Title: Optimizing LI-RADS: Ancillary features screened from LR-3/4 categories can improve
the diagnosis of HCC on MRI
Version: 1 Date: 06 Jan 2024
Reviewer:  Sidong Xie
Reviewer's report:
This study has a certain degree of innovation, exploring the high-efficiency auxiliary features
(AFs) screened from LR-3/4 lesions and the HCC/non-HCC group to optimize LI-RADS v2018,
with the hope of improving MRI diagnosis of early small liver cancer or atypical liver cancer.
Although the result of the study showed that the sensitivity increased from 33.2% (MFs) to
53.4% or 56.4% for HCC, and the specificity increased from 52.8% (MFs) to 74.5% or 77.2%,
there are five independently signifcant AFs, and their clinical application maybe not very
convenient.The methodology is not very clear, and there are many inadequacies in this study
that need to be revised.
1. In the section of Reference standard# as to “typical imaging features: 82 lesions in 79
patients were enrolled, most of the lesions with typical MRI findings of hepatic hemangioma
and transient enhancement focus.”, are you sure that so many hepatic hemangioma and transient
enhancement focus were classified as LR-3 or LR-4? In LI-RADS, most of hepatic hemangioma
and transient enhancement with focus typical imaging features are classified as LR-1 or LR-2.
2. In the section of MRI examination, the study included two contrast agent, one is non liver
cell specific contrast agent, and the other is liver cell specific contrast agent. For the evaluation
indicator TP and HBP, the former is not applicable and the article does not mention how to
handle it specifically.
3. In the section of Image analysis, “For lesions with only malignant AFs, it was upgraded; for
lesions with only benign AFs, it was degraded; and for lesions with both malignant and benign
AFs, it was not modified.”, This statement is not clear enough#for lesions with only malignant
AFs, is it possible to upgrade directly from LR-3 or LR-4 to LR-5?
4. Among 311 HCCs, when using LI-RADSv2018 for classification, what are the respectively
specific classifications of LR-3, LR-4, and LR-5? Not mentioned in the text.
5. In Figure 1, flowchart of study population#the number of cases is confused with the number
of lesions, which is inconsistent with the description in the text.
6. In Table 1, some parameters with multiple classifications have incorrect expression of P-
values.
7. In Table 1, "APF * *" should be "AFP * *".
8. In Table 2, what statistical differences do the first column P values refer to for comparison?
What statistical difference does the second column P value refer to for comparison? Why do
some project columns have three P-values while others only have one P-value?
9. In Table 2 and Table 5, the former is LR-3less (n=153), LR-4less (n=129), LR-5less (n=191),
while the latter is LR-3less (n=133), LR-4less (n=149). Why is the data inconsistent between the
two?, The sensitivity and specificity of the calculations in Table 5 are also difficult to understand.
Please verify if there are any errors in the data calculations?
10. In Figure 2, Are you sure that the image of (e) is HBP pahse? Why are the blood vessels still
bright, the biliary tract not visualized. The nodule show T1-weight hyperintensity on precontrast,
it is difficult to determine whether there is high enhancement during the arterial phase, I suggest
using the silhouette method to determine. And , the image of (c) and (d) had been swapped. The
lesion in the portal venous phase (PVP) showed washout and capsule sign which is classifed
as LR-4 in LI-RADS v2018 with MFs. The image of (f) is TP hypointensity, but not “TP
hyperintensity”.
11. In Figure 3, The identification code of the image was also mistaken, this lesion looks like a
circular hyperenhancement in the arterial phase, do you consider categorizing it as LR-M#
12. In the section of Frequency of major and ancillary features, in the sentence of "To ensure the
accuracy of the results, in this study, "threshold growth", "threshold growth", ...”, the "threshold
growth" is repeated.
13. At the end of the article, “This study has the following two limitations: 1. There is insufficient
research on LR-5 AFs...”, the article only has one limitation?, and “the LI-5 category” should
be “the LR-5 category”
Title: Optimizing LI-RADS: Ancillary features screened from LR-3/4 categories can improve
the diagnosis of HCC on MRI
Version: 1 Date: 06 Jan 2024
Reviewer:  Sidong Xie
Reviewer's report:
This study has a certain degree of innovation, exploring the high-efficiency auxiliary features
(AFs) screened from LR-3/4 lesions and the HCC/non-HCC group to optimize LI-RADS v2018,
with the hope of improving MRI diagnosis of early small liver cancer or atypical liver cancer.
Although the result of the study showed that the sensitivity increased from 33.2% (MFs) to
53.4% or 56.4% for HCC, and the specificity increased from 52.8% (MFs) to 74.5% or 77.2%,
there are five independently signifcant AFs, and their clinical application maybe not very
convenient.The methodology is not very clear, and there are many inadequacies in this study
that need to be revised.
1. In the section of Reference standard# as to “typical imaging features: 82 lesions in 79
patients were enrolled, most of the lesions with typical MRI findings of hepatic hemangioma
and transient enhancement focus.”, are you sure that so many hepatic hemangioma and transient
enhancement focus were classified as LR-3 or LR-4? In LI-RADS, most of hepatic hemangioma
and transient enhancement with focus typical imaging features are classified as LR-1 or LR-2.
2. In the section of MRI examination, the study included two contrast agent, one is non liver
cell specific contrast agent, and the other is liver cell specific contrast agent. For the evaluation
indicator TP and HBP, the former is not applicable and the article does not mention how to
handle it specifically.
3. In the section of Image analysis, “For lesions with only malignant AFs, it was upgraded; for
lesions with only benign AFs, it was degraded; and for lesions with both malignant and benign
AFs, it was not modified.”, This statement is not clear enough#for lesions with only malignant
AFs, is it possible to upgrade directly from LR-3 or LR-4 to LR-5?
4. Among 311 HCCs, when using LI-RADSv2018 for classification, what are the respectively
specific classifications of LR-3, LR-4, and LR-5? Not mentioned in the text.
5. In Figure 1, flowchart of study population#the number of cases is confused with the number
of lesions, which is inconsistent with the description in the text.
6. In Table 1, some parameters with multiple classifications have incorrect expression of P-
values.
7. In Table 1, "APF * *" should be "AFP * *".
8. In Table 2, what statistical differences do the first column P values refer to for comparison?
What statistical difference does the second column P value refer to for comparison? Why do
some project columns have three P-values while others only have one P-value?
9. In Table 2 and Table 5, the former is LR-3less (n=153), LR-4less (n=129), LR-5less (n=191),
while the latter is LR-3less (n=133), LR-4less (n=149). Why is the data inconsistent between the
two?, The sensitivity and specificity of the calculations in Table 5 are also difficult to understand.
Please verify if there are any errors in the data calculations?
10. In Figure 2, Are you sure that the image of (e) is HBP pahse? Why are the blood vessels still
bright, the biliary tract not visualized. The nodule show T1-weight hyperintensity on precontrast,
it is difficult to determine whether there is high enhancement during the arterial phase, I suggest
using the silhouette method to determine. And , the image of (c) and (d) had been swapped. The
lesion in the portal venous phase (PVP) showed washout and capsule sign which is classifed
as LR-4 in LI-RADS v2018 with MFs. The image of (f) is TP hypointensity, but not “TP
hyperintensity”.
11. In Figure 3, The identification code of the image was also mistaken, this lesion looks like a
circular hyperenhancement in the arterial phase, do you consider categorizing it as LR-M#
12. In the section of Frequency of major and ancillary features, in the sentence of "To ensure the
accuracy of the results, in this study, "threshold growth", "threshold growth", ...”, the "threshold
growth" is repeated.
13. At the end of the article, “This study has the following two limitations: 1. There is insufficient
research on LR-5 AFs...”, the article only has one limitation?, and “the LI-5 category” should
be “the LR-5 category”
Please review this paper.
user
Title: Optimizing LI-RADS: Ancillary features screened from LR-3/4 categories can improve
the diagnosis of HCC on MRI
Version: 1 Date: 06 Jan 2024
Reviewer:  Sidong Xie
Reviewer's report:
This study has a certain degree of innovation, exploring the high-efficiency auxiliary features
(AFs) screened from LR-3/4 lesions and the HCC/non-HCC group to optimize LI-RADS v2018,
with the hope of improving MRI diagnosis of early small liver cancer or atypical liver cancer.
Although the result of the study showed that the sensitivity increased from 33.2% (MFs) to
53.4% or 56.4% for HCC, and the specificity increased from 52.8% (MFs) to 74.5% or 77.2%,
there are five independently signifcant AFs, and their clinical application maybe not very
convenient.The methodology is not very clear, and there are many inadequacies in this study
that need to be revised.
1. In the section of Reference standard# as to “typical imaging features: 82 lesions in 79
patients were enrolled, most of the lesions with typical MRI findings of hepatic hemangioma
and transient enhancement focus.”, are you sure that so many hepatic hemangioma and transient
enhancement focus were classified as LR-3 or LR-4? In LI-RADS, most of hepatic hemangioma
and transient enhancement with focus typical imaging features are classified as LR-1 or LR-2.
2. In the section of MRI examination, the study included two contrast agent, one is non liver
cell specific contrast agent, and the other is liver cell specific contrast agent. For the evaluation
indicator TP and HBP, the former is not applicable and the article does not mention how to
handle it specifically.
3. In the section of Image analysis, “For lesions with only malignant AFs, it was upgraded; for
lesions with only benign AFs, it was degraded; and for lesions with both malignant and benign
AFs, it was not modified.”, This statement is not clear enough#for lesions with only malignant
AFs, is it possible to upgrade directly from LR-3 or LR-4 to LR-5?
4. Among 311 HCCs, when using LI-RADSv2018 for classification, what are the respectively
specific classifications of LR-3, LR-4, and LR-5? Not mentioned in the text.
5. In Figure 1, flowchart of study population#the number of cases is confused with the number
of lesions, which is inconsistent with the description in the text.
6. In Table 1, some parameters with multiple classifications have incorrect expression of P-
values.
7. In Table 1, "APF * *" should be "AFP * *".
8. In Table 2, what statistical differences do the first column P values refer to for comparison?
What statistical difference does the second column P value refer to for comparison? Why do
some project columns have three P-values while others only have one P-value?
9. In Table 2 and Table 5, the former is LR-3less (n=153), LR-4less (n=129), LR-5less (n=191),
while the latter is LR-3less (n=133), LR-4less (n=149). Why is the data inconsistent between the
two?, The sensitivity and specificity of the calculations in Table 5 are also difficult to understand.
Please verify if there are any errors in the data calculations?
10. In Figure 2, Are you sure that the image of (e) is HBP pahse? Why are the blood vessels still
bright, the biliary tract not visualized. The nodule show T1-weight hyperintensity on precontrast,
it is difficult to determine whether there is high enhancement during the arterial phase, I suggest
using the silhouette method to determine. And , the image of (c) and (d) had been swapped. The
lesion in the portal venous phase (PVP) showed washout and capsule sign which is classifed
as LR-4 in LI-RADS v2018 with MFs. The image of (f) is TP hypointensity, but not “TP
hyperintensity”.
11. In Figure 3, The identification code of the image was also mistaken, this lesion looks like a
circular hyperenhancement in the arterial phase, do you consider categorizing it as LR-M#
12. In the section of Frequency of major and ancillary features, in the sentence of "To ensure the
accuracy of the results, in this study, "threshold growth", "threshold growth", ...”, the "threshold
growth" is repeated.
13. At the end of the article, “This study has the following two limitations: 1. There is insufficient
research on LR-5 AFs...”, the article only has one limitation?, and “the LI-5 category” should
be “the LR-5 category”
assistant