Reply:
We thank Dr. Pulitanò et al for their interest in our paper. They provide general comments on the potential benefits of hepatic arterial chemotherapy as neoadjuvant treatment for unresectable liver metastases. This was not considered in our manuscript. One potential aim of the treatment of liver metastases from colorectal cancer is to render possible the resection of nonresectable lesions. Portal vein embolization increasing the size of the normal liver to be kept in place can help to remove large unilobar lesions. Local ablative therapies combined to resection allow treating in one session otherwise nonresectable lesions. But in the majority of cases, liver metastases are nonresectable because they are too numerous or too large and, in this setting, systemic chemotherapy with or without biotherapy is recommended. The question of preoperative HAI may arise in selected cases of metastases confined to the liver, well controlled by systemic chemotherapy but still unresectable and when systemic CT has to be discontinued because of some degree of toxicity. However, such a situation is probably very rare considering the wide range of effective drugs now available for intravenous use. To avoid the need of a laparotomy for catheter implantation, a percutaneous placement with a transaxillary approach is possible as suggested by Pulitanò et al, but the complication rate associated with the technique remains high. The catheter in the hepatic artery may also compromise subsequent liver resection, and this has not yet been clearly studied. Moreover, after prolonged systemic chemotherapy followed by HAI, it is reasonable to think that the risks of postoperative morbidity will be increased as compared with systemic chemotherapy alone. Finally, a very important issue is the outcome of metastases that have disappeared after chemotherapy. In many cases, these lesions are left in situ after resection. The risk of relapse is not known; and the survival benefit for the patient in these situations, although suggested by few retrospective studies, is not clear. Probably, before embarking into complex procedures, such as preoperative hepatic arterial infusion, it should be relevant to further assess the real benefit of resection of residual disease in patient who had numerous unresectable liver metastases that become amenable to resection after prolonged chemotherapy.
B. Nordlinger
S. Benoist
C. Penna
AP-HP Hôpital Ambroise Paré
Service de Chirurgie Digestive et Oncologique
Boulogne, France