Open Biopsy of Children’s Liver Tumors Triggered Severe Bleeding in Three Cases, Surgeons Warn

Three children arrived at a German tertiary pediatric liver center within a short period, each transferred after open surgery on a liver tumor had gone catastrophically wrong. All three had bled severely during or after an open surgical biopsy or unplanned manipulation of a liver tumor, and all required intensive care, abdominal packing and blood transfusions before their underlying cancers could even be treated. One of the children, an 18-month-old boy, bled so extensively that he went into hemorrhagic shock, lost liver and kidney function, and needed an urgent, high-priority liver transplantation for hepatoblastoma before chemotherapy could begin.

The case series, published in Frontiers in Pediatrics by pediatric surgeons and specialists at University Hospital Essen, is small by design: it reports three consecutive referrals rather than a large cohort. But its message is pointed. The authors argue that open surgical biopsy of a childhood liver tumor should never be treated as a minor diagnostic step, and that when tissue is genuinely needed, image-guided core needle biopsy should be the default approach wherever it is feasible.

Pediatric liver tumors are rare, accounting for roughly 1 to 2 percent of all childhood malignancies, and hepatoblastoma is the most common primary malignant liver tumor in young children. Managing these tumors relies on high-quality imaging, serum alpha-fetoprotein measurements, risk stratification, chemotherapy, surgery and, in selected patients, liver transplantation. Histopathological confirmation still matters in most children with a suspected malignant liver tumor, particularly when upfront complete resection is not appropriate or when the tumor type is uncertain, because tissue is needed to distinguish hepatoblastoma from malignant rhabdoid tumor, hepatocellular carcinoma, metastatic disease, vascular tumors and other rare hepatic lesions.

The first case involved a 15-month-old boy who had developed progressive abdominal distension, fatigue, night sweats and anemia over about six weeks. Ultrasound and magnetic resonance imaging revealed a large, heterogeneous, partially cystic liver tumor with an estimated volume of around 800 milliliters and multiple pulmonary metastases. Because the nature of the tumor remained unclear, an open surgical biopsy was performed at the referring institution. Severe bleeding followed, along with marked swelling of the liver and progressive coagulopathy, and the abdominal wall could not be closed primarily. After transfusion of six units of packed red blood cells, fresh frozen plasma and platelets, the child was transferred on mechanical ventilation. Reference pathology eventually established a diagnosis of malignant rhabdoid tumor of the liver, a tumor in which tissue diagnosis was genuinely necessary and, the authors note, a core needle biopsy would have been appropriate.

The second case began deceptively. A 7-year-old boy presented with acute abdominal pain and was initially suspected of having appendicitis. Diagnostic laparoscopy instead revealed a small amount of blood in the peritoneal cavity and an unexpected liver tumor. The operation was converted to laparotomy and the tumor was biopsied, after which active bleeding from the biopsy site could only be controlled by packing the abdomen with surgical towels. Two units of packed red blood cells were transfused before helicopter transfer. At a planned second-look operation, the tumor in segment VII was found to be necrotic and ruptured, and staging reached PRETEXT III. The final diagnosis was a hepatocellular neoplasm not otherwise specified with a TERT promoter mutation, and the preoperative alpha-fetoprotein level was 159,393 IU/mL. The authors are careful here: bleeding in this child cannot be attributed to the biopsy alone, because the tumor had already ruptured, and percutaneous biopsy of a ruptured tumor may itself be hazardous. Stabilization and imaging should take priority in such situations.

The third case was the most severe. An 18-month-old boy presented with severe abdominal pain and a distended abdomen; imaging was highly suspicious for hepatoblastoma, alpha-fetoprotein exceeded 150,000 IU/mL, and the tumor was classified PRETEXT IV, meaning it was not amenable to upfront resection. At the referring institution, a Broviac catheter was implanted and an open liver biopsy was performed. Diffuse bleeding followed and could not be controlled at re-operation, requiring abdominal packing. After transfer, the child developed hemorrhagic shock with acute liver failure and kidney failure requiring hemodialysis, which made planned neoadjuvant chemotherapy impossible. He was listed with high urgency for transplantation and received a left lateral split liver graft. The explanted liver contained a large embryonal hepatoblastoma with capsular breakthrough and portal vein infiltration. Severe coagulopathy during the transplant operation required transfusions of red cells, plasma, platelets, fibrinogen, prothrombin complex concentrate and tranexamic acid, and the postoperative course was complicated by hemothorax, septic shock and a biloma requiring revision of the biliary anastomosis. Two months after transplantation, dialysis was no longer needed and follow-up imaging showed no definite pulmonary metastases.

Why does open biopsy carry such risk in these children? The authors lay out several mechanisms. Hepatoblastomas and other malignant liver tumors can be hypervascular and fragile. Large tumors frequently distort vascular anatomy, stretch the capsule or contain necrotic areas. Infants and toddlers have limited blood volume, so blood loss that would appear moderate in an adult can be catastrophic in a small child. And open surgical exposure may disrupt the tumor capsule or necrotic surface, creating a bleeding area that lacks the tamponade effect of a narrow transhepatic needle tract. All of these mechanisms, the authors argue, were reflected in their three cases.

The strongest supporting evidence they cite comes from outside their own institution. In the Children’s Oncology Group AHEP0731 analysis of 121 children with initially unresectable hepatoblastoma who underwent biopsy at diagnosis, all biopsy approaches yielded adequate tissue, but clinically significant post-biopsy hemorrhage requiring transfusion occurred in 36 percent of children after open biopsy, 27 of 76, and 24 percent after laparoscopic biopsy, 4 of 17, while no child, 0 of 28, bled significantly after percutaneous biopsy. A systematic review by the APSA Cancer Committee covering 307 children with liver tumors, most commonly hepatoblastoma, found that core needle biopsy was associated with markedly lower overall morbidity and lower bleeding risk than surgical biopsy while maintaining high diagnostic yield. More recent hepatoblastoma-specific data from Schoeman and colleagues reported high diagnostic adequacy, reliable histological subtyping and successful molecular profiling after image-guided percutaneous biopsy, without hemoperitoneum. Guidance from the ESPGHAN committee likewise recommends ultrasound- or CT-guided biopsy for focal liver lesions requiring sampling, reserving plugged-tract, transjugular, laparoscopic or open approaches for selected situations where standard percutaneous access is unsafe or inadequate.

The authors also describe the technical principles that make percutaneous biopsy safer. Trajectory planning is central: whenever feasible, the needle should pass through healthy liver parenchyma before entering the tumor rather than puncturing a subcapsular tumor surface directly, because the transhepatic route may provide a tamponade effect along the needle tract and reduce the risk of free intraperitoneal bleeding. The target should be viable tissue at the tumor-parenchyma interface, avoiding necrotic cavities and major vessels, with Doppler ultrasound used to map the vascular anatomy beforehand. Coaxial biopsy systems allow multiple cores through a single capsular puncture, reducing repeated capsular trauma. If ultrasound cannot assure a safe trajectory, the team’s practice is to perform the needle biopsy under laparoscopic visualization, with trocars placed for the camera and working instruments so that immediate bipolar coagulation can be applied if needed. General anesthesia with endotracheal intubation, controlled ventilation and respiratory holds requested from the anesthesiologist can improve targeting accuracy and reduce unintended vascular injury or capsular rupture. The authors note that systematic Doppler mapping and respiratory holds reflect their own institutional practice and expert opinion, while the other elements are described in published pediatric literature.

The report has clear limitations that the authors state plainly. It describes three consecutive referrals rather than a large institutional cohort, the children arrived after complications had occurred, and information from the outside hospitals was incomplete for some variables, including exact operative timing, total transfusion volumes and long-term oncologic outcomes. The cases cannot prove that image-guided core needle biopsy, which is not risk-free, would have prevented these events, and the narrative literature review was selected non-systematically. Notably, in the third case the authors question whether a biopsy was needed at all: with an age of 18 months, markedly elevated alpha-fetoprotein, typical imaging and PRETEXT IV disease, treatment could have been started without histology, although the decision to obtain tissue was made jointly with pediatric oncologists who requested histological confirmation. The authors propose a stepwise framework in response: multidisciplinary imaging review, an explicit decision on whether tissue is required, exclusion of tumor rupture or active bleeding before biopsy, image-guided core needle biopsy as the default, performance under pediatric general anesthesia with controlled ventilation and appropriate visualization, and a defined post-biopsy monitoring and hemorrhage escalation pathway at every institution undertaking these procedures, with blood products immediately available and interventional radiology or hepatobiliary surgery backup identified in advance.

Subject of Research: Hemorrhagic complications of open surgical biopsy in pediatric liver tumors and the case for image-guided core needle biopsy

Article Title: Hemorrhagic complications following open surgical biopsy in pediatric liver tumors: 3 cases, a review of literature and a plea for image-guided core needle biopsy

Article References: Kolorz, J., Sabo, J., Schulze, M., Fritzemeier, S., Schündeln, M. M., Kathemann, S., Lainka, E., Pape, L., & Berger, M. (2026). Hemorrhagic complications following open surgical biopsy in pediatric liver tumors: 3 cases, a review of literature and a plea for image-guided core needle biopsy. Frontiers in Pediatrics, 14, Article 1971804. https://doi.org/10.3389/fped.2026.1971804

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1971804

Keywords: pediatric liver tumors, hepatoblastoma, open surgical biopsy, core needle biopsy, hemorrhage, coagulopathy, liver transplantation, interventional radiology, case series, patient safety, PRETEXT staging, alpha-fetoprotein