Review for 10.1186/s12876-025-03949-1 (2025)

Title: The Prognostic Value of AST-Lymphocyte Ratio Index in Liver Cancer Patients Treated
with TACE: A Systematic Review and Single-Center Retrospective Study
Version: 1 Date: 09 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-The search strategy is broadly defined, but the search terms could be more specific. For
example, including variations in terminology for liver cancer and ALRI could help ensure the
comprehensive inclusion of studies. A more explicit search strategy flow (e.g., PRISMA flow
diagram) would help readers visualize how studies were selected for inclusion in the meta-
analysis.
-While the inclusion of Chinese and English-language studies is appropriate given the authors'
context, limiting the inclusion to just these languages could introduce bias. A broader language
inclusion strategy, or at least a justification of this decision, would improve the manuscript's
global applicability and generalizability.
-The methodology for determining the ALRI cutoff value is mentioned, but further clarification
regarding how X-tile software is used and why this approach was chosen would be useful. It
would be beneficial to explain the sensitivity and specificity considerations in choosing the
optimal cutoff, as this is critical to establishing the clinical relevance of ALRI.
-While the inclusion of key factors like AST and lymphocyte count is appropriate, additional
variables related to liver cancer progression, such as Child-Pugh classification, MELD score,
or serum AFP levels, could further refine the prognostic model. These variables are commonly
used in clinical settings and could provide a more nuanced understanding of patient outcomes.
-While the authors mention that ALRI reflects both liver injury and immune status, a deeper dive
into the biological mechanisms behind these two factors and their combined impact on tumor
progression could enhance the explanation. For example, discussing the exact role of AST in
liver injury and the immune evasion mechanisms facilitated by low lymphocyte counts would
provide more insight into how ALRI might predict survival.
-The authors mention that other markers, such as the Systemic Immuno-Inflammation Index
(SII), Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR), could
complement ALRI. However, a more detailed comparison of ALRI with these other markers
in terms of their prognostic accuracy and clinical applicability would be helpful. Additionally,
some clinical factors like the Child-Pugh score or MELD score, which are widely used in liver
disease, could have been mentioned as part of the broader discussion on prognosis.
-The authors rightly identify the potential regional bias of their findings, given that most
studies included in the meta-analysis were from China. However, the difference in ALRI
significance between the North American cohort and the Chinese cohort could be explored
further. Understanding the reasons for this discrepancy (e.g., differences in liver cancer etiology,
treatment protocols, or immune status) would add depth to the discussion and guide future
research in different regions.