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Policlinico San Matteo Pavia, Italy
The results presented in the article "Usefulness of Intraoperative Sonography for Revealing Hepatic Metastases from Colorectal Cancer in Patients Selected for Surgery After Undergoing FDG PET" emission tomography" [1] are very interesting and show that positron emission tomography (PET) can be considered an accurate method for preoperative staging of focal hepatic lesions.
However, the limits of PET beyond those cited in the article (poor definition of anatomic details, nonoptimal resolution) are represented by the high cost of the procedure and its poor availability worldwide—in both developed and underdeveloped countries. Thus, although PET remains an excellent preoperative staging method, its cost-to-benefit ratio is rather high.
Furthermore, the role of intraoperative sonography in guiding surgeons who perform hepatic resections remains fundamental, and it is used widely, not only in selected cases.
The advantages of intraoperative sonography are obvious. First, the evaluation of the vascular pattern and its relationships with neoplasia must be taken into account [2]. Then, the sonographic contrast medium facilitates the detection of hepatic focal lesions and differentiation between those that are benign and those that are malignant [3, 4].
In this article [1], only open resections were considered, but interstitial treatments, such as radiofrequency ablation and alcoholization, as well as resection, can be performed with a minimally invasive approach (laparoscopy). In these cases, the use of intraoperative sonography is mandatory.
We performed a 3-year study in which 45 patients who underwent hepatic surgery were examined before surgery with sonography and helical CT. Intraoperative sonography enhanced diagnosis in 30% of patients and changed the surgical approach in 20% of patients by revealing more lesions, by defining the relationship between neoplasia and vascular and biliary structures, and by improving discrimination between benign and malignant lesions.
Even if PET is an excellent preoperative staging method, we firmly believe intraoperative sonography to be the standard imaging technique in hepatic surgery. In our experience, laparoscopic sonography represents the method of choice for the management of hepatic neoplasia.
References
Edward Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis, MO 63110
We thank Dr. Prati and colleagues for their interest in our article [1]. We agree that position emission tomography (PET) is not available widely or uniformly worldwide, particularly in the developing world. However, this should not prevent the study and publication of its utility in clinical practice, considering that in this country, PET has become the standard of care for the evaluation of patients with a variety of tumors, including colorectal cancer. Prati et al. question the cost-to-benefit ratio of PET. There is good evidence in the literature that using PET is a cost-effective strategy for the management of patients with recurrent colorectal cancer [2, 3]. Additionally, we have previously shown that using PET to evaluate patients being considered for hepatic resection of colorectal carcinoma metastases makes it possible to effectively define a cohort of patients with a high likelihood of resectability and survival [4]. We have not studied the contribution of PET and intraoperative sonography in regard to the management of patients with more extensive disease who are undergoing radiofrequency ablation, chemoembolization, or other treatments, nor have we evaluated patients undergoing laparoscopic hepatic resection. Accordingly, we did not suggest that our findings were directly applicable in these settings.
We agree that intraoperative sonography is a useful tool for evaluating patients with hepatic metastases, but we believe that the use of this modality is limited when preoperative FDG PET is used to select patients for open hepatic resection. The purpose of our study was not to criticize intraoperative sonography but to show the impact of this modality in conjunction with FDG PET in the management of patients with colorectal cancer. We also believe that intraoperative sonography plays an important role in identifying patients for hepatic surgery when preoperative FDG PET is not performed.
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