Review for 10.1186/s12876-025-04101-9 (2025)

Title: MRI findings of confluent hepatic fibrosis caused by different etiologies
Version: 1 Date: 28 Feb 2025
Reviewer's report:
Overall Recommendation
Accept with Major Revisions
This is a valuable and necessary study, but it requires clearer methodological rigor, improved
clinical framing, and tighter presentation to reach the quality expected for a radiology journal.
The authors have made significant progress with the revision but should carefully address these
scientific and editorial issues to maximize impact and readability.
General Impression
This study addresses an important and underexplored aspect of liver fibrosis imaging,
particularly in the context of confluent hepatic fibrosis (CHF). The revised manuscript reflects a
good effort in addressing prior reviewer comments and improving the clarity of methods, results,
and discussion. However, several key areas still need further attention in order to elevate the
scientific rigor, clinical relevance, and overall readability of the manuscript.
Major Comments
1. Scientific Rigor and Clinical Relevance
The study would benefit from better framing the clinical importance of differentiating CHF from
malignancies such as infiltrative HCC or ICC. Although this is alluded to in the introduction
and discussion, it is not emphasized strongly enough as a clear clinical gap driving this study.
The following should be addressed:
Explicitly state the diagnostic dilemma faced in routine practice—how often is CHF mistaken
for malignancy?
What are the actual consequences of misdiagnosis (unnecessary biopsies, overtreatment, or
mismanagement)?
Highlight how the proposed MRI patterns provide practical diagnostic clues for radiologists.
2. Patient Selection and Bias
There is a critical lack of detail about how CHF was diagnosed (particularly in non-biopsy cases).
The text says diagnosis was made based on "clinical history and laboratory results" in many
cases, but this is insufficiently rigorous for imaging studies. This creates a circular reasoning
risk—how do you know the imaging patterns describe CHF and not some other pathology?
Clarify if consensus diagnosis was reached by a multidisciplinary team (MDT) including
hepatologists, radiologists, and pathologists.
State the exact diagnostic criteria used to confirm CHF in the absence of biopsy.
Consider discussing the potential for misclassification bias in the limitations section.
3. Statistical Analysis Concerns
Some of the subgroup comparisons (Tables 1 and 2) involve very small cell counts, making
statistical testing unreliable.
Consider removing tests where n<5 per cell—these do not provide valid p-values.
Instead, these could be described narratively (e.g., "Although statistical significance was not
reached, there was a clear trend toward X pattern in the autoimmune hepatitis group").
Clarify if any post-hoc power analysis was conducted.
Moderate Comments
4. Terminology Consistency
There is inconsistent terminology across sections:
"radially distributed from the second hepatic portal" is difficult for international readers.
Consider rephrasing to "radial distribution centered on the hepatic hilum."
Some terms (like "patchy signal" and "fibrous strand") are vague and should be tied to specific
MRI findings (e.g., low signal on T1WI, high signal on T2WI).
5. Lesion Definition and Measurement
There is no mention of lesion size or exact criteria for defining a lesion. This is particularly
important given that diffuse fibrosis and confluent fibrosis may overlap.
Were lesions required to meet a minimum size threshold on imaging?
Was there any assessment of lesion size variation across etiologies?
Consider adding representative measurement ranges to the results.
6. Imaging Protocol Standardization
The MRI machines and contrast agents varied widely (multiple vendors and agents).
Explain how the authors controlled for this variation—were all images re-analyzed on a
standardized workstation?
Were any images excluded for suboptimal quality across platforms?
This heterogeneity should also be mentioned in the limitations.
7. Figures and Tables Enhancement
Figure captions should provide more interpretation—currently, they just describe sequences.
Add brief diagnostic takeaways (e.g., "This case illustrates typical radial distribution with
delayed enhancement, supporting CHF diagnosis").
Table 2 could be reorganized to group parameters into clearer categories:
Location & Distribution
Morphology (Shape, Margin)
Signal Characteristics (T1WI, T2WI, DWI, ADC)
Enhancement Patterns (Arterial, Portal, Delayed)
Accompanied Findings (Capsular Retraction, Cirrhosis)
Minor Comments
8. Language & Grammar
Although the manuscript has improved, some grammatical and structural issues remain:
Example: "The CHF lesions mainly reveal radially distributed from the hepatic portal..." would
be better as "CHF lesions predominantly exhibit radial distribution from the hepatic hilum."
The term "hepatocyte absence" (Discussion) is unclear—better to say "absence of functioning
hepatocytes."
Throughout the text, tense usage should be consistent—stick to past tense for methods/results
and present tense for conclusions.
9. Declarations Section Cleanup
The "Consent for Publication" section is too generic and refers to "names, photographs, and
statements" which is inappropriate for a radiology study. Revise to something more targeted,
e.g., "All patients provided written informed consent for use of anonymized imaging data and
clinical characteristics in this publication."
10. Reference Accuracy and Updates
Some references (e.g., Reference 5) appear somewhat outdated (2013) for a fast-moving field
like liver MRI.
Consider adding recent review articles (2022-2024) on liver fibrosis imaging.
Also, some references should directly support the imaging features you describe—not just
general fibrosis reviews.
11. Discussion Balance
The discussion is somewhat unbalanced—it focuses heavily on patterns seen in CHF, but the
real diagnostic challenge is differentiating CHF from malignancies.
Add a dedicated paragraph comparing CHF vs. infiltrative HCC vs. ICC with key discriminators.
Highlight how the findings could change clinical decision-making (e.g., avoid biopsy in typical
CHF, but biopsy if enhancement pattern is atypical).