Liver transplantation for pediatric liver tumors: a case report of hepatic angiosarcoma with literature review

Introduction

Pediatric liver tumors encompass a wide variety, such as hepatoblastoma (HB) and hepatocellular carcinoma (HCC), among which hepatic angiosarcoma (HAS) is a rare, highly aggressive malignant vascular tumor of the liver, with fewer than 50 pediatric cases reported globally. It occurs more frequently in elderly males than it does in children; in the pediatric population, it predominantly affects girls, with a mean age of onset of approximately 3 years. The common presenting symptoms include abdominal masses and pain. Initial misdiagnosis as hepatic hemangioma (HH) is common, and some patients present with metastatic disease at diagnosis, particularly in the lungs (1).

Liver transplantation (LT) is a potential therapeutic strategy for children with unresectable liver tumors, particularly malignant tumors. The maturity of surgical techniques is evidenced by reported outcomes, including a remarkable 20-year overall survival (OS) rate of 95% across indications (2). In the United States, LT acceptance for pediatric HB rose from 8% [1998] to 27% [2016], reflecting its growing role (3), with 5-year OS for HB and HCC reaching 80% (4). Complete surgical resection is considered the best opportunity for long-term survival, yet HAS is typically unresectable at diagnosis, and the role of LT in unresectable HAS continues to be defined (5,6).

In this study, we report the first Chinese pediatric HAS case managed with LT, detailing the journey from diagnosis to treatment, and review the available evidence on LT across pediatric liver tumors reported over the past 15 years, aiming to describe the imaging and pathological features of pediatric HAS and explore the clinical value of LT in pediatric HAS and other pediatric liver tumors. We present this article in accordance with the CARE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2026-1-0035/rc).

Case presentation

A 2-year-old male child presented with abdominal pain, distension, fever, dyspnea, and suspected hepatic malignancy without a history of hepatitis B or hereditary disorders. No prior interventions had been performed. Physical examination revealed a firm fixed mass in the hepatic region. Color Doppler flow imaging (CDFI) showed hepatomegaly with multiple, moderately vascularized heterogeneous masses in both hepatic lobes, the largest measuring 13.3 cm × 9.3 cm × 8.1 cm (Figure 1A). Contrast-enhanced ultrasound (CEUS) revealed peripheral heterogeneous nodular enhancement with progressive centripetal filling during the early arterial phase; focal areas started to washout in the late arterial phase. In the portal venous and delayed phases, the lesion demonstrated heterogeneous enhancement with both hypo-enhancing and moderately hyper-enhancing components, and several internal patchy areas showed persistent non-enhancement throughout all phases, indicative of internal necrosis, supporting the diagnosis of a neoplastic lesion (Figure 1B,1C). Further contrast-enhanced abdominal computed tomography (CECT) (Figure 1D) demonstrated a large, ill-defined soft-tissue mass (15.1 cm × 11.1 cm) involving both hepatic lobes. The lesion showed marked heterogeneous enhancement in the arterial phase, which progressed in the portal venous phase, with tumor involvement obscuring the portal vein and its tributaries. Multiple weakly enhancing hypodense nodules were also present, raising concern for intrahepatic metastases, and the computed tomography (CT) imaging appearance was also highly suggestive of a malignant neoplasm. Laboratory investigations revealed mild cancer antigen 125 (CA125) elevation (35.6 U/mL), leukocytosis (14.83×10⁹/L), and mild anemia (Hb 102 g/L); the alpha-fetoprotein (AFP) level was within the normal range at 3.57 ng/mL. Other relevant markers, including carbohydrate antigen 199 (CA199), carcinoembryonic antigen (CEA), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), and platelet count (PLT) remained within normal limits.

Figure 1 Preoperative and postoperative imaging. (A) Preoperative CDFI showed moderate internal vascularity within the primary lesion. (B) Preoperative CEUS at early arterial phase (12 s) revealed peripheral heterogeneous nodular enhancement. (C) Preoperative CEUS at parenchymal phase (2 min 52 s) demonstrated focal washout, resulting in a heterogeneous appearance with both hypo-enhancing and moderately hyper-enhancing components. (D) Preoperative CECT identified a large hepatic mass with heterogeneous enhancement. (E) Postoperative CDFI and (F) postoperative CECT scans were unremarkable, confirming well-maintained vascular flow in the graft. Arrows indicate the tumor as defined above. CDFI, color Doppler flow imaging; CECT, contrast-enhanced computed tomography; CEUS, contrast-enhanced ultrasound.

The patient underwent ultrasound-guided needle biopsy. Pathological examination revealed vascular-derived cells forming irregular cord-like structures that were positive for platelet endothelial cell adhesion molecule-1 (CD31), hematopoietic progenitor cell antigen (CD34), glucose transporter 1 (GLUT-1), and ETS-related gene (ERG), with a Ki-67 index of 15%, suggesting infantile hepatic hemangioma (IHH). A multidisciplinary team assessment deemed the tumor unresectable; additionally, given the mildly elevated CA125, imaging characteristics, elevated Ki-67 index, malignant transformation could not be excluded. Following thorough communication, the family expressed a strong willingness for treatment, and the parents opted for living-donor liver transplantation (LDLT) using the left lobe from the mother. LT was performed successfully following comprehensive imaging that confirmed the absence of metastases or surgical contraindications. Postoperative CDFI monitoring was performed intensively (every 1–2 days for the first 10 days, then weekly, with emergency bedside examinations, as needed). All surveillance studies demonstrated normal morphology and hemodynamics in the graft liver; however, postoperative histopathological examination revealed focal transformation of IHH to intermediate to HAS. The IHH component demonstrated weak P53 positivity, negative P16, and a low Ki-67 proliferation index (<1%). In contrast, the HAS component exhibited extensive strong P53 positivity, P16 positivity, and a markedly elevated Ki-67 index of approximately 20%. The patient also developed IHH-associated consumptive hypothyroidism (CH) [decreased total triiodothyronine (TT3) and free triiodothyronine (FT3)], prompting thyroxine replacement therapy.

Postoperative care consisted of routine rehabilitation and immunosuppression (tacrolimus and mycophenolate mofetil). The family expressed satisfaction with the surgical course and consented to this regimen but declined adjuvant chemotherapy. Pre-discharge ultrasound and CT scans of the graft liver showed no abnormalities (Figure 1E,1F) and he was discharged one month after surgery. All follow-ups remained stable until the eighth month, when a new heterogeneously hyperdense lesion was detected in the right tenth rib on CT; a whole-body bone scan showed no evidence of metastatic disease, however, pathological examination of the resected lesion confirmed metastatic hemangiosarcoma. The parents continued to decline chemotherapy. The patient died of multifocal bone metastases 21 months after transplantation.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was provided by the patient’s legal guardians for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

We report a case of pediatric HAS and present a literature review of English-language studies on LT for pediatric liver tumors published over the past 15 years, identified via PubMed and Web of Science.

Hepatic vascular tumors

According to the International Society for the Study of Vascular Anomalies (ISSVA) classification, pediatric hepatic vascular tumors are classified into three categories: the most common benign tumor is IHH, and locally aggressive or borderline vascular tumors include entities such as kaposiform hemangioendothelioma (KHE). Malignant variants encompass HAS and hepatic epithelioid hemangioendothelioma (HEH), among others (7).

Over the past 15 years, nine pediatric cases of LT for HAS have been reported (Table 1). The patients, aged 1 to 7 years with a female predominance (8/9), most commonly presented with abdominal distension (7/9) and pain (3/9). Imaging findings of HAS on CT and magnetic resonance imaging (MRI) typically demonstrate a large, heterogeneously enhancing mass, which may exhibit diffuse arterial enhancement with centripetal filling. Multiple intrahepatic satellite lesions are commonly observed. The tumor frequently causes compression of the inferior vena cava (IVC), portal vein (PV), and superior mesenteric vein (SMV). Arteriovenous (AV) shunting may also be present. On conventional ultrasound, the tumor typically appears as a predominantly hyperechoic large mass with heterogeneous echotexture. CEUS findings were not described in any of the cases. Imaging features suggestive of tumor progression or aggressive behavior include rapid tumor growth, vascular invasion or compression, AV shunting, coalescence of satellite lesions, and the presence of preoperative extrahepatic metastases. In the pediatric patients, the rapid increase in abdominal girth and significantly worsening symptoms are ominous signs concerning for malignancy. Although the final diagnosis of HAS was pathologically confirmed in all cases, only one was correctly diagnosed prior to LT based on a liver lesion biopsy, whereas the other patient was diagnosed with HH or hemangioendothelioma. Among the five patients with detailed records, post-LT complications included acute rejection (3/5), vascular (2/5), biliary (1/5), and infectious/viral complications (3/5). Of the nine patients, four developed clinically evident hypothyroidism. Regarding recurrence, one of the two patients with preoperative metastases recurred at 9 months, whereas the other did not. Two of the remaining seven patients also developed metastases postoperatively. The post-LT survival time for all nine patients ranged from 3 to 66 months (5,6,8-10).

Table 2 summarizes the reported LT cases of IHH and pediatric HEH. Six cases of IHH, which occurred before 2010, lacked follow-up data (11-13). Pharmacotherapy is the cornerstone of treatment for IHH, with favorable outcomes typically achieved using steroids. Since 2008, propranolol has demonstrated remarkable efficacy even in multifocal or diffuse disease, leading to a marked reduction in surgical intervention. Lekwittikarn et al. successfully rescued a child with life-threatening IHH using combination pharmacotherapy, suggesting that such regimens may eliminate the need for radical resection or LT, thereby averting associated lifelong immunosuppression. According to the United Network for Organ Sharing (UNOS) data, hemangiomas accounted for 0.4% (35/8,047) of LT in infants under one year from 1989 to 2008, falling to 0% (0/2,672) from 2009 to 2017. Consequently, LT is now reserved as the ultimate therapeutic option for children who fail pharmacotherapy and are not candidates for primary resection (13,16). No cases of LT for primary hepatic KHE have been reported in children. For HEH, a UNOS study focusing on HEH demonstrated a 5-year OS of 60.6%, suggesting that LT is a viable alternative for patients with unresectable disease (14). Supporting this, Samuk et al. reported favorable outcomes in one case and concluded that pre-existing limited extrahepatic metastases may not be an absolute contraindication for LT in such patients (15).

HB

HB, the most common pediatric malignant liver tumor, demonstrates excellent long-term survival following LT. As summarized in Table 3, recent large cohort studies consistently reported 5-year OS rates of 80–90%, and one study with extended follow-up demonstrated a 15-year OS of 73%. An analysis by Ezekian et al. of the UNOS database demonstrated an improvement in 5-year OS from 75.1% [1987–2009] to 82.6% [2010–2017] following LT for pediatric HB (4). Similarly, in Japan, Uchida et al. noted a marked increase, rising from 63.2% [1996–2008] to 89.8% [2009–2018] (18). However, treatment for high-risk patients remains challenging. A small single-center study from India reported a 5-year OS rate of 73% after LT (25), whereas a Spanish study by Barrena et al. reported a comparable rate of 73.2%±26.8% (26). Surgical intervention, liver resection (LR), or LT, plays a crucial role in its management with the goal of complete macroscopic tumor resection. A systematic review of 55 studies indicated no significant difference in OS or event-free survival between LT and LR for locally advanced HB (27). LT for HB is now part of standard therapy and serves as a valuable salvage option following tumor recurrence after initial resection; however, the choice between primary LT and salvage LT remains controversial (28), with recent studies demonstrating no significant difference in 5-year OS between the two strategies (18,29). Furthermore, a large cohort study found no significant difference in patient survival or graft survival based on the type of donor graft (20).

HCC

HCC is the second most common malignant liver tumor in children. A review of eight studies on survival after LT for HCC over the past 15 years (Table 4) revealed significant improvements in outcomes. Studies enrolling patients after 2010 consistently reported 5-year OS rates exceeding 80%, which is markedly superior to studies that included patients from the 1990s or earlier. This trend is quantified by Ezekian et al., who reported an improvement in 5-year OS from 59.9% in a historical cohort [1987–2009] to 80.8% in a contemporary cohort [2010–2017] (4). Furthermore, a systematic review of 67 studies reported a combined 5-year OS of 74.3% (35). Analyses by Ziogas et al. using Surveillance, Epidemiology, and End Results Program (SEER) and UNOS registries compared survival outcomes between LT and LR for pediatric HCC; their findings indicated that LT yielded comparable, if not superior, survival to LR, with both interventions outperforming margin-positive resection (32,33). Most available studies are based on deceased-donor grafts; although a study by Stefanowicz et al. showed no significant difference in patient survival between LDLT and deceased-donor liver transplantation (DDLT), the finding is limited by the small patient cohort (23). Consequently, the influence of graft type on outcomes remains unresolved, warranting future investigation in larger cohorts.

Other hepatic malignancies

An overview of reported LT cases of hepatic undifferentiated embryonal sarcoma (HUES), biliary tract rhabdomyosarcoma (BT-RMS), and malignant rhabdoid tumor (MRT) of the liver is provided in Table 5. For HUES, available studies have demonstrated favorable survival outcomes; the largest series to date confirmed a 5-year OS rate of 90% and concluded that LT represents a viable therapeutic option when LR is not achievable (22). For BT-RMS, scholars maintain a positive view of LT, regarding it as a therapeutic option for patients with locally advanced, unresectable disease or those who do not respond to standard treatments. An analysis by the Children’s Oncology Group (COG) of 25 patients with BT-RMS concluded that although the majority presented with unresectable disease, favorable outcomes were observed even in cases with postoperative residual tumor, suggesting that overly aggressive resection may be unwarranted (44). Reports of LT for unresectable MRT of the liver are exceedingly rare. Yanagi et al. described one such case, achieving a disease-free survival of over 3.5 years after LDLT. Furthermore, their review of 46 pediatric cases established the critical importance of surgical intervention by documenting no survivors in its absence. They noted that localized disease and complete resection were associated with improved survival and suggested that LT should be considered an option for MRT of the liver that is unresectable if they are responsive to chemotherapy without metastatic lesions (43). Nevertheless, further experience and case accumulation are required to definitively establish the role of LT for these rare malignancies.

In light of the foregoing literature review, we now discuss the key findings and clinical implications of this case. Pediatric HAS is a rare malignancy. It is believed to be the malignant transformation of IHH; however, the etiology of HAS in children is still unclear (45). The disease lacks specific clinical features or circulating biomarkers (such as AFP for HB). In our case, the elevated CA125 level was likely attributable to tumor compression of the hepatic capsule rather than being a specific indicator of HAS.

Medical imaging

Given the absence of specific clinical and laboratory features, early imaging detection plays a critical role. The current understanding of the imaging characteristics of HAS remains limited, primarily derived from adults and mainly focusing on CT and MRI findings. Reports on ultrasound, especially CEUS, are extremely rare. In adults, CT and MRI features overlap with those of hemangiomas, including peripheral nodular enhancement during the arterial phase and progressive centripetal filling. However, one study suggested that HAS significantly more often showed lesion multiplicity with irregular, rim-like, nodular, linear, or other bizarre enhancement patterns (46). In the study by Wang et al., small lesions on conventional ultrasound often appeared isoechoic with well-defined borders; although large lesions appeared hypoechoic with poorly defined borders, all lesions were heterogeneous. In their study, three cases of primary HAS showed a similar enhancement pattern on CEUS, characterized by remarkable central non-enhancement and peripheral irregular enhancement in the arterial and portal phase, and complete wash-out in the late phase (47). In the case reported by Zhao et al., the lesion manifested peripheral irregular arterial enhancement with variable amounts of central unenhanced area. Peripheral enhancement declined gradually in the portal phase and washed out entirely in the late phase (48). In children, the density of the mass on CT is typically lower than that of the adjacent liver parenchyma, although hyperdense foci representing acute hemorrhage may be present. After contrast administration, peripheral nodular, central, or rim-like enhancement may occasionally occur. Delayed images reveal persistent heterogeneous enhancement with bizarre progressive filling rather than a centripetal pattern, possibly due to central fibrosis or necrosis. MRI shows similar enhancement features to CT. Ultrasound may demonstrate a large solitary mass or multifocal heterogeneously hypoechoic to isoechoic nodules, or diffuse heterogeneous echotexture of the entire liver, with echogenicity varying by hemorrhage and necrosis. On CEUS, peripheral nodular enhancement is predominantly seen in arterial and portal phases, along with diffuse chaotic or reticular enhancement. The late phase typically shows hypoenhancement, possibly with partial rim-like or isoenhancement, without centripetal filling (45). Children and adults show similar imaging features.

Our case review indicates that pediatric HAS may present as a large, predominantly hyperechoic heterogeneous mass. In our case, although hemangioma-like enhancement predominated, some areas of the mass exhibited washout in the late arterial phase that persisted through the portal and delayed phases, suggesting the presence of malignant components, which is consistent with the features described above. Common characteristics of HAS can be observed on CEUS, which may provide valuable diagnostic clues for this rare disease. Therefore, for children initially diagnosed with HH but suspected of malignant transformation based on clinical or CT/MRI findings, we recommend CEUS combined with multi-site or repeated core needle biopsy of suspicious lesions to improve the diagnostic yield.

CH

Additionally, hypothyroidism was noted in a subset of pediatric patients. CH is a rare and potentially overlooked complication occurring in patients with HH that overexpress deiodinase. This condition was first described by Huang et al. in 2000 in a 6-week-old infant with multiple HHs (49). Subsequently, other authors have also described this association. In the study by Kulungowski et al., hypothyroidism was identified in 100% of patients with diffuse HH and in 21.4% of those with multifocal HH (12). Furthermore, CH has also been reported in association with extrahepatic hemangiomas, such as cutaneous and parotid gland hemangiomas (50). Studies have demonstrated that CH is attributable to the hemangioma components, specifically the overexpression of type 3 iodothyronine deiodinase (D3) in vascular endothelial cells. This enzyme converts thyroxine (T4) to reverse triiodothyronine (rT3) and triiodothyronine (T3) to diiodothyronine (T2). The expression of D3 within hemangiomas is induced by basic fibroblast growth factor and vascular endothelial growth factor, and its activity increases with tumor size, irrespective of tumor location (51). The gold standard for diagnosing CH is the demonstration of increased D3 activity in tumor tissue. However, given the high risk of bleeding associated with biopsy, this procedure is rarely performed in patients with HH. Therefore, the current diagnosis is primarily based on clinical inference, including: elevated serum thyroid-stimulating hormone (TSH) levels, a poor response to conventional doses of levothyroxine (LT4), progressive normalization of thyroid function following effective hemangioma treatment and tumor shrinkage, and the exclusion of congenital hypothyroidism (52). Treatment of CH involves hormone replacement therapy. However, due to extensive peripheral conversion of thyroid hormones into inactive forms, the required LT4 replacement dose is often considerably higher than that used for congenital hypothyroidism. In severe cases, liothyronine (T3) may be administered. In recent years, propranolol has demonstrated excellent efficacy in the treatment of IHH. The study by Bettini et al. suggested that propranolol not only effectively treats IHH but also helps restore euthyroidism by reducing tumor size. Furthermore, early recognition of IHH and prompt initiation of propranolol therapy can effectively manage CH without the need for hormone replacement (53). Furthermore, considering the critical role of thyroid hormones in infant central nervous system development, routine evaluation of thyroid function is recommended in infants with IHH.

Pathology

Pathology is essential for a definitive diagnosis; however, the initial diagnostic accuracy of pediatric HAS is low. In one case series, none of the eight children were initially diagnosed with angiosarcoma (8). Our review similarly revealed an extremely low initial diagnostic accuracy (1/9), with the correct diagnosis typically established by open surgical biopsy. Immunohistochemical markers, such as CD31, CD34, and factor VIII-related antigens, which are expressed in endothelial cells, serve as diagnostic indicators for angiosarcoma. One study demonstrated that ERG is a more sensitive and specific diagnostic marker than other endothelial markers evaluated (54). Although GLUT-1 is considered a specific marker for IHH, it may also be expressed in HAS. None of these markers can fully differentiate HAS from IHH; however, the differential expression of P53, P16, and Ki-67, characterized by strong positivity in angiosarcoma regions versus low expression in hemangioma areas, may aid in discrimination, and the absence of clear demarcation between these zones suggests malignant transformation from a benign hemangioma (55). This phenomenon complicates accurate diagnosis, particularly in cases of hemangioma with focal sarcomatous transformation. For benign hemangiomas with atypical features, regular monitoring is recommended.

Treatment and prognosis

The current management of pediatric HAS lacks standardized protocols, with therapeutic strategies primarily centered on chemotherapy and surgical resection. In our patient, tumor involvement precluded complete resection and caused significant compressive symptoms, prompting the decision to perform LT. Although LDLT was technically successful, the family declined chemotherapy, and early osseous metastasis occurred at 8 months postoperatively. Theoretically, chemotherapy may delay or prevent metastasis by eliminating microscopic residual disease in malignant tumors. However, due to the rarity of pediatric HAS, substantial heterogeneity in treatment regimens, and variability in disease stage at diagnosis, high-level evidence confirming a definitive survival benefit of adjuvant therapy remains lacking. Nevertheless, based on a literature review, Aldén et al. speculated that the 2-year survival rate for pediatric patients with primary HAS receiving adjuvant therapy alone is approximately 25%, whereas combining LT with adjuvant therapy could increase the 2-year survival rate to approximately 50%. Although HAS is an absolute contraindication for LT in adults, successful cases in pediatric patients are undoubtedly documented in the literature (5). Novel targeted approaches, including tyrosine kinase inhibitors and anti-VEGF monoclonal antibodies, are under investigation (56). More effective adjuvant agents are eagerly awaited. Other therapeutic modalities such as embolization and radiation have demonstrated limited clinical benefits. The overall prognosis is very poor, regardless of treatment or stage, with a mean survival time ranging from 10 months to 2 years (6).

In summary, pediatric HAS lacks specific clinical and laboratory features. Although CT and MRI show findings similar to those of hemangiomas, the enhancement pattern is not centripetal but rather bizarre, which helps distinguish HAS from IHH. CEUS reveals common characteristics of HAS, and tumors often contain areas of late washout. For IHH children with malignant signs on CT or MRI, the possibility of malignant transformation to HAS should be taken seriously. In such cases, we recommend the following: Shortening the imaging follow-up interval to dynamically monitor tumor changes; Performing CEUS and conducting multi-site or repeat needle biopsy of suspicious lesions to increase the diagnostic yield; Adjusting treatment strategies promptly based on biopsy results, including evaluation for chemotherapy, resection, or LT. Given the risk of malignant transformation and the possible complication of hypothyroidism, regular liver ultrasound and thyroid function testing are recommended for children with HH. No standardized treatment exists for pediatric HAS. Given the limited clinical experience and poor long-term survival, LT or combined chemotherapy remains an exploratory therapy. However, it represents the only treatment option for unresectable tumors and aligns with the family’s strong desire for curative intervention. LT for pediatric liver tumors, although controversial, has demonstrated substantial progress and notable differentiation across various tumor types over the past 15 years. The spectrum of pediatric liver tumors is highly diverse. Among vascular tumors, the relatively common IHH is benign and has been effectively managed with pharmacotherapy, eliminating the need for surgery. There are no documented cases of LT for primary hepatic involvement in children with KHE, a borderline tumor. HEH, a rare malignancy, has a 5-year OS rate of 60.6% in the largest reported series. Among other hepatic malignancies, the 5-year OS rates for HUES was 90.0% in the largest reported study, BT-RMS and MRT of the liver are exceptionally rare, with limited evidence supporting LT. HB and HCC have achieved improved survival outcomes in recent years, guided by established treatment pathways in clinical guidelines that define the role of transplantation (57,58). The high survival rates of LT for HB and HCC offer a promising blueprint and with advances in surgical techniques and increased living donor availability, greater attention should be directed toward pediatric LT.

Our report provides valuable insights into imaging and clinical management for pediatric HAS and evaluates the role of LT in pediatric liver tumors, thereby helping to advance understanding in these fields. This single case report has inherent limitations, including the difficulty of generalizing findings from one case and the lack of comparative analysis between CEUS and pathology. Previous reports suggest that non-enhancing areas in HAS may be rich in tumor tissue rather than pure necrosis, presumably due to extremely slow local blood flow (47).

Conclusions

HAS is a rare malignancy with nonspecific clinical and laboratory features, and it is difficult to distinguish from IHH. CT/MRI enhancement patterns aid differentiation and suggest malignant transformation. CEUS may show late washout areas. For children with suspected malignant transformation, CEUS and ultrasound-guided multi-site or repeated biopsy are recommended. Currently, no standardized treatment exists for pediatric HAS. Given its poor long-term survival rate, LT or combined chemotherapy remains an exploratory therapy. However, it represents the only treatment option for unresectable tumors. The high survival rates achieved by LT for HB and HCC provide a promising therapeutic blueprint. With advances in surgical techniques and increased availability of living donors, greater attention should be directed toward pediatric LT.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2026-1-0035/rc

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2026-1-0035/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from patient’s legal guardians for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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