DOI:10.2214/AJR.06.5049.1
AJR 2006; 187:W126
© American Roentgen Ray Society
Reply
Anne M. Covey1 and
Lynn A. Brody1
1 Memorial Sloan-Kettering Cancer Center New York, NY
We thank Dr. Denys and colleagues for their interest in our article
[1] and for their insightful
comments. We are equally grateful for the opportunity to respond.
The cohort we analyzed in our study
[1] consisted of all of the
patients with metastatic disease to the liver who underwent portal vein
embolization (PVE) in preparation for major hepatectomy. The relatively
generous predicted future remnant liver (FRL) reflects the practice and
preference of the referring hepatobiliary surgeons at our institution who
believe that exposure to chemotherapy limits hepatic reserve and that small
lesions necessitating large resections present a high risk for liver
failure.
In our study, 93% of patients had received preoperative chemotherapy. The
concept that neoadjuvant chemotherapy adversely affects posthepatectomy
morbidity was most recently demonstrated in a recent study by Mehdi et al
[2]. Anecdotally, we have noted
a decrease in postoperative complications and liver insufficiency in these
patients when PVE was performed before resection. Together with the fact that
our major complication rate following PVE is very low, we have expanded the
indications to include FRL of greater than 30% in selected patients. In
addition, our surgeons consider the response to PVE in these patients as a
"stress test" to determine the individual patient's potential for
liver regeneration [3].
Therefore, although Dr. Denys et al. suggest that "...this technique
should be limited to accepted indications and should not be extended to
situations in which it has never been proven of any benefit," we believe
that if we carve the indications for a given procedure in stone, we run the
risk of impeding progress. The indications must remain adaptable to new
information.
References
- Covey AM, Tuorto S, Brody LA, et al. Safety and efficacy of
preoperative portal vein embolization with polyvinyl alcohol in 58 patients
with liver metastases. AJR 2005;185
: 1620-1626[Abstract/Free Full Text]
- Mehdi K, Penna C, Amin-Hashem M, et al. Influence of preoperative
chemotherapy on the risk of major hepatectomy for colorectal liver metastases.
Ann Surg 2006;243
: 1-7[CrossRef][Medline]
- Fong Y, Bentrem D. CASH (chemotherapy-associated steatohepatitis)
costs. (editorial) Ann Surg 2006;243
: 8-9[Medline]
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