Leading the Way in Pediatric Liver Tumor Management

For Physicians

At Texas Children’s Liver Tumor Program, a unique team of specialists work together to provide expert diagnosis and state-of-the-art treatment for pediatric liver tumors.

Each member of the team (pictured, clockwise from top-left) enriches the program by providing the following specialty and subspecialty expertise:

This wealth of experience is key to combining expert clinical care with groundbreaking treatment strategies, while servicing a sizable catchment area. 

“Our program is one of the largest in the country,” said Dr. Heczey, who has led the program for over a decade. “We see 25-30 new patients each year including children with hepatoblastoma, hepatocellular carcinoma, undifferentiated embryonal sarcoma and several other malignant and benign tumors.”

This volume is noteworthy given that in the United States only a few hundred patients are diagnosed with liver tumors per year. Thus, caring for a significant portion of these cases has enabled the team to build unparalleled expertise for these rare diseases.

A multidisciplinary approach

A defining feature of the Liver Tumor Program is its comprehensive, multidisciplinary approach. It brings together a cadre of pediatric specialists, including oncologists, interventional and diagnostic radiologists, surgical oncologists, pathologists, and transplant physicians as well as social workers and child life specialists to assure the best care for children.

“Our team includes preeminent leaders in pediatric liver tumor treatment,” Dr. Heczey said. “When a physician sends their patient to us, they can rest assured the family is in the right place.”

The team works in tandem to evaluate and treat liver tumors, employing a multi-pronged strategy that encompasses the latest in surgical techniques, chemotherapy protocols and innovative treatments like CAR-T cell therapy for liver tumors.

Members of the Liver Tumor Program on the Miracle Bridge at Texas Children’s Hospital, which connects the Women’s Pavilion with the West and Wallace Towers. (L-R) Drs. Heczey, Kukreja, Lopez-Terrada, Leung, Masand and Vasudevan.

While surgical, medical and radiation oncology expertise serve as the cornerstone for programs around the country, Texas Children’s also tightly integrates pathology into this winning formula. “Pathology enables us to unlock deep insights into the genomics and biology of pediatric liver tumors – through our national and international trials it enriches discovery research, and makes a difference in clinical decision-making,” says Dr. Lola Lopez-Terrada.

The surgical oncology team also works closely with the transplant team to determine whether resection is possible, based on the tumor’s characteristics and impact on liver function. Here, Texas Children’s ability to perform complex surgical care, including vascular or biliary reconstruction, and extreme multifocal resections, sets the hospital apart from most centers in the country.

To enhance these complex operative techniques, intraoperative ultrasound is used to provide real-time guidance to surgeons, leading to better outcomes. The team also uses fluorescence-guided surgery to safely separate the tumor from critical bile ducts and blood vessels in the liver. The dye illuminates the edges of the tumors more clearly for successful resection and can help identify small malignant lesions not visible with standard imaging. In an article published in the Journal of Pediatric Surgery, the team demonstrated that this approach enabled enhanced identification and guidance for surgical resection.

“We’re one of the few hospitals in the nation to use this approach,” Dr. Vasudevan said. “We have used this approach in 80+ cases of both liver and lung tumors. Other hospitals use this approach for lung tumors, but very few use it to guide liver resection.”

Advanced diagnostics used at Texas Children’s also include MRI-based dynamic liver imaging, which has become a mainstay for diagnosis and follow up. This approach involves use of gadolinium-based hepatocyte-specific contrast agents (e.g., Eovist) to visualize focal masses. Sometimes this technique can also be used to differentiate benign from malignant lesions. When encountering aggressive disease, such as hepatoblastoma, cross sectional imaging with CT/MRI is also used. This can provide vital information on vascular invasion, distant spread and, more importantly, whether a mass is surgically resectable.

If resection isn’t possible, the team employs an innovative interventional radiology approach that may downstage the tumor enough for surgery. The program’s use of transarterial radioembolization (TARE) with Yttrium-90 (Y90) represents a revolutionary advancement in treatment, offering new hope to patients with limited options. During TARE, an interventional radiologist injects tiny Y90-laced radioactive beads directly into the tumor. This enables the team to target and kill cancer cells with minimal effect on surrounding healthy tissue.

“TARE can help us to prevent the tumor from spreading further or shrink the tumor to a size that can be optimized for resection — and at Texas Children’s, we are only one of only two pediatric institutions in the United States offering this,” says Dr. Kamlesh Kukreja.

TARE can also be a bridge to liver transplant. Time can be precious for children with liver tumors, with tumors quickly reaching the point of being unresectable or too large to achieve the margins desired. “That’s why the liver transplant program at Texas Children’s — the largest in the U.S. — is part of the evaluation from the start. The program has transplanted more than 39 patients with liver tumors since 2013.

Despite all these tools, the team remains passionate about expanding the envelope by finding novel treatment approaches and optimizing outcomes through research. Discoveries at Texas Children’s have identified molecular and therapeutic targets, unlocked novel biologic therapeutics and pioneered the use of CAR-T therapy for relapsed and refractory cases.

“While we excel in care delivery, our team pursues research because we want to make that care even better,” Dr. Heczey said, pointing to the program’s commitment to improving patient care through scientific discovery.

For potential referring physicians

Texas Children’s integrated approach to patient care ensures that families receive comprehensive support throughout their journey, from diagnosis to treatment and beyond. For physicians in need of a center of excellence for their patients with liver tumors, Texas Children’s offers an unparalleled track record of success. The team is ready and able to move quickly, with the capability to tackle the most challenging cases with state-of-the-art treatment options when every second counts.

Learn more about referring a patient or obtaining a second opinion at Texas Children’s.

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