Predictors of survival following liver transplantation for pediatric hepatoblastoma and hepatocellular carcinoma: Experience from the Society of Pediatric Liver Transplantation (SPLIT)

Abstract

Management of unresectable pediatric hepatoblastoma (HB) and hepatocellular carcinoma (HCC) remains challenging. The Society of Pediatric Liver Transplantation (SPLIT) database was used to study survival predictors in pediatric liver transplantation (LT) for HB and HCC. Event‐free survival (EFS), associated risk factors, and postoperative complications were studied in children requiring LT for HB/HCC at 16 SPLIT centers. Three‐year EFS was 81% for HB (n = 157) and 62% for HCC (n = 18) transplants. Of HB transplants, 6.9% were PRETEXT II and 15.3% were POST‐TEXT I/II. Tumor extent did not impact survival (p = NS). Salvage (n = 13) and primary HB transplants had similar 3‐year EFS (62% versus 78%, p = NS). Among HCC transplants, 3‐year EFS was poorer in older patients (38% in ≥8‐year‐olds vs 86% <8‐year‐olds) and those with larger tumors (48% for those beyond versus 83% within Milan criteria, p = NS). Risk of infection (HR 1.5, 95% CI 1.1–2.2, p = .02) and renal injury (HR 2.4, 95% CI 1.7–3.3, p < .001) were higher in malignant versus nonmalignant LT. Survival is favorable for pediatric HB and HCC LT, including outcomes after salvage transplant. Unexpected numbers of LTs occurred in PRE/POST‐TEXT I/II tumors. Judicious patient selection is critical to distinguish tumors that are potentially resectable; simultaneously, we must advocate for patients with unresectable malignancies to receive organs.

Competitive risk analysis of the therapeutic value of liver transplantation for liver cancer in children: A population-based study

“…In this study, the prognosis of CLCa treated with LT was good, with 1-year, 3-year, 5-year, and 10-year OS rates of 96.0%, 89.9%, 87.0%, and 83.0%, respectively. Studies have shown that LT could be considered an effective option for the treatment of CLCa to improve prognosis, especially when complete tumor excision is unlikely to be performed by partial hepatectomy ( 10 , 25 ). Studies have shown that tumor burden including tumor size and tumor number, biomarkers including AFP and NLR, post-treatment extent of disease (POST-TEXT) stages, tumor differentiation, vascular invasion, and chemotherapy could predict the prognosis of liver cancer patients undergoing LT ( 25 , 26 ).…”

“…Studies have shown that LT could be considered an effective option for the treatment of CLCa to improve prognosis, especially when complete tumor excision is unlikely to be performed by partial hepatectomy ( 10 , 25 ). Studies have shown that tumor burden including tumor size and tumor number, biomarkers including AFP and NLR, post-treatment extent of disease (POST-TEXT) stages, tumor differentiation, vascular invasion, and chemotherapy could predict the prognosis of liver cancer patients undergoing LT ( 25 , 26 ). We found that age of diagnosis, T, grade, and histopathology were closely related to the prognosis of CLCa treated with LT, especially T. In our nomogram, we found that CLCa undergoing LT may have a better prognosis than CLCa undergoing other surgeries.…”

Recent advances in surgical strategies and liver transplantation for hepatoblastoma

“…In recent years, the application of pediatric living donor domino LT, improvement in perioperative management for ABO‐incompatible LDLT, and development of split deceased donor LT have increased the opportunity to obtain grafts for LT, especially in areas where there is a shortage of organs for transplantation 55–57 . The latest multicenter study using the Society of Pediatric Liver Transplantation (SPLIT) database revealed that tumor extent or the presence of metastasis and vascular involvement did not affect event‐free survival for HB transplants, suggesting that transplant outcomes can be favorable despite a high tumor burden 58 . Moreover, the risks of infection and renal injury were higher in malignant compared with non‐malignant pediatric LT 58 .…”

Pediatric Liver Transplantation: Long-Term Follow-Up Issues

“…41 Reported disease-free survival is >80% at 3 years. 42 Hepatocellular carcinoma is mainly associated with inherited liver diseases. Although the recurrence rate is high, with a reported disease-free survival rate at 3 years post-LT of 62%, 42 LT still provides a long-term survival advantage, 43 even in the pediatric population.…”

“…42 Hepatocellular carcinoma is mainly associated with inherited liver diseases. Although the recurrence rate is high, with a reported disease-free survival rate at 3 years post-LT of 62%, 42 LT still provides a long-term survival advantage, 43 even in the pediatric population. For long-term management of these malignancies, a multidisciplinary approach 44,45 that includes oncologists, hepatologists, and radiologists is recommended.…”