Reviewer ’s report  
 
Title: Tissue sublimation follow transarterial embolization of a follicular nodular hyperplasia of  
the liver. Report of a case  
 
Version: 0 Date: 27 Feb 2017  
 
Reviewer: Daniel R. Ganger  
 
Reviewer's report:  
 
Please provide imaging obtained on day 1 post TACE.  
 
 
Please provide or comment on the pathology of the gallbladder removed 6 weeks later.  
 
 
You state that patient left 12 days post procedure in good condition with resolution of symptoms 
and improvement or normalization of liver tests. The gas resolved three weeks later How often 
did you image the patient?  
 
 
If gas was till present for almost 3 weeks, but patient improved with in a shorter periof time, do 
you believe that antibiotics should be standard post procedure for what duration if the target is 
such a large lesion?  
 
 
The elevation of alkaline phospahtase is very high and usually not that high in patient with liver 
induced i schemic injury? What is your explanation? Gallbladder injury?  
 
 
How long did i take fo rthe ALP to drop back to normal.  
 
 
Do you have any additional recommendation regarding the embolization procedure with 
Embozene for larger lesions, like in your case to pr event the same presentation with 
complications?  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comme nts to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical r eview?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the man uscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any  other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
This is a single case and authors report with the term sublimation the formation of gas in the 
tissue of a large focal nodular hyperplasia that underwent Embozene mic rospheres embolization.  
 
 
Although they could only speculate about the gas formation physiology, there was significant 
necrosis of the lesion and possible injury to non lesional liver tissue as the patient suffered from 
fever, pain and significant elevation  of liver enzymes, all of which improved with time, IV fluids 
and broad spectrum antibiotics. The gas formation took 3 weeks to resolve. There was no fluid 
within the lesion, so abscess was excluded. No sampling of the gas tissue was done for infectious 
purposes.  
 
 
The authors discuss two issues: teh sublimation and expectant strategy ( non surgical). First, the 
reason for sublimation is unknown. The expectant approach is routine in similar cases of 
malignancy that undergo the TACE procedure.  
 
 
The authors al so blamed acute cholecystitis for part of the symptoms and the patient underwent 
cholecystectomy 6 weeks later, but no details were provided about the pathology of the 
gallbladder. In summary, interesting case, but no major contribution to those who manage  
patients post arterial embolization together with the interventional radiologists.  
 
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named repo rt 
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understan d that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Tissue sublimation follow transarterial embolization of a follicular nodular hyperplasia of  
the liver. Report of a case  
 
Version: 0 Date: 27 Feb 2017  
 
Reviewer: Daniel R. Ganger  
 
Reviewer's report:  
 
Please provide imaging obtained on day 1 post TACE.  
 
 
Please provide or comment on the pathology of the gallbladder removed 6 weeks later.  
 
 
You state that patient left 12 days post procedure in good condition with resolution of symptoms 
and improvement or normalization of liver tests. The gas resolved three weeks later How often 
did you image the patient?  
 
 
If gas was till present for almost 3 weeks, but patient improved with in a shorter periof time, do 
you believe that antibiotics should be standard post procedure for what duration if the target is 
such a large lesion?  
 
 
The elevation of alkaline phospahtase is very high and usually not that high in patient with liver 
induced i schemic injury? What is your explanation? Gallbladder injury?  
 
 
How long did i take fo rthe ALP to drop back to normal.  
 
 
Do you have any additional recommendation regarding the embolization procedure with 
Embozene for larger lesions, like in your case to pr event the same presentation with 
complications?  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comme nts to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical r eview?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the man uscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any  other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
This is a single case and authors report with the term sublimation the formation of gas in the 
tissue of a large focal nodular hyperplasia that underwent Embozene mic rospheres embolization.  
 
 
Although they could only speculate about the gas formation physiology, there was significant 
necrosis of the lesion and possible injury to non lesional liver tissue as the patient suffered from 
fever, pain and significant elevation  of liver enzymes, all of which improved with time, IV fluids 
and broad spectrum antibiotics. The gas formation took 3 weeks to resolve. There was no fluid 
within the lesion, so abscess was excluded. No sampling of the gas tissue was done for infectious 
purposes.  
 
 
The authors discuss two issues: teh sublimation and expectant strategy ( non surgical). First, the 
reason for sublimation is unknown. The expectant approach is routine in similar cases of 
malignancy that undergo the TACE procedure.  
 
 
The authors al so blamed acute cholecystitis for part of the symptoms and the patient underwent 
cholecystectomy 6 weeks later, but no details were provided about the pathology of the 
gallbladder. In summary, interesting case, but no major contribution to those who manage  
patients post arterial embolization together with the interventional radiologists.  
 
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named repo rt 
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understan d that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Tissue sublimation follow transarterial embolization of a follicular nodular hyperplasia of  
the liver. Report of a case  
 
Version: 0 Date: 27 Feb 2017  
 
Reviewer: Daniel R. Ganger  
 
Reviewer's report:  
 
Please provide imaging obtained on day 1 post TACE.  
 
 
Please provide or comment on the pathology of the gallbladder removed 6 weeks later.  
 
 
You state that patient left 12 days post procedure in good condition with resolution of symptoms 
and improvement or normalization of liver tests. The gas resolved three weeks later How often 
did you image the patient?  
 
 
If gas was till present for almost 3 weeks, but patient improved with in a shorter periof time, do 
you believe that antibiotics should be standard post procedure for what duration if the target is 
such a large lesion?  
 
 
The elevation of alkaline phospahtase is very high and usually not that high in patient with liver 
induced i schemic injury? What is your explanation? Gallbladder injury?  
 
 
How long did i take fo rthe ALP to drop back to normal.  
 
 
Do you have any additional recommendation regarding the embolization procedure with 
Embozene for larger lesions, like in your case to pr event the same presentation with 
complications?  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comme nts to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical r eview?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the man uscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any  other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
This is a single case and authors report with the term sublimation the formation of gas in the 
tissue of a large focal nodular hyperplasia that underwent Embozene mic rospheres embolization.  
 
 
Although they could only speculate about the gas formation physiology, there was significant 
necrosis of the lesion and possible injury to non lesional liver tissue as the patient suffered from 
fever, pain and significant elevation  of liver enzymes, all of which improved with time, IV fluids 
and broad spectrum antibiotics. The gas formation took 3 weeks to resolve. There was no fluid 
within the lesion, so abscess was excluded. No sampling of the gas tissue was done for infectious 
purposes.  
 
 
The authors discuss two issues: teh sublimation and expectant strategy ( non surgical). First, the 
reason for sublimation is unknown. The expectant approach is routine in similar cases of 
malignancy that undergo the TACE procedure.  
 
 
The authors al so blamed acute cholecystitis for part of the symptoms and the patient underwent 
cholecystectomy 6 weeks later, but no details were provided about the pathology of the 
gallbladder. In summary, interesting case, but no major contribution to those who manage  
patients post arterial embolization together with the interventional radiologists.  
 
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named repo rt 
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understan d that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant