Potentially misleading bone scan findings in patients with hepatoblastoma

2017 PRETEXT: radiologic staging system for primary hepatic malignancies of childhood revised for the Paediatric Hepatic International Tumour Trial (PHITT)

Imaging is crucial in the assessment of children with a primary hepatic malignancy. Since its inception in 1992, the PRETEXT (PRE-Treatment EXTent of tumor) system has become the primary method of risk stratification for hepatoblastoma and pediatric hepatocellular carcinoma in numerous cooperative group trials across the world. The PRETEXT system is made of two components: the PRETEXT group and the annotation factors. The PRETEXT group describes the extent of tumor within the liver while the annotation factors help to describe associated features such as vascular involvement (either portal vein or hepatic vein/inferior vena cava), extrahepatic disease, multifocality, tumor rupture and metastatic disease (to both the lungs and lymph nodes). This manuscript is written by members of the Children's Oncology Group (COG) in North America, the International Childhood Liver Tumors Strategy Group (SIOPEL) in Europe, and the Japanese Study Group for Pediatric Liver Tumor (JPLT; now part of the Japan Children's Cancer Group) and represents an international consensus update to the 2005 PRETEXT definitions. These definitions will be used in the forthcoming Trial to Pediatric Hepatic International Tumor Trial (PHITT).

Fractures in children with newly diagnosed hepatoblastoma

BACKGROUND

Hepatoblastoma is the most common primary hepatic malignancy in children. We have recently noticed an increased incidence of unsuspected fractures in children with newly diagnosed hepatoblastoma. This association has been suggested in the past, but the incidence and pathophysiology remain uncertain.

OBJECTIVE

To define the incidence and imaging features of fractures in children with newly diagnosed hepatoblastoma.

MATERIALS AND METHODS

We searched the oncology database and the radiology picture archiving and communication system of our large tertiary care children's hospital between January 2000 and August 2013 for all patients who presented to our institution with newly diagnosed hepatoblastoma. We reviewed all available imaging exams (radiographs, CT scans, MRIs, and nuclear medicine studies) to identify children who had radiologically apparent fractures on exams during the 50 days prior to diagnosis or up to 2 weeks after the date of hepatoblastoma diagnosis.

RESULTS

Forty-five children were included in this retrospective study. Eight children (17.8%) had fractures within 50 days prior to diagnosis or up to 2 weeks after the date of diagnosis, with a mean number of 4.9 fractures per patient (range 1-13). Only 21 of the 39 fractures (54%) were diagnosed during the initial image interpretation. Fractures most commonly occurred in the ribs (n=21) and vertebral bodies (n=10). The presence of a fracture was not associated with an identified demographic, tumor or laboratory finding.

CONCLUSION

Unsuspected fractures are relatively common in children with newly diagnosed hepatoblastoma.

Hepatoblastoma in a patient with methylmalonic aciduria

Childhood malignant tumors and their treatment are not well described in the natural history of methylmalonic aciduria (MMA). Here we present a case of hepatoblastoma occurring in the native liver of a 19-month-old male with MMA. His tumor was unresectable at diagnosis and he received neoadjuvant chemotherapy with cisplatin, 5-fluorouracil and vincristine. He developed metabolic acidosis and hyperglycemia during chemotherapy. In addition, he developed anemia, thrombocytopenia and febrile neutropenia. He underwent a combined liver-kidney transplant for local control of his tumor and to treat MMA. He remains in remission more than five years after his transplant. In addition, his transplant has cured his MMA and he is able to tolerate a regular diet without developing metabolic crises.

Equine Primary Liver Tumors: A Case Series and Review of the Literature

Hepatoblastoma (HB) is an uncommon pediatric liver tumor in humans and horses. In humans, HB is most frequently diagnosed in fetuses, neonates, and young children, whereas hepatocellular carcinoma (HCC) affects juvenile and adult humans. Hepatoblastoma in the horse is rare, with only 9 reported cases. Affected horses ranged in age from late-term aborted fetuses to 3 years. The current study describes 3 new cases of primary liver tumors in horses and reviews findings in relation to other reports on this condition. Tumors classified as HB were identified in a male Standardbred aborted fetus and in a 4-year-old Thoroughbred filly. Hepatocellular carcinoma was diagnosed in a 15-month-old Paint filly. In the Standardbred fetus, the tumor was only present in the liver. In the Thoroughbred and Paint fillies, primary tumors were in the right liver lobe and at the hilus, respectively, and there were metastases to other lobes (HB) and mesenteric lymph nodes (HCC). Tumors were sharply demarcated from adjacent tissue, nonencapsulated, compressive, and invasive. Consisting of cords and nests, or disorganized sheets of epithelial cells, tumors had variable stromal and vascular components. The fetal tumor contained areas of smaller, less differentiated cells with a pronounced mesenchymal component interpreted to be embryonal hepatic tissue. Diagnoses were based on tumor histomorphologic features, resemblance to hepatocyte developmental stages, age of the animal, and patterns of metastasis. Tumors classified as HB were α-fetoprotein immunoreactive. Primary hepatic tumors in the horse are diverse in morphology and include subtypes compatible with classification criteria applied to human tumors.

2005 PRETEXT: a revised staging system for primary malignant liver tumours of childhood developed by the SIOPEL group

Over the last 15 years, various oncology groups throughout the world have used the PRETEXT system for staging malignant primary liver tumours of childhood. This paper, written by members of the radiology and surgery committees of the International Childhood Liver Tumor Strategy Group (SIOPEL), presents various clarifications and revisions to the original PRETEXT system.

Radiological staging in children with hepatoblastoma

Hepatoblastoma is the most common malignant liver tumour of childhood. Accurate radiological staging is very important, especially in children who are treated according to the protocols of the International Childhood Liver Tumor Strategy Group (SIOPEL). These protocols use risk stratification, based almost entirely on imaging findings, to minimize the treatment for localized tumours and to intensify treatment for extensive tumours and those with extrahepatic spread.

Where do we stand with hepatoblastoma? A review

Hepatoblastoma (HB) is the most common pediatric liver malignancy, comprising approximately 1% of all pediatric cancers. The disparate clinical staging systems and histologic classifications that were developed during the last decades, nevertheless, reflect the remaining difficulties and uncertainties in characterizing HB. Furthermore, the combination of surgery and (neo)adjuvant chemotherapy has improved patient outcomes dramatically. A poor prognosis is associated with large tumor size, multifocality, extrahepatic disease, and metastatic spread. The exact etiology of HB remains unknown, but the cytogenetic alterations, phenotypic features, and biologic aspects that accompany this neoplasm yield more and more insight into its pathogenesis. New cell-biologic and molecular-biologic insights may lead to the development of new treatment modalities, especially for patients with a bad prognosis. This review summarizes the different aspects of this intriguing tumor and discusses the current status of research and treatment for patients with HB.

Hepatoblastoma with spinal metastases

Spinal cord compression secondary to metastases is an infrequent complication of childhood cancer. We describe an infant with hepatoblastoma in whom cord compression developed because of extensive epidural metastases during treatment. This is a hitherto undescribed metastatic site for hepatoblastoma.

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

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

Efficiency and toxicity of ifosfamide, cisplatin and doxorubicin in the treatment of childhood hepatoblastoma. Study Committee of the Cooperative Paediatric Liver Tumour Study HB89 of the German Society for Paediatric Oncology and Haematology

The Cooperative German Paediatric Liver Tumour Study HB89 was conceived to evaluate the efficiency and toxicity of ifosfamide, cisplatin and doxorubicin (IPA) in children with resectable and non-resectable hepatoblastoma (HB) and to determine late sequelae including tubular nephropathy of tumour treatment. The study also assessed the results of a surgical strategy, which adapts the procedure at the initial operation to the tumour's extension in the liver. The relationship of the tumours' histological differentiation to response to chemotherapy was also examined. Patients with a HB restricted to one liver lobe underwent primary resection. Larger tumours were initially treated with IPA chemotherapy and resected at second-look surgery. All patients received IPA adjuvantly after tumour resection. The IPA regimen consisted of ifosfamide 3.5 g/m2 (over 72 h days 1-3), cisplatin 100 mg/m2 (over 5 days 4-8) and doxorubicin 60 mg/m2 (over 48 h, days 9-10). Median follow-up of survivors was 64 months (range 28-82). Long-term disease-free survival (DFS) was for stage I: 21/21; stage II: 3/6; stage III: 28/38; and stage IV: 2/7 (overall 75%). Severe surgical complications occurred in 15% (4/27) of primary and 21% (8/38) of secondary resections with no lethality. 44/45 stage III/IV HB displayed PR after two IPA courses. Drug resistance developed in 8/12 tumours after four or five chemotherapy courses. Acute toxicity was observed in 34/242 (14%) IPA courses. Late sequelae were found in 7/54 (13%) of survivors, and subclinical renal tubulopathy occurred in 7/41 investigated patients (17%). Despite a more favourable prognosis in pure fetal and predominantly fetal histology, statistical analysis revealed no relationship between tumour differentiation and response to chemotherapy. In conclusion, IPA chemotherapy in combination with delayed surgery was highly effective in the treatment of HB.