Pediatric Hepatocellular Carcinoma Follow-up
- Author: Paulette Mehta, MD, MPH; Chief Editor: Max J Coppes, MD, PhD, MBA more...
Further Inpatient Care
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Follow-up of patients with hepatocellular carcinomas (HCCs) varies. For the child who requires only surgery, only good postoperative management of the surgical site and assessment of liver function tests may be required. If the α -fetoprotein or B12 binding protein levels are abnormal, these markers of tumor burden, in addition to previously abnormal imaging studies, necessitate close follow-up monitoring. Patients with abnormal scans also require follow-up monitoring, usually at 2-month to 3-month intervals or sooner if clinically indicated.
Grade III to grade IV mucositis, grade III to grade IV myelosuppression, febrile neutropenia, anorexia, and cachexia most likely occur in the patient who receives chemotherapy. These problems require hospitalization and management by a team of individuals who are versed in the toxicities of high-dose chemotherapy.
The 5-year survival rates for patients undergoing multiagent therapy and surgical resection are as follows:
Group I - Approximately 85-90%
Group II - 55-60%
Groups III and IV - Less than 20%
Surgery is the mainstay of treatment in hepatocellular carcinoma; thus, factors like multifocal tumor, vascular invasion, and presence of metastatic disease, which preclude surgical resection, are important prognostic factors for survival.[1, 6]
Liver transplantation may play a role in the treatment of children with advanced disease; however, survival rates have not exceeded 30% at 2 years follow-up, and distant metastatic disease precludes this therapeutic strategy.
However, one study noted favorable outcomes in children with cirrhosis, hepatocellular carcinoma, and no extrahepatic disease after primary orthotopic liver transplantation. In 8 of 10 patients studied, no tumor recurrence was noted after a median follow up of 4 years.
Another study noted that surgical resection resulted in superior patient survival versus liver transplantation. Of 413 patients studied, 1- and 5-year survival rates were similar in both groups; however, survival rates were significantly improved in resected patients with hepatocellular carcinoma and model end-stage liver disease (MELD) scores of less than 10. Surgical resection should remain the first line of therapy for hepatocellular carcinoma patients who are candidates for resection.
Although chemotherapeutic and radiotherapeutic modalities are associated with numerous toxicities, even a temporary reduction in tumor size can greatly enhance a child's quality of life by alleviating tumor-associated pain and hepatic dysfunction.
Earlier claims for a better outcome of fibrolamellar versus hepatocellular carcinoma have not been substantiated.
Identification in a young patient requires a careful evaluation for a preexisting underlying liver disorder. With careful staging and adjuvant therapy, many patients can be treated with intent-to-cure, especially if localized disease is identified in the initial staging workup.
This disease awaits a well-organized clinical trial to best determine which chemotherapeutic agents, duration of therapy, and use of radiation might best benefit affected children. The formation of the Children's Oncology Group within the United States suggests that a clinical trial specifically designed to answer these questions may be forthcoming.
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