Review for 10.1186/s12876-022-02180-6 (2022)

Reviewer’s report
Title: 
The monocyte to lymphocyte ratio not only at baseline but also at relapse
predicts poor outcomes in patients with hepatocellular carcinoma receiving
locoregional therapy
Version: 
0 
Date: 
21 Jan 2022
Reviewer's report:
Abstract
The abstract is well structured in all its sections, and therefore it properly reflects
the text, highlighting the most important aspects of this paper. Therefore, no
adjustments are needed. 
Introduction
I recommend introducing some lines about the role of TACE in the treatment of
HCC. It is important to briefly describe the different types of transarterial
treatments options. In particular, it is demonstrated that there is a non-superiority
of transarterial chemoembolization with respect to bland embolization in
hepatocarcinoma patients [United European Gastroenterol J. 2017;5(4):511-518.
doi:10.1177/2050640616673516]. Please, the Authors have to report why they
used TACE (and not TAE), citing the above-mentioned article.
I suggest introducing some lines also concerning combined treatments, for
example citing: Sequential transarterial chemoembolization and early
radiofrequency ablation improves clinical outcomes for early-intermediate
hepatocellular carcinoma in a 10-year single-center comparative study. BMC
Gastroenterol. 2021;21(1):182. Published 2021 Apr 20. doi:10.1186/s12876-021-
01765-x.
Materials & Methods
Some points need to be clarified:
- The authors must describe in which patients they performed combined
treatments. In particular: did they perform combined treatment in all patients
that, according to EASL guidelines, need to be treated or with ablation (alone) or
with TACE (alone)? Please, specify.
- The authors must report if they used mRECIST in the follow-up. Furthermore,
it is well known that the decision on whether a HCC patient is a responder or
progressor after treatment may vary among different radiologists, with different
experiences. Therefore, patients should be evaluated by experienced radiologists
to minimize the variability in this critical phase [Eur Radiol. 2018;28(9):3611-
3620. doi:10.1007/s00330-018-5393-3]. The Authors have to report if one or
more experienced radiologists evaluated imaging in the follow-up.? This is
important, according to the aforementioned paper [Eur Radiol. 2018;28(9):3611-
3620. doi:10.1007/s00330-018-5393-3] because the results are based on a correct
and reproducible evaluation of the imaging.
- The authors stated: "All enrolled patients were treated with TACE combined
with local ablation, which were performed by three qualified hepatologists".
Were The tace procedure performed by Hepatologists? Not by Interventional
Radiologists?
- Furthermore: could the authors specify the word "qualified"? Are the operators
expert in performing TACE? How many years of experience characterized the
operators? This point, in my opinion, is crucial. In fact, during the execution of
the procedures, did the authors consider accurately the amount of absorbed
radiant dose? In my opinion, it is also possible to reduce the number of rays
absorbed for both patients and radiologists and reduce possible stochastic and
non-stochastic effects [Med Phys. 2012;39(5):2491-2498.
doi:10.1118/1.3702457] if the procedures were performed by experienced
interventional radiologists. Were the interventional radiologists who performed
TACE, expert in order to reduce the dose in patients that received a systemic
treatment [cite the paper: Med Phys. 2012;39(5):2491-2498.
doi:10.1118/1.3702457]? In my opinion, this theme could be briefly analyzed in
this section but most of all, in the discussion section.
Results
Could the authors reduce in length the section results?.
It is not clear the tumor dimension: mean? It is important to understand your
study population.
Discussion
Could the authors cite and discuss this interesting Letter: "Sequential or
combined treatment? That is the question. Radiology. 2014;272(2):612-613.
doi:10.1148/radiol.14140678", highlighting their strategy of defining combined
treatment as a sequential treatment. 
The authors must discuss and stress an important theme: the association of a
percutaneous therapy such as ablation (which already has its complications) with
another locoregional therapy such as TACE (which has its complications)
requires that no further dramatic implications such as those of X-rays absorption.
Therefore, with the intent to highlight the results of this paper, especially for
these combined treatments, it is necessary that Interventional radiological
procedures must be performed by experienced radiologists (or hepatologists) to
reduce stochastic and non-stochastic risks from x-ray exposure [Med Phys.
2012;39(5):2491-2498. doi:10.1118/1.3702457]. 
Tables
The tables, in the present form, are difficult to read.
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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?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes