Review for 10.1186/s12876-025-04003-w (2025)

Title: Helicobacter pylori is associated with less tumor-infiltrating lymphocytes and a poor
prognosis in gastric cancer
Version: 2 Date: 25 Mar 2025
Reviewer's report:
General Assessment:
This study investigates the association between *H. pylori* infection, tumor-infiltrating
lymphocytes (TILs), and prognosis in gastric adenocarcinoma (GAC). The authors demonstrate
that *H. pylori* infection correlates with reduced TILs/CD8+ TILs, increased PD-
L1 expression, and poorer survival. While the findings are clinically relevant, several
methodological and presentation issues require attention.
Major Comments:
1. Sample Size and Study Design:
- The retrospective design and small sample size (*n=96*) limit the generalizability of findings.
A larger, prospective cohort would strengthen conclusions.
- The discrepancy between univariate (significant) and multivariate (non-significant) Cox
regression for *H. pylori* (p=0.088) needs deeper discussion. Potential confounders (e.g., PD-
L1 status, treatment heterogeneity) should be explored.
2. Methodological Clarifications:
- Cutoff Values:Justify the predefined thresholds for CD3 (20%) and CD8 (10%) positivity with
references or validation data.
- PD-L1 Scoring: The mention of "70" in the PD-L1 CPS definition appears to be a typo. Clarify
this section.
- Statistical Analysis:Provide details on handling missing data, multiple testing adjustments, and
software parameters (e.g., SPSS/GraphPad settings).
3. Mechanistic Limitations:
- The study correlates *H. pylori* with immune markers but lacks mechanistic evidence (e.g.,
in vitro models or animal studies). Including experiments to validate causal relationships (e.g.,
*H. pylori*-induced PD-L1 upregulation) would enhance impact.
4. Results Interpretation:
- The inverse association between CD3 and prognosis (non-significant in Cox regression but
significant in KM analysis) is contradictory. Discuss potential reasons (e.g., CD3+ T cell
heterogeneity).
- Address the conflicting PD-L1 prognosis results between the cohort (poor prognosis) and KM
database (no significance).
5. Presentation Issues:
- Tables/Figures:
- Table 1 has formatting errors (misaligned columns). Ensure consistency in percentage
reporting.
- Figures 1–3 and supplementary images are referenced but not included, hindering evaluation.
- Repetition:Keywords are duplicated in the abstract. Remove the second instance.
Minor Comments:
1. Introduction:
- Streamline the immunotherapy section (e.g., excessive details on pembrolizumab/nivolumab).
Focus on relevance to TME and *H. pylori*.
2. Discussion:
- Expand on the role of CD8+ T cells vs. CD3+ T cells in prognosis. Reference claims about
immunosuppressive T cell subsets (e.g., Tregs).
- Elaborate on the proposed mechanisms of *H. pylori*-induced PD-L1 upregulation (e.g., NF-
#B, JAK/STAT).
3. References:
- Ensure consistent formatting (e.g., journal abbreviations, use of "et al.").
- Update citations where possible (e.g., reference 52 lists "e13880" without a journal name).
Additional Notes:
- Ensure all figures are included in the final submission.
- A language edit is recommended to polish grammar and syntax.