title: Surgical strategies for unresectable hepatoblastomas.
abstract: BACKGROUND
  The aim of this study was to assess the surgical strategies for unresectable hepatoblastomas at the initial diagnosis based on the experience of two institutions.
  
  
  METHODS
  The PRETEXT (Pretreatment evaluation of tumor extent) and POST-TEXT (Post treatment extent of disease) staging, surgical treatments, and clinical outcomes were retrospectively analyzed for 12 cases with PRETEXT III or IV and M(-) of 29 hepatoblastomas treated based on the JPLT-2 (The Japanese Study Group for Pediatric Liver Tumor-2) protocol at two institutions between 1998 and 2011.
  
  
  RESULTS
  Two of the 9 cases with PRETEXT III status were downstaged to POST-TEXT II. One of the 3 cases with PRETEXT IV showed downstaging to POST-TEXT III. Four of the 7 cases with P2 or V3 (indicated for liver transplantation) in the PRETEXT staging system showed P2 or V3 in POST-TEXT staging after 2 cycles of CITA (JPLT-2 standard regimen), and one case showed P2 or V3 in POST-TEXT staging at the initial operation and underwent primary liver transplantation. The initial surgical treatments were 1 lobectomy, 2 segmentectomies, 6 trisegmentectomies, 2 mesohepatectomies, and 1 primary liver transplantation. Both patients who underwent mesohepatectomies had bile leakage, and 1 of 5 trisegmentectomies had an acute obstruction of the right hepatic vein. Two patients underwent rescue living donor liver transplantation. Both of these patients showed P2 or V3 positive findings in POST-TEXT staging after 2 cycles of CITA.
  
  
  CONCLUSIONS
  POST-TEXT staging and P and V factors should be evaluated after 2 cycles of CITA for unresectable hepatoblastomas detected at the initial diagnosis. The patients should be referred to the transplantation center if the POST-TEXT IV, P2, or V3 is positive at that time. Liver resection by trisegmentectomy is recommended in view of the incidence of surgical complications. Careful treatment, such as back-up transplantation, should thus be considered for liver resection in the cases with POST-TEXT IV, P2, or V3 status after initial 2 cycles of CITA.
authors.affiliation: Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan. taji@koto.kpu-m.ac.jp
authors.forename: Tatsuro
authors.initials: T
authors.lastname: Tajiri
authors.forename: Osamu
authors.initials: O
authors.lastname: Kimura
authors.forename: Shigehisa
authors.initials: S
authors.lastname: Fumino
authors.forename: Taizo
authors.initials: T
authors.lastname: Furukawa
authors.forename: Tomoko
authors.initials: T
authors.lastname: Iehara
authors.forename: Ryota
authors.initials: R
authors.lastname: Souzaki
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Kinoshita
authors.forename: Yuhki
authors.initials: Y
authors.lastname: Koga
authors.forename: Aiko
authors.initials: A
authors.lastname: Suminoe
authors.forename: Toshiro
authors.initials: T
authors.lastname: Hara
authors.forename: Kenichi
authors.initials: K
authors.lastname: Kohashi
authors.forename: Yoshinao
authors.initials: Y
authors.lastname: Oda
authors.forename: Tomoro
authors.initials: T
authors.lastname: Hishiki
authors.forename: Hajime
authors.initials: H
authors.lastname: Hosoi
authors.forename: Eiso
authors.initials: E
authors.lastname: Hiyama
authors.forename: Tomoaki
authors.initials: T
authors.lastname: Taguchi
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage; D017024:Chemotherapy, Adjuvant; D002648:Child; D015331:Cohort Studies; D018572:Disease-Free Survival; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D018197:Hepatoblastoma / Q000188:drug therapy / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D008113:Liver Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods* / Q000401:mortality; D008297:Male; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D011182:Postoperative Care; D011300:Preoperative Care; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome