider
- Department of Pediatrics, Thomas E. Starzl Transplantation Institute, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
| | | |
Collapse
|
10
|
Liu YW, Concejero AM, Chen CL, Cheng YF, Eng HL, Huang TL, Chen TY, Wang CC, Wang SH, Lin CC, Yong CC, Yang CH, Jordan AP, Jawan B. Hepatic pseudotumor in long-standing biliary atresia patients undergoing liver transplantation. Liver Transpl 2007; 13:1545-51. [PMID: 17969188 DOI: 10.1002/lt.21320] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A pseudotumor, giant regenerative nodule, or macroregenerative nodule is an unusual benign hepatic lesion in biliary atresia (BA) patients. This tumor may mimic malignant transformation and may preclude liver transplantation (LT). The clinical and imaging surveillance of patients after the Kasai procedure is therefore an important aspect of management of BA patients. Our objective is to report our experience and describe the incidence, imaging, and pathologic features of pseudotumors in BA patients awaiting LT. From August 1990 to December 2006, 133 LTs for BA were performed. Five (3.8%; 4 female, 1 male) patients were diagnosed with pseudotumor. The patients' records were reviewed. The diagnostic imaging modalities used were abdominal ultrasound (US), computed tomography (CT) scan, and magnetic resonance imaging (MRI). Histologic confirmation of the lesions was obtained in all cases. All underwent the Kasai operation in early infancy. Six of 7 lesions in 4 of 5 patients were demonstrated by pretransplant imaging. Two of 7 tumors were detected by US. Five of 7 lesions were detected by CT, and 5 of 7 lesions were demonstrated by MRI. In 1 patient, the lesion was not seen in the US, CT, or MRI but was found during surgery and confirmed by histology. An additional tumor was found incidentally during histologic examination in a patient previously diagnosed to have 2 tumors by CT and MRI. In another patient diagnosed to have 2 tumors on imaging, pathology revealed only a single tumor. In conclusion, although unusual, pseudotumor should be included in the differential diagnosis of liver masses in BA children.
Collapse
Affiliation(s)
- Yueh-Wei Liu
- Liver Transplantation Program, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Outcome in adulthood of biliary atresia: a study of 63 patients who survived for over 20 years with their native liver. Hepatology 2005; 41:366-71. [PMID: 15660386 DOI: 10.1002/hep.20547] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To define the long-term prognosis of children undergoing the Kasai operation for biliary atresia, a retrospective study was undertaken comprising 271 patients operated between 1968 and 1983. Twenty years after surgery, 63 (23%) were alive with their native liver. Serum bilirubin was normal in 21 of these patients, 12 also had normal serum aminotransferase and gamma-glutamyltransferase activities, all but 2 had signs of cirrhosis, 44 had signs of portal hypertension, 19 had late bacterial cholangitis, and 6 had gallstones. Seven female patients gave birth to 9 children, and 3 male patients fathered 6 children. After age 20, 2 patients died of liver failure and 14 underwent or are awaiting liver transplantation. Twenty-year survival with native liver was significantly better in children with biliary atresia restricted to the hepatic ducts or with cysts at the porta hepatis. In conclusion, in the long term, less than 18% of infants with biliary atresia who are treated with corrective surgery may avoid liver transplantation, but even these patients require assiduous lifelong care.
Collapse
|
12
|
Hara F, Kishikawa T, Tomishige H, Nishikawa O, Nishida Y, Kongo M. A child with adrenocortical carcinoma who underwent percutaneous ethanol injection therapy for liver metastasis. J Pediatr Surg 2003; 38:1237-40. [PMID: 12891501 DOI: 10.1016/s0022-3468(03)00276-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The authors encountered a 2-year-old-girl with adrenocortical carcinoma who underwent percutaneous ethanol injection therapy (PEIT) for liver metastasis. The patient had functional adrenocortical carcinoma diagnosed and underwent excision of the tumor in the right adrenal gland. Because liver metastasis was detected 11 months after surgery, the patient underwent PEIT under general anesthesia. After the treatment, the size of the metastatic tumor was reduced with calcification and then disappeared. The patient was in a good condition 3 years, 3 months after the occurrence of liver metastasis.
Collapse
Affiliation(s)
- Fujio Hara
- Department of Pediatric Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | | | | | | | | | | |
Collapse
|
13
|
Tatekawa Y, Asonuma K, Uemoto S, Inomata Y, Tanaka K. Liver transplantation for biliary atresia associated with malignant hepatic tumors. J Pediatr Surg 2001; 36:436-9. [PMID: 11226990 DOI: 10.1053/jpsu.2001.21600] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The authors report 3 cases of liver transplantations in children between 4 and 10 years of age, complicated with malignant hepatic tumors after biliary atresia. The preoperative abdominal computed tomography (CT) scans of all 3 cases showed hepatic masses. The serum alpha-fetoprotein levels were elevated highly in 2 cases. After living-related liver transplantation (LRLT), the pathologic findings of the masses in the resected livers showed hepatocellular carcinoma in 2 cases and hepatoblastoma in the other. All cases were associated with biliary cirrhosis. The stage of the liver tumor in the 3 cases using the TNM system was IVA (T4, N0, M0), II (T2, N0, M0) and IVA (T4, N0, M0). Chemotherapy was used in all cases after liver transplantation, and all patients survived with no recurrence. The results suggest that even though malignant liver tumors rarely are complicated with biliary atresia in childhood, one should be alert to the occurrence of hepatic malignancy and perform routine screening of alpha-fetoprotein levels, abdominal CT scans, and magnetic resonance imagings.
Collapse
Affiliation(s)
- Y Tatekawa
- Department of Transplantation and Immunology, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | | | | | | | | |
Collapse
|
14
|
Ijiri R, Tanaka Y, Kato K, Misugi K, Ohama Y, Shinkai M, Nishi T, Aida N, Kondo F. Clinicopathological study of a hilar nodule in the livers of long-term survivors with biliary atresia. Pathol Int 2001; 51:16-9. [PMID: 11148458 DOI: 10.1046/j.1440-1827.2001.01161.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
With the application of liver transplantation for patients with biliary atresia (BA), we have had the opportunity to review the clinicopathologic features of the native livers from 10 transplanted BA patients. A single large nodule at porta hepatis (hilar nodule) was noted in three of 10 patients, and an ill-defined nodule-like lesion at porta hepatis was present in two other patients. The three BA patients with hilar nodules were long-term survivors, compared to the patients with nodule-like and those without nodules. The hilar nodules measured between 5.0 cm and 8.0 cm and histologically, they were partly surrounded by fibrous septa with relatively well-preserved liver architectures and fewer inflammatory cells at the portal triads when compared to the surrounding cirrhotic lesions. No nuclear or cellular atypia was observed. Proliferating cell nuclear antigen labeling index was higher in the surrounding cirrhotic lesions than the hilar nodules. The nodule-like lesions at porta hepatis also showed similar light microscopic and immunohistochemical features as the hilar nodules. These hilar nodules did not seem to contain any malignant potential. The benign histology with relatively well-preserved liver architecture and the preferential site of occurrence at porta hepatis where bile seemed to flow more smoothly, suggested possible residues of less-affected hepatic tissues.
Collapse
Affiliation(s)
- R Ijiri
- Division of Pathology, Kanagawa Children's Medical Center, Minamiku Mutsukawa 2-138-4, Yokohama city, Kanagawa Prefecture, 232-8555, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
Liver tumors in children are rare, potentially complex, and encompass a broad spectrum of disease processes. Any age group may be affected, including the fetus. Most present with abdominal distension and/or a mass. Accurate preoperative diagnosis is usually possible using a combination of ultrasound scanning and cross-sectional imaging techniques (CT and/or MR), supplemented by liver biopsy and measurement of tumor markers. The most common benign tumors are hemangiomas, but mesenchymal hamartoma, focal nodular hyperplasia, and adenoma also are found. In Western countries, hepatoblastoma is the most common primary malignant liver tumor; disease-free survival is now possible in more than 80% of affected patients because of advances in combination chemotherapy, improved techniques of surgical resection, and the selective use of liver transplantation. In contrast, there has been less progress in the management of hepatocellular cancer, which still poses many therapeutic challenges.
Collapse
Affiliation(s)
- M D Stringer
- Children's Liver Centre, St James University Hospital, Leeds, UK
| |
Collapse
|
16
|
Abstract
The combination of portoenterostomy with subsequent liver transplantation is the treatment of choice for patients with biliary atresia. It is important, however, to attempt to keep the patient's own organ by continuing efforts to achieve the best possible results with portoenterostomy. Additional basic research, perhaps concerning on the role of cytokines and apoptosis in the control of biliary atresia, may provide insight into possible new medical strategies for treating patients with biliary atresia. For example, in addition to portoenterostomy, control of apoptosis at various cellular levels and of bile duct cell proliferation and maturation by manipulation of the growth factors and cytokines may become part of future treatment modalities. Another direction of research should be the control of fibrogenesis, which might be accomplished by blocking TGF-beta 1 and platelet-derived growth factor and by HGF gene therapy. The author's current strategy for surgical treatment for patients with biliary atresia include (1) early diagnosis, including prenatal diagnosis and broader use of mass screening programs, (2) hepatic portoenterostomy, without stoma formation; (3) close postoperative care, especially for prevention of postoperative cholangitis; (4) revision of portoenterostomy only in selected cases; (5) early liver transplantation in patients with absolutely failed portoenterostomy; (6) avoidance of laparotomy for the treatment of esophageal varices and hypersplenism; (7) consideration of exploratory laparotomy or primary liver transplantation for patients with advanced liver disease at the time of referral. The development of new treatment modalities based on the understanding of the pathogenesis of the disease, and especially on the biology of intrahepatic bile ducts and hepatic fibrosis, is essential.
Collapse
Affiliation(s)
- R Ohi
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan
| |
Collapse
|
17
|
Abstract
Hepatocellular carcinoma (HCC) occurs more frequently in subsaharan Africa and the Orient than in other geographical regions, but remains an uncommon tumour of childhood. We review six children with HCC (mean age 13 years) treated by the paediatric oncology unit at Tygerberg Hospital in Cape Town over an 8-year period (1983 - 1990). Patients presented with epigastric and right upper quadrant discomfort and hepatomegaly. The hepatitis B serum antigen (HbsAg) was positive in three patients; serum alpha-fetoprotein (AFP) levels were markedly elevated in three (range 100 - 453,000 microg/l). Age and sex did not differ significantly and all patients initially had irresectable advanced-stage tumours. Morphologically, three were highly malignant adult-type pleomorphic HCCs, two were differentiated tumours, and one a fibrolamellar subtype. The mean 2-year survival was 33% and the 5-year survival 16.6%. The biological behaviour and response to treatment of the tumours varied. Whereas three patients had a poor response to therapy, two with poorly-differentiated tumours, negative HbsAg, and normal serum AFP levels responded to doxorubicin/cisplatinum chemotherapy. This facilitated radical surgical excision. One patient of this group has survived for more than 75 months following surgical resection and remains well. HCC remains an uncommon tumour of childhood with a high mortality. Aggressive chemotherapeutic regimes in combination with surgical resection may lead to improved survival in some cases. Prevention of hepatitis B remains a priority.
Collapse
Affiliation(s)
- S W Moore
- Department of Paediatric Surgery, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa
| | | | | | | |
Collapse
|