Iwatsuki, S

Starzl, TE

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Hepatectomy in children

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International Advances in Surgical Oncology 5:163-171 (1982) Hepatectomy in Children Shunzaburo Iwatsuki, MD and Thomas E. Starzl, MD, PhD Tumors of the liver in infants and children are uncommon. A committee of the Sur-gical Section of the American Academy of Pediatrics surveyed liver tumors in chil-dren who were operated upon during the 10 years preceding 1974. They collected only 375 liver tumors of which 252 were malignant and 123 benign [1]. The most common malignant tumor was hepatoblastoma followed closely by hepatocellular carcinoma. Complete excision of the tumor was achieved in a little less than a half of the children with hepatoblastoma or hepatocellular carcinoma [l]. Because of the infrequency with which partial hepatic resections are done, there are few pediatric surgeons who are experienced with such operations. However, in the personal series of 129 subtotal hepatectomies compiled by us since 1963, there have been 14 patients in the pediatric age group. The treatment in these 14 cases will be dis-cussed. In addition, eight children with primary malignant liver tumors were treated by total hepatectomy and liver replacement (orthotopic liver transplantation) during the same period. This latter experience has shown that cure of a liver tumor is a possibility after transplantation. SUBTOTAL HEPATECTOMY Technical Considerations The four kinds of liver resection commonly used are shown in Figure 1. They con-sist of true right lobectomy, true left lobectomy, excision of the lateral segment of the left lobe, and right trisegmentectomy. With a right trisegmentectomy, the true right lobe is removed in continuity with the medial segment of the left lobe. The surgical techniques have been described by which these procedures can be performed safely [2, 3]. A fifth resection may be applicable, namely left trisegmentectomy. With this opera-tion, the true left lobe is removed, in continuity with the anterior segment of the right lobe. We have performed such an operation four times with success on each occasion. One patient was a lO-year-old boy (Fig. 2). To our knowledge, these are the only examples of this radical operation being performed in humans. The patient shown in Figure 2 is free of disease after 12 months. 163 © 1982 Alan R. Liss, Inc., 150 Fifth Avenue, New York, NY 10011 164 I Iwatsuki and Starzl Right hepatic vein RIGHT LOBECTOMY I. v. c. TRISEGMENTECTOMY Middle hepatic vein / I Left hepati c vein Fig. 1. Conventional hepatic resections. Case Material Fourteen children were treated with subtotal hepatectomy (Table I). Six were male and eight female. The age ranged from 11 months to 16 years. Ten children had pri-mary malignant liver tumors; one hepatoblastoma, six hepatocellular carcinomas, and three sarcomas. Two children had metastatic liver tumors, one from a neuroblas-toma of the right adrenal gland and another from a Wilms' tumor of the kidney. One child had an adenoma. One child had a liver resection for trauma. Follow-ups here have been for 1 to 15 years (Table I). There were nine right trisegmentectomies, one left trisegmentectomy, one right lobectomy, two left lobectomies, and one nonanatomical resection of the liver (Table I). There were no operative deaths nor any serious complications such as bleeding, subphrenic abscess formation, or bile duct injury. The earliest death after hepatic resection occurred 6 months after a left hepatic lobectomy, due to the recur-Hepatectomy In Children I 165 Fig. 2. A child with a large hepatoma dominant in the true left lobe could not be treated by con -ventional left lobectomy. A left trisegmentectomy was carried out along the line. renee of hepatoblastoma (Table 1). Minor bile leaks through the drain site were common, but these were all closed spontaneously. Adjuvant Therapy Eleven of the 12 patients with malignant disease received chemotherapy after hepatic resection, and four were given radiation therapy (Table I). One patient had chemotherapy before, but not after resection . The agents used for chemotherapy were variable and were influenced by the histo-pathology (Table II). Initially, the most common treatment for hepatomas and hepatoblastomas was cyclophosphamide, 5-fluorourcil, and vincristine, as described by Holton and co-workers [4]. This was followed with adriamycin, if necessary, for recurrences . Later, those four agents were begun simultaneously as soon as the children recovered from the surgical procedure. The time after surgery usually ranged TABLE I. Hepatic Resections in Pediatric Patients Case No. Age (yr) Sex Diagnosis Primary malignant tumor 1 16/12 M Hepatoblastoma 27M Hepatocellular ca 39M Hepatocellular ca 4 5 M Hepatocellular ca 5 15 F Hepatocellular ca 6 IS F Hepatocellular ca 7 10 M Hepatocellular ca 8 12 F Sarcoma 9 11112 F Rhabdomyosarcoma 10 12 F? Sarcoma Metastatic malignant tumor 112M Neuroblastoma of rt. adrenal gland 12 12 F Wilms'tumor Benign disease 13 16 F Adenoma 14 16 F Trauma Surgery Lt. Lobectomy Rt. trisegmentectomy Rt. trisegmentectomy Rt. trisegmentectomy Rt. trisegmentectomy Rt. trisegmentectomy Lt. trisegmentectomy Rt. trisegmentectomy Nonanatomical resection Rt. trisegmentectomy Adjuvant therapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy Chemotherapy, radiation Chemotherapy (before operation) Chemotherapy Chemotherapy, radiation Chemotherapy Rt. trisegmentectomyand Chemotherapy, radiation rt. adrenalectomy Lt. lobectomy Chemotherapy, radiation, and Rt. trisegmentectomy Rt. lobectomy pulmonary resection Results Died 6 mos. with disease Alive without disease over 5 years Alive without disease over 7 years Died 19 mos. with disease Alive with disease at 4 years Died 17 mos. with disease Alive without disease at 1 year Alive without disease over 5 years Alive without disease over 2 years Alive without disease over 5 years Alive without disease over 6 years Died 10 mos. with disease Alive over 6 years Alive over 15 years ...... en CJ) i" III -III C 2!. III j C. en -III ti TABLE II. Adjuvant Chemotherapy Case No. I 2 3 4 5 6 7 8 9 10 11 12 Diagnosis Hepatoblastoma Hepatocellular ca Hepatocellular ca Hepatocellular ca Hepatocellular ca Hepatocellular ca Hepatocellular ca Sarcoma Rhabdomyosarcoma Sarcoma (?) Neuroblastoma Wilm's tumor Hepatectomy in Children I 167 Chemotherapy agents Cytoxan, vincristine, 5-FU Cytoxan, vincristine, 5-FU Cytoxan, vincristine, 5-FU Cytoxan, vincristine, 5-FU Cytoxan, vincristine, 5-FU, Adriamycin Cytoxan, vincristine, 5-FU, Adriamycin None after resection Cytoxan, vincristine, 5-FU Vincristine, dactinomycin, cytoxan Cytoxan, vincristine, dactinomycin, DTIC, adriamycin Cytoxan, vincristine, CCNU, adriamycin Dactinomycin, vincristine from a few days to several weeks. The heterogeneity of agents, dosage, and timing of adjuvant therapeutic protocols and small number of cases precluded conclusions about effectiveness beyond the observation that good long-term survival was obtained with adjuvant therapeutic treatment, even in some patients who had known recurrences. Late Results Primary hepatic malignant tumor. The results are summarized in Table 1. Nine of 10 children survived at least 1 year. Seven of the 10 children are alive with follow-up periods of 1 to 7 years, and six of them are free of disease. Another with stable pul-monary metastasis is under new chemotherapy after 4 years. Three children died with disease 6, 17, and 19 months after hepatic resection. Four children are alive and free of disease for more than 5 years and are considered to be cured. Metastatic malignant tumor. One child with neuroblastoma is alive more than 6 years after resection and is considered to be cured. Another child with Wilms' tumor died with disease after 10 months (Table I). Benign disease. These two children recovered completely and have no com-plaints or hepatic function abnormalities after many years (Table I). TOTAL HEPATECTOMY AND LIVER REPLACEMENT (ORTHOTOPIC LIVER TRANSPLANTATION) Primary liver malignancy which cannot be treated with conventional techniques of subtotal hepatectomy could theoretically be cured by total hepatectomy and liver re-placement. Eight children with primary liver malignancy received orthotopic liver transplantation since 1963. - ------------------------ ----168 I Iwatsuki and Starzl TABI,E 1lI. Eight Children with Primary Liver Malignancy Wbo Were Treated by Total Hepatectomy and Liver Replacement (Orthotopic Liver Transplantation) Case No. Age (yr) Sex 15. 3 F 16. 7 F 17. 5 F 18. 11 F 19. 9 F 20. 17/12 F 21. 16 F 22. 15 M Case Material Diagnosis Biliary atresia, incidental hepatocellular carcinoma Biliary atresia, incidental hepatocellular carcinoma Alpha-I-antitrypsin deficiency incidental hepatoblastoma Biliary atresia, concomitant hepatocellular carcinoma Tryosinernia, concomitant hepatocellular carcinoma Hepatocellular carcinoma Hepatocellular carcinoma Hepatocellular carcinoma Survival Alive 12 years without disease Operative death Alive 3 years without disease Died 3 months with disease Died 3 months with disease Died 14 months with disease Died 15 months with disease Died 5 months with disease Three children received liver transplantation for end-stage liver disease. In the excised livers were found incidental primary liver malignancies (Table Ill). Two other children had end-stage liver disease and concomitant primary liver malignancy which was known prior to transplantation (Table Ill). The three final children had primary liver malignancy which was not resectable by conventional tech-nique of subtotal hepatectomy (Table III). Transplantation was decided upon as a means of extending the limit of resection. There were seven hepatocellular carcinomas and one hepatoblastoma. The age ranged between 1 year and 7 months old to 16 years old. Surgical and Medical Therapy The surgical techniques of orthotopic liver transplantation have been described elsewhere [5]. The new liver was placed in the anatomical position. For immunosuppression, these eight patients were given azathioprine, prednisone, and horse antilymphocyte globulin. Hepatectomy in Children I 169 TABLE IV. Tumors or Tumor-like Lesions of the Liver in Infants and Children Malignant group I. Liver cell carcinoma Hepatoblastoma Hepatocellular carcinoma 2. Hepatic mixed tumors 3. Mesenchymoma (malignant) 4. Sarcoma 5. Metastatic tumor Benign group I. Tumor-like epithelial lesions Focal nodular hyperplasia Multiple nodular hyperplasia Accessary lobe 2. Benign eipithelial tumors Adenoma Adrenal rest tumor 3. Cysts and tumor-like mesenchymal tumor Mesenchymal hamartoma Nonparasitic cyst 4. Benign mesenchymal tumors Cavernous hemangioma Infantile hemangioendotheliomas 5. Teratoma Survival There was one operative death (12.5070 operative mortality). Five children died with recurrent tumor between 3 and 15 months after transplant, after a mean survival of 8 months (Table III). These five children all had advanced stages of liver malignancy with bulky tumors. Two children are alive and free of disease 3 years and 12 years, re-spectively, after transplant. In both children, primary liver malignancy was discov-ered at the pathological examination of the removed organ (Table III), and thus the tumors were incidental findings. COMMENT Edmondson [6], classified liver neoplasms in his classic paper in 1956 (Table IV). In the 1974 survey of the American Academy of Pediatrics [1], the ratio of malignant to benign lesions was 2 to 1. Among the benign lesions hemangioma, hamartoma, epithelioma, benign cyst, and adenoma were the most common in that order of fre-quency. Ninety percent of the malignant tumors were hepatoblastomas or hepato-cellular carcinomas. Hepatoblastoma occurred largely in the infant population; almost half the patients were 18 months of age or younger. In the patients with 170 I Iwatsuki and Starzl hepatocellular carcinoma, there appeared to be two age peaks, one in the age below 4 years, and another in age between 12 and 15 years. An unacceptably high (20-300,70) operative mortality from hepatic resection has been reported in the literature. Ishak and Glunz [7], reported that 4 of the 18 patients with hepatoblastoma or hepatocellular carcinoma died on the operating table during hepatic resection. The survey by the American Academy of Pediatrics, Surgical Section, also reported that 25 of 223 patients with hepatoblastoma or hepatocellular carcinoma who had exploratory celiotomy died on the operating table or in the imme-diate postoperative period. Since definitive resections were carried out in less than half the cases, the operative mortality from resection apparently exceeded 200,70. At an earlier time at the Boston Children's Hospital there was an 180,70 operative mortality [8], and at the Hospital for Sick Children in London, the death rate was 310,70 [9]. Major hepatic resections can now be done quite safely. In our 14 hepatic resections, there was no operative mortality. The earliest death occurred 6 months after opera-tion due to recurrence of tumor. The authors' personal series of 129 major hepatic re-sections were carried out with the operative mortality of only 30,70 during the last 18 years. Wilson, Adson, and Weiland from Mayo Clinic also reported the operative mortality of less than 50,70 [10, 11]. Thus, major hepatic resection has become a safe operative procedure at places where hepatic operations are performed rather frequently. Surgical resection offers the only chance of survival for patients with malignant hepatic neoplasms. Ishak and Glunz [7] reported that none of the children who did not have the benefit of surgical resection survived more than 1 year, but that 9 of the 11 children whose tumors were resected were alive; 6 of these 9 children had survived for 4,5,6,8,9, and 13 years, respectively, without evidence of recurrence. The survey by the American Academy of Pediatrics [1] also reported that there were no survivors at 2 years after biopsy only or incomplete resection of tumors, but that 600,70 of the children with hepatoblastoma and 350,70 of them with hepatocellular carcinoma sur-vived. The prognosis of hepatocellular carcinoma has been said to be poorer than that of he pat obi as tom a [1,7,12]. In our present series 7 ofthe 10 children who had cura-tive hepatic resections for primary hepatic malignancy are alive for 1 to 7 years includ-ing 4 of 6 with hepatomas and 3 of 3 with sarcomas. The role of adjuvant chemotherapy and radiation therapy has been questioned for a long time [1, 7]. The lack of significant numbers of cases has precluded a meaningful conclusion. However, our satisfactory long-term results of hepatic resection with adjuvant therapy have been noted and defended elsewhere [3]. The limits of resectability can be extended by treating primary liver malignancy with total hepatectomy and orthotopic liver transplantation. However, a high recur-rence rate of the original malignancy after successful transplantation has dampened enthusiasm for this approach. Nevertheless, a small but significant palliation has been achieved with this approach, even in some patients who eventually have died of recur-rence [13-15]. Further gains will be possible only with extremely discriminating selec-Hepatectomy in Children I 171 tion of prospective recipients and better immunosuppressive therapy. Effective adjuvant therapy to prevent recurrence is awaited. REFERENCES 1. Exelby PR, Filler RM, Grosfeld lL: Liver tumors in children in particular reference to hepatoblastoma and hepatocellular carcinoma: American Academy of Pediatrics Surgical Section Survey, 1974. J Ped Surg 10:329, 1975. 2. Starzl TE, Bell RH, Beart RW, Putnum CW: Hepatic trisegmentectomy and other liver resections. Surg Gynecol Obstet 141 :429, 1975. 3. Starzl TE, KoepLJ, Weil R III, Lilly JR, PutnumCW, Aldrete lA: Right trisegmentectomy for hepatic neoplasms. Surg Gynecol Obstet 150:208, 1980. 4. Holton CP, Burrington JD, Hatch EI: A multiple chemotherapeutic approach to the management of hepatoblastoma. Cancer 35:1083,1975. 5. Starzl TE: "Experience in Hepatic Transplantation." Philadelphia: W.B. Saunders Co., 1969. 6. Edmondson HA: Differential diagnosis of tumors and tumor-like lesions of liver in infancy and childhood. AMAJ Dis Children 91:168, 1956. 7. Ishak KG, Glunz PR: Hepatoblastoma and hepatocarcinoma in infancy and childhood: Report of 47 cases. Cancer 20:396, 1967. 8. Taylor PH, Filler RM, Nebesar RA, Tefft M: Experience with hepatic resection in childhood. Am 1 Surg 117:435, 1969. 9. Howat JM: Major hepatic resections in infancy and childhood. Gut 12:212, 1971. 10. Wilson SM, Adson MA: Surgical treatment of hepatic metastases from colorectal cancers. Arch Surg 111:330,1976. 11. Adson MA, Weiland LH: Resection of primary solitary hepatic tumors. Am 1 Surg 141:18, 1981. 12. Randolph IG, Atlman RP, Arensman RM, Matlak ME, Leikin SL: Liver resection in children with hepatic neoplasms. Ann Surg 187:599, 1978. 13. Starzl TE, Koep LJ, Halgrimson CG, Hood 1, Schroter GP, Porter KA, Weil R III: Fifteen years of clinical liver transplantation. Gastroenterology 77:375-388, 1979. 14. Iwatsuki S, Klintmalm GBG, Starzl TE: Total hepatectomy and liver replacement (orthotopic liver transplantation) for primary hepatic malignancy. World J Surg 1982, in press. 15. CaIne RY, Williams R: Liver transplantation. In Ravitch MN (ed): "Current Problems in Surgery." Chicago: Year Book Medical Publishers, 1978, pp 1-44. 

Hepatectomy in children.

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Hepatectomy in children.

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