Review for 10.1186/s12876-025-03851-w (2025)

Title: Quantitative literature analysis on efficacy and safety of balloon-occluded transarterial
chemoembolization for hepatocellular carcinoma
Version: 2 Date: 09 Mar 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-The introduction could benefit from a more in-depth discussion of specific challenges faced in
comparing B-TACE with other TACE methods, particularly in clinical practice (e.g., variations
in patient populations, and treatment protocols).
-The mention of balloon-occluded TACE's broader adoption in certain countries could use more
specific details about how it was implemented in these regions and its comparative performance
over time.
-The methods for handling study heterogeneity could be more clearly explained. For example,
the rationale for using the chi-square test and I² statistics should be elaborated for clarity, as
these statistics are central to evaluating the homogeneity of the included studies.
-While the search strategy mentions the use of "MeSH" terms, it could clarify whether this
approach was followed for all databases and if any hand-searching or grey literature was
considered.
-It would be helpful to specify any additional criteria for the quality assessment of studies besides
the Newcastle-Ottawa Scale, such as assessing the risk of bias or specific outcomes relevant to
the B-TACE procedure.
-It would be useful to provide more detail on how potential sources of heterogeneity were
identified and managed, particularly with regard to treatment protocols, patient populations, or
other methodological differences between studies.
-While the use of P-values is mentioned, more clarification on how statistical significance is
determined (e.g., handling multiple comparisons) would improve transparency.
There is no mention of how outliers or missing data will be handled, which could be a source
of bias or statistical variation.
-While the discussion mentions the potential sources of heterogeneity, it stops short of exploring
these in detail. For instance, it does not address how the study methodology (e.g., differences
in treatment protocols, follow-up duration, or patient characteristics) might have impacted the
results in a more granular way. A more explicit explanation of how these factors may interact
could have provided clearer guidance for clinicians considering B-TACE in their practice.
-Although the discussion highlights sources of heterogeneity in the data, the section could be
strengthened by including more details about how the statistical analyses (such as subgroup
analyses or sensitivity testing) were performed to account for these factors. While the authors
acknowledge the limitations of the analysis, more clarity regarding the handling of these
variations would have added depth to the discussion.
-The limitations section mentions the sample size and retrospective nature of the studies
included, but it could be further expanded. Specifically, the potential for confounding variables,
biases in data extraction, and differences in study design or inclusion criteria are areas that could
have been more thoroughly addressed. Additionally, while publication bias is noted, it would
be valuable to discuss how potential biases within the studies themselves (such as selective
reporting or small sample sizes) may have influenced the findings.
-The discussion mentions that the incidence of PES was higher in the B-TACE group, but it
doesn't provide a clear understanding of the clinical relevance of this finding. While PES is a
known side effect of TACE procedures, it would be useful to discuss how the increased incidence
of PES impacts patient outcomes and whether these side effects are manageable or concerning in
a clinical setting. For example, are patients with PES more likely to require additional treatment
or prolonged hospitalization?
-The discussion focuses largely on short-term outcomes, particularly tumor response (CR rates),
but does not delve as much into the long-term survival benefits of B-TACE. While short-term
CR is important, the study could be strengthened by discussing how these findings correlate
with longer-term survival, disease recurrence, and quality of life. Addressing the sustainability
of these results over time would provide a fuller picture of B-TACE's impact.