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Page 4 of 7 Weeda et al. Hepatoma Res 2021;7:43 https://dx.doi.org/10.20517/2394-5079.2021.10

Patients with unresectable and/or metastatic HCC will be randomized to a time-intensive treatment with
PLADO with sorafenib or PLADO with sorafenib and GEMOX (gemcitabine and oxaliplatin) and re-
evaluated at set time points. Doxorubicin + sorafenib has been previously explored in adults with advanced
HCC, and GEMOX + sorafenib is another example of a regimen that has shown some efficacy in adult HCC
and is now used in pediatric patients [21-23] . A prolonged complete response in a 25-year-old woman with FL-
[24]
HCC on this regimen showed potential for efficacy in a young, non-cirrhotic patient . The data from the
PHITT trial will need to answer whether there is efficacy in a larger group of pediatric and adolescent
patients.

Identification and where possible validation of prognostic biomarkers and toxicity biomarkers will also be
performed within the PHITT trial. In the meantime, analyses from molecular research efforts point in the
direction of different HCC subtypes which may respond best to precision medicine [25-27] .

LOCOREGIONAL TREATMENT
When both surgery and systemic treatment fail, only locoregional treatment options remain. Transarterial
chemoembolization (TACE), transarterial radioembolization with yttrium-90 (TARE-Y90), stereotactic
radio frequency ablation (SRFA), and magnetic resonance imaging-guided high-intensity focused
ultrasound (MR-HIFU) are such options. However, there is limited experience in children with these
methods.

Recently, Aguado et al. reported a clinical trial investigating 10 patients (3 FL-HCC, 3 HCC, 2 HB, and 2
[28]
HCN-NOS) with unresectable and/or metastatic disease who received treatment with TARE-Y90 as
palliative treatment or bridge to liver transplant. All patients received prior chemotherapy and/or targeted
therapy. Six had laparotomies with lobectomies performed in 4 cases. One patient had TACE and RFA.
Median survival post-TARE-Y90 was 4 months (range, 2-20 months). In one patient with HCN-NOS the
response after TARE-Y90 allowed for a liver transplant. The possibility to provide radiation to the tumor,
thus reducing toxicity, is a major advantage. TARE-Y90 is commonly used in adult patients with HCC,
where it is superior to TACE in terms of time-to-progression of disease, toxicity, and posttreatment quality
[29]
of life .
Weiss et al. described 21 TACE procedures that were performed on 8 patients with HCC (including one
[30]
with FL-HCC). It was well tolerated by all 8 patients with adverse events mainly classified as grade 1. Three
patients had a partial response, five demonstrated stable disease and 2 patients died due to progression.
Bridging to transplantation was achieved in 6 patients after a mean of 3 TACE procedures. The 5-year
overall survival was 83% with a mean follow up of 8.2 years (range 3.4-11 years).

The complete response rate after SRFA is comparable with that achieved by liver resection . In 2020,
[31]
[32]
Hetzer et al. presented the largest pediatric series of 10 patients with 15 liver masses (including one with
HCC), who underwent SRFA. Complete radiological response was observed in all cases. Complications
included temporary portal vein thrombosis, and temporary paresis of the diaphragm (each one patient). For
one patient with HCC (centrally located tumor, 3 cm in diameter), SRFA was applied as a bridge to
transplantation. Histological examination confirmed complete tumor apoptosis in this patient.

High-intensity focused ultrasound (HIFU) is a non-invasive ablation method that uses focused ultrasonic
waves (0.8-1.6 MHz) to destruct the target located deep in the body (by thermic effect or by phenomenon of
[33]
[34]
cavitation) . In 2013 Wang et al. presented their first experience with HIFU combined with TACE in 12
patients with unresectable hepatoblastoma. Complete ablation was achieved in 10 patients (83%). Two