Intrahepatic chemioembolization in unresectable pediatric liver malignancies

Objective. To determine the effectiveness of a new multidisciplinary approa ch using neoadjuvant intrahepatic chemoembolization (IHCE) and liver transp lant (OLTx) in patients with unresectable hepatic tumors who have failed sy stemic chemotherapy. Materials and methods. From November 1989 to April 1998, 14 children (2-15 years old) were treated with 50 courses of intra-arterial chemotherapy. Bas eline and post-treatment contrast-enhanced CT and alpha-fetoprotein levels were: performed. Seven had hepatoblastoma, and 7 had hepatocellular carcino ma (1 fibrolamellar variant). All patients had subselective hepatic angiogr aphy and infusion of cisplatin and/or adriamycin (36 courses were followed by gelfoam embolization). The procedure was repeated every 3-4 weeks based on hepatic function and patency of the hepatic artery. Results. Six of 14 children received orthotopic liver transplants (31 cours es of IHC). Pretransplant, 3 of 6 showed a significant decrease in alpha-fe toprotein, while only 1 demonstrated a significant further reduction in tum or size). Three of 6 patients are disease free at this time. Three of 6 pat ients died of metastatic tumor 6, 38, and 58 months, respectively post-tran splant. One of 14 is currently undergoing treatment, has demonstrated a pos itive response, and is awaiting OLTx. Three of 14 withdrew from the program and died. Four of 14 patients developed an increase in tumor size, develop ed metastatic disease, and were not transplant candidates. Two hepatic arte ries thrombosed, and one child had a small sealed-off gastric ulcer as comp lications of intrahepatic chemoembolization. Conclusion. The results of intrahepatic chemoembolization are promising and suggest that some children who do not respond to systemic therapy can be e ventually cured by a combination of intrahepatic chemoembolization orthotop ic liver transplant. Alpha-fetoprotein and cross-sectional imaging appear t o be complementary in evaluating tumor response. IHCE does not appear to co nvert an anatomically unresectable lesion to a candidate for partial hepate ctomy.