Review for 10.1186/s12876-022-02110-6 (2022)

Reviewer’s report
Title: 
Diaphragmatic Perforation after Transcatheter Arterial
Chemoembolization of Hepatocellular Carcinoma via Inferior Phrenic Artery: A
Case Report
Version: 
1 
Date: 
07 Jan 2022
Reviewer's report:
SPECIFIC COMMENTS
This manuscript is pleasurable and flowing, in general; no major issues are
appreciable. 
Although language used is appropriate, I recommend to Editorial staff to check
the final version because I am not a native English speaker. 
TITLE
The title is very interesting. 
ABSTRACT
The abstract appears clear. I believe that the authors could make the conclusions
more attractive. 
KEYWORDS
Authors did not correctly report all keywords from MeSH Browser. In particular,
for example, I checked "chemoembolization" on MeSH Browser and I did not
find this KW. This is important, in my personal opinion, in order to increase the
traceability of this paper (and consequently the possibility of the Journal to be
cited by Readers and Stakeholders). I suggest the check of the all KWs. 
SECTION: Background
Please, could the authors introduce the theme of chemoembolization performed
via extrahepatic feeding vessels? Is this procedure rare? Or not? Please, refer to
different papers that analyze this theme that is vary important because this
procedure is performed via extrahepatic vessel about in ¼ - 1/3 of cases/nodules.
In the background and in discussion section, the authors stated that: "However,
irreversible diaphragmatic injury after TACE without radiofrequency ablation is
an extremely rare complication.". Please, could the authors reports a percentage
of extremely rare? Obviously, referring to some series.
SECTION: Case presentation
Please, describe better the BCLC classification of the patient to justify the TACE
procedures.
To obtain results that are comparable from different studies, it is essential to
report the type of chemo-embolization that has been performed by the Authors.
In particular, according to [Ann Hepatol. 2021;22:100278.
doi:10.1016/j.aohep.2020.10.006], what kind of chemo-embolization is used:
Water-in-oil (Wio) or chemotherapeutic-in-oil (Cio)? DEB-TACE? Other ftypes
of TACE? The authors could discuss this theme.
In my opinion, this section should be expanded with comments regarding the
strategy the authors adopted for re-treatment. They used the scheduled strategy?
Or on-demand strategy? This point is very important and the authors must
discuss this point. In fact, it is well known that the decision on whether a HCC
patient needs a re-treatment after treatment may vary among different
radiologists, especially in case of a non-specifically trained radiologist and,
therefore, regardless of the adopted criteria, patients should be evaluated by
experienced radiologists to minimize variability in this critical instance [Eur
Radiol. 2018;28(9):3611-3620. doi:10.1007/s00330-018-5393-3]. Please, could
the Authors report that it is important that experienced radiologists evaluate
imaging prior to a re-treatment, and that one or more experienced radiologists
must evaluated imaging according to mRECIST. Please, cite the aforementioned
paper [Eur Radiol. 2018;28(9):3611-3620. doi:10.1007/s00330-018-5393-3].
Furthermore, during the execution of the TACE procedures there is an amount of
absorbed radiant dose. In my opinion a correct standardization of the procedures,
including TACE, it is also possible to reduce the number of rays absorbed for
both patients and radiologists and reduce possible stochastic effects [Med Phys.
2012;39(5):2491-2498. doi:10.1118/1.3702457]. in my opinion, the
interventional radiologists who performed TACE should be necessary expert
radiologists in order to reduce the dose in patients that received these treatments
[cite the paper: Med Phys. 2012;39(5):2491-2498. doi:10.1118/1.3702457].
according to the aforementioned paper, could the authors report if the
interventional radiologist who performed these procedures were expert, to reduce
the risks of x-ray exposure particularly if the treatments were performed via
extrahepatic vessels? In my opinion, this theme could be briefly analyzed in this
section, highlighting that in non dedicated centers without expert interventional
radiologist, the possibility to use a systemic therapy would be considered.
Finally, linked to the above theme, did the interventional radiologist performed
the TACE as selective as possible also in non-hepatic vessels to reduce the risks?
SECTION: Discussion
Please, in my opinion the authors must discuss an important theme: the theme of
associating a systemic therapy with TACE. There are many papers concerning
the associations of systemic and trans.arterial therapies. Please, the authors must
write some lines about this theme. Furthermore, it is necessary that
Interventional radiological procedures are performed by experienced
inteventional radiologists to reduce stochastic and non-stochastic risks from x-
ray exposure [Med Phys. 2012;39(5):2491-2498. doi:10.1118/1.3702457] and to
reduce these complications.
Please, could the authors discuss the possible roule in these procedure of cone-
beam CT, citing this paper: 
Bannangkoon K, Hongsakul K, Tubtawee T. Impact of cone-beam computed
tomography with automated feeder detection software on the survival outcome
of patients with hepatocellular carcinoma during treatment with conventional
transarterial chemoembolization. BMC Gastroenterol. 2021;21(1):419. Published
2021 Nov 8. doi:10.1186/s12876-021-02004-z
SECTION: Conclusion
I believe that the authors could make the conclusions more attractive.
Figures
OK.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
No
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Yes
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Yes
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from apparent manipulation?
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