Second Malignant Neoplasms Following Treatment for Hepatoblastoma: An International Report and Review of the Literature

Treatment intensification has improved survival in patients with hepatoblastoma (HB); however, these treatments are associated with an increased risk of late effects, including second malignant neoplasms (SMNs). Data is limited regarding SMNs following HB treatment. Cases of SMNs following treatment for HB reported in the literature and from personal communication were analyzed to further assess this late effect. Thirty-eight patients were identified. The median age at diagnosis of HB was 16 months (range: 3 to 168 mo). All patients had received a platinum agent, and almost all had anthracycline exposure. The SMNs reported were hematopoietic malignancies (n=19), solid tumors (n=12), and post-transplant lymphoproliferative disorder (n=7). Of the 36 patients with outcome data, 19 survived. SMNs following HB treatment were primarily seen in patients with chemotherapy exposure, a history of liver transplantation, hereditary tumor predisposition syndromes, and/or a history of radiation treatment. Hematopoietic malignancies were the most common SMN reported in this cohort and were diagnosed earlier than other SMNs. Prospective collection of data through a companion late effects study or international registry could be used to further evaluate the rates and risks of SMNs as well as tumor predisposition syndromes in patients treated for HB.

Associations between birth defects with neural crest cell origins and pediatric embryonal tumors

BACKGROUND

There are few assessments evaluating associations between birth defects with neural crest cell developmental origins (BDNCOs) and embryonal tumors, which are characterized by undifferentiated cells having a molecular profile similar to neural crest cells. The effect of BDNCOs on embryonal tumors was estimated to explore potential shared etiologic pathways and genetic origins.

METHODS

With the use of a multistate, registry-linkage cohort study, BDNCO-embryonal tumor associations were evaluated by generating hazard ratios (HRs) and 95% confidence intervals (CIs) with Cox regression models. BDNCOs consisted of ear, face, and neck defects, Hirschsprung disease, and a selection of congenital heart defects. Embryonal tumors included neuroblastoma, nephroblastoma, and hepatoblastoma. Potential HR modification (HRM) was investigated by infant sex, maternal race/ethnicity, maternal age, and maternal education.

RESULTS

The risk of embryonal tumors among those with BDNCOs was 0.09% (co-occurring n = 105) compared to 0.03% (95% CI, 0.03%-0.04%) among those without a birth defect. Children with BDNCOs were 4.2 times (95% CI, 3.5-5.1 times) as likely to be diagnosed with an embryonal tumor compared to children born without a birth defect. BDNCOs were strongly associated with hepatoblastoma (HR, 16.1; 95% CI, 11.3-22.9), and the HRs for neuroblastoma (3.1; 95% CI, 2.3-4.2) and nephroblastoma (2.9; 95% CI, 1.9-4.4) were elevated. There was no notable HRM by the aforementioned factors.

CONCLUSIONS

Children with BDNCOs are more likely to develop embryonal tumors compared to children without a birth defect. Disruptions of shared developmental pathways may contribute to both phenotypes, which could inform future genomic assessments and cancer surveillance strategies of these conditions.

Incidence and 5-year survival of children and adolescents with hepatoblastoma in the United States

OBJECTIVE

Hepatoblastoma (HB) is the most common pediatric primary malignant liver tumor, its incidence has been increasing worldwide, but recent changes in incidence and outcomes with high population coverage are not well characterized.

METHODS

We defined the incidence of HB diagnosed during 2003-2017 from United States Cancer Statistics (USCS) database, and survival during 2001-2016 from the National Program of Cancer Registries (NPCR). Data were stratified by sex, race/ethnicity, age, tumor stage, county population, and diagnosis year. Incidence trends were assessed by calculating average annual percent change (AAPC) using Joinpoint regression. Differences in overall 5-year survival were estimated using Cox regression analysis.

RESULTS

2178 HB cases with an annual incidence rate of 1.76 per million persons were identified and incidence increased over time (AAPC = 2.2, 95% confidence interval [CI], 0.9-3.6). The 5-year relative survival was 76.9% (95% CI: 74.9-78.8) and the risk of death was lower for cases diagnosed after 2009 (hazard ratio [HR] = 0.77, 95% CI: 0.63-0.94), higher for ages 3-7 years and 8-19 years compared to 0-2 years (HR = 1.38, 95% CI: 1.10-1.76 and 1.83, 95% CI: 1.31-2.70, respectively), for distant compared to locoregional stage (HR = 2.77, 95% CI: 2.27-3.36), and for non-Hispanic Black compared to non-Hispanic White cases (HR = 1.39, 95% CI: 1.02-1.84).

CONCLUSIONS

HB incidence increased, and survival improved over the study period. Disparities in survival exist by age, race or ethnicity, and stage. Further studies could identify factors affecting increases in HB cases, inform future interventions, and address disparities in outcomes.

Primary Malignant Liver Tumors: eight-year experience in a Pediatric Hospital in Brazil. A cross-sectional study

INTRODUCTION

liver tumors are rare neoplasms in childhood (1-2%), and about 2/3 are malignant. Hepatoblastoma (HB) is the most frequent, followed by hepatocellular carcinoma (HCC). In both, the main treatment is surgical resection. Currently, chemotherapy and liver transplantation have improved outcomes.

OBJECTIVE

study of the epidemiological profile and evolution of liver cancer cases in a referral pediatric hospital.

METHODOLOGY

a retrospective survey of medical records of patients aged up to 18 years with a diagnosis of primary malignant hepatic neoplasm between 2012 and 2020, carried out in the largest exclusively pediatric hospital in Brazil.

RESULTS

a total of 13 patients with malignant liver tumors (HB 12, HCC 1) were treated. Of the HB cases, 66,7% were male, with a mean age of 2 years and the main alteration in the palpable abdominal mass. Tumors involved an average of 3 liver segments, more in the right lobe (54%). Only one patient was treated with surgery without neoadjuvant therapy, another one underwent transplantation like the first treatment, and another 2 required liver transplantation as a rescue. The middle follow-up time of patients with HB was 39 months and only 1 case died due to febrile neutropenia. The 5-year overall and disease-free survival was 91.7% and 81.5%, respectively.

CONCLUSION

Advanced staging at the time of diagnosis has always been a poor prognostic factor in patients with primary malignant liver tumors. However, the results and survival have improved with the advancement of chemotherapy, surgical technique, and liver transplantation.

Independent Assessment of the Children's Hepatic Tumors International Collaboration Risk Stratification for Hepatoblastoma and the Association of Tumor Histological Characteristics With Prognosis

IMPORTANCE

Hepatoblastoma is the most common pediatric liver malignant neoplasm, and accurate risk stratification is essential for guiding treatment.

OBJECTIVE

To validate the Children's Hepatic Tumors International Collaboration-Hepatoblastoma Stratification (CHIC-HS) in an independent cohort of patients with hepatoblastoma and evaluate the association of pretreatment hepatoblastoma histological subtype with prognosis.

DESIGN, SETTING, AND PARTICIPANTS

This is a single-institution retrospective cohort study of 96 pediatric patients with hepatoblastoma diagnosed and treated between June 1, 2000, and December 31, 2016, with recent therapy and independent of the CHIC-HS discovery cohort. Each patient was assigned a risk group according to CHIC-HS. The histological characteristics of each tumor were assessed based on the International Pediatric Liver Tumor Consensus Classification. Data were analyzed from May 2018 to May 2019.

MAIN OUTCOMES AND MEASURES

The main outcomes were event-free survival (EFS) and overall survival (OS). Cox regression analysis was used to examine the associations of patient characteristics and tumor histological characteristics with survival.

RESULTS

A total of 96 patients (median [range] age, 1.9 [0.4-18] years; 36 [38%] girls and 60 [63%] boys) were assessed, including 15 with very low risk, 28 with low risk, 23 with intermediate risk, and 30 with high risk, according to CHIC-HS criteria. There were a total of 13 cancer-related deaths; median (range) follow-up was 3.5 (0.1-17.8) years for those alive at the last follow-up. The estimated 5-year OS rates were 100% in the very low-risk group, 94.7% (95% CI, 68.1%-99.2%) in the low-risk group, 89.2% (95% CI, 63.1%-97.2%) in the intermediate-risk group, and 57.9% (95% CI, 34.6%-75.5%) in the high-risk group. In a multivariable analysis, we confirmed that CHIC-HS significantly estimated EFS (high-risk group vs very low- and low-risk groups: hazard ratio [HR], 45.59; 95% CI, 9.39-209.5; P < .001) and OS (high-risk group vs very low- and low-risk groups: HR, 21.95; 95% CI, 2.76-174.29; P < .001). In the subcohort of 84 patients for whom pretreatment tumor histological data were available, tumor epithelial histological subtypes were found to be significantly associated with both EFS and OS. Patients in the CHIC-HS high-risk group and with embryonal-only histological subtype had the highest risk of relapse or disease progression (high-risk: HR, 42.62; 95% CI, 9.91-203.9; embryonal: HR, 3.28; 95% CI, 1.21-8.9) and death (high-risk: HR, 18.78; 95% CI, 2.31-152.84; embryonal: HR, 7.12; 95% CI, 1.51-33.52).

CONCLUSIONS AND RELEVANCE

This cohort study found that CHIC-HS performed as expected in an independent cohort that was more recently treated. Incorporation of pretreatment tumor histological data into CHIC-HS may provide additional prognostic value.

[Clinical features and prognostic analysis of hepatoblastoma in children under six years old]

Objective: To summarize and analyze the clinical features, treatment effects and related factors affecting the prognosis of hepatoblastoma (HB) in children under six years old. Methods: Clinical data of 382 children with HB under six years old who were pathologically diagnosed at the Pediatric Single Center of Beijing Tongren Hospital from May 2005 to May 2019 were analyzed retrospectively. The factors affecting the treatment effect and survival rate of HB were analyzed. The independent risk factors affecting the prognosis of HB were studied by Cox regression model. The χ(2) test was used to compare the enumeration data between groups. Kaplan-Meier method was used for survival analysis. Log-rank test was used to compare the survival rates among subgroups. Results: Children enrolled were with median age of 1.75 (0.08 ~ 5.92) years old and a male to female ratio of 1.5. Alpha-fetoprotein (AFP) median level was 197 406.5 μg/L at initial diagnosis, and the pathological tissue type was mainly epithelial (55.8%). Preoperative PRETEXT stage was mostly stage III (58.6%). 86 cases (22.5%) had portal vein or hepatic vein, and vena cava invasion. 73 cases (19.1%) had extrahepatic adjacent tissues and organs invasion. Twenty-four cases (6.3%) had tumor rupture and bleeding. 171 cases (44.8%) had distant metastases, and 96 cases (25.1%) had multiple intrahepatic lesions. Patients were followed-up to May 2020 (median follow-up time was 56 months). After comprehensive treatment, 218 cases were completely relieved, and 69 cases were partially relieved, and the treatment efficiency was 75.1%. Kaplan-Meier survival analysis showed that the 1, 3, and 5-years overall survival rates (OS) were 93.7%, 84.0%, and 73.9%, respectively, and the event-free survival rates were 90.5%, 79.2%, and 67.5%, respectively. Comparison of the clinical factors of 5-year OS showed that AFP < 100 μg/L (HR = 3.341, P = 0.005), PRETEXT stage IV (HR = 4.026, P = 0.001), vascular invasion (HR = 2.178, P = 0.019) and distant metastasis (HR = 2.634, P = 0.010) were independent risk factors in each subgroup affecting the prognosis of children with HB, and the difference was statistically significant. Conclusion: HB prognosis is related to AFP level, PRETEXT stage, presence or absence of vascular invasion and distant metastasis. Therefore, its survival and prognosis will be different in the presence of different risk factors.

Prevalence and risk factors for cisplatin-induced hearing loss in children, adolescents, and young adults: a multi-institutional North American cohort study

BACKGROUND

Cisplatin is used to treat a wide range of childhood cancers and cisplatin-induced hearing loss (CIHL) is a common and debilitating toxicity. We aimed to address persistent knowledge gaps in CIHL by establishing benchmarks for the prevalence of and risk factors for CIHL.

METHODS

In this multi-institutional cohort study, children (age 0-14 years), adolescents, and young adults (age 15-39 years) diagnosed with a cisplatin-treated tumour from paediatric cancer centres, who had available cisplatin dosing information, and primary audiology data for central review from consortia located in Canada and the USA were eligible for inclusion. Audiology was centrally reviewed and CIHL graded using the consensus International Society of Pediatric Oncology (SIOP) Boston Ototoxicity Scale. We assessed the prevalence of moderate or severe CIHL (SIOP grade ≥2) at latest follow-up and end of therapy, in each demographic, diagnosis, and treatment group and their relative contributions to risk for CIHL. Secondary endpoints explored associations of cisplatin dose reductions and CIHL with survival. We also examined whether cisplatin dose reductions and CIHL were associated with survival outcomes.

FINDINGS

We included 1481 patients who received cisplatin. Of the 1414 (95·5%) participants who had audiometry at latest follow-up (mean 3·9 years [SD 4·2] since diagnosis), 620 (43·8%) patients developed moderate or severe CIHL. The highest prevalence of CIHL was seen in the youngest patients (aged <5 years; 360 [59·4%] of 606 patients) and those with a CNS tumour (221 [50·9%] of 434 patients), hepatoblastoma (110 [65·9%] of 167 patients), or neuroblastoma (154 [62·1%] of 248 patients). After accounting for cumulative cisplatin dose, higher fractionated doses were associated with risk for CIHL (for each 10mg/m2 increase per day, adjusted odds ratio [aOR] 1·15 [95% CI 1·07-1·25]; for each 50 mg/m2 increase per cycle aOR 2·16 [1·37-3·51]). Vincristine exposure was newly identified as a risk factor for CIHL (aOR 3·55 [2·19-5·84]). Dose reductions and moderate or severe CIHL were not significantly associated with survival differences.

INTERPRETATION

Using this large, multicentre cohort, benchmarks were established for the prevalence of CIHL in patients treated with cisplatin. Variations in cisplatin dosing confer additive risk for developing CIHL and warrant investigation as a potential approach to decrease the burden of therapy.

FUNDING

US National Institutes of Health and National Institute on Deafness and Other Communication Disorders, US National Institutes of Health and National Cancer institute, St Baldrick's Foundation, Genome Canada, Genome British Columbia, Canadian Institutes of Health Research, the Canada Foundation for Innovation, University of British Columbia, British Columbia Children's Hospital Research Institute, British Columbia Provincial Health Services Authority, Health Canada, and C17 Research Network.

Cancer risk in children and young adults born preterm: A systematic review and meta-analysis

Introduction

Risk of developing a malignancy when born premature is unknown. We hypothesised that risk of certain cancers might be increased in youth born preterm versus term. We therefore performed a systematic review and meta-analysis to evaluate the incidence of malignancy in the context of preterm birth, according to various cancer types.

Methods

The study was designed per MOOSE and PRISMA guidelines. Articles were identified through November 2015. Observational studies exploring the association between childhood malignancy and birth characteristics were included. Of the 1658 records identified, 109 full text articles were evaluated for eligibility. Random effects meta-analyses were conducted on 10/26 studies retained; 95% confidence intervals were computed and adjusted following sensitivity analysis. Publication bias was evaluated using funnel plots, Begg’s and Egger’s tests.

Results

No differences in risk of primary central nervous system tumor [OR 1.05; 95% CI 0.93–1.17, 5 studies, 580 cases] and neuroblastoma [OR 1.09; 95% CI 0.90–1.32, 5 studies, 211 cases] were observed in individuals born <37 versus ≥37 weeks’ gestation. Preterm birth was consistently associated with hepatoblastoma [ORs 3.12 (95% CI 2.32–4.20), 1.52 (95% CI 1.1–2.1), 1.82 (95% CI 1.01–3.26), and 2.65 (95% CI 1.98–3.55)], but not leukemia, astrocytoma, ependymoma, medulloblastoma, lymphoma, nephroblastoma, rhabdomyosarcoma, retinoblastoma or thyroid cancer.

Conclusions

Children born premature may be at increased risk for hepatoblastoma but there is no strong evidence of an increased risk of primary central nervous system tumours or neuroblastoma. There is insufficient evidence to conclude whether prematurity modulates the risk of other childhood cancers.

Hepatoblastoma incidence in Taiwan: A population-based study

BACKGROUND

The incidence of hepatoblastoma is not well known in Taiwan. The goal of this study was to investigate the incidence rates of hepatoblastoma by age and sex.

METHODS

The data of patients with hepatoblastoma diagnosed from 1995 to 2012 were obtained from the population-based Taiwan Cancer Registry. Incidence rates of hepatoblastoma according to sex and age were analyzed. This study employed the published methods of International Agency for Research on Cancer to calculate the age-standardized incidence rates (ASIRs), standard errors, 95% confidence intervals (CIs), and standardized incidence rate ratios (SIRRs).

RESULTS

In total, 211 patients were diagnosed with hepatoblastoma during the 18-year study period. The ASIR was 0.76 per million person-years. Hepatoblastoma was predominantly diagnosed in children (n = 184, 87.2%). By contrast, adolescents/adults (n = 10, 4.7%) and elderly people (n = 17, 8.1%) were rarely affected. The incidence peaked at ages 0-4 years with corresponding ASIR of 7.3 per million person-years. A significant male predilection was only found in children and elderly people, with male-to-female SIRRs of 1.23 and 1.89, respectively. During 1995-2012, the overall incidence of hepatoblastoma significantly increased only in children (annual percent change: 7.4%, 95% CI 3.9%-11.1%, p < 0.05) and specifically in boys (annual percent change: 6.5%, 95% CI 1.9%-11.2%, p < 0.05).

CONCLUSION

Only 27 patients aged ≥ 15 years with hepatoblastoma were identified in this study, the existence of adult hepatoblastoma still requires novel molecular tools to elucidate. The association between the upward trend of hepatoblastoma incidence in boys and increased survival of prematurity in Taiwan warrants further investigations.

Hepatoblastoma in an 11-year-old: Case report and a review of the literature

RATIONALE

Hepatoblastoma is a rare malignancy. Approximately 100 cases are diagnosed yearly in the United States. The highest incidence occurs in infants and in children younger than 5 years. Cases involving patients older than 5 years are very rare. We describe the case of a patient who was diagnosed with hepatoblastoma at an atypical age of presentation for this type of malignancy. We also performed Ovid MEDLINE search for hepatoblastoma and epidemiology reports occurring in children between the ages of 5 and 18 years. In this article we review the epidemiology and summarize case reports published between 1997 and 2012 of patients with hepatoblastoma, who were older than 5 years.

PATIENT CONCERNS AND DIAGNOSIS

Our patient is an 11 year old boy with stage IV hepatoblastoma with lung and omental metastases at diagnosis.

INTERVENTIONS

The patient received 7 cycles of chemotherapy following the treatment plan of COG protocol AHEP 0731, off study. He also had tumor resection and omentectomy and achieved complete remission.

OUTCOMES

He later had disease recurrence and after undergoing treatment with different modalities, ultimately died of his disease. Review of SEER program data shows that the incidence of hepatoblastoma in children above the age of 5 years is too infrequent to be calculated. Literature review revealed 13 cases of patients diagnosed at age older than 5 years. Most cases were published due to unusual associations and/or complications. There are no obvious unifying characteristics for these cases, although there may be a slight male preponderance and many patients in this selected series presented with elevated Alpha-fetoprotein.

LESSONS

The reported case is rare, given the very low incidence of hepatoblastoma outside of infancy. A systematic review of characteristics and outcomes for patients older than 5 years who are enrolled in cooperative group hepatoblastoma trials may reveal important information about the epidemiology and tumor biology in this rare patient population.

Phenotype, cancer risk, and surveillance in Beckwith-Wiedemann syndrome depending on molecular genetic subgroups

Patients with Beckwith-Wiedemann syndrome (BWS) have an increased risk to develop cancer in childhood, especially Wilms tumor and hepatoblastoma. The risk varies depending on the cause of BWS. We obtained clinical and molecular data in our cohort of children with BWS, including tumor occurrences, and correlated phenotype and genotype. We obtained similar data from larger cohorts reported in the literature. Phenotype, genotype and tumor occurrence were available in 229 of our own patients. Minor differences in phenotype existed depending on genotype/epigenotype, similar to earlier studies. By adding patients from the literature, we obtained data on genotype and tumor occurrence of in total 1,971 BWS patients. Tumor risks were highest in the IC1 (H19/IGF2:IG-DMR) hypermethylation subgroup (28%) and pUPD subgroup (16%) and were lower in the KCNQ1OT1:TSS-DMR (IC2) subgroup (2.6%), CDKN1C (6.9%) subgroup, and the group in whom no molecular defect was detectable (6.7%). Wilms tumors (median age 24 months) were frequent in the IC1 (24%) and pUPD (7.9%) subgroups. Hepatoblastoma occurred mostly in the pUPD (3.5%) and IC2 (0.7%) subgroups, never in the IC1 and CDKN1C subgroups, and always before 30 months of age. In the CDKN1C subgroup 2.8% of patients developed neuroblastoma. We conclude tumor risks in BWS differ markedly depending on molecular background. We propose a differentiated surveillance protocol, based on tumor risks in the various molecular subgroups causing BWS. © 2016 Wiley Periodicals, Inc.

Cancer risk among children born after assisted conception

BACKGROUND

Accurate population-based data are needed on the incidence of cancer in children born after assisted conception.

METHODS

We linked data on all children born in Britain between 1992 and 2008 after assisted conception without donor involvement with data from the United Kingdom National Registry of Childhood Tumours to determine the number of children in whom cancer developed before 15 years of age. Cohort cancer rates were compared with population-based rates in Britain over the same period, with stratification for potential mediating and moderating factors, including sex, age at diagnosis, birth weight, singleton versus multiple birth, parity, parental age, type of assisted conception, and cause of parental infertility.

RESULTS

The cohort consisted of 106,013 children born after assisted conception (700,705 person-years of observation). The average duration of follow-up was 6.6 years. Overall, 108 cancers were identified, as compared with 109.7 expected cancers (standardized incidence ratio, 0.98; 95% confidence interval [CI], 0.81 to 1.19; P=0.87). Assisted conception was not associated with an increased risk of leukemia, neuroblastoma, retinoblastoma, central nervous system tumors, or renal or germ-cell tumors. It was associated with an increased risk of hepatoblastoma (standardized incidence ratio, 3.64; 95% CI, 1.34 to 7.93; P=0.02; absolute excess risk, 6.21 cases per 1 million person-years) and rhabdomyosarcoma (standardized incidence ratio, 2.62; 95% CI, 1.26 to 4.82; P=0.02; absolute excess risk, 8.82 cases per 1 million person-years), with hepatoblastoma developing in 6 children and rhabdomyosarcoma in 10 children. The excess risk of hepatoblastoma was associated with low birth weight.

CONCLUSIONS

There was no increase in the overall risk of cancer among British children born after assisted conception during the 17-year study period. Increased risks of hepatoblastoma and rhabdomyosarcoma were detected, but the absolute risks were small. (Funded by Cancer Research UK and others.).

Solar UV radiation and cancer in young children

BACKGROUND

Studies have shown that higher solar UV radiation exposure (UVR) may be related to lower risk of some cancers in adults. Recently, an ecologic study reported lower risks of some cancers among children living in higher UVR cities and countries. In a large population-based case-control study in California, we tested the hypothesis that childhood cancers may be influenced by UVR.

METHODS

Cancers in children ages 0 to 5 years were identified from California Cancer Registry records for 1988 to 2007 and linked to birth certificate data. Controls were sampled from the birth certificates at a ratio of 20:1. Based on birth address, we assigned UVR exposure in units of Watt-hours/m(2) using a geostatistical exposure model developed with data from the National Solar Radiation Database.

RESULTS

For cases with UVR exposure of 5,111 Watt-hours/m(2) or above, we estimated a reduction in odds of developing acute lymphoblastic leukemia (OR: 0.89, 95% CI: 0.81-0.99), hepatoblastoma (OR: 0.69, 95% CI: 0.48-1.00), and non-Hodgkin's lymphoma (OR: 0.71, 95% CI: 0.50-1.02) adjusting for mother's age, mother's race, and child's year of birth. We also observed a small increase in odds for intracranial/intraspinal embryonal tumors (OR: 1.29, 95% CI: 1.01-1.65).

CONCLUSIONS

Our findings suggest that UVR during pregnancy may decrease the odds of some childhood cancers. Future studies should explore additional factors that may be correlated with UVR exposure and possibly include biomarkers of immune function and vitamin D.

IMPACT

This study shows protective associations of UVR with some childhood cancers.

Maternal pregnancy events and exposures and risk of hepatoblastoma: a Children's Oncology Group (COG) study

BACKGROUND

Hepatoblastoma is a rare childhood liver cancer with an obscure etiology, however it is potentially associated with selected pregnancy events and hepatoblastoma risk in offspring.

METHODS

Adjusted unconditional logistic regression estimated odds ratios (OR) and corresponding 95% confidence intervals (CI) for self-reported pregnancy events and medication use in a sample of mothers of 383 childhood hepatoblastoma cases and 387 controls.

RESULTS

Risk of hepatoblastoma was significantly associated with maternal first trimester weight gain (OR = 1.02; 95% CI 1.00, 1.04 per 1 lb increase and nearly significantly with maternal multivitamin use (OR = 0.73; 95% CI 0.51, 1.03). Hepatoblastoma was not associated with other maternal weight changes, maternal illness or medication use during pregnancy.

CONCLUSION

We found little evidence that maternal illness or most medication use during pregnancy are associated with hepatoblastoma in offspring.

Hepatic tumours in childhood: an experience at the Children Hospital and Institute of Child Health, Lahore

OBJECTIVES

In this report, we share our experience about the common types of childhood hepatic tumours during 10 years (2001-2010) and compare them with other studies.

METHODS

During 10 years (2001-2010), all the hepatic tumours of childhood received at Pathology Department of the Children Hospital and Institute of Child Health, Lahore Pakistan are recorded. This includes both resected specimens and biopsies. All the slides were reviewed and the pathologic diagnosis was confirmed.

RESULTS

We diagnosed 48 liver tumour cases in children (below 18 years of age). Among these tumours, 39 (81.25%) were malignant. Male to female ratio was 2:1. Hepatoblastoma was the most common liver tumour in this age group accounting for 69.23% of all malignant tumours (27 cases). The second most common primary tumour was hepatocellular carcinoma diagnosed in six patients (15.38%). Other malignant tumours were undifferentiated embryonal sarcoma and biliary rhabdomyosarcoma. Benign tumours included mesenchymal hamartoma, infantile haemangioendotheloima, hemangioma and benign cyst. There were also three metastatic tumours during these 10 years. In one case there was tumour necrosis only and as such no definitive diagnosis was rendered.

CONCLUSION

The spectrum of hepatic tumours in children is different from that found in the older age group and most of them are malignant.

[Retrospective analysis of maternal and infant birth features of hepatoblastoma patients]

OBJECTIVE

To explore the risk factors for hepatoblastoma.

METHODS

A case-cohort study using Logistic regression multiple variables analysis of medical record data sets was conducted to examine infant and perinatal risk factors for hepatoblastoma.

RESULTS

Birth weight less than 1,000 g was associated with a strongly increased risk of hepatoblastoma (odds risk, OR = 26.0, 95% confidence interval, CI: 14.0 to 65.7). After adjustment of birth weight, a moderately increased risk of hepatoblastoma was found for older maternal age ( > 35 years vs. 20 to 34 years: OR = 2.6, 95% CI: 0.9 to 5.9), maternal smoking (OR = 2.9, 95% CI: 1.1 to 4.2) and higher maternal pregnancy body mass index (OR = 3.2, 95% CI: 1.0 to 6.7).

CONCLUSION

Very low birth weight and maternal characteristics including overweight, smoking are associated with hepatoblastoma risk.

Liver tumors in children

Malignant liver tumors account for slightly >1% of all pediatric malignancies, with roughly 150 new cases of liver tumors diagnosed in the U.S. annually. The embryonal tumor, hepatoblastoma, accounts for two thirds of malignant liver tumors in children. Other liver malignancies in children include hepatocellular carcinoma, sarcomas, germ cell tumors, and rhabdoid tumors. Benign tumors of the liver in children include vascular tumors, hamartomas, and adenomas. There is an apparent increase in the incidence of hepatoblastoma with perinatal exposures and decreased premature infant mortality as postulated causes for this increased risk. The known causes and associations of liver tumors in children as well as the approaches to diagnosis and treatment of children are discussed in this review article.

Feasibility of nationwide birth registry control selection in the United States

As random digit dialing becomes increasingly unfeasible for many types of studies, alternative methods for control selection are needed, especially for studies of childhood cancer. US birth registries are an appealing source of young control children because they are population based, provide demographic and pregnancy data for comparison of participants with the study base, and maintain data that enable matching on birth characteristics. Here the authors describe the ability of US birth registries to release information sufficient to locate potential control subjects for two ongoing case-control studies of hepatoblastoma and infant leukemia. The birth registries of 32 states, in which 75.8% of US children 0-5 years of age resided in 2004, agreed to participate in control selection. Data sufficient to track participants and to characterize nonrespondents were available from a majority of registries. These results suggest that birth registries may be used to select controls for studies of rare childhood diseases on a national scale.

Treatment outcomes for hepatoblastoma: an institution's experience over two decades

Our objective is to review a leading Australian tertiary referral centre's experience in treating hepatoblastoma over two decades. This is a retrospective study of clinical, radiological and pathological data in hepatoblastoma patients treated at our institution between 1984 and 2004. Thirty children (17 male, 13 female) ranging in age from 5 months to 6.5 years (median 19 months) at diagnosis were reviewed. This is the largest case series reported in Australia to date. The median length of follow-up was 6.3 years (range 7 months to 20.9 years). On average, the number of new cases increased by 0.12 each year (P=0.01). A total of 29 patients underwent definitive surgery for primary tumour control. Of these, two (7%) had initial primary surgery, while 27 (93%) had delayed surgery following neo-adjuvant chemotherapy. Chemotherapy regimens included the SIOPEL study protocols. Patients not enrolled in SIOPEL tended to be given more courses of chemotherapy. Ten patients (34%) received an extended right hemi-hepatectomy, six (21%) had right hemi-hepatectomy, seven (24%) had left hemi-hepatectomy, three (10%) had left lateral segmentectomy, and two (7%) had a non-anatomical resection. In addition, two patients required IVC reconstruction at the time of their primary liver resection. Overall survival at 5 years was 89.1% (95% CI 69.8-96.4%). Event-free survival at 5 years was 75.7% (95% CI 53.2-88.5%). There was a clear increase in the risk of recurrence (RR=4.8) and death (RR=4.5) where margins were not microscopically clear. However, neither reached statistical significance in this small cohort. Surgery was still worthwhile even when margins were involved. There was no correlation between mean AFP level at diagnosis, and outcome. Our experience suggests that the achievement of microscopically clear margins at the time of primary tumour resection is an important factor in achieving a positive long-term outcome. In addition, extended courses of neo-adjuvant chemotherapy in patients with pulmonary metastases achieves good long-term outcomes, provided adequate surgical resection of the primary tumour with clear microscopic margins can be achieved.

[Structure, use, and risks of biomaterial repositories of embryonal tumors]

Availability of statistically sufficient numbers of tumor samples and other biomaterials in high quality together with corresponding clinical data is crucial for biomedical research. Tumor repositories from individual scientists are mostly not sufficient to satisfy these criteria, especially since pediatric tumors are rare. In 2000 three centralized tumor repositories (neuroblastoma in Cologne, nephroblastoma in Würzburg, hepatoblastoma, brain tumors in Bonn) have been established by the "German Competence Net Pediatric Oncology und Hematology". The aim was to collect biomaterial including tumor samples, normal tissue, and blood in high quality for research and diagnostic purposes at a central institution. Informed consent of the parents or patients is a prerequisite for scientific use of the samples and is requested by the therapy trial. The samples are collected according to accepted standards and shipped in the specially designed Tumorbox. The tumor repository organizes the distribution of the samples to the cooperating diagnostic laboratories. The number of collected tumor samples has increased over the years. In 2000, samples from 200 patients were collected while the patient number increased to 321 in 2005. Over the years the tumor repositories collected more than 7,150 samples (fresh frozen tumor, fresh frozen normal tissue, and blood). Through links with clinical trial databases the samples can be connected with clinical data. 12 of 14 applications for tumor material to be used in specific scientific projects have been approved by an independent supervisory board. The establishment of central tumor repositories represents a major step for biomedical research activities and quality control in pediatric oncology.

Maternal and infant birth characteristics and hepatoblastoma

Hepatoblastoma is a rare embryonal tumor with unknown etiology. The authors conducted a case-cohort study using public health surveillance data sets to examine perinatal risk factors for hepatoblastoma. Hepatoblastoma cases (n = 58) diagnosed between 1985 and 2001 were identified from the New York State Cancer Registry and were matched to electronic birth records for 1985-2001 from New York State, excluding New York City. Controls (n = 6,056) were selected from the birth cohorts for the same years. Having a birth weight less than 1,000 g was associated with a strongly increased risk of hepatoblastoma (relative risk (RR) = 56.9, 95% confidence interval (CI): 24.0, 130.7). After adjustment for birth weight, a moderately increased risk of hepatoblastoma was found for younger maternal age (<20 years vs. 20-29 years: RR = 2.5, 95% CI: 1.0, 5.5), presumptive use of infertility treatment (RR = 9.2, 95% CI: 2.1, 31.5), maternal smoking (RR = 2.1, 95% CI: 1.0, 4.2), and higher maternal prepregnancy body mass index (body mass index of 25-29 vs. 20-24: RR = 2.9, 95% CI: 1.2, 7.6).

Hepatitis virus B is not a risk factor in hepatoblastoma patients

The prevalence of primary liver cancer varies throughout the world. Hepatoblastoma is the most common pediatric liver malignancy, comprising approximately 1% of all pediatric cancers. The exact etiology of hepatoblastoma remains undetermined. Concerning hepatitis B infection, whether there are links with hepatoblastoma is poorly documented. Here, we summarize knowledge on the prevalence of hepatitis B seropositives among the patients with hepatoblastoma. According to the literature review, six reports were recruited for metanalysis, with a total of 60 cases. The overall prevalence of seropositive cancer was 3.3 % (2/560). Further analysis revealed no correlation between prevalence rate and nationality of the studied population (P > 0.05). Therefore, hepatitis B infection does not appear to be a contributing factor for hepatoblastoma. Further studies are needed to clarify which are the risk factors for the hepatoblastoma.

Primary tumours of the liver in children: an African perspective

Primary tumours of the liver present diagnostic and management difficulties. In Africa, outcomes reflect limitations imposed by comorbidity and lack of resources, both human and material, for major liver resection. Whilst hepatoblastoma and hepatocellular carcinoma can be readily distinguished on clinical and biochemical grounds, there is a high incidence of sarcomatous tumours that mandate biopsy. In our experience, hepatocellular carcinoma in childhood is a lethal condition, usually bilateral and associated with hepatitis B infection. Sarcomatous tumours are often resectable but have a high rate of local recurrence. Hepatoblastoma is a surgically curable tumour in many patients. Resection for benign liver tumours can be safely accomplished and augments institutional experience with major liver surgery.

Hepatoblastoma and hepatocellular carcinoma in children

BACKGROUND

After nation-wide hepatitis B vaccination in Taiwan, the authors reviewed retrospectively their experience to investigate how the histopathology type of pediatric malignant hepatic tumors changed and whether the survival rate was improved with current surgical technique and adjuvant chemotherapy.

METHODS

Cases of hepatoblastoma and hepatocellular carcinoma were retrospectively analyzed and divided into 2 groups by time of diagnosis. Group I was those who received treatments during 1978 to 1990. Group II was those treated during 1991 to 2001.

RESULTS

There were 20 cases of hepatoblastoma and 15 cases of hepatocellular carcinoma. Male predominance was noted in both groups (male:female, 12:8 and 9:6, respectively). The patients with hepatoblastoma were younger than those with hepatocellular carcinoma (mean/range, 9/2-36 months and 10/0.7-15 years, respectively). Cases of hepatocellular carcinoma were all hepatitis B carriers. The ratio of hepatoblastoma:hepatocellular carcinoma increased from 11:12 in group I to 9:3 in group II. Three-year survival rate of hepatoblastoma was zero in group I and 55% (5/9) in group II. Three-year survival rate of hepatocellular carcinoma was zero in both groups. Operative mortality was 9% (2/23) in group I and zero in group II.

CONCLUSIONS

Since the institution of national program of universal hepatitis B vaccination, the incidence of hepatocellular carcinoma in children have declined in Taiwan. The improved survival of hepatoblastoma resulted from better surgical technique and chemotherapy.

Birth characteristics and hepatoblastoma risk in young children

BACKGROUND

Although hepatoblastoma is a very rare childhood cancer, its incidence appears to be rising, especially among children with very low birth weight. With the exception of documented correlations with certain congenital anomalies, the etiology of hepatoblastoma remains largely unknown.

METHODS

Using California's population-based cancer registry, the authors identified 113 children ages birth-4 years with hepatoblastoma who were diagnosed between 1988 and 1997. Ninety-nine of those 113 children (88%) were matched to a California birth certificate, and randomly selected controls from the same birth certificate files were matched to cases (4:1) according to the month and year of birth and gender. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using conditional logistic regression analyses.

RESULTS

A strikingly elevated risk of hepatoblastoma was found in children who were born with very low birth weight (< 1500 g; OR, 50.57; 95% CI, 6.59-387.97). A plot of the distribution by birth weight showed interesting peaks at birth weights < 1000 g and 3000-3499 g among cases. Children who weighed < 1000 g showed a statistically significant, linear trend toward being diagnosed at an older age (P = 0.036), which seemed to be explained in part by gestational age.

CONCLUSIONS

The results confirmed previously reported findings of an increased hepatoblastoma risk among children with very low birth weight and suggested that the etiology may differ between children with very low birth weight and children with normal birth weight.

Folic acid food fortification is associated with a decline in neuroblastoma

BACKGROUND

Neuroblastoma, an embryonic tumor, is the second most common pediatric tumor and is the most prevalent extracranial solid tumor in children. Results of previous studies have suggested that maternal vitamin intake may decrease the risk of several childhood cancers. In January 1997, Canada began fortifying flour with folic acid for the prevention of neural tube defects. The effect of folic acid fortification on the rate of neuroblastoma in offspring is not known.

METHODS

We investigated the rates of neuroblastoma (<1 year), acute lymphoblastic leukemia, and hepatoblastoma registered by the Pediatric Oncology Group of Ontario, which captures 95% of all pediatric cancers in Ontario, before and after the introduction of folate fortification.

RESULTS

An interventional time series analysis showed that the incidence of neuroblastoma declined from 1.57 cases per 10,000 births before to 0.62 case per 10,000 births after folic acid fortification (P <.0001). The crude incidence rate ratio (0.40; 95% confidence interval, 0.25-0.64) remained significant after adjustment for both age and disease stage at diagnosis (adjusted incidence rate ratio, 0.38; 95% confidence interval, 0.23-0.62). In contrast, there was no significant change in the rate of infant acute lymphoblastic leukemia (incidence rate ratio, 0.97; 95% confidence interval, 0.41-2.27) or hepatoblastoma (incidence rate ratio, 0.81; 95% confidence interval, 0.35-1.89).

CONCLUSIONS

Folic acid fortification was associated with a 60% reduction in neuroblastoma but was not associated with any change in the rate of infant acute lymphoblastic leukemia or hepatoblastoma. Further investigation is needed into the role of metabolism in the formation and prevention of neuroblastoma and other embryonically determined cancers.

Epidemiology of primary hepatic malignancies in U.S. children

The epidemiology of primary hepatic malignancies in U.S. children is poorly characterized. We analyzed the incidence, mortality, and characteristics of primary hepatic malignancies in U.S. residents less than 20 years of age. Fatal primary hepatic malignancies in persons less than 20 years of age, between 1979 and 1996, were identified using the multiple-cause-of-death database (National Center for Health Statistics). Histologically confirmed primary hepatic malignancies occurring between 1973 and 1997 were identified using the Surveillance, Epidemiology, and End Results (SEER) database. Between 1979 and 1996, 918 primary hepatic malignancy deaths (average, 0.7/1,000,000/year) were reported nationally among persons less than 20 years of age; rates were higher among Asians and among foreign-born children. Between 1973 and 1997, 271 primary hepatic malignancy cases were reported to SEER among persons less than 20 years of age, of which 184 (67%) and 83 (31%) were hepatoblastoma and hepatocellular carcinoma, respectively. Among children less than 5 years of age, hepatoblastoma accounted for 91% of primary hepatic malignancy cases, whereas among those 15 to 19 years of age, hepatocellular carcinoma accounted for 87% of cases. Five-year survival for hepatoblastoma was 52%, compared with 18% for hepatocellular carcinoma. In the SEER sites, between 1973 and 1977 and 1993 and 1997, hepatoblastoma rates increased (0.6 to 1.2/1,000,000, respectively), while hepatocellular carcinoma rates decreased (0.45 to 0.29/1,000,000, respectively). In conclusion, histologically confirmed hepatocellular carcinoma was reported in children less than 5 years of age, also, where hepatoblastoma is the predominant primary hepatic malignancy. Hepatocellular carcinoma has worse survival rates than hepatoblastoma, and its incidence has not increased. Better maintenance of databases may provide information about associated factors behind this unexpected occurrence.

Risk factors for pediatric human immunodeficiency virus-related malignancy

CONTEXT

Although cancers occur with increased frequency in children with human immunodeficiency virus (HIV) infection, the specific clinical, immunological, and viral risk factors for malignancy have not been identified.

OBJECTIVE

To identify risk factors for malignancy among HIV-infected children.

DESIGN, SETTING, AND PATIENTS

A multicenter case-control study of children with HIV at 26 institutions participating in the Pediatric Oncology Group. Forty-three case patients with a new malignancy and 74 control patients without a malignancy were matched based on the duration of their infection. Patients were enrolled between January 1992 and July 1998.

MAIN OUTCOME MEASURES

Clinical and laboratory factors assessed as putative risk factors included demographic characteristics, HIV characteristics, prior antiretroviral treatment, and CD4 cell count. Coviral infections with Epstein-Barr virus (EBV), cytomegalovirus, and human herpesvirus 6 were assessed by semiquantitative polymerase chain reaction assays and serological testing.

RESULTS

Case malignancy diagnoses included 28 non-Hodgkin lymphoma, 4 B-cell acute lymphoblastic leukemia, 1 Hodgkin disease, 8 leiomyosarcoma, 1 hepatoblastoma, and 1 schwannoma. Epstein-Barr virus viral load of more than 50 viral genome copies per 105 peripheral blood mononuclear cells was strongly associated with cancer risk but only for children with CD4 cell counts of at least 200/ microL (odds ratio [OR], 11.33; 95% confidence interval [CI], 2.09-65.66, P<.001). High EBV viral load was not associated with cancer for children with CD4 cell counts of less than 200/ microL (OR, 1.12; 95% CI, 0.13-9.62; P =.99). Zidovudine antiretroviral therapy did not confer a significant protective effect for either the high (OR, 0.81; 95% CI, 0.22-3.09; P =.77) or the low CD4 cell count groups (OR, 0.27; 95% CI, 0.04-1.46; P =.16). The route of HIV infection was not associated with increased cancer risk.

CONCLUSIONS

Route of infection, demographic characteristics, and zidovudine use were not associated with the development of malignancy in HIV-infected children. High viral burden with EBV was associated with the development of malignancy in HIV-infected children although the effect was modified by CD4 cell count. The pathogenesis of HIV-related pediatric malignancies remains unclear and other contributing risk factors can be elucidated only through further study.

Parental smoking and childhood cancer: results from the United Kingdom Childhood Cancer Study

There are strong a priori reasons for considering parental smoking behaviour as a risk factor for childhood cancer but case - control studies have found relative risks of mostly only just above one. To investigate this further, self-reported smoking habits in parents of 3838 children with cancer and 7629 control children included in the United Kingdom Childhood Cancer Study (UKCCS) were analysed. Separate analyses were performed for four major groups (leukaemia, lymphoma, central nervous system tumours and other solid tumours) and more detailed diagnostic subgroups by logistic regression. In the four major groups, after adjustment for parental age and deprivation there were nonsignificant trends of increasing risk with number of cigarettes smoked for paternal preconception smoking and nonsignificant trends of decreasing risk for maternal preconception smoking (all P-values for trend >0.05). Among the diagnostic subgroups, a statistically significant increased risk of developing hepatoblastoma was found in children whose mothers smoked preconceptionally (OR=2.68, P=0.02) and strongest (relative to neither parent smoking) for both parents smoking (OR=4.74, P=0.003). This could be a chance result arising from multiple subgroup analysis. Statistically significant negative trends were found for maternal smoking during pregnancy for all diagnoses together (P<0.001) and for most individual groups, but there was evidence of under-reporting of smoking by case mothers. In conclusion, the UKCCS does not provide significant evidence that parental smoking is a risk factor for any of the major groups of childhood cancers.

Hepatoblastoma in children of extremely low birth weight: a report from a single perinatal center

BACKGROUND/PURPOSE

The incidence of hepatoblastoma (HB) in children of low birth weight is increasing. In the authors' institute, 5 infants of extremely low birth weight (ELBW) were found to have HB. The purpose of this study was to identify the characteristics of these infants to elucidate the pathogenesis of HB arising in ELBW infants.

METHODS

Birth weight (BW) ranged from 554 to 750 g (mean, 654 g) and gestational age from 23 to 29 weeks (mean, 25.8 weeks). Medical records of the 5 patients were reviewed, and perinatal treatments were compared with those of ELBW infants without HB.

RESULTS

One patient with intraabdominal hemorrhage had emergency operation, which was followed by early postoperative death. The parents of one child refused treatment because of associated severe anomalies. He died of the growing tumor 4 months after diagnosis. The remaining 3 patients had radical operation performed after intraarterial chemoembolization and systemic chemotherapy. One died of hepatic failure 7 months after operation. Two are alive 5 and 9 months after operation. The incidence of HB among ELBW infants was estimated to be about 0.5% in our institute. The mean durations of mechanical ventilation, oxygen inhalation, and hospitalization during the neonatal periods in cases of HB were significantly longer than those in BW matched control infants (P <.01).

CONCLUSIONS

ELBW children have a high risk for HB. In follow-up of ELBW infants, serum alpha-fetoprotein or abdominal ultrasonography may be useful to detect early HB. The children with HB received perinatal treatments for a significantly longer time, which suggests that perinatal intensive and long-term medical treatments may be involved in the tumorigenesis in the highly sensitive immature liver.

Hepatoblastoma and low birth weight: a trend or chance observation?

BACKGROUND

Several reports have suggested an association between prematurity and hepatoblastoma (HB).

PROCEDURE

Data were collected by questionnaires from 105 children with HB enrolled in a Children's Cancer Group (CCG) study.

RESULTS

Observed over expected rates were increased about 2- and 15+-fold for prematurity (<37 weeks at birth) and low birth weight (<1,000 g) respectively. Similar data were derived from a later CCG study of 36 HB children.

CONCLUSIONS

Early reports of a possible association between prematurity and HB have been confirmed.

Hepatoblastomas in mice in the US National Toxicology Program (NTP) studies

Over the last 8 years, a 5-fold increase in the incidence of mice with spontaneous hepatoblastomas and a moderate increase in the incidence of chemically induced hepatoblastomas in B6C3F1 mice occurred in 2-year NTP studies compared to the previous 7 years. There was a positive association between an increased incidence of mice with hepatoblastoma and an increased incidence of mice with hepatocellular tumors in the treated mice. The rate of pulmonary metastases for hepatoblastoma was similar to that of pulmonary metastasis for hepatocellular carcinomas. Although a variety of chemicals caused an increased incidence of mice with hepatoblastoma, there was no apparent association between a specific chemical structure or a biological class of compounds and their capacity to induce hepatoblastomas. Hepatoblastomas frequently arose within hepatocellular carcinomas or adenomas and were induced by the same compounds that induced hepatocellular neoplasms. Therefore, it seems reasonable to combine the incidence of mice with hepatoblastomas and the incidence of mice with hepatocellular carcinomas in hazard identification studies.

[Trends in the incidence of hepatic tumors in childhood]

OBJECTIVE

To evaluate the incidence trends of hepatic tumors among children living in Mexico City.

MATERIAL AND METHODS

A cross-sectional hospital survey was conducted to yield two databases. The first database contains the registry of all the cases of hepatic tumors occurring during the period 1982-1991, in public hospitals of Mexico City. The second database contains all hepatic tumor cases found between 1996 and 1999 in Hospital de Pediatría del Centro Médico Nacional "Siglo XXI" and in Hospital General del Centro Médico La Raza, both hospitals pertaining to Instituto Mexicano del Seguro Social (Mexican Institute of Social Security). The average annual incidence rates (AAIR) were calculated for each type of hepatic tumor. The rates were standardized with the direct method, using as standard the world population under 15 years of age. The trends were evaluated with the annual incidence rates and the average rate of change assuming a Poisson distribution.

RESULTS

The AAIR for hepatoblastoma during the period 1982-1991 was three times higher for men than for women, with a value of 0.6 x 10(6). The group of 1-4 years of age was the most affected. For hepatocarcinomas the AAIR was two-fold for women (0.14) as compared to men. Between 1996-1999 the AAIR for hepatoblastoma was 5.11 in women and 1.85 in men. The age group with the highest rate was women under one year of age. The AAIR for hepatocarcinoma was 0.64 for males and 1.23 for females. The most affected age group was males aged 10 to 14 years. No significant upward or downward trend was found in the incidence of hepatoblastomas. A non-significant change rate of 10% was found for hepatocarcinoma.

CONCLUSIONS

No significant trends were observed in the incidence of hepatic tumors in children of Mexico City aged under 15 years, during the periods 1982-1991 and 1996-1999. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Paediatric hepatoblastoma and hepatocellular carcinoma: retrospective study

OBJECTIVES

To compare and contrast clinical characteristics and outcomes of hepatoblastoma or hepatocellular carcinoma in paediatric patients.

DESIGN

Retrospective study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS AND METHODS

Medical records of 22 paediatric patients with hepatoblastoma (n=11) or hepatocellular carcinoma (n=11) admitted to Queen Mary Hospital between 1989 and 2000 were reviewed. Data gathered included demographic data, results of liver function tests, hepatitis A, B, and C titres, and alpha-foetoprotein levels, and imaging studies including chest X-ray, ultrasound study, computed tomography scan, and magnetic resonance imaging/hepatic angiogram for tumour staging and resectability.

RESULTS

The mean age of patients with hepatoblastoma was 18 months (range, 5 months to 3 years), while that of patients with hepatocellular carcinoma was 10.2 years (range, 2 to 16 years). Females predominated in the hepatoblastoma group (female:male, 8:3) and males in the hepatocellular carcinoma group (male:female, 10:1). None of the patients with hepatoblastoma were hepatitis B surface antigen positive, in contrast to 64% of the hepatocellular carcinoma group. Only 45% of the hepatocellular carcinomas were resectable at presentation and this figure remained unchanged following chemotherapy. A total of 91% of hepatoblastomas were resectable, four at presentation, and a further six after chemotherapy. Tumour rupture was more common in patients with hepatoblastoma than in those with hepatocellular carcinoma (36% versus 9% of cases, respectively). Mortality rates were considerably higher among the hepatocellular carcinoma group than the hepatoblastoma group in this series.

CONCLUSION

Childhood hepatoblastoma and hepatocellular carcinoma differ with respect to age and tumour stage at presentation, hepatatis B surface antigen status, tendency to rupture, chemosensitivity, and prognosis.

Screening for Wilms tumor and hepatoblastoma in children with Beckwith-Wiedemann syndromes: a cost-effective model

BACKGROUND

We undertook a cost-benefit analysis of screening for Wilms tumor and hepatoblastoma in children with Beckwith-Wiedemann syndrome (BWS), a known cancer predisposition syndrome. The purpose of this analysis was twofold: first, to assess whether screening in children with BWS has the potential to be cost-effective; second, if screening appears to be cost-effective, to determine which parameters would be most important to assess if a screening trial were initiated.

PROCEDURES

We used data from the BWS registry at the National Cancer Institute, the National Wilms Tumor Study (NWTS), and large published series to model events for two hypothetical cohorts of 1,000 infants born with BWS. One hypothetical cohort was screened for cancer until a predetermined age, representing the base case. The other cohort was unscreened. For our base case, we assumed: (a) sonography examinations three times yearly (triannually) from birth until 7 years of age; (b) screening would result in one stage shift downward at diagnosis for Wilms tumor and hepatoblastoma; (c) 100% sensitivity and 95% specificity for detecting clinical stage I Wilms tumor and hepatoblastoma; (d) a 3% discount rate; (e) a false positive result cost of $402. We estimated mortality rates based on published Wilms tumor and hepatoblastoma stage specific survival.

RESULTS

Using the base case, screening a child with BWS from birth until 4 years of age results in a cost per life year saved of $9,642 while continuing until 7 years of age results in a cost per life-year saved of $14,740. When variables such as cost of screening examination, discount rate, and effectiveness of screening were varied based on high and low estimates, the incremental cost per life-year saved for screening up until age four remained comparable to acceptable population based cancer screening ranges (< $50,000 per life year saved).

CONCLUSIONS

Under our model's assumptions, abdominal sonography examinations in children with BWS represent a reasonable strategy for a cancer screening program. A cancer screening trial is warranted to determine if, when, and how often children with BWS should be screened and to determine cost-effectiveness in clinical practice.

Multicenter retrospective analysis of various primary pediatric malignant hepatic tumors--management in a series of 47 Polish patients (1985-1995)

Forty-seven children treated in various Polish centers between 1985 and 1995 for primary malignant liver tumors were retrospectively analyzed. Hepatoblastoma (HB) prevailed--it was found in 39 cases. There were 6 hepatocarcinoma (HCC) cases and 2 cases of undifferentiated sarcoma (UDS). In 44% of HB patients the tumor involved both liver lobes. 18% of children with HB presented with pulmonary metastases at diagnosis. Chemotherapy was applied in 92% of cases (preoperatively in 67%). Tumor resection was performed in 56% of HB patients. Overall survival of patients with hepatoblastoma was 43.6%, while it was 50% for hepatocarcinoma and 100% for undifferentiated sarcoma (2 cases only). Mean observation time was 58 months. The hepatoblastoma subgroup, being the largest (83% of all cases), was analyzed separately for prognostic factors. Completeness of tumor excision strongly influenced survival. Involvement of both lobes of the liver and multifocality of the tumor were other adverse prognostic factors.

Survival and distribution pattern of childhood liver cancer in Taiwan

Studies of survival and distribution of liver cancer in children are scarce. In this study, using data from the cancer registry of Taiwan, from 1979 to 1992, we identified 377 young patients (0-15 years of age) suffering from liver cancer, coded 155 according to the International Classification of Diseases. Among these patients, 122 were histopathologically proven hepatocellular carcinoma (HCC) and 43 hepatoblastoma (HB). For survival analysis, we also searched for cases of liver cancer in 0-16 year old children in the Taiwan cancer registry for the period between 1988 and 1992. We found 109 cases with identification numbers and birth dates which allowed our cases to be linked with the death registry of the National Health Department of Taiwan enabling the calculation of 5-year survival rates using actuarial life tables. Between 1979 and 1992, for 122 HCC cases, there was a peak incidence at the age of 1 year, then a decline to a trough at the age of 4 years, after which the number of cases increased to the age of 15 years. After the age of 4 years boys outnumbered the girls by 2:1. 36 (84%) of 43 HB cases were under the age of 5 years and boys tended to outnumber girls by 2.9:1. Between 1988 and 1992, of the 109 patients, 49 were diagnosed histopathologically and 60 patients clinically. Their overall 5-year survival rate was 19%. The 5-year survival rate of the 28 HCC patients was 17%, whereas that of the 17 HB patients was 47%. In conclusion, our epidemiological findings indicate that the HCC distribution among children is different according to age and to some extent sex. The overall 5-year survival rate of children suffering from liver cancer was still unfavourable.

Hepatic neoplasms in childhood - a clinicopathologic study

Primary hepatic tumours are rare in childhood. We observed nine cases between 1976 and 1995, of which eight were hepatoblastomas and one a mesenchymal hamartoma. A male-to-female ratio of 2:1 was noted; 78% of the cases occurred in children below 2 years of age. Five hepatoblastomas were of the pure epithelial type; mesenchymal components encountered in the mixed type were cartilage, bone, and spindle sarcomatous cells.

Increased risk of hepatoblastoma among immature children with a lower birth weight

Hepatoblastomas among children with very low birth weights have significantly increased recently, according to the data from the Japan Children's Cancer Registry for the years 1985-1993. We then analyzed more Registry data for 1969-1994 to clarify the possible relationship between low birth weight and hepatoblastoma. The percentage of low birth weights was compared between 543 hepatoblastoma children in the Registry and all live births in Japan in four successive periods during the 26 years from 1969 to 1994, in relation to the given birth year. The percentage of children with birth weights of 1500-1999 g among hepatoblastomas was higher, at 2.94-1.60%, than that among all live births in each of the four periods (0.79-0.92%), and the percentage of children with birth weights of 2000-2499 g was slightly higher. The percentage of children with birth weights of <1500 g and, especially, <1000 g, has increased rapidly among children born after 1988 (1.60 and 6.40%, respectively), when most very low birth weight infants began to survive. Compared with children with a birth weight of 2500 g or more, the relative risks of hepatoblastoma among children with birth weights of <1000, 1000-1499, 1500-1999, and 2000-2499 g were 15.64 (P < 0.001), 2.53 (P = 0.129), 2.71 (P = 0.001), and 1.21 (P = 0.381), respectively, suggesting the lower the birth weight, the higher the risk of hepatoblastoma. There was no association between hepatoblastomas with a low birth weight and either age at diagnosis or congenital malformations or light-for-date weight. The risk of hepatoblastoma for low birth weight children may be inherently high, especially for lower birth weights, and the recent rapid increase may be a result of an increase in the number of more immature infants with a more sensitive liver and also more frequent exposure to risk factors related to perinatal treatment.

Hepatoblastoma incidence in the United States from 1973 to 1992

BACKGROUND

There is recent evidence to suggest that extremely low birth weight is associated with the occurrence of hepatoblastoma.

PROCEDURE

In light of this possibility, we evaluated trends in hepatoblastoma incidence in the United States among children age 4 years and younger.

RESULTS

We found an increasing trend (5.2%) in hepatoblastoma incidence over the past two decades, a period that corresponds with improved survival of very low birth weight children.

CONCLUSION

Future studies of hepatoblastoma that incorporate birth weight are appropriate.

Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry

To determine the incidence and relative risk (RR) of cancer in children with Beckwith-Wiedemann syndrome (BWS), children with BWS were followed up from birth until death, diagnosis of cancer, fourth birthday, or last day of follow-up. A total of 183 children with BWS were followed up for 482 person-years. The end points were incidence of cancer, RR of cancer, and RR associated with specific BWS phenotypic features. Thirteen children were identified with cancers before the fourth year of life in comparison with fewer than one cancer expected in this group on the basis of general population rates over the same period. The average annual incidence of cancer in the first 4 years of life was 0.027 cancer per person-year. The RR of Wilms tumor (RR = 816; 95% confidence interval [CI], 359-1156), neuroblastoma (RR = 197; 95% CI, 22-711), and hepatoblastoma (RR = 2280; 95% CI, 928-11,656) were statistically significant. Asymmetry of the limbs (hemihypertrophy) was the only clinical feature associated with an increased RR of cancer (RR = 4.6; 95% CI, 1.5-14.2). Given the high incidence of cancer in infancy and early childhood of patients with BWS, a prospective study is warranted to address the utility of screening for cancer.

Thirty-eight years experience of malignant hepatic tumors in infants and childhood

A description is given of therapeutic experiences with 39 cases of malignant liver tumors in infancy and childhood during the past 38 years. Of these patients, 9 not undergoing hepatic resection all died, while 18 (60%) of 30 patients treated by hepatic resection survived. When only patients with hepatoblastoma are considered, 14 of 24 patients are alive, although 3 of them had local recurrence and had lung metastasis. Among patients with other types of liver tumor, those with hepatocellular carcinomas (2 cases) and vascular neoplasms all died in a short period of time, whereas 2 with yolk sac tumor and one with metabolic pancreatic tumor are alive despite of tumor recurrence. In summary, the results of surgical treatment of malignant liver tumors in infancy and childhood, which formerly were poor, have been improved remarkably, which we owe mainly to: 1) advances in diagnostic imaging techniques (e.g., angiography, ultrasonography, CT and MRI) permitting early diagnosis, localization of tumor, visualization of the coursing of major vessels (particularly, hepatic artery & vein) and more accurate definition of resectability, 2) technical improvement of hepatic resection and 3) progress of chemotherapy mainly with cisplatin and adriamycin.