LAUSR

BACKGROUND Hepatocellular carcinoma (HCC) constitutes 0.5% of childhood malignancies and exhibits poor prognosis. Complete tumor extirpation either by partial liver resection (LR) or liver transplantation (LT) is the only curative treatment. Due to the poor initial outcomes of LT, LR has remained the mainstay of treatment for all but select children fulfilling the Milan criteria (originally designed for adults). METHODS Retrospective cohort study of pediatric HCC patients (<18 years) registered in the Surveillance, Epidemiology, and End Results database between 2004-2015. Survival analysis was performed by means of Kaplan-Meier methods, two-sided stratified log-rank tests, and Cox regression models. RESULTS Out of 127 children with HCC, 46 did not undergo surgery (36.2%), 32 underwent LT (25.2%), and 49 underwent LR (38.6%). Using Kaplan-Meier method, the 5-year cancer-specific survival (CSS) rates for LT and LR were 87%, and 63%, respectively. LT exhibited superior CSS vs. LR (log-rank, P=0.007). For T1 stage, LT showed equivalent CSS when compared to LR (log-rank, P=0.23), while for T2 and T3 stage, LT exhibited superior CSS (log-rank, P=0.047, and P=0.01, respectively). On multivariable Cox regression model, T3/T4 stage (adjusted HR: 13.63, 95%CI: 2.9-64.07; P=0.001), and LR (adjusted HR: 7.51, 95%CI: 2.07-27.29; P=0.002) were found to be independently associated with cancer-specific mortality. Fibrolamellar histology and lymph node status were not found to be associated with mortality. CONCLUSIONS Our findings suggest that children diagnosed with non-metastatic advanced-stage HCC shows a favorable prognosis after LT when compared to LR. Early inclusion of a LT consultation after initial diagnosis is warranted, especially in children with unresectable HCC or when complete tumor extirpation with LR is not feasible.