Review for 10.1186/s12876-023-02952-8 (2023)

Title: CLINICAL MANIFESTATION, STAGING AND PROGNOSIS OF
HEPATOCELLULAR CARCINOMA IN GAMBIAN PATIENTS
Version: 2 Date: 16 Jul 2023
Reviewer's report:
Thank you very much for the invitation to review. The article is titled
"CLINICAL MANIFESTATION, STAGING AND PROGNOSIS OF HEPATOCELLULAR
CARCINOMA IN GAMBIAN PATIENTS" by Bittaye et al. and discusses the clinical pattern
of such patients.
The topic is very important as evidence pertaining to HCC patterns in Africa is limited, and the
study includes 260 patients, which is a sizable sample size. This is an important topic, and I
congratulate the authors for coming up with this study.
· The nature of the study design is not well elucidated. This needs to be explicitly stated as
retrospective vs. Prospective or cohort. If this is a prospective study, pre-defined tools to be used
to make a diagnosis of HCC and pre-defined data points need to be outlined.
· The methodology used to diagnose HCC is unclear regarding the proportion of patients included
in each category. What proportion of patients underwent a CT scan, and if so, with a 3-phase
contrast study? Normally, such proper dynamic studies are preferred to make a diagnosis of
HCC. The limitation of plain non-contrast ultrasound to diagnose HCC needs to be discussed
in the paper.
· What proportion of patients underwent a biopsy of lesions to diagnose liver cancer? The
manuscript states that some patients underwent a biopsy. This is an invasive tool used in
situations where the diagnosis is unclear. I suggest the authors include when a biopsy is used
to diagnose the patients.
· I have a question regarding a diagnosis of cirrhosis in the study population. The manuscript does
not discuss what proportion of patients are cirrhotics. The implication is that in HBV infection,
HCC can occur without the development of cirrhosis, and the clinical presentation of a cirrhotic
is very different from a noncirrhotic one. Additionally, mortality rates would differ too. The
authors need to discuss cirrhosis in the paper well and describe it in the patients.
· Fibroscan data is included, but it is unclear how many patients this was done. I understand
Fibroscan is not routinely available in African setting, but since the manuscript mentions few
points about it, it is good to indicate the proportion of patients who had a Fibroscan reading.
Furthermore, I think the authors need to include data points on non-invasive markers of liver
fibrosis, like APRI and FIB4. This also alludes to the notion that the study needs to discuss
cirrhosis.
· The number of clinical symptoms included in the study is quite extensive. I understand in a
resource-limited setting, such data are important, but the utility in a clinical situation is very
limited. I worry such extensive symptoms with statistics make the manuscript less readable.
The authors could re-look into ways to present the data in a more readable and more clinically
relatable way.
· In the aetiology section, the authors discuss some points about HBsAg positivity but not include
a discussion about other causes. There is rather discussion about signs and symptoms in the
aetiology section, and I suggest this need to be revised. Regarding etiologies, the authors do not
discuss about Hepatitis C and this is glaringly missing from the paper. Particularly, if this is
presented as a prospective cohort paper, at some point, including patients with HCV needs to
be thought of. Other etiologies of cirrhosis and liver cancer also need to be discussed, even if
diagnostic tools are locally unavailable, to complete a rigorous discussion of causes.
· Under the methods section, there is considerable discussion about the importance of Gambia
Hepatitis B vaccination (GHIS), and I suggest this could be trimmed down. More description of
the patient population can be instead discussed in the section.
· Not clear if patients were recruited from a clinic or the hospital. This is important in terms of
discussing median survival times.
· Authors included a Kaplan Meir of BCLC class of patients with follow-up. The merit of this
is not clear for me. This is a well-established scientific knowledge and I doubt the benefit of
including these graphs.
· If survival data are being plotted, I would also expect some discussion about intervention done
for patients in the other subcategories with lower BCLC scores. The study does not discuss about
interventions offered for patients.
· The discussion of the manuscript seems to dwell on a few points, and I worry some of them
are just stating the obvious. For example, the authors discuss survival rates are lower in parts
of Africa where liver cancer services are limited. This has limited merit for the reader and the
scientific community. I think the authors could tease out more discussion points that address the
unique challenges of HCC in African settings.
. The authors also should have discussed about strengths and limitations of the paper.
· Other comments. I suggest that authors use standard reference management software. Multiple
references are truncated and not properly cited. Some improvement in grammar and flow of
writing could also be considered.