With an increased incidence of liver cancer in U.S. children, pediatricians need to understand the most common tumors, pick up on possible signs and know first workup steps. Pediatric hematologist-oncologist Arun A. Rangaswami, MD, offers this guide, including stats to show when hepatoblastoma (the most common childhood liver malignancy) is likely – and when it's not. Learn how UCSF's pediatric experts approach diagnosis, using advanced techniques that inform prognosis, and how an international effort to enhance risk stratification helps clinicians select the best treatment for individual kids. Bonus: Hear about relevant clinical trials currently underway at UCSF.
It's my very great privilege to uh be able to talk with you. Um Today, I'm gonna talk about uh our pediatric liver tumor program and also about our pediatric Liver Center of Excellence. Um So if I'm gonna share my slides and then put it in presenter mode. All right. Um So I have no disclosures and this is the outline of the talk. So I'm gonna start off with a case summary of a patient and, and that patient's clinical course. Then um I'm gonna give an introduction to pediatric liver tumors. Um Talk a little bit about the role of the primary care provider um in managing these patients. Then I'm gonna focus on hepatoblastoma, which is the most common uh pediatric liver malignancy in childhood. Um I will talk a little bit about our uh pediatric liver tumor program and then more generally about our pediatric Liver Center of Excellence um which uh Emily and I can both sort of uh do and, and answer any questions. So again, thanks so much for um attending and, and for having me. So I'm gonna start off with AAA pretty typical case summary. So an eight month old patient um obviously with pab Blastoma. Um Oh, sorry, this is the uh sorry, I I put up the wrong case summary. I don't know how I did that. Let's see, um apologies for this. Um But the the an eight month old patient who presents with a right abdominal mass, uh and a seven day history of progressive abdominal pain, fever and fussiness. I mean, it presents to the primary care physician's office who uh primary care physician noted the right abdominal mass and ordered an ultrasound which uh demonstrated a large right sided hepatic mass. Um The Doppler portion of the ultrasound demonstrated attenuation of the intra paic portal vein and the patient was uh referred to the U CS F emergency department. There. Again, a right sided mass was palpated as well as hepatomegaly. Um at the ultrasound, uh as mentioned, showed a large hyper echoic mass situated in the right lobe of the liver. The labs were significant for a platelet count of 675,000. A hemoglobin of eight and then tumor markers were significant for an alpha theta protein of 1 million. Um The patient went on to have an MRI scan with a hepatobiliary contrast agent called EOVIST, which demonstrated a 10 by 12 by eight centimeter mass in the right hepatic lobe um with complex uh free fluid presence in the abdomen and the mass involved uh queen art segments 56 and seven with right portal Venus involvement AC T of the chest was negative and a pretext uh uh stage was three with an annotation factors being one p, one for portal vein, R, one for rupture because of the presence of fluid in the abdomen and the other annotation factors were negative. And I will, I will talk a little bit about what that terminology means that nomenclature of pretext and annotation factors. CT shows is very large, right sided abdominal mass and one can sort of notice that there is um rupture of the cortex or the capsule rather of the, of the mass. Um This shows uh the mass scene um in a coronal view. Um And an MRI again, with U of S shows this large enhancing mass in the right lobe of the liver. The patient underwent an ir guided biopsy which demonstrated hepatoblastoma with mixed fetal and embryonal histology. Uh consultation with pediatric surgery uh suggested that given the presence of tumor rupture, delayed resection was uh preferred over upfront resection. Um Because of the other clinical features of this patient, um they were deemed low risk and they started neoadjuvant chemotherapy with a combination of uh agents called C five VD, which uh indicates CIS platinum five fluorouracil vinCRIStine and DOXOrubicin. The patient received four cycles of chemotherapy and underwent resection and then received two cycles of adjuvant treatment with um normalization of the A FP uh during that time period and that patient remains in a continuous uh complete remission at this time. So to turn gen more generally to pediatric liver tumors, about two thirds of all liver masses in Children are malignant. So when we see a liver mass in a child, the odds are more likely than not that it will be a malignant lesion. Um However, malignant liver tumors themselves are rare. Accounting for only about a 1% of all childhood malignancies in the sere database. Um there are 100 to 100 and 50 cases of malignant liver tumors in Children each year in the US. And of those um two thirds are hepatoblastoma. When we look at the approximate distribution of pediatric liver masses by diagnosis. Again, 43% are hepatoblastoma. Um 23% hepatocellular carcinoma, 13% vascular lesions, 6% mesenchymal hamartoma, which are benign, 6% sarcomas, 2% hepatocellular adenoma, again, a benign lesion but nevertheless, relevant. Um 2% focal nodular hyperplasia which again um is a benign lesion and 5% comprising other diagnoses such as malignant rhabdo tumors of the liver, um undifferentiated embry embryonal sarcoma of the liver and primary biliary tract rhabdomyosarcoma. So, in considering a differential diagnosis for a liver tumor, um the age of the child is very, very important. So, early in infancy, we see in the benign tumors, we see hemangioendothelioma, um mesenchymal hematoma and teratoma. Um he hemangioendothelioma are actually quite uh important diagnosis for to recognize because these can cause significant clinical uh uh um adverse effects. For example, we can see a consumptive coagulopathy called cassava merits syndrome in large cavernous heelas. We can also see um a high output uh congestive heart failure. Um And then interestingly enough, a perineoplasty syndrome that is seen with these lesions as hypothyroidism because they secrete an enzyme that degrades thyroxine with respect to malignant lesions. Again, hepatoblastoma by and as far as the most common followed by rhabdo tumors, yolk sac tumors that are primary tumors of the liver, which are rare longer hunt cell histiocytosis and metastatic neuroblastoma in early childhood. Again, we still see heio neilio um and mesenchymal hamor toas. But now we see more inflammatory myofibroblast tumors in the benign category and in the malignant category, we see a pat blastoma and then rhabdomyosarcoma. Um Later in childhood, uh you may see an angiolipoma as a benign lesion. Um or again, hepatic cellar adenoma in the malignant category, you're starting to see more uh hepatocellular carcinoma and actually a intermediate entity that has been recently identified, which is called hepatoblastoma with carcinoma features. Um is um the most uh likely um diagnosis in Children over the age of eight who have a malignant uh tumor of the liver. This is a, a lesion that is, as I said very recently di um uh classified, it hasn't yet entered the formal uh classification is the consensus classification for theatric liver tumors because it, it really is fairly recently identified based on both histopathologic and molecular findings. Uh and then embryonal sarcomas can occur in this age group as well as you see, hepatoblastoma is extraordinarily unlikely in this age group. And then in adolescence, um benign lesions include adenoma, um and cyst Anoma of the biliary tract. Again, hepatocellular carcinoma, more classical hepatocellular carcinoma now and then fibro lamellar carcinoma, which is a uh previously thought to be a variant of hepatocellular carcinoma, but which is now uh classified uh by a pathetic um uh chimeric fusion that identifies it as a distinct entity. One can also see lymphomas uh in the liver and leom myo sarcomas. So, as you can see, the age at diagnosis is extraordinarily important in approaching the differential diagnosis. Um the clinical presentation of liver tumors, they're usually asymptomatic masses detected by a parent or by the physician. Um the patient, if they're symptomatic can present with abdominal pain, weight loss, rarely anorexia, vomiting with more advanced disease. Um Jaundice and liver function abnormalities are rare. They do happen when tumors impinge on uh the biliary tract. And then of course, there are rare entities in um young adults where there is a composite tumor of cholangiocarcinoma and hepatocellular carcinoma that also will present with um jaundice. Um You can also see jaundice uh and LFT elevations in the context of fibro lamellar carcinomas which have a tendency to cause a lot of local regional nodal disease which in turn can cause um biar out o outflow obstruction. Um If you remember the case I presented had a very high platelet count. Um and that thrombocytosis is due to the production of thrombo potin by hepatoblastoma. So, in a patient who has a liver mass and a very high platelet count, the suspicion for hepatoblastoma should be increased because um that is one of the kind of characteristic features. If, if thrombocytosis is not seen, it doesn't exclude hepatoblastoma. But if it is seen, it strongly points towards a pat blastoma. And then of course, uh we see elevations in alpha theta protein in 90% of hepatoblastoma. We also see elevations of a FP in hepatocellular carcinoma, although usually not as high as hepatoblastoma. And then in fibro lamellar carcinoma, the A FP is usually normal. A FP elevations can actually be seen in a number of benign conditions. You can see elevation with anything that causes hepatocellular injury. So, hemangioendothelioma and mesenchymal hamartoma simply by mass effect can uh elevate A FP. Um It it usually is not in the range of hepatoblastoma which uh presents with a FPs of 10,000 all the way to over a million. Um And so I, you know, I think it's important to also recognize that patients with Beck with Wiedeman syndrome and we'll talk a little bit about this later, um can have a baseline, elevated alpha fee of protein and that can be confounding as those patients are also at increased risk for development of a pat blastoma. So what is the role of um primary care providers such as yourself in the management of pediatric liver tumors? Well, of course, the primary care provider is often the very first to detect an asymptomatic abdominal mass. And I will say that I would probably about half of my patients are referred because of an astute primary care physician who feels a mass. As I mentioned, the differential diagnosis is really dependent on a diagnosis, clinical and laboratory features such as a FP imaging findings. Tissue diagnosis is the gold standard for all primary hepatic neoplasms. I say this because in prior um treatment eras, um an elevated A FP and a liver mass would have been sufficient to make a diagnosis of hepatoblastoma. However, we are in now the era of next generation sequencing and molecular phenotyping and therefore, there's a lot to be gained by both histopathologic examination um of a biopsy as well as running next gen sequencing such as our U CS F 500 which can I identify prognostic variables as well as potential therapeutic targets. Um Initial laboratory evaluation would be a CBC D. Um A complete metabolic panel, rarely hepatoblastoma. Patients like neuroblastoma patients can present with hyperuricemia. Um and they can certainly develop tumor lysis syndrome in the context of chemotherapy. Um patients uh with uh hepatoblastoma that are large lesions, um can sometimes have associated renal insufficiency. Um and then hepatic function is important to assay the other reason to look at renal function is because if one is ordering AC T scan with contrast, one needs to understand that the renal function is normal. In order to do so, um we normally do get coagulation studies mainly to look at hepatic synthetic function as I mentioned previously in A FP. And then um at our institution, we do tend to get urine catecholamines H VA and V MA because another possibility other than a primary liver tumor would be a metastatic tumor to the liver. And um we know that that happens, for example, in neuroblastoma, um it could happen in sarcomas. So uh we do order H VA and V MA routinely as part of our work up of these patients. The initial radiologic study of choice, which is what the primary care physician really. Um orders is an ultrasound with Doppler and that is really to assess the abdomen, the mass, of course. But also is there adenopathy, is there any macrovascular invasion? Um once the mass is detected, the patient uh is usually referred to the emergency department. And we tend to admit these patients for an expedited oncologic work up because we can get um for example, an MRI scan arranged much quicker on an inpatient than we can on an outpatient. And then the other important role of the primary care provider, which is a more anticipatory is in the context of Beck with Wiedeman syndrome. And I'm sure that you're all familiar with Beckwith Wiedeman syndrome, uh which is a syndrome that is uh genetic syndrome um uh that uh maps to love and p um and these patients are at risk for development of hepatoblastoma as well as Wilms tumor. And so they are um getting, you know, ultrasounds frequently as well as a FP measurements. And this is something that our primary care physicians um you know, uh do for us screen these patients and then refer if they find a uh concerning lesion. So I'm gonna turn now to hepatoblastoma. Um Hepatoblastoma, as I mentioned previously is the most common primary liver neoplasm in Children under 15 years of age. However, at 1.6 cases per million, it is a rare pediatric tumor. Um It comprises over two thirds of all uh malignant liver tumors in the pediatric A Y A population and 90% of all liver tumors in Children under four years of age. Um We have noted an increasing incidence annually in the United States and in the European Union. The reason for this is unclear, um it may be uh linked to, for example, increased use of fertility medications or for um our ability to salvage premature infants at earlier and earlier ages. Um and nicu exposures, um risk factors for a pat blastoma are prematurity and I mean extreme prematurity. Um So that's any patient under uh 30 weeks. Um very low birth rate, which is defined in this context is less than 1.5 kg, parental tobacco exposure and then potential associations that are yet to be proven ionizing radiation such as happens in the NICU when we have babies getting frequent x-rays, erythropoietin um for for infants with acute kidney injury in the NICU uh TPN exposure and then fertility medications. These are potential associations. They have yet to be shown to reach significance. We have an epidemiology um working group within the liver Tumor Committee and the Children's Oncology Group. And Logan Specter who is um our lead epidemiologist and based at the University of Minnesota has um published a lot of very compelling data about linkages with hepatoblastoma and other congenital conditions and exposures. Historically, four international co-operative groups uh undertook the study and treatment of this disease Children's oncology Group here in North America, SEL in the UK and Europe, the GPO H uh in Germany and the JP LT. Um the G GPO H no longer exists. The German uh pediatric oncology and hematology group has merged with SEL and the JP LT uh has also merged with the Japanese Children's Cancer group or the JCCG. So both of those um are now legacy Cooper Groups. However, their trials are continuing to be published as um those mergers were fairly recent and this um is uh data from the CR database uh 2017 that shows age adjusted incidence rates for a pat blastoma shown here in blue and then hepatocellular carcinoma. Um And what is very interesting to me now, is patients in this middle group who we often called either patients with hepatoblastoma or HCC hepatoblastoma being, you know, older patients HCC being younger patients. But in fact, as we do more and more molecular uh studies of these patients, it appears that that intermediate age group um may be a distinct entity unto itself. This um histology alluded to earlier called hepatoblastoma with carcinoma features. And these are patients that typically have both um unusual histology and molecular findings such as mutations in the telomerase, uh reverse transcriptase promoter, um arid one, a other uh genomic markers that are seen in hepatic cellar carcinoma, but they can also harbor CTNNB one beta ken and mutations seen more frequently in hepatoblastoma. And they seem to be some sort of an intermediate diagnosis, um intermediate as well in response to treatment and in respon and in overall survival and event free survival. So, this is a group that we are very interested in studying in the future hepatoblastoma. Um has a median age of diagnosis of 16 months and only 5% of cases occur in Children over four years of age. It is more common in males than females and uh it's associated as I mentioned with extreme prematurity. Um The relative risk of hepatoblastoma is inversely proportional to birth weight. And in Japan, hepatoblastoma accounts for 58% of all malignancies diagnosed in surviving preemies weighing less than 1 kg at birth hepatoblastoma, um associated with a number of cancer, predisposition syndromes and genetic syndromes. Foremost upon uh uh among these is Beck with Wiedeman, um which I mentioned earlier and these are patients for whom uh there are defined screening guidelines to promote early detection of uh patients with a pab blastoma or with Wilms tumor patients. Uh who are have a history of familial adenomatous polyposis uh caused by mutations in the adenomatous polyposis coli gene or A PC gene are at increased risk for hepatoblastoma. On patients with hereditary hemorrhagic tong Mutasa caused by mutations in SMD. Four other overgrowth syndromes such as Prod Willie syndrome, Soto syndrome, Simpson Globe Bemmel Syndrome, and then patients with Williams Syndrome or Trisomy 18, which um used to be uh considered uniformly fatal uh genetic syndrome. But these patients with improved supportive care and uh surgical interventions are living longer and now are surviving long enough to get hepatoblastoma. Um Now, other than Beck with Wiedeman Syndrome and familial adenomatous polyposis, um We do not have screening guidelines for any of these other conditions as of yet. That's mainly because we have to ascertain more accurately what the true incidence of of hepatoblastoma is in these other diagnoses which are are quite rare compared with Beck with Wiedeman Syndrome. Um And so at the present, we are only really screening back with patients and fa p patients for embryonal tumors. Um And so I just uh wanted to talk a little bit about back with Wiedeman syndrome and the defective imprinting at the IGF two H 19 locus on chromosome 11 P 15, as well as um the cause being your uniparental dys soy. Um where there is um you know, a single uh chromosome 11 inherited um from uh rather two chromosome elevens inherited from one parent, usually the father. Um and turning to FA P, um there has been a lot of variable estimates of Germline ABC mutations in a Pat Blastoma. The Germans in 2006 published a fairly high incidence rate of 10%. The group in Cincinnati found a higher incidence with a lower number of patients but they included variants of uncertain significance. We have an ongoing retrospective study of now over 100 and 20 patients. These are patients um that are um enrolled on this study from Stanford U CS F, the DFC I, uh Children's Oakland Huntsman Institute in, in Utah as well as in uh the French uh database. Um And we are trying to perform a correlation between um ABC gene mutations and clinical characteristics as well as prognosis. Um And, and I am the um senior P I for that um that study. All right. And then the other thing that I wanted to talk a little bit about is the biology of hepatoblastoma. Um Hepatoblastoma, um classically is associated with acquired mutations in the wind pathway. Typically mutations in beta kinin an A in one but also in A PC, as we mentioned earlier, um typically, one sees only one of these wind pathway mutations in any patient. So either beta Kinin or AON one or A PC, um there are mutations associated with overexpression of downstream genes like Cyclin D one and then over expression of wind related proteins for which now we have developed um antagonists that are being deployed in early phase clinical trials to see whether these wind driven tumors such as hepatoblastoma can be um treated by um by reversing the uh the amount of protein in their um blood. Um And so, the role of the wind pathway really is in um pat in, in, in neoplasia and proliferation. So what wind does is take a normal fetal hepatocyte and when wind is constitutive um expressed that fetal hepatocyte transforms into a malignant cell or a. Uh this is of course, 90% of what hepatoblastoma patients have beta AEN and mutations or wind pathway mutations. So, historically, in terms of staging, there were two approaches um surgical staging um which is the children's oncology Group's historical approach, um looked at uh extent of resection. So, stage one completely resected. A stage two resected with microscopic residual disease. A stage three is a patient who has gross residual disease, including involvement of local regional lymph nodes and an inability or, and or an inability to resect the primary tumor and stage four distant metastatic disease more recently. However, our European colleagues developed a more sophisticated staging system called pretext or pretreat extent of disease. Um This was developed by the PSY OP group um in Europe and it's based on the number of liver sectors, not segments, sectors. So if you look at the uh liver in an A P uh dimension and divide that liver into four equal sections, um This is based on the number of contiguous sections that are involved. Um We look at the degree of extra paic extension and whether me metastatic disease is present and these are characteristics that help to determine resect il. Although this is really ultimately determined by the surgeon, um because we do not want surgeons to operate outside of their comfort zone on patients like this. Um Because for example, a uh rupture of a tumor that could have been shrunk with neoadjuvant chemotherapy um is AAA significant complication and uh a risk category for patients. Um The Europeans developed pretext staging as well um out of an interest in in giving preoperative chemotherapy in a more um individualized fashion based on extent of disease. Um Multivariate analysis in the Copel one chemotherapy trial uh showed that pretext staging uh was the only predictor of overall survival. I mean, we believe that it was because pretext staging is a surrogate for resect il and possibly biology. And um the other thing that was predictive of event free survival was um uh the presence or absence of metastatic disease. And so this is where a group called CHIC that I chair comes in. Chic stands for the childhood A paddock tumor International Collaboration. And CHIC is a uh um a attempt to unify the language of uh risk stratification and harmonize it among the different National Cooper groups. So as I as I show here, historically, North America used the Evans staging or the cog staging. And sel used the pretext staging system. So the traditional Evans staging, we've already been through the cell staging system. Um is actually, and this is the historic uh staging system because there was a modification on the staging system published in 2018. But that modification is somewhat controversial. So I'm gonna discuss the historic staging system. Um So again, pretext stands for pretreat extent of disease. We now are looking at post text or post treatment, extent of disease to see whether post text correlates with outcome. Um Patients can be pretext 123 or four based on how many sections of the liver are involved. Here are the four equally divided sections of the liver and then there are these annotation factors. Um And this is what I alluded to earlier in the case presentation. So in patients who have in growth in the vena cava or all three hepatic veins, we call those patients v positive um in, in growth in the right and left portal vein or at the bifurcation, we call P positive E stands for contiguous extrahepatic tumor, F for multifocal tumor, um R for preoperative tumor rupture. See, for caudate lobe involvement, the caudate lobe sits here. It's, it's actually um the Coard segment, one of the uh uh liver and because it is so closely associated with the vasculature, um caudate lobe involvement in and of itself can increase um the potential necessity of using transplant as the local control measure rather than resection because um only about 25% of patients who have co caudate lobe involvement can be resected. The majority of those patients require transplant. N stands for lymph node involvement and M for distant metastatic disease. So you can see that this is a much more um nuanced way of approaching tumors of the liver, looking at both local extent of disease and also macrovascular involvement and also metastatic disease in a unified system. So, going back to chic chic is the largest database extent in a pediatric rare tumor. Um it comprises 1605 patients um drawn from four historical co-operative groups and eight clinical trials. And actually, recently, this database has now increased to 2000 uh 200 patients because we recently added um data from more contemporary trials that have been published. Um Then in the um original uh database was formed of eight clinical trials. These were the German HP 8999 trials int 0098 from the US uh OG 9645 from the US JP LT one and two from Japan and Syal, two and three from uh Europe. And what we did was we pre we pooled all of this data using a U A common set of prognostic risk factors that were uh agreed upon by consensus. We performed a univariate analysis and then we performed a statistical methodology called backwards elimination um to perform a Multivariate analysis um within these four actually five backbone groups um which are backbone, one pretext, one and two backbone, two pretext, three backbone, three pretext, four backbone, four metastatic disease and backbone five A FP under 100 as a um putative negative prognostic marker. Historically, we also looked at age um as a prognostic factor and this is one of the most um I think important uh um discoveries by Sheikh, we uh actually determined that age appears to be a continuous adverse prognostic variable in hepatoblastoma. So increasing age inversely affects the hazard ratio um for metastatic disease and annotation factor positivity. What I mean by that is that when you become old enough, like over the age of 11, it doesn't matter whether you're nonmetastatic or metastatic, your outcomes are very poor regardless. And this shows that effect of increasing age abrogating the effect of metastatic disease which you see here. So here are the pretext um and uh sorry, the chic stratification uh algorithms or trees as we call them. And um the, this is what we use to stratify patients to treatment to, to this day. Um And then we have no longer using a FP under 100 because the chic uh database was analyzed. And what we found is when you take out all the patients who had wrong diagnoses. So for example, rhabdo tumors who have normal A FPs that low A FP in and of itself was not an adverse prognostic factor in typical hepatoblastoma. So what about local control of hepatoblastoma? Well, hepatoblastoma is a surgical disease and complete surgical resection is necessary for cure. Only 40 to 50% of primary tumors are resectable at the time of diagnosis. And the goal is a lobectomy with a clear margin for pretext, one in two patients and then pretext three and four patients should really be biopsied. The diagnosis with an early referral to a transplantation center such as here at U CS F. Um for consideration of either liver transplantation or a complex or extended liver resections, which really should be done by um centers where transplantation um allows for greater surgical expertise to conduct these types of operations. Um Cis platinum based chemotherapy regimens generally make about 50% of unresectable tumors resectable. So that, that's good news. Chemotherapy when administered, uh neoadjuvant um does help to shrink tumors and make them resectable. But that leaves about 25% of tumors that may require advanced surgical approaches including transplant or Ortho topic, liver transplant. Um And then there is some evidence that the Copel chemotherapy regimens which are CISplatin intensive may actually be superior to the cog regimens in terms of rendering resect. And this is under active study currently also for patients who have pulmonary metastatic disease. Hepatoblastoma is the one type of metastatic childhood cancer for which a uh liver transplant can be allocated. Hepatocellular carcinoma is not in that category, at least not yet. Um And so, however, they do need to have um resolution of their metastatic disease, either by resection, if they don't disappear with chemotherapy or if they have an excellent chemotherapy response and a negative CT scan that is also adequate for proceeding with liver transplantation in terms of chemotherapy. Um The mainstay is multimodal therapy with um CISplatin based pre and post operative chemotherapy. The children's oncology group, as I mentioned earlier uses a regimen called C five V or C five VD in um standard risk or intermediate risk or high risk patients. Cis pla um sel used play do CISplatin and DOXOrubicin in high risk patients and CISplatin monotherapy in low and standard risk patients. The Germans used IOS and CIS platinum and found a higher incidence of second malignant neoplasms. And the Japanese used epiRUBicin and CISplatin and they also found an increased risk of a second malignant neoplasms. Um salvage therapy with vinCRIStine and Ninan is effective as are other salvage regimens like carboplatin and an topic side which tends to be my go to actually based on German data that's been published recently. The utility of radiotherapy um in hepatoblastoma is principally confined to the treatment of extrahepatic nodal disease, especially for example, a patient who has jaundice that limits administration of chemotherapeutic agents like vinCRIStine or dox Rusin. You can use radiotherapy to relieve the the point of uh obstruction and allow the bilirubin to return into a range where you can deliver um appropriate chemotherapy. And then I was um the P I the, the US P I of A Copel trial that looked at um Ammas. Um I'm sorry, that looked at sodium thy sulfate to uh reduce ototoxicity in uh Children receiving CISplatin based chemotherapy and we found an almost 50% reduction in uh ototoxicity in patients receiving um uh CISplatin based uh chemotherapy. Um This was in standard risk patients. The cog trial looked at Ammas as a auto protectant and unfortunately, ammas did not bear out to be a protective but sodium thul uh does. And so that um was published actually in the New England Journal of Medicine. So this very complicated scheme is how we treat hepatoblastoma. Currently, this is the ah e 1531 cog nomenclature or the fit the Pediatric Hepatic International Tumor trial. This trial recently closed in January of this year. Um It was a trial conducted across um North America Europe, Japan, um Australia, New Zealand and um Asian sites such as India, Hong Kong and Singapore which enrolled patients uh under the Japanese umbrella. It was the first international trial for a uh pediatric liver tumor. And it was really quite a successful experiment in our ability to, to study a relatively rare disease by leveraging the numbers of patients available through international collaboration. So just to summarize pediat hepatoblastoma is a rare pediatric tumor with all the inherent challenges that that means in studying it, the four major cooper groups that have studied hepatoblastoma I've mentioned and there were variable approaches to staging and treatment which were harmonized through the chic uh uniform wrist stratification system. So I'd like to turn a little bit to the U CS F pediatric liver tumor program. Um and our liver tumor program, um you know, uh treats Children to young adults with a variety of diagnoses including hepatoblastoma. HCC hepatoblastoma with carcinoma features fibro lamellar, carcinoma, undifferentiated embryonal sarcoma, the liver rhabdo tumor and cholangiocarcinoma. Um We are uh employing a number of strategies to improve outcomes. We are leading uh a, a National pediatric International pediatric Liver tumor Board. Um We have international research collaborations, as I mentioned, leadership in clinical trials. Um as well as I should mention Emily's role in uh leadership and uh approaches to immunosuppression in the con uh in the transplant context. We're defining a better clinical and biological risk factors and trying to identify molecular targets. Um Ours is a multidisciplinary team which includes hepatobiliary transplant surgeons, um Hepatologists, oncologists, radiologists interventional radiologists, pathologists, um and molecular pathologists in genomics. Uh Our faculty have leadership positions in the Cog Liver Tumor Committee. They have 1531 study committee, the Sel uh Consortium, the Sheik Consortium. As I mentioned, we are participating in a uh development of a pilot trial for fibro Andell carcinoma. And as well, we're participating in a pilot trial for high risk hepatoblastoma. Both of which are have been drafted and submitted to the Cog Science Council for consideration. We are participating in a relapse refractory Hepatoblastoma registry. Um uh Emily has, you know, has leadership in Unos and the Starzl Network. And then we participate in the pediatric Surgical oncology Research Consortium. We have a monthly International Multi Center liver tumor board which I'll talk a little bit more about. Uh later, we have integration with the pediatric hereditary cancer clinic which I lead with our molecular tumor board and our early phase uh um program. And uh and um and of course integration with the U CS F Liver Center and ongoing research collaborations such as risk factors and a Pat blastoma HCC through chic incidence of de Novo germline A PC mutations in the Multi Institutional trial genomic profiling of pediatric liver malignancies in a collaboration with the Sweet Cordera Lab. And then uh both Doctor uh Bruce Wang and AMR Njal have laboratories that are looking at single cell sequencing of a Pat blastoma. While doctors Sweet Cordero's laboratory really looks at bulk sequencing of those tumors. We have a number of um trials, open a phase two trial of immune checkpoint inhibitors, pembrolizumab and relapsed and refractory hepatocellular carcinoma and H CNN OS that is open in accruing a phase two trial of CISplatin recall with sodium thio sulfate um for odor protection in patients with relapse and refractory solid tumors that are sensitive to CISplatin. This of course is uh extends beyond hepatoblastoma and this is pending site committee review at our institution and then we recently opened and treated our first patient with an industry sponsored trial of an A FP specific car T uh agent in Children and adolescents with relapse and refractory hepatic cellar neoplasms. And, and actually, um uh this is uh for any patient with a high A FP secreting tumor, meaning an A FP greater than 100 that patient a as long as they have the correct HL A type HLA A two that patient will be eligible for enrollment in this trial. The U CS F Multi Center International Hepatobiliary Tumor Board is a monthly forum with participation by an international panel of experts um spanning all of the disciplines of listed there. Um Many of our panel lists are members of the Cog Liver Committee SEL or the Japanese Group. Um It provides consultations to clinicians managing these rare and challenging diagnoses. Um I say it lasts 60 minutes. It, it now typically goes to 75 minutes. Um We have an average of three cases per tumor board and a max of four cases. And it, on occasion, when we have the time we incorporate a 15 minute didactic lecture focused on clinical and basic science research or new clinical tri trials that are available. The goals are to really provide access to global expertise um in managing challenging cases to update clinicians on developments and risk stratification and treatment approaches and to advertise available early phase clinical trials for eligible patients. Um We have considered patient confidentially confidentiality and autonomy. Uh We have a secure platform for PH I, we have integration of global expertise and pediatric liver tumors. Uh We are supporting enrollment in Cooper group trials, uh a user friendly interface and a quick turnaround and case review. And we do have the capacity for expedited reviews and anybody uh any physician is welcome to, to participate. Um You don't have to be a pediatric oncologist. If you're a primary care physician, you have a, you're managing a patient with a liver tumor and would like to, you know, have that patient considered. We're always happy to do that. Um Current participation spa spans a number of sites across the United States, Germany and Europe, Canada, Mexico, Brazil, New Zealand, Japan, Hong, Kong, Vietnam, India, and the United Arab Emirates. And the sites that I have highlighted and read to note um centers that serve uh uh uh enriched rural minority, uh indigenous or resource challenged populations. We have been selected as the site of the next international pediatric liver tumor symposium in spring of 2025. Previously, this was hosted at Texas Children's Cincinnati Children's and most recently, Boston Children's, the symposium is biannual. Um and its center is considered to have expertise in the management of pediatric liver cancer. The duration is 2 to 3 days of scientific sessions with concurrent poster and abstract sessions and one day of patient family advocacy forum. Uh Usually we have 100 to 100 and 20 individuals attending from across the world, representing a variety of um specialties, referring local oncologists are invited and covered. And of course, if there are any pediatricians are interested in this area, you would be more than welcome uh to uh join I'll pivot now to our pediatric liver center of excellence which uh expands beyond uh liver tumors into other conditions um associated with pathologies of liver in Children and adolescents and young adults. We have multiple missions caring, healing, teaching and discovery and um and, and these are reflected by, for example, you know, clinical consultations that we provide or advanced fellowships and oncology and transplant and uh you know, hepatology and an interventional radiology. And by uh our research endeavors both in terms of clinical trials, discovery through the sequencing efforts of our uh of our scientists and looking at things like health outcomes and disparities. Uh And so, uh we try to do multiple uh missions uh that support the U CS F mission. Um In 2017, we could came together to launch the pediatric Liver Center. And I don't know, Emily, would you like to sort of, uh, take over to talk about this? Sure. That, can you guys hear me? Ok. Yep. Ok. Um I, this has been a really exciting effort for us, um, you know, to, to really work together and try to make sure that when a child is recognized to have some sort of liver disorder by their primary pediatrician or somewhere else of the experience for the the child and the family and the referring doctors is really seamless that you can access sort of whoever in our team you need as the sort of work up evolves. Um And so it has been a really exciting opportunity for arun and I and several of our other specialists to work together to really try to create a medical home for every child diagnosed the liver disorders so that we can really both offer and and deploy our team of experts in a really comprehensive and equitable way to provide services for families. Um as well as providing a great platform for us to do things like advancing research um in, in a lot of different areas related to pediatric liver conditions so that we can increase children's opportunities for long term recovery and health, not just the U CS F, but in a broader community as well. Um This is what our clinical team looks like. As you kind of saw presage on the last slide, we are really excited to have a team of folks from a lot of different specialties that include arun as you see here, Emer who's one of our pediatric surgeons um and me as the co-director um from our different specialties as well as radiology, transplant surgery, um interventional radiology, radiology, and folks really on both sides of the bay so that um kids and families can access this kind of care wherever it's most convenient for them. Um This is a list of conditions treated in a little bit about how we work together on all of them. But again, I think the important thing here is that our goal is to be sort of uh to have a relatively seamless point of entry for the child and the family as well as the referring doctor. So that if you have something happen where you identify a liver mass on an ultrasound from a PC P, um that you can be referred to U CS F in the liver center. And if arun is the right person for you, because it's have had a blastoma, then you get hooked up with his team. But if you, you know, finds that it actually is something smaller and a non malignant mass that um it's a very sim like easy sort of transition over to my team, maybe in conjunction with the interventional radiologist or even the third. So we try to take on a lot of that work in terms of who does the family need to access to really get the best care um behind the scenes. So that from a family perspective and from your perspective, as a referring provider, that it's really easy. And I mean, I mean, um, you know, doesn't require sort of separate, going to different folks and trying to figure out where you need to be. So this is, I think just a um, a longer again list of, of all the things we do, which is essentially anything that has to do with the liver. It sent the blood vessels in and out of the liver, the bile duct, um you know, all the way through obviously to the liver transplant team that I helped lead as well for those kids who need that.
