Congenital portosystemic shunts are rare malformations in which blood flowing through the portal vein, which normally delivers nutrient-rich blood from the intestines to the liver for processing, bypasses the liver entirely and drains directly into the systemic venous system. In this patient, the malformation was classified as a Park type I shunt, the category in which an abnormal vessel connects the portal circulation directly to the inferior vena cava. The consequences of such a shortcut are profound. Deprived of its full portal blood supply, the liver may fail to grow and develop normally, and a cascade of metabolic and hormonal disturbances can follow, because substances that would ordinarily be cleared or processed by the liver pass unfiltered into the general circulation. Among the most serious long-term consequences documented in the literature is an elevated risk of hepatic tumors, including hepatocellular carcinoma and, far more rarely, hepatoblastoma, the most common malignant liver tumor of early childhood.

Hepatoblastoma on its own is already a formidable diagnosis, typically arising in children under three years of age and demanding a combination of chemotherapy and surgical resection for any chance of cure. When the disease appears multifocally, meaning it involves several distinct regions of the liver rather than a single mass, surgical planning becomes considerably more complex. In this case the tumor was staged as PRETEXT stage III, a designation indicating that three of the four sections of the liver were involved, leaving only one contiguous healthy section. In a liver already compromised by a portosystemic shunt, with abnormal perfusion and potentially reduced functional reserve, the surgical team faced a clinical puzzle with no established playbook. The authors of the report emphasize that standardized diagnostic and therapeutic protocols for managing congenital portosystemic shunts accompanied by multifocal hepatoblastoma simply do not exist, forcing clinicians to improvise on the basis of first principles and close multidisciplinary collaboration.

The strategy the team ultimately pursued was deliberately sequenced. First, they performed an anatomical segment IV resection, removing the dominant tumor along with the entire liver segment in which it was based, an approach designed to secure clear margins rather than simply shelling out the visible mass. Critically, they combined this resection with concurrent closure of the congenital shunt in the same operative session. The shunt was occluded using a patent ductus arteriosus occluder, a device originally engineered to close abnormal openings between the great vessels of the heart, repurposed here to plug the aberrant portosystemic channel. Restoring normal portal blood flow to the liver is not merely a corrective maneuver for the vascular defect; it also matters for oncologic control, because re-establishing proper hepatic perfusion supports liver regeneration and function after major resection, and it removes the abnormal hemodynamic environment that is thought to contribute to tumor formation in these patients.

Once the dominant mass had been removed and the shunt closed, the team turned to the remaining multifocal tumor deposits. Instead of additional resections, which would have consumed precious liver volume in a child whose organ was already under strain, they deployed ultrasound-guided microwave ablation. Microwave ablation uses high-frequency electromagnetic waves to induce rapid heating within tumor tissue, causing coagulative necrosis at precisely targeted locations. Guided by real-time ultrasound, the surgeons could treat each residual lesion while sparing the surrounding healthy parenchyma, an advantage of particular importance in multifocal disease where the goal is to preserve as much functional liver as possible. The combination of anatomical resection for the largest lesion and ablation for the smaller deposits represents an elegant tissue-sparing division of labor that the authors argue may serve as a reference model for similar cases in the future.

Chemotherapy completed the treatment protocol, acting as a systemic safeguard against microscopic disease that imaging cannot detect. The specific regimen details illustrate the standard armamentarium of pediatric hepatoblastoma therapy, adapted to the patient’s recovery from major surgery. What distinguishes this case is not any single component, since each element, whether resection, ablation, chemotherapy, or shunt closure, is individually established in clinical practice, but the integration of all four into a coherent, coordinated plan executed across surgical oncology, interventional radiology, and pediatric oncology disciplines. The authors describe the protocol as safe and feasible based on their experience, and the outcome lends weight to that assessment: the shunt was successfully occluded, complete local tumor control was achieved, and the child has remained well through a ten-month follow-up period.

Surveillance in this case rested on three complementary pillars. Serial monitoring of alpha-fetoprotein, a protein produced abundantly by hepatoblastoma cells and normally present at high levels in newborns but declining through infancy, provided a sensitive biochemical indicator of any residual or recurrent tumor activity. Contrast-enhanced abdominal magnetic resonance imaging offered detailed anatomical assessment of the liver, allowing clinicians to verify that the ablated zones contained no viable tumor and that the liver itself was regenerating as expected after resection. Chest computed tomography completed the picture by excluding pulmonary metastases, the most common site of distant spread in hepatoblastoma. The convergence of a normalized alpha-fetoprotein trend, clean imaging, and the child’s clinical well-being at ten months constituted strong evidence of complete remission, though the authors are careful to frame the follow-up interval as meaningful rather than definitive, given the long horizon over which pediatric liver tumors can recur.

The broader significance of the case extends beyond a single patient. Congenital portosystemic shunts were once considered almost incidental findings, but accumulated evidence over recent decades has established that they carry real long-term risks, including hepatic encephalopathy, portopulmonary hypertension, liver nodules, and malignancy. The association between shunts and hepatoblastoma, while exceedingly rare, underscores the importance of longitudinal surveillance in children diagnosed with these vascular anomalies. This case also demonstrates that the traditional staging logic for hepatoblastoma, which assumes a normally perfused liver, must be adapted when a shunt alters hepatic hemodynamics. The Shenzhen team’s decision to address the shunt and the tumor simultaneously reflects a growing recognition that in complex congenital disease, fragmenting care among specialties that do not coordinate can compromise outcomes that an integrated plan could achieve.

Technically, the case highlights the versatility of devices and techniques crossing traditional disciplinary boundaries. The use of a patent ductus arteriosus occluder for shunt closure borrows from interventional cardiology, while microwave ablation is a technology shared between hepatology, radiology, and surgical oncology. Anatomical liver resection in a toddler demands precision given the small size of the liver and the limited tolerance for volume loss, and combining it with endovascular occlusion in the same anesthetic session required careful intraoperative planning. The report, supported by the Sanming Project of Medicine in Shenzhen and approved by the ethics committee of Shenzhen Children’s Hospital with written informed consent from the child’s legal guardians, is presented as an early-release, peer-reviewed, citable account intended to give clinicians confronting similar cases a documented precedent where none previously existed.

For the scientific and medical community, the message is twofold. First, children with congenital portosystemic shunts deserve vigilant, structured follow-up that includes liver imaging and tumor marker surveillance, because the risk of hepatic malignancy, though rare, is real and potentially curable when caught early. Second, when malignancy does arise in this setting, the experience from Shenzhen suggests that a single-stage approach combining anatomical resection of the dominant lesion, concurrent shunt closure, ultrasound-guided microwave ablation of satellite tumors, and adjuvant chemotherapy can deliver excellent local control without overwhelming the liver’s limited reserve. Ten months after surgery, a two-year-old who faced a combination of anomalies that most pediatric surgeons will never encounter is free of disease, and the medical literature has gained a template for the next patient unlucky enough to share the diagnosis.

Subject of Research: A rare pediatric case of congenital portosystemic shunt complicated by multifocal hepatoblastoma treated with multidisciplinary therapy.

Article Title: Multidisciplinary management of congenital portosystemic shunt complicated by multifocal hepatoblastoma: a case report

Article References: Multidisciplinary management of congenital portosystemic shunt complicated by multifocal hepatoblastoma: a case report. (n.d.). https://doi.org/10.1186/s12887-026-07743-0

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07743-0

Keywords: congenital portosystemic shunt, hepatoblastoma, pediatric liver tumor, microwave ablation, alpha-fetoprotein, multidisciplinary management, liver resection, Park type I shunt, PRETEXT staging, chemotherapy, BMC Pediatrics, case report