The radiological investigation of hepatic tumors in childhood

Congenital infantile hepatic hemangioendothelioma type II treated with orthotopic liver transplantation

The authors describe a 10-week-old girl with infantile hepatic hemangioendothelioma who initially presented with difficulty feeding, hepatomegaly, and multiple hemangiomas of the skin. Six weeks of steroid therapy and 2 weeks of chemotherapy failed to produce clinical improvement. The patient underwent split liver transplantation. A definitive diagnosis of hemangioendothelioma type II was made. Imaging studies cannot differentiate between hemangioendothelioma and angiosarcoma. Treatment modalities for this condition remain unclear. The patient continues to do well.

Hemangioendotelioma hepático: aspectos radiológicos e evolução clínica de um caso

Os tumores vasculares constituem um espectro de lesões que variam de benignas, os hemangiomas, a altamente malignas, os angiossarcomas, passando por um estágio intermediário de malignidade, no qual se incluem os hemangioendoteliomas. Relatamos um caso de hemangioendotelioma hepático de evolução benigna em um recém-nato do sexo feminino, e mediante revisão da literatura descrevemos os principais aspectos desta afecção.

The continued value of angiography in planning surgical resection of benign and malignant hepatic tumors in children

We assessed the accuracy of angiography or digital subtraction angiography (DSA) in diagnosing malignancy in hepatic tumors in children. In addition, these results were correlated with sonographic and computed tomographic findings of the liver in selected patients. Twenty-seven patients with primary liver tumors were examined with celiac or selective hepatic arteriography. Sonography was performed in 15 and computed tomography in 15 of the 27 patients. Angiographic criteria for malignancy or benignancy were established. These findings were correlated with computed tomographic and sonographic findings of the liver vascularity in selected patients. The final pathologic diagnosis was established surgically or by percutaneous biopsy. Sonography and computed tomography can be used as the initial procedure for evaluating tumor size, location and hepatic vascularity. However, the exact vascular anatomy demonstrated by angiography in children is more accurate and is often needed prior to surgical resection of primary liver tumors.

The role of radionuclide-labeled cells in the diagnosis of abdominal disease in children

The use of radionuclide-labeled blood cells can provide diagnostic information concerning abdominal disease in children that may not be available by any other imaging method. The use of technetium-labeled red blood cells to identify bleeding sites in the gastrointestinal tract, to define mass lesions, or to localize the spleen offers a relatively quick and inexpensive method of evaluation. In the evaluation of Crohn's disease of the small bowel or involvement of the colon in inflammatory bowel disease, white blood cells labeled with either indium-111 or technetium-99m provide meaningful diagnostic information. There also may be a role for the use of labeled white cells in the evaluation of appendicitis. The individualized use of labeled blood cells provides the nuclear physician with a unique opportunity to contribute in a meaningful manner to the care of children using information that is critical in patient care.

Hepatobiliary tumours of childhood: investigation and management

The most commonly encountered complications include wound infections, subphrenic collections and bile leaks from the cut liver surface. Stress ulceration of the stomach or duodenum is also not uncommon. Inadvertent bile duct damage has also been reported after major resection in children. The results of surgery for benign lesions are very good and usually depend simply on technical expertise. The results for malignant lesions, however, remain poor. Six series, including our own experience, reported in the last 5 years have shown an overall survival rate of 43% for patients whose tumours were resected for cure. It is difficult to compare results as authors differ in their presentation of results, but details of the series are listed in Table 7. There were no definite prognostic factors to be drawn from these series other than that children with the fibrolamellar variant of hepatocellular carcinoma fared better than those with other hepatomas. It is a sad fact that overall 56% of patients in these series presented with unresectable disease. Mahour et al. described seven patients with unresectable disease who were treated by either chemotherapy alone or in combination with radiotherapy, followed by 'second look' laparotomy and resection. Five of these patients were alive and disease-free for a minimum of 2.5 years after surgery. Thus it is necessary to adopt an aggressive approach to these tumours if one is to see any improvement on the overall figures.

Ultrasonography and computed tomography for diagnosis and follow-up of biliary duct rhabdomyosarcomas in children

The authors report eight cases of biliary duct rhabdomyosarcoma in children, examined by US and CT. There were five boys and three girls, aged 2 to 17 years. At presentation, US demonstrates the tumor mass within the liver or the hepatic hilum; it allows measurement of it and defines the relationship with portal vessels, biliary tract and other important structures. CT complements the US evaluation and determines operability. As US and CT cannot assess the histological origin of the tumor, a biopsy is mandatory before treatment. If complete surgical excision does not seem possible, percutaneous biopsy is preferable to incomplete excision and its possible complications. During the follow-up period, US can be repeated to measure tumor regression under chemotherapy. After surgery, CT seems preferable because of gas interposition. Both US and CT proved to be valuable for the early detection of local recurrence. The prognosis of these tumors remains bad. However, with more aggressive and hopefully more efficient chemotherapy a precise evaluation of the tumor extension by US and CT is very important. Surgery will then be performed only on localized tumors or on residual masses after chemotherapy.

Pediatric applications in nuclear oncology

Imaging procedures (both as they apply to initial diagnosis and assessing the response to therapy) using radionuclides are indispensible in the evaluation of malignant diseases that afflict infants and children. The diagnosis and accurate staging are extremely critical because of continuing improvements in the survival of children with malignant disease when treated with appropriate therapy. The major role of nuclear medicine in this patient group serves to evaluate the skeletal system and the liver and spleen. It is important to keep the pediatric specialist well informed concerning the role that nuclear medicine can play in elucidating many of the clinical problems that this specialist faces.

Hepatocellular carcinoma in an infant presenting with calcified soft tissue mass. Case report and 25-year experience

We recently encountered an 8-week-old male with hepatocellular carcinoma, whose presenting feature was a calcified soft tissue mass. This manifestation has not been reported previously in the literature and was not observed in our review of the 31 patients with primary hepatic neoplasms seen during the past 25 years at the Children's Hospital of Philadelphia.

Thirty years of experience with pediatric primary malignant liver tumors

Since 1950, 48 infants and children from 10 weeks to 16 years of age presented with primary hepatic malignancy. Signs and symptoms ranged from asymptomatic to those of malignant disease. All patients had a palpable abdominal mass. Jaundice was seen in five patients, four of whom had preexisting cirrhosis. Three male children had evidence of precocious puberty. Whereas liver function tests were usually normal, alpha-fetoprotein levels, when elevated, proved useful diagnostically and as a tumor marker in follow-up. Hepatic angiography and computed tomography (CT) scans have provided the most valuable preoperative assessment of hepatic architecture. Sixteen infants and children underwent resection for cure. Eleven of these patients are alive and disease free 6 months to 23 years later. Six additional patients had incomplete resection with subsequent radiotherapy and/or chemotherapy; only one such patient is disease-free past 3 years. Twenty-six tumors could only be biopsied; most of these patients died within 12 months regardless of what treatment they received. The histology was hepatoblastoma in 39 patients, hepatocellular carcinoma in 4, fibrolamellar carcinoma in 4, and malignant mesenchymal tumor (mesenchymoma) in 1. The patients with hepatocellular carcinoma and mesenchymoma all died. Three of four patients with fibrolamellar carcinoma are alive and disease-free following resection up to 3 years; this histology seems favorable. The other survivors had hepatoblastoma. The role of adjunctive chemotherapy and/or radiotherapy has not yet been determined.

Primary hepatic tumors of childhood

A clinicopathologic review of 73 cases of primary liver tumors at Texas Children's Hospital, Houston, and Children's Medical Center, Dallas, has documented important prognostic and therapeutic implications for the histologic classification of hepatoblastoma. The pure "fetal" pattern was associated with cure in every instance that surgical excision was achieved (six of six patients), whereas only two of 19 patients with "embryonal" or other undifferentiated patterns of growth survived five years. The relationship of hepatoblastoma and hepatocarcinoma in childhood to antecedent conditions is discussed in detail. The uncommon liver sarcomas are also reviewed in the light of experience at these two institutions.

Neonatal hepatic malignant tumor. A correlative imaging approach

We report the hepatobiliary study of a neonate with hepatomegaly. Biliary atresia was ruled out. Fortuitous demonstration of massive parenchymal lesions redirected the clinical management of the child. Other imaging modalities were employed to define further the nature of the lesions. Pediatric reports of non-biliary lesions demonstrated by hepatobiliary scintigraphy are uncommon. To our knowledge, the present case of multiple hepatoblastomas discovered by hepatobiliary imaging is the first report in the literature.

Focal nodular hyperplasia of the liver imaging by differing modalities

The logistic approach in diagnosis of focal nodular hyperplasia (FNH) of the liver is discussed, based on the experience with three children. In only one child could the diagnosis be made without angiography. In that child the combination of hypervascularity on the radionuclide angiogram and uptake of the radiocolloid by Kupffer cells was sufficient for the diagnosis of FNH. If the radionuclide scintigraphy is inconclusive, angiography has to be done to show the typical features of FNH, seen in all three patients. Only if scintigraphy and angiography are not able to differentiate FNH from hepatic adenoma, biopsy or exploratory laparotomy is indicated as a final diagnostic procedure. Ultrasonography or computerized tomography is of value only in screening for hepatic mass lesions.

Echographic aspects of hepatic metastases of nephroblastomas

We report a retrospective study of 293 cases of nephroblastoma treated at the Gustave Roussy Institute (I.G.R.) from 1971 to 1980, and 39 similar cases treated at the Curie Institute (I.C), from June 1977 to June 1981. Twenty-two cases of hepatic metastases were found. We were primarily interested in the echographic aspects of the lesions and particularly in their evolution. Despite the fact that the patients came from different centers with varying types of work-up, ten cases were fully documented and are presented in detail. They show the use to which ultrasound may be put.

Infantile hepatic hemangioendothelioma with subsequent malignant degeneration

A 4 year old child was seen because of an enlarging epigastric mass and a rapidly falling hematocrit 31/2 years following steroid treatment for multiple hepatic hemangioendotheliomas. Technetium 99m sulfur colloid liver scan and hepatic angiography confirmed the presence of a large, vascular mass involving the left lobe of the liver. A left hepatic lobectomy was performed and histopathology showed angiosarcoma. As children with hemangioendotheliomas of the liver begin to survive for longer periods of time, surveillance for the possible development of neoplastic disease is recommended.

Multicystic hepatic mesenchymal hamartoma of childhood. Computerized tomography and ultrasound characteristics

A case of massive mesenchymal hamartoma of the liver is described in a 13-month-old infant. A complex multicystic mass was demonstrated by ultrasound and computed tomography (CT). The appearances suggested the preoperative diagnosis.

Ultrasonography in primary hepatic tumors in early childhood

Ultrasonography was useful in preoperative investigation of primary hepatic tumors in nine children, aged 4 weeks to 4 years. In all patients, the hepatic origin and the solid or mixed echogenic nature of the tumor was determined. In two children (one with hemangioendothelioma, one with cystic mesenchymoma) the ultrasonographic findings were even more specific when correlated with angiography and/or histology. Ultrasonography in children with hepatomegaly should be performed as a screening procedure before angiography, to determine if enlargement of the liver is of tumorous origin. For follow-up, ultrasonography should be preferred over radionuclide imaging because it does not require the use of ionizing energy.

Arteriography in childhood tumours

Percutaneous arteriography was used as the investigation of choice in 121 children with clinically suspected malignancy on 132 occasions. Major complications occurred in 2% of the investigations and misdiagnosis in 10%. The arteriographic information was complementary to that of other, routine, investigations in 18% (25 investigations) but in 70% it was crucial, either ruling out a malignancy or defining its nature, site and size while also serving as a guide for biopsy, surgical manipulation, radiotherapy and/or chemotherapy. Arteriography can shorten the work-up in childhood tumours, especially those of the abdomen, eliminating the need for less informative radiological investigations. However, the complications encountered confirmed the peculiar difficulties and risks of paediatric arteriography and the need for strict case selection and a high degree of skill.