Hepatic Abscess following Yttrium-90 Radioembolization in Patients with Surgical Bilioenteric Anastomosis or Compromised Sphincter of Oddi: A Tertiary Cancer Center Experience

Round 1

Reviewer 1 Report

Reviewers comments: Hepatic Abscess Following Yttrium-90 Radioembolization in 2 Patients with Surgical Bilioenteric Anastomosis or Compro- 3 mised Sphincter of Oddi: A Tertiary Cancer Center Experience

Summary:

The authors provided a retrospective study on complications after Yttrium-90 TARE in patients with previous biliary interventions with a focus on hepatic abscess incidence. This topic has been investigated in TACE patients as also mentioned by the authors, and therefore provides new insight in the complications coming from a treatment that is often compared to TACE, namely TARE. The paper includes interesting case of hepatic abscess after glass Yttrium-90 TARE.

General concept comments:

               Article

The overall methodology of the article is clear, but the authors could improve clarity if they would take another critical look at the information that is provided in the methods and results. For example, in the methods the authors refer to the patient characteristics in table 1, while in the results some patient characteristics are referred to as a result.

Since the complication of the hepatic abscess is the main focus of this paper the authors could provide some more background information of this case. For example the amount of time between the surgery and TARE procedure, previous complications as part of the surgery, start of the symptoms after TARE.

As the authors also mention in their discussion, the research is focused on a small population with different background and treatments, and therefore comparison to the complication incidence of similar studies on TACE with much bigger populations should be made with caution. Slight attenuation of the concluding paragraph and the conclusion in the abstract would therefore be in place.

               Review

The gap in knowledge that has been resolved by this paper is towards the small side compared to the papers the authors compare their work to given the limited patient population and the wide variation in the patient's history in both tumor type and previous treatments. However, the authors do stress the need for further research in order to overcome this gap and stress the lack of research on this topic on TARE while similar research is available for TACE. The literature that is used by the authors is mostly older literature, but does seem to still be relevant on this specific topic.

Specific comments

LN 11: The purpose in the abstract could stress the significance of the research more.

LN 69: When did these patients get their previous treatment compared to their TARE treatment?

LN 85: Consider moving the table to the results, since some patient demographics are recalled there. Furthermore, the outlay of the table could be clarified by using bold typography to distinguish topics within the table rather than having a long list as is presented right now.

Put HCC and Cholangio in a subline (for instance left Primary liver tumor and 1 cm right HCC and Cholangio). Also for Metastic desease.

LN 100 “…shunt fraction on single-photon emission computed tomography/computed tomography (SPECT/CT) scans..” Please also give the term SPECT

computed tomography/computed tomography (CT) scans after

LN 123: In my opinion it would be more clinically relevant to include the media follow up time rather than the mean given the broad range and the limited population.

LN 124: One of the included patients had a follow up time of 29 days. Why was this patient lost in follow up? And is it fair to include this patient given there is no information on complications of this patient?

LN 129: Consider using the SI unit Bq or adding the administered dose in Bq.

LN 139 Please give also information how many days before  prior treatment was given. And the dose and approximately number of particles. Can you also give an estimate on the activity distribution: dose on healthy and tumor tissue. And dose on the tissue that resulted in an abscess. Add a SPECT image to figure 1.

LN 150: What microspheres was the patient treated with, (resin If correct) ? Please give also information how many days before  prior treatment was given. And the dose and approximately number of particles. Can you also give an estimate on the activity distribution: dose on healthy and tumor tissue. And dose on the tissue that resulted in cholanchitis.

LN 200 You describe that resin can be hypothesized with greater risk of abscess forming. Please give approximately the difference in numbers of microspheres that can be expected.

LN 213: I would describe this part in the results section, put the events in chronological order.

LN219 I would also like to see something about the heterogeneity in tumor types, prior treatments etc.  

LN226: By putting in the conclusion the glass microspheres in relation to the abscess it suggest that glass maybe is related to more abscesses. Skip this part from the conclusion, since it cannot be supported by the low patient numbers and variations in patients.

Author Response

Thank you so much for you comments. Please find the attached point-by-point response to the comments.

Author Response File: Author Response.docx

Reviewer 2 Report

This is a retrospective review of patients in a specific population - hepatic abscess in patients s with Surgical Bilioenteric Anastomosis or Compromised Sphincter of Oddi treated with TARE. Authors reported just one abscess which is in line with available literature. 

It is a simple straightforward descriptive study. Could not identify any specific risk factors (by UVA or MVA) as the numbers are very low for such analysis. They could have made it more helpful by giving us baseline liver functions (by child-pugh score) and seeing the change in it post-procedure and correlating it with abscess/infection. Similarly, WBC count before the procedure - was that particular patient having low counts prior to the procedure? Do we have immediate post-procedure counts?

In table 1: Please clarify the breakdown of the primary tumors. Primary liver (6, 4HCC + 2 CCA) vs metastatic (9). 

Overall, it is a simple review, and is reasonable to accept it for publication

Author Response

Thank you so much for you comments. Please find the attached point-by-point response to the comments.

Author Response File: Author Response.docx

Reviewer 3 Report

General comments: Overall, well written manuscript that is clinically relevant.

There are several articles discussing risk of chemoembolization in patients with incompetent Sphincter of Oddi.  However, very little data exists concerning yttrium 90. 

Specific comments: 

Limitations: Small sample size of 15 patients/17 procedures.  

Excellent long term follow-up of mean 445.4 days

It would be interesting/helpful if the authors could address how well the aggressive antibiotic regimen with bowel prep was tolerated by patients.  That is an important point and it has been my experience that some patients are inclined to decline therapy with this regimen.  

Figures/tables: adequate

References: adequate

Discussion/conclusion: no edits.

 

 

 

Author Response

Thank you so much for you comments. Please find the attached point-by-point response to the comments.

Author Response File: Author Response.docx