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Page 6 of 9 Calinescu et al. Hepatoma Res 2021;7:54 https://dx.doi.org/10.20517/2394-5079.2021.25

Table 2. PRETEXT, COG and IRS liver tumor staging systems
PRETEXT
PRETEXT I 3 contiguous sections tumour free
PRETEXT II 2 contiguous sections tumour free
PRETEXT III 1 contiguous section tumour free
PRETEXT IV No contiguous section tumour free
COG staging system
Stage I Complete gross resection at diagnosis with clear margins
Stage II Complete gross resection at diagnosis with microscopic residual disease at the margins of resection
Stage III Biopsy only at diagnosis or gross total resection with nodal involvement or tumor spill or incomplete resection
with gross intra-hepatic disease
Stage IV Metastatic disease at diagnosis
IRS clinical grouping
Group I Localized disease, completely resected
Group II Macroscopic complete but microscopic residual
Group III Macroscopic residual disease
Group IV Metastatic

PRETEXT: Pre Treatment Extent of Disease; COG: children’s oncology group; IRS: intergroup rhabdomyosarcoma study.

bypass followed later by hepatic tumor resection, or the opposite, hepatic tumor resection first, followed by
removal of cardiac extension under cardiopulmonary bypass [29,30] .

Preoperative tumor rupture
Preoperative tumor rupture raises questions about recurrence as it can lead to inappropriate primary tumor
resection . Spontaneous tumor rupture was reported to occur in 6.5% of the patients . The emergency
[31]
[9]
treatment in case of spontaneous or post biopsy tumor rupture is arterial embolization of the feeding
artery [32,33] . Recent data supports that secondary tumor resection with preoperative chemotherapy is more
successful than primary resection without an effective adjuvant regimen in this particular setting .
[31]
Unresectable UESL and liver transplantation
In the context of unresectable tumors [Table 3] , two strategies might be adopted and can be defended,
[20]
aggressive resections versus liver transplantation as an alternative . A recent review reported on twelve
[20]
liver transplanted patients within the United Network for Organ Sharing, with only one needing a
retransplantation and another one succumbing the disease . Individual case reports are supporting this
[14]
increasingly accepted indication [10,14,34-37] . Overall, transplantation seems to concern 10% of UESL patients .
[12]
COMPLICATIONS AFTER UESL SURGICAL TREATMENT
Complications after surgical management of UESL are rarely reported, but exist as in all liver surgery.
Typically, biliary complications were the most frequently reported complication. In a series of seven
patients, bile leaks occurred in 28% (2/7) of patients, with one resolving spontaneously and one needing an
endoscopic retrograde cholangiopancreatography with biliary drainage . Biloma rate was higher in a five-
[29]
patient case series, in which two (right lobectomy) patients required a drain placement, and one (left
lobectomy) a cholecystectomy with bile duct ligation; this last patient also had a cavernomatous
transformation of the portal vein . A bile duct injury after a right hepatectomy needed a redo surgery with
[38]
a Roux-en-Y loop .
[9]