Texas Children’s Cancer Center is renowned for extraordinary care and outcomes and is ranked No. 2 in the nation by U.S. News & World Report. An important part of the program’s success is the multidisciplinary care children here receive – particularly in the area of surgical oncology. Many solid tumors – such as liver tumors, bone tumors, neuroblastomas and sarcomas – require complete surgical removal. Chemotherapy and radiation may be used to shrink the size of the tumor or to keep it from coming back after surgery, but surgical removal is a critical step for children with these cancers. In these cases, oncologists and surgical oncologists must work together to carefully plot the course of treatment and time the surgery just right to give young patients the very best chance at a cancer-free life.
Patient diagnosed with hepatoblastoma
In September 2015, Dr. Maria Garcia Fernandez, a pediatric infectious disease specialist, and Dr. Fernando Padilla, a family practitioner, discovered a mass in their 17-month-old baby Victoria’s abdomen. Fearing the worst, they immediately contacted the Solid Tumor Program at Texas Children’s Hospital, where Victoria was promptly evaluated and diagnosed with stage 3 hepatoblastoma.
Hepatoblastoma is a relatively rare type of childhood cancer, with approximately 200 cases diagnosed per year in the country. Usually occurring in children under the age of 5, there are often no initial symptoms other than the mass.
“Hepatoblastomas tend to present very large, because the liver is tucked under the ribs so the mass is hard to feel,” said Dr. Sanjeev Vasudevan, Victoria’s surgical oncologist specializing in liver surgery. “You have to remove the side of the liver that the tumor inhabits without damaging the normal side and still get the tumor completely out.”
The stakes for this type of surgery couldn’t be higher.
“If you attempt to remove the mass and wind up leaving some of it behind, the prognosis for the child becomes much more serious,” Vasudevan said. “Basically, if you can’t guarantee a negative-margin resection, it’s safer to skip the attempt and go straight to liver transplantation.”
Aggressive chemotherapy treatment
At the time of diagnosis, Victoria’s tumor was 6 cm in diameter and covered both sides of her liver. She had to undergo an aggressive regimen of chemotherapy to see if resection would be an option, or if transplant would be required.
“We were devastated,” Fernandez said. “We didn’t know if the chemotherapy would work, what kind of toll it would take on her, or if she’d have to have a transplant and deal with that her whole life. But, what we did know was that Texas Children’s was the best possible place for us to be. They had the numbers. They had the best track record for treating this type of cancer, whether it’s from an oncology perspective or surgery or transplant or intensive care.”
Only a handful of major centers in the country are equipped to take a case like Victoria’s. Of the 200 cases diagnosed in the U.S. annually, Texas Children’s treats approximately 10 percent of them.
“In addition to a strong cancer program, you need to have pediatric ICUs and intensivists, surgical expertise, anesthesia and pain services, all for children under the age of 5 – and enough volume to do it well and have good outcomes,” Vasudevan said.
Victoria underwent four intense cycles of chemotherapy. Each time, she was admitted back to the hospital for about a week, fighting fever, neutropenia and RSV. Knowing that four cycles was probably as much as the petite toddler could take, Victoria’s physicians were hoping to take her for surgery after one or two rounds. After the third cycle, she was placed on the transplant list briefly before scans finally showed a glimmer of hope. Victoria underwent a fourth cycle and was scanned again, and the team was delighted to find a margin of healthy tissue that made surgery possible.
“This entire team of oncologists, radiologists, pathologists, surgeons and transplant surgeons met so many times and discussed her case, all diligently trying to figure out what was best for Victoria,” Fernandez said. “It showed tremendous perseverance and dedication, and I will never forget that as long as I live.”
Surgical tumor removal
On January 6, 2016, Victoria went in for surgery, and she didn’t come out for more than nine hours. The vicinity of the tumor to the main portal vein, the primary blood supply to the liver, was close and required special attention to ensure that the tumor was completely removed.
“When operating on the liver, there is a high risk of disrupting the blood vessels and the bile ducts,” Vasudevan said. “What makes it really complicated is the fact that the liver is brown and completely opaque, and you can’t see the tumor. You rely on ultrasound guidance and external cues, the rest is up to feel and experience.”
Victoria’s procedure went smoothly. Vasudevan removed the tumor and the left lobe and was able to preserve about 60 percent of her liver.
There is a 30 percent chance of liver insufficiency post surgery, but after four or five days, the liver begins to regenerate and compensate for its loss. Victoria was stable and extubated by the next morning, and she went on to have two more cycles of chemotherapy to ensure no microscopic seeding had occurred. She has since celebrated her second birthday and returned to her normal, vibrant self.
Although Victoria is still checked regularly for signs of recurrence, overall her prognosis is excellent. She has an approximately 90 percent chance of an event-free, five-year survival.
“This is exactly why I got into this field,” Vasudevan said. “It’s an amazingly rewarding thing to do. Cancer is so devastating, in general, and to see a small 1- or 2-year-old child robbed of her whole life…that’s motivation enough for me.”
For more information about our Surgical Oncology Program, click here.