We read with great interest the recently published study written by Kim and colleagues entitled “Sarcopenia with systemic inflammation can predict survival in patients with hepatocellular carcinoma undergoing curative resection” (1), which was published in the Journal of Gastrointestinal Oncology. The authors showed that sarcopenia and a high platelet lymphocyte ratio (PLR) were both significantly associated with poor OS. While we applaud the encouraging findings, some issues need to be addressed.
To begin with, after a careful review, we noticed that the authors appeared to have made some typographic mistakes in the article. Tab. 1 was listed to show the main characteristics of the patients in the sarcopenia (n=74) and non-sarcopenia (n=86) groups in this article. In fact, the number of the non-sarcopenia group is 85 not 86. Meanwhile, there is an obvious typographic error in Tab. 1, in which the Child-Pugh score with B of the sarcopenia group is 4 but not 1. What’s more, in the results section of survival analysis, the authors claimed that histology grades 3–4 (HR: 2.56, 95% CI: 1.043–2.631, P=0.033) were significantly associated with poor RFS. But in Tab. 2, the HR of histology grade 3–4 is 2.656. Moreover, as shown in Tab. 3, sarcopenia (HR: 0.026, 95% CI: 1.092–4.142, P=0.026). The HR of sarcopenia is 2.127 in Tab. 3.
Second, we think the title of this article “Sarcopenia with systemic inflammation can predict survival in patients with hepatocellular carcinoma undergoing curative resection” can be ambiguous. There are many representative blood markers of systemic inflammation including neutrophil-lymphocyte ratio, lymphocyte-to-monocyte ratio, and platelet lymphocyte ratio (2). The authors chose PLR to represent systemic inflammation and the readers may think that systemic inflammation is significantly associated with cancer survival, while actually, the authors intended to demonstrate the PLR. A better description may be “Sarcopenia with elevated platelet lymphocyte ratio can predict survival in patients with hepatocellular carcinoma after curative resection”. We suggest the title shall be transformed to reduce misinterpretation.
Third, we noticed that the BMI is significantly difference between sarcopenia and non-sarcopenia groups. The author chose the cut-off values for skeletal muscle index (SMI) defined as 52.4 cm2/m2 for men and 38.5 cm2/m2 for women (3). We recommend the authors to choose optimal stratification to select BMI and sex-specific cutoffs for SMI to define sarcopenia according to Feliciano et al.’s study (4). For BMI <30, these were less than 52.4 cm2/m2 for men and less than 38.5 cm2/m2 for women, while for BMI ≥30, these were less than 54 cm2/m2 for men and less than 47 cm2/m2 for women (4).
Finally, the cut-off value for PLR was established to be >132 with an area under the curve of 0.647 using time-dependent ROC curve analyses based on the peak, and cut-off points for OS rates were not presented. We suggest that the investigators provide the ROC curve in supplementary materials. What’s more, the survival curve will be clearer if it is expressed in different colors in Figs. 3,4.
We acknowledge the authors for their contribution in supplying us with a study to examine the predicted value of a combination of PLR and sarcopenia survival for patients with hepatocellular carcinoma. In our opinion, furthermore well-designed studies with a large sample size are still needed to further validate these findings.
Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-604/coif). The authors have no conflicts of interest to declare.
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- Kim H, Choi HZ, Choi JM, et al. Sarcopenia with systemic inflammation can predict survival in patients with hepatocellular carcinoma undergoing curative resection. J Gastrointest Oncol 2022;13:744-53. [Crossref] [PubMed]
- Hirahara T, Arigami T, Yanagita S, et al. Combined neutrophil-lymphocyte ratio and platelet-lymphocyte ratio predicts chemotherapy response and prognosis in patients with advanced gastric cancer. BMC Cancer 2019;19:672. [Crossref] [PubMed]
- Kamachi S, Mizuta T, Otsuka T, et al. Sarcopenia is a risk factor for the recurrence of hepatocellular carcinoma after curative treatment. Hepatol Res 2016;46:201-8. [Crossref] [PubMed]
- Feliciano EMC, Kroenke CH, Meyerhardt JA, et al. Association of Systemic Inflammation and Sarcopenia With Survival in Nonmetastatic Colorectal Cancer: Results From the C SCANS Study. JAMA Oncol 2017;3:e172319. [Crossref] [PubMed]