Radio-surgical decision-making in hepatoblastoma in the post-PHITT era: SIOPEL consensus recommendations

Following the closure of the Paediatric Hepatic International Tumour Trial (PHITT), interim guidance is required to support surgical decision-making in hepatoblastoma. Current PRETEXT/POST-TEXT staging does not fully reflect contemporary imaging capabilities and evolving surgical strategies.

The SIOPEL radiology and surgery committees developed the first-ever consensus-based recommendations integrating expert opinion, institutional experience, and available evidence to refine radio-surgical decision-making.

Current evidence is reviewed and we provide updated criteria to guide upfront, early, standard, and complex resections, and to support decision-making between organ-preserving surgery and liver transplantation. Key domains addressed include vascular involvement, multifocal disease, surgical margins, extrahepatic extension, lymph node disease, and metastatic spread. We highlight limitations of the current PRETEXT system and advocate for more detailed, surgically relevant radiologic reporting, including refined descriptors of vascular contact, tumour thrombus, and future liver remnant considerations.

This review and consensus framework aims to bridge the gap between existing staging systems and modern radiological as well as surgical practice, standardize multidisciplinary communication, and optimize curative-intent treatment strategies in children with hepatoblastoma.