Elevated Serum Protein Induced by Vitamin K Absence or Antagonist II Levels in Patients with Hepatic Hemangiomas
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsI have the following comments:
1) I am somewhat confused by the statements in the Introduction (lines 40-43): “serum PIVKA-II levels were significantly increased in patients with larger hemangiomas and coagulation disorders [7–9]. There have been no previous reports of the association between PIVKA-II levels and hemangiomas”. The first sentence indicates that a previous study reported an association between PIVKA-II levels and hemangiomas, while the next sentence claims that there are no previous reports about this association. It would be helpful if the authors could clarify the novelties of this study and what distinguishes it from existing studies.
2) Do the authors believe that multiple hypothesis correction should be applied to the statistical tests conducted in this study?
3) Given that the study involves 335 participants, including 122 males and 213 females, have the authors explored any potential difference in PIVKA-II association between males and females?
Author Response
Reviewer 1
1) I am somewhat confused by the statements in the Introduction (lines 40-43): “serum PIVKA-II levels were significantly increased in patients with larger hemangiomas and coagulation disorders [7–9]. There have been no previous reports of the association between PIVKA-II levels and hemangiomas”. The first sentence indicates that a previous study reported an association between PIVKA-II levels and hemangiomas, while the next sentence claims that there are no previous reports about this association. It would be helpful if the authors could clarify the novelties of this study and what distinguishes it from existing studies.
Reply
According to reviewer’s comments, we changed the latter half of introduction in order to clarify the novelties of our study.
Page 3, Line 8
Introduction
Serum protein induced by vitamin K absence or antagonist II
(PIVKA-II) levels are often elevated in patients with hepatocellular
carcinoma (HCC). PIVKA-II is a sensitive and specific tumor marker
for the diagnosis of HCC [1,2], although several other factors such as
insufficiency of vitamin K, administration of vitamin K antagonists, use
of antibiotics that alter gut flora, alcoholic liver disease [2], hepatitis E
[3], and other liver diseases [4,5] or malignant tumors [6,7] have been
reported to increase serum PIVKA-II levels in patients without HCC.
However, there have been no previous reports of the association
between PIVKA-II levels and hemangiomas. Our previous study
demonstrated the relationship between the size of hemangiomas and
coagulation factors, and it showed that serum PIVKA-II levels were
significantly increased in patients with larger hemangiomas and
coagulation disorders [8-10]. Therefore, a retrospective study was
performed to evaluate the effect of hemangiomas on serum PIVKA-II
levels in hemangioma patients without HCC and elucidate the
mechanism for the elevation of PIVKA-II levels by hemangiomas.
2) Do the authors believe that multiple hypothesis correction should be applied to the statistical tests conducted in this study?
Reply
We performed a postHoc analysis using the Bonferroni method, and the results are shown in table 3.
We have added following sentence in statistical analysis on page 11, line 11:
The Bonferroni method was used as the post Hoc test.
3) Given that the study involves 335 participants, including 122 males and 213 females, have the authors explored any potential difference in PIVKA-II association between males and females?
Reply
We used an unpaired t-test to examine sex differences in PIVKA-II. The results showed that PIVKA-II was significantly higher in women than in men.
We have added following sentences on page 4, line 7:
In the patient group of 122 men and 213 women, PIVKA-II levels were significantly higher in women than in men (p<0.01).
Reviewer 2 Report
Comments and Suggestions for AuthorsGeneral Considerations
This study addresses a relatively unexplored topic: the correlation between serum PIVKA-II levels and hepatic hemangiomas. The approach is innovative and could have significant clinical implications, particularly in differentiating hepatic hemangiomas from hepatocellular carcinoma (HCC). The study is based on a large cohort (335 patients) with good follow-up, and the statistical analyses (t-test, ANOVA, linear regression) are appropriately applied. Well-structured tables facilitate data interpretation.
However, the paper requires a major revision in the following areas:
- Introduction: Additional references should be included to highlight the role of PIVKA-II as a biomarker in various neoplasms, such as pancreatic ductal adenocarcinoma (PDAC), emphasizing its emerging relevance beyond HCC.
- Hypothesis: The proposed compensatory role of prothrombin precursor production is based on indirect evidence. Therefore, data on serum precursor levels should be incorporated to support this hypothesis.
- Results: Histological analyses confirming PIVKA-II production in tissues should be included.
- Discussion: Some sections are redundant and should be streamlined. Additionally, a comparison with findings from other studies would be valuable, highlighting similarities, differences, and potential clinical implications.
- Conclusion: The conclusion should be more impactful, emphasizing the clinical significance and implications of the findings.
- Limitations: Consider adding a clearer section outlining the study’s limitations.
The english language should be improved
Author Response
General Considerations
This study addresses a relatively unexplored topic: the correlation between serum PIVKA-II levels and hepatic hemangiomas. The approach is innovative and could have significant clinical implications, particularly in differentiating hepatic hemangiomas from hepatocellular carcinoma (HCC). The study is based on a large cohort (335 patients) with good follow-up, and the statistical analyses (t-test, ANOVA, linear regression) are appropriately applied. Well-structured tables facilitate data interpretation.
However, the paper requires a major revision in the following areas:
- Introduction: Additional references should be included to highlight the role of PIVKA-II as a biomarker in various neoplasms, such as pancreatic ductal adenocarcinoma (PDAC), emphasizing its emerging relevance beyond HCC.
Reply
According to reviewer’s comments, we added new additional reference (see reference 7) related to the relationship between PDAC and PIVKA-II.
Page 16, Line 25
Farina, A.; Tartaglione, S.; Preziosi, A.; Mancini, P.; Angeloni, A.;
Anastasi, E. PANC-1 cell line as an experimental model for
characterizing PIVKA-II production, distribution, and molecular
mechanisms leading to protein release in PDAC. Int. J. Mol. Sci. 2024,
25, 3498. https://doi.org10.3390/ijms25063498
- Hypothesis: The proposed compensatory role of prothrombin precursor production is based on indirect evidence. Therefore, data on serum precursor levels should be incorporated to support this hypothesis.
Reply
In Japan, it is not easy to measure prothrombin precursors and our facility does not have the equipment to measure them. Therefore, we could not measure serum levels of prothrombin precursors, and thus the increased formation of prothrombin precursors was not serologically proven, and it was indirectly proven according to the trends in prothrombin levels.
- Results: Histological analyses confirming PIVKA-II production in tissues should be included.
Reply
I am sorry, but we could not perform the liver biopsy for confirmation of PIVKA-II production in tissues, because this study was conducted among outpatients. Therefore, its histological data could not be obtained.
- Discussion: Some sections are redundant and should be streamlined. Additionally, a comparison with findings from other studies would be valuable, highlighting similarities, differences, and potential clinical implications.
Reply
According to reviewer’s comments, we deleted unnecessary sections or similar sentence as much as possible.
Page 7. Line 29
Based on our results, we speculated on the possible relationship
between each coagulation factor in an accelerated coagulation
-fibrinolysis system in hepatic hemangiomas (Figure 1). A previous
study reported that fibrinogen levels were correlated with platelet
counts [27], and our results also demonstrated that fibrinogen levels
were significantly correlated with platelet counts. Low platelet counts
and fibrinogen levels were considered to be the result of intravascular
coagulation in hemangiomas [28]. Almost all patients with elevated
levels of D-dimer and FDP exhibited increased levels of TAT.
Furthermore, a significant correlation was observed between each of
five coagulation factors (platelet, fibrinogen, TAT, D-dimer, and FDP)
except prothrombin. Therefore, it is assumed that prothrombin behaves
differently from these five other coagulation factors in the process of
the coagulation-fibrinolysis, resulting from compensatory increased
synthesis of prothrombin in hepatic cells.
Page 8, Line 10
(Our previous studies showed that PIVKA-II levels were significantly
elevated in patients with larger hemangiomas and coagulation disorders
[7-9], and → delete)
The present results relating to the change in PIVKA-II levels by tumor
growth demonstrated an elevation of PIVKA-II levels in patients with
increases in tumor size and abnormal coagulation factors, no change in
patients with stable lesions, and a decrease in patients with decreases in
tumor size and abnormal coagulation factors. Furthermore, PIVKA-II
levels were significantly correlated with tumor size and all coagulation
factors except prothrombin. From the above results, PIVKA-II levels
were closely associated with changes in hemangioma size and
abnormal coagulation factors.
- Conclusion: The conclusion should be more impactful, emphasizing the clinical significance and implications of the findings.
Reply
According to reviewer’s comments, conclusion was changed to the following in order to emphasize the clinical implications.
Page 11, Line 23
Conclusions
Present study is the first to demonstrate the correlation of hepatic
hemangiomas with serum PIVKA-II levels. Hemangiomas were
significantly associated with elevated serum PIVKA-II levels, which
was attributed to increased production of prothrombin precursors
caused by the accelerated coagulation-fibrinolysis within
hemangiomas. Although further studies are required to evaluate the
exact relationship between hepatic hemangiomas and PIVKA-II
levels, we recommend that elevated serum PIVKA-II levels in patients
with hemangiomas should be interpreted with close attention to
differentiating them from HCC.
- Limitations: Consider adding a clearer section outlining the study’s limitations.
Reply
According to reviewer’s comments, we eleted some parts and added a clearer section.
Page 9, Line 15
The present study has several limitations. First, serum levels of
prothrombin precursors were not measured, and thus the increased
formation of prothrombin precursors was not serologically proven, and
it has only been indirectly proven according to the trends in
prothrombin levels. Second, the levels of prothrombin, vitamin K, and
PIVKA-II in liver tissues were not measured, and our views were
established based on the serological levels; therefore, measurements
and results at the histological level are needed to validate the role of
PIVKA-II in hemangiomas. Third, the length of follow-up and the
number of patients, especially those with giant hemangiomas, were
limited; therefore, a longer follow-up period and a larger patient cohort
with giant hemangiomas are needed to evaluate the elevation of serum
PIVKA-II levels. Therefore, further studies are required to evaluate the
exact relationship between hemangiomas and the elevation of serum
PIVKA-II levels.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsMost of the issues raised by the reviewers have been addressed meaningfully in the revised version of the manuscript. It may now be accepted for publication.
Author Response
Thank you so much for your peer review.
Reviewer 2 Report
Comments and Suggestions for AuthorsAccept in the present form
Comments on the Quality of English LanguageAccept in the present form
Author Response
Thank you so much for your peer review. I am looking for publication.
