Review for 10.1186/1471-230X-9-29 (2009)

Reviewer's report
Title:Outcomes and factors influencing the survival in cases with spontaneous
rupture of hepatocellular carcinoma: a multicenter study
Version: 2Date:15 December 2008
Reviewer: Jeong Won W. Jang
Reviewer's report:
Dear the editor,
Kirikoshi et al. conducted a study of the prognosis and outcome in cases of
spontaneous rupture of hepatocellular carcinoma (HCC). From the analysis, the
authors stated that transarterial embolization (TAE) appears to be a very useful
treatment strategy associated with a longer survival for patients with
spontaneous rupture of HCC, and the size of the tumor is an important survival
factor in HCC patients in whom TAE was accomplished successfully. The
manuscript is easy to read. However, the data analyses and descriptions are
basically limited by the small number of the case series. Moreover, no
conclusions can be drawn by the lack of randomization and retrospective nature
in this manuscript, which could skew the results.
<Major criticisms>
1. Method: The authors stated that the decision to perform TAE was taken
according to the patients’ will. This appears to make no sense; more patients in
the conservative group had worsened liver function, in terms of high bilirubin,
AST levels, and Child-Pugh scores, more cases of ascites in the conservative
group. Given that all of these are found to be associated with early 30-day
mortality (even though they are not significant in the multivariate analysis), the
discrepancies between patient characteristics in the two groups are a challenging
issue for the data interpretation. This could introduce an unintentional bias and
perhaps may not strengthen the conclusions from these data.
2. Table 1: The data suggest that some proportion of patients had very
decreased hepatic function at baseline. This implies that those were intrinsically
not eligible for TAE. It is highly likely that such patients with decompensated liver
function could have contributed to confounding factors in the analyses. To
substantiate the role of TAE, it is relevant to include only patients with reasonable
hepatic function who are eligible for TAE.
3. There have been many reports concerning natural course, prognostic factors,
and treatment strategy for ruptured HCC. Thus, the overall findings are not new
in this field.
<Minor criticisms>
1. Some previous publications including review articles have indicated that
surgical resection (including delayed resection following TAE) for ruptured HCC,
if resectable, is a reasonable approach and offers a better, long-term survival.
Are there any surgical cases in this study?
2. Results, Page 10: TAE was identified as the only independent predictor of the
30-day survival. These data could be provided by Table.
3. Page 6, background: The sentence, “– increasing prevalence of hepatitis B..
infections”, appears to be inappropriate. With the introduction of HBV
vaccination, the prevalence of HBV infection is now decreasing in many
countries.
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests.