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Abstract

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

From October 1993 to February 2007, 25 liver transplantations were performed for hepatoblastoma. Of these 25, 18 children received cadaveric grafts, and 7 received left lateral segments from living donors. Fifteen patients were at level IV in the pretreatment extent of disease staging system for hepatoblastoma (PRETEXT IV; 11 received cadaveric grafts and 4 underwent living related liver transplantation [LRLT]) and 10 were level III (PRETEXT III; 7 received cadaveric grafts and 3 underwent LRLT). Preoperative chemotherapy was given according to the risk stratification system for children with hepatoblastoma protocols of the International Childhood Liver Tumour Strategy Group of the International Society of Paediatric Oncology (SIOPEL): SIOPEL I in the first 3 patients, SIOPEL II in 6, SIOPEL III in 10, and SIOPEL IV in 3 patients. Patient and graft survival after cadaveric transplantation was 91%, 77.6%, and 77.6%, at 1, 5, and 10 years, respectively, with no retransplantations. Patient and graft survival for children undergoing LRLT was 100%, 83.3%, and 83.3%, at 1, 5, and 10 years, respectively. All surviving children but 1 remain disease-free, with a median follow up of 6.8 years (range, 0.9-14.9). There were 5 deaths at a median of 13 months post-transplantation, secondary to tumor recurrence (4) and respiratory failure (1). Liver transplantation is an established treatment for unresectable hepatoblastoma confined to the liver following chemotherapy. LRLT is a therapeutic option given that the outcome is similar to that of resection and cadaveric transplantation. Liver Transpl 14:1614–1619, 2008. © 2008 AASLD.

Hepatoblastoma (HB) is the most common malignant liver tumor of early childhood, with an incidence of 0.5-1.5 per 1 million population, and accounting for approximately 60%-85% of all hepatic tumors in children.1, 2 The advent of effective chemotherapy has transformed the prognosis of this tumor over the past 25 years. Resectable tumors have an excellent prognosis, with an overall survival rate of 80% at 5 years.3–5 More than 60% of lesions that appear unresectable on initial imaging will shrink with chemotherapy and become resectable.6 However, approximately 20% of tumors remain unresectable after chemotherapy; for these, liver transplantation has been used in the absence of visible extrahepatic disease.7–9 Early reports of liver transplantation for children with unresectable HB reported a 50% 5-year survival rate, with tumor recurrence being the most common cause of death.9, 10 More recently survival has improved to approximately 80% at 5 years post-transplantation.

The majority of children have received cadaveric grafts; however, living donor liver grafts have also been used, to allow the transplant surgery to fit into the chemotherapy schedule. We have reviewed our experience with 25 liver transplantations for HB from living and cadaveric donation.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Patients were identified by review of a prospectively acquired liver database. Recipient and donor demographics, perioperative findings, and postoperative outcome were obtained. Descriptive data are reported as medians and ranges.

From October 1993 to February 2007, 68 patients were referred for treatment of HB, and 25 received liver transplants. Thirteen of the 25 patients have been reported.11 All of the patients were treated according to the contemporary protocol guidelines from the International Childhood Liver Tumour Strategy Group of the International Society of Paediatric Oncology (SIOPEL) risk stratification system for children with hepatoblastoma for preoperative and postoperative chemotherapy, SIOPEL I-IV. The indication for liver transplantation was nonresectability of the HB and biological response to chemotherapy (fall in alpha-fetoprotein [AFP]), in the absence of lung metastases.

Twenty-five liver transplantations were performed. Of these, 18 received cadaveric grafts (12 male and 6 female, median age 2.5 years [range, 0.5-10], median weight 11 kg [range, 5.9-24.2], and median height 85 cm [range, 74-140]). Cadaveric transplants included 6 reduced grafts (left lobe in 4, right lobe in 1, and left lateral segment [LLS] in 1). Nine children received split cadaveric grafts, of which 8 were LLSs and 1 was right lobe. Three children received whole cadaveric liver grafts. Seven children received LLS grafts from living donors (5 male and 2 female, median age 2 years [range, 0.9-11], median weight 11.7 kg [range, 6.6-32.3], and median height 74.3 cm [range, 73-130]).

The AFP at the time of diagnosis was a median of 263,500 kU/L (range, 2846-3,200,000) for children who received cadaveric grafts and 75,474 kU/L (range, 538-1,300,000) for children who received living-related liver transplantation (LRLT). AFP at the time of transplantation was a median of 220 kU/L (range, 10-376,000) for cadaveric grafts and 251 kU/L (range, 26-6881) for LRLT grafts. Other blood results included serum aspartate aminotransferase median 50 IU/L (range, 19-380), bilirubin (total) 5 μmol/L (range, 2-11), gamma-glutamyl transferase 51 IU/L (range, 20-108), alkaline phosphatase 201 IU/L (range, 154-365), albumin 39 g/L (range, 34-45), creatinine 45 μmol/L (range, 33-60), hemoglobin 10.6 g/dL (range, 6.5-13.9), and international normalized prothrombin 1.03 (range, 0.89-1.06). All children underwent serial computed tomography scans to assess response to treatment and identify extrahepatic disease.

According to the pretreatment extent of disease (PRETEXT) staging system for hepatoblastoma, 15 patients were PRETEXT IV (11 for cadaveric and 4 for LRLT grafts) and 10 were PRETEXT III (7 for cadaveric and 3 for LRLT grafts). Preoperative chemotherapy was given according to SIOPEL I in the first 3 patients, SIOPEL II in 6, SIOPEL III in 10, and SIOPEL IV in 3 (Tables 1 and 2).

Table 1. Disease and Chemotherapy Data for Cadaveric OLT Patients
PatientAge (Years)SexSerum AFP at DiagnosisSerum AFP at TransplantPRETEXTSIOPELPretransplantation ChemotherapyPosttransplantation ChemotherapyFollow-Up Time (Years)Survival
  1. Abbreviations: Vin, vincristine; Cis, cisplatin; 5 FU, 5 fluorouracil; Car, carboplatin; Dox, doxorubicin.

12Female311,50074IIIIVin, Cis, 5 FUNo14.9Alive
25Male299,00033IIIICis, DoxNo14Alive
39Male173,000491IVICis, Car, DoxYes10.8Alive
42.9Male68,89090IIIICis, Car, DoxNo0Dead
50.4Male600,0001600IIIIICis, adriamycinYes9.1Alive
62.5Male540,00012,251IIIIICis, Car, DoxYes9Alive
72Male1,687,4903,000IVIICis, Car, DoxYes8.6Alive
810Male668,31016IVIICis, Car, DoxYes1Dead
99Male284610IIIIICis, Car, DoxYes6.8Alive
101Male12,05093IVIICis, Car, DoxYes5.5Alive
112Female10,950239IVIIICis, Car, DoxYes5Alive
120.7Male213,010155IVIIICis, Car, DoxYes5Alive
132.5Female3,200,000376,000IVIIICis, Car, DoxYes2Dead
142.6Male228,0002,270IVIIICis, Car, DoxYes4.3Alive
151Female2,500,000287IVIIICis, Car, DoxYes3.5Alive
164Female10,9901360IVIIICis, Car, DoxYes1.8Dead
172.3Female9,979202IVIVCis, Car, DoxYes1Alive
181.1Male1,100,00050IIIIVCis, Car, DoxYes0.9Alive
Table 2. Disease and Chemotherapy Data for LRLT Patients
PatientAge (Years)SexSerum AFP at DiagnosisSerum AFP at TransplantationPRETEXTSIOPELPretransplantation ChemotherapyPosttransplantation ChemotherapyFollow-Up Time (Years)Survival
  1. Abbreviations: Cis, cisplatin; Car, carboplatin; Dox, doxorubicin.

11.5Male82,500230IVIICis, Car, DoxYes9.8Alive
22Female16926IVIICis, Car, DoxYes10Alive
311Male5,280251IIIIIICis, Car, DoxYes8.7Alive
42.5Male1,031,3092190IIIIIICis, Car, DoxYes8Alive
51.5Male36,3002320IVIIICis, Car, DoxYes1.8Dead
60.9Female1,300,0006881IIIIICis, Car, DoxYes2Alive
72Male75,47430IVIVCis, Car, DoxYes1.5Alive

All living donors were related and included 3 mothers, 3 fathers, and 1 uncle, with a median age of 30 years (range, 25-37) and median weight of 70 kg (range, 55.3-85). Donation occurred after a 2-stage consent protocol based on that published by Broelsch et al.12 A standard investigation protocol was performed for all donors.13 Abdominal computed tomography scan was performed to estimate the volume of the LLS and to assess the vascular supply to the potential graft. Serology was negative for human immunodeficiency virus, hepatitis C, and hepatitis B. Of the 7 donors, 5 were cytomegalovirus (CMV) immunoglobulin G (IgG)-positive and 3 were Epstein-Barr virus IgG-positive. For the transplantation, 19 children were admitted from home 4 were in the hospital, and 1 was from the pediatric intensive care unit.

Pretransplantation laparotomy was undertaken in 8 children. Of these 8, 3 children underwent attempted resection with an available liver graft, to proceed to orthotopic liver transplantation (OLT) if the tumor was unresectable. All 3 proceeded to OLT with the available graft. One child underwent extended right hepatectomy, but had positive tumor margins on histology with involvement of the portal vein and inferior vena cava and received transplantation 4 months later. One child underwent left hepatectomy followed by OLT after 9 months. Three children underwent laparotomy for resection (including 1 patient who underwent an attempted liver resection performed at another hospital). All 3 were found to be unresectable and referred for transplantation, which was performed between 10 days and 4 months later.

RESULTS

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Overall actuarial patient and graft survival was 91%, 77.6%, and 77.6% at 1, 5, and 10 years, respectively, with no retransplantations at a median follow-up of 60 months (range, 1-179) (Fig. 1). Of the 25 cases, 5 died at a median of 13 months (range, 3 weeks to 28 months) post-transplantation, secondary to tumor recurrence in 4 and respiratory failure in 1. Patient and graft survival for LRLT was 100%, 83.3%, and 83.3% at 1, 5, and 10 years, respectively, with 1 death at 20 months from pulmonary recurrence, with a median follow-up of 96 months (range, 18-125). All surviving children, but 1, remain disease free.

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Figure 1. Kaplan-Meier plot showing survival at 1, 5, and 10 years post-transplantation, with the number of patients at risk for each point in time.

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The recipient operative time was a median of 6.4 hours (range, 4.5-6.6) for both groups. The median blood loss was 83.2 mL/kg (range, 27.8-540) for cadaveric and 49.5 mL/kg (range, 17-352) for the living donor group. The median cold ischemic time was 10 hours (range, 6.4-15.5) for cadaveric and 2.5 hours (range, 0.5-8) for LRLT. The median living donor operative time was 3.2 hours (range, 2.5-4.5) with median blood loss of 250 mL (range, 100-1500) and a median hospital stay of 7 days (range, 6-16). The surgical techniques of both living donor hepatectomy and transplantation were as described.14–16 The recipient surgery was started with the child first, to assess resectability and confirm the absence of extrahepatic disease in the 4 cases using a cadaveric graft. Four children had involvement of the inferior vena cava by the tumor and reconstruction was performed using cadaveric iliac venous grafts. One child had an exophytic extension of the primary tumor involving the porta hepatis and the body of the pancreas at the time of transplantation and underwent resection of the extrahepatic extension, including resection of the body and tail of the pancreas in addition to liver replacement.

There were no vascular complications in either recipient group. In the cadaveric group there were 2 bile leaks that resolved with laparotomy and drainage in 1 and percutaneous drainage in the other. One child had a laparotomy and bowel resection for small bowel obstruction on day 16 without sequelae. One child developed chylous ascites that settled spontaneously. One child developed two lung metastases 7 months after liver transplantation (previously had pulmonary metastases). One child developed acute liver and respiratory failure after attempted liver resection at another institution and despite emergency transplantation he died 3 weeks later from his lung injury with good graft function.

There were no biliary complications in the LRLT group. One child developed intestinal obstruction 13 days post-transplantation, secondary to a volvulus treated by laparotomy and small bowel resection. Two children had lung metastases pretransplantation, which resolved with chemotherapy. However, 1 recurred 1 year post-transplantation with secondary lung diseases, and despite pulmonary resection died of recurrent disease in the lungs and liver. CMV prophylaxis with ganciclovir was given to 7 CMV IgG-negative children receiving a graft from an IgG-positive donor. Three children developed (CMV) infection and responded to ganciclovir therapy.

The postoperative immunosuppression consisted of cyclosporine, steroids, and azathioprine in 6 patients, tacrolimus and steroids in 12 patients, and tacrolimus and mycophenolate mofetil (MMF) in 5. Two children were converted to MMF and steroids for renal toxicity on late follow-up. Cellular rejection was diagnosed on clinical and biochemical grounds, and confirmed by histological examination of liver biopsy. Treatment of acute cellular rejection was with a 3-day course of methylprednisolone (intravenously, 10 mg/kg/day). Of the 25 children, 20 received postoperative chemotherapy after a median interval of 5 weeks (range, 2-8) depending on the postoperative recovery of the patients.

All 7 living donors are alive with normal liver function at a median follow up of 5 years (range, 1.5-10 years). Twenty children have normal graft function without tumor recurrence at a median post-transplantation follow-up of 73 months (range, 10-178). Renal function as measured by the estimated glomerular filtration rate was a median 88 mL/minute (range, 55-115). Of 20 children, 7 showed reductions in the estimated glomerular filtration rate and were converted to MMF with steroid or low-dose tacrolimus with MMF.

DISCUSSION

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

HB remains unresectable by conventional surgery in up to 20% of cases despite effective chemotherapy.17, 18 Current treatment protocols have improved the outcome of HB, with several studies showing 90%-95% chemosensitivity rates, with 75%-85% of previously unresectable tumors having a good outcome.5, 19–23 Liver transplantation has been employed to resect tumors with grafts from cadaveric or living donation. Caval replacement is often required for complete clearance and can be achieved by the use of donor iliac vein interpositional grafts.24–27 The use of grafts from living donors offers some potential advantages over cadaveric donation, including shorter waiting time, better graft quality, more rapid recovery, and improved timing of transplant to comply with chemotherapy regimes.

We report 25 children with unresectable HB treated with OLT. Of these, 7 received LRLT. Similar results have been reported by others, with overall survival ranging from 62.5%-90%. (Table 3). Our results are comparable with survival rates reported after radical liver resection and cadaveric liver transplantation.25, 28–30 The most common cause of death was tumor recurrence, as is reflected in the majority of series: 20%-25% of recipients died, usually within 2 years of transplantation.9, 25 In our series, four patients (16%) developed tumor recurrence and died at a median of 13 months post-transplant. Previous lung metastases was a marker of risk for recurrence

Table 3. Summary of World Experience in Liver Transplantation for Hepatoblastoma
AuthorsYearNumber of ChildrenCadaveric DonorsLiving DonorsOverall Survival (%)
Al-Qabandi et al.10199988062.5
Reyes et al.3120001212083
Molmenti et al.33200299066
Pimpalwar et al.1920021212083
Chardot et al.34200240475
Mejia et al.352005108270
Kasahara et al.2420051401465.5
Otte et al.2820051221090
Avila et al.262006129382
Chen et al.4200697289
Beaunoyer et al.3620071515086.7
This study20072518777.6

The value of posttransplantation chemotherapy in this context has been questioned. Otte et al.25 reviewed the published experience of liver transplantation for HB and identified 65 children who received posttransplantation chemotherapy (82 patients did not receive any). Of the 65, 61 had pretransplantation chemotherapy with an overall survival of 77%, and a 5-year survival of 70% for those who did not. The lack of statistical difference in outcome and the added morbidity of posttransplantation chemotherapy when given with immunosuppression led to some centers avoiding such a protocol.25 We favor further chemotherapy at a time when the tumor burden is at its lowest, and the morbidity with this approach has been acceptably low. The incidence of recurrent disease compares favorably with studies without chemotherapy post-surgery, which have a 30% incidence of recurrence.32

Liver transplantation appears to be associated with better outcome when performed as a primary rather than as a salvage procedure and should be offered to all children with unresectable disease. Otte et al.25 reported 85% overall survival for 7 children undergoing primary liver transplantation and 40% for 5 children who underwent “rescue” transplantation after partial hepatectomy. In our series, 4 patients underwent “rescue” liver transplantation, of which 1 died at 20 months post-transplantation from pulmonary recurrence. The only contraindication to transplantation is the persistence of 1 or more sites of extrahepatic disease that do not respond to chemotherapy.19

LRLT is a practical therapeutic option for unresectable HB, with long-term outcome similar to that achieved for cadaveric liver transplantation and surgically-resectable tumors. Appropriate staging and early referral to centers with the expertise to optimize results provides good outcome for the majority of children with HB.

REFERENCES

  1. Top of page
  2. Abstract
  3. PATIENTS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
  • 1
    Parkin DM, Stiller CA, Draper GJ, Bieber CA. The international incidence of childhood cancer. Int J Cancer 1988; 42: 511520.
  • 2
    Stringer MD. Liver tumors. Semin Pediatr Surg 2000; 9: 196208.
  • 3
    Otte JB, de Ville de Goyet J, Reding R. Liver transplantation for hepatoblastoma: indications and contraindications in the modern era. Pediatr Transplant 2005; 9: 557565.
  • 4
    Chen LE, Shepherd RW, Nadler ML, Chapman WC, Kotru A, Lowell JA. Liver transplantation and chemotherapy in children with unresectable primary hepatic malignancies: development of a management algorithm. J Pediatr Gastroenterol Nutr 2006; 43: 487493.
  • 5
    Carceller A, Blanchard H, Champagne J, St-Vil D, Bensoussan AL. Surgical resection and chemotherapy improve survival rate for patients with hepatoblastoma. J Pediatr Surg 2001; 36: 755759.
  • 6
    Perilongo G, Shafford E, Plaschkes J, Liver Tumour Study Group of the International Society of Paediatric Oncology. SIOPEL trials using preoperative chemotherapy in hepatoblastoma. Lancet Oncol 2000; 1: 94100.
  • 7
    Brown J, Perilong G, Shafford E, Keeling J, Pritchard J, Brock P, et al. Pretreatment prognostic factors for children with hepatoblastoma—results from the International Society of Pediatric Oncology (SIOP) study SIOPEL 1. Eur J Cancer 2000; 36: 14181425.
  • 8
    Dower NA, Smith LJ. Liver transplantation for malignant liver tumours in children. Med Pediatr Oncol 2000; 34: 136140.
  • 9
    Koneru B, Flye MW, Busuttil RW, Shaw BW, Lorber MI, Emond JC, et al. Liver transplantation for hepatoblastoma: the American experience. Ann Surg 1991; 213: 118121.
  • 10
    Al-Qabandi W, Jenkinson HC, Buckels JA, Mayer AD, McKiernan P, Morland B, et al. Orthotopic liver transplantation for unresectable hepatoblastoma: a single center's experience. J Pediatr Surg 1999; 34: 12611264.
  • 11
    Srinivasan P, McCall J, Pritchard J, Dhawan A, Baker A, Vergani GM, et al. Orthotopic liver transplantation for unresectable hepatoblastoma. Transplantation 2002; 74: 652655.
  • 12
    Broelsch CE, Whitington PF, Emond JC, Heffron TG, Thistlethwaite JR, Stevens L, et al. Liver transplantation in children from living related donors. Ann Surg 1991; 214: 428439.
  • 13
    Baker A, Dhawan A, Devlin J, Mieli-Vergani G, O'Grady J, Williams R, et al. Assessment of potential donors for living related liver transplantation. Br J Surg 1999; 86: 200205.
  • 14
    Ozawa K, Uemoto S, Tanaka K, Yamaoka Y, Kobayashi N, Inamoto T, et al. An appraisal of pediatric liver transplantation from living relatives: initial clinical experiences in 20 pediatric liver transplantations from living relatives as donors. Ann Surg 1992; 216: 547553.
  • 15
    Broelsch CE, Emond JC, Whitington PF, Thistlethwaite JR, Baker AL, Lichtor JL. Application of reduced-sized liver transplants. Ann Surg 1990; 212: 368375.
  • 16
    Emond JC, Heffron TG, Kortz EO, Gonzalez-Vallina R, Contis JC, et al. Improved results of living-related liver transplantation with routine application in a pediatric program. Transplantation 1993; 55: 835840.
  • 17
    Kuo CY, Liu HC, Chang MH, Wu MZ, Lin DT, Li YW, et al. Hepatoblastoma in infancy and childhood: a clinical and pathological study of 32 cases. Zhonghua Min Guo Shou Yi Xue Hui Za Zhi 1991; 32: 7987.
  • 18
    Pritchard J, Brown J, Shafford E, Perilongo G, Brock P, Dicks-Mireaux C, et al. Cisplatin, doxorubicin, and delayed surgery for childhood hepatoblastoma: a successful approach—results of the first prospective study of the International Society of Pediatric Oncology. J Clin Oncol 2000; 18: 38193828.
  • 19
    Pimpalwar AP, Sharif K, Ramani P, Stevens M, Grundy R, Morland B, et al. Strategy for hepatoblastoma management: transplant versus nontransplant surgery. J Pediatr Surg 2002; 37: 240245.
  • 20
    Okada A, Fukuzawa M, Oue T, Kohmoto Y, Kusafuka T, Fukui Y, et al. Thirty-eight years experience of malignant hepatic tumours in infants and childhood. Eur J Pediatr Surg 1998; 8: 1722.
  • 21
    Otte JB, Aronson D, Vraux H, de Ville de Goyet J, Reding R, Ninane J, et al. Preoperative chemotherapy major liver resection, and transplantation for primary malignancies in children. Transplant Proc 1996; 28: 23932394.
  • 22
    Emre S, McKenna GJ. Liver tumours in children. Pediatr Transplant 2004; 8: 632638.
  • 23
    Van Winkle P, Angiolillo A, Krailo M, Cheung YK, Anderson B, Davenport V, et al. Ifosfamide, carboplatin, and etoposide (ICE) reinduction chemotherapy in a large cohort of children and adolescents with recurrent/refractory sarcoma: the Children's Cancer Group (CCG) experience. Pediatr Blood Cancer 2005; 44: 338347.
  • 24
    Kasahara M, Ueda M, Haga H, Hiramatsu H, Kobayashi M, Adachi S, et al. Living-donor liver transplantation for hepatoblastoma. Am J Transplant 2005: 5: 22292235.
  • 25
    Otte JB, Pritchard J, Aronson DC Brown J, Czauderna P, Maibach R, et al. Liver transplantation for hepatoblastoma: results from the International Society of Pediatric Oncology (SIOP) study SIOPEL-1 and review of the world experience. Pediatr Blood Cancer 2004; 42: 7483.
  • 26
    Avila LF, Luis AL, Hernandez F, Garcia Miguel P, Jara P, Andres AM, et al. Liver transplantation for malignant tumours in children. Eur J Pediatr Surg 2006; 16: 411414.
  • 27
    Chen LE, Shepherd RW, Nadler ML, Chapman WC, Kotru A, Lowell JA. Liver transplantation and chemotherapy in children with unresectable primary hepatic malignancies: development of a management algorithm. J Pediatr Gastroenterol Nutr 2006; 43: 487493.
  • 28
    Otte JB, de Ville de Goyet J, Reding R. Liver transplantation for hepatoblastoma: indications and contraindications in the modern era. Pediatr Transplant 2005; 9: 557565.
  • 29
    Finegold M. Chemotherapy for suspected hepatoblastoma without effort at surgical resection is bad practice. Med Pediatr Oncol 2002; 39: 484486.
  • 30
    Al-Qabandi W, Jenkinson HC, Buckels JA, Mayer AD, McKiernan P, Morland B, et al. Orthotopic liver transplantation for unresectable hepatoblastoma: a single center's experience. J Pediatr Surg 1999; 34: 12611264.
  • 31
    Reyes JD, Carr B, Dvorchik I, Kocoshis S, Jaffe R, Gerber D, et al. Liver transplantation and chemotherapy for hepatoblastoma and hepatocellular cancer in childhood and adolescence. J Pediatr 2000; 136: 795804.
  • 32
    Feusner JH, Krailo MD, Haas JE, Campbell JR, Lloyd DA, Ablin AR. Treatment of pulmonary metastases of initial stage I hepatoblastoma in childhood. Report from the Children Cancer Group. Cancer 1993; 71: 859864.
  • 33
    Molmenti EP, Wilkinson K, Molmenti H, Roden JS, Squires RH, Fasola CG, et al. Treatment of unresectable hepatoblastoma with liver transplantation in the pediatric population. Am J Transplant 2002; 6: 535538.
  • 34
    Chardot C, Saint Martin C, Gilles A, Brichard B, Janssen M, Sokal E, et al. Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma. Transplantation. 2002; 15: 73: 902.
  • 35
    Mejia A, Langnas AN, Shaw BW, Torres C, Sudan DL. Living and deceased donor liver transplantation for unresectable hepatoblastoma at a single center. Clin Transplant. 2005; 19: 7215.
  • 36
    Beaunoyer M, Vanatta JM, Ogihara M, Strichartz D, Dahl G, Berquist WE, et al. Outcomes of transplantation in children with primary hepatic malignancy. Pediatr Transplant. 2007; 11: 65560.