Min-Ju Li

Dear Editor,

As we do not receive the third issue of Hong Kong Journal of Paediatrics (2009, print version), we haven't read the "Letter to the Editor - An unconceivable Commentary from the Reviewer on Medical Ethics" by Dr. KP Fung until recently through internet. Therefore, it is a little late to make an additional commentary to explain issues discussed by Dr. Fung and Professor Chan.

We are very grateful to Dr. Fung for the remark on our article entitled Prognostic Factors and Outcome of Wilms' Tumour in a Tertiary Children's Hospital, China published in HK J Paediatr (new series);14:108-114.

We want to have an explanation here that we really do not know the commentary from the reviewer with labeled as 'unethical' in bold fonts and underlined will be published together with our paper. Of course, the reviewer and editors had their own considerations.

The outcome for patients with Wilms' tumour (WT) has improved remarkably during the past few decades owing to the use of systemic chemotherapy. However, management of children with advanced Wilms' tumour remains a challenge. Novel treatment strategies are necessary for the efforts to increase the possibility of cure for the patients with advanced Wilms' tumour.

Interventional radiology is a minimally-invasive surgery technique. Transcatheter arterial chemoembolization (TACE) is accepted as an effective and safe method for the treatment of liver tumour and cancers in other parts of the body. For those experienced in interventional radiology specialist, the implementation of renal TACE is relatively easy and safe. Therefore we used renal TACE in the treatment of advanced Wilms' tumour. The total dose of chemotherapy drugs used in TACE is slightly lower than the total dose of conventional pre-operative chemotherapy regimen. We have selectively applied the TACE, rather than "on its routine pre-operative use in Wilm's tumour" as described by the reviewer. As we have stated in the paper, the criteria of pre-operative TACE are as following: the maximal tumour diameter greater than 10 cm, suspicion of capsular penetration, involvement of periaortic lymph nodes, inferior vena cava invasion or distal metastasis, and tumour with anaplastic histology. Among the 56 patients with preoperative treatment, 16 received conventional preoperative systemic chemotherapy and 40 received TACE.

The reviewer thinks that 'TACE is an invasive procedure with potential additional risk and "unethical" to the patients'. 'The journal also has to balance between "scientific value" and "ethical" concerns. The final judgement will rest on the patients' risks and benefits'. Our results demonstrate that preoperative renal TACE is a safe, effective, and feasible modality for the treatment of advanced Wilms' tumour. The benefit is reducing the tumour size and vascularity prior to surgery, increasing the rate of tumour complete resection.

The reviewer mistakenly believes that our approach is "pre-treated patients with systemic chemotherapy first, but added on TACE afterwards. That makes the TACE an additional therapy". Actually, no actinomycin D and just a single dose of vindesine were used in the TACE. Therefore we gave some patients two weeks short-term systemic chemotherapy with vindesine (3 mg/m²) once and actinomycin D (15 mg/kg daily) in a 5-day course after TACE. Thus the total dose of chemotherapy drugs was the same as conventional preoperative systemic chemotherapy. This combination further improved the complete tumour resection rate and survival rate in advanced tumour patients.