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Hepatoblastoma: Update Course 2014

Video Published 2018-11-10 Updated 2026-08-01

Timestops (8)

PRETEXT Staging System Overview

PRETEXT vs POST-TEXT Staging

Imaging Modalities and Staging Accuracy

Surgical Margins and Resection Planning

Complex Resections vs Liver Transplantation

Referral Patterns and Center Expertise

Surgical Approach and Metastatic Disease

Global Collaboration in Hepatoblastoma Research

Topic Overview

A surgical discussion of hepatoblastoma staging and management, focusing on the PRETEXT/POSTTEXT staging system based on segmental liver anatomy and its implications for treatment decisions. The core clinical debate centers on when to proceed with primary resection versus neoadjuvant chemotherapy versus early transplant referral, with emphasis that rescue transplants after failed resection have worse outcomes than planned primary transplants. The group discusses imaging requirements (CT vs MRI), the role of surgical margins, tumor response patterns to chemotherapy (maximal shrinkage within 2 cycles, predominantly volume reduction rather than vascular margin improvement), and the emerging consensus against heroic resections in favor of early transplant center involvement for complex cases.

Key Takeaways

Tumor shrinkage peaks within 2 cycles of chemo; if not resectable then, evaluate for transplant rather than continuing. (10:14)
Rescue transplants after failed resection have worse outcomes than planned primary transplants—refer early to transplant centers. (14:09)
Heroic resections (vascular reconstructions, ex vivo) yield worse survival than transplant; trend is away from these procedures. (12:10)
Tumors shrink in volume with chemo but preserve vascular relationships—don't expect them to pull away from vessels. (11:06)
PRETEXT 1-2 without vascular involvement and 1 cm margins achievable can proceed to upfront resection per COG guidelines. (7:41)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — guest
Speaker 2 — host
Speaker 3 — guest
Speaker 4 — guest
Speaker 5 — guest
Speaker 6 — guest

Chapters

0:00PRETEXT staging system and case presentation — Introduction to PRETEXT (pre-treatment extent of disease) staging based on segmental liver anatomy, presentation of a multifocal hepatoblastoma case, and discussion of staging criteria including vascular involvement annotations.
4:24Management of PRETEXT 2 tumors and imaging — Debate over primary resection versus neoadjuvant chemotherapy for PRETEXT 2 lesions without vascular involvement, discussion of imaging modalities (CT vs MRI) for staging accuracy, and the challenge of trusting imaging for surgical decision-making.
7:34Chemotherapy response patterns and timing — Discussion of tumor shrinkage patterns with chemotherapy (maximal response within 2 cycles), the observation that tumors shrink in volume but not away from vascular structures, and recommendations for transplant evaluation after 2 cycles if not resectable.
11:32Resection versus transplant decision-making — Debate over extended resections versus primary transplant, the poor outcomes of rescue transplants after failed resection, survival differences between primary resection and chemotherapy-first approaches, and organ availability considerations.
16:50Referral patterns and surgical expertise — Discussion of when to refer to transplant centers, the role of liver transplant surgeons in complex resections, differences between US and European approaches, and the value of early consultation even when transplant may not be needed.
21:00Biopsy practices and pulmonary metastases — Brief discussion of biopsy techniques (core needle vs open wedge) for atypical presentations, debate over timing of pulmonary metastasectomy relative to hepatectomy, and mention of the PLUTO international registry for unresectable tumors.

Key claims

2:02PRETEXT staging stands for pre-treatment extent of disease and is based on segmental liver anatomy prior to chemotherapy — Speaker 1
2:28PRETEXT staging has a tendency to overstage because it is based purely on imaging and bulky tumors make it hard to assess true vascular invasion versus mass effect — Speaker 1
2:51POSTTEXT refers to extent of disease after neoadjuvant chemotherapy has been given — Speaker 1
4:07The two key annotations in PRETEXT staging are involvement of the retrohepatic cava or hepatic veins and involvement of the portal vein bifurcation — Speaker 1
7:41COG recommendations state that PRETEXT 2 tumors without vascular involvement and with achievable 1 cm margins should proceed to upfront hepatectomy — Speaker 1
8:05COG feels that PRETEXT 1 and 2 tumors can be resected locally if the surgeon feels competent and do not necessarily require referral to centers with liver resection expertise — Speaker 1
10:14Most tumor volume shrinkage with chemotherapy occurs within the first 2 cycles — Speaker 1
10:33Current recommendations are that after 2 cycles of chemotherapy, if the tumor has not shrunk to a resectable point, the patient should be evaluated for transplant — Speaker 1
11:06As hepatoblastoma tumors shrink with chemotherapy, they do not shrink away from the vascular supply significantly - they shrink in size but preserve similar vascular relationships — Speaker 1
12:10Survival after very extensive or heroic resections (tumor liver explants with back table resections and reimplants, portal vein reconstructions, hepatic vein reconstructions) is not as good as transplant survival — Speaker 1
12:40There has been a move away from heroic resections based on survival data — Speaker 1
14:09Rescue transplants after failed resection have significantly worse outcomes than planned primary transplants — Speaker 1
14:36Current thinking is to refer to transplant center early, which does not necessarily mean the patient will go to transplant but allows pre-transplant evaluation and system integration — Speaker 1
15:13Primary transplant patients do surprisingly well despite immunosuppression for cancer — Speaker 2
15:57In the UK, all complex liver resections for hepatoblastoma are done in centers that do pediatric liver transplants — Speaker 2
11:32The imaging goal for resection is a 1 centimeter margin — Speaker 1
9:32North American and European approaches to hepatoblastoma management are converging — Speaker 1
9:47There are approximately 100 hepatoblastomas per year in the United States — Speaker 3
10:03The only way to make progress with hepatoblastoma is through combined approaches with European groups — Speaker 3
19:43Despite all available imaging, the truth about resectability is determined at the time of operation — Speaker 2
19:58In Europe, all liver tumors receive chemotherapy up front before surgery because it results in smaller tumors and may avoid transplantation — Speaker 2
21:25For core needle biopsies of hepatoblastoma, approximately 10 passes are recommended through an area that includes normal parenchyma and tumor — Speaker 1
22:11There is debate over whether to resect pulmonary metastases before or after hepatectomy, with one camp concerned that liver regeneration growth factors may stimulate previously unrecognized lung disease — Speaker 1
22:45Data on pulmonary metastases management is limited to a handful of patients on both sides with no good conclusions possible — Speaker 1
23:38There may be reporting bias in transplant outcomes because successes are reported but not all failures — Speaker 1

Points of disagreement

4:49Primary resection versus neoadjuvant chemotherapy for PRETEXT 2 tumors
- Speaker 1: COG recommends upfront hepatectomy for PRETEXT 2 with clear 1cm margins and no vascular involvement
- 60% of audience chose chemotherapy first rather than immediate resection
15:39Whether complex hepatoblastoma resections should be centralized to transplant centers
- Speaker 6: Complex liver resections should be done in centers that do pediatric liver transplants due to expertise and backup options
- Speaker 4: Non-transplant center surgeons can proceed if they feel 95% confident of success with their skill set
22:11Timing of pulmonary metastasectomy relative to hepatectomy
- Resect pulmonary metastases upfront before hepatectomy
- Wait until after hepatectomy because liver regeneration growth factors may stimulate previously unrecognized lung disease

Open questions

What is the optimal imaging modality (CT versus MRI) for PRETEXT staging accuracy?
Should pulmonary metastases be resected before or after hepatectomy?
What are the true survival outcomes for patients with stage 4 disease who respond to chemotherapy but have residual lung nodules?
Should all complex hepatoblastoma resections be centralized to transplant centers?
What is the significance of microscopic positive margins in hepatoblastoma resection?
Is there a role for PET scanning in hepatoblastoma staging and management?
Should biopsy be performed routinely in atypical presentations (older children, uncertain diagnosis)?
What is the optimal biopsy technique - core needle versus open wedge?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Hepatoblastoma Resection: When Confidence Matters More Than Courage

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

PRETEXT staging overstages by design

PRETEXT (pre-treatment extent of disease) classifies hepatoblastoma based on segmental liver anatomy before chemotherapy 2:02. The system has an inherent limitation: it tends to overstage because bulky tumors on imaging make it difficult to distinguish true vascular invasion from mass effect 2:28. A tumor pressing against the portal vein may look invasive when it is merely compressive. The two annotations that matter most are involvement of the retrohepatic cava or hepatic veins and involvement of the portal vein bifurcation 4:07. These determine whether the tumor can be separated from critical vascular structures.

Chemotherapy preserves parenchyma but not vascular margins

Most tumor volume shrinkage occurs within the first two cycles of chemotherapy 10:14. After two cycles, if the tumor has not shrunk to a resectable point, the patient should be evaluated for transplant 10:33. The critical insight: as hepatoblastomas shrink, they do not shrink away from vascular structures — they decrease in size but preserve similar vascular relationships 11:06. Chemotherapy buys you liver parenchyma, not clearance from vessels. Giving additional cycles hoping for better vascular margins is not supported by the biology.

Heroic resections have been abandoned for a reason

Survival after very extensive resections — tumor liver explants with back table resections and reimplants, portal vein reconstructions, hepatic vein reconstructions — is not as good as transplant survival 12:10. This has driven a move away from heroic resections 12:40. The margin assessment itself is complicated: shaving tumors off vessels may not represent true negative margins, and cautery artifact can obscure margin status. The 1-centimeter margin goal 11:32 is aspirational on imaging but often uncertain intraoperatively.

Rescue transplants fail where primary transplants succeed

Rescue transplants after failed resection have significantly worse outcomes than planned primary transplants 14:09. This creates the central judgment call: a surgeon must be highly confident of successful resection or refer early. Current thinking is to refer to a transplant center early, which does not necessarily mean the patient will proceed to transplant but allows pre-transplant evaluation and system integration 14:36. Primary transplant patients do surprisingly well despite immunosuppression for cancer 15:13. The immunosuppression concern has not materialized as a barrier to good outcomes.

The decision threshold is surgeon confidence, not tumor stage

COG recommendations state that PRETEXT 2 tumors without vascular involvement and with achievable 1-centimeter margins should proceed to upfront hepatectomy 7:41, and COG feels these can be resected locally if the surgeon feels competent 8:05. But "feels competent" is doing heavy lifting. One discussant stated the standard clearly: the surgeon needs to feel very comfortable before starting the procedure that they will succeed, and if they don't feel confident, they should refer to a transplant center because being in between represents a significant disservice 19:43. Despite all available imaging, the truth about resectability is determined at the time of operation 19:43. The error is not attempting a difficult resection and succeeding — it is attempting one without confidence and creating a rescue transplant scenario.

The convergence point

North American and European approaches to hepatoblastoma management are converging 9:32. In Europe, all liver tumors receive chemotherapy up front because it results in smaller tumors and may avoid transplantation 19:58. In the UK, all complex liver resections for hepatoblastoma are done in centers that do pediatric liver transplants 15:57. The discussants emphasized that with approximately 100 hepatoblastomas per year in the United States 9:47, progress requires combined approaches with European groups 10:03. The teaching point the discussants returned to repeatedly: refer early to a transplant center if you are not confident of complete resection. The penalty for being wrong is not a complication — it is converting a primary transplant candidate into a rescue transplant patient.

Takeaways from this story

Hepatoblastomas shrink with chemo but maintain vascular relationships—additional cycles won't improve vessel clearance.
Rescue transplants after failed resection have worse outcomes than primary transplants—refer early if not confident.
PRETEXT staging tends to overstage because imaging cannot distinguish true vascular invasion from mass effect.
Despite imaging advances, resectability is determined at operation—surgeon confidence matters more than staging.

Upfront Resection Versus Chemotherapy First for PRETEXT 2 Hepatoblastoma

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

When a child presents with a PRETEXT 2 hepatoblastoma—tumor confined to two adjacent liver segments, no vascular involvement, achievable 1 cm margins on imaging—should the surgeon proceed directly to hepatectomy or give neoadjuvant chemotherapy first?

The Case for Upfront Resection

COG recommendations state that PRETEXT 2 tumors without vascular involvement and with achievable 1 cm margins should proceed to upfront hepatectomy 7:41. The imaging goal is a 1 centimeter margin 11:32. These guidelines further specify that PRETEXT 1 and 2 tumors can be resected locally if the surgeon feels competent and do not necessarily require referral to centers with liver resection expertise 8:05.

The rationale rests on two principles: first, that these tumors are technically resectable at presentation, and second, that primary resection—when successful—avoids the toxicity and delay of chemotherapy. One discussant emphasized the survival advantage: patients who undergo successful primary resection tend to do better than those who receive chemotherapy first 2:28. The critical qualifier is surgical confidence. One discussant described needing to feel very comfortable before starting the procedure, with confidence in a high likelihood of success within their skill set 2:28. If that confidence exists, the COG pathway supports proceeding.

The Case for Chemotherapy First

When the same clinical scenario was presented to the audience, 60% chose chemotherapy before resection rather than immediate hepatectomy 0:00. This preference reflects several concerns that complicate the straightforward COG recommendation.

First, PRETEXT staging has a tendency to overstage because it is based purely on imaging, and bulky tumors make it hard to assess true vascular invasion versus mass effect 2:28. What appears resectable on CT may prove otherwise at operation. One discussant noted that despite available imaging, the truth about resectability is determined at the time of operation 2:28.

Second, rescue transplants after failed resection have significantly worse outcomes than planned primary transplants 14:09. The risk calculation therefore includes not just the probability of successful resection but the consequence of failure. One discussant emphasized that attempting resection and failing does not serve the patient well because it worsens survival 14:09. Chemotherapy first provides additional information—tumor biology, response to therapy, clarification of vascular relationships—before committing to an irreversible surgical decision.

Third, most tumor volume shrinkage with chemotherapy occurs within the first 2 cycles 10:14, meaning the delay is brief and the potential benefit—converting a marginal resection into a clear one, or identifying patients who need transplant—is substantial. Current recommendations are that after 2 cycles of chemotherapy, if the tumor has not shrunk to a resectable point, the patient should be evaluated for transplant 10:33.

The European approach reflects this philosophy systematically: all liver tumors receive chemotherapy up front before surgery because it results in smaller tumors and may avoid transplantation 19:58.

Where They Agree

Both positions converge on several critical points. First, that surgical judgment about resectability is paramount—no one advocates attempting a resection the surgeon doubts they can complete. One discussant stated that without confidence in resectability, referral to a transplant center is appropriate because being in between represents a significant disservice 14:36.

Second, that early referral to a transplant center is appropriate for complex cases, even if transplant is not the intended path. Current thinking is to refer to transplant center early, which does not necessarily mean the patient will go to transplant but allows pre-transplant evaluation and system integration 14:36. This creates a safety net without forcing a premature decision.

Third, that North American and European approaches to hepatoblastoma management are converging 9:32, suggesting the field is moving toward consensus even if individual case decisions remain nuanced.

What Would Resolve It

The discussants did not identify a specific trial or dataset that would definitively answer this question. The fundamental challenge is numbers: there are approximately 100 hepatoblastomas per year in the United States 9:47, and PRETEXT 2 tumors represent a subset of that already-small cohort. The only way to make progress with hepatoblastoma is through combined approaches with European groups 10:03, but even pooled international data may struggle to power a randomized comparison of immediate resection versus brief neoadjuvant chemotherapy in this specific staging group. The question remains unresolved, decided case by case based on imaging quality, surgical experience, and institutional philosophy.

Takeaways from this story

PRETEXT staging overstages because imaging cannot distinguish true vascular invasion from mass effect in bulky tumors.
Rescue transplants after failed resection have significantly worse outcomes than planned primary transplants.
Most hepatoblastoma shrinkage occurs in the first 2 cycles of chemotherapy, limiting delay if neoadjuvant therapy is chosen.
Tumors shrink in size with chemotherapy but do not shrink away from vascular structures, preserving parenchyma but not vascular margins.

Keywords

hepatoblastoma hepatocellular carcinoma biliary atresia Wilms tumor hepatectomy liver transplant right tri-segmentectomy central hepatectomy tumor liver explant with back table resection portal vein reconstruction hepatic vein reconstruction pulmonary metastasectomy core needle biopsy open wedge biopsy laparoscopic liver resection

Hashtags

#Hepatoblastoma #PediatricOncology #LiverTumor #PediatricSurgery

Transcript

So, um, There we go. OK, so, um, my goals with this, um, were first of all, just to sort of blow through some quick stuff which is sort of an update on, um, staging because I don't know that um everyone necessarily is well informed about the pretext and post-text um staging of hepatoblastomas and then. After that, get into um some of the current recommendations from COG in terms of uh resections of tumors based on that staging and then hopefully at the end um get into the area of controversy and with ptoblastoma, we don't really have um the, the areas of controversy aren't, don't have studies that are well powered like blastoma and so, um, it really is, I think, um, maybe an area for more debate and um. Probably has a lot of opinion built into it. So, um, so this is the first scenario that I, um, put up to cover this, um, staging issue. And, um, so you have a 2 year old boy who presents to the emergency room with abdominal pain, lethargy, uh, 5 pound weight loss, jaundice, and dark urine. Um, on exam has a large abdominal mass and uh CTA of your pelvis is done with IV contrast shows the image shows multifocal. Disease affecting all sectors of the liver with an elevated AFP. So the presumptive diagnosis of hepatoblastoma is made based on that. Um, how would, how would people um uh stage this patient? You be. So 75% are saying 4. 80%. OK, so, so yeah, so, um, so. The, the issue of staging, so, so pretext staging, um, sorry. Pretext staging stands for pre-treatment extent of disease, and um this staging system is based on segmental liver anatomy. And the important thing about this is this is staging prior to chemotherapy has been given. So, so this patient is definitely a pretext and, um, and then, you know, I've tried to make it relatively straightforward as 1 or 4 and with multifocal disease, you're clearly not going to be a 1. The interesting thing about pretext staging is that um it has a tendency to overstage, um, because this is based purely on imaging and many of these tumors are so bulky, um, it's hard to assess whether or not there's true vascular invasion sometimes or if it's just a big mass effect on the tumor pressing on oral vein, hepatic veins, things of that nature. Post-text, uh, in contradistinction refers to extended disease after neoadjuvant chemotherapy has been given. So, um, these are just some images that I borrowed from, um. COG website and you can see that pretext stage one involves one sector of disease. Um, 2 involves two sectors of the disease of the liver. 3 is 3 sectors, um, with 1 specifically spared because it's not uh necessarily 3 contiguous, and then 4 is, um, the, the image that I showed which is multifocal disease. So, um, so the next question for the audience would be which of the following other considerations are not factored in the staging? There. OK. Getting the pull up in a second. We can blow through this pretty quickly. Yeah, OK, alright. So basically, um, the extramedullary hematoposis is not involved. I mean, there are a bunch of additional annotations that are made. I think the two key ones that people look at are involvement of the retropatic cava or um hepatic veins, and then um the portal vein bifurcation, uh, whether or not that's involved. Um OK. So, this image isn't coming up clearly, but, um, for some reason the slide's not loading right. But the, the image that I have, um, let's just say that you have a tumor that's classified as a pretext too. There's no involvement of the retropatic cava or the, uh, hepatic veins, and the portal vein confluence is spared. So, appropriate management, um, strategies for this patient would include, Following, is that up, people can actually pull off of it or. Yeah, Mark, can we get these polls or? We're not seeing them. Yeah Sorry, Matt, we'll try to get that's OK. So, so we can just sort of go through it. I mean, um, the, the question is really, I think boils down to um What would people do in the setting of a pretext to with no involvement of the hepatic veins or portal veins? So maybe while we're waiting for that to come up, we could just and Mark, if you can't find the polls, at least just write A, B, C, D, even if you can't, the last two we don't see. There, there it goes, songs opening. You have to scroll up to it. So you had commented before about the fact that the the pretext overstages patients and in a case like this, would you Base this on what kind of imaging studies do you get to make this kind of a decision? Yes, that's a good question. So I think, I think there's People favor different things. Some people look at CT with multi contrast phase, and other people favor MR. And I think that I don't know that one's been shown to be superior, um, but I think clearly cross sectional imaging is absolutely critical to staging these. So does anybody get other studies other than, would you get a CT or an MR? Steve, would you CT or MR in your institution? We're using more and more MR, MR, MR. Both, both, yeah, well, that's one of my concerns is frequently we end up they end up with both somehow. Any role for PET scan? I don't know that pets really, I mean. I don't think that's going to be useful to have the converse is also true. If you have one available, right. Well, I mean, our, we don't even have the oncologists are just getting PET scans and more and more patients in a diffuse area and it's like you have information and kind of what do you do with it. Because if you're going to make a decision based on the pretext staging, you have to be able to trust your imaging or your imaging may play a factor in the answer to this question as to whether you think you would proceed directly to surgery or not. Absolutely. And so the audience, 60% is going with B. So getting chemo first, chemo first. So yeah, so this, so this is sort of an interesting thing because if you look at the recommendations by COG, they would say that, you know, if you can get a clear margin on a pretext to, um, you know, a good margin, 1 centimeter margin, doesn't involve any of the vascular structures that you just go for the um hepatectomy up front. Um, and, and, you know, and, and I think that they're pretty clear also that they feel that this is not something that necessarily gets referred to an area of, you know, expertise and liver resection, that the ones and twos, um. If the surgeon feels competent, should be resected locally, which is sort of interesting. Well, your diagram showed the tumor pretty close to the portal. So I think that might have scared some people because you want a margin. Yes, absolutely. So, so, and, and this issue of margin, I bring up later on, um, because I think it, um, There's some controversy there too in terms of what people refer to as a negative margin. People talk about shaving tumors off the vessels and whether or not that's a negative margin or whether, um, you know, cautery artifact actually obscures the fact that you may or may not actually have a negative margin. People use the Cuso to come through the liver, that there's actually, you know, some width there, probably, you know, 56 millimeters of tissue division. And so does some of your tissue margin actually go up the suction device, so. Some of the, some of the decisions on this may also be related to differences in philosophy in the approach in the United States versus the approach in Europe. Is that true? Um, certainly for Wilms tumor, there is the European approach is to get chemotherapy first no matter what. Yes, um, I think that's true. I think that um. Interestingly, the um. It's from from what I've read, it seems to me that the North American and European approaches seem to be converging similarly. I think that's true, and people like Rebecca Myers, who has spent Years getting those, uh, getting the two groups to come together on uh, on an approach because as you mentioned at the outset, they're very few, there are 100 hematoblastomas in the country a year. So the only way to make progress with this is to, to have a combined approach with the European groups and Rebecca spent a lot of time getting that organized. Um, so, Another thing I think that's worth mentioning here is just, um, this issue of tumor shrinkage, and we were talking about chemotherapy affected, um, with hepatoblastoma, I think the, the recommendations are pretty clear now that most of the shrinkage of the tumor volume that you're going to get is going to be within the first two cycles. And so there are some, you know, Groups that in the past have advocated for giving more chemo before proceeding with resection, and I think now the recommendations are pretty clear that after 2 cycles, if you haven't shrunk to a point that makes the tumor resectable, that the patient be evaluated for transplant. Um, there's been some nice studies done on that. The other interesting thing about that, um, I think the group out of Vanderbilt looked at this, but the, the, the ways in which the tumors shrink is, um, something to consider because, um. You know, some people would say, well, you know, if you get more chemo maybe you get more of a vascular margin. It turns out that as the tumor shrinks, it doesn't really shrink away from the vascular supply all that, all that much. And so, um, so that sort of, you know, shrinks down in in terms of size. It does give you more of a margin, exactly. So. Maybe you preserve parenchyma but not vascular margins. So don't do, so don't do chemo for the vascular margin. Exactly. Well, so, so when you evaluate imaging, do you want a 1 centimeter margin? Is that what you'd recommend to the audience? Yes, I would say a 1 centimeter margin is imaging is the goal, yeah. Now, if you If you look at the survival results, I mean, I'm sure you're probably going to show the data if you can get, you can get the thing out. Don't those patients do better? They tend to do better and, you know, and we'll go through a little bit of this because I think some of the controversy exists. Who has better survival, um, somebody who has a very extended resection, like, you know, a right tri-segmentectomy or somebody who goes on and just gets a transplant. And I think um in years past, it was felt that um very extensive or quote unquote heroic resections were undertaken, you know. Things like tumor liver explants with back table resections and reimplants, portal vein reconstructions, hepatic vein reconstructions, and I think the, the take home message from that after. It having been done for years, um, is that the survival on those patients is actually not as good as the transplant survival. So there's been sort of this move away from some of these sort of heroic resections. I think the other question is chemo, you know, if if you're going to commit them to two rounds of chemo, those patients that get chemo don't have as high survival as a primary resection, or do they? That's the question. I was just gonna say. Prior to that, the previous discussion about you should, if you can get it out, you should try to get it out because you have a better survival, but if you try to get it out and you can't. And they require, then you have not done them a favor because then they have worse survival. So you have to be pretty confident that you're going to be successful in getting them out with a margin or you're with a margin, although I, you know the data better than I, but the significance of a microscopic margin is unclear. What's the incidence of the ones that they recently opt for a liver transplant, getting a liver transplant. Uh, what is the availability of organs, because you have to factor that into which course you're going to take. Yeah, and I, and I think that that's an important point is, you know, when you're looking at, and I probably have a slide on this, but. When, when, when you're looking at patients that are going to go the route of transplant versus a right tri-segmentectomy, you have to say, well, you know, if we put them into the transplant group, #1, what's organ availability like? and number 2, you've committed now a very young child to lifelong immunosuppression, which is not an entirely benign thing, so. Um, but to Dr. von Almen's point, you know, these what they call rescue transplants, there's a failed resection that then goes on and needs a transplant. Those patients, it's pretty clear, do far worse off than patients that are a planned transplant up front. Yeah, so that's been my rule of thumb. If I don't think I can get a margin and they don't respond to chemo, so I can get a margin, they should be referred for transplant before resection. Is that still? True. Yeah, so, so the, the critical point, yeah, I think the current thinking is that you refer to the transplant center early. It doesn't necessarily mean that the patient's going to go towards transplant. You still might give two cycles of chemo and see where you end up, but at least you want the patient plugged into the system, have all the pre-transplant evaluation done, sort of have them sort of plugged in. In the event that they need to go that route. I think the concept is that the patients in whom transplantation is done a salvage therapy don't do as well as a primary transplant. Right. That's very clear. Yes. The primary transplant patient, Does surprisingly well, you know, doing a transplant and immunizing somebody against rejection who has cancer has always been a major question, is that a safe thing to do? And it seems as though the liver patients do extremely well following the transplantation despite being immunosuppressed. So, so should all these complex liver resections for hepatoblastoma be done and here we go back again? It took the words right out of my mouth. I was going to ask you exactly, but it's a critical question we have to ask ourselves in a session like this. Should they be done in centers that do pediatric liver transplants? Uh, I think that's the way they do it in the UK. I mean, I, I think that's a critical, obviously a very complicated question in terms of biliary. Yeah, so, so for the biliary atresia is different. That's that operation, it's not a big operation. It's easy to do, but the transplant is, so they, they all those patients who have biliaryresia are referred up. Front to a transplant center, but they have time. I mean, a tree, you slowly get sick over time. This is different. These people, these children are going to get sick fairly quickly. If you're in a place that doesn't have a transplant program, you can't do all the arranging for a potential transplant. I'm not advocating total specialization for everything we do, but these are issues that are in the current era important to look at. So, so for the people who are at non-transplant centers, do you have criteria that you use to try? How would you manage a patient who has a questionably resectable tumor? Would you do it appears to be inactive and will be ended soon. Saved by the bell. Any on your telephone are we off the air? We just got a message. I think the audio is down. OK, OK, so, so non-transplant center surgeons, I don't even know how many we have. So, so what, what, how do you manage because you do liver liver. I think if there's, I need to feel very comfortable that I can do the resection. I mean, you know, first of all, you have to decide, are you comfortable doing major liver resections. Assuming that, then I need to feel very comfortable before I start the procedure that I'm gonna, I'm going to succeed. And that's not that you couldn't have a complication or problem, but that within my skill set, there's a 95% chance that we're gonna, we're going to do that. And if I don't feel confident with that, then I will refer them to a transplant center because To be in between is, I think you've, you've done a significant disservice. It's a risky business. Yeah. Yeah, for us, I think if you can do an anatomic resection with a good margin, I think that's fine. You would proceed down, but if it's anything close to the hepatic veins, if you have disease that extends across the liver or anything it's the portal vein, you should send it. And would you give pre-op chemotherapy to get to that point, or would you send them before? Well, you know, we've, we've actually had 3 in the last 2 months and then we go 6 months and don't really have them. I think it's case by case, but we have sent, sent them early when we just as surgeons felt like they couldn't be resectable, and I, I would say we've had a couple that we sent to your institution for that, and you guys were able to safely resect it, um, because you probably had a little bit more confidence and do a lot more liver resections, and the patient never did need a transplant. So I think that's another value, but, but that brings up another, I don't want to be creating all these paradigms, but it brings up another situation that's real, and that is that the liver transplant surgeon has a lot of experience with operating on the liver. And so if there are issues being close to the portal vein, being close to the hepatic veins, it's not so bad to have somebody like that that might be available to help the pediatric surgeon who's done a lot of liver resections do it even better. In this day and age, and there's no reason that the scans can't be sent to somebody from that center to have them look at to help you make the decision if that's somebody they should see earlier. There's nothing like looking at the anatomy with the belly open. We do all these laparoscopically. So yeah, well, despite, despite all the imaging that, that, that's available, uh, I think anybody who's done a fair number of liver resections will tell you that the truth is at the time of the operation, whether it's resectable or not. Yeah, despite of all that, and, uh, People in Europe, early on will give all liver tumors chemotherapy up front. And then do the surgery. Because it's easier, it's a smaller tumor, they perhaps can avoid transplantation. Yeah. And that was their reasoning for it. But in, in our country, avoiding a transplant, lifelong immunosuppression, you know, is something, if you can avoid it, it's probably OK. So, I, I would not hesitate doing a tri-segmentectomy for cure. And perhaps in certain centers, I know Mike has had some experience doing central hepatectomies, which is a difficult operation, but he's done them successfully and the patients have been cured without requiring a transplant. So, you know, there's a lot of thought process that goes into it, but certainly those procedures should be done by experienced personnel. We've had a couple of kids who are over the age of 3, like 8 and 9 with hepatoblastoma. Likewise, we've had hepatocellular. Do you biopsy kids outside? Do you have a You biopsy before you treat with chemo, just to be sure it's really a one or the other? And how do you do that? Do you do it open or do you do it? Yeah, so, so I think, um, Based on what I've read, um, it seems that the field is sort of divided. So there are some people that would say you could do core needle biopsies, and they usually recommend, I think, about 10 passes of the needle and that you're supposed to go through an area that includes normal parenchyma and that, um, and obviously, you know, your tumor as well. Our practice has not necessarily been to do that. We typically do an open wedge for, you know. To get tissue, I'd be interested to see what other people do. OK, I think we got, we're gonna have to is there any final, final things that you wanted to hit before we move, but you've got in the last 60 seconds? Well, the only other thing I would say is that I think a topic of debate is really this other issue of pulmonary metastases in hepatoblastoma and the treatment of the pulmonary meds. Because um there are two different camps on this issue, and one would say, you know, if you, um, you should resect the metastases up front and then go on to do your hepatectomy after. There's others that would say, um, well, you know, the, the growth factors that are secreted by the liver as it regenerates are going to stimulate growth of other. Sites in the lung that may not have been previously recognized and so that maybe there's a benefit to waiting and doing it after because then you can actually clear them of disease, but I, I don't know that there's good data on either side of this. All of it's limited to a handful of patients in both sides, so. Matt, one last question on that. Uh, the thought had been that that they're treated with chemotherapy and have stage 4 disease and the, tumor in the lung disappears on chemotherapy alone. Do you go ahead and do the transplant. What do you do the resections and what happens then if you have everything that responds, but you only have one or two nodules left in the lung that didn't respond to chemotherapy, which you operate on those patients. Right. And so, um, so again, that's, um, a small subset of, uh, patients and the, the papers that are out there are limited literally to a cohort of, I think, less than 20. Um, where this has really been looked at. So it's hard to really draw any good conclusions. Um, the, the other piece to this is that there may be some selection bias in what's reported or reporting bias, because if you have a good response to chemo, and you go on to do a transplant, and your patient is a long-term survivor, that's a patient that gets reported as a success. But I don't know that they, um, all the failures are being reported. So. To that point, um, there's, um, a group, and I think this would just be the last little thing to mention, there's a group, um, called, um, let's see, I go back to it. Pluto, um, this Pediatric Liver unresectable Tumor Observatory, and this is an international group, and, and they're really seeking to answer those questions because it's not answerable at individual centers or even multi-centers within North America or Europe. This really takes, you know, a global initiative to answer some of these questions, and so they're looking at all these things, but I think it's probably going to be several years before we can really answer any of those questions. OK. Thank you very much.

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