Evaluation of the diagnostic biopsy approach for children with hepatoblastoma: A report from the children's oncology group AHEP 0731 liver tumor committee

Management of undifferentiated embryonal sarcoma of the liver: A Pediatric Surgical Oncology Research Collaborative study

BACKGROUND

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare tumor for which there are few evidence-based guidelines. The aim of this study was to define current management strategies and outcomes for these patients using a multi-institutional dataset curated by the Pediatric Surgical Oncology Research Collaborative.

METHODS

Data were collected retrospectively for patients with UESL treated across 17 children's hospitals in North America from 1989 to 2019. Factors analyzed included patient and tumor characteristics, PRETEXT group, operative details, and neoadjuvant/adjuvant regimens. Event-free and overall survival (EFS, OS) were the primary and secondary outcomes, respectively.

RESULTS

Seventy-eight patients were identified with a median age of 9.9 years [interquartile range [IQR): 7-12]. Twenty-seven patients underwent resection at diagnosis, and 47 patients underwent delayed resection, including eight liver transplants. Neoadjuvant chemotherapy led to a median change in maximum tumor diameter of 1.6 cm [IQR: 0.0-4.4] and greater than 90% tumor necrosis in 79% of the patients undergoing delayed resection. R0 resections were accomplished in 63 patients (81%). Univariate analysis found that metastatic disease impacted OS, and completeness of resection impacted both EFS and OS, while multivariate analysis revealed that R0 resection was associated with decreased expected hazards of experiencing an event [hazard ratio (HR): 0.14, 95% confidence interval (CI): 0.04-0.6]. At a median follow-up of 4 years [IQR: 2-8], the EFS was 70.0% [95% CI: 60%-82%] and OS was 83% [95% CI: 75%-93%].

CONCLUSION

Complete resection is associated with improved survival for patients with UESL. Neoadjuvant chemotherapy causes minimal radiographic response, but significant tumor necrosis.

Percutaneous core needle biopsy of neuroblastoma in the pediatric population: what have we learned in the last decade

INTRODUCTION

Historically, neuroblastoma has been diagnosed by surgical open biopsy (SB). In recent decades, core needle biopsy (CNB) has replaced surgical biopsy due to its safe and adequate method of obtaining tissue diagnosis.

AIM

Our study aimed to assess the effectiveness of CNB in obtaining tissue diagnosis for neuroblastoma and evaluate its safety profile in terms of post-operative complications, in comparison to SB.

METHODS

A retrospective cohort study, including all patients younger than 18 years who were diagnosed with neuroblastoma from 2012 until 2022 in a single tertiary medical center. Patients' demographics, tumor size and location, pathological results, and clinical outcomes were collected.

RESULTS

79 patients were included in our study: 35 biopsies were obtained using image-guided CNB and 44 using SB. Patients' and tumor characteristics including age, gender, tumor volume, and stage were similar in both groups. The biopsy adequacy rate in the CNB group was 91% and 3 patients in this group underwent repeated biopsy. The safety profile in the CNB group was similar to the SB group.

CONCLUSIONS

CNB is a safe method and should be considered the first choice for obtaining tissue diagnosis when feasible due to its high adequacy in terms of tumor histopathological features.

An update on diagnosis and treatment of hepatoblastoma

Hepatoblastoma (HB) remains the most common paediatric liver tumour and survival in children with hepatoblastoma has improved considerably since the advent of sequential surgical regimens of chemotherapy based on platinum-based chemotherapeutic agents in the 1980s. With the advent of modern diagnostic imaging and pathology techniques, new preoperative chemotherapy regimens and the maturation of surgical techniques, new diagnostic and treatment options for patients with hepatoblastoma have emerged and international collaborations are investigating the latest diagnostic approaches, chemotherapy drug combinations and surgical strategies. Diagnosis of hepatoblastoma relies on imaging studies (such as ultrasound, computed tomography, and magnetic resonance imaging), alpha-fetoprotein (AFP) levels, and histological confirmation through biopsy. The standard treatment approach involves a multimodal strategy with neoadjuvant chemotherapy followed by surgical resection. In cases where complete resection is not feasible or tumors exhibit invasive characteristics, liver transplantation is considered. The management of metastatic and recurrent hepatoblastoma poses significant challenges, and ongoing research focuses on developing targeted therapies and exploring the potential of immunotherapy. Further studies are necessary to gain a better understanding of the etiology of hepatoblastoma, develop prevention strategies, and personalize treatment approaches. We aim to review the current status of diagnosis and treatment of hepatoblastoma.

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.

Aggressive Pursuit of No Evidence of Disease Status in Hepatoblastoma Improves Survival: An Observational Study

BACKGROUND

The utility of repeated surgical interventions in hepatoblastoma to achieve no evidence of disease (NED) is not well-defined. We examined the effect of aggressive pursuit of NED status on event-free (EFS) and overall survival (OS) in hepatoblastoma with subgroup analysis of high-risk patients.

METHODS

Hospital records were queried for patients with hepatoblastoma from 2005 to 2021. Primary outcomes were OS and EFS stratified by risk and NED status. Group comparisons were performed using univariate analysis and simple logistic regression. Survival differences were compared with log-rank tests.

RESULTS

Fifty consecutive patients with hepatoblastoma were treated. Forty-one (82%) were rendered NED. NED was inversely correlated with 5-year mortality (OR 0.006; CI 0.001-0.056; P < .01). Ten-year OS (P < .01) and EFS (P < .01) were improved by achieving NED. Ten-year OS was similar between 24 high-risk and 26 not high-risk patients when NED was attained (P = .83). Fourteen high-risk patients underwent a median of 2.5 pulmonary metastasectomies, 7 for unilateral disease, and 7 for bilateral, with a median of 4.5 nodules resected. Five high-risk patients relapsed, and three were salvaged.

CONCLUSIONS

NED status is necessary for survival in hepatoblastoma. Repeated pulmonary metastasectomy and/or complex local control strategies to obtain NED can achieve long-term survival in high-risk patients.

LEVEL OF EVIDENCE

Level III - Treatment Study - Retrospective Comparative Study.

Pediatric and Young Adult Image-Guided Percutaneous Bone Biopsy-A New Standard of Care?

BACKGROUND

There are no consensus guidelines regarding the use of percutaneous needle biopsy for the diagnosis of soft tissue and bone tumors. The aim of this study was to understand the efficacy of image-guided percutaneous biopsy for pediatric patients with soft tissue and bony masses, the role of intraoperative image guidance, and diagnostic accuracy.

PATIENTS AND METHODS

A retrospective institutional chart review was performed on patients who underwent percutaneous biopsy of soft tissue or bone tumors between 2007 and 2017. Data collected included preoperative imaging, type of biopsy, demographics, insurance status, number of samples taken, and pathologic results.

RESULTS

One hundred forty-one children and young adults underwent 169 biopsies. Female patients received 48.2% of biopsies. The mean age was 14.3 ± 7.0 years. Core needle biopsies made up 89.4% of procedures, while 10.6% were fine needle aspirate. The mean number of samples per patient was 3.6 ± 2.5. All patients had imaging guidance, with computed tomography used in 44.7% of patients, 9.9% using fluoroscopy, 7.1% using ultrasound for guidance, and 53 (37.6%) patients had more than one modality. Diagnostic specimens were obtained in 97.9% of biopsies. The most common overall pathology was osteoid osteoma. The most common malignant tumors were osteosarcoma and Ewing's sarcoma.

CONCLUSION

Image-guided percutaneous biopsy is a safe and effective method of obtaining accurate tissue samples in children and young adults with soft tissue or bone masses.

LEVEL OF EVIDENCE

Level 4-Study of diagnostic test.

Doxorubicin in combination with cisplatin, 5-flourouracil, and vincristine is feasible and effective in unresectable hepatoblastoma: A Children's Oncology Group study

BACKGROUND

The Children's Oncology Group (COG) adopted cisplatin, 5-flourouracil, and vincristine (C5V) as standard therapy after the INT-0098 legacy study showed statistically equivalent survival but less toxicity in comparison with cisplatin and doxorubicin. Subsequent experience demonstrated doxorubicin to be effective in patients with recurrent disease after C5V, and this suggested that it could be incorporated to intensify therapy for patients with advanced disease.

METHODS

In this nonrandomized, phase 3 COG trial, the primary aim was to explore the feasibility and toxicity of a novel therapeutic cisplatin, 5-flourouracil, vincristine, and doxorubicin (C5VD) regimen with the addition of doxorubicin to C5V for patients considered to be at intermediate risk. Patients were eligible if they had unresectable, nonmetastatic disease. Patients with a complete resection at diagnosis and local pathologic evidence of small cell undifferentiated histology were also eligible for an assessment of feasibility.

RESULTS

One hundred two evaluable patients enrolled between September 14, 2009, and March 12, 2012. Delivery of C5VD was feasible and tolerable: the mean percentages of the target doses delivered were 96% (95% CI, 94%-97%) for cisplatin, 96% (95% CI, 94%-97%) for 5-fluorouracil, 95% (95% CI, 93%-97%) for doxorubicin, and 90% (95% CI, 87%-93%) for vincristine. Toxicity was within expectations, with death as a first event in 1 patient. The most common adverse events were febrile neutropenia (n = 55 [54%]), infection (n = 48 [47%]), mucositis (n = 31 [30%]), hypokalemia (n = 39 [38%]), and elevated aspartate aminotransferase (n = 28 [27%]). The 5-year event-free and overall survival rates for the 93 patients who did not have complete resection at diagnosis were 88% (95% CI, 79%-93%) and 95% (95% CI, 87%-98%), respectively.

CONCLUSIONS

The addition of doxorubicin to the previous standard regimen of C5V is feasible, tolerable, and efficacious, and this suggests that C5VD is a good regimen for future clinical trials.

Percutaneous Core Needle Biopsy: Considerations in the Pediatric Patient

Image-guided percutaneous biopsy is the cornerstone of solid tissue diagnosis. The ability to safely sample tissue in locations that previously required surgery or necessitated empiric therapy has allowed for more personalized treatment options, as well as more rapid development of novel therapeutics. In children, these same advantages are accompanied by a smaller margin for error and rapidly expanding indications. The intent of this review is to outline the role of image-guided biopsy in the management of childhood disease, how this role is changing, and the practical aspects of managing and performing pediatric biopsies.

The morbidity of open tumor biopsy for intraabdominal neoplasms in pediatric patients

PURPOSE

Tumor biopsy is often essential for diagnosis and management of intraabdominal neoplasms found in children. Open surgical biopsy is the traditional approach used to obtain an adequate tissue sample to guide further therapy, but image-guided percutaneous core-needle biopsy is being used more often due to concerns about the morbidity of open biopsy. We used a national database to evaluate the morbidity associated with open intraabdominal tumor biopsy.

METHODS

We identified all patients undergoing laparotomy with tumor biopsy in the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database from 2012 to 2018 and measured the frequency of complications in the 30 days postoperatively. We tested associations between patient characteristics and outcomes to identify risk factors for complications.

RESULTS

We identified 454 patients undergoing laparotomy for biopsy of an intraabdominal neoplasm. Median postoperative hospital stay was 7 days (IQR 4-12) and operative time was 117 min (IQR 84-172). The overall complication rate was 12.1%, with post-operative infection (6%) and bleeding (4.2%) being the most common complications. Several patient characteristics were associated with bleeding, but the only significant association on multivariable analysis was underlying hematologic disorder.

CONCLUSION

Open abdominal surgery for pediatric intraabdominal tumor biopsy is accompanied by significant morbidity. Postoperative infection was the most common complication, which can delay initiation of further therapy, especially chemotherapy. These findings support the need to prospectively compare percutaneous image-guided core-needle biopsy to open biopsy as a way to minimize risk and optimize outcomes for this vulnerable population.

A narrative review of the challenges and countermeasures in hepatoblastoma management during COVID-19 epidemic

An infectious disease named "coronavirus disease 2019" (COVID-19) currently has brought a threat to global health security and trends to be more and more severe in many countries. It also has introduced great challenges to the diagnosis and management of children with hepatoblastoma (HB). During the COVID-19 pandemic, pediatric surgeons should not only develop personalized treatment plans for HB therapy, but also emphasize the diagnosis, prevention, and treatment of this virus. Children with both HB and COVID-19 are recommended to undertake multidisciplinary assessment. Anti-SARS-CoV-2 therapy may be a preferred treatment for the infected without presenting a surgical emergency. However, emergent operation may be necessary for HB children with concurrent COVID-19 who developed a life-threatening surgical emergency condition. Otherwise, for children with negative virus examination results, treatment advice should be based on the impact of the epidemic and regional economic considerations. A "wait and see" strategy is recommended for children with resectable tumors after new adjuvant chemotherapy treatment (NACT). Assessment of liver transplantation is recommended for children with HB whose tumors cannot be resected after NACT. Children with HB with pulmonary metastasis may have abnormal findings on chest imaging due to COVID-19. Besides, the detailed therapeutic regimens may vary for children with HB with or without an emergency presentation. Based on previous consensus, current research, and the experiences of our hospital, we aim to offer available management plans for the above-mentioned concerns.

Update on pediatric rhabdomyosarcoma: A report from the APSA Cancer Committee

BACKGROUND/PURPOSE

Rhabdomyosarcoma is the most common soft tissue sarcoma in children and young adults and requires multimodality treatment. The purpose of this review is to present an update on risk stratification as well as surgical and medical management strategies in pediatric rhabdomyosarcoma.

METHODS

A comprehensive review of the current literature on pediatric rhabdomyosarcoma, including the most recent Children's Oncology Group studies and several international collaboratives, was performed by the authors and key findings were summarized in the manuscript.

RESULTS

FOXO1 fusion status is a stronger prognostic factor than histology and is now used for risk stratification in treatment protocols. For assessment of regional nodal involvement, FDG-PET-CT shows poor sensitivity and specificity to detect histologically confirmed nodal metastasis. Thus, surgical assessment of regional lymph nodes is required for rhabdomyosarcoma of the extremities or trunk as well as paratesticular rhabdomyosarcoma in patients ≥10 years of age, although adherence to surgical guidelines remains poor. Hemiscrotectomy performed for scrotal violation in paratesticular rhabdomyosarcoma has not shown an improvement in event free survival and is not recommended.

CONCLUSIONS

Surgical and medical treatment strategies for rhabdomyosarcoma in children continue to evolve. This review provides current evidence-based treatment standards with an emphasis on surgical care.

TYPE OF STUDY

Review.

LEVEL OF EVIDENCE

Level IV.

Liver biopsy for hepatoblastoma: a single institution's experience

BACKGROUND/PURPOSE

Hepatoblastoma diagnoses require liver biopsies. We aimed to investigate factors affecting the success of liver biopsy for hepatoblastoma diagnoses.

METHODS

Data from patients with hepatoblastoma, including their demographic and clinical data, biopsy procedure information, pathologic diagnoses and subclassification, and surgical complications, were retrospectively reviewed.

RESULTS

Of 153 patients who underwent liver biopsy, 28, 93, and 31 underwent computed tomography-guided, digital subtraction angiography-guided, and ultrasound-guided percutaneous biopsies, respectively, and one underwent a laparoscopic liver biopsy. One patient developed postoperative bleeding requiring a blood transfusion. The median number of specimens collected was 3. One-hundred and forty-four (94.1%) patients' HB diagnoses were confirmed through biopsies, and 96 (62.7%) patients' HB diagnoses were subclassified. Seven surgeons and eight interventional radiologists performed the biopsies. The diagnostic success rate did not correlate with the biopsy technique or the specialist who performed the biopsy. Significantly more specimens were biopsied from the patients whose diagnoses were subclassified (3.34 ± 1.08) than from those whose diagnoses were not subclassified (2.81 ± 0.79). Surgeons tended to collect more specimens than the interventional radiologists.

CONCLUSION

Percutaneous liver biopsy is safe and effective for diagnosing hepatoblastoma, and its complication rate is very low. Collecting >3 pieces of tissue is preferred.

LEVEL OF EVIDENCE

III.

Outcomes of children with hepatoblastoma who underwent liver resection at a tertiary hospital in China: a retrospective analysis

BACKGROUND

To report the outcomes of hepatoblastoma resected in our institution.

METHODS

We diagnosed 135 children with hepatoblastoma at our institution between January 2010 and December 2017. Patients who underwent liver resection were included for analysis. However, patients who abandoned treatment after diagnosis were excluded from analysis, but their clinical characteristics were provided in the supplementary material.

RESULTS

Forty-two patients abandoned treatment, whereas 93 patients underwent liver resection and were included for statistical analysis. Thirty-six, 23, 3, and 31 patients had PRETEXT stages II, III, IV, and unspecified tumours, respectively. Seven patients had ruptured tumour; 9 had lung metastasis (one patient had portal vein thrombosis concurrently). Sixteen patients underwent primary liver resection; 22, 25, and 30 patients received cisplatin-based neoadjuvant chemotherapy and delayed surgery, preoperative transarterial chemoembolization (TACE) and delayed surgery, and a combination of cisplatin-based neoadjuvant chemotherapy, TACE, and delayed surgery, respectively. Forty patients had both PRETEXT and POST-TEXT information available for analysis. Twelve patients were down-staged after preoperative treatment, including 2, 8, and 2 patients from stages IV to III, III to II, and II to I, respectively. Ten patients with unspecified PRETEXT stage were confirmed to have POST-TEXT stages II (n = 8) and I (n = 2) tumours. Seven tumours were associated with positive surgical margins, and 12 patients had microvascular involvement. During a median follow-up period of 30.5 months, 84 patients survived without relapse, 9 experienced tumour recurrence, and 4 died. The 2-year event-free survival (EFS) and overall survival (OS) rates were 89.4 ± 3.4%, and 95.2 ± 2.4%, respectively; they were significantly better among patients without metastasis (no metastasis vs metastasis: EFS, 93.5 ± 3.7% vs 46.7 ± 19.0%, adjusted p = 0.002. OS, 97.6 ± 2.4% vs 61.0 ± 18.1%, adjusted p = 0.005), and similar among patients treated with different preoperative strategies (chemotherapy only vs TACE only vs Both: EFS, 94.7 ± 5.1% vs 91.7 ± 5.6% vs 85.6 ± 6.7%, p = 0.542. OS, 94.1 ± 5.7% vs 95.7 ± 4.3% vs 96.7 ± 3.3%, p = 0.845).

CONCLUSION

The OS for patients with hepatoblastoma who underwent liver resection was satisfactory. Neoadjuvant chemotherapy and TACE seemed to have a similar effect on OS. However, the abandonment of treatment by patients with hepatoblastoma was common, and may have biased our results.

Optimization of percutaneous biopsy for diagnosis and pretreatment risk assessment of neuroblastoma

BACKGROUND

Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma.

PROCEDURE

A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification.

RESULTS

A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy.

CONCLUSIONS

PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality.