Hepatoblastoma Surgery

Most hepatoblastomas can be removed. And a child's liver grows back.

Your child has been told the lump in the liver is a hepatoblastoma, and someone has used the word surgery. Hepatoblastoma surgery removes the part of the liver that holds the tumor, after a short course of chemotherapy has shrunk it, and in the largest trial of standard-risk disease 95 percent of children had the tumor removed completely and 95 percent were alive three years later. This page explains what the operation involves, when a transplant replaces it, how long a family stays in Istanbul, what the first weeks at home look like, and what to send us if you want a pediatric surgeon to read your child's scans before you book anything.

How curable is hepatoblastoma?

Hepatoblastoma is the most common liver cancer of early childhood and one of the more curable solid tumors a child can have, because it responds to cisplatin and because the liver tolerates having a large piece removed. It appears before the age of three in nearly every case. Fewer than one child in a million is diagnosed each year, so few local hospitals see enough cases to be confident operating on them.

How far the tumor has spread at diagnosis sets the cure rate, and the numbers come from one of the largest datasets ever assembled for a childhood cancer. The Children's Hepatic tumors International Collaboration pooled 1,605 children treated in eight trials over 25 years and sorted them into four groups, from very low risk to high risk, using the PRETEXT group, the age of the child, the AFP level and whether the tumor had reached the main veins, broken through the liver capsule, spread to the lungs or ruptured. Children whose tumor sits in one or two sections of the liver with a normal AFP pattern and no spread form the very low and low risk groups, and these children do very well. Children whose tumor fills all four sections, has an AFP below 100, or has already reached the lungs sit in the high risk group. Surgery is hardest there.

In the SIOPEL-3 trial, published in the New England Journal of Medicine in 2009, 255 children with standard-risk hepatoblastoma received cisplatin before surgery, and the tumor was removed completely in 95 percent of the cisplatin-only group, three-year event-free survival was 83 percent and three-year overall survival was 95 percent. Advanced tumors do worse, and still far better than parents expect. A 2026 series from Toronto followed 68 children with PRETEXT III and IV disease for a median of five years and found five-year survival of 88 percent after liver resection and 79 percent after transplant, with no deaths from the surgery itself. Relapse is the thing that changes the outlook. In a Texas series of 129 children, five-year survival was 93.1 percent in children who never relapsed and 45.4 percent in those who did, and PRETEXT IV disease was the only independent predictor of relapse. Removing the whole tumor the first time, with a clear margin, is what prevents that.

What the PRETEXT stage decides

PRETEXT stands for pretreatment extent of tumor. On the MRI or CT scan the radiologist divides the liver into four sections and counts how many of them are free of tumor. One section involved is PRETEXT I. Two adjoining sections involved is PRETEXT II. Three is PRETEXT III. All four is PRETEXT IV. The 2017 international definitions, agreed by the North American, European and Japanese study groups, add annotation letters for the things that decide whether an operation is possible. V means the three hepatic veins or the vena cava are involved. P means the portal vein is involved at its division. E means the tumor has grown out of the liver into a neighboring organ. F means more than one tumor. M means spread to the lungs or elsewhere. R means the tumor has ruptured and bled.

After chemotherapy the same scan is repeated and restaged as POSTTEXT, and the operation is planned on that picture, because by then the tumor is smaller and the margins clearer.

Group and letters together decide the surgical plan.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Scans overstate the tumor more often than they understate it. When the SIOPEL-1 trial compared the PRETEXT group given before treatment with what the pathologist found after the operation, the two matched in only 51 percent of children, and 37 percent had been staged higher than the tumor deserved.

PRETEXT III on the first scan is a reason to plan carefully and a poor reason to despair.

Chemotherapy before the operation

Cisplatin made hepatoblastoma curable, and it is given before surgery in nearly every protocol in use today. A standard-risk child on the European protocol receives four cycles, two weeks apart, over roughly eight weeks, then has the operation, then receives two more cycles, while the North American protocol reassesses after two cycles and operates as soon as the surgeon judges the tumor removable, with the remaining cycles given afterward. Both protocols agree on one thing the SIOPEL-3 trial settled. Adding doxorubicin to cisplatin for standard-risk disease raised the rate of serious side effects from 20.6 percent to 74.4 percent and did not improve the resection rate or survival, so cisplatin on its own is the standard for that group.

Shrinkage comes early, mostly in the first two cycles.

Alpha-fetoprotein, AFP, is the blood marker that tracks all of this. Hepatoblastoma cells make it, so the blood level is high at diagnosis, falls with each cycle, and should drop to normal after the tumor is out, and an AFP that fails to fall by at least 95 percent during chemotherapy was linked with poorer survival in the Toronto series. The oncologist checks it before every cycle, and your child's AFP results are the first thing a surgeon here will ask to see.

Cisplatin damages hearing in a proportion of young children, permanently, and the risk rises with the number of cycles. Audiology testing before the first cycle and after the last belongs in every plan, and it is one of the reasons the field has worked so hard to give fewer cycles. Upfront surgery for a tumor that is clearly removable is one way to do that, and a Chinese series of 37 children with PRETEXT III and IV tumors found that those operated on first received five cycles instead of six and had fewer episodes of fever, low blood counts and vomiting, with the same three-year event-free survival.

The operation, step by step

Hepatoblastoma surgery is a partial hepatectomy, meaning removal of the part of the liver that contains the tumor together with a margin of healthy tissue, under general anesthesia, through an incision across the upper abdomen, with a pediatric surgeon operating alongside a liver surgeon or transplant surgeon for the larger resections and an anesthesiologist who looks after small children running the anesthetic. It takes three to six hours. How much liver comes out and how close the tumor sits to the main veins decide which end of that range applies. Inside the abdomen, the first step is an ultrasound probe placed directly on the liver. The scan from two weeks ago showed where the tumor was. The probe shows where it is now, where the veins run around it and whether there is a second nodule the MRI missed. Some centers add indocyanine green, a dye injected into a vein the day before, which makes tumor tissue glow under near-infrared light. A 2021 series found the dye picked out 91 percent of primary and metastatic deposits and identified nodules as small as one millimeter, and it helps the surgeon confirm that nothing has been left at the cut edge.

Next the surgeon controls the blood supply. The liver receives blood from the portal vein and the hepatic artery and drains through three hepatic veins into the vena cava, and the branch feeding the part to be removed is tied off first. The liver tissue is divided along the plane between sections, using an ultrasonic dissector that breaks up liver cells and leaves the small vessels and bile ducts intact so each one can be sealed. The piece containing the tumor is lifted out whole and sent to pathology, where the pathologist measures the margin and checks the tissue under the microscope. Across 68 resections in a 2025 series from Hong Kong, 58.8 percent of the operations took the right lobe, which is where most hepatoblastomas sit. A drain is left for a few days. The incision is closed in layers and the child goes to the pediatric intensive care unit overnight.

Laparoscopic removal, through small ports rather than an open incision, has been reported for small tumors well away from the veins, with one Korean group publishing 19 safe cases, yet for the extended resections that most PRETEXT III and IV tumors need, open surgery remains the standard everywhere, because the surgeon needs both hands and a direct view of the vena cava.

Lymph nodes around the liver are examined and sometimes removed. A 2026 systematic review of 277 hepatoblastoma cases found no positive nodes in any child whose nodes were removed, so routine node dissection adds nothing and is no longer standard.

How much liver can a child lose?

A child can lose up to three quarters of the liver in one operation, and the remainder grows back to close to its original size within weeks.

Among the solid organs, only the liver regenerates. A young child's regenerates faster than an adult's. What has to be left behind is called the future liver remnant, and the surgeon calculates it from the scan before agreeing to the operation. Around a quarter of the healthy liver volume, with its own artery, portal vein, hepatic vein and bile duct intact, is enough for a child who has had chemotherapy. Where the remnant would be too small, a two-stage approach can grow it first. The portal vein to the diseased side is tied off or blocked, blood is diverted to the healthy side, and the healthy side enlarges. One report in Annals of Surgery described a 54-day-old infant whose remnant grew by 91 percent in seven days after the first stage, and the second operation removed the tumor side once the remnant was large enough. Computer-assisted planning on the scan allowed 85 percent of children with complex tumors in a German series to have an extended resection rather than a transplant.

Liver function tests are raised for the first week after surgery and settle as the remnant grows, and by the time your child flies home the blood tests have usually returned to a range the oncologist at home will recognize as normal.

When a transplant replaces resection

A liver transplant becomes the operation of choice when the tumor still fills all four sections after chemotherapy, when it still surrounds the portal vein at its division or all three hepatic veins, or when there are many separate tumors scattered through both lobes. Those are the POSTTEXT IV, P plus, V plus and F plus situations in the staging language, and they are the reason a transplant team is contacted early for any PRETEXT IV child, so that a donor can be found by the time the decision is made, with no delay afterward. Published results for the two operations are closer than most families expect. A 2024 pooled analysis in Pediatric Blood and Cancer gathered 189 children from 55 studies, all of whom met the transplant criteria above, and compared the 111 who were transplanted with the 78 who had an extended resection instead. Five-year overall survival was 75.3 percent after transplant and 87.6 percent after resection, a difference that did not reach statistical significance. Local recurrence in the liver was more common after resection, 14 percent against 3 percent, while recurrence at a distance was more common after transplant, 16 percent against 5 percent, and the authors concluded that resection is an effective alternative to transplant in selected children even with locally advanced disease.

For a family the practical difference is large. A resection means a week in hospital and a liver that is the child's own. A transplant means a donor, most often a parent giving part of their own liver, a longer admission, lifelong medication to stop rejection, and a return to the transplant center for life. Where the scan after chemotherapy leaves room for either, the surgeon chooses resection.

Lung spread does not rule out surgery. Nodules that have cleared on chemotherapy need no further treatment. Nodules that remain are removed through the chest, in a separate operation, when they are few enough to count. Of 38 children with lung spread at diagnosis in a North American study, eight of the nine who had the nodules removed survived.

Risks and how each one is managed

Two centers in Hong Kong give the clearest recent picture. Across 68 resections between 1995 and 2024, 17.6 percent of children had a complication within 30 days and six needed a second operation. Two things predicted trouble. A tumor that had ruptured before surgery doubled the risk, and an operation lasting more than six hours raised it two and a half times. Five-year disease-free survival in that series was 80 percent, with a clear improvement in both complications and survival among the children treated after 2010.

Death from the operation itself is rare.

The Toronto series of 68 advanced cases recorded no perioperative or graft-related deaths at all. Every death in that series came from the tumor coming back.

Recovery week by week

The first week

Your child wakes in the pediatric intensive care unit with a drip, a drain from the abdomen, a catheter and a pain pump, and a continuous infusion through an epidural or a vein keeps a small child comfortable enough to sleep. One parent sits with the child. By the next morning most children are back on the ward. Sips of water on day one or two, milk or soft food once the bowel wakes up, and the drip comes down as feeding comes up. The drain comes out when the fluid is clear and the volume falls, usually around day three to five. Blood tests every day watch the liver enzymes, bilirubin and clotting. Toddlers are walking or being carried around the ward within two days. Published series and the pediatric surgery units treating international children in Turkey report five to ten nights in hospital for a partial hepatectomy, with the longer stays after extended resections, and two to four weeks after a transplant.

Weeks two and three

The wound is checked at ten days, with nothing to remove because the stitches sit under the skin, and the first AFP after surgery is taken in the same window, where it should be clearly lower than the last value before the operation. Eating well, a healing wound and normal clotting clear a child to fly two to three weeks after a resection. That date is written on the discharge letter rather than left to a phone call.

Weeks three to six

Chemotherapy resumes three to four weeks after surgery, once the wound has healed and the blood counts have recovered, which on the European protocol means two more cycles of cisplatin, two weeks apart. Here or at home. The next section sets out what each choice means.

Within a month most children are running. The scar fades over a year.

How long a family stays in Istanbul

Two patterns cover nearly every family who contacts us, and the stay differs by months between them.

One more pattern exists, for a child who needs a transplant, and it runs to two to three months because the donor has to be assessed and operated on as well, and the child stays near the center until the anti-rejection drug levels are stable.

Whichever pattern fits, the pediatric surgeon reviewing your child's scans tells you which one before you travel, with the expected number of weeks, so the family can plan leave from work and school for the other children.

If the plan changes

Published reviews put the share of tumors that look unresectable at diagnosis at around 60 percent, and the share still unresectable after chemotherapy at 15 percent. It changes for a large minority of children, in both directions.

Most often the change is good news. A tumor staged PRETEXT III or IV on the first scan shrinks off the veins after two cycles and becomes removable with a resection, so the transplant that was discussed never happens. The reverse also occurs. The restaging scan shows that the tumor has not pulled back from the portal vein, and the decision moves to a transplant. The transplant team is involved from the first review of a PRETEXT IV child for exactly that reason.

Pathology can change the plan too. The microscope occasionally shows a small cell undifferentiated pattern, which behaves differently and is now understood to be a separate tumor in most cases, treated with a sarcoma protocol in place of the hepatoblastoma one. Or the margin is involved and the oncologist adds a cycle. Or the AFP, which should fall to normal within four to six weeks of a complete resection, plateaus instead, and the lungs are rescanned.

Every one of these changes is handled on this site. Chemotherapy and radiotherapy are both delivered at Biruni Hospital, so a child whose pathology calls for more treatment continues with the same oncologist and the same surgeon, without a referral to another hospital and without a second set of records. A family who prefers to go home for the extra treatment receives a written handover to their own oncologist, with the pathology report, the operation note and the AFP trend, and that choice stays open at every step.

Relapse, when it happens, happens early.

Most recurrences in the Toronto series came within the first year after surgery. In the Texas series, children whose relapse was treated with surgery as well as chemotherapy were far likelier to survive than those given chemotherapy alone, so a relapse in the liver or the lungs is a reason to come back for another operation rather than a reason to stop.

When we would say not yet

A surgeon who looks at your child's scans and books a flight the same day is not reading them carefully.

Sometimes the right answer from a free review is to wait.

Any child who has had no chemotherapy and whose tumor touches the main veins should receive two cycles at home before anyone talks about an operation, because six weeks of cisplatin makes most of those tumors removable. Blood counts that have not recovered from the last cycle mean another week or two before a long anesthetic. A ruptured tumor needs the bleeding settled and chemotherapy started before any travel. Lung nodules still growing on chemotherapy call for a different drug combination before surgery can succeed. And scans that point clearly to a transplant mean a living donor has to be identified in the family before the trip is booked, because the donor assessment takes longer than the child's.

None of these is a refusal. Each one comes with a date to send the next scan.

What drives the cost

No figure on a web page will match your child's case, because the operation itself changes with the stage.

Two children both described as having hepatoblastoma surgery can have quotes that differ several times over, and the reasons are visible on the scan.

Extent of resection comes first. One section removed in three hours costs less than an extended hepatectomy with the vena cava reconstructed in six. A transplant sits in a different category altogether, with a donor operation and anti-rejection drugs inside it. Whether chemotherapy is given here or at home changes the total more than anything else, because four to six cycles of cisplatin with the blood tests, the admissions for fever and the audiology between them add up to more than the operation. A lung operation for remaining nodules is a separate procedure with its own fee, and intensive care beyond the planned night, a bile leak that needs a drain placed by radiology, or a second operation each add to the bill, with no package covering them in advance. The two-stage approach for a small remnant means two admissions.

Patient factors matter as much as the tumor. An infant under a year old needs more intensive care support than a three-year-old, underweight children after chemotherapy sometimes need feeding support before surgery, and genetic syndromes such as Beckwith-Wiedemann, which raise the risk of hepatoblastoma, bring other specialists into the plan.

Packages published by Turkish private hospitals and medical travel agencies for pediatric liver surgery include the surgeon and anesthesia fees, the operating theater, the intensive care night, the ward stay for a set number of nights, the pathology, the pre-operative tests and scans, an interpreter, airport transfers and a stated number of hotel nights for the family. They leave out flights, travel insurance, extra hospital nights, blood products beyond a set number of units, chemotherapy unless it is listed, and the treatment of any complication.

Five questions separate a real quote from a headline. Which PRETEXT group and which operation does the figure assume, and is chemotherapy inside it, with how many cycles. What happens financially if the child needs a second night in intensive care. Is the pathology report inside it. And is the remnant volume calculation inside it, since that is the test that decides between one operation and two.

Real figures come only from a pediatric surgeon reading your child's own scans and AFP results, and that review costs nothing.

Traveling with a small child

One parent sleeps in the room. Every patient room has a companion bed, and for a child under three that bed is occupied every night of the admission, including the first night, when the child is in intensive care and a parent sits at the bedside. The other parent and any siblings stay in accommodation the international patients office arranges for the nights either side of the admission. The same office books the airport transfer and the daily trips between hotel and hospital. A coordinator who speaks your language is assigned from the first message and stays with your family through discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, and interpreting in other languages is arranged on request. The consent conversation before surgery, the ward round each morning and the pathology result are all explained in your language, and the coordinator remains reachable on the same WhatsApp number after you fly home.

An appointment confirmation and an invitation letter naming the hospital and the treating surgeon go out ten days before travel, which is exactly the letter most consulates ask for with a medical visa application, and a parent traveling as the companion is named on it. Halal, vegetarian and diabetic meals come from the hospital kitchen, which matters more than usual here because a toddler after liver surgery eats small amounts many times a day and a parent needs to be fed too. A prayer room is on site.

Say in your first message if you would prefer a female physician, because the request goes to the department and is met wherever the rota allows.

Bring the original scan discs, every AFP result with its date, the chemotherapy record with the dates and doses of each cycle, the hearing test, the growth chart and the vaccination record. The pathology slides, if a biopsy was done, travel in hand luggage.

After you fly home

You leave with a discharge summary, the operation note, the pathology report, the AFP values before and after surgery, and a letter to your child's oncologist setting out the remaining cycles and the follow-up schedule, and the coordinator sends the same documents by e-mail before the flight so that the oncologist at home has read them before your first appointment.

Once you are back home, AFP is the follow-up. The oncologist checks it every month for the first year, then every two to three months in the second year, then at longer intervals, and a value that rises on two consecutive tests triggers an MRI of the liver and a CT of the chest. Imaging on a schedule is added to that in most protocols, with an ultrasound of the liver and a chest X-ray or CT at intervals that stretch out as the years pass. Hearing is tested again at the end of treatment. The result goes in the school record. Kidney function, which cisplatin can affect, is checked once a year.

Call the coordinator the same day for a fever above 38 degrees, a wound that becomes red, swollen or leaks, yellow skin or eyes, pale stools, vomiting that stops the child keeping fluids down, or a swollen abdomen. A local emergency department handles the first assessment of any of these, and the surgeon here speaks to that doctor by phone with the operation note in front of them.

Remote reviews after discharge are free.

New AFP results, scan reports and questions from the oncologist at home go to the same WhatsApp number, and the surgeon who operated replies.

What to send for a free review

Send the most recent MRI or CT of the abdomen, as images and with the written report, the AFP results with their dates, the chemotherapy record so far, and the biopsy report if one was taken. Your child's date of birth and current weight help the surgeon judge the remnant.

Together, a pediatric surgeon and a pediatric oncologist read them and reply with the PRETEXT or POSTTEXT group as they see it, whether a resection or a transplant is the likelier operation, which of the two stay patterns fits, how many weeks that means, and whether anything should happen at home first. It costs nothing. There is no obligation to travel.

Hepatoblastoma surgery FAQ

References

1. Meyers RL, Maibach R, Hiyama E, et al. Risk-stratified staging in paediatric hepatoblastoma: a unified analysis from the Children's Hepatic tumors International Collaboration. Lancet Oncol. 2017;18(1):122-131.
2. Perilongo G, Maibach R, Shafford E, et al. Cisplatin versus cisplatin plus doxorubicin for standard-risk hepatoblastoma. N Engl J Med. 2009;361(17):1662-1670.
3. Fuchs J, Rabaux-Eygasier L, Ruping F, et al. Reappraisal of liver resection as an alternative to transplantation in locally advanced hepatoblastoma: A systematic review and analysis of pooled individual patient data. Pediatr Blood Cancer. 2024;71(12):e31339.
4. Chung PHY, Yeung F, Wong KKY. Risk factors for adverse surgical outcomes after liver resection for hepatoblastoma. A review of 30 years of experience. J Pediatr Surg. 2025;61(4):162426.
5. Mehta S, Sayed BA, Shaikh F, et al. Definitive surgical outcomes in children with advanced hepatoblastoma (PRETEXT III-IV): A retrospective single-center Canadian experience. Liver Transpl. 2026, published online September 29. doi:10.1097/LVT.0000000000001006
6. Towbin AJ, Meyers RL, Woodley H, et al. 2017 PRETEXT: radiologic staging system for primary hepatic malignancies of childhood revised for the Paediatric Hepatic International Tumour Trial (PHITT). Pediatr Radiol. 2018;48(4):536-554.
7. Espinoza AF, Patel KR, Shetty PB, et al. Navigating relapsed hepatoblastoma: Predictive factors and surgical treatment strategy. Cancer Med. 2023;12(23):21270-21278.