Review for 10.1186/s12876-021-01884-5 (2021)

Reviewer’s report
Title: 
Increasing incidence of non-HBV- and non-HCV-related hepatocellular
carcinoma: single-institution 20-year study
Version: 
1 
Date: 
05 Jan 2021
Reviewer's report:
This is a case series on patients with liver cancer across a long period of time.
The authors focus on the characteristics of non-Anon B patients.
Major points:
In my view, this design is not a cohort study but a case series. this should be
clarify in the text (or the authors can dispute this assertion)
The authors present interesting descriptive data. These, however, cannot inform
any potential strategy for screening or surveillance.
The hepatic resection sample is a very biased sample since includes likely most
of the non-cirrhotic patients. Therefore, the percentages of non-cirrhotic patients
in these sample do not reflect the percentage of non-cirrhosis in the overall
sample of tumors. This should be clarified and stressed
"These observation shows us that NBNC patients need to be aware that HCC
develops independently of fibrosis stage". This assertion is not accurate because
the risk of HCC is much greater in advanced fibrosis and even higher in
cirrhosis.
Please discuss the criteria for diagnosing HCC on imaging in non-cirrhotics.
Current european guidelines require a biopsy in non-cirrhosis patients.
"This is because patients with NBNC-HCC do not receive regular HCC
surveillance". This only applies to non-cirrhotics.
"it is necessary to recommend to receive regular HCC surveillance using
ultrasonography and/or other available modalities even if patients don't have
liver disease such as viral hepatitis, since still so many NBNC-HCC is detected
in an advanced stage.Moreover, it is also important to perform screening using
CT and MRI with new imaging and scoring system, we think it is necessary to
diagnose HCC earlier. [48, 49]. Therefore,in order to diagnose HCC at an early
stage, it is necessary to use FIB-4 index together",This is not based on any
evidence and this study does not provide any to support this. The evidence
needed to support such an assertion would necessarily come from assessing the
association between FIB-4 and and risk of liver cancer in a cohort study.
Please also refer to current AGA guidelines for HCC screening in NAFLD
Cryptogenic etiology: there is a large number of patients in this bucket. What did
the histology show? Were these patients lean NAFLD?
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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?
No
Are the methods sufficiently described to allow the study to be repeated?
No
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