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Published on: April 19, 2022
Implementation of Comprehensive Surgical Guidelines for Hepatoblastoma: Analysis of the Children's Oncology Group
Zachary J Kastenberg1, Sanjeev A Vasudevan2, Lucy Dolmadjian3
1Department of Surgery, University of Utah School of Medicine and Primary Children's Hospital, Salt Lake City, UT.
Insights
Surgical guidelines for pediatric hepatoblastoma improved resection rates. However, nonadherence sometimes led to liver transplants when partial hepatectomy was possible, without affecting survival outcomes.
Area of Science:
- Pediatric Oncology
- Surgical Oncology
- Hepatobiliary Malignancies
Background:
- The Children's Oncology Group (COG) study AHEP0731 introduced the first surgical management guidelines for pediatric hepatoblastoma.
- These guidelines aimed to standardize treatment based on radiographic staging (PRETEXT, POST-TEXT).
Purpose of the Study:
- To assess the impact of COG AHEP0731 surgical guidelines on hepatoblastoma management in children.
- To compare outcomes between patients who adhered to and those who deviated from the surgical guidelines.
Main Methods:
- Children with hepatoblastoma were enrolled between 2009-2018.
- Guideline adherence was assessed via central imaging review at specific chemotherapy points.
- Resection rates, event-free survival (EFS), overall survival (OS), and complications were compared between groups.
Main Results:
- 93% of evaluable patients (205/221) underwent definitive surgical resection.
- Guideline adherence for resection timing was 65% (133/205).
- No significant differences in EFS, OS, or complication rates were observed between adherent and nonadherent groups.
Conclusions:
- Implementing surgical guidelines increased definitive tumor resection rates for hepatoblastoma compared to historical data.
- Nonadherence to guidelines occasionally resulted in liver transplantation when partial hepatectomy may have been feasible.
- The study highlights the importance of standardized surgical approaches in pediatric hepatoblastoma treatment.
Objective:
To evaluate the impact of surgical guidelines on the management of children with hepatoblastoma.
Background:
The Children's Oncology Group study AHEP0731 was the first pediatric cooperative group trial to propose guidelines for the surgical management of children with hepatoblastoma.
Methods:
AHEP0731 enrolled children with hepatoblastoma between 2009 and 2018. Surgical guidelines were based upon radiographic extent of disease (PRETEXT, POST-TEXT). Planned non-real-time central review of imaging was completed at diagnosis and after two, four, and six cycles of chemotherapy to determine guideline adherence. Resection rate, event-free survival (EFS), overall survival (OS), and complications were compared between guideline adherent and nonadherent groups.
Results:
Of 226 enrolled patients, 221 were evaluable of whom 205 (93%) underwent definitive surgical resection. Guideline adherence for protocol recommended timing of resection was 65% (133/205). The nonadherent group included 44/205 (21%) patients who underwent early resection and 28/205 (14%) patients who underwent late resection or late transplantation. Eighty-five patients met criteria for early referral to a liver transplant center, of whom 55 (65%) were referred within the recommended timeframe. Twelve patients received liver transplants outside of surgical guidelines. There were no significant differences in EFS, OS, or complication rates between adherent and nonadherent groups.
Conclusions:
Implementation of surgical guidelines, in combination with effective chemotherapy and radiologic staging, produced a higher rate of definitive tumor resection compared to historical trials. Nonadherence with surgical guidelines resulted in liver transplantation in some patients for whom partial hepatectomy might have been an option.
