Pediatric Liver Malignancy Research Articles

Liver transplantation for malignancies in children

Key Points 1. Hepatoblastoma (HB) is the most common primary pediatric liver malignancy. The majority of children with HB are resection candidates. Determining which children should undergo resection or primary liver transplantation is essential to the prognosis. 2. Hepatocellular carcinoma (HCC) is the second most common pediatric primary liver malignancy. Most children with HCC are not resection candidates. Transplantation offers improved survival for appropriate candidates in comparison with nontransplant options. 3. Unlike children with HCC, children with HB and extrahepatic spread to the lungs have acceptable transplant outcomes if the disease has been eradicated by chemotherapy or surgical removal at the time of transplantation. 4. Chemotherapy is an important adjuvant for improving outcomes for children with HB, but its benefits for children with HCC are unproven. 5. Demonstrated extrahepatic spread at the time of transplantation is a contraindication to transplantation for patients with HCC or HB. Macroinvasion at the time of transplantation is a relative contraindication to transplantation. 6. Children with primary hepatic malignancies who are transplant candidates should be prioritized on the deceased donor waiting list. However, the criteria for prioritizing adult HCC patients have not been proven to be relevant for children. Liver Transpl 16:S13-S21, 2010. © 2010 AASLD.

Subcutaneous and intrahepatic growth of human hepatoblastoma in immunodeficient mice

Hepatoblastoma is the most frequent malignant pediatric liver tumor. Approximately 25% of hepatoblastoma patients cannot be cured with current treatment protocols. Additional treatment options must, therefore, be developed. Subcutaneous animal models for hepatoblastoma exist, but a more physiologic intrahepatic model is lacking. The alpha-fetoprotein-expressing hepatoblastoma-cell lines HepT1, HuH6 and the childhood hepatocellular carcinoma-cell line HepG2 were injected subcutaneously and intrasplenically into NMRI nu/nu mice. Tumor growth was monitored by measuring tumor size for subcutaneous and serum human alpha-fetoprotein levels for intra-abdominal tumors. Tumors were characterized microscopically. Subcutaneous tumor growth occurred in 70% (7/10) of mice injected with HuH6 and 50% (5/10) of mice injected with HepG2. HepT1 did not form tumors. Accumulation of serum alpha-fetoprotein reflected tumor growth. Intrasplenic growth was seen in 50% (14/27, HuH6) and 10% (3/10, HepG2) of the mice, with only HuH6 forming intrahepatic tumors in 25% (7/27) of the mice. Growth pattern and alpha-fetoprotein production were similar at the subcutaneous and intra-abdominal location. Intrahepatic grafting occurred by metastatic spread from the spleen, produced well-defined nodules, and was accompanied by a weakened expression of the hepatocyte marker carbamoylphosphate synthetase, and the canalicular markers CD10 and cytokeratin7. The expression of cytokeratin18 and -19, active caspase3, and beta-catenin was increased. There were no lung metastases. We established an intrahepatic mouse model for human hepatoblastoma, in which tumor growth could be monitored by serum alpha-fetoprotein levels. Engrafting in the liver occurred by metastatic spread from the spleen and was accompanied by some loss of differentiation features.

Diagnostic and prognostic impact of β-catenin alterations in pediatric liver tumors

Hepatoblastoma (HBL), a major childhood malignant neoplasm, represents the most frequent malignant liver tumor in childhood. Recent reports have shown the CTNNB1 coding beta-catenin protein to be frequently mutated or deleted at hot-spot regions involving exon 3 in HBL. We investigated the genetic alterations of the CTNNB1 coding beta-catenin protein and expression of several genes downstream of Wnt signals in 4 benign and 17 malignant pediatric liver tumors (PLTs) consisting of 15 HBL, 1 hepatocellular carcinoma, and 1 hepatic immature sarcoma. Of 17 malignant PLTs, 10 (56%) revealed pathogenic alterations of the CTNNB1 gene, including 4 with missense mutations at codons 28, 32, 34 or 44, and 6 with interstitial deletions that partially or totally affected exon 3. All 6 deletions were in-frame deletions without a frame shift. The high frequency without any correlation to histological type indicates that the CTNNB1 gene alteration is a crucial event in the tumorigenesis of malignant PLTs. The immunohistochemical studies in 17 malignant PLTs demonstrated the nuclear/cytoplasmic accumulation of beta-catenin to be positive in all tumor specimens except for one hepatic sarcoma. A histological examination revealed all HBL cases involving tumors without detectable CTNNB1 gene alterations to show high expression of beta-catenin, thus indicating the accumulation of beta-catenin to be a common event in malignant PLTs, including HBL and hepatocellular carcinoma. Among the Wnt signal genes downstream of beta-catenin, E-cadherin is expressed in all malignant PLTs, while cyclin D1 expression was significantly detected in malignant PLTs with an advanced stage of disease. An immunohistological examination of nuclear accumulation of beta-catenin may thus be useful for diagnosing malignant PLTs. On the other hand, the expression of cyclin D1, a gene downstream of beta-catenin, might play a role in tumor progression.

Where do we stand with hepatoblastoma? A review.

Hepatoblastoma (HB) is the most common pediatric liver malignancy, comprising approximately 1% of all pediatric cancers. The disparate clinical staging systems and histologic classifications that were developed during the last decades, nevertheless, reflect the remaining difficulties and uncertainties in characterizing HB. Furthermore, the combination of surgery and (neo)adjuvant chemotherapy has improved patient outcomes dramatically. A poor prognosis is associated with large tumor size, multifocality, extrahepatic disease, and metastatic spread. The exact etiology of HB remains unknown, but the cytogenetic alterations, phenotypic features, and biologic aspects that accompany this neoplasm yield more and more insight into its pathogenesis. New cell-biologic and molecular-biologic insights may lead to the development of new treatment modalities, especially for patients with a bad prognosis. This review summarizes the different aspects of this intriguing tumor and discusses the current status of research and treatment for patients with HB.

Pediatric liver tumors

The role of US has not changed significantly in pediatric liver tumors. Detection and characterisation is still the primary role. Follow up the patients after surgery and/or chemotherapy in case of malignancy. Results of interventional radiology treatments (RF, laser, cryoablation) can be followed by US. Characterisation of the liver tumors remains a challenge for US, and additional methods are needed. Tissue harmonic imaging and SonoCT can improve the ability to identify liver masses and analyse their structure. Color Doppler is of little help in the differential diagnosis of solid masses, and power Doppler is seldom useful. Very little data are available about the use of US contrast agents in pediatric patients with liver tumors. Panoramic US images and 3D US may be helpful to present the results for consultation. Helical CT and/or MR are frequently needed for further workup before treatment. One of the most difficult tasks of imaging is the differentiation between residual liver tumors and recurrencies in case of hepatoblastoma or metastatic liver disease. The differentiation between various benign and malignant pediatric liver masses is sometimes extremely difficult due to the overlap of so-called typical signs. To select the imaging modality of choice in a given case needs a clear understanding of the strength and weaknesses of the radiology imaging methods. Learning objectives: 1) overview of the strength and and weaknesses of US in pediatric patients with various liver masses and tumor-like lesions; and 2) brief overview on the US appearance of the most typical pediatric liver tumors.

Undifferentiated (embryonal) sarcoma of the liver in middle-aged adults: Smooth muscle differentiation determined by immunohistochemistry and electron microscopy

Undifferentiated (embryonal) sarcoma of the liver (UESL) is a rare pediatric liver malignancy that is extremely uncommon in middle-aged individuals. We studied 2 cases of UESL in middle-aged adults (1 case in a 49-year-old woman and the other in a 62-year-old man) by histology, immunohistochemistry, and electron microscopy to clarify the cellular characteristics of this peculiar tumor. One tumor showed a mixture of spindle cells, polygonal cells, and multinucleated giant cells within a myxoid matrix and also revealed focal areas of a storiform pattern in a metastatic lesion. The other tumor was composed mainly of anaplastic large cells admixed with few fibrous or spindle-shaped components and many multinucleated giant cells. In both cases, some tumor cells contained eosinophilic hyaline globules that were diastase resistant and periodic acid-Schiff positive. Immunohistochemically, the tumor cells showed positive staining for smooth muscle markers, such as desmin, alpha-smooth muscle actin, and muscle-specific actin, and also for histiocytic markers, such as alpha-1-antitrypsin, alpha-1-antichymotrypsin, and CD68. Electron microscope examination revealed thin myofilaments with focal densities and intermediate filaments in the cytoplasm of tumor cells. Our studies suggest that UESL exhibits at least a partial smooth muscle phenotype in middle-aged adults, and this specific differentiation may be more common in this age group than in children. Tumor cells of UESL with smooth muscle differentiation in middle-aged adults show phenotypic diversity comparable to those of malignant fibrous histiocytoma with myofibroblastic differentiation.

Comparative genomic hybridization detects multiple chromosomal amplifications and deletions in undifferentiated embryonal sarcoma of the liver

Undifferentiated embryonal sarcoma (UES) is the third most common hepatic malignancy in children. Previous reports have described a broad range of complex cytogenetic abnormalities in individual cases of hepatic UES. Herein we report the cytogenetic findings of six cases of hepatic UES at our institution analyzed by conventional cytogenetic methods and comparative genomic hybridization (CGH). The CGH demonstrated several chromosomal gains and deletions in each case, but there was no specific abnormality seen in every case. Patterns of chromosomal changes included gains of chromosome 1q (four cases), 5p (four cases), 6q (four cases), 8p (three cases), and 12q (three cases), and losses of chromosome 9p (two cases), 11p (two cases), and chromosome 14 (three cases). The three cases in which CGH showed gains in the 12q region were studied specifically for amplifications of MDM2 and CDK4, two genes that have been shown to be amplified in other soft tissue sarcomas. However, Southern analysis showed no amplification of MDM2 or CDK4 in these three cases. Further analysis will be needed to determine the critical events in the pathogenesis of these malignant pediatric liver tumors.

Hepatocyte transplant combined with nonparenchymal cells in the mesenteric fat pad in mouse

Hepatoblastoma is the most frequent malignant pediatric liver tumor. Approximately 25% of hepatoblastoma patients cannot be cured with current treatment protocols. Additional treatment options must, therefore, be developed. Subcutaneous animal models for hepatoblastoma exist, but a more physiologic intrahepatic model is lacking.The α-fetoprotein-expressing hepatoblastoma-cell lines HepT1, HuH6 and the childhood hepatocellular carcinoma-cell line HepG2 were injected subcutaneously and intrasplenically into NMRI nu/nu mice. Tumor growth was monitored by measuring tumor size for subcutaneous and serum human α-fetoprotein levels for intra-abdominal tumors. Tumors were characterized microscopically.Subcutaneous tumor growth occurred in 70% (7/10) of mice injected with HuH6 and 50% (5/10) of mice injected with HepG2. HepT1 did not form tumors. Accumulation of serum α-fetoprotein reflected tumor growth. Intrasplenic growth was seen in 50% (14/27, HuH6) and 10% (3/10, HepG2) of the mice, with only HuH6 forming intrahepatic tumors in 25% (7/27) of the mice. Growth pattern and α-fetoprotein production were similar at the subcutaneous and intra-abdominal location. Intrahepatic grafting occurred by metastatic spread from the spleen, produced well-defined nodules, and was accompanied by a weakened expression of the hepatocyte marker carbamoylphosphate synthetase, and the canalicular markers CD10 and cytokeratin7. The expression of cytokeratin18 and -19, active caspase3, and β-catenin was increased. There were no lung metastases.We established an intrahepatic mouse model for human hepatoblastoma, in which tumor growth could be monitored by serum α-fetoprotein levels. Engrafting in the liver occurred by metastatic spread from the spleen and was accompanied by some loss of differentiation features.