Extreme hepatic resections for the treatment of advanced hepatoblastoma: Are planned close margins an acceptable approach?

BackgroundOrthotopic liver transplantation (OLT) is considered the standard for children with hepatoblastoma (HB) in whom complete surgical resection is not possible. However, OLT is not always available or feasible. ObjectiveTo describe the outcome of children with HB who were initially deemed unresectable and underwent complex hepatectomy with planned close margins, and ultimately avoided OLT. MethodsDemographic data, surgical and pathologic details, and survival information were collected from children treated for HB between January 2010 to December 2015. ResultsAmong six children (median age 12 months (3-41 months)), PRETEXT classification was III (n=2), III/IV (n=1), and IV (n=3). Patients received a median of six cycles (range 4-7) of platinum-based induction chemotherapy; five received doxorubicin. Experienced pediatric surgeons performed extended right and left hepatectomy in five and one patients, respectively, with assistance of an experienced liver transplant surgeon (n=4). Microscopic margins were positive (n=2) and negative but close (n=4; 2-5mm). Two patients required vascular reconstruction of the vena cava. At median follow-up of 3.3 years (1.7-4.6 years), there was no evidence of local recurrence. One patient had recurrence of pulmonary disease 3 months after surgery. ConclusionsPatients with advanced HB treated with complex surgical resections with positive or close negative margins had good outcomes without OLT. We suggest that planned positive or close microscopic margins in highly selected HB patients may spare the morbidity of OLT and offer an alternative for those ineligible for OLT. Our experience illustrates the importance of a multidisciplinary team specialized in the management of liver tumors.