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Ezekian B, Mulvihill MS, Schroder PM, Gilmore BF, Leraas HJ, Gulack BC, Jane Commander S, Mavis AM, Kreissman SG, Knechtle SJ, Tracy ET, Barbas AS. Improved contemporary outcomes of liver transplantation for pediatric hepatoblastoma and hepatocellular carcinoma. Pediatr Transplant 2018; 22:e13305. [PMID: 30341782 DOI: 10.1111/petr.13305] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/14/2018] [Accepted: 09/19/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Improvement in outcomes of LT for pediatric HB and HCC has been reported in small series. We analyzed national outcomes and changes in donor, recipient, and perioperative factors over time that may contribute to survival differences. METHODS The UNOS database was queried for patients age <21 years that underwent LT for a primary diagnosis of HB or HCC (1987-2017). Subjects were divided into historic (transplant before 2010) and contemporary (transplant after 2010) cohorts. Baseline characteristics were compiled and examined. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS In total, 599 children with HB received LT (320 historic vs 279 contemporary). Concurrently, 141 children with HCC received LT (92 historic vs 49 contemporary). For both tumors, waitlist time decreased (HB 56.2 days historic vs 33.2 days contemporary, P = 0.017; HCC 189.3 days historic vs 71.7 days contemporary, P = 0.012). In the historic cohorts, patients with HB had a 1-year and 5-year OS of 84.6% and 75.1%, respectively. Survival for HCC was 84.4% and 59.9%, respectively. Outcomes improved in the contemporary era to 89.1% and 82.6% for HB, and 94.7% and 80.8% for HCC, respectively (both log-rank test P < 0.0001). CONCLUSION Outcomes of LT have improved significantly, with contemporary survival now equivalent between these tumors and exceeding 80% 5-year OS. Future studies are needed to explore whether offering LT in patients that are resectable is justifiable.
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Affiliation(s)
- Brian Ezekian
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael S Mulvihill
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul M Schroder
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Harold J Leraas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Alisha M Mavis
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Susan G Kreissman
- Division of Hematology-Oncology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Stuart J Knechtle
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elisabeth T Tracy
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Umeda K, Okajima H, Kawaguchi K, Nodomi S, Saida S, Kato I, Hiramatsu H, Ogawa E, Yoshizawa A, Okamoto S, Uemoto S, Watanabe K, Adachi S. Prognostic and therapeutic factors influencing the clinical outcome of hepatoblastoma after liver transplantation: A single-institute experience. Pediatr Transplant 2018; 22. [PMID: 29341393 DOI: 10.1111/petr.13113] [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: 12/07/2017] [Indexed: 12/14/2022]
Abstract
LT has contributed to an elevation in cure rates for patients with unresectable HB; however, patients with recurrent HB after LT have poor prognosis. To analyze the prognostic and therapeutic factors that influence the clinical outcome of patients with HB receiving LT, we retrospectively analyzed 24 patients with HB who underwent LT between 1997 and 2015. The 5-year OS rate of all patients was 69.6±9.7%. The 5-year OS rate of 11 patients receiving salvage LT for recurrent tumor after a primary resection was comparable to that of 13 patients receiving primary LT. Among 12 evaluable patients receiving primary LT, six of 10 patients with a decline of serum AFP >95% at LT are currently alive and in remission, whereas two patients with a decline of AFP ≤95% experienced post-LT relapse. Among 9 evaluable patients receiving salvage LT, all three patients with any decline of AFP at LT are currently alive in remission, and three of six patients with no response to pre-LT salvage chemotherapy are also alive and in remission. Response to chemotherapy may be a reliable marker for prediction of post-LT relapse, even for patients receiving salvage LT.
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Affiliation(s)
- Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawaguchi
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Seishiro Nodomi
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Saida
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Itaru Kato
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hidefumi Hiramatsu
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eri Ogawa
- Department of Pediatric Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yoshizawa
- Department of Pediatric Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinya Okamoto
- Department of Pediatric Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Pediatric Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Watanabe
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Souichi Adachi
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Trobaugh-Lotrario AD, Meyers RL, Tiao GM, Feusner JH. Pediatric liver transplantation for hepatoblastoma. Transl Gastroenterol Hepatol 2016; 1:44. [PMID: 28138611 DOI: 10.21037/tgh.2016.04.01] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/16/2016] [Indexed: 01/03/2023] Open
Abstract
Hepatoblastoma is the most common pediatric liver tumor and is usually diagnosed before five years of age. Treatment consists of a combination of chemotherapy and surgery, with the goal being attainment of complete local control by surgical resection and eradication of any extrahepatic disease. Neoadjuvant chemotherapy is utilized and is often beneficial in rendering tumors resectable; however, prolonged chemotherapy administration attempting to render tumors resectable by conventional resection should be avoided. For patients whose tumors are too extensive to be conventionally resected, liver transplantation can be curative and remains the treatment of choice for eligible patients otherwise incurable by conventional resection.
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Affiliation(s)
- Angela D Trobaugh-Lotrario
- Department of Pediatric Hematology/Oncology, Providence Sacred Heart Children's Hospital, Spokane, WA, USA
| | - Rebecka L Meyers
- Department of Pediatric Surgery, Primary Children's Medical Center, Salt Lake City, UT, USA
| | - Greg M Tiao
- Department of Pediatric Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - James H Feusner
- Department of Pediatric Hematology/Oncology, Children's Hospital & Research Center Oakland, Oakland, CA, USA
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Hackl C, Schlitt HJ, Kirchner GI, Knoppke B, Loss M. Liver transplantation for malignancy: Current treatment strategies and future perspectives. World J Gastroenterol 2014; 20:5331-5344. [PMID: 24833863 PMCID: PMC4017048 DOI: 10.3748/wjg.v20.i18.5331] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/31/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
In 1967, Starzl et al performed the first successful liver transplantation for a patient diagnosed with hepatoblastoma. In the following, liver transplantation was considered ideal for complete tumor resection and potential cure from primary hepatic malignancies. Several reports of liver transplantation for primary and metastatic liver cancer however showed disappointing results and the strategy was soon dismissed. In 1996, Mazzaferro et al introduced the Milan criteria, offering liver transplantation to patients diagnosed with limited hepatocellular carcinoma. Since then, liver transplantation for malignant disease is an ongoing subject of preclinical and clinical research. In this context, several aspects must be considered: (1) Given the shortage of deceased-donor organs, long-term overall and disease free survival should be comparable with results obtained in patients transplanted for non-malignant disease; (2) In this regard, living-donor liver transplantation may in selected patients help to solve the ethical dilemma of optimal individual patient treatment vs organ allocation justice; and (3) Ongoing research focusing on perioperative therapy and anti-proliferative immunosuppressive regimens may further reduce tumor recurrence in patients transplanted for malignant disease and thus improve overall survival. The present review gives an overview of current indications and future perspectives of liver transplantation for malignant disease.
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Meyers RL, Czauderna P, Otte JB. Surgical treatment of hepatoblastoma. Pediatr Blood Cancer 2012; 59:800-8. [PMID: 22887704 DOI: 10.1002/pbc.24220] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 05/08/2012] [Indexed: 11/10/2022]
Abstract
Surgical resection remains the cornerstone of cure in hepatoblastoma (HB). Meticulous review of contrast enhanced CT/MR imaging facilitates PRETEXT and POST-TEXT grouping to determine optimal timing and desired extent of liver resection. Excellent knowledge of liver anatomy is essential and the dissection must ensure protection of the vascular inflow and outflow to the remaining liver at all times. Referral to a liver specialty center in advanced cases may facilitate resectability. Potential surgical complications include bleeding, vascular injury, cardiac arrest, liver failure, and bile leak. The risk of complications can be minimized with preoperative planning, appropriate referral, and precise surgical technique.
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Affiliation(s)
- Rebecka L Meyers
- Division of Pediatric Surgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah 84113, USA.
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7
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Faraj W, Dar F, Marangoni G, Bartlett A, Melendez HV, Hadzic D, Dhawan A, Mieli-Vergani G, Rela M, Heaton N. Liver transplantation for hepatoblastoma. Liver Transpl 2008; 14:1614-9. [PMID: 18975296 DOI: 10.1002/lt.21586] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
From October 1993 to February 2007, 25 liver transplantations were performed for hepatoblastoma. Of these 25, 18 children received cadaveric grafts, and 7 received left lateral segments from living donors. Fifteen patients were at level IV in the pretreatment extent of disease staging system for hepatoblastoma (PRETEXT IV; 11 received cadaveric grafts and 4 underwent living related liver transplantation [LRLT]) and 10 were level III (PRETEXT III; 7 received cadaveric grafts and 3 underwent LRLT). Preoperative chemotherapy was given according to the risk stratification system for children with hepatoblastoma protocols of the International Childhood Liver Tumour Strategy Group of the International Society of Paediatric Oncology (SIOPEL): SIOPEL I in the first 3 patients, SIOPEL II in 6, SIOPEL III in 10, and SIOPEL IV in 3 patients. Patient and graft survival after cadaveric transplantation was 91%, 77.6%, and 77.6%, at 1, 5, and 10 years, respectively, with no retransplantations. Patient and graft survival for children undergoing LRLT was 100%, 83.3%, and 83.3%, at 1, 5, and 10 years, respectively. All surviving children but 1 remain disease-free, with a median follow up of 6.8 years (range, 0.9-14.9). There were 5 deaths at a median of 13 months post-transplantation, secondary to tumor recurrence (4) and respiratory failure (1). Liver transplantation is an established treatment for unresectable hepatoblastoma confined to the liver following chemotherapy. LRLT is a therapeutic option given that the outcome is similar to that of resection and cadaveric transplantation.
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Affiliation(s)
- Walid Faraj
- Institute of Liver Studies, King's College Hospital, School of Medicine, King's College London, London, UK
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Stringer MD. The role of liver transplantation in the management of paediatric liver tumours. Ann R Coll Surg Engl 2007; 89:12-21. [PMID: 17316514 PMCID: PMC1963524 DOI: 10.1308/003588407x155527] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In recent years, considerable progress has been made in the treatment of children with hepatoblastoma largely due to effective pre-operative chemotherapy. Total hepatectomy and liver transplantation has emerged as an effective treatment for the small proportion of children with unresectable hepatoblastoma limited to the liver. A 5-year survival of 70% can be achieved in such cases. In contrast, the results of liver transplantation in children with hepatocellular cancer remain poor because these tumours are usually advanced with evidence of major vascular invasion and/or extrahepatic spread at the time of presentation. An exception is those children in whom the hepatocellular carcinoma is detected during surveillance of chronic liver disease - they typically have smaller tumours and frequently have a good prognosis after liver transplantation. The role of liver transplantation in children with other primary hepatic malignancies remains uncertain because experience is very limited. Liver transplantation is rarely needed in the management of children with benign liver tumours but, if other treatments have failed, it can be a life-saving intervention.
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Affiliation(s)
- Mark D Stringer
- Children's Liver & GI Unit, St James's University Hospital, Leeds, UK.
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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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Hasegawa T, Kimura T, Ihara Y, Tazuke Y, Yoneda A, Kusafuka T, Fukuzawa M, Okuyama H, Inoue M. Living-related liver transplantation with removal of inferior vena cava for unresectable hepatoblastoma. Pediatr Transplant 2006; 10:521-4. [PMID: 16712615 DOI: 10.1111/j.1399-3046.2006.00516.x] [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: 11/28/2022]
Abstract
We report a case of a two-yr-old boy with hepatoblastoma resectable only by total hepatectomy including the vena cava. Successful LTx was performed with a living donor segment without vena cava reconstruction. The tumor was located in the bilateral lobe, surrounding the IVC. In spite of the high-dose chemotherapy, the tumor did not become resectable. LTx was performed using left lateral segment after removal of the IVC combined with total hepatectomy. Because the collaterals were well developed, the patient tolerated the procedure well. The serum AFP level decreased from 186 699 to 8 ng/mL in 11 months after LTx without local recurrence or distant metastasis.
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Affiliation(s)
- Toshimichi Hasegawa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan.
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