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Calinescu et al. Hepatoma Res 2021;7:59 https://dx.doi.org/10.20517/2394-5079.2021.26 Page 5 of 17

requirements for transfusions.

Secondly, temporary portocaval shunting could maintain renal perfusion pressure, which might contribute
to the preservation of the postoperative renal function as well as diminish the splanchnic congestion of HBL
patients that do not have portosystemic collaterals and thus increase the likelihood of an optimal healing of
the Roux en Y loop . In this series investigating the early inflow exclusion, a recurrence free survival rate of
[48]
[48]
88.9% at one year with preservation of residual renal function was obtained .
Finally, an extensive en bloc hepatectomy technique was described in a series with excision of retrocaval
retroperitoneal tissue, en bloc lymphadenectomy with peri-choledochal and hepatic hilum nodules along
the common hepatic artery, and frozen section from all resection margins; the overall survival in this seven-
patient series was 100% without recurrence seven years after LT .
[49]

Timing of liver transplantation and metastasectomy for hepatoblastoma
The timing of LT should not be delayed after four weeks after the last course of chemotherapy given the
impact on survival; if an expeditious access to deceased donation is not possible, a living related donation
should be considered [33,39] . A possible option for those who are waiting for a liver from a deceased donor is to
plan a new course of chemotherapy if they are not transplanted during the first window of four weeks; these
cases are of course not offered a graft during chemotherapy, but this strategy allows a second window of
transplantability of one month, after the new course. The latter strategy imposes of course that not all
chemotherapy courses are done before the registration of the patient on the list for transplant, but it has
been very effective in avoiding exposing the patient to prolonged periods with no chemotherapy and
allowing a LT within these time windows.

Children’s Oncology Group recommendations in 2016 stated that evaluation for surgery should be done
[50]
after two cycles of neoadjuvant chemotherapy ; nevertheless, some tumors continue to regress between
Cycles 3 and 4. Thus, after four rounds of neoadjuvant chemotherapy, 45% of the tumors are down staged,
vs. only 30% after two cycles; thus, if chemotherapy is well tolerated, it should be continued to allow more
patients to undergo successful resections .
[51]

Clearance for metastasis should be achieved earlier in the chemotherapy course, with SIOPEL 4
recommendations to achieve metastatic control after three induction cycles of chemotherapy .
[17]
Complications after liver transplantation for hepatoblastoma
Morbidity after LT in HBL might arise from three origins: (1) chemotherapy toxicity, namely
nephrotoxicity, ototoxicity, and sepsis with early discontinuation of adjuvant treatment; (2) surgical
morbidity; and (3) immunosupression .
[50]

At transplantation, the renal function of patients with HBL is reduced because of the toxicity of neoadjuvant
chemotherapy; although it can be expected, it has been clearly emphasized that the renal function further
deteriorates after LT [52,53] . As the cause for further decline of renal function after LT is directly caused by the
sequential and combined toxic effects of chemotherapy and immunosuppression, the strategy has been to
use either lower anticalcineurin levels for these patients (compared to standard LT in other indications) [33,53]
or low-dose anticalcineurin treatment in association with other immunosuppressives (i.e., mycophenolate
mofetil) or early conversion to mechanistic target of rapamycin inhibitors .
[54]
[55]