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

Title: MRI findings of confluent hepatic fibrosis caused by different etiologies
Version: 2 Date: 01 Jun 2025
Reviewer's report:
I would like to begin by congratulating the authors for their work on the topic. The clinical
relevance of confluent hepatic fibrosis is evident. However, several key points require further
clarification and methodological refinement, as outlined below:
1. The manuscript does not specify the search terms used to identify patients diagnosed with
confluent hepatic fibrosis. It would be important to detail the search strategy applied in the PACS
system, the initial radiological criteria for case identification, or the rationale for the selected
time frame.
The absence of this information hinders reproducibility and introduces the potential for selection
bias. The fact that all retrospectively identified cases were confirmed upon re-evaluation is
noteworthy and may indicate overly restrictive selection criteria or confirmation bias.
We suggest clearly specifying the diagnostic terms used in the search, the case identification
strategy, and the rationale for the study period (January 2017 to July 2024—this last point being
of secondary importance).
2. The manuscript does not present specific criteria for distinguishing confluent hepatic fibrosis
from diffuse fibrosis or other liver abnormalities commonly observed in fibrotic or cirrhotic
livers (e.g., perfusion-related changes).
Substantial variation in lesion appearance is described without providing reproducible
operational definitions. Standardized morphological criteria are essential, including minimum
lesion dimensions, shape, and clear demarcation parameters.
3. Providing a clear histological definition of confluent hepatic fibrosis would enhance the
validity of imaging findings.
This is especially relevant given that only 36% of cases underwent histopathological
confirmation. Such correlation could help delineate the condition more precisely and
differentiate it from other fibrotic processes.
4. It remains unclear whether the radiologists were truly blinded to the presumptive diagnosis of
confluent hepatic fibrosis during image review. While the text refers to a “blinded” assessment,
it does not specify whether the readers were aware of the clinical suspicion, which could
compromise the objectivity of the analysis and the validity of imaging findings.
5. A 12-month imaging follow-up was not defined as a mandatory inclusion criterion but is later
used as part of the non-histological diagnostic definition. Clarification of this aspect within the
methodology section would improve methodological transparency.
6. Although previously addressed in the first review, this issue remains critical. Statistical
comparisons involving subgroups with only two to four patients yield results that lack
interpretability, regardless of the test employed.
Comparisons involving fewer than five patients per subgroup should be presented as “observed
trends” without p-values, accompanied by power analyses indicating the minimum detectable
effect size with the current sample.
It may also be helpful to conduct a combined analysis of all subgroups in the tables to support
diagnostic decision-making in patients with chronic liver disease.
7. The multidisciplinary consensus referenced in the manuscript is insufficient to confirm that
the described imaging patterns specifically represent confluent hepatic fibrosis as opposed to
other similar fibrotic entities.
It would be advisable to clearly state the exclusion criteria applied to rule out other fibrotic
conditions.