Background: Hepatic tumors constitute major disease burden in children and hepatocellular carcinoma (HCC) is the second most common malignant liver tumor. While the management algorithm and outcomes of liver transplantation (LT) for hepatoblastoma are well documented, those for pediatric HCC(pHCC) remain relatively undefined.

Methods: A prospectively collected database of over a decade (2012-2022) of children with HCC who underwent LT was collated. Data with regards to demography, indications of LT, outcomes (early and late), survival and applicability of adult HCC LT selection criteria (Milan criteria, UCSF) was analyzed.

Results: Of 650 pediatric LT, 33(5.1%) had a diagnosis of HCC. Five children had mixed tumours (hepatoblastoma with HCC component) and were excluded from the analysis. 22(78%) patients had an incidental diagnosis of HCC on explant liver histology, 4 underwent LT for Tyrosinemia and HCC, and 1 each for fibrolamellar HCC and Abernathy malformation. On application of Milan & UCSF criteria into the pediatric HCC cohort, 4 children had HCC beyond the criteria. Of whom 2 (50 %) developed metastatic disease following LT. The overall 1-year and 5-year disease-free survival following LT was 93% and 86% respectively.

Conclusion: Paediatric HCC may represent a different spectrum of HCC as they appear to have a better tumour biology than adult HCC. Further, they arise often in metabolic liver diseased livers than due to viral hepatitis etc. We show excellent outcomes of LT for pediatric HCC. Given that it is rare to have children coming for LT beyond adult HCC LT criteria, we demonstrate that those who do, have a poorer outcome than the children within criteria. We propose that due to the rarity of the disease, there is a need for multicentric collaborations to evaluate and potentially introduce LT selection criteria for pHCC.