Pediatric Hepatocellular Carcinoma 

  • Author: Girindra G Raval, MD; Chief Editor: Max J Coppes, MD, PhD, MBA   more...
 
Updated: Sep 8, 2011
 

Background

Hepatocellular carcinoma (HCC) is an aggressive hepatic neoplasm that most commonly affects adults. Nevertheless, children who are affected with biliary atresia, infantile cholestasis, glycogen-storage diseases, and a wide array of cirrhotic diseases of the liver are predisposed to developing hepatocellular carcinoma.

The 2 pathological subtypes are classic hepatocellular carcinoma and fibrolamellar carcinoma. Although surgical resection remains the mainstay of curative therapy, adjunctive chemotherapeutic and radiotherapeutic strategies are also helpful. The presenting signs and symptoms, epidemiology, biology, and current therapeutic strategies for hepatocellular carcinoma follow.

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Pathophysiology

The pathophysiology of hepatocellular carcinoma is not clearly understood; however, underlying liver dysfunction, especially cirrhosis, is a predisposing condition. In contrast to adults, most pediatric hepatocellular carcinomas arise de-novo, without underlying liver abnormalities.[1] Karyotypic abnormalities are not common. Although children and adolescents are unlikely to have chronic liver disease, congenital liver disorders increase the chance of developing hepatocellular carcinoma. These findings are suggestive of a multihit model of malignant transformation in hepatic tissue.

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Epidemiology

Frequency

United States

Primary liver tumors are uncommon in children and adolescents, accounting for approximately 0.5-2% of all neoplasms in these age groups. Annual incidence in children is approximately 0.5 cases per million. This is the second most common hepatic malignancy in children after hepatoblastoma.

International

The international incidence is highly associated with endemic hepatitis B exposure such as Southeast Asia and sub-Saharan Africa. In China, aflatoxin exposure has been associated with the development of hepatocellular carcinoma in the fifth, sixth, and seventh decades of life.

Mortality/Morbidity

Morbidity and mortality directly correlate with surgical resectability of the primary tumor. Although chemotherapy and radiation control may improve in the clinical course, in selected patients, the overriding objective of these modalities is to render the tumor completely resectable. (See Surgical Care for details.)

Race

In older adults, race may play a role in the development of hepatocellular carcinoma; however, excluding environmental factors from these determinations is difficult. Because the condition is so rare in adolescents and children (0.5 cases per million population), ethnic data are not readily available for these age groups. Most studies of hepatocellular carcinoma have involved patients of Asian descent.

Sex

Because most congenital forms of liver dysfunction (eg, urea cycle defects, storage diseases, hereditary hemochromatosis) are inherited in an autosomal recessive manner, the female-to-male occurrence ratio in children and adolescents is equal. After congenital Hepatitis B infection the life time risk of developing hepatocellular carcinoma is 50% for men and 20% for women.

Age

The incidence is lower in infants and higher in children and adolescents. The patient is usually an older school-aged child or adolescent, often with no preexisting diagnosis of cirrhotic liver disease. In patients with underlying liver dysfunction, the likelihood of developing the condition increases with age.

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Contributor Information and Disclosures
Author

Girindra G Raval, MD  Staff Physician, Department of Internal Medicine, University of Arkansas School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Paulette Mehta, MD, MPH  Professor of Hematology/Oncology, Department of Internal Medicine, Co-Director of Fellowship Program, Medical Director of Hematology/Oncology at CAVHS, University Arkansas for Medical Sciences and Central Arkansas Veterans Hospital System

Paulette Mehta, MD, MPH is a member of the following medical societies: American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, and American Society of Hematology

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephan A Grupp, MD, PhD  Director, Stem Cell Biology Program, Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Stephan A Grupp, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Hematology, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steven K Bergstrom, MD  Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland

Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology

Disclosure: Nothing to disclose.

Helen SL Chan, MBBS, FRCP(C), FAAP  Senior Scientist, Research Institute; Professor, Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Canada

Helen SL Chan, MBBS, FRCP(C), FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Society of Hematology, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA  Senior Vice President, Center for Cancer and Blood Disorders, Children's National Medical Center; Professor of Medicine, Oncology, and Pediatrics, Georgetown University School of Medicine; Clinical Professor of Pediatrics, George Washington University School of Medicine and Health Sciences

Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Stuart Winter, MD, to the development and writing of this article.

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