PONE-D-20-07323

Elevated neutrophil-to-lymphocyte ratio and predominance of intrahepatic cholangiocarcinoma prediction of poor hepatectomy outcomes in  patients with combined hepatocellular–cholangiocarcinoma

PLOS ONE

Dear Dr. Chen,

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PLOS ONE

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This study was funded by grant obtained by Dr. Yen-Yang Chen from Kaohsiung Chang Gung Memorial Hospital Taiwan (Grant nos. CMRPG8E0881, CMRPG8F1771/1772). This study was also funded by grants obtained by Dr. Tai-Jan Chiu from Kaohsiung Chang Gung Memorial Hospital Taiwan (Grant CMRPG8E0811/0812/0813, CMRPG8C0531 and CMRPG8D0801).

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the privilege of reviewing the paper by Chiu, Chen et al examining N-L ratio (NLR) in patients with resection of combined HCC-Cholangioca (intrahepatic) with a predominance of CCA.

Reference 28 signifies that the finding is not terribly novel, but it was a small study (n=59( The study adds incrementally to the body of literature that supports the utility of NLR as a prognostic marker for recurrence post hepatectomy for IHC, HCC here examining combined HCC-IHC. This is still worthwhile in my opinion since there isn’t a lot of data or large numbers in published studies to date. The angle of IHC predominance is of some interest, but there may be confounding, see below.

Some clarifications would be useful

Did any cases have branch portal vein invasion? If so it has to be included in the descriptive analysis and model

Is there an approved definition of HCC-CCA or predominance of IHC vs HCC in mixed lesions? Consider the paper by Brunt et al PMID: 29360137. I believe the authors have been careful in their case selection but important to add some references here where possible

Where did the cut-offs for Age CEA CA199 AFP NLR and IHC% come from? This would be important to describe, especially for NLR, some descriptive analysis on this in particular is warranted

Did NLR correlate with CA19-9 or IHC percentage? Nice to describe and does not negative the validity of data if there was a relationship, but we have to overtly recognize the risk of confounding then

In Table 4, please provide by footnote the factors not associated with disease recurrence or mortality

For sake of sensitivity analysis how would dose NLR as a continuous or categorical variable predict endpoints when age AFP CA199 CEA and IHC% are included as continuous variables

Figures, formatting needed, change days to years, text too small on axes, image quality poor and add nothing to data shown in tables

Consider a graph for NLR above and below threshold that is adjusted for all other factors, this can be done in Cox-regression in SPSS, that includes all factors, making NLR a categorical variable and clicking plot, follow the prompts to show smoothed survival curves by selected cat variable (NLR). This way you have two graphs with risk adjusted outcomes for recurrence and OS

Reviewer #2: THis is a descriptive, paper describing NLR in intrahepatic cholangiocarcinoma looking at a series of cases collected over 13 years at a single institution

Suggestions: it is stated that cutoff of 3 determined from ROC curve, but curve not shown

The authors suggest that this is a predictive model but is actually a descriptive case series.

Reviewer #3: The manuscript titled “Elevated neutrophil-to-lymphocyte ratio and predominance of intrahepatic cholangiocarcinoma prediction of poor hepatectomy outcomes in patients with combined hepatocellular–cholangiocarcinoma” is a study about prognostic value of elevated neutrophil-to-lymphocyte ratio in surgical treated combined hepatocellular – cholangiocarcinoma. The Authors should be congratulated for collecting a clinical series of 42 patients resected with this rare disease

The manuscripts have the following limitations:

• The Authors should discuss the criteria for dividing patients according to the proportion of IHC cell (more or less than 55%);

• The Authors should clarify the reason for reporting univariate analysis at 2-year for recurrence-free survival and at 5 years for overall survival;

• The Authors should report the rate of positive and negative margins among patients submitted to resection;

• The small sample size and the distribution of different characteristics may have influenced the power of statistical analysis, the authors should comment the HR rate for T stage for recurrent disease (HR= 219.682). I suggest to review the statistical analysis by a statistician.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Andrea Ruzzenente

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Elevated neutrophil-to-lymphocyte ratio and predominance of intrahepatic cholangiocarcinoma prediction of poor hepatectomy outcomes in  patients with combined hepatocellular–cholangiocarcinoma

PONE-D-20-07323R1

Dear Dr. Chen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Aldo Scarpa

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed my comments, other reviewer comments seem less comprehensively approached and overall there are minimal changes to the paper, nevertheless the data is what it is and for a purely descriptive study it is reasonable to publish

Reviewer #3: The Authors addressed the comments of the reviewers, and they imporved the manuscript accordignto the suggestions of the reviewers

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: Yes: Andrea Ruzzenente