Can Emax and platelet count truly differentiate between benign and malignant liver lesions?

Abstract

This letter critically evaluates Jiang et al's article on the differentiation of benign and malignant liver lesions using Emax and platelet count. Despite notable findings, significant methodological and interpretative limitations are identified. The study lacks detailed assay conditions for Emax measurement, employs inadequate statistical methods without robust multivariate analysis, and does not provide clinically relevant threshold values. The nomogram's reliance on Emax as a major diagnostic contributor is questionable due to attenuation in hepatocellular carcinoma patients with cirrhosis. Moreover, the study's limitations, such as selection bias and confounding factors, are not adequately addressed. Future research should adopt more rigorous methodologies, including prospective studies with larger cohorts and standardized protocols for biomarker measurement, to enhance validity and clinical applicability.

Key Words: Emax; Platelet count; Benign liver lesions; Malignant liver lesions; Hepatocellular carcinoma; Cirrhosis; Diagnostic biomarkers; Shear wave elastography; Methodological limitations; Clinical utility

Core Tip: This letter critically analyzes the Jiang et al's study to differentiate benign and malignant liver lesions using Emax and platelet count, but faces critical methodological issues. The lack of transparency in Emax measurement, inadequate control for confounding variables, and absence of clinically relevant thresholds limit the study’s practical applicability. The nomogram's heavy reliance on Emax is questionable due to its attenuation in hepatocellular carcinoma patients with cirrhosis, further confounding the results. Future research should employ rigorous methodologies, including larger, diverse cohorts and standardized protocols, to validate these biomarkers' clinical utility and ensure their reliability in practice.

TO THE EDITOR

We have reviewed with keen interest the recent article by Jiang et al[1], published in the World Journal of Gastroenterology, which investigated the differentiation of benign and malignant liver lesions using Emax and platelet count. While the study provided noteworthy findings, it also embodied significant methodological and interpretative limitations that need addressing to validate the conclusions drawn[1].

The article underscored the significance of Emax and platelet count as discriminative parameters between benign and malignant liver lesions. However, there was a conspicuous lack of detail regarding the specific methodologies employed to measure Emax. The omission of precise assay conditions, calibration standards, and control measures raises concerns about the reproducibility and accuracy of the findings. Such transparency is essential for ensuring the reliability of the results presented.

Statistically, the study's approach to analyzing the data invites scrutiny. The reported significant differences in Emax and platelet count between the benign and malignant groups are compelling. Nonetheless, the statistical methods employed did not adequately control for potential confounding variables. The absence of a robust multivariate analysis to adjust for these confounders undermined the validity of the reported associations. Given the study's small sample size, risks of type I and type II errors are markedly elevated, casting doubt on the purported statistical significance of the findings.

From a clinical perspective, the study fell short of establishing the practical applicability of Emax and platelet count as diagnostic tools. The authors failed to provide clinically relevant threshold values for these parameters, which limited their utility in real-world settings. Without clear cut-off points that clinicians can use to differentiate between benign and malignant lesions, the study's findings remain of limited practical value.

The nomogram generated in the study identified Emax of the tumors as the single largest contributor to the diagnostic model. However, this parameter is likely to be attenuated in patients with hepatocellular carcinoma, particularly those with underlying cirrhosis. The significant difference in cirrhosis prevalence between the two groups further complicated the interpretation of Emax as a reliable marker, as cirrhosis itself can influence liver stiffness measurements, potentially confounding the results.

Unfortunately, the limitations of the study were not adequately discussed. The potential biases introduced by the heterogeneity of the patient population, selection bias inherent in retrospective analyses, and the influence of concurrent medications and comorbidities on Emax and platelet count were not considered. Yet, these factors are critical as they could significantly confound the study's results and interpretations.

For future research, it is imperative to adopt a more rigorous methodological framework. Prospective studies with larger and more diverse cohorts, employing comprehensive multivariate analyses, are essential to confirm the findings. Moreover, establishing standardized protocols for measuring Emax and platelet count will enhance the reproducibility and clinical applicability of these biomarkers.

In conclusion, while Jiang et al's study[1] provides valuable insights into the differentiation of liver lesions using Emax and platelet count, significant methodological and interpretive issues must be addressed. We encourage the authors to consider these limitations and recommendations in future research endeavors to strengthen the validity and clinical relevance of their findings.