AGGRESSIVE EXCISION OF PULMONARY METASTASES IS WARRANTED IN THE MANAGEMENT OF CHILDHOOD HEPATIC-TUMORS

Although most children who die of liver malignancies do so as the result of complications of pulmonary metastases, little has been published regarding the efficacy of surgically excising such lesions. To the 12 previously reported cases of children who have undergone excision of pulmonary metastases of hepatic tumors, are added 5, 4 with hepatobiastoma and 1 with hepatocellular carcinoma. Total excision of a primary hepatic tumor leads to survival much more frequently than does incomplete excision. No patient had metastases at diagnosis. The length of time between resection of the primary tumor and the development of pulmonary disease resistant to chemotherapy is available for 9 of the 17 children; it was under 6 months for the 2 who died but over 6 months for the 7 who survived. Postoperative α-fetoprotein (AFP) levels accurately predicted the development of metastases in our 5 patients. Resection of metastases benefitted the 4 whose AFP levels had declined to <25 ng/mL following initial chemotherapy and who underwent operation before their levels increased above 1,000 ng/mL. They are alive and free of disease 4 to 83 months following excision of their lesions. Resection did not benefit the 1 nonsurvivor whose AFP level fell only to 5,000 ng/mL before beginning to increase, eventually reaching 58,000 ng/mL at the time of operation. Incomplete resection of metastases unresponsive to chemotherapy predictably leads to death. Multiple thoracotomies were successful in achieving the long-term survival of 4 children in this series. Resection of metastases resistant to chemotherapy is most efficacious when: (1) the primary tumor has been completely resected; (2) the metastases develop more than 6 months after excision of the primary tumor; (3) the metastases had initially shown a positive response to chemotherapy as evidenced by a markedly reduced AFP titer, particularly when the level had fallen to <25 ng/mL before beginning to increase; (4) resection takes place soon after the AFP level has indicated unresponsiveness to maximum chemotherapy; and (5) all gross disease is excised. Because the child's prognosis is otherwise dismal, aggressive attempts should be made to excise pulmonary metastases of hepatic malignancies unless widespread and diffuse or accompanied by unresponsive recurrent primary disease. © 1991.