LETTER TO THE EDITOR Another point of view on 2017 PRETEXT: reply to Pariente et al. Alexander J. Towbin 1 & Rebecka L. Meyers 2 & Helen Woodley 3 & Osamu Miyazaki 4 & Christopher B. Weldon 5 & Bruce Morland 6 & Eiso Hiyama 7 & Piotr Czauderna 8 & Derek J. Roebuck 9 & Greg M. Tiao 10 Received: 19 July 2018 /Accepted: 31 July 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018 Dear Editors, We would like to thank our friends and colleagues from the French Pediatric Liver Tumor Group for their helpful critique of our paper titled “2017 PRETEXT: radiologic staging sys- tem for primary hepatic malignancies of childhood revised for the Paediatric Hepatic International Tumour Trial (PHITT)” [1, 2]. Their participation in past studies, and their collabora- tion and leadership in the PHITT trial are both valuable and important to the success of this trial. Each of their concerns warrants our response. Imaging recommendations We believe that the treating institution can and should deter- mine the imaging modality used in children with a liver tumor. However, pediatric liver tumors are rare, and most institutions have little experience with the imaging management of these children. The 2017 version of the PRETEXT (pre-treatment extent of tumor) categorization represents a consensus state- ment from many of the world’ s pediatric liver tumor experts [1]. The recommendations are based on the literature, where available, and expert opinion when the literature is not avail- able. The expert opinion is based on the authors having reviewed imaging studies for hundreds of children with hepat- ic malignancies. Patient safety is a key concern with all imaging studies. As Pariente et al. [2] noted, the risk of a prolonged MRI exami- nation under general anesthesia in an infant with a hepatic malignancy must be balanced with the risk of ionizing radia- tion employed with CT. In constructing a risk–benefit analy- sis, it is important to understand all potential risks and benefits of each imaging study. For MRI, the risks include the need for general anesthesia and the potential risk of gadolinium depo- sition/retention, while for CT the potential risks include the use of ionizing radiation and the use of iodinated contrast agents. Much has been written about these risks and the like- lihood is that they are largely overstated for both modalities [3]. In reality, the children we are talking about all have a hepatic malignancy and the risk to their life from this malig- nancy far outweighs any potential risk of either CT or MRI. Thus we believe that it is important to image each child as * Alexander J. Towbin alexander.towbin@cchmc.org 1 Department of Radiology, Cincinnati Children’ s Hospital Medical Center, 3333 Burnet Ave., MLC 5031, Cincinnati, OH 45229, USA 2 Division of Pediatric Surgery, Primary Children’ s Hospital, University of Utah, Salt Lake City, UT, USA 3 Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK 4 Department of Radiology, National Center for Child Health and Development, Tokyo, Japan 5 Departments of Surgery and Oncology, Boston Children’ s Hospital/Dana Farber Cancer Institute, Boston, MA, USA 6 Department of Oncology, Birmingham Women’ s and Children’ s Hospital, Birmingham, UK 7 Department of Pediatric Surgery, Hiroshima University Hospital, Hiroshima, Japan 8 Department of Surgery and Urology for Children and Adolescents, Medical University of Gdansk, Gdansk, Poland 9 Department of Radiology, Great Ormond Street Hospital for Children, London, UK 10 Division of General and Thoracic Surgery, Cincinnati Children’ s Hospital Medical Center, Cincinnati, OH, USA Pediatric Radiology https://doi.org/10.1007/s00247-018-4228-3