Prenatal diagnosis of fetal hepatoblastoma with a good neonatal outcome: case report and narrative literature review

Congenital hepatoblastoma: Expanding knowledge, improving outcomes

Hepatoblastoma (HB) is a rare liver tumour, and its congenital counterpart (CHB) is even less frequent. CHB has a clinically challenging management and a generally perceived worse outcome. This study aims to review the literature on CHB to better define presentation, diagnosis, available treatments and management options. The analysis of outcomes suggests that a significant portion of mortality is unrelated to the malignant nature of the tumour. Key factors influencing overall outcomes were identified: mortality linked to the 'mass effect' during both the prenatal (22%) and perinatal (32%) stages, as well as 'oncological' mortality encompassing tumour and/or treatment-related factors (46%). Overall, after birth, CHB does not seem to confer a worse oncological prognosis per se, and should be managed similarly to older children, if patients are stable enough to undergo proper staging and treatment. A deeper knowledge and better outcomes would come from a large, homogeneous, collection of data possibly allowing a global protocol, focusing on a comprehensive management of CHB.

Congenital hepatoblastoma presenting with hepatic arteriovenous fistulas: a case report

Aim

Congenital hepatoblastoma, a rare malignant liver tumor in infancy, typically presents with abdominal distension or mass. Tumors detected antenatally or during the first three months of age are considered congenital hepatoblastoma. Hepatic arteriovenous fistulas (HAVF) are associated with high mortality in the neonatal period and can be caused by many secondary factors. This case report focuses on a patient with congenital hepatoblastoma accompanied by HAVF, highlighting the clinical and imaging characteristics and management strategies.

Case presentation

A term infant presented with sudden tachypnea and heart failure on his first day of life. A cystic-solid mixed lesion in the fetus's liver was detected by an antenatal ultrasound scan. Postnatal digital subtraction angiography confirmed the presence of arteriovenous fistulas, which were treated with trans-arterial embolization. However, despite the intervention, the patient's heart failure did not improve. The patient underwent a left hepatectomy, and hepatoblastoma was discovered by histology of the resected hepatic lobe. Unfortunately, metastases were later discovered in the intracranial and ocular regions. Ultimately, the family decided to discontinue further treatment.

Conclusion

Congenital hepatoblastoma presenting with hepatic arteriovenous fistulas has not been previously described. Hepatoblastoma should be considered when alpha-fetoprotein levels show a significant elevation in newborns. Prenatal diagnosis may improve pre- and postnatal management.

Liver Resection Using Saline-Linked Radiofrequency Technology in an Infant with Congenital Hepatoblastoma

We herein report a case of giant congenital hepatoblastoma in a 3-month-old male treated with neoadjuvant chemotherapy and hepatic resection. After considerable reduction of the tumor with chemotherapy, a right bloodless hemihepatectomy using saline-linked radiofrequency technology (SLRT) and without clamping of the hepatic pedicle was performed. Intraoperative blood loss was minimal, and consequently, no blood transfusions were required. The surgery lasted 140 min, and SLRT was used for a total of 60 min. No complications were observed during or after the surgery. In conclusion, congenital hepatoblastoma is a very rare cancer for which surgery is an essential therapeutic step, and in our presented case, we showed that SLRT allowed for a safe and effective bloodless liver resection.

Case Report of Congenital Hepatoblastoma With the Onset at 30-Weeks' Gestation

This study reports a case of hepatoblastoma with onset at 30-weeks' gestation and rapid growth rate. The postnatal enhanced CT confirmed an intrahepatic mass with a size of 8.5 cm × 6.6 cm and a clear boundary accompanied by uneven enhancement, displacement, and narrow lumen of the hepatic vein due to compression. The alpha-fetoprotein (AFP) at birth was 1,002,632 ng/ml (normal level 48,406 [±34,718] ng/ml). A diagnosis of congenital hepatoblastoma was established based on the imaging and laboratory outcomes. The infant received chemotherapy of Cisplatin-5 fluorouracil-Vincristine (C5V) on the fourth day after birth. After four courses of C5V, a complete tumor resection was performed, and the postoperative pathology was consistent with mixed epithelial and mesenchymal hepatoblastoma. Four more courses of C5V and one course of C5VD (C5V plus doxorubicin) followed the surgery. Infectious diarrhea and acute kidney injury (stage I) occurred during chemotherapy, which recovered after anti-infection and symptomatic treatment. The patient is currently 2 years old and still in complete remission. In this case, the onset of hepatoblastoma was early, and the tumor grew rapidly, resulting in an obvious compression effect. Chemotherapy was started early after birth, and the curative effect was satisfactory, suggesting that the hepatoblastoma based on clinical diagnosis with rapid tumor progression and severe dysfunction of surrounding organs caused by compression should undergo chemotherapy as soon as possible if a pathological diagnosis cannot be obtained temporarily, which also plays an important role in improving the complete resection rate of intraoperative tumor and reducing the recurrence rate of postoperative tumor.

Challenges Faced During the Ventilation of a Child With Bronchobiliary Fistula: A Case Report

Hepatoblastoma is the most frequently occurring malignant tumor of the liver in children (ages ≤5 years). The formation of bronchobiliary fistula is a rare complication. We present a case report that describes the associated anesthetic challenges that we encountered for the treatment of this pathology.

Rare cause of emergency in the first week of life: congenital hepatoblastoma (case report)

During the first week of life, a sudden deterioration in a newborn commonly includes investigations to rule out infections, lung pathologies, cardiac lesions, neurological insults, metabolic disorders or gastrointestinal emergencies. It is unusual, however, to consider malignancy as the primary causative factor. In this case report, we describe a rare and unusual presentation of congenital hepatoblastoma, its complications and management in a neonate with multi-organ dysfunction. A term infant presented with sudden deterioration, hemodynamic instability and an acute abdomen on his 4th day of life. Surgical exploration revealed a ruptured neoplasm that pathology diagnosed as a congenital hepatoblastoma. After the patient was stabilized, chemotherapy was initiated. At present, the patient is 8 months old and under continuous follow-up of oncology service. This case highlights the importance of considering rare diagnoses including congenital malignancy when investigating and managing a sick newborn with multi-organ dysfunction.

Management of fetal tumors

In this review article, we discuss the most common fetal tumors, their prenatal management, and outcomes. Overall, the most important outcome predictors are tumor histology, size, vascularity, and location. Very large lesions, lesions causing cardiac failure, and hydrops and lesions obstructing the fetal airway have the poorest outcome, as they may cause fetal death or complications at the time of delivery. Fetal therapy has been developed to improve outcomes for the most severe cases and can consist of transplacental therapy (sirolimus for rhabdomyomas or steroids for hemangiomas and microcystic lung lesions) or surgical intervention (shunting of cystic masses, tumor ablation, occlusion of blood flow or airway exploration, and protection). Given the rarity of fetal tumors, patients should be referred to expert centers where care can be optimized and individualized to allow the best possible outcomes.

Diagnosis and Treatment of a Preterm Infant With Inoperable Congenital Hepatoblastoma--A Case Report

Reports of hepatoblastoma (HB) in preterm infants are quite rare. Herein, we report the clinical management of a preterm infant with inoperable congenital HB. A female fetus that had been diagnosed with a large liver tumor consistent with hemangioma was delivered by emergency cesarean section at 33 weeks of gestation because of fetal distress. Effective antitumor therapy could not be performed, resulting in rapid deterioration and death. The postmortem histopathologic analysis confirmed the tumor as a HB. This report demonstrates the difficulties inherent in both the image diagnosis of HB and in providing efficacious treatments for preterm infants with HB.

Neonatal cancer

Neonatal cancer is rare and comprises a heterogeneous group of neoplasms with substantial histological diversity. Almost all types of paediatric cancer can occur in fetuses and neonates; however, the presentation and behaviour of neonatal tumours often differs from that in older children, leading to differences in diagnosis and management. The causes of neonatal cancer are unclear, but genetic factors probably have a key role. Other congenital abnormalities are frequently present. Teratoma and neuroblastoma are the most common histological types of neonatal cancer, with soft-tissue sarcoma, leukaemia, renal tumours, and brain tumours also among the more frequent types. Prenatal detection, most often on routine ultrasound or in the context of a known predisposition syndrome, is becoming more common. Treatment options pose challenges because of the particular vulnerability of the population. Neonatal cancer raises diagnostic, therapeutic, and ethical issues, and management requires a multidisciplinary approach.

Outcomes for patients with congenital hepatoblastoma

BACKGROUND

Congenital hepatoblastoma, diagnosed in the first month of life, has been reported to have a poor prognosis; however, a comprehensive evaluation of this entity is lacking.

PROCEDURE

We retrospectively reviewed two patients from the senior authors' personal series and 25 cases identified in the databases of several multicenter group studies (INT-0098, P9645, 881, P9346, HB 89, HB94, and HB 99). We compared this series with cases of congenital hepatoblastoma previously published in the literature.

RESULTS

The 3-year survival in our case series was 86% (18/21) with a follow-up of 44-230 months (median 85.5 months). Presentation and treatment were not substantially different from hepatoblastoma cohorts unselected for age. Survival was comparable to the reported disease free survival for a similar cohort of hepatoblastoma patients unselected for age between 1986 and 2002 (82.5%) [von Schweinitz et al., Eur J Cancer 1997; 33:1243-1249]. The 2-year survival of cases reported in the literature was 0% (0/9) and 42% (10/24) for patients reported before and after 1990, respectively.

CONCLUSIONS

Congenital hepatoblastoma does not appear to confer a worse prognosis. The improved survival of our current series of patients, collected from the past 20 years of German and American multicenter trials and personal series, suggests that the outcome of hepatoblastoma at this young age is much better than has been historically reported. More rigorous analysis should be conducted in future multicenter trials. It is possible that congenital hepatoblastoma should be treated like all other patients with hepatoblastoma provided that the child is stable enough to proceed with surgery and chemotherapy.

Perinatal management of infant tumors and the promise of fetal surgery

PURPOSE OF REVIEW

This review outlines the current approaches to prenatal imaging, differential diagnosis, antenatal natural history, and the available treatment options for the most commonly prenatally diagnosed malignant tumors.

RECENT FINDINGS

In-utero diagnosis of fetal tumors, although still a rare event, has become more common as prenatal imaging modalities have improved. In general, this prenatal diagnosis allows more informed prenatal counseling and better perinatal planning for potentially high-risk deliveries. There are rare indications for prenatal fetal intervention.

SUMMARY

Diagnosis of a fetal tumor should prompt referral to a specialized center. Further understanding of these rare patients will require multicenter collaboration.

Hepatoblastoma in the neonatal period: An unusual presentation

Hepatoblastoma (HBL) is a rare primary malignant liver tumor affecting mainly pediatric patients in the age group 6 months to 3 years. Presentation of HBL in the neonatal period is rare. HBL can be diagnosed on cytology along with subtyping. Estimation of serum alpha-fetoprotein (AFP) is essential as a tumor marker. Fetal type HBL usually shows high AFP level. In this report, diagnosis of HBL in a 10-day-old baby with low serum AFP is being described for its unusual presentation.

The epidemiology of hepatoblastoma

Few causes of hepatoblastoma have been conclusively identified, mainly due to the extreme rarity of the disease. Inherited conditions including Familial Adenomatous Polyposis and Beckwith-Wiedemann Syndrome dramatically raise risk of hepatoblastoma but account for few cases overall. A small number of case-control studies investigating risk factors for sporadic hepatoblastoma have been conducted to date. Although most of these studies feature fewer than 200 cases, several clues have emerged. Most notably there is a roughly 20-fold increased risk of hepatoblastoma among children with very low birth weight (<1,500 g) and a doubling of risk among those with moderately low birth weight (1,500-2,500 g). A modicum of evidence points to a possible role of parental tobacco use prior to or during pregnancy in the causation of hepatoblastoma as well.

Perinatal hemorrhage complicating neonatal hepatoblastoma: case report

Hepatoblastoma is the most common malignant liver tumor of infancy and presents most frequently at a median age of 18 months. Presentation in the neonatal period is rare, and there are very few reports of an antenatal diagnosis of hepatoblastoma. We recently encountered a neonate who presented with hemoperitoneum after rupture of a congenital hepatoblastoma during vaginal delivery. After successful right hepatectomy and adjuvant cis-platinum-based chemotherapy, the child is doing well. We draw attention to rarity of this condition and difficulty in definitively establishing a diagnosis both in the antenatal and neonatal periods and discuss the management dilemmas in congenital presentations of hepatoblastoma.

Congenital ascites due to hepatoblastoma with extensive peritoneal implantation metastases in a premature equine fetus

A premature dead equine fetus with excessive fluctuating distension of the abdomen was delivered by extraction. Post-mortem examination revealed ascites and a solitary, irregular, bulging, multinodular, firm, yellow mass of 25 cm in diameter in the right liver lobe. Extensive peritoneal implantation metastases were present. The masses were composed of polygonal embryonal cells arranged in sheets and nests. Based on the immunohistochemical expression of Ki67, low molecular weight cytokeratin and alpha-1 fetoprotein, a diagnosis of hepatoblastoma with peritoneal implantation metastases was made.