Clinical Efficacy and Prognosis Factors for Advanced Hepatoblastoma in Children : A 6-year Retrospective Study

OBJECTIVE
This study aimed to investigate the effect of multimodality treatment of advanced paediatric hepatoblastoma (HB) and the factors affecting prognosis.


METHODS
A total of 35 children underwent multimodality treatments consisting of chemotherapy, surgery, interventional therapy, and autologous peripheral blood stem cell transplantation. The patients were followed up every month.


RESULTS
Serum AFP levels in 33 out of 35 patients in this study were significantly increased (P = 0.0002). According to the statistical scatter plot, the values of serum AFP on the 25th, 50th, and 75th percentages were 1,210, 1,210 and 28,318 ng/dl, respectively. Of the 35 cases, 21 were stage IV. 18 cases were treated with systemic chemotherapy before surgery, and 3 cases with locally interventional chemotherapy before surgery. Statistical analysis showed that the preferred interventional treatment affected prognosis, and that there was a statistically significant difference (P = 0.024). Some 33 patients completed the follow-up, of which 17 were in complete remission (CR), 5 were in partial remission (PR), 1 became disease progressive (DP) , and 10 died. The remission and overall survival rates were 66.7% (22/33) and 69.7% (23/33), respectively. Patients with the mixed HB phenotypes had worse prognoses than the epithelial phenotype (P < 0.001), and patients in stage IV had a lower survival rate than those in stage III (P < 0.001).


CONCLUSION
Multimodality treatment can effectively improve remission rate and prolong the survival of children with advanced HB. In addition, alpha-fetoprotein (AFP), a tumor marker of liver malignant tumors, HB pathological classification, and staging are highly useful in predicting prognosis.


Clinical Efficacy and Prognosis Factors for Advanced Hepatoblastoma in Children: A 6-year Retrospective Study
Yi Zhang, Wei-Ling Zhang, Dong-Sheng Huang*, Liang Hong, Yi-Zhuo Wang, Xia Zhu, Hui-Min Hu, Pin-Wei Zhang, You Yi, Tao Han chemotherapy, especially platinum chemotherapy, has significantly improved prognosis; and the 5-year survival rate increased by about 75% (Towu et al., 2004;Tiao et al., 2005).However, patients with advanced HB have poor prognosis, especially those with distant metastases (i.e., cancer has spread to other organs and tissues of the body) (Honeyman and La Quaglia, 2012).Currently, the main treatment methods include surgery, chemotherapy, liver transplantation, and local infusion chemotherapy (Czauderna et al., 2006;von Schweinitz, 2006;Gupta et al., 2011;Meyers and Otte, 2011;Perilongo et al., 2011).Reports on stage IV and progress stage HB with high-dose chemotherapy and autologous peripheral blood stem cell transplantation (APBSCT) are rare.In the current work, our aim is to review the clinical efficacy and prognosis of HB, especially advanced HB, with chemotherapy and APBSCT, and to review the clinical efficacy of locally interventional chemotherapy before surgery, as well as to provide some clinical experience.
In this study, we summarized the clinical data of from April 2006 to January 2012.We then analyzed the clinical therapeutic effects of chemotherapy, interventional therapy, surgery, and APBSCT as administered to these patients.

Materials and Methods
Patients A total of 35 patients (25 males and 10 females) with HB were recruited in this study.All patients were pathologically confirmed and diagnosed using tumor markers and imaging from April 2006 to January 2012 (Figure 1).The median age was 3 years (5 months to 11.5 years).According to the international staging system for HB of the American Pediatric Oncology Group (POG/ CCG) (Ross and Gurney, 1998;Linabery and Ross, 2008), the patients were classified into 14 cases in stage III and 21 cases in stage IV.Other clinical data are shown in Table 1.This study was conducted in accordance with the declaration of Helsinki.This study was conducted with approval from the Ethics Committee of Capital Medical University.Written informed consent was obtained from all participants.

Diagnosis
Histopathological diagnosis is the gold standard for the diagnosis of HB.Diagnosis through fine-needle aspiration is feasible for huge tumor cases without surgical resection.Meanwhile, imaging diagnosis, AFP, and the presence or absence of distant metastasis is used for clinical diagnosis for huge tumor cases with hemorrhagic tendency.

Clinical stage standard
According to the international staging standard for HB of POG/CCG (Ross and Gurney, 1998;Linabery and Ross, 2008), HB is divided into stage I to stage IV.Stage III and stage IV are considered as advanced stages.According to the Society of International Pediatric Oncology (SIOP) (Schnater et al., 2002), HB with pre-operation is divided into stage I to stage IV.

Treatment programs
Comprehensive diagnosis and treatment programs are shown in Figure 2A.The commonly used chemotherapy regimens in advanced HB are AEP program (Cisplatin+ doxorubicin+Etoposide), and ACP program (Ifosfamide + doxorubicin+Cyclophosphamide), ICE (Ifosfamide+ Carboplatin+ Etoposide), and the chemotherapy regimen of the refractory cases is CTX + CBP + VP-16 + VCR (Table 2).In the current work, high-dose chemotherapy with APBSCT was carried out after surgery or chemotherapy, achieving complete remission (CR) or partial remission (PR).
High-dose chemotherapy and APBSCT: Chemotherapy combined with recombinant human granulocyte colonystimulating factor (rhGGSF) was used as a mobilizing agent.The following pretreatment chemotherapy program of APBSCT: CEM method was performed as described (Rosito et al., 2002)

A B
Locally interventionaltreatment was impletmented in other hospital (Figure 2A).

Laboratory parameter and observed end
Quantification Kit of Serum AFP: Roche, USA, Lot number: 167399-01.
Test methods of AFP: Chemiluminescence Determination.The normal reference value of serum AFP at our hospital was 0 µg/dL to 20 µg/dL.
Primary end points were determined by recurrence, death, and recurrence-free survival.

Therapeutic efficacy evaluation
When CR is achieved, this means that there are no radiographic signs of tumor residue and that the normal level of serum AFP lasts more than 4 weeks (Corrias et al., 2006)

Statistical analysis
Statistical analysis of clinical data of patients was performed using SPSS 17.0.X 2 test was adopted in data measurement, enumeration data were expressed by percentage and rate, and t-test was adopted for rate comparison.

Efficacy and side effect of high-dose chemotherapy plus APBSCT
One case of a 10-year-old male child with stage IV HB was initially diagnosed as having large space occupying lesion with intrahepatic metastasis, lung metastasis, extensive bone metastases, and bone marrow metastasis.The pathological typing was epithelial.The patient was treated by 1 time liver embolization, and 2 times locally radiotherapy and 4 cycles small-dose chemotherapy before surgery.The patient was part of the residual tumor and 2 cycles chemotherapy after surgery, but patient's condition was disease progressive.The APBSCT mobilized program was the recommended AEP regiment.The collected MNCs were 6.396 × 10 8 /kg, and CD34 positive cells were 2.18 × 10 6 /kg.Hematopoietic reconstitution time was 26 d (peripheral blood nucleated cell count ≥ 0.5 × 10 9 /L, PLT≥20 × 10 9 /L).At 30 days after transplantation, the results of abdominal CT showed that primary lesion was reduced to 10 cm × 8 cm × 4 cm from 18 cm × 15 cm × 9 cm (Figures 3A and B, respectively).Bone marrow metastases were relieved, and bone and lung metastases were also reduced (Figure 2A).PR was up to 6 months.The diagnosis and treatment process can be seen in Figure 4.The side-effect was mainly fever, oral ulcers, and gastrointestinal reactions.The patient was no long-term organ dysfunction.

Preferred treatment program of stage IV cases significantly affected prognosis
The preferred treatment programs among 21 of the patients with stage IV HB, were different.18 cases with HB were treated with systemic chemotherapy before surgery, followed by surgery and chemotherapy after surgery.In contrast, 2 cases with HB were treated with locally interventional chemotherapy before surgery, followed by surgery, and chemotherapy after surgery; 1 case was treated with locally interventional chemotherapy before surgery, followed by surgery, and by chemotherapy and APBSCT after surgery.Statistical analysis showed that the preferred interventional treatment affected prognosis, and that there was a statistically significant difference (P = 0.024) (Table 3).This result suggested that the preferred interventional treatment can induce prognosis of the advanced HB patients in stage IV.

Serum AFP in children with hepatoblastoma is closely associated with clinical efficacy
All 35 cases were conformed HP.Serum AFP levels in 33 out of 35 patients admitted patients in this study significantly increased (P = 0.0002).The data also demonstrated that 1 patient had levels slightly higher than normal (25.08 ng/dl) and that 1 other patient had normal levels (1.2 ng/dl).Patients with increased serum AFP accounted for 97.1% (34/35) of the sample.The compliance rate was 97.1% between diagnosis result and serum AFP level.The lowest and highest values of serum AFP in patients were 1.2 and 484,000 ng/dL, respectively, with the median being 42,066.2ng/dl.According to the statistical scatter plot, the values of serum AFP on the 25 th , 50 th , and 75 th percentages were 1210, 1210 and 28318 ng/ dl, respectively (Figure 4).

Multimodality treatment effectively improved remission rate and prolonged overall survival
All of the 35 cases received 1 to 6 cycles of chemotherapy before surgery except 1, who was lost during follow-up.The average cycles of chemotherapy was 5.8 (2 to 22 cycles).Preoperative embolism  interventional therapy was performed in 3 cases in stage III, and APBSCT was carried out in 1 case in stage IV.Follow-up was performed until March 2012.The median follow-up time was 2 to 67 months.Among the 35 cases of HB, 1 case gave up treatment, 1 case was lost to followup, and 33 cases were followed-up.Among the 33 cases that were followed-up, 10 cases died, whereas the other 1, 17, and 5 cases had PD, CR and PR, respectively.The remission rate was 66.7% (22/33), and overall survival rate was 69.7% (23/33).The total median survival time of advanced HB was 51 months, 95% confidence interval (CI) was 37.1 months to 58.2 months and the 5-year estimated survival rate was 40%, according to the Kaplan-Meier statistical analysis (Figure 5 A).

Hepatoblastoma pathological phenotypes and stages are closely related to prognosis
Prognosis and pathological type: In this study, the histological types of 34 cases were clear (in addition to 1 case who died), consisting ofepithelial and mixed types.epithelial and mixed types were 17 cases and 17 cases.respectively.Among the 10 cases of death, 9 had clear histological types, consisting of 5 mixed types and 4 epithelial types.The follow-up was performed until March 2012.The median follow-up time of patients with epithelial type was 59 months (range: 8 months to 86 months), and the median follow-up time of patients with mixed type was 21 months (range; 7 months to 65 months).In advanced cases of HB in children, the prognosis of epithelial type was poorer than that of the mixed type, according to the Kaplan-Meier Survival Function statistical analysis (t=8.050,P = 0.001) (Figure 5 B).
Prognosis and clinical stage: Among the 33 cases of HB that were followed-up, 19 cases were in stage IV and 14 cases were in stage III.The overall survival rate of stage IV cases was 42.1% (8/19).Among the 19 cases in stage IV, the follow-up time of 16 cases was more than 12 months, the mortality rate was 50% (8/16), the 1-year survival rate was 100% (16/16), the 2-year survival rate was 81.25% (13/16), and the 4-year survival rate was 50% (8/16).In comparison, the overall mortality rate of stage III was 21.4% (3/14); of these, the follow-up time of 9 cases was more than 12 months, the 1-year survival rate was 88.9% (1/9), the 2-year survival rate was 77.8% (3/9), and the 4-year survival rate was 66.7% (3/9).
The long term survival rate in stage IV was lower than that in stage III, and this difference had statistical significance (t= 9.0345, P = 0.001) (Figure 5 C).Annual survival rates of advanced HB patients in stages III and IV were compared, and we found no significant difference between the 1-year and 2-year survival rates (P = 0.75).However, there was a significant difference in the 4-year survival rates (P = 0.012).

Discussion
HB is one of the most common malignant liver tumors in children, accounting for 25% to 45% of all liver tumors.HB is commonly seen in infants and patients under age 3, accounting for 85% to 90% of all cases (Matsunaga et al., 2003).In this study, the median age of disease onset is 3 years, which is in agreement with that reported in the literature.Generally, HB is commonly seen in boys, and the occurrence proportion among males and females is about 3:2 to 2:1 (Brugières et al., 2012).In the current study, all cases were advanced, but the disease was still commonly seen in boys (25/35).Serum AFP is a tumor marker in liver malignant tumors (Marsh et al., 2012).In this study, the serum AFP levels in 33 patients significantly increased, accounting for 97.1% (34/35).The diagnosis compliance rate was very high, account for 97.1%.Therefore, if no condition has pathological diagnosis for primary tumor lesions in the liver with recommended surgery and biopsy to avoid bleeding, then serum AFP can serve as a diagnosis marker for chemotherapy.According to our results, if the serum AFP value is more than 1210 ng/dl along with live lesion, the possibility of HB should be noted.
HP in children is sensitive to chemotherapy.The prognosis of HB with complete operation was better, while the prognosis of HB with metastases to distant organs and tissues was very poor.Some studies have shown that the 5-year survival rate of HB with distant organs and tissues metastases is less than 50%.Therefore, improving the clinical efficacy of advanced HB must be a focus of further studies (Maibach et al., 2012).In recent years, the development of biological treatment for malignant tumors has rapidly progressed; however, the application level and the clinical efficacy of these biological treatments remain unclear (Koh et al., 2011).In our study, analysis of the clinical data and efficacy of 35 cases with advanced HB showed that the overall survival rate was 69.7% and that the survival rate of stage IV was 50%, demonstrating better clinical efficacy.Our objective was to discuss the key factors related with the prognosis of advanced HB, along with operation opportunity, preoperative chemotherapy courses, preoperative condition assessment, postoperative chemotherapy courses according to clinical stage, pathological type, residual tumor after surgery, and so on.
In this study, we selected a reasonable treatment program for advanced HB in children according to various clinical stages and different pathological types.Better efficacy was realized, with an overall survival rate of 69.7% among the 35 cases.According to the results of clinical efficacy analysis and treatment selection, the clinical efficacy of advanced HB with preoperative chemotherapy was better than that of preoperative local interventional treatment, especially in stage IV HB.With better efficacy, local interventional treatment is widely used in treating liver cancer in adults (Vogl et al., 2006).Some studies also reported on HB in children treated with local interventional treatment, but the efficacy was limited (Vogl et al., 2006).In this study, 3 cases of stage IV HB with preferred preoperative local interventional treatment died.The local intervention with advanced HB in children resulted in remission, which can be attributed to several reasons such as strong tumor proliferation of HB in children, and the short distance between the portal vein and the superior vena cava.Therefore, we assume that preoperative systemic chemotherapy should be selected as the treatment course for advanced inoperable HB cases with huge lesions and portal vein tumor thrombus (PVTT).
Meanwhile, high-dose chemotherapy with APBSCT is widely applied in malignant solid tumors in children, for instance, in neuroblastoma (NB), lymphoma, primitive neuroectodermal tumor (PNET), etc.However, reports on HB with transplantation have mainly focused on liver transplantation (Meyers et al., 2012), and few on HB with APBSCT.In our study, 1 case with progressive HB was treated with high-dose chemotherapy with APBSCT.The patient had PR after APBSCT, and his survival time was 9 months after APBSCT.Therefore, high-dose chemotherapy with APBSCT for progressive HB, to some extent, had clinical value with respect to achieving remission and prolonging survival time, although no change in the final prognosis occurred.Thus, high-dose chemotherapy with APBSCT can be a possible treatment method for HB with advanced or prognosis stage.
In addition to reasonable, comprehensive and regular treatment programs, determining the important prognostic factor, pathologic type, clinical stage, and metastases can also affect prognosis.The high-risk group includes stage III and stage IV patients, in accordance with the POG/ CCG and SIOP clinical stage standard.In our study, the prognosis of stage III was better than that of stage IV, and the 4-year overall survival rate of stage III was better than of stage IV.This difference had statistical significance.The results are consistent with previously reported findings (Ismail et al., 2012).
Histological types of HB were classified as epithelial type and mixed type.The epithelial type can be further classified into mesenchymal, fetal, and embryonic types.The mesenchymal type and mixed type are generally undifferentiated and/or poorly differentiated tumors, which have a poor prognosis.Among these types, the prognosis of fetal type is better compared with others, followed by that of embryonic type (Malogolowkin et al., 2012).However, in this study, prognosis of the epithelial type was worse than that of mixed type.This finding is not in agreement with that reported in the literature (Czauderna et al, 2005;Malogolowkin et al., 2012).The median follow-up time of the epithelial type is possibly longer than that of mixed type.Patients with epithelial type have better prognosis; however, once patients show evident tumor residue or distant tissue and organ metastases, the prognosis would be worse.
At present, local and international studies (Ismail et al., 2012;Tsai and Mattei, 2012) have shown that the survival rates of patients with HB treated with chemotherapy, interventional therapy, surgery, and APBSCT have been significantly improved, with 5-year survival rate of about 70%.However, the survival rate of patients accompanied by distant organ and tissue metastases is still unsatisfactory; the lowest value of the survival rate is only 15% to 20%.In this study, the 2-year estimated survival rate reached 66.7%, 95% CI of survival time was 37.1 months to 58.2 months.The survival rate of HB with lung metastasis was 66.66% (8/12), and clinical remission rate of HB with lung metastasis was 58.3% (7/12).
The study results showed that advanced and progressive HB in children had clinical treatment value once a reasonable and comprehensive treatment program was chosen.Cases of advanced HB in children came from a single center in our hospital.Collection time and follow-up time of the cases were shorter in this study.However, the advanced HB, especially the progressive diseases, still had treatment value according to the study results.
In conclusion, advanced HB should be treated through multidisciplinary combination therapy, along with long-term and regular treatment, to improve the clinical remission rate and prolong survival time.In this light, high-dose chemotherapy with APBSCT may be a valuable treatment approach in improving progressive and refractory casesof HB.

Figure
Figure 3. A. Multiple Large Lesions in Liver were Observed Before APBSCT.B. Large Lesions in Liver Alleviated after APBSCT

Table 1 . Clinical Data of 35 Cases of Advanced HB
After intervention twice, the right atrium metastases observed, then after surgery twice, 11 cycles of chemotherapy, progress of the disease got worse and the patient died

A: Comprehensive Diagnosis and Treatment Programs; B: Diagnosis and Treatment Process of High-dose Chemotherapy Combined with Autologous Peripheral Blood Stem Cell Transplantation
No remission and deathSpace-occupying Lesion in LiveAccording to SIOP Staging Imaging diagnosis and serum AFP value Hepatoblastoma stage ( large space occupying lesion) liver embolization treatment once Intrahepatic metastasis accompanied by distant metastases local radiotherapy twice, and low-dose chemotherapy 4 times Surgery treatment: partially remain Reached PR Two cycles of chemotherapy after surgery, but the disease progressed Treatment of high-dose chemotherapy combined with APBSCT Prognosis: PR time of 6 months after transplantation, tumor relapsed and died after transplantation, and overall survival reached 9 months