P.387: Outcomes of pediatric Hepatocellular Carcinoma: A single-center experience with resection vs transplantation.

Objective: Pediatric hepatocellular carcinoma (HCC) presents significant challenges due to its aggressive and chemoresistant nature, with survival depending on complete resection. The definition of which tumors are potentially resectable and which patients may benefit from OLT has not yet been applied in children. We aimed to assess outcomes in pediatric HCC between liver resection (LR) and liver transplantation (OLT). Methods: An institutional retrospective review of children who underwent LR vs OLT for histologically confirmed HCC was performed. Demographic data, age at diagnosis, neoadjuvant or adjuvant therapies, primary treatment option, disease-free survival, recurrence and mortality were noted. The number and location of tumors, maximal tumor diameter and the presence of vascular invasion were evaluated through imaging techniques, pathology reports and surgical data. Kaplan-Meier survival curves were constructed for the different therapeutic groups. Results: A total of 25 patients (16 male and 9 female) were identified, 14 with an underlying chronic liver disease. The mean age was 12.1 ± 3.5 years in de novo HCC and 7.8 ± 6.1 years in children with cirrhotic liver. 7 patients were eligible for LR, while 14 were directly considered for OLT. Transplantation was ultimately performed in 17 children. Recurrence of HCC was detected in 8 (38%) patients, showing location differences between LR and OLT groups. De novo tumors had a higher recurrence rate and a poorer prognosis (P <.05). Overall survival in de novo HCC was 100%, 85% and 51% for 12, 36 and 60 months, respectively. Patients with underlying chronic liver disease exhibited survival rates of 100% if candidates for surgical intervention. The event-free survival was significantly higher among transplanted children compared to the non-transplanted group (93%, 82% and 82% vs 57%, 26% and 14%). Neoadjuvant chemotherapy effectively downstaged 4 patients (57%) with diseminated HCC, enabling surgical intervention. All patients received PLADO chemotherapy after LR, while 50% did so after OLT. Preoperative alpha-fetoprotein (AFP) levels were elevated in 71% of children, but did not correlate with recurrence or comprimised survival. Elevated AFP 3 months post resection affected the course negatively (P <.05). Tumor number and diameter were not associated with higher post-OLT mortality and recurrence rates. Conclusions: Transplantation is controversial in adults with HCC beyond defined morphologic criteria, yet differences in predisposition and biology suggest exploring expansion guidelines in children. Therefore, OLT should be considered as primary treatment option in children with HCC even when macrovascular invasion and multifocal tumors are present, with no number or size limitations. Extrahepatic disease post-neoadjuvant chemotherapy remains the only absolute contraindication for OLT.