Review for 10.1186/s12876-025-03823-0 (2025)

Title: A nomogram for the prediction of overall survival and Prognostic significance of different
treatment modalities for elderly Hepatocellular carcinoma
Version: 3 Date: 27 Jan 2025
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: In their present report, authors aimed at developing a nomogram in
order to more accurately predict overall survival in elderly patients diagnosed with HCC during
the 2000-2020 period, identified through a specific request to the US SEER database. Authors
might consider the following issues to improve the content of their manuscript.
REQUESTED REVISIONS:
Introduction section:
redundant statement “Some studies have also proved portal vein tumor thrombus, an early
phenomenon of vascular invasion in hepatocellular carcinoma, seriously affects the prognosis
of hepatocellular carcinoma”, please revise appropriately.
The following part from: “This article is divided…” to “treatment decisions for patients.” should
rather be part of the method section. Instead of supporting their methodological approach here,
authors should rather justify more strongly why there is a need of an updated nomogram to
predict survival in HCC of the elderly given the variety of already existing tools: Barcelona
Clinic Liver Cancer staging, Okuda, Japan Integrated Staging, Cancer of the Liver Italian
Program score, Chinese University Prognostic Index and so on…
Portal vein tumor thrombus (PVTT) defined twice in the text,
“there exists some bias in the variable of race, so race information was not used to develop the
regression formula.” So why excluding participants with missing values on race?
“Finally, 7694 eligible patients were gathered for analysis.Then the training cohort (n= 5385)
and validation cohort (n= 2309) were generated using R software in randomized groups in a 7:3
ratio.The complete data screening process was shown in Figure 1.” This should be part of the
result section, to be shifted, paying attention to avoid any redundancies.
The propensity score matching section is unclear. First it should be embedded in the statistical
analysis section as it a component of authors analyses. “utilized to minimize the effects
of selection bias and confounding variables.” Which variables? Please clarify and provide
contextual elements supporting the approach here. “scores were calculated according to the
Logistic regression model”, please expand on how the logistic model was constructed.
On major flaw is that variables considered in the nomogram are highly correlated. Indeed, TNM
staging directly drive the therapeutic approach selecting surgery/chemo/radiation. As reminded
by authors some key known predictors of OS are not available in the SEER including liver
biomarkers limiting the capacity to accurately predict OS.
Another main limitation: participants finally included in this analysis are highly selected based
on exclusion criteria. Therefore, results are hardly applicable to the overall population of elderly
HCC initially identified in SEER.