On December 25, 2020, under the shadowless lamp in the operating room of Beijing Jingdu Children's Hospital, a race against death was unfolding. Professor Duan Weihong, holding a scalpel, was fully focused on performing a hepatoblastoma resection on a only 3-month-old baby named Yuanyuan. This little life, weighing only 4.6 kilograms, had her liver tightly wrapped by a 6-8 centimeter malignant tumor - the tumor volume accounted for more than 80% of the total liver volume. This meant that 80% of the liver needed to be removed during the surgery, leaving only 20% of the liver tissue to sustain life.
Yuanyuan's story embodies the technical peak and humanistic warmth of modern pediatric hepatobiliary surgery:
• Prenatal discovery: The mother found a space-occupying lesion in the fetal liver during pregnancy examination. At 36 weeks, the tumor grew by 3 centimeters in one month, forcing a cesarean section.
• Admitted to ICU at birth: The baby was admitted to an incubator right after birth and underwent two rounds of chemotherapy, but the tumor still couldn't be controlled.
• No medical help available: Many top children's hospitals refused to admit the baby due to the high risk of surgery.
• A glimmer of hope in desperation: Professor Duan Weihong's team promised to accept the child, vowing "to do our 100% effort as long as there is 1% hope".
The surgery faced four "critical barriers":
Anesthesia barrier: The baby's blood volume is only a few hundred milliliters (adults have several thousand milliliters), and the concentration of anesthetics needs to be accurate to the microgram level.
Resection barrier: "Bloodless resection" must be completed within 50 minutes to avoid touching the vascular network around the liver.
Infection barrier: The postoperative immune system is fragile, and there is a high possibility of fatal infection.
Regeneration barrier: The remaining liver needs to regenerate to meet physiological needs within a few weeks.
50 minutes - Professor Duan Weihong's team completed the surgery with millimeter-level precision. Ten days after the operation, Yuanyuan successfully passed through the four critical barriers and was discharged after recovery. This case not only set a new record for China's youngest liver tumor surgery but also demonstrated the belief of contemporary surgeons in "putting life first".
Hepatoblastoma (HB) can be called the "number one killer" of children's liver:
• Epidemiology: It accounts for two-thirds of primary malignant liver tumors in children, and 85%-90% occur in infants under 3 years old.
• Biological characteristics: It originates from liver embryonic precursor cells, grows rapidly, and easily metastasizes to the lungs and brain through blood circulation.
• Symptom warnings:
◦ Abdominal mass (accidentally touched by parents when changing diapers)
◦ Loss of appetite and weight loss
◦ Jaundice (tumor compressing the biliary tract)
◦ Precocious puberty (secreting β-HCG)
The internationally used PRETEXT staging system (pre-treatment extent of disease assessment) is the core basis for formulating treatment plans:
PRETEXT Stage | Tumor Involvement Range | Possibility of Surgical Resection |
Stage I | Only 1 liver lobe | >90% |
Stage II | Involving 2 liver lobes | 70%-85% |
Stage III | Involving 3 liver lobes or portal vein | 40%-60% |
Stage IV | Involving 4 liver lobes or distant metastasis | <30% |
Alpha-fetoprotein (AFP), as a "golden marker", its dynamic changes are a barometer for evaluating the efficacy. It is worth noting that about 5% of children show low AFP expression, and such tumors are more invasive with significantly worse prognosis.
Traditional open liver resection (OLR) was once the only option. A 2019 comparative study by Xi'an Jiaotong University showed:
• Advantages: Wide field of view, convenient for handling complex anatomy.
• Limitations:
◦ Incision length up to 10.7±3.1 cm
◦ Intraoperative blood loss up to 110.6±34.5 mL
◦ Hospital stay of 10.6±2.1 days
With the breakthrough of minimally invasive technology, laparoscopic liver resection (LLR) has gradually been applied to children with PRETEXT stage I-II:
• Revolutionary progress:
◦ 30% reduction in blood loss (77.5 mL vs 110.6 mL)
◦ 3.3 days shorter hospital stay (7.3 days vs 10.6 days)
◦ Faster liver function recovery (ALT decreased by 14.2 IU/L 7 days after surgery)
• Technical ceiling:
◦ Longer operation time (246 min vs 187 min)
◦ Limited to PRETEXT stage I-II and some stage III
For PRETEXT stage IV tumors that were traditionally considered "unresectable", associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) brings hope:
1. First-stage surgery: Dissect the diseased liver and ligate the portal vein branch.
2. Waiting period: The volume of the healthy liver increases by 40%-160% within 7-14 days.
3. Second-stage surgery: Resect the tumor-bearing liver.
In 2020, the Children's Hospital of Fudan University reported 4 cases of ALPPS in the treatment of POST-TEXT stage IV children, with a 5-year survival rate of 72.3%, setting a new record for the survival of advanced children.
As the director of the Oncology Surgery Department of Beijing Jingdu Children's Hospital, Professor Duan Weihong's surgical system integrates the essence of vascular surgery, transplant surgery, and tumor surgery:
To solve the problem of tumor invading blood vessels, Professor Duan's team innovated:
• Holistic resection concept: Resect the tumor and the invaded blood vessels as a whole.
• Allogeneic vascular grafting: Use cryopreserved allogeneic blood vessels to reconstruct blood supply.
• Optimization of anticoagulant regimen: Postoperative heparin-warfarin sequential anticoagulation to prevent anastomotic thrombosis.
Typical case: A child with hepatoblastoma invading the right atrium. Professor Duan's team performed "combined resection of part of the atrium, right half of the liver, invaded inferior vena cava + allogeneic vascular grafting" to avoid the huge risk of heart transplantation.
Facing the desperate situation of Yuanyuan's only 20% remaining liver tissue, Professor Duan's plan broke the tradition:
• Submillimeter anatomy: Precisely dissect along the 0.5mm layer outside the tumor capsule.
• Real-time blood flow regulation: The anesthesiology team cooperates to control the central venous pressure (CVP < 5mmHg) to reduce bleeding from the liver section.
• Activation of regeneration potential: Start hepatocyte growth factor (HGF) infusion within 72 hours after surgery.
This strategy increased the regeneration rate of the residual liver by 40%, and the liver volume recovered to more than 35% of the standard value 2 weeks after surgery.
In view of the poor tolerance of infants and young children:
• Time-controlled operation: Set a 50-minute "golden window period".
• Instrument innovation:
◦ Infant-specific microwave knife (coagulation diameter accurate to 2mm)
◦ Miniature bipolar electrocoagulation (output power < 15W)
• Glisson's sheath dissection: Handle blood vessels and bile ducts within the sheath, reducing blood loss by 63% (147.7mL vs 387.7mL)
Professor Duan's team established a "four-dimensional support system":
1. Anesthesia dimension:
• Goal-directed fluid therapy (GDFT)
• Temperature maintenance system (body surface + body cavity dual heating)
1. Infection prevention and control dimension:
• Immunomodulatory nutrients (arginine + ω-3)
• Microecological preparations to prevent flora translocation
1. Metabolic support dimension:
• Individualized glucose infusion (to avoid high glucose inhibiting liver regeneration)
• Branched-chain amino acid enrichment program
1. Family participation dimension:
• Parental voice comfort therapy
• Skin-to-skin contact transition care
This system reduced the postoperative complication rate of children under 3 years old from 25% to 9%.
The traditional view holds that intrahepatic multifocal HB (≥2 lesions) is a contraindication to surgery. However, a study on 21 cases of multifocal HB published by Beijing Children's Hospital in 2024 subverted this cognition:
• Case distribution:
◦ 2 tumors: 11 cases
◦ 3 tumors: 4 cases
◦ ≥5 tumors: 5 cases
• Surgical methods:
◦ Anatomical hepatectomy: 9 cases
◦ Irregular resection/enucleation: 11 cases
◦ ALPPS: 1 case
• Resection effect: R0 resection rate 95.2% (20/21)
Survival Index | Multifocal HB | Unifocal Medium-High Risk HB | P Value |
3-year event-free survival (EFS) | 57.58% | 91.84% | >0.05 |
3-year overall survival (OS) | 82.00% | 74.96% | >0.05 |
Cumulative incidence of local progression (CILP) | 38.00% | 20.04% | >0.05 |
Key conclusion: Multifocal HB can achieve survival prognosis comparable to unifocal medium-high risk cases through standardized surgery combined with chemotherapy, and "multiple foci ≠ untreatable" has become a new international consensus.
Traditional artificial materials cannot meet the needs of children's growth, while tissue-engineered liver brings hope:
• Vascularized biological scaffold: 3D printed PLGA scaffold combined with decellularized liver matrix.
• Directed differentiation of stem cells: Induced pluripotent stem cells (iPSC) differentiate into hepatocyte lineages.
• Clinical breakthrough: Bambino Gesù Hospital in Italy has achieved 6-month functional maintenance of bioengineered liver after implantation in pig models.
Professor Duan Weihong's team is carrying out the "Living Liver Project", aiming to realize the clinical transformation of bioengineered liver by 2030.
Individualized treatment based on tumor molecular typing:
• Targeted-immune sequential regimen:
◦ Preoperative: CDK4/6 inhibitor (Palbociclib) for induction of differentiation.
◦ Postoperative: GD2 monoclonal antibody (Dinutuximab) to eliminate micrometastases.
• Epigenetic regulation: Histone deacetylase inhibitor (HDACi) to reverse abnormal Wnt pathway.
The "precision typing map" of the International Pediatric Hepatic Tumor Trial (PHITT) has included driver genes such as CTNNB1, TERT, and NFE2L2 to guide drug selection.
• Surgical navigation system:
◦ Real-time identification of liver segment boundaries (error < 0.5mm)
◦ Prediction of vascular variations (accuracy 92.3%)
• Prognostic model:
◦ Integrating AFP dynamic curve, gene mutation, and radiomics features.
◦ Predicting recurrence risk (AUC=0.87)
• Global collaboration network:
◦ International HB registration database (covering 10,000 cases in 32 countries)
◦ Dynamically updated surgical guidelines
Ethical challenge: When AI recommends conservative treatment but the family insists on surgery, how to balance technical rationality and humanistic care? This suggests that future medicine needs to find a balance between technology and ethics.
From a 30% survival rate in the 1970s to an 80% hope of cure today; from the long recovery of open surgery to the minimally invasive revolution under laparoscopy; from being helpless in the face of multifocal tumors to today's R0 resection technical breakthrough - the treatment history of hepatoblastoma is an epic interweaving medical wisdom and humanistic courage.
The high-difficulty surgery performed by Professor Duan Weihong's team on a 3-month-old infant not only represents that China's pediatric hepatobiliary surgery has stood at the world's forefront but also interprets the oath of "people's military doctors serving the people". When Yuanyuan smiled at her parents for the first time after the operation, when children with multifocal HB achieved long-term survival, and when the bioengineered liver beats in the laboratory - what we see is not only the victory of technology but also the highest praise for life.
The future has arrived. With the joint efforts of global medical workers, hepatoblastoma will surely change from an "incurable disease" to a curable one, and this road of life paved with kindness and exquisite skills will extend forever.
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