Novel technique used to remove tumor in infant's liver

July 21, 2006

On June 28, infant Chloe Lobins received a liver resection--removal of part of the organ--and a new chance at life at the University of Chicago Comer Children's Hospital. Born prematurely and diagnosed with hepatoblastoma, Lobins is believed to be the smallest infant ever to undergo massive liver resection for a primary liver cancer.

Within weeks of her birth, doctors at the Gary, Indiana, campus of Methodist Hospitals realized the child needed immediate specialized care. When they noticed eating problems, they performed a CAT scan. They found a fast-growing, cancerous tumor and quickly transferred her to Comer Children's Hospital.

Born April 26 at 29 weeks, Lobins's size presented a challenge for pediatric surgeon Donald Liu, MD, surgeon-in-chief at Comer Children's Hospital. At the time of surgery, she was 63 days old and weighed only 2 kg (approximately 4 lbs. 6 oz.).

"Her small blood volume was a significant operative risk," said Mindy Statter, MD, director of Pediatric Trauma. Statter, who assisted Liu with the operation, was the first physician to examine Lobins at Comer Children's Hospital.

An infant that tiny has only 200 cc, about a teacup of blood, Liu said. Because of the great number of blood vessels, the liver is a fragile organ, especially in babies. "If you can't stop the bleeding, then they die on the operating table," Liu explained.

He knew he needed to work quickly to keep blood loss low and to preserve the remaining liver. "The liver is one of the most vascular organs," Liu said. "When you do the resection, you isolate all the vessels to control bleeding."

The Catch-22: the liver cannot endure long without blood flow. An adult liver can survive without permanent damage for about an hour. "The length of time a baby's liver can go without blood flow is anyone's guess," Liu said.

Liu reviewed all possible types of resection and chose a new method. Using a linear stapler, a device that looks like a vise, he simultaneously cut out the tumor and minimized the bleeding.

He placed the stapler along the edge of the portion to be removed and clamped down. In one action, the stapler sliced and sealed the liver by firing four rows of staples and cutting in between them, leaving two rows in the remaining liver and two rows in the removed portion. The operation took about 40 minutes, the resection about 30 seconds.

For many children with hepatoblastoma, doctors use chemotherapy to shrink the tumor before removing it. In Lobins's case, her doctors felt it was too risky to wait.

"We did surgery because such tumors are very aggressive, and without expeditious resection, it could fast become unresectable," Liu said. He added, "It is hard to give them [infants] chemo."

The tumor turned out to be one-tenth of the baby's body weight.

Attending physician William Meadow, MD, co-section chief of Neonatalogy, said, "It looks like they saved her life."

A biopsy of the removed mass concluded the infant had embryonal hepatoblastoma, which is more aggressive than fetal hepatoblastoma. Because of this discovery, doctors will give her post-operative chemotherapy as a precautionary measure.

"Chloe will be receiving some chemotherapy to insure that the tumor will not come back elsewhere in the body," said Dr. Charles Rubin, MD, a pediatrician at Comer Children's Hospital and an authority on childhood cancers. "The chemotherapy is designed for infants and small children and is dosed according to weight of the child. With scheduled monitoring and rapid attention to symptoms, such as fever, infants can tolerate chemotherapy in most cases."

Today, tests show the remaining liver is cancer-free. Since enough healthy tissue remained, Lobins's liver eventually should regain its normal size.