Adjusted Tumor Enhancement on Dual-Phase Cone-Beam CT: Predictor of Response and Overall Survival in Patients with Liver Malignancies Treated with Hepatic Artery Embolization

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1) The sample size of 13 patients with 29 hepatic tumors is relatively small to draw conclusion and reliability of the results. 

2) The authors need to provide more details regarding inclusion/exclusion criteria for patient selection.

3) The authors need to provide specific details regarding the criteria used to determine complete arterial stasis during treatment administration

4) The authors need to provide additional information on the radiation dose associated with CBCT acquisition and any measures taken to minimize radiation exposure for patients. 

Author Response

Thank you for reviewing our manuscript and thank you for your comments and suggestions.

Reviewer #1 comments and suggestions:

1) The sample size of 13 patients with 29 hepatic tumors is relatively small to draw conclusion and reliability of the results. 

2) The authors need to provide more details regarding inclusion/exclusion criteria for patient selection.

Response: More detail is now included.

Inclusion criteria included: 1. Patients with primary or metastatic liver cancer that were treated with HAE; 2. Pre- and post-treatment CBCT was available; 3. Tumor enhancement parameters were measurable on the dual-phase CBCT. Patients treated with radioembolization were excluded. Additionally, patients with poor quality or incomplete dual-phase CBCT precluding accurate measurement of tumor enhancement parameters were also excluded.

3) The authors need to provide specific details regarding the criteria used to determine complete arterial stasis during treatment administration

Response: This criteria is now added to the article.

The definition of complete stasis was no forward flow in the treated vessel with reflux of contrast with injection.

4) The authors need to provide additional information on the radiation dose associated with CBCT acquisition and any measures taken to minimize radiation exposure for patients. 

Response: This information was not collected in the current study. This is mainly because CBCT is part of the standard of care for embolization or any other liver-directed arterial therapy. No additional radiation was utilized to calculate the enhancement parameters.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript entitled "Adjusted Tumor Enhancement on Dual-Phase Cone-Beam CT: Predictor of Response and Overall Survival in Patients with Liver Malignancies treated with Hepatic Artery Embolization." submitted by Yarmohammadi et.al. discusses the use of automated tumor imaging enhancement paraments on the cone-beam CT before and after hepatic artery embolization in order to predict the treatment response, progression free survival and overall survival. The authors carried out this retrospective study from patients treated with primary or liver-dominate metastasis disease between 2016 to 2023 and the authors found efficacy of subtracted dual-phase Cone Beam Computed Tomography (CBCT) in predicting response to Hepatic Arterial Embolization (HAE) in patients with Hepatocellular Carcinoma (HCC) or metastatic liver disease. The authors highlighted the concept of ΔATE which is the change in arterial tumor enhancement as a potential predictor of treatment response and survival outcomes. The authors also did a comparison between their findings and previous reported findings.

The authors have a clear hypothesis and to test this the author used appropriate experimental design. The manuscript is well written, and the statistical methods used are appropriate to the best of my knowledge. The discussion is well written highlighting the strengths and the weaknesses of the study. However, there are few concerns which are as follows. 

Did the authors check for any confounding factors during the study which can impact the potential outcome of the study?

Overall, the work done by  Yarmohammadi et.al is commendable and adds to the necessary information. 

Author Response

Thank you for your review and special thanks to your comments.

In regard to confounding factors, we checked for few of them and found 2 factors including:  1. Vascular anatomy and 2. Cardiovascular status of the patients. In order to prevent them from impacting the outcome we compared each patient with themselves, before and after injection. That way we were able to prevent bias in the results. This has been added to the revised article.   

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors has incorporated all the required corrections.