Hot Keywords
non-alcoholic fatty liver disease epidemiology microenvironment nonalcoholic steatohepatitis transplantation cholangiocarcinoma direct-acting antiviral immunotherapy hepatitis B hepatitis C liver resection imaging cancer stem cell diagnosis gene cirrhosis biomarker recurrence

Hepatoma Res 2021;7:59. 10.20517/2394-5079.2021.26 © The Author(s) 2021.
Open Access Review

A practical approach to pediatric liver transplantation in hepatoblastoma and hepatocellular carcinoma

1Division of Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospitals, Geneva 1205, Switzerland.

2Pediatric Surgery Unit, Bicêtre Hospital, Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre 94270, France.

3Department for the Treatment and Study of Pediatric Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo 90127, Italy.

#Authors contributed equally.

Correspondence to: Dr. Ana M. Calinescu, Division of Pediatric Surgery, University Center of Pediatric Surgery of Western Switzerland, Geneva University Hospitals, 6 Rue Willy Donze, Geneva 1205, Switzerland. E-mail:

    This article belongs to the Special Issue Hepatoblastoma and Other Pediatric Liver Tumors
    Views:1218 | Downloads:213 | Cited:0 | Comments:2 | :0
    Academic Editors: Piotr Czauderna, Guang-Wen Cao | Copy Editor: Yue-Yue Zhang | Production Editor: Yue-Yue Zhang

    © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (, which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.


    Progressively, as chemotherapy has become more effective, more children with liver malignancies are amenable to liver transplantation, and indications have expanded from a limited range of cases (mostly hepatoblastoma) to a range of other unresectable malignant liver tumors; as a result, more children with hepatocellular carcinoma are also now proposed to transplantation, even and often outside the Milan criteria, for a cure. Recent series have highlighted that patient and graft survivals after transplantation for hepatoblastoma and hepatocellular carcinoma have improved in the last decade. Although consensus has not yet been reached about transplantation as a possible cure for other tumor types than hepatoblastoma and hepatocellular carcinoma, liver transplantation, generally speaking, has become an important pillar in the management of pediatric liver malignancies. Remaining limitations and inquiries relate to patient selection (in term of selection criteria considering the risk of recurrence), the role and usefulness of chemotherapy after transplantation, or the best immunosuppression strategy to both protect renal function and improve outcome. Although some prospective studies are on the way regarding these aspects, more studies are needed to explore this rapidly changing aspect of care.


    Despite initial concerns about the risks of exposing oncological patients to immunosuppression, many series have confirmed that the outcome can be excellent even though these children are exposed to immunosuppression after total liver resection and liver transplantation (LT). As a result, LT has expanded as a possible cure and its role has become increasingly important in the management of pediatric liver malignancies. Overall, pediatric liver malignancies account for a tenth of all pediatric LT performed in the United States[1]; in Europe, 6% of all pediatric liver transplantations are performed for an oncological indication within the European Liver Transplant Registry[2]. By far, the most frequent pediatric liver malignancies proposed to LT are hepatoblastoma (HBL) and hepatocellular carcinoma (HCC)[3]. Although the place of LT is growing in the pediatric liver oncology setting, determinants of long-term survival are not very clear yet[4].

    Unresectable HBL and HCC have as the only curable alternative total hepatectomy and orthotopic LT; it is a conclusion that was readily available in the early 1990s, with the advent of the first LT for unresectable pediatric liver malignancies[5]. The first study providing results for survival was SIOPEL 1[6]: it highlighted the importance of proposing LT as a primary strategy and avoiding using it as a last option or as a rescue of previous (failed) surgical attempts; while the former strategy provided excellent results, the latter was associated with poorer prognosis.

    Tumor biological behavior has been shown to be not only an important parameter for patient selection but also an essential predictor of the outcome after LT[7]. Although 60%-80% of the patients presenting with HBL are unresectable at presentation and diagnosis[8,9], most respond so well to cisplatin and doxorubicin neoadjuvant chemotherapy that they become “resectable”[3] (up to 85% of the initially “unresectable” tumors ending resected). Recent series have evidenced that in fact only 20% of the newly diagnosed patients with HBL eventually will need a LT[10-13]; for these patients, total hepatectomy and LT is the only option and possible cure, with standard/extreme resection less likely to be curative. More interestingly, even in these unresectable cases proposed to LT, it was suggested in 2002[7] and confirmed later that good responders to chemotherapy [as judged by dropping levels of alpha-fetoprotein (AFP) and reduction of tumor mass] have a better outcome after LT - this is common sense and can be used as a selection criterion.

    HCC in children is rare and has a different biological behavior compared to HBL. In children, it also has a different physiopathology and behavior compared to that in adults, who present HCC mostly on cirrhotic liver, while in children HCC is usually a primary tumor on healthy liver. HCC in children is often unresectable at diagnosis (80%)[14]; however, multimodal treatment (i.e., chemotherapy and transarterial chemoembolization) has limited effect on HCC, with only 50% of HCC patients proposed for resection[15], and up to 25% will eventually need a LT[15,16].


    Indications and contraindications in liver transplantation for hepatoblastoma


    Based on SIOPEL (International Childhood Liver Tumour Strategy Group), indications for LT in HBL patients include:

    (1) Multifocal PRETEXT IV tumors are the typical indication for LT, as by definition all liver sectors are invaded by the tumor or at least by one tumor node. In these cases, the concept of radical resection imposes total hepatectomy; the latter strategy is based on the fact that, although a tumor node (or metastasis) can clear on imaging, viable microscopic tumor residues may persist at the very site that seems “cleared” on imaging. In the latter situation, the only adequate strategy is to radically resect all liver segments that were positive for nodes at diagnosis - although they may be negative on POSTTEXT staging. Controversy persists about the former strategy, with some groups advocating the “pulmonary metastasis” approach, where the clearance of metastatic nodes after chemotherapy allows a “wait and see” policy - allowing to consider liver replacement and transplantation, as metastasis clearance is then considered “absence of active extrahepatic disease”[17-23]. In that context, proceeding with partial resection instead of total hepatectomy for PRETEXT IV HBL (and leaving in place liver segments that were positive at diagnosis but cleared during chemotherapy) made sense to a few teams in the last decade. Initial reports were rare and anecdotical (2 cases by Baertschiger et al.[18] in 2010 and 5 cases by Lautz et al.[20] in 2011); in the latter series, the only patient who died had partial hepatectomy in the absence of history of metastasis, and one emergency transplant was lifesaving for a child with ischemia after resection. Two other, larger series were reported recently (12 and 21 cases, respectively) (de Freitas Paganoti et al.[19] in 2019 and Fahy et al.[21] in 2020). In the de Freitas Paganoti series, 5/12 had partial hepatectomy (only 1/5 had an extensive hepatectomy), which was followed by a 31.0% recurrence within three years[19]. In the Fahy series, although the outcome is, generally speaking, satisfactory, the cohort description is insufficient to come to a precise conclusion about the children with a PRETEXT IV condition[21]. In a recent paper, Uchida et al.[24] reported a series of 24 HBL (22 POSTTEXT II or III and 2 POSTTEXT IV) who were proposed for resection (N = 12) or LT (N = 12) on the basis of a local algorithm based on pre- and peri-operative imaging. Overall, recurrent disease was observed in 2/12 cases after LT and 5/12 cases after resection (2/5 received rescue LT successively), while overall survival was 100% after LT and 91.7% after resection (recurrence-free survival being 91.7% and 58.3%, respectively).

    Initial reports of non-transplant approach for PRETEXT IV cases triggered comments from many expert surgeons, worldwide, highlighting the risk of encouraging fewer expert teams to proceed with inappropriate surgical strategies when extreme surgery is associated with higher technical complications rates[23]. This has been followed by a series of reports in recent years where there is evidence that:

    - PRETEXT IV stage is one of, or “the”, most negative prognostic factor for HBL patients[22,25,26].

    - Radical resection and efficient chemotherapy are both essential for the cure of HBL, which supports the role of LT for complete disease removal in the case of PRETEXT IV at diagnosis, in order to avoid local recurrence[17,25-27].

    - Liver transplantation played an important complementary role in managing HBL children and contributed to the recent increase of survival[24,28,29].

    - Although transplantation might be viewed as an “over-treatment” in some cases, it is associated with excellent outcome, while late rescue transplantation (for local recurrence of disease) is the worst scenario, with very poor outcome[6].

    The debate is still active[17,24,30,31], and only dedicated structured prospective studies will be able to answer this delicate question, which cannot be answered at the level of single centers. This might be addressed in the future by the upcoming international protocol “Pediatric Hepatic International Tumour Trial” (PHITT)[32].

    (2) Large solitary PRETEXT IV tumor, unless downstaged after chemotherapy[33].

    (3) Large central PRETEXT II and III tumors invading bilaterally the confluence at the porta hepatis or all three hepatic veins[6,34-38].

    (4) Local (intra-hepatic) recurrence of HBL after liver resection[3].

    (5) Complications of “extreme resections”, i.e., early liver failure (due to small-for-size, ischemic damage, or other intraoperative complications) or late complications[6].

    The two last categories are defined as “rescue” or “salvage” transplantation, accounting for 15%-40% of all LT performed for HBL in a recent review[17]. In the latter situations, LT is associated with poor outcome (30% survival with most deaths due to recurrence[39]), yet LT remains an option in well selected cases[3,38].


    Persistence of macroscopic metastasis (visible on imaging) after chemotherapy and not amenable to surgical excision remains the only absolute contraindication for LT[39]. Although there is no consensus, some consider that response to chemotherapy is a requisite for transplantation, with progression of disease under chemotherapy being a contraindication to LT[3,8].

    In all indications, although the presence of metastases at diagnosis is not a contraindication, the control under chemotherapy (with disappearance at imaging) of the metastasis is mandatory before LT. In cases with some residues at the location of previous metastases, the strategy may consist in surgical resection of these metastases before LT.

    The clearance of lung metastasis prior to LT is of utmost importance: a wedge resection is performed the most often; in the case of more than four nodules in the same lobe, lobectomy might be considered as a surgical option[17]. Median sternotomy with manual palpation of both lobes might be a valuable option in bilateral lung residual metastasis[40-42]. The alternative is sequential surgeries in the case of bilateral involvement[17].

    Surgery tips and tricks

    In cases with tumors very close to, encircling or infiltrating, the retro hepatic vena cava, en bloc resection of liver with the vena cava is recommended, with some teams deliberately using this approach for all cases. Venous reconstruction is performed by using donor iliac vein allograft in the case of LT with deceased donation[39]. As the latter reconstruction is challenging in the context of living donor LT (lack of donor vein allograft), this situation (that was once considered a contraindication for LT from living related donors[43]) is nowadays managed by using the jugular vein of the recipient or from the same donor[3,44,45]. Other options of using vessels from the same living donor have been proposed (recanalized umbilical vein, external jugular vein, or superficial femoral venous graft) and others have proposed cryopreserved vessels from unrelated donors[45,46]. Of note, in the case of large tumors compressing the inferior vena cava with pre-LT sufficient venous return via collaterals to the azygous system, caval vein reconstruction has not been systematically needed[47].

    The impact of an early inflow (arterial and portal) exclusion with temporary portocaval shunt was studied for the effect on recurrence: firstly, early inflow interruption might prevent tumor dissemination through the hepatic veins because of surgical manipulations as well as diminish blood losses minimizing the requirements for transfusions.

    Secondly, temporary portocaval shunting could maintain renal perfusion pressure, which might contribute to the preservation of the postoperative renal function as well as diminish the splanchnic congestion of HBL patients that do not have portosystemic collaterals and thus increase the likelihood of an optimal healing of the Roux en Y loop[48]. In this series investigating the early inflow exclusion, a recurrence free survival rate of 88.9% at one year with preservation of residual renal function was obtained[48].

    Finally, an extensive en bloc hepatectomy technique was described in a series with excision of retrocaval retroperitoneal tissue, en bloc lymphadenectomy with peri-choledochal and hepatic hilum nodules along the common hepatic artery, and frozen section from all resection margins; the overall survival in this seven-patient series was 100% without recurrence seven years after LT[49].

    Timing of liver transplantation and metastasectomy for hepatoblastoma

    The timing of LT should not be delayed after four weeks after the last course of chemotherapy given the impact on survival; if an expeditious access to deceased donation is not possible, a living related donation should be considered[33,39]. A possible option for those who are waiting for a liver from a deceased donor is to plan a new course of chemotherapy if they are not transplanted during the first window of four weeks; these cases are of course not offered a graft during chemotherapy, but this strategy allows a second window of transplantability of one month, after the new course. The latter strategy imposes of course that not all chemotherapy courses are done before the registration of the patient on the list for transplant, but it has been very effective in avoiding exposing the patient to prolonged periods with no chemotherapy and allowing a LT within these time windows.

    Children’s Oncology Group recommendations in 2016 stated that evaluation for surgery should be done after two cycles of neoadjuvant chemotherapy[50]; nevertheless, some tumors continue to regress between Cycles 3 and 4. Thus, after four rounds of neoadjuvant chemotherapy, 45% of the tumors are down staged, vs. only 30% after two cycles; thus, if chemotherapy is well tolerated, it should be continued to allow more patients to undergo successful resections[51].

    Clearance for metastasis should be achieved earlier in the chemotherapy course, with SIOPEL 4 recommendations to achieve metastatic control after three induction cycles of chemotherapy[17].

    Complications after liver transplantation for hepatoblastoma

    Morbidity after LT in HBL might arise from three origins: (1) chemotherapy toxicity, namely nephrotoxicity, ototoxicity, and sepsis with early discontinuation of adjuvant treatment; (2) surgical morbidity; and (3) immunosupression[50].

    At transplantation, the renal function of patients with HBL is reduced because of the toxicity of neoadjuvant chemotherapy; although it can be expected, it has been clearly emphasized that the renal function further deteriorates after LT[52,53]. As the cause for further decline of renal function after LT is directly caused by the sequential and combined toxic effects of chemotherapy and immunosuppression, the strategy has been to use either lower anticalcineurin levels for these patients (compared to standard LT in other indications)[33,53] or low-dose anticalcineurin treatment in association with other immunosuppressives (i.e., mycophenolate mofetil)[54] or early conversion to mechanistic target of rapamycin inhibitors[55].

    Overall, morbidity associated to LT might be as high as 67%[56], with infection being the first cause. This risk may be increased in patients who are exposed to both immunosuppression and chemotherapy; in a monocentric report, infection was identified as the most common morbidity and reached a level of 36% (cholangitis, bacteremia, central line infections, abdominal collections, and pneumonia)[57]. Vascular complications are the second most frequent cause of problems after LT and seem to be higher in patients transplanted for malignancies. Hepatic artery thrombosis is reported to be as high as 28%[4,11,58]. Although some groups do not mention a higher thrombosis risk after LT for HBL patients[59], this might be because these patients do not have liver dysfunction, portal hypertension, or hyper splenism and their coagulation profile is normal at LT, with a possible increased procoagulant activity due to cisplatin. This might justify the systematic use of antithrombotic and/or anticoagulant strategy after LT for HBL[11].

    Biliary complications might occur in up to 40% of the cases, as in other indications for LT[60,61]. In a 19-patient series, one patient (5%) developed a bile duct stricture treated with percutaneous transhepatic cholangioplasty and one bile leak (5%) was treated by percutaneous drainage[50]. Faraj et al.[59] described an incidence of 8% biliary complications: two bile leaks, one needing a percutaneous drainage and the other laparotomy and drainage. The Japanese national cohort of living donor LT for HBL showed overall 47.2% surgical complications: 21.7% biliary complications for the hepaticojejunostomy subgroup and 31.3% for the duct-to-duct anastomosis subgroup[62].

    Other complications such as small bowel obstruction[59] and chylous ascites resolving spontaneously[59] were described more rarely.

    Rejection-free survival in HBL recipients with living related donor grafts was 91% compared to 58% in controls; it is thought that less immunosuppression is required after LT for hepatoblastoma as a result of diminished immunity after neoadjuvant chemotherapy[3,33,53,58]. The findings of rejection rates seem different in the case of deceased donation with 50% and 70% in two series with 8 and 10 patients, respectively[60,63]. A larger study confirmed the difference in rejection rates with 50% rejection in HBL patients vs. 75% in a matched biliary atresia LT patient cohort[52]. Furthermore, decreased rejection rates persist many months after completion of chemotherapy, probably suggesting an immunomodulatory effect other than just immunosuppression[58]. Together with the altered renal function, the decreased rejection rates suggest a need for immunosuppression modulation after LT for HBL.

    Post-transplant lymphoproliferative disease was reported in 10% of patients[60]. Nevertheless, none of them died in a United Network Organ Sharing (UNOS) database inquiry[64].

    Retransplantation was reported to occur in 10% of the patients after LT for HBL, because of vascular thrombosis (60.6%), primary non-function (15.2%), and rejection (9.1%)[11,60].

    Survival after liver transplantation for hepatoblastoma

    Historically, patients with advanced and metastatic HBL had a 5-year survival of 69%, as reported in 2006[65]. Almost 10 years later, improved chemotherapy and aggressive transplant listing upgraded 10-year patient survival to 84%[4,21]. A retrospective UNOS analysis identified an overall survival of 76% with a graft survival of 77%. The three-year overall patient and graft survival was of 85% starting with 2009[8]. These results are in line with the SIOPEL 3 and 4 trials that found a 75% overall survival for patients with unresectable HBL[22,66][Table 1].

    Table 1

    Overview of articles looking at survival after pediatric liver transplantation for hepatoblastoma

    AuthorNr pxPeriodPatient survivalGraft survivalFollow-up
    Koneru et al.[102], 19911250%44 ± 19 months
    Tagge et al.[5], 199261980-199083%1.3 ± 0.9 years
    Al-Quabandy et al.[61], 199991991-199762.5%
    1 year: 88%
    5 years: 65%
    22 months (9-82)
    Reyes et al.[90], 2000111989-19981 year: 92%
    3 years: 83%
    5 years: 83%
    1 year: 92%
    3 years: 83%
    5 years: 83%
    76 months (18-146)
    Molmenti et al.[10], 200181984-199963%6.8 years
    Pimpalwar et al.[7], 2002121991-2000Good responders: 100%
    Bad responders: 60%
    Rescue transplant: 50%
    86%3.7 years
    Srinivasan et al.[78], 2002131992-2001100%33 months (1-108)
    Cillo et al.[103], 200371990-20031 year: 83.3%
    3 years: 83.3%
    5 years: 56%
    41.4 months (3-108)
    Tiao et al.[63], 200481986-200287.5%
    Mejia et al.[60], 2005101985-200370%
    10.8 ± 5.4 years
    Kasahara et al.[76], 2005141990-200465.5%78.6%
    42 months
    Otte et al.[33], 20051476 years: 82%
    30 % for rescue liver transplantation
    38 months (1-121)
    Casas-Melley et al.[104], 200782001-200575%7-53 months
    Faraj et al.[59], 2008251993-20071 year: 91%
    5 years: 77.6%
    10 years: 77.6%
    1 year: 91%
    5 years: 77.6%
    10 years: 77.6%
    60 months (1-179)
    Browne et al.[73], 2008141990-200471%46 months
    Malek et al.[56], 2010231990-200795%
    Hery et al.[105], 2011132001-200977%
    1 year: 100%
    4 years: 83.3%
    3.3 years (1-5 years)
    Barrena et al.[106], 2011151991-20091-5-10 years: 93.3% ± 6.4%4.8 ± 2.9 years
    Cruz et al.[11], 20123321988-20101 year: 84%,
    3 years: 75.7%
    5 years: 73.1%
    1 year: 80.2%
    3 years: 70.7%
    5 years: 68.1%
    McAteer et al.[12], 2013531998-20095 years: 86.5%
    Ruth et al.[52], 2014201991-20082 years: 75%7 years and 6 months
    Sakamoto et al.[62], 2014391996-20093 years: 84.3%
    5 years: 77.3%
    10 years: 77.3%
    Pham et al.[4], 2015301997-201484%83%
    Kueht et al.[50], 2016192000-201330 days: 94.7%
    1 year: 86.1%
    5 years: 73.8%
    Uchida et al.[48], 2016122005-201592%92%2.7 years
    Umeda et al.[68], 2017241997-20155 years: 69.6% ± 9.7%
    Kirnap et al.[107], 201762001-201583.3% recurrence free29.9 months
    Ezekian et al.[108], 20182791 year: 89.1%
    5 years : 82.6%
    Hamilton et al.[8], 20183761987-201276%
    Isono et al.[79], 201882002-201675%
    77 months
    Ramos-Gonzalez et al.[57], 2018252001-201510 years: 84%1 year: 96%
    3 years: 87%
    5 years: 80%
    4, 6 years (2.6-8.6)
    Uchida et al.[24], 2018122011-2016100%
    38 months (9-75)
    Triana Junco et al.[69], 2018311992-20171 year: 93.3% ± 4.6%
    5 years: 86.4% ± 6.3%
    9 years (1-25)
    Fahy et al.[21], 2019602001-201593%78 months
    Okur et al.[109], 2019102009-201490%13.5 months (8-120)
    Feng et al.[110], 2019932004-201610 years: 87.2%60 months
    Herden et al.[49], 201972007-2012100%7.1 years (5.7-10.7)
    Laufermann et al.[80], 2019212005-20185 years: 90%22 months (0-127)

    In an attempt to reduce the time between diagnosis and LT, an early referral practice was introduced in the late 2000s, with a parallel evaluation of resection and potential LT; the major success of this approach was to reduce the number of secondary LT[50].

    Survival in the case of “rescue LT” seems worse at five years, at less than 30%[12,63]. Overall, a literature review identified a survival of 41% for rescue LT[67]. A Japanese study identified a 72% 5-year overall survival in a series of 11 “rescue LT” patients[68].

    LT outcomes for HBL patients with synchronous lung metastasis eradicated before LT are excellent at one and five years, 93.3% ± 4.6% and 86.4% ± 6.3%, respectively[69]. Single pulmonary metastasis and patients with lesions visible only on CT vs. lesions visible on both CT and chest X-ray have a better outcome[35,70].

    The need for chemotherapy after LT is a matter of debate: a review did not identify a statistically significant difference in survival rates with and without post-LT chemotherapy[6], nor did the Pediatric Liver Unresectable Tumour Observatory registry[71]. Some studies promote its use in the case of vascular invasion or large proportion of viable tumor in the explanted liver[72]. The survival rates seem improved even if statistical significance was not reached in the series inquiring into this issue[73].

    Recurrence after liver transplantation for hepatoblastoma

    Tumor recurrence is the most frequent cause of death: up to 50% of the patients with tumor recurrence die, usually within two years after LT[21,59,65]; the longest interval between LT and recurrent HBL was 2.8 years in the Japanese national survey[62]. A review identified 14.6% of the relapse HBL patients after LT to be alive and disease free[68].

    Recurrence after LT for HBL presents itself mainly as metastatic disease and is encountered in as high as 40% of the cases[11,60]. It is thought to correspond to a more aggressive type of tumor to which transplantation will not respond better than initial resection[73]. This seems to be supported by the findings of Khan et al.[74]: in their institutional review, none of the HBL patients had a complete tumor response. As a surrogate marker for recurrence, AFP levels after LT could be a valuable adjunct, with a series reporting a normalization of AFP values in the subgroup of patients without recurrence and staying increased or even further increasing in patients with recurrence[75][Table 2]. In cases with limited and regional relapse (typically a single node in the abdominal area), re-resection strategy may offer a cure (personal communication)[62].

    Table 2

    Risk factors associated with hepatoblastoma recurrence after pediatric liver transplantation

    1. Anatomic tumor related factors
    Hepatic vein invasion
    2. Patient related factorsAge at presentation
    Pretransplant metastatic disease
    3. Pretransplant treatment related factors
    Serum AFP at time of LT
    Percentage of decline AFP from diagnosis to LT
    Response to chemotherapy
    < 50% tumor necrosis
    4. Transplant related factors
    Time to transplant
    Segmental donor graft
    Salvage LT

    The long-term survival of patients having a LT for HBL shows the following risk factors for tumor recurrence: PRETEXT IV, tumor rupture, higher time spent within the waiting list (15 days vs. 31 days), older age (78 months vs. 48 months)[4], macroscopic vascular invasion, extrahepatic lesions at the time of LT, presence of viable tumor (tumor necrosis less than 50% and high preoperative AFP values), tumor shrinkage rate of ≤ 30%, and high AFP at diagnosis and LT[11,59,62,76,24].

    Previous lung metastases, initially considered as favoring recurrence, were recently proved not to be risk factors for tumor recurrence[77]. In the case of limited recurrence, especially if recurrence is at sites previously diagnosed and clearing under chemotherapy, an aggressive surgical approach and resection has been proposed; the latter outcome may be favorable as these recurrences are in fact local relapse rather than new secondaries associated to systemic relapse[62].

    The 3-year recurrence free survival was reported to be 78% in a cohort of 15 patients with rescue LT[62]. Later, an 11-patient Japanese series reported a recurrence rate of only 27% in this subgroup of rescue LT[68].

    Segmental grafts (from cadaveric or living donors) versus cadaveric whole liver grafts seem also to make HBL recipients more prone to recurrence; whether this difference is due to the cava-sparing hepatectomy technique is not clear yet[8,11].

    Overall, longer waiting list time was found to be associated with higher recurrence risk, a rather intuitive finding[4].

    Post-transplantation chemotherapy seems to decrease the tumor recurrence[6,73,78]. It is thus recommended, although it might be difficult to practically implement because of complications after transplantation[73]. There is actually no uniform policy for the post-LT chemotherapeutic regimen and its clinical relevance is still debated[68].

    In recurrent HBL after LT, the increasing AFP levels pretransplant despite continued neoadjuvant chemotherapy led to the conclusion that LT should be performed before the tumor acquires chemoresistance and thus before the decrease in AFP levels reaches a plateau[79]. Patients with higher pre-LT AFP also exhibited a higher risk for non-curable relapse than patients benefiting from LT at lower AFP[80].


    Indications and contraindications in liver transplantation for hepatocellular carcinoma


    The first study inquiring the role of LT as primary surgical treatment for HCC without extrahepatic involvement was from Czauderna et al.[81] in the early 2000s. They highlighted that the results of the conventional resective approach in cases with resectable tumors were far less favorable than those who benefited from LT for unresectable masses. This opened a window of opportunity for proposing LT as a curative strategy for children with unresectable HCC. Although there is still no consensus about the criteria for proposing LT to manage HCC in children, the results of Czauderna et al.[81] emphasize that HCC in children is different from that in adults. Hence, an opposite strategy to that of HCC in adults could be followed: while HCC are selected for LT in adults with smaller tumors, in term of mass and/or number (the Milan criteria)[82], there are no well-defined pediatric criteria to contraindicate the HCC candidate for LT[82] as follows:

    (1) Unlike adults, HCC occurs in children mainly in the absence of concomitant cirrhosis[12], and this is one reason for a different selection strategy. The Milan criteria, developed for adults with cirrhotic liver disease, have been adopted by some centers (one tumor of 5 cm or less or no more than three nodules of 3 cm or less) in an effort to improve survival rates[3]. The more liberal criteria of the University of California San Francisco (UCSF) are partially adopted by some other centers[72]. More extensive criteria, “up to seven” (number of lesions and diameter), show a minimal decrease in survival rate, from 71% to 65%[83].

    (2) The practice guidelines of the American Association for Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommend an individualized indication for LT for each patient[84]. Basically, LT is recommended for HCC patients in the case of no extrahepatic tumor or gross vascular invasion on radiological imaging, irrespective of the number or size of the lesions[84].

    (3) In Japan, the Japanese Organ Transplantation Act proposed the rule of 5-5-500: tumor size ≤ 5 cm diameter, tumor number ≤ 5, and AFP level ≤ 500 ng/mL for living donor LT for HCC in adults[85]. Modifications of this rule were adopted (Kyoto criteria, Tokyo 5-5 rule, and Kyushu University) with larger inclusion of patients but lower survival and higher recurrence rates[85].

    Of note, none of these are validated in pediatric HCC[86]. A general consensus is to offer LT for unresectable HCC patients and no extrahepatic disease[87], while LT should be considered even for patients with HCC PRETEXT I or II in selected cases[88].


    Because HCC in children is different to that in adults and the Milan criteria do not strictly apply, proposing LT in pediatric HCC remains a delicate choice and strategy: patients should be evaluated individually within multidisciplinary teams including oncologists, hepatologists, pediatric surgeons, and pediatric liver transplant surgeons[89]. As evidenced for HBL, tumor behavior during chemotherapy and downsizing may be important elements to consider for indicating LT as a curative option.

    Major vascular venous invasion (especially the extrahepatic invasion of vena cava and portal vein trunk) is a contraindication for transplantation in HCC due to poor long-term prognosis - unless neoadjuvant chemotherapy achieves an evident down staging[90]. As for HBL, the presence of extrahepatic tumor is a contraindication for transplantion[14]. Fibrolamellar variant of HCC constitutes the third contraindication[91].

    Survival after liver transplantation for hepatocellular carcinoma

    HCC seems to behave differently in children than in adults as LT for lesions outside the Milan and UCSF criteria still lead to excellent long-term survival[4]. A Surveillance, Epidemiology and End Results database review identified an 89% 4-year overall survival with 27.6% of the patient most likely outside and 34.5% definitely outside the Milan criteria[92]. A retrospective UNOS database analysis identified an overall patient and graft survival of 63% with 3-year overall patient and graft survival of 84% starting with 2009[8] [Table 3].

    Table 3

    Overview of articles looking at survival after pediatric liver transplantation for hepatocellular carcinoma

    AuthorNr pxPeriodSurvivalFollow-up
    Tagge et al.[5], 199291980-199044%2.3 ± 1.2
    Reyes et al.[90], 2000191989-19981 year: 79%
    3 years: 73%
    5 years: 68%
    19.5 months (6-58)
    Ozcay et al.[94], 200662001-2005100%17.7 ± 6 months
    Arikan et al.[111], 200671997-20031-4 years: 72%36 months
    Sevmis et al.[112], 200892001-2007100% graft and patient 19.8 ± 10.6 months
    Ismail et al.[88], 2009111990-200772%43 months (32-85)
    Malek et al.[56], 201061990-200767%
    Romano et al.[113], 2011101997-200980%4 years
    McAteer et al.[12], 2013201998-20095 years: 85.3%
    Pham et al.[4], 2015101997-201472% patient
    85% graft
    Triana et al.[87], 2016101994-201520%78 months (66-90)
    Vinayak et al.[1], 2017251981-201436%
    Baumann et al.[93], 20181751985-20121 year patient: 81.2%
    2 years patient: 68.3%
    5 years patient: 57.6%
    1 year graft-2-5: 73.6%
    2 years graft: 58.5%
    5 years graft: 56.3%
    Ezekian et al.[108], 2018492010-20181 year: 94.7%
    5 years: 80.8%
    Hamilton et al.[8], 2018851987-20125 years patient and graft: 63%
    Weiss et al.[114], 201862005-201383%3.4-11 years
    Ziogas et al.[92], 2020342004-20151 year: 96.2%
    3 years: 88%
    5 years: 88%
    52.9 months (46.7-59)
    D’Souza et al.[82], 2020112004-201582% 58.8 months (26.5-157.6)

    Poor prognostic factors for HCC are as follows: metastasis, large tumor size, lymph node extension, and macroscopic vascular invasion[1,3][Table 4].

    Table 4

    Risk factors associated with hepatocellular carcinoma outcome after pediatric liver transplantation

    1. Anatomic tumor related factors
    Vascular and lymph node invasion
    Size of tumor

    2. Patient related factorsAge at presentation
    Associated diseases
    Metastatic disease
    3. Pretransplant treatment related factors
    Response to chemotherapy
    4. Post-transplant related factors
    Sorafenib use

    Younger age was found as a prognostic factor for a better survival in LT after HCC[93].

    Survival seems worse for HCC newly diagnosed in a healthy liver than HCC diagnosed during surveillance for a chronic disease or incidentally discovered in the explants of LT for another disease[3,93,94].

    The role of chemotherapy in pediatric HCC is still debated: although it responds to chemotherapy more than adult HCC, pediatric HCC for which chemotherapy was administrated failed to show an improved survival in both adjuvant and neoadjuvant settings[89,92]. Data from the PHITT that administers neoadjuvant chemotherapy to patients with unresectable HCC at diagnosis will eventually answer this question[89]. Survival rates were higher for patients responding to preoperative chemotherapy[81].

    The use of sorafenib has shown better survival rates in the adult population, demonstrating an improvement in median overall survival (10.7 months vs. 7.9 months)[95]; in children, few data have been published in this respect[15].

    Overall survival was not different in subgroups according to 5 cm cut off, vascular invasion, and the Milan criteria[89]. No differences in survival have been found when comparing living donors to deceased donors[96].

    When studying treatment choice, a 21-patient series comparing outcomes for resection and chemotherapy vs. LT in pediatric HCC reveals a superior survival (72% vs. 40%) in the LT subgroup, pointing out the need for the early evaluation of transplantability of pediatric HCC patients in the treatment course[88].

    Recurrences after liver transplantation for hepatocellular carcinoma

    During surgery for HCC, operative manipulation, increased intraoperative blood loss, and blood transfusions are thought to be potential mechanisms for tumor recurrence[97,98].

    The risk factors identified for recurrence of HCC are as follows: tumor stage, vascular invasion, and lymph node involvement. In the long term, older age and metastatic disease were additionally identified[1,4,90].

    Few series describe the outcome of HCC patients with macrovascular invasion undergoing LT; a 5-year recurrence free survival of 89% is reported in a 10-patient series[99].

    Unlike adults, the risk for recurrence is not higher if patients do not meet the Milan criteria[8]. Given higher recurrence rates of HCC after surgical resection than after LT, it is hypothesized that LT should be liberalized even for resectable tumors[8].

    Of note, no recurrence was identified in the patients for whom HCC was incidentally discovered in the liver explant[1].

    The recurrences and impact on survival of deceased versus living LT has been studied in the adult literature but very few data are available within the pediatric literature[100].

    Whether corticosteroids and calcineurin inhibitors increase the likelihood of tumor recurrence after LT for HCC is not clear yet; it is the reason for some centers to privilege the use of sirolimus, as it has been shown to inhibit the growth of a wide variety of tumors[3]. An adult study did not show an improved long-term recurrence free survival beyond five years, but it increased the overall survival and the recurrence-free survival in the first three to five years after LT[101].


    Pediatric LT has a growing place in the management of unresectable HBL and HCC. There are still unanswered questions concerning the role of post-LT chemotherapy for HBL, immunosuppression modulation, and the correlation of the AFP levels after LT with survival. Besides an obvious need for validated LT criteria for pediatric HCC patients, the impact of chemotherapy and waiting time for LT are still to be studied.


    Pediatric LT in the oncological setting has evolved during the last two decades into an effective procedure for a selected subgroup of patients. Indications are quite clear in HBL but still need validation in pediatric HCC patients. This review focuses on indications and limitations in the LT treatment of unresectable pediatric HBL and HCC. The ongoing PHITT trial will probably provide evidence-based guidelines for the LT management of pediatric patients with unresectable HBL and HCC.


    Authors’ contributions

    Made substantial contributions to conception and design of the study, performed data analysis and interpretation, finally approved the version to be published and agreed to be accountable for all aspects of the work: Calinescu AM, Héry G, Branchereau S, de Ville de Goyet J

    Performed the draft: Calinescu AM, de Ville de Goyet J

    Critical revision of the intellectual content: de Ville de Goyet J, Branchereau S, Héry G

    Availability of data and materials

    Not applicable.

    Financial support and sponsorship


    Conflicts of interest

    All authors declared that there are no conflicts of interest.

    Ethical approval and consent to participate

    Not applicable.

    Consent for publication

    Not applicable.


    © The Author(s) 2021.


    • 1. Vinayak R, Cruz RJ Jr, Ranganathan S, et al. Pediatric liver transplantation for hepatocellular cancer and rare liver malignancies: US multicenter and single-center experience (1981-2015). Liver Transpl 2017;23:1577-88.

      DOIPubMed PMC
    • 2. Registry ELT. Available from: [Last accessed on 14 Jul 2021].

    • 3. Stringer MD. The role of liver transplantation in the management of paediatric liver tumours. Ann R Coll Surg Engl 2007;89:12-21.

      DOIPubMed PMC
    • 4. Pham TA, Gallo AM, Concepcion W, Esquivel CO, Bonham CA. Effect of liver transplant on long-term disease-free survival in children with hepatoblastoma and hepatocellular cancer. JAMA Surg 2015;150:1150-8.

    • 5. Tagge EP, Tagge DU, Reyes J, et al. Resection, including transplantation, for hepatoblastoma and hepatocellular carcinoma: Impact on survival. J Pediatr Surg 1992;27:292-7.

      DOIPubMed PMC
    • 6. Otte JB, Pritchard J, Aronson DC, et al. International Society of Pediatric Oncology (SIOP). Liver transplantation for hepatoblastoma: results from the International Society of Pediatric Oncology (SIOP) study SIOPEL-1 and review of the world experience. Pediatr Blood Cancer 2004;42:74-83.

    • 7. Pimpalwar AP, Sharif K, Ramani P, et al. Strategy for hepatoblastoma management: Transplant versus nontransplant surgery. J Pediatr Surg 2002;37:240-5.

    • 8. Hamilton EC, Balogh J, Nguyen DT, Graviss EA, Heczey AA, Austin MT. Liver transplantation for primary hepatic malignancies of childhood: the UNOS experience. J Pediatr Surg ;2017:163-8.

    • 9. Trobaugh-Lotrario AD, Meyers RL, O'Neill AF, Feusner JH. Unresectable hepatoblastoma: current perspectives. Hepat Med 2017;9:1-6.

      DOIPubMed PMC
    • 10. Molmenti E, Nagata D, Roden J, et al. Liver transplantation for hepatoblastoma in the pediatric population. Transplant Proc 2001;33:1749.

    • 11. Cruz RJ Jr, Ranganathan S, Mazariegos G, et al. Analysis of national and single-center incidence and survival after liver transplantation for hepatoblastoma: new trends and future opportunities. Surgery 2013;153:150-9.

    • 12. McAteer JP, Goldin AB, Healey PJ, Gow KW. Surgical treatment of primary liver tumors in children: outcomes analysis of resection and transplantation in the SEER database. Pediatr Transplant 2013;17:744-50.

    • 13. Superina R, Bilik R. Results of liver transplantation in children with unresectable liver tumors. J Pediatr Surg 1996;31:835-9.

    • 14. Ng K, Mogul DB. Pediatric liver tumors. Clin Liver Dis 2018;22:753-72.

    • 15. Kohorst MA, Warad DM, Matsumoto JM, et al. Management of pediatric hepatocellular carcinoma: a multimodal approach. Pediatr Transplant 2017;21:e13007.

    • 16. Sindhi R, Rohan V, Bukowinski A, et al. Liver transplantation for pediatric liver cancer. Cancers (Basel) 2020;12:720.

      DOIPubMed PMC
    • 17. Lake CM, Tiao GM, Bondoc AJ. Surgical management of locally-advanced and metastatic hepatoblastoma. Semin Pediatr Surg 2019;28:150856.

    • 18. Baertschiger RM, Ozsahin H, Rougemont AL, et al. Cure of multifocal panhepatic hepatoblastoma: is liver transplantation always necessary? J Pediatr Surg 2010;45:1030-6.

    • 19. Freitas Paganoti G, Tannuri ACA, Dantas Marques AC, Torres RR, Mendes Gibelli NE, Tannuri U. Extensive hepatectomy as an alternative to liver transplant in advanced hepatoblastoma: a new protocol used in a pediatric liver transplantation center. Transplant Proc 2019;51:1605-10.

    • 20. Lautz TB, Ben-Ami T, Tantemsapya N, Gosiengfiao Y, Superina RA. Successful nontransplant resection of POST-TEXT III and IV hepatoblastoma. Cancer 2011;117:1976-83.

    • 21. Fahy AS, Shaikh F, Gerstle JT. Multifocal hepatoblastoma: what is the risk of recurrent disease in the remnant liver? J Pediatr Surg 2019;54:1035-40.

    • 22. Meyers RL, Tiao G, de Ville de Goyet J, Superina R, Aronson DC. Hepatoblastoma state of the art: pre-treatment extent of disease, surgical resection guidelines and the role of liver transplantation. Curr Opin Pediatr 2014;26:29-36.

    • 23. Czauderna P, Otte JB, Roebuck DJ. International Childhood Liver Tumors Strategy Group (SIOPEL). Comments on surgical treatment of locally advanced hepatoblastoma. Cancer 2012;118:4092-3; author reply 4094.

    • 24. Uchida H, Sakamoto S, Sasaki K, et al. Surgical treatment strategy for advanced hepatoblastoma: resection versus transplantation. Pediatr Blood Cancer 2018;65:e27383.

    • 25. Czauderna P, Haeberle B, Hiyama E, et al. The Children's Hepatic tumors International Collaboration (CHIC): Novel global rare tumor database yields new prognostic factors in hepatoblastoma and becomes a research model. Eur J Cancer 2016;52:92-101.

      DOIPubMed PMC
    • 26. Maibach R, Roebuck D, Brugieres L, et al. Prognostic stratification for children with hepatoblastoma: the SIOPEL experience. Eur J Cancer 2012;48:1543-9.

    • 27. Meyers RL, Maibach R, Hiyama E, et al. Risk-stratified staging in paediatric hepatoblastoma: a unified analysis from the Children's Hepatic tumors International Collaboration. Lancet Oncol 2017;18:122-31.

      DOIPubMed PMC
    • 28. Koh KN, Namgoong JM, Yoon HM, et al. Recent improvement in survival outcomes and reappraisal of prognostic factors in hepatoblastoma. Cancer Med 2021;10:3261-73.

      DOIPubMed PMC
    • 29. Zsíros J, Maibach R, Shafford E, et al. Successful treatment of childhood high-risk hepatoblastoma with dose-intensive multiagent chemotherapy and surgery: final results of the SIOPEL-3HR study. J Clin Oncol 2010;28:2584-90.

    • 30. Fonseca A, Gupta A, Shaikh F, et al. Extreme hepatic resections for the treatment of advanced hepatoblastoma: are planned close margins an acceptable approach? Pediatr Blood Cancer 2018;65:e26820.

    • 31. Fuchs J, Cavdar S, Blumenstock G, et al. POST-TEXT III and IV hepatoblastoma: extended hepatic resection avoids liver transplantation in selected cases. Ann Surg 2017;266:318-23.

    • 32. Aronson DC, Meyers RL. Malignant tumors of the liver in children. Semin Pediatr Surg 2016;25:265-75.

    • 33. Otte JB, de Ville de Goyet J, Reding R. Liver transplantation for hepatoblastoma: indications and contraindications in the modern era. Pediatr Transplant 2005;9:557-65.

    • 34. Perilongo G, Shafford E, Plaschkes J. SIOPEL trials using preoperative chemotherapy in hepatoblastoma. Lancet Oncol 2000;1:94-100.

    • 35. Brown J, Perilongo G, Shafford E, et al. Pretreatment prognostic factors for children with hepatoblastoma - results from the International Society of Paediatric Oncology (SIOP) Study SIOPEL 1. Eur J Cancer 2000;36:1418-25.

    • 36. Bucuvalas JC, Alonso E. Long-term outcomes after liver transplantation in children. Curr Opin Organ Transplant 2008;13:247-51.

    • 37. Perilongo G, Shafford E, Maibach R, et al. International Society of Paediatric Oncology-SIOPEL 2. Risk-adapted treatment for childhood hepatoblastoma. final report of the second study of the International Society of Paediatric Oncology--SIOPEL 2. Eur J Cancer 2004;40:411-21.

    • 38. Aronson DC, Schnater JM, Staalman CR, et al. Predictive value of the pretreatment extent of disease system in hepatoblastoma: results from the International Society of Pediatric Oncology Liver Tumor Study Group SIOPEL-1 study. J Clin Oncol 2005;23:1245-52.

    • 39. Otte JB, de Ville de Goyet J. The contribution of transplantation to the treatment of liver tumors in children. Semin Pediatr Surg 2005;14:233-8.

    • 40. Fuchs J, Seitz G, Ellerkamp V, et al. Analysis of sternotomy as treatment option for the resection of bilateral pulmonary metastases in pediatric solid tumors. Surg Oncol 2008;17:323-30.

    • 41. Gupta AA, Gerstle JT, Ng V, et al. Critical review of controversial issues in the management of advanced pediatric liver tumors. Pediatr Blood Cancer 2011;56:1013-8.

    • 42. Takahashi N, Yamada Y, Hoshino K, et al. Living donor liver re-transplantation for recurrent hepatoblastoma in the liver graft following complete eradication of peritoneal metastases under indocyanine green fluorescence imaging. Cancers (Basel) 2019;11:730.

      DOIPubMed PMC
    • 43. Kalicinski P, Ismail H, Broniszczak D, et al. Non-resectable hepatic tumors in children - role of liver transplantation. Ann Transplant 2008;13:37-41.

    • 44. Namgoong JM, Choi JU, Hwang S, Oh SH, Park GC. Pediatric living donor liver transplantation with homograft replacement of retrohepatic inferior vena cava for advanced hepatoblastoma. Ann Hepatobiliary Pancreat Surg 2019;23:178-82.

      DOIPubMed PMC
    • 45. Hort A, Karpelowsky J, Shun A, Thomas G. Use of a donor iliac vein graft for reconstruction of the inferior vena cava in liver transplantation for hepatoblastoma with caval extension. Pediatr Transplant 2019;23:e13409.

    • 46. Chardot C, Saint Martin C, Gilles A, et al. Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma. Transplantation 2002;73:90-2.

    • 47. Hasegawa T, Kimura T, Ihara Y, et al. Living-related liver transplantation with removal of inferior vena cava for unresectable hepatoblastoma. Pediatr Transplant 2006;10:521-4.

    • 48. Uchida H, Fukuda A, Sasaki K, et al. Benefit of early inflow exclusion during living donor liver transplantation for unresectable hepatoblastoma. J Pediatr Surg 2016;51:1807-11.

    • 49. Herden U, Grabhorn E, Lenhartz H, Kütemeier R, Fischer L. Excellent outcome following liver transplantation for hepatoblastoma using an extensive en bloc hepatectomy technique. Transplant Proc 2019;51:1887-91.

    • 50. Kueht M, Thompson P, Rana A, Cotton R, O'Mahony C, Goss J. Effects of an early referral system on liver transplantation for hepatoblastoma at Texas Children's Hospital. Pediatr Transplant 2016;20:515-22.

    • 51. Venkatramani R, Stein JE, Sapra A, et al. Effect of neoadjuvant chemotherapy on resectability of stage III and IV hepatoblastoma. Br J Surg 2015;102:108-13.

    • 52. Ruth ND, Kelly D, Sharif K, Morland B, Lloyd C, McKiernan PJ. Rejection is less common in children undergoing liver transplantation for hepatoblastoma. Pediatr Transplant 2014;18:52-7.

    • 53. Lee WS, Grundy R, Milford DV, et al. Renal function following liver transplantation for unresectable hepatoblastoma. Pediatr Transplant 2003;7:270-6.

    • 54. Zavala R, Marzouki M, Beaunoyer M, Alvarez F. Glomerular filtration rate in liver transplant for unresectable hepatoblastoma. Pediatr Transplant 2020;24:e13746.

    • 55. Hendrickson RJ, Sujka J, Fischer R, Manalang M, Daniel J, Andrews WS. Indications and efficacy of conversion from tacrolimus- to sirolimus-based immunosuppression in pediatric patients who underwent liver transplantation for unresectable hepatoblastoma. Pediatr Transplant 2019;23:e13369.

    • 56. Malek MM, Shah SR, Atri P, et al. Review of outcomes of primary liver cancers in children: our institutional experience with resection and transplantation. Surgery 2010;148:778-82; discussion 782.

    • 57. Ramos-Gonzalez G, LaQuaglia M, O'Neill AF, et al. Long-term outcomes of liver transplantation for hepatoblastoma: a single-center 14-year experience. Pediatr Transplant 2018:e13250.

    • 58. Suh MY, Wang K, Gutweiler JR, et al. Safety of minimal immunosuppression in liver transplantation for hepatoblastoma. J Pediatr Surg 2008;43:1148-52.

    • 59. Faraj W, Dar F, Marangoni G, et al. Liver transplantation for hepatoblastoma. Liver Transpl 2008;14:1614-9.

    • 60. Mejia A, Langnas AN, Shaw BW, Torres C, Sudan DL. Living and deceased donor liver transplantation for unresectable hepatoblastoma at a single center. Clin Transplant 2005;19:721-5.

    • 61. Al-oabandi W, Jenkinson H, Buckels J, et al. Orthotopic liver transplantation for unresectable hepatoblastoma: a single center's experience. J Pediatr Surg 1999;34:1261-4.

    • 62. Sakamoto S, Kasahara M, Mizuta K, et al. Japanese Liver Transplantation Society. Nationwide survey of the outcomes of living donor liver transplantation for hepatoblastoma in Japan. Liver Transpl 2014;20:333-46.

    • 63. Tiao GM, Bobey N, Allen S, et al. The current management of hepatoblastoma: a combination of chemotherapy, conventional resection, and liver transplantation. J Pediatr 2005;146:204-11.

    • 64. Ng K, Rana A, Masand P, et al. Fatal central nervous system post-transplant lymphoproliferative disease in a patient who underwent liver transplantation for hepatoblastoma. J Pediatr Gastroenterol Nutr 2018;66:e21-3.

    • 65. Austin MT, Leys CM, Feurer ID, et al. Liver transplantation for childhood hepatic malignancy: a review of the United Network for Organ Sharing (UNOS) database. J Pediatr Surg 2006;41:182-6.

    • 66. Zsiros J, Brugieres L, Brock P, et al. Dose-dense cisplatin-based chemotherapy and surgery for children with high-risk hepatoblastoma (SIOPEL-4): a prospective, single-arm, feasibility study. Lancet Oncol 2013;14:834-42.

      DOIPubMed PMC
    • 67. Yang T, Whitlock RS, Vasudevan SA. Surgical management of hepatoblastoma and recent advances. Cancers (Basel) 2019;11:1944.

      DOIPubMed PMC
    • 68. Umeda K, Okajima H, Kawaguchi K, et al. Prognostic and therapeutic factors influencing the clinical outcome of hepatoblastoma after liver transplantation: a single-institute experience. Pediatr Transplant 2018;22:e13113.

    • 69. Triana Junco P, Cano EM, Dore M, et al. Prognostic Factors for Liver Transplantation in Unresectable Hepatoblastoma. Eur J Pediatr Surg 2019;29:28-32.

    • 70. Perilongo G, Brown J, Shafford E, et al. Liver Tumour Study Group of the International Society of Paediatric Oncology (SIOP). Hepatoblastoma presenting with lung metastases: Treatment results of the first cooperative, prospective study of the International Society of Paediatric Oncology on childhood liver tumors. Cancer 2000;89:1845-53.

    • 71. Otte JB, Meyers R. PLUTO first report. Pediatr Transplant 2010;14:830-5.

    • 72. Kosola S, Lauronen J, Sairanen H, Heikinheimo M, Jalanko H, Pakarinen M. High survival rates after liver transplantation for hepatoblastoma and hepatocellular carcinoma. Pediatr Transplant 2010;14:646-50.

    • 73. Browne M, Sher D, Grant D, et al. Survival after liver transplantation for hepatoblastoma: a 2-center experience. J Pediatr Surg 2008;43:1973-81.

    • 74. Khan AS, Brecklin B, Vachharajani N, et al. Liver Transplantation for malignant primary pediatric hepatic tumors. J Am Coll Surg 2017;225:103-13.

    • 75. Kim T, Kim DY, Kim KM, et al. Pediatric liver transplantation for hepatoblastoma: a single center experience. Transplant Proc 2012;44:523-5.

    • 76. Kasahara M, Ueda M, Haga H, et al. Living-donor liver transplantation for hepatoblastoma. Am J Transplant 2005;5:2229-35.

    • 77. Angelico R, Grimaldi C, Gazia C, et al. How do synchronous lung metastases influence the surgical management of children with hepatoblastoma? Cancers (Basel) 2019;11:1693.

      DOIPubMed PMC
    • 78. Srinivasan P, McCall J, Pritchard J, et al. Orthotopic liver transplantation for unresectable hepatoblastoma. Transplantation 2002;74:652-5.

    • 79. Isono K, Ohya Y, Lee KJ, et al. Pretransplant trends in α-fetoprotein levels as a predictor of recurrence after living donor liver transplantation for unresectable hepatoblastoma: a single-institution experience. Pediatr Transplant 2018;22:e13221.

    • 80. Lauferman L, Halac E, Aredes D, et al. Prognostic factors for event-free survival in liver transplantation for hepatoblastoma: a single-center experience. Pediatr Transplant 2019;23:e13581.

    • 81. Czauderna P, Mackinlay G, Perilongo G, et al. Liver Tumors Study Group of the International Society of Pediatric Oncology. Hepatocellular carcinoma in children: results of the first prospective study of the International Society of Pediatric Oncology group. J Clin Oncol 2002;20:2798-804.

    • 82. D'Souza AM, Towbin AJ, Gupta A, et al. Clinical heterogeneity of pediatric hepatocellular carcinoma. Pediatr Blood Cancer 2020;67:e28307.

    • 83. Mazzaferro V, Llovet JM, Miceli R, et al. Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. Lancet Oncol 2009;10:35-43.

    • 84. Schmid I, von Schweinitz D. Pediatric hepatocellular carcinoma: challenges and solutions. J Hepatocell Carcinoma 2017;4:15-21.

      DOIPubMed PMC
    • 85. Sugawara Y. Living-donor liver transplantation for patients with hepatocellular carcinoma in Japan: current situations and challenge. Hepatobiliary Pancreat Dis Int 2020;19:1-2.

    • 86. Ville de Goyet J, Meyers RL, Tiao GM, Morland B. Beyond the Milan criteria for liver transplantation in children with hepatic tumours. Lancet Gastroenterol Hepatol 2017;2:456-62.

    • 87. Triana P, Dore M, Romo MM, et al. Hepatocellular carcinoma: referral to a transplantation unit. Eur J Pediatr Surg 2017;27:16-9.

    • 88. Ismail H, Broniszczak D, Kaliciński P, et al. Liver transplantation in children with hepatocellular carcinoma. Do Milan criteria apply to pediatric patients? Pediatr Transplant 2009;13:682-92.

    • 89. Ziogas IA, Benedetti DJ, Matsuoka LK, et al. Surgical management of pediatric hepatocellular carcinoma: an analysis of the National Cancer Database. J Pediatr Surg 2021;56:772-7.

    • 90. Reyes JD, Carr B, Dvorchik I, et al. Liver transplantation and chemotherapy for hepatoblastoma and hepatocellular cancer in childhood and adolescence. J Pediatr 2000;136:795-804.

    • 91. Kelly D, Sharif K, Brown RM, Morland B. Hepatocellular carcinoma in children. Clin Liver Dis 2015;19:433-47.

    • 92. Ziogas IA, Ye F, Zhao Z, et al. Population-based analysis of hepatocellular carcinoma in children: identifying optimal surgical treatment. J Am Coll Surg 2020;230:1035-44.e3.

    • 93. Baumann U, Adam R, Duvoux C, et al. European Liver and Intestine Transplant Association. Survival of children after liver transplantation for hepatocellular carcinoma. Liver Transpl 2018;24:246-55.

    • 94. Ozçay F, Canan O, Bilezikçi B, Torgay A, Karakayali H, Haberal M. Effect of living donor liver transplantation on outcome of children with inherited liver disease and hepatocellular carcinoma. Clin Transplant 2006;20:776-82.

    • 95. Llovet JM, Ricci S, Mazzaferro V, et al. SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med 2008;359:378-90.

    • 96. Liang W, Wu L, Ling X, et al. Living donor liver transplantation versus deceased donor liver transplantation for hepatocellular carcinoma: a meta-analysis. Liver Transpl 2012;18:1226-36.

    • 97. Katz SC, Shia J, Liau KH, et al. Operative blood loss independently predicts recurrence and survival after resection of hepatocellular carcinoma. Ann Surg 2009;249:617-23.

    • 98. Nishizaki T, Matsumata T, Kanematsu T, Yasunaga C, Sugimachi K. Surgical manipulation of VX2 carcinoma in the rabbit liver evokes enhancement of metastasis. J Surg Res 1990;49:92-7.

    • 99. Beaunoyer M, Vanatta JM, Ogihara M, et al. Outcomes of transplantation in children with primary hepatic malignancy. Pediatr Transplant 2007;11:655-60.

    • 100. Ravaioli M, Ercolani G, Neri F, et al. Liver transplantation for hepatic tumors: a systematic review. World J Gastroenterol 2014;20:5345-52.

      DOIPubMed PMC
    • 101. Geissler EK, Schnitzbauer AA, Zülke C, et al. Sirolimus use in liver transplant recipients with hepatocellular carcinoma: a randomized, multicenter, open-label phase 3 trial. Transplantation 2016;100:116-25.

      DOIPubMed PMC
    • 102. Koneru B, Flye MW, Busuttil RW, et al. Liver transplantation for hepatoblastoma. The American experience. Ann Surg 1991;213:118-21.

      DOIPubMed PMC
    • 103. Cillo U, Ciarleglio FA, Bassanello M, et al. Liver transplantation for the management of hepatoblastoma. Transplant Proc 2003;35:2983-5.

    • 104. Casas-Melley AT, Malatack J, Consolini D, et al. Successful liver transplant for unresectable hepatoblastoma. J Pediatr Surg 2007;42:184-7.

    • 105. Héry G, Franchi-Abella S, Habes D, et al. Initial liver transplantation for unresectable hepatoblastoma after chemotherapy. Pediatr Blood Cancer 2011;57:1270-5.

    • 106. Barrena S, Hernandez F, Miguel M, et al. High-risk hepatoblastoma: results in a pediatric liver transplantation center. Eur J Pediatr Surg 2011;21:18-20.

    • 107. Kirnap M, Ayvazoglu Soy E, Ozcay F, Moray G, Ozdemir BH, Haberal M. Pediatric liver transplant for hepatoblastoma: a single-center experience. Exp Clin Transplant 2017;15:50-2.

    • 108. Ezekian B, Mulvihill MS, Schroder PM, et al. Improved contemporary outcomes of liver transplantation for pediatric hepatoblastoma and hepatocellular carcinoma. Pediatr Transplant 2018;22:e13305.

    • 109. Okur MH, Yankol Y, Cimşit B, et al. Liver transplant in children with hepatoblastoma. Exp Clin Transplant 2019;17:644-7.

    • 110. Feng J, He Y, Wei L, et al. Assessment of survival of pediatric patients with hepatoblastoma who received chemotherapy following liver transplant or liver resection. JAMA Netw Open 2019;2:e1912676.

      DOIPubMed PMC
    • 111. Arikan C, Kilic M, Nart D, et al. Hepatocellular carcinoma in children and effect of living-donor liver transplantation on outcome. Pediatr Transplant 2006;10:42-7.

    • 112. Sevmis S, Karakayali H, Ozçay F, et al. Liver transplantation for hepatocellular carcinoma in children. Pediatr Transplant 2008;12:52-6.

    • 113. Romano F, Stroppa P, Bravi M, et al. Favorable outcome of primary liver transplantation in children with cirrhosis and hepatocellular carcinoma. Pediatr Transplant 2011;15:573-9.

    • 114. Weiss KE, Sze DY, Rangaswami AA, et al. Transarterial chemoembolization in children to treat unresectable hepatocellular carcinoma. Pediatr Transplant 2018;22:e13187.


    Cite This Article

    Calinescu AM, Héry G, Goyet JV, Branchereau S. A practical approach to pediatric liver transplantation in hepatoblastoma and hepatocellular carcinoma. Hepatoma Res 2021;7:59.




    Comments must be written in English. Spam, offensive content, impersonation, and private information will not be permitted. If any comment is reported and identified as inappropriate content by OAE staff, the comment will be removed without notice. If you have any queries or need any help, please contact us at

    • Patricia Desmond   
      Dr. Riaria cured my herpes virus that have been in my body since two years, ever since then my life has been incomplete, I have used so many drugs that was prescribed to me by doctors, but it didn't cure my herpes virus, i was checking for solution on the internet then I miraculously came across Dr. Riaria the powerful herbalist that  can cure herpes infection, then I contacted him through his email, I explained everything to him and he prepared a herbal medicine and sent it to me through FedEx, which I took for 14 days with the instruction he gave me, and when I did a test in the hospital my result came out negative it was the happiest day of my life that am cure from HSV 2,  are you also suffering from same virus or another diseases you can simply contact him via email:  you can also call or WhatsApp him on: +2349134987375.  
      You can visit his website for more info: 

      24 Oct 2021 22:05


    • Nicole Liam   
      I NEVER BELIEVED IN HERBS BUT DOCTOR RAZOR MADE ME A BELIEVER. Massive Gratitude to doctor Razor who got my Genital Herpes cured a month ago. I got diagnosed with herpes on Feb 13, 2017.  I have been reading so many comments of some people who were cured from various diseases by Doctor Razor, but I never believed them. I was hurt and depressed, I was too curious and wanted to try Doctor Razor, then I contacted him through his email ( when I contacted him, he assured me 100% that he will heal me, I pleaded with him to help me out. I also got His Website :  My treatment was a great success, he healed me just as he promised. He sent me his medication and asked me to go for check up after 18 days of taking his herbal medicine. I agreed with him and I took his medication and went for check up, to my greatest surprise my result came out negative after the treatment, I'm really delighted that i'm completely cured and healthy again. I waited for a month to be very sure I was completely healed before writing this testimony. I did another blood test one week ago and it was still Herpes negative. so i guess it's time i recommend anyone going through Herpes HSV-1 or HSV-2, HIV, HPV, Hepatitis B, Diabetes, Cancer should reach him. EMAIL: WHATSAPP: +2349065420442  My greatest joy is having back my happiness  

      11 Sep 2021 08:05


    © 2016-2022 OAE Publishing Inc., except certain content provided by third parties