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A tenth of all pediatric liver transplantations (LTs) are performed for unresectable liver malignancies, especially the more common hepatoblastoma (HBL). Less understood are outcomes after LT for the rare hepatocellular carcinoma, nonhepatoblastoma embryonal tumors (EMBs), and slow growing metastatic neuroendocrine tumors of childhood. Pediatric LT is increasingly performed for rare unresectable liver malignancies other than HBL. We performed a retrospective review of outcomes after LT for malignancy in the multicenter US Scientific Registry of Transplant Recipients (SRTR; n = 677; 1987‐2015). We then reviewed the Children's Hospital of Pittsburgh (CHP; n = 74; 1981‐2014) experience focusing on LT for unresectable hepatocellular cancer (HCC), EMBs, and metastatic liver tumors (METS). HBL was included to provide reference statistics. In the SRTR database, LT for HCC and HBL increased over time ( P  < 0.001). Compared with other malignancies, the 149 HCC cases received fewer segmental grafts ( P  < 0.001) and also experienced 10‐year patient survival similar to 15,710 adult HCC LT recipients (51.6% versus 49.6%;  P  = 0.848, not significant [NS], log‐rank test). For 22 of 149 cases with incidental HCC, 10‐year patient survival was higher than 127 primary HCC cases (85% [95% confidence interval (CI), 70.6%‐100%] versus 48.3% [95% CI, 38%‐61%];  P  = 0.168, NS) and similar to 3392 biliary atresia cases (89.9%; 95% CI, 88.7%‐91%). Actuarial 10‐year patient survival for 17 EMBs, 10 METS, and 6 leiomyosarcoma patients exceeded 60%. These survival outcomes were similar to those seen for HBL. At CHP, posttransplant recurrence‐free and overall survival among 25 HCC, 17 (68%) of whom had preexisting liver disease, was 16/25 or 64%, and 9/25 or 36%, respectively. All 10 patients with incidental HCC and tumor‐node‐metastasis stage I and II HCC survived recurrence‐free. Only vascular invasion predicted poor survival in multivariate analysis ( P  < 0.0001). A total of 4 of 5 EMB patients (80%) and all patients with METS (neuroendocrine‐2, pseudopapillary pancreatic‐1) also survived recurrence‐free. Among children, LT can be curative for unresectable HCC confined to the liver and without vascular invasion, incidental HCC, embryonal tumors, and metastatic neuroendocrine tumors.  Liver Transplantation 23 1577–1588 2017  AASLD.

Pediatric liver transplantation for hepatocellular cancer and rare liver malignancies: US multicenter and single‐center experience (1981‐2015)