Portal Hypertension and Liver Surgery Following Selective Internal Radiation Therapy With 90Yttrium Microspheres

TO THE EDITOR: I wish to comment on the letter in the November 10, 2005, issue of the Journal of Clinical Oncology by Ayav et al. During the last 7 years, we have treated more than 200 patients with Yttrium microspheres and have published a number of papers on the subject. We and others have previously commented on the development of portal hypertension following this treatment, but have never seen this become a clinical problem. Certainly it adds an additional dimension to any subsequent abdominal surgery, including hepatectomy, but so too does neoadjuvant chemotherapy used for downstaging before liver resection. While we think it useful that Ayav et al have highlighted this feature of selective internal radiation therapy (SIRT), we think their conclusions are rather strong and should not go unchallenged. We have reoperated on many patients after SIRT, including five patients for hepatic cryoablation and four patients for hepatic resection, as have other groups from around the world with large experience of this treatment. Prohibitive problems and complications have not been encountered by us or reported by others, even when this treatment has been given to those with underlying liver disease, as is so often the case in patients with hepatocellular carcinoma. For the authors to conclude on the basis of a single bad experience that, “this therapy should be considered as a treatment option only for unresectable patients without any co-existing portal hypertension, and should not be considered as a downstaging therapy” is simply not justifiable. Liver resection has and can be performed safely after SIRT. Any treatment that can achieve downstaging of nonresectable liver tumors to such a degree as to allow subsequent resection should be considered a triumph. The fact that the subsequent resection presents additional challenges for the surgeon is no reason to not use the treatment in this context. Those groups with a large experience of SIRT can all attest to the high response rate achieved by the treatment and to the fact that occasionally further surgical options become possible. It would be a shame if the use of the modality was curtailed to any extent as a result of a poor experience in one patient.