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Cancer Health Center

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Childhood Liver Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage Information


PRETEXT stage 1


  • Tumor involves only one liver sector; three adjoining liver sectors are free of tumor.

PRETEXT stage 2


  • Tumor involves one or two liver sectors; two adjoining liver sectors are free of tumor.

PRETEXT stage 3


  • Tumor involves three liver sectors and one liver sector is free of tumor or tumor involves two liver sectors and two nonadjoining liver sectors are free of tumor.

PRETEXT stage 4


  • Tumor involves all four liver sectors; there is no liver sector free of tumor.

PRETEXT designations

Any stage may have involvement of:

  • V-Vena cava or all three hepatic veins.
  • P-Main portal or portal bifurcation vein.
  • C-Caudate.
  • E-Extrahepatic contiguous.
  • M-Distant metastatic.

Hepatoblastoma and hepatocellular carcinoma prognosis by PRETEXT stage

The PRETEXT staging system has a moderate degree of interobserver variability, and the preoperative PRETEXT stage agrees with postoperative pathologic findings only 51% of the time, with overstaging in 37% of patients and understaging in 12% of patients.[3]

The 5-year overall survival (OS) in the first international study of hepatoblastoma, in which the study protocol called for treatment of children with preoperative doxorubicin and cisplatin chemotherapy and included children with metastasis, was as follows:

  • 100% for PRETEXT stage 1.
  • 91% for PRETEXT stage 2.
  • 68% for PRETEXT stage 3.
  • 57% for PRETEXT stage 4.
  • 25% for patients with metastasis.[6,7]

The second international study compared 3-year OS among hepatoblastoma patients by PRETEXT stage absent of extrahepatic disease. The 3-year OS was as follows:

  • 100% for PRETEXT stage 1.
  • 95% for PRETEXT stage 2.
  • 84% for PRETEXT stage 3.
  • 61% for PRETEXT stage 4.[8]

The study also prospectively analyzed OS in patients by the presence of intraabdominal extrahepatic disease without distant metastasis (OS, 58%) and distant metastases (OS, 44%).[8] Patients who underwent orthotopic liver transplant are included in all of the international study results.[9] The COG is investigating prospective staging of hepatoblastoma patients using the PRETEXT system to determine the timing of surgery and the timing of early notification of liver transplant centers (COG-AHEP0731).

The 5-year OS for PRETEXT staged hepatocellular carcinoma was as follows:

  • 44% for PRETEXT stage 1.
  • 44% for PRETEXT stage 2.
  • 22% for PRETEXT stage 3.
  • 8% for PRETEXT stage 4.[10]
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