Surgical management in hepatoblastoma: points to take

A Novel Visual Model for Predicting Prognosis of Resected Hepatoblastoma: A Multicenter Study

RATIONALE AND OBJECTIVES

This study aimed to evaluate the application of a contrast-enhanced CT-based visual model in predicting postoperative prognosis in patients with hepatoblastoma (HB).

MATERIALS AND METHODS

We analyzed data from 224 patients across three centers (178 in the training cohort, 46 in the validation cohort). Visual features were extracted from contrast-enhanced CT images, and key features, along with clinicopathological data, were identified using LASSO Cox regression. Visual (DINOv2_score) and clinical (Clinical_score) models were developed, and a combined model integrating DINOv2_score and clinical risk factors was constructed. Nomograms were created for personalized risk assessment, with calibration curves and decision curve analysis (DCA) used to evaluate model performance.

RESULTS

The DINOv2_score was recognized as a key prognostic indicator for HB. In both the training and validation cohorts, the combined model demonstrated superior performance in predicting disease-free survival (DFS) [C-index (95% CI): 0.886 (0.879-0.895) and 0.873 (0.837-0.909), respectively] and overall survival (OS) [C-index (95% CI): 0.887 (0.877-0.897) and 0.882 (0.858-0.906), respectively]. Calibration curves showed strong alignment between predicted and observed outcomes, while DCA demonstrated that the combined model provided greater clinical net benefit than the clinical or visual models alone across a range of threshold probabilities.

CONCLUSION

The contrast-enhanced CT-based visual model serves as an effective tool for predicting postoperative prognosis in HB patients. The combined model, integrating the DINOv2_score and clinical risk factors, demonstrated superior performance in survival prediction, offering more precise guidance for personalized treatment strategies.

Early Surgical Outcome of Hepatoblastoma in Children Receiving Chemotherapy After Hepatic Resection

OBJECTIVE

 The aim of this study was to evaluate surgical outcomes in children with hepatoblastoma who underwent hepatic resection after receiving neoadjuvant chemotherapy.

METHODOLOGY

A prospective observational longitudinal study was conducted from February 2019 to July 2020 in the Department of Pediatric Surgery at Bangabandhu Sheikh Mujib Medical University, Bangladesh. A total of 13 children diagnosed with hepatoblastoma and classified as PRETEXT (Pre-Treatment Extent of Disease) stages I to III were included. Detailed medical histories were recorded, and diagnoses were confirmed through histopathological analysis. Preoperative evaluations included liver function tests (LFTs), serum alpha-fetoprotein (AFP) levels, and imaging for tumor staging and liver volume. Postoperative assessments were conducted at one, three, and six months to monitor changes in serum AFP levels, LFTs, liver volume, and hepatic echotexture. The type of hepatic resection performed and any complications encountered were also documented.

RESULTS

Among the 13 patients, the majority were male, with a male-to-female ratio of 12:1. The average age at diagnosis was 4.44 years, with most patients under three years old. Pathological analysis revealed epithelial tumors in 38.45% of cases, fetal-type tumors in 46.15%, and mixed tumors in 15.4%. PRETEXT stage III was the most common (53.85%), and 61.54% of patients underwent major hepatic resections. Postoperative serum AFP levels showed a significant decline, reflecting successful tumor resection and improvements in LFTs. Improvements in LFTs, including key enzymes like ALT and AST, were observed. A marked increase in hepatic regeneration was observed within six months, with no local recurrences recorded.

CONCLUSIONS

This study highlights the effectiveness of combining hepatic resection with neoadjuvant chemotherapy in treating pediatric hepatoblastoma. A significant decline in serum AFP levels after surgery reflects the success of tumor removal, while improvements in LFTs underscore the recovery of hepatic health. Furthermore, the observed increase in hepatic regeneration within six months demonstrates the liver's remarkable ability to recover and sustain long-term function. These findings emphasize the importance of early diagnosis, precise surgical techniques, and individualized treatment planning in improving outcomes for pediatric hepatoblastoma.

Precocious Puberty as a Unique Presentation of Hepatoblastoma in a Pediatric Patient: A Case Report

Hepatoblastoma is a rare pediatric cancer. Hepatoblastoma typically presents asymptomatically with an enlarging abdominal mass but can be associated with paraneoplastic secretion of beta-gonadotropin leading it to present like peripheral precocious puberty. This case highlights a rare initial presentation of hepatoblastoma as precocious puberty in a two-year-old patient who presented with persistent abdominal and genital pain. The patient was treated with right hepatic lobectomy and subsequently two cycles of cisplatin and was considered to be in remission without concern for recurrent disease. Considering that there have been more reports of this pathology in recent years, it is crucial to discuss the presentation, diagnosis, and treatment of this pathology. This case emphasizes the importance of maintaining hepatoblastoma as a differential diagnosis when evaluating precocious puberty and abdominal pain to avoid delays in diagnosis and treatment. This article also highlights our team's approach to the workup and treatment of this pathology, which can serve as a roadmap for other clinicians.

Staging and Restaging Pediatric Abdominal and Pelvic Tumors: A Practical Guide

The most common abdominal malignancies diagnosed in the pediatric population include neuroblastoma, Wilms tumor, hepatoblastoma, lymphoma, germ cell tumor, and rhabdomyosarcoma. There are distinctive imaging findings and patterns of spread for each of these tumors that radiologists must know for diagnosis and staging and for monitoring the patient's response to treatment. The multidisciplinary treatment group that includes oncologists, surgeons, and radiation oncologists relies heavily on imaging evaluation to identify the best treatment course and prognostication of imaging findings, such as the image-defined risk factors for neuroblastomas, the PRETreatment EXtent of Disease staging system for hepatoblastoma, and the Ann Arbor staging system for lymphomas. It is imperative for radiologists to be able to correctly indicate the best imaging methods for diagnosis, staging, and restaging of each of these most prevalent tumors to avoid inconclusive or unnecessary examinations. The authors review in a practical manner the most updated key points in diagnosing and staging disease and assessing response to treatment of the most common pediatric abdominal tumors. ©RSNA, 2024 Supplemental material is available for this article.

Computer-assisted three-dimensional individualized extreme liver resection for hepatoblastoma in proximity to the major liver vasculature

BACKGROUND

The management of hepatoblastoma (HB) becomes challenging when the tumor remains in close proximity to the major liver vasculature (PMV) even after a full course of neoadjuvant chemotherapy (NAC). In such cases, extreme liver resection can be considered a potential option.

AIM

To explore whether computer-assisted three-dimensional individualized extreme liver resection is safe and feasible for children with HB who still have PMV after a full course of NAC.

METHODS

We retrospectively collected data from children with HB who underwent surgical resection at our center from June 2013 to June 2023. We then analyzed the detailed clinical and three-dimensional characteristics of children with HB who still had PMV after a full course of NAC.

RESULTS

Sixty-seven children diagnosed with HB underwent surgical resection. The age at diagnosis was 21.4 ± 18.8 months, and 40 boys and 27 girls were included. Fifty-nine (88.1%) patients had a single tumor, 39 (58.2%) of which was located in the right lobe of the liver. A total of 47 patients (70.1%) had PRE-TEXT III or IV. Thirty-nine patients (58.2%) underwent delayed resection. After a full course of NAC, 16 patients still had close PMV (within 1 cm in two patients, touching in 11 patients, compressing in four patients, and showing tumor thrombus in three patients). There were 6 patients of tumors in the middle lobe of the liver, and four of those patients exhibited liver anatomy variations. These 16 children underwent extreme liver resection after comprehensive preoperative evaluation. Intraoperative procedures were performed according to the preoperative plan, and the operations were successfully performed. Currently, the 3-year event-free survival of 67 children with HB is 88%. Among the 16 children who underwent extreme liver resection, three experienced recurrence, and one died due to multiple metastases.

CONCLUSION

Extreme liver resection for HB that is still in close PMV after a full course of NAC is both safe and feasible. This approach not only reduces the necessity for liver transplantation but also results in a favorable prognosis. Individualized three-dimensional surgical planning is beneficial for accurate and complete resection of HB, particularly for assessing vascular involvement, remnant liver volume and anatomical variations.

Case Report: ALPPS hepatectomy, an alternative to liver transplantation in central PRETEXT III hepatoblastomas: a case series

Introduction

Hepatoblastoma is the most common malignant primary liver tumor in the pediatric population, accounting for 67% of cases in the United States. Surgical resection is the only curative treatment option; however, it can be performed in only 10% of patients with primary tumors. The two most common limitations for resection are the need for extensive resections and tumors in central locations. The therapeutic hypertrophy of healthy tissue achieved with ALPPS (Associating Liver Partition and Portal vein ligation for Staged Hepatectomy) enables larger resections and has been successfully employed in the pediatric population in recent years.

Objective

To present three cases of patients with centrally located PRETEXT II or III hepatoblastomas who underwent ALPPS procedure as a viable therapeutic alternative to liver transplantation.

Discussion and results

Central PRETEXT III hepatoblastomas are typically indications for liver transplantation. Transplantation offers high five-year survival rates (73%). However, the associated morbidity, healthcare system costs, and limited availability make it necessary to explore alternative options. Series have reported the successful application of the ALPPS procedure in PRETEXT II and PRETEXT III hepatoblastomas in other locations. Therapeutically induced hypertrophy, characterized by an increase in the volume of healthy tissue in unaffected lobes or segments, enabled the resection of previously deemed unresectable lesions. The patients experienced uncomplicated postoperative courses and expected reduction in tumor markers. Chemotherapy selection followed the guidelines outlined in Block C of the SIOPEL IV protocol.

Conclusions

ALPPS hepatectomy is a viable therapeutic option for patients with centrally located PRETEXT III or II hepatoblastomas.

Pediatric Hepatoblastoma After Neoadjuvant Chemotherapy: Diagnostic Performance of MR in Staging POSTTEXT and Vascular Involvement

BACKGROUND

The assessment of resectability after neoadjuvant chemotherapy of hepatoblastoma is dependent on Post-Treatment EXTENT of Disease (POSTTEXT) staging and its annotation factors P (portal venous involvement) and V (hepatic venous/inferior vena cava [IVC] involvement), but MR performance in assessing them remains unclear.

PURPOSE

To assess the diagnostic performance of contrast-enhanced MR imaging for preoperative POSTTEXT staging and diagnosing vascular involvement in terms of annotation factors P and V in pediatric hepatoblastoma following neoadjuvant chemotherapy.

STUDY TYPE

Retrospective.

SUBJECTS

Thirty-five consecutive patients (17 males, median age, 24 months; age range, 6-98 months) with proven hepatoblastoma underwent preoperative MR imaging following neoadjuvant chemotherapy.

FIELD STRENGTH/SEQUENCE

3.0 T; T2-weighted imaging (T2WI), T2WI with fat suppression, diffusion weighted imaging, radial stack-of-the-star/Cartesian 3D Dixon T1-weighted gradient echo imaging.

ASSESSMENT

Three radiologists independently assessed the POSTTEXT stages and annotation factors P and V based on the 2017 PRE/POSTTEXT system. The sensitivities and specificities were calculated for 1) diagnosing each POSTTEXT stage; 2) discrimination of stages III and IV (advanced) from those stages I and II (non-advanced) hepatoblastomas; and 3) annotation factors P and V. The combination of pathologic findings and surgical records served as the reference standard.

STATISTICAL TESTS

Sensitivity, specificity, Fleiss kappa test.

RESULTS

The sensitivity and specificity ranges for discriminating advanced from non-advanced hepatoblastomas were 73.3%-80.0% and 80.0%-90.0%, respectively. For annotation factor P, they were 66.7%-100.0% and 90.6%, respectively. For factor V, they were 75.0% and 67.7%-83.9%, respectively. There was excellent, substantial, and moderate agreement on POSTTEXT staging (Fleiss kappa = 0.82), factors P (Fleiss kappa = 0.64), and factors V (Fleiss kappa = 0.60), respectively.

DATA CONCLUSION

MR POSTTEXT provides reliable discrimination between advanced and non-advanced tumors, and MR has moderate to excellent specificity at identifying portal venous and hepatic venous/IVC involvement.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Operative and Hepatic Function Outcomes of Laparoscopic vs. Open Liver Resection: A Systematic Review and Meta-Analysis

Liver resection is a pivotal treatment for various liver diseases, and the choice between laparoscopic (LR) and open (OR) methods is debatable. This study aims to compare their respective complications and hepatic outcomes comprehensively, providing critical insights to guide clinical decisions and optimize patient results. We conducted a comprehensive review across PubMed, SCOPUS, WOS, and the Cochrane Library until September 2023. Randomized controlled trials (RCTs) comparing laparoscopic (LR) and open (OR) liver resections were included. Data screening, extraction, and quality assessments utilized the Risk of Bias (ROB-2). We conducted our analysis using Review Manager (RevMan 5.4) software, and the data were presented as risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI). Our comprehensive research yielded 3,192 relevant records, and 9 RCTs were finally included. LR exhibited reduced operative bleeding (MD = -82.87 ml, 95% CI: -132.45 to -33.30, P=0.001) and shorter hospital stays (MD = -2.32 days, 95% CI: -3.65 to -0.98, P=0.0007). The risk of complications was significantly lower in the LR group (RR = 0.57, 95% CI: 0.43-0.76, P<0.0001), especially in Clavian-Dindo classification degree 1 and 2 complications (RR = 0.47, 95% CI: 0.28-0.79, P=0.005). LR patients also had lower postoperative AST levels at one day (MD = -123.16 U/L, 95% CI: -206.08 to -40.24, P=0.004) and three days (MD = -35.95 U/L, 95% CI: -65.83 to -6.06, P=0.02). These findings underscore LR's superiority, emphasizing its potential to significantly enhance patient outcomes, reduce complications, and improve recovery in liver resection procedures.

Anti-ferroptotic PRKAA2 serves as a potential diagnostic and prognostic marker for hepatoblastoma

Background

The incidence rate of hepatoblastoma (HB), which is the most prevalent malignant tumour among children, rises each year. According to recent studies, a number of neoplastic disorders and ferroptosis are intimately connected. This study aims to identify key ferroptosis-related genes in HB and explore new directions for the diagnosis and treatment of HB.

Methods

Differentially expressed ferroptosis-related genes were identified using the Gene Expression Omnibus datasets. The functional annotation of candidate genes was evaluated through Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Machine learning and receiver operating characteristic (ROC) curves revealed protein kinase AMP-activated catalytic subunit alpha 2 (PRKAA2), tribbles homolog 2 (TRIB2), and liver-type glutaminase (GLS2) as potential diagnostic genes of HB. By using quantitative reverse transcription polymerase chain reaction (qRT-PCR) and immunohistochemistry, relative expression of PRKAA2 was examined. The effect of PRKAA2 on proliferation, apoptosis, and ferroptosis of HB cells was verified in vitro and in vivo. Fisher's exact test was used to evaluate the clinical significance of PRKAA2 in HB.

Results

The prognostic indicators had a substantial correlation with PRKAA2 expression, which rose dramatically in HB tissues. PRKAA2 promotes proliferation and inhibits ferroptosis in HB cells. PRKAA2 plays a role in ferroptosis by regulating hypoxia-inducible factor 1α (HIF-1α) and transferrin receptor 1 (TFR1).

Conclusions

PRKAA2 functions as a tumor-promoting factor in HB by promoting cell proliferation and prohibiting ferroptosis. Ferroptosis-related genes PRKAA2 is a potential diagnostic and prognostic marker for HB as well as a novel therapeutic target in the future.

Advances in pediatric liver transplantation from the pediatric surgeon's perspective

Pediatric liver transplantation is a lifesaving state-of-the-art operation for children with various liver diseases, including cholestatic diseases, metabolic disorders, acute liver failure, and primary malignant liver tumors. Among these indications, transplantation for biliary atresia and hepatoblastoma is discussed in this review because pediatric surgeons are usually involved in their initial treatments. For biliary atresia, pediatric surgeons are advised to keep dissection of the hilar structures to a minimum during Kasai portoenterostomy in order to make total hepatectomy easier at transplantation. Early referral to a transplant team is recommended when worrisome signs of liver dysfunction, cirrhosis, portal hypertension and growth retardation are noted. Hepatoblastoma with multiplicity or located close to major vessels may indicate unresectability, and the transplant team needs to be consulted early after neoadjuvant chemotherapy is started. The graft size, including its thickness, needs to be evaluated before transplantation for small children, as tailoring the shape of the partial graft may be necessary during the transplant procedure.