Title: A single-center prospective study evaluating the usefulness of artificial intelligence for
the diagnosis of esophageal squamous cell carcinoma in a real-time setting
Version: 1 Date: 23 Mar 2023
Reviewer:  Atsushi Imagawa
Reviewer's report:
This study is to evaluate the usefulness of an AI system for real-time diagnosis of esophageal
squamous cell carcinoma (ESCC) in a clinical setting. This study is a clinical study with negative
results. However, the design and method of this study is fine and excellent. Furthermore, the
study results are very interesting, indicating the problems with endoscopic diagnosis by AI at
the current stage. There were a few points that were a little confusing, so I think corrections and
additional descriptions would be desirable.
Minor points
1#Determination of Sample Size
The pre-assumed frequency of target lesions was 46% (160/350), but the actual frequency was
62% (237/380).
Is this due to a different patients or situation from the previous study? Or as you describe in
the discussion, does the difference in frequency of cancer affect the difference in frequency of
target lesions?
Do you have any considerations?
If you have additional comments, please add them.
2. Is there any factor such as peristalsis of the esophagus, presence of mucus, patient's reflexes,
etc. that may have contributed to the poor accuracy of the AI systems in this result in the real-
time endoscopic procedure?
3. If possible, please add discussions of the results of the subgroup analysis. For example, why
is the accuracy inferior by -10% with AI systems for lesions larger than 10mm?
Title: A single-center prospective study evaluating the usefulness of artificial intelligence for
the diagnosis of esophageal squamous cell carcinoma in a real-time setting
Version: 1 Date: 23 Mar 2023
Reviewer:  Atsushi Imagawa
Reviewer's report:
This study is to evaluate the usefulness of an AI system for real-time diagnosis of esophageal
squamous cell carcinoma (ESCC) in a clinical setting. This study is a clinical study with negative
results. However, the design and method of this study is fine and excellent. Furthermore, the
study results are very interesting, indicating the problems with endoscopic diagnosis by AI at
the current stage. There were a few points that were a little confusing, so I think corrections and
additional descriptions would be desirable.
Minor points
1#Determination of Sample Size
The pre-assumed frequency of target lesions was 46% (160/350), but the actual frequency was
62% (237/380).
Is this due to a different patients or situation from the previous study? Or as you describe in
the discussion, does the difference in frequency of cancer affect the difference in frequency of
target lesions?
Do you have any considerations?
If you have additional comments, please add them.
2. Is there any factor such as peristalsis of the esophagus, presence of mucus, patient's reflexes,
etc. that may have contributed to the poor accuracy of the AI systems in this result in the real-
time endoscopic procedure?
3. If possible, please add discussions of the results of the subgroup analysis. For example, why
is the accuracy inferior by -10% with AI systems for lesions larger than 10mm?
Please review this paper.
user
Title: A single-center prospective study evaluating the usefulness of artificial intelligence for
the diagnosis of esophageal squamous cell carcinoma in a real-time setting
Version: 1 Date: 23 Mar 2023
Reviewer:  Atsushi Imagawa
Reviewer's report:
This study is to evaluate the usefulness of an AI system for real-time diagnosis of esophageal
squamous cell carcinoma (ESCC) in a clinical setting. This study is a clinical study with negative
results. However, the design and method of this study is fine and excellent. Furthermore, the
study results are very interesting, indicating the problems with endoscopic diagnosis by AI at
the current stage. There were a few points that were a little confusing, so I think corrections and
additional descriptions would be desirable.
Minor points
1#Determination of Sample Size
The pre-assumed frequency of target lesions was 46% (160/350), but the actual frequency was
62% (237/380).
Is this due to a different patients or situation from the previous study? Or as you describe in
the discussion, does the difference in frequency of cancer affect the difference in frequency of
target lesions?
Do you have any considerations?
If you have additional comments, please add them.
2. Is there any factor such as peristalsis of the esophagus, presence of mucus, patient's reflexes,
etc. that may have contributed to the poor accuracy of the AI systems in this result in the real-
time endoscopic procedure?
3. If possible, please add discussions of the results of the subgroup analysis. For example, why
is the accuracy inferior by -10% with AI systems for lesions larger than 10mm?
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