Childhood Liver Cancer

There are two main types of childhood liver cancer: hepatoblastoma and hepatocellular carcinoma. Less common types include undifferentiated embryonal sarcoma, infantile choriocarcinoma, and vascular liver tumors.

*Childhood liver cancer facts written by Charles P. Davis, MD, PhD

• Childhood liver cancer is a disease in which abnormal liver cells multiply unregulated and may metastasize (migrate to other organs).
• There are two main types of childhood liver cancer: hepatoblastoma and hepatocellular carcinoma. Less common types include undifferentiated embryonal sarcoma, infantile choriocarcinoma, and vascular liver tumors.
• Risk factors for childhood liver cancer (mainly hepatoblastoma) include Aicardi syndrome, Beckwith-Wiedemann syndrome, familial adenomatous polyposis (FAP), glycogen storage disease, very low weight at birth, Simpson-Golabi-Behmel syndrome, and genetic changes, such as trisomy 18. Other risk factors for childhood liver cancer (mainly hepatocellular carcinoma) include Alagille syndrome, glycogen storage disease, hepatitis B virus infection that was passed from mother to child at birth, progressive familial intrahepatic disease, and tyrosinemia.
• Signs and symptoms of childhood liver cancer commonly appear as the tumor enlarges. A lump or swelling in the abdomen, weight loss for unknown reasons, loss of appetite, and nausea and vomiting are the most common symptoms and signs.
• Childhood liver cancer may be detected (diagnosed) with the following tests and/or procedures: physical exam and history, serum tumor marker test (several types), complete blood count (CBC), liver function tests, blood chemistry studies, Epstein-Barr virus (EBV) test, hepatitis assay, ultrasound, CT scan, abdominal X-ray, MRI, biopsy, and immunohistochemistry tests.
• The prognosis and treatment options for childhood liver cancer are affected by the following: if cancer has spread to other places in the body; if cancer can be removed by surgery; how cancer responds to chemotherapy; how the cancer cells appear when examined under a microscope; if the AFP blood levels go down after treatment; if the cancer is newly diagnosed or if it has recurred; the age of the child; which group the patient belongs to (PRETEXT or POST TEXT groups, see below); and if the child has a hepatitis B infection.
• Staging (also known as grouping) initially begins with one of two grouping systems: the PRETEXT group or the POST TEXT group. PRETEXT describes the tumor before treatment while POST TEXT describes the tumor after treatment. Both groups are subdivided into groups I-IV, with the group I with cancer in only one liver lobe while group IV has cancer cells in all four liver lobes.
• Childhood liver cancer spreads to other parts of the body by invading structures near the liver, the lymph vessels, and by the blood.
• Six types of standard treatment for childhood liver cancer are surgery, chemotherapy, radiation therapy, ablation therapy, watchful waiting, and antiviral treatment.
• New types of treatments (targeted therapy) are being tested in clinical trials.

The liver is one of the largest organs in the body. It has four lobes and fills the upper right side of the abdomen inside the rib cage. Three of the many important functions of the liver are:

• To filter harmful substances from the blood so they can be passed from the body in stools and urine.
• To make bile to help digest fats from food.
• To store glycogen (sugar), which the body uses for energy.

Liver cancer is rare in children and adolescents.

There are two main types of childhood liver cancer:

• Hepatoblastoma: Hepatoblastoma is the most common type of childhood liver cancer. It usually affects children younger than 3 years of age. In hepatoblastoma, the histology (how the cancer cells look under a microscope) affects the way the cancer is treated. The histology for hepatoblastoma may be one of the following:
  • Pure fetal histology.
  • Small cell undifferentiated histology.
  • Non-pure fetal histology, non-small cell undifferentiated histology.
• Hepatocellular carcinoma: Hepatocellular carcinoma usually affects older children and adolescents. It is more common in areas of Asia that have high rates of hepatitis infection than in the U.S.

Three less common types of childhood liver cancer include the following:

• Undifferentiated embryonal sarcoma of the liver is a type of liver cancer that usually occurs in children between 5 and 10 years of age. It often spreads all through the liver and/or to the lungs.
• Infantile choriocarcinoma of the liver is a very rare tumor that starts in the placenta and spreads to the fetus. The tumor is usually found during the first few months of life. Also, the mother of the child may be diagnosed with choriocarcinoma. Choriocarcinoma is a type of gestational trophoblastic disease.
• Vascular liver tumors are tumors that form in the liver from cells that make blood vessels or lymph vessels. Vascular liver tumors may be benign (not cancer) or malignant (cancer).

This summary is about the treatment of primary liver cancer (cancer that begins in the liver). Treatment of metastatic liver cancer, which is cancer that begins in other parts of the body and spreads to the liver, is not discussed in this summary. Primary liver cancer can occur in both adults and children. However, treatment for children is different than treatment for adults.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your child’s doctor if you think your child may be at risk.

Risk factors for hepatoblastoma include the following syndromes or conditions:

• Aicardi syndrome.
• Beckwith-Wiedemann syndrome.
• Familial adenomatous polyposis (FAP).
• Glycogen storage disease
• A very low weight at birth.
• Simpson-Golabi-Behmel syndrome.
• Certain genetic changes, such as Trisomy 18.

Risk factors for hepatocellular carcinoma include the following syndromes or conditions:

• Alagille syndrome.
• Glycogen storage disease.
• Hepatitis B virus infection that was passed from mother to child at birth.
• Progressive familial intrahepatic disease.
• Tyrosinemia.

Some patients with tyrosinemia or progressive familial intrahepatic disease will have a liver transplant before there are signs or symptoms of cancer.

Signs and symptoms are more common after the tumor gets big. Other conditions can cause the same signs and symptoms. Check with your child’s doctor if your child has any of the following:

• A lump in the abdomen that may be painful.
• Swelling in the abdomen.
• Weight loss for no known reason.
• Loss of appetite.
• Nausea and vomiting.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
• Serum tumor marker test: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs, tissues, or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the blood. These are called tumor markers. The blood of children who have liver cancer may have increased amounts of a hormone called beta-human chorionic gonadotropin (β-hCG) or a protein called alpha-fetoprotein (AFP). Other cancers and certain noncancer conditions, including cirrhosis and hepatitis, can also increase AFP levels.
• Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
  • The number of red blood cells, white blood cells, and platelets.
  • The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.
  • The portion of the blood sample made up of red blood cells.
• Liver function tests: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. A higher than normal amount of a substance can be a sign of liver damage or cancer.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as bilirubin or lactate dehydrogenase (LDH), released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Epstein-Barr virus (EBV) test: A blood test to check for antibodies to the EBV and DNA markers of the EBV. These are found in the blood of patients who have been infected with EBV.
• Hepatitis assay: A procedure in which a blood sample is checked for pieces of the hepatitis virus.
• MRI (magnetic resonance imaging) with gadolinium: A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the liver. A substance called gadolinium is injected into a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later. In childhood liver cancer, an ultrasound exam of the abdomen to check the large blood vessels is usually done.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. In childhood liver cancer, a CT scan of the chest and abdomen is usually done.
• Abdominal x-ray: An x-ray of the organs in the abdomen. An x-ray is a type of energy beam that can go through the body onto film, making a picture of areas inside the body.
• Biopsy: The removal of a sample of cells or tissues so it can be viewed under a microscope to check for signs of cancer. The sample may be taken during surgery to remove or view the tumor. A pathologist looks at the sample under a microscope to find out the type of liver cancer.
  
  The following test may be done on the sample of tissue that is removed:
  • Immunohistochemistry: A test that uses antibodies to check for certain antigens in a sample of tissue. The antibody is usually linked to a radioactive substance or a dye that causes the tissue to light up under a microscope. This type of test is used to check for a certain gene mutation and to tell the difference between different types of cancer.

The prognosis (chance of recovery) and treatment options for hepatoblastoma depend on the following:

• The PRETEXT or POST TEXT group.
• Whether cancer has spread to other places in the body, such as the lungs or certain large blood vessels.
• Whether cancer can be removed completely by surgery.
• How cancer responds to chemotherapy.
• How the cancer cells look under a microscope.
• Whether the AFP blood levels go down after treatment.
• Whether cancer has just been diagnosed or has recurred.
• Age of the child.

The prognosis (chance of recovery) and treatment options for hepatocellular carcinoma depend on the following:

• The PRETEXT or POST TEXT group.
• Whether cancer has spread to other places in the body, such as the lungs.
• Whether cancer can be removed completely by surgery.
• How cancer responds to chemotherapy.
• How the cancer cells look under a microscope.
• Whether the child has hepatitis B infection.
• Whether cancer has just been diagnosed or has recurred.

For childhood liver cancer that recurs (comes back) after initial treatment, the prognosis and treatment options depend on:

• Where in the body the tumor recurred.
• The type of treatment used to treat initial cancer.

Childhood liver cancer may be cured if the tumor is small and can be completely removed by surgery. Complete removal is possible more often for hepatoblastoma than for hepatocellular carcinoma.

The process used to find out if cancer has spread within the liver, to nearby tissues or organs, or to other parts of the body is called staging. In childhood liver cancer, the PRETEXT and POSTTEXT groups are used instead of stage to plan treatment. The results of the tests and procedures done to detect, diagnose, and find out whether the cancer has spread are used to determine the PRETEXT and POSTTEXT groups.

There Are Two Grouping Systems for Childhood Liver Cancer.

Two grouping systems are used for childhood liver cancer:

• The PRETEXT group describes the tumor before the patient has treatment.
• The POSTTEXT group describes the tumor after the patient has treatment.

There Are Four PRETEXT and POSTTEXT Groups:

The liver is divided into 4 sections. The PRETEXT and POSTTEXT groups depend on which sections of the liver have cancer.

PRETEXT and POSTTEXT Group I

In group I, the cancer is found in one section of the liver. Three sections of the liver that are next to each other do not have cancer in them.

PRETEXT and POSTTEXT Group II

In group II, cancer is found in one or two sections of the liver. Two sections of the liver that are next to each other do not have cancer in them.

PRETEXT and POSTTEXT Group III

In group III, one of the following is true:

• Cancer is found in three sections of the liver and one section does not have cancer.
• Cancer is found in two sections of the liver and two sections that are not next to each other do not have cancer in them.

PRETEXT and POSTTEXT Group IV

In group IV, cancer is found in all four sections of the liver.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer May Spread From Where It Began to Other Parts of the Body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if childhood liver cancer spreads to the lung, the cancer cells in the lung are actually liver cancer cells. The disease is metastatic liver cancer, not lung cancer.

Recurrent childhood liver cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the liver or in other parts of the body. Cancer that is growing or worsening during treatment is progressive disease.

Different types of treatments are available for children with liver cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Taking part in a clinical trial should be considered for all children with liver cancer. Some clinical trials are open only to patients who have not started treatment.

Treatment will be overseen by a pediatric oncologist, a doctor who specializes in treating children with cancer. The pediatric oncologist works with other healthcare providers who are experts in treating children with liver cancer and who specialize in certain areas of medicine. It is especially important to have a pediatric surgeon with experience in liver surgery who can send patients to a liver transplant program if needed. Other specialists may include the following:

• Pediatrician.
• Radiation oncologist.
• Pediatric nurse specialist.
• Rehabilitation specialist.
• Psychologist.
• Social worker.

Side effects from cancer treatment that begin after treatment and continue for months or years are called late effects. Late effects of cancer treatment may include:

• Physical problems.
• Changes in mood, feelings, thinking, learning, or memory.
• Second cancers (new types of cancer).

Some late effects may be treated or controlled. It is important to talk with your child's doctors about the effects cancer treatment can have on your child.

Surgery

When possible, the cancer is removed by surgery.

• Partial hepatectomy: Removal of the part of the liver where cancer is found. The part removed may be a wedge of tissue, an entire lobe, or a larger part of the liver, along with a small amount of normal tissue around it.
• Total hepatectomy and liver transplant: Removal of the entire liver followed by a transplant of a healthy liver from a donor. A liver transplant may be possible when cancer has not spread beyond the liver and a donated liver can be found. If the patient has to wait for a donated liver, other treatment is given as needed.
• Resection of metastases: Surgery to remove cancer that has spread outside of the liver, such as to nearby tissues, the lungs, or the brain.

Factors that affect the type of surgery used include the following:

• The PRETEXT group and POSTTEXT group.
• The size of the primary tumor.
• Whether there is more than one tumor in the liver.
• Whether the cancer has spread to nearby large blood vessels.
• The level of alpha-fetoprotein (AFP) in the blood.
• Whether the tumor can be shrunk by chemotherapy so that it can be removed by surgery.
• Whether a liver transplant is needed.

Chemotherapy is sometimes given before surgery, to shrink the tumor and make it easier to remove. This is called neoadjuvant therapy.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Watchful Waiting

Watchful waiting is closely monitoring a patient’s condition without giving any treatment until signs or symptoms appear or change. In hepatoblastoma, this treatment is only used for small tumors that have been completely removed by surgery.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Treatment using more than one anticancer drug is called combination chemotherapy.

Chemoembolization of the hepatic artery (the main artery that supplies blood to the liver) is a type of regional chemotherapy used to treat childhood liver cancer. The anticancer drug is injected into the hepatic artery through a catheter (thin tube). The drug is mixed with a substance that blocks the artery, cutting off blood flow to the tumor. Most of the anticancer drug is trapped near the tumor and only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on the substance used to block the artery. The tumor is prevented from getting the oxygen and nutrients it needs to grow. The liver continues to receive blood from the hepatic portal vein, which carries blood from the stomach and intestine. This procedure is also called transarterial chemoembolization or TACE.

The way the chemotherapy is given depends on the type of the cancer being treated and the PRETEXT or POSTTEXT group.

Radiation Therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type of the cancer being treated and the PRETEXT or POSTTEXT group. Radioembolization of the hepatic artery (the main artery that supplies blood to the liver) is a type of internal radiation therapy used to treat hepatocellular carcinoma. A very small amount of a radioactive substance is attached to tiny beads that are injected into the hepatic artery through a catheter (thin tube). The beads are mixed with a substance that blocks the artery, cutting off blood flow to the tumor. Most of the radiation is trapped near the tumor to kill the cancer cells. This is done to relieve symptoms and improve quality of life for children with hepatocellular carcinoma. External radiation therapy is used to treat hepatoblastoma that cannot be removed by surgery or has spread to other parts of the body.

Ablation Therapy

Ablation therapy removes or destroys tissue. Different types of ablation therapy are used for liver cancer:

• Radiofrequency ablation: The use of special needles that are inserted directly through the skin or through an incision in the abdomen to reach the tumor. High-energy radio waves heat the needles and tumor which kills cancer cells. Radiofrequency ablation is being used to treat recurrent hepatoblastoma.
• Percutaneous ethanol injection: A small needle is used to inject ethanol (pure alcohol) directly into a tumor to kill cancer cells. Several treatments may be needed. Percutaneous ethanol injection is being used to treat recurrent hepatoblastoma.

Antiviral Treatment

Hepatocellular carcinoma that is linked to the hepatitis B virus may be treated with antiviral drugs.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied.

Targeted Therapy

Targeted therapy is a type of treatment that uses drugs or other substances to attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. Targeted therapy is being studied for the treatment of all types of childhood liver cancer that have come back.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country.

Some of the tests that were done to diagnose the cancer or to find out the treatment group may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Hepatoblastoma

Treatment options for hepatoblastoma that can be removed by surgery at the time of diagnosis may include the following:

• Surgery to remove the tumor, followed by watchful waiting or chemotherapy, for hepatoblastoma with pure fetal histology.
• Surgery to remove the tumor, with combination chemotherapy given either before surgery, after surgery, or both, for hepatoblastoma that is not pure fetal histology. For hepatoblastoma with small cell undifferentiated histology, aggressive chemotherapy is given.

Treatment options for hepatoblastoma that cannot be removed by surgery or is not removed at the time of diagnosis may include the following:

• Combination chemotherapy to shrink the tumor, followed by surgery to remove the tumor.
• Combination chemotherapy followed by a liver transplant.
• Chemoembolization of the hepatic artery to shrink the tumor, followed by surgery to remove the tumor.

For hepatoblastoma that has spread to other parts of the body at the time of diagnosis, combination chemotherapy is given to shrink the cancer in the liver and cancer that has spread to other parts of the body. After chemotherapy, imaging tests are done to check whether the cancer can be removed by surgery.

Treatment options may include the following:

• If the cancer in the liver and other parts of the body can be removed, surgery will be done to remove the tumors followed by chemotherapy to kill any cancer cells that may remain.
• If the cancer in the liver cannot be removed by surgery but there are no signs of cancer in other parts of the body, the treatment may be a liver transplant.
• If the cancer in other parts of the body cannot be removed or a liver transplant is not possible, chemotherapy, chemoembolization of the hepatic artery, or radiation therapy may be given.

Treatment options in clinical trials for newly diagnosed hepatoblastoma include:

• A clinical trial of new treatment regimens based on how far and where the cancer has spread at diagnosis.

Hepatocellular Carcinoma

Treatment options for hepatocellular carcinoma that can be removed by surgery at the time of diagnosis may include the following:

• Surgery alone to remove the tumor.
• Surgery to remove the tumor, followed by chemotherapy.
• Combination chemotherapy followed by surgery to remove the tumor.

Treatment options for hepatocellular carcinoma that cannot be removed by surgery at the time of diagnosis may include the following:

• Chemotherapy to shrink the tumor, followed by surgery to completely remove the tumor.
• Chemotherapy to shrink the tumor. If surgery to completely remove the tumor is not possible, further treatment may include the following:
  • Liver transplant.
  • Chemoembolization of the hepatic artery to shrink the tumor, followed by surgery to remove as much of the tumor as possible or liver transplant.
  • Chemoembolization of the hepatic artery alone.
• Radioembolization of the hepatic artery as palliative therapy to relieve symptoms and improve the quality of life.

Treatment for hepatocellular carcinoma that has spread to other parts of the body at the time of diagnosis may include:

• Combination chemotherapy to shrink the tumor, followed by surgery to remove as much of the tumor as possible from the liver and other places where cancer has spread. Studies have not shown that this treatment works well but some patients may have some benefit.

Treatment options for hepatocellular carcinoma related to hepatitis B virus (HBV) infection include:

• Surgery to remove the tumor.
• Antiviral drugs that treat infection caused by the hepatitis B virus.

Undifferentiated Embryonal Sarcoma of the Liver

Treatment options for undifferentiated embryonal sarcoma of the liver (UESL) may include the following:

• Combination chemotherapy to shrink the tumor, followed by surgery to remove as much of the tumor as possible. Chemotherapy may also be given after surgery to remove the tumor.
• Surgery to remove the tumor followed by chemotherapy. A second surgery may be done to remove tumor that remains, followed by more chemotherapy.
• Liver transplant if surgery to remove the tumor is not possible.
• A clinical trial of a combination of targeted therapy, chemotherapy and/or radiation therapy before surgery.

Infantile Choriocarcinoma of the Liver

Treatment options for choriocarcinoma of the liver in infants may include the following:

• Combination chemotherapy to shrink the tumor, followed by surgery to remove the tumor.
• Surgery to remove the tumor.

Recurrent Childhood Liver Cancer

Treatment of progressive or recurrent hepatoblastoma may include the following:

• Surgery to remove isolated (single and separate) metastatic tumors with or without chemotherapy.
• Combination chemotherapy.
• Liver transplant.
• Ablation therapy (radiofrequency ablation or percutaneous ethanol injection).
• A clinical trial of a new treatment. A clinical trial that checks a sample of the patient's tumor for certain gene changes. The type of targeted therapy that will be given to the patient depends on the type of gene change.

Treatment of progressive or recurrent hepatocellular carcinoma may include the following:

• Chemoembolization of the hepatic artery to shrink the tumor before liver transplant.
• Liver transplant.
• A clinical trial of a new treatment.
• A clinical trial that checks a sample of the patient's tumor for certain gene changes. The type of targeted therapy that will be given to the patient depends on the type of gene change.

Treatment of recurrent undifferentiated embryonal sarcoma of the liver (UESL) may include the following:

• A clinical trial that checks a sample of the patient's tumor for certain gene changes. The type of targeted therapy that will be given to the patient depends on the type of gene change.

Treatment of recurrent choriocarcinoma of the liver in infants may include the following:

• A clinical trial that checks a sample of the patient's tumor for certain gene changes. The type of targeted therapy that will be given to the patient depends on the type of gene change.