Review for 10.1186/s12876-024-03298-5 (2024)

Title: Pathological complete response after conversion therapy in unresectable hepatocellular
carcinoma: A retrospective study
Version: 0 Date: 29 Jan 2024
Reviewer's report:
1) The title is not entirely consistent with the content of the manuscript, as the title deals
generically with "hepatocarcinoma", without specifying that it is a study that investigates the
response to a particular combined therapy that is carried out in "unresectable" hcc . Therefore
it would be more correct to title it "PATHOLOGICAL COMPLETE RESPONSE AFTER
CONVERSION THERAPY IN UNRESECTABLE HEPATOCELLULAR CARCINOMA".
2) The introduction is too short. The authors could better explain conversion therapy and the
various techniques used, which are explained in a confusing and scattered manner throughout
the article.
3) In the final part of the introduction the aim of the study is not clearly written, that is, it is written
that this article summarizes the treatment experiences of 60 patients with pathological complete
responses after conversion therapy in their center. It would instead be more correct to say that
the aim is to understand the importance of conversion therapy in patients with unresectable
hepatocellular carcinoma in terms of survival and recurrence of the disease.
4) This study is useful because it explains the importance of a new therapeutic possibility
(conversion therapy) for those patients who previously could not undergo surgery and can
therefore increase their life expectancy, especially due to the spread of HCC in the world (third
cause of death). However, the importance of the new research conducted compared to existing
research is not made clear.
5) Clarifications should be made regarding the methods. First of all, in the inclusion criteria
there is that patients undergo surgery after conversion therapy, while in the results it is written
that only 8 received SBRT before undergoing resection surgery (syntax error? other?). It is also
stated that surgical removal is performed five weeks after SBRT. However, it is not stated how
long after the surgery is performed after the other conversion therapy techniques (TACE/PVE).
6) The methods section does not accurately report all the steps performed. In particular,
pathological complete response is defined as the complete disappearance of all known lesions
based on radiography: radiography is too generic a term, the radiological technique used
should be precisely defined (ultrasound? computerized axial tomography? magnetic resonance
imaging?) so that the study can be reproducible in other centers and therefore comparable.
Furthermore, as already mentioned above, it should be specified how long after each conversion
therapy (TACE, PVE..) the surgery is carried out.
7) Statistical analysis is performed correctly, but in the results in the "demographic
characteristics" paragraph the patients who received pve and srbt are expressed in absolute
numbers and not in percentages. Should you then specify that it is statistically significant at p
< 0.05 or is it implicit? The motivation that led to the use of this method rather than another
is not specified.
8) The results are not clearly reported. First of all, it appears that only 8 patients (those who
received sbrt) undergo surgery after conversion therapy. Surgery after therapy is instead an
inclusion criterion. In the results it is then mentioned that 12 patients received adjuvant therapy
after liver resection. tThe concept of adjuvant therapy was never mentioned in the introduction,
nor among the inclusion criteria or among conversion therapies. We are only talking about the
various conversion therapy techniques that precede surgical resection and not that are carried
out after surgery. This aspect is not very clear and should be better defined.
9) Finally, please pay attention to two mistakes I found in the methods paragraph: first, at point
3 of the inclusion criteria, it is not "pathology" confirmed complete response but "pathological";
second, in the "procedures and treatments" section when talking about cisplatin chemotherapy
it is repeated twice.