Liver Transplantation for Pediatric Hepatocellular Carcinoma: A Systematic Review

Risk for Recurrence in Long-Term Follow-Up of Children after Liver Transplantation for Hepatoblastoma or Hepatocellular Carcinoma

The aim of this study was to assess the long-term results of liver transplantation (LT) in pediatric patients with unresectable hepatoblastoma (HB) or hepatocellular carcinoma (HCC) with special reference to the risk of tumor recurrence. We retrospectively analyzed data from 46 HB and 26 HCC patients who underwent LT between 1990 and 2022. In HCC patients, we compared outcomes depending on donor type. We evaluated the impact of a number of risk factors on recurrence-free survival after LT. Estimated patient survival after 5, 10, and 15 years was 82%, 73%, and 73% in the HB group and 79%, 75%, and 75% in the HCC group, respectively (p = 0.76). In the HCC group, living donor LT (LDLT) and deceased donor LT (DDLT) provided similar patient survival (p = 0.09). Estimated recurrence-free survival in patients who had three or fewer risk factors was significantly better than in patients with more than three risk factors (p = 0.0001). Adequate patient selection is necessary when considering LT for primary liver tumors in children. The presence of more than three risk factors is associated with a very high risk of recurrence and indicates poor prognosis, whereas extrahepatic disease may be considered a contraindication for transplantation.

Critical elements of pediatric liver cancer surgery

The appropriate management of pediatric liver malignancies, primarily hepatoblastoma and hepatocellular carcinoma, requires an in depth understanding of contemporary preoperative risk stratification, experience with advanced hepatobiliary surgery, and a good relationship with one's local or regional liver transplant center. While chemotherapy regimens have become more effective, operative indications more well-defined, and overall survival improved, the complexity of liver surgery in small children provides ample opportunity for protocol violation, inadequate resection, and iatrogenic morbidity. These guidelines represent the distillation of contemporary literature and expert opinion as a means to provide a framework for preoperative planning and intraoperative decision-making for the pediatric surgeon.

Liver cirrhosis in children - the role of imaging in the diagnostic pathway

Liver cirrhosis in children is a rare disease with multifactorial causes that are distinct from those in adults. Underlying reasons include cholestatic, viral, autoimmune, hereditary, metabolic and cardiac disorders. Early detection of fibrosis is important as clinical stabilization or even reversal of fibrosis can be achieved in some disorders with adequate treatment. This article focuses on the longitudinal evaluation of children with chronic liver disease with noninvasive imaging tools, which play an important role in detecting cirrhosis, defining underlying causes, grading fibrosis and monitoring patients during follow-up. Ultrasound is the primary imaging modality and it is used in a multiparametric fashion. Magnetic resonance imaging and computed tomography are usually applied second line for refined tissue characterization, clarification of nodular lesions and full delineation of abdominal vessels, including portosystemic communications.

The Landscape of HNF1B Deficiency: A Syndrome Not Yet Fully Explored

The hepatocyte nuclear factor 1β (HNF1B) gene is involved in the development of specialized epithelia of several organs during the early and late phases of embryogenesis, performing its function mainly by regulating the cell cycle and apoptosis pathways. The first pathogenic variant of HNF1B (namely, R177X) was reported in 1997 and is associated with the maturity-onset diabetes of the young. Since then, more than 230 different HNF1B variants have been reported, revealing a multifaceted syndrome with complex and heterogenous genetic, pathologic, and clinical profiles, mainly affecting the pediatric population. The pancreas and kidneys are the most frequently affected organs, resulting in diabetes, renal cysts, and a decrease in renal function, leading, in 2001, to the definition of HNF1B deficiency syndrome, including renal cysts and diabetes. However, several other organs and systems have since emerged as being affected by HNF1B defect, while diabetes and renal cysts are not always present. Especially, liver involvement has generally been overlooked but recently emerged as particularly relevant (mostly showing chronically elevated liver enzymes) and with a putative relation with tumor development, thus requiring a more granular analysis. Nowadays, HNF1B-associated disease has been recognized as a clinical entity with a broader and more variable multisystem phenotype, but the reasons for the phenotypic heterogeneity are still poorly understood. In this review, we aimed to describe the multifaceted nature of HNF1B deficiency in the pediatric and adult populations: we analyzed the genetic, phenotypic, and clinical features of this complex and misdiagnosed syndrome, covering the most frequent, unusual, and recently identified traits.

Comparison of surgical resection and radiofrequency ablation for stages I and II elderly hepatocellular carcinoma patients (≥ 65 years): A SEER population-based propensity score matching’s study

Objectives

The treatment for hepatocellular carcinoma (HCC) remains controversial and limited in elderly patients. Therefore, we aimed to explore treatment choices for the elderly patients (≥ 65years) following surgical resection (SR) versus radiofrequency ablation (RFA) with HCC (single lesion less than 5 cm).

Methods

We used SEER database to identify HCC patients who received treatment of SR/RFA. Kaplan–Meier method and Cox proportional hazards regression method were used to determine the prognostic factors associated with overall survival (OS) and disease-specific survival (DSS). In addition, RFA group and SR group patients were matched with 1:1 propensity score matching (PSM) for diagnosis age, sex, race, marital, American Joint Committee on Cancer (AJCC), grade, radiotherapy, and chemotherapy to decrease the possibility of selection bias. Conditional disease-specific survival (CS) was estimated using the life-table method.

Results

A total of 794 patients who underwent SR and 811 patients who underwent RFA were confirmed from the SEER database. Surgery type was an independent risk factor for HCC. Survival analysis indicated that SR, races, AJCC I, no chemotherapy treatment, and grade I were cumulative risk factors that can significantly improve median survival for HCC (P < 0.05). After PSM analysis, only surgery type was significantly improved median survival of HCC patients (SR vs. RFA, HR: 0.644, 95% CI: 0.482–0.86; P < 0.001). For RFA group, the 2-, 3-, and 5-year CS rates were approximately 71%, 65%, and 62%, respectively, and corresponding to 82%, 80%, and 78% in the SR group.

Conclusion

SR treatment can provide survival benefits for elderly patients of <5 cm single lesion HCC.