BOB Ped Surg 2023 - Andrew Fleming, AAP - Presentation

I'd like to thank the program committee as well as the St. Jude Department of Surgery for allowing me to present this research. We have no disclosures. Hepatoblastoma is the most common pediatric liver cancer. The number of contiguous hepatic sections uninvolved by tumor can be used radiographically to determine the pre-treatment extent of disease, uh thus making the pretext group. This in combination with the presence or absence of metastatic disease, alpha feta protein at diagnosis, pretext modifiers, patient age and resectability at diagnosis can be used to risk stratify patients according to the AHEAD 1531 clinical trial. Complete surgical resection has been determined uh to be necessary for patient survival. Um, and cis-Platin based chemotherapies have fortunately improved rates of resectability and subsequently survival for these patients. This has led to more aggressive surgical resections uh for attempts at local control. However, in some patients, achieving no evidence of disease status may require further resection including pulmonary metastasectomy, um as can be seen in this patient here. However, the reported survival benefits of pulmonary metastasectomy for hepatoblastoma, um have varied in the literature. Uh so our aim in this analysis was to investigate the utility of aggressively pursuing no evidence of disease status for patients with hepatoblastoma, um as well as to perform a planned subgroup analysis of patients with AHEAD 1531 high risk designation. Uh just of note for this presentation, no evidence of disease is defined as a normal AFP and the absence of detectable radiographic disease on interval surveillance imaging. Uh this is a retrospective single institution observational study, uh performed analyzing patients treated from 2005 to 2021. Patients were excluded if they were not treated for their hepatoblastoma at St. Jude, or if they were awaiting resection of their primary tumor, thus precluding them, um from the opportunity for no evidence of disease status. This was IRB approved and these data are reported according to strobe recommendations. Uh amongst 50 patients included for analysis, 24 were determined to be high risk. All patients received chemotherapy and 41 patients were successfully able to be rendered uh no evidence of disease status. Our group takes a fairly aggressive approach to pulmonary metastasectomy for these patients, including bilateral uh reoperative pulmonary resections if necessary. As you can see, 14 patients underwent a total of 31 pulmonary uh procedures, having a median of four nodules resected per patient with a median of three nodules per patient uh containing pathologically confirmed viable hepatoblastoma, thus confirming a high degree of concordance between radiographic evidence of disease, um and pathological confirmation of disease. On logistic regression for three-year mortality, uh only achieving no evidence of disease was associated with a significant decrease in patient mortality. When we look at these survival data, uh using time to event analysis, you can see in panel A, the overall survival of the uh, the entire cohort is quite high. The event-free survival is lower, um and that's due to relapse events after achieving no evidence of disease. Panel C, we stratify patients by whether or not we were able to render them no evidence of disease. and you can see the overall survival, and then indeed the event-free survival of the group, uh in whom we were unable to render them no evidence of disease is significantly lower, um with no patients in these cohorts uh surviving past two years. Panels E and F um are looking at high risk and not high risk patients uh that we were able to render no evidence of disease status. And as you can see the overall survival is actually similar between these groups. Now the event-free survival uh remains significantly lower uh for the high-risk no evidence of disease group and this is due to five high-risk patients who relapsed in this cohort, um three of which were actually able to be successfully salvaged uh using a combination of chemotherapy and further pulmonary resections. So from these data we concluded that no evidence of disease status is necessary for survival in patients with hepatoblastoma, and repeated pulmonary metastasectomy and or complex local control strategies to obtain no evidence of disease uh benefit high risk patients. Um here's some of our uh references and uh thank you again for this opportunity.