In contrast, an American Intergroup protocol for treatment of children with hepatoblastoma encouraged resection at the time of diagnosis for all tumors amenable to resection without undue risk. The protocol (COG-P9645) did not treat children with stage I tumors of purely fetal histology with preoperative or postoperative chemotherapy unless they developed progressive disease. Further study will be needed to determine whether presurgical chemotherapy is preferable to resection followed by chemotherapy for children with PRETEXT stage 2, 3, and 4 hepatoblastoma.
Chemotherapy and metastatic disease
In rare cases, chemotherapy has eradicated pulmonary metastases and eliminated multinodular tumor foci in the liver. Intensive platinum- and doxorubicin-based multidrug chemotherapy can induce complete regressions in approximately 50% of patients, with subsequent 3-year event-free survival of 56%. Chemotherapy has been much more successful in the treatment of hepatoblastoma than in hepatocellular carcinoma.[4,5,30,31,33,34,35]
Limited Role for Radiation Therapy
The utility of radiation therapy is questioned because the liver cannot tolerate high doses of radiation.[34,36]
Radiation therapy, even in combination with chemotherapy, has not cured children with unresectable tumors. There may be a role for radiation therapy in the management of incompletely resected hepatoblastoma,[34,36] although a study of 154 patients with hepatoblastoma did not confirm this finding. This study showed that second resection of positive margins and/or radiation therapy may not be necessary in patients with incompletely resected hepatoblastoma whose residual tumor is microscopic.
For patients with stage IV disease in which extrahepatic disease is controlled, but the primary tumor remains unresectable following standard chemotherapy, radiation therapy has been used as an interim treatment measure prior to surgical re-exploration.
Antiviral Treatment of Hepatitis B Virus (HBV)–related Hepatocellular Carcinoma
Although HBV-related hepatocellular carcinoma is not common in children in the United States, nucleotide/nucleoside analog HBV inhibitor treatment improved postoperative prognosis in HBV-related hepatocellular carcinoma. In the randomized controlled trial, antiviral treatment significantly decreased hepatocellular carcinoma recurrence and hepatocellular carcinoma-related death, with hazard ratios (HR) of 0.48 (95% confidence interval [CI], 0.32–0.70) and 0.26 (95% CI, 0.14–0.50), respectively, in multivariate Cox analyses. Patients who received antiviral treatment had significantly decreased early recurrence (HR, 0.41; 95% CI, 0.27–0.62) and improved liver function 6 months after surgery compared with the controls (P< .001).