Reviewer’s report
Title: 
Ectopic pancreas 
appearing as a giant gastric cyst mimicking gastric
lymphangioma: a case report and a brief review
Version: 
2 
Date: 
04 Feb 2021
Reviewer's report:
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER: 
Has the author addressed your concerns sufficiently for you to now recommend
the work as a technically sound contribution? No
Reviewer comments: HAVE THE AUTHORS RESPONDED ADEQUATELY
TO EACH OF THE QUESTIONS YOU RAISED IN YOUR COMMENTS
Yes they have answered most but certainly not all the queries
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE
MANUSCRIPT 
I am afraid that many of my suggested changes were either ignored or not
accepted ( inappropriately)
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED
MANUSCRIPT 
This is an interesting case of an EP with an associated oligocystic serous
cystadenoma but too much of the text is meaningless and in many places
incorrect. To be publishable, it will take some serious editing.
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD
MAKE
1. Page 2 line 6. I would delete the last part of the sentence starting from the
word "but". The function is NOT identical (no pancreatic duct etc.) and the local
environment also is not identical. Deleting this part at the send of the sentence
does not in any way alter your report
2. Page 3 line 28. Add the phrase "a typical" before the word "endoscopic" and
add the word "mucosal" after the word "endoscopic".
3. Page 4 line 22 change to 5.5 X 3.8 ". 
One cannot measure endoscopically with
such precision
4. Page 4 line 28 do you really think this had the features of a lymphangioma?
These neoplasms usually have very thin walls. Why not say that it resembled a
GIST tumor with necrosis?
5. Page 4 line 36. I suggest strongly that you reword this section about
performing a Billroth II gastrectomy and say "because of the size, the unknown
pathology, and it's involvement of the antrum whereby an attempt at local
resection would have markedly narrowed the antrum, a decision was made to
perform a distal gastrectomy.
6. Page 4 line 39. I would change this to say that clear transparent fluid was
found in this cystic mass when opened in the pathology laboratory."
7 page 4 line 42 change the word "specimen" to " mass" and line 45 change the
word "in" to "involving"
8. Page 5 lines 6-9. See #1 above - the fact that ref 8 may have said this does not
make it correct!
9. Page 5 lines 34-42 I will again state that this description of the possible origin
of the pain is not in any way evidence based- no matter what ref 10 says. Why
would the patient not have had this pain before? I would just say. "One possible
explanation for the pain was the associated inflammation of the involved tissue"
but remember did the pathologist describe inflammation in histology ? You
haven't mentioned inflammation in the preceding section AND I see no
inflammation on the histology slides you show . If there is no obvious
inflammation I would just say that the cause of the pain is unknown rather than
trying to involve hormones and enzymes as the cause of the pain- honestly I
unless you can demonstrate true inflammation , I do not think you can blame the
pain on the role of enzymes and hormones causing "inflammation ".
10. Page 5 line 50 change the word "stretching" to " involving"
11. Page 6 line 28 did you biopsy the lesion for frozen section BEFORE you did
the gastrectomy? If so what did the biopsy show? If you had a good biopsy you
would have seen the typical small non- mucous columnar epithelial lining of the
cystic lesion. I would delete any reference to frozen section for several reasons.
1).You do not show the histology and 2) it seems like you would not have been
able to do a local resection without narrowing the antral lumen - thus you had to
perform a gastrectomy.
12. Page 6 line 44 this is frankly ridiculous sorry these oligocystic serous
cystadenomas are NOT premalignant and do not require a cancer type operation.
One rare report may have described a malignant cyst adenocarcinoma but 99%
are benign.
13. Page 7 line 20 delete the words "mixed serous" from the phrase "mixed
serous-neuroendocrine tumors" and call them "cystic neuroendocrine neoplasms"
14. Page 7 line 28 there is no such thing as a solid serous cystadenoma- indeed
the last word "cystadenoma" means a cyst ( the CT imaging may appear to show
a solid lesion but on EUS it will have obvious small cystic changes delete this
claim of a "solid cystadenoma". You must be careful and be precise with your
terms
15.page 7 line 34. No the fluid is not similar to serum! The word serous means
clear and neither mucinous, bilious, nor hemorrhagic. Again the words must be
precise
16. Page 8 lime 39 Whalen you say can also present with the above phenomena,
what phenomena are you referring to? A large serous cyst lined by cuboidal
cells- NO. I would delete all of this and just say that gastric lymphomas can
present with pain
17 page 4 line 3 NO! look at the CT--- this is a posterior lesion not an anterior
lesion you need to change this
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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 publication 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 currently applying for any patents relating to the
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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
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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 reviewer has been recruited by a partner organization, Research Square.
Reviewers with declared or apparent competing interests are not utilized for
these reviews. This reviewer has agreed to publication of their comments online
under a Creative Commons Attribution License attributed to Research Square
and was paid a small honorarium for completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
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will not be able to publish your name.
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do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
Ectopic pancreas 
appearing as a giant gastric cyst mimicking gastric
lymphangioma: a case report and a brief review
Version: 
2 
Date: 
04 Feb 2021
Reviewer's report:
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER: 
Has the author addressed your concerns sufficiently for you to now recommend
the work as a technically sound contribution? No
Reviewer comments: HAVE THE AUTHORS RESPONDED ADEQUATELY
TO EACH OF THE QUESTIONS YOU RAISED IN YOUR COMMENTS
Yes they have answered most but certainly not all the queries
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE
MANUSCRIPT 
I am afraid that many of my suggested changes were either ignored or not
accepted ( inappropriately)
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED
MANUSCRIPT 
This is an interesting case of an EP with an associated oligocystic serous
cystadenoma but too much of the text is meaningless and in many places
incorrect. To be publishable, it will take some serious editing.
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD
MAKE
1. Page 2 line 6. I would delete the last part of the sentence starting from the
word "but". The function is NOT identical (no pancreatic duct etc.) and the local
environment also is not identical. Deleting this part at the send of the sentence
does not in any way alter your report
2. Page 3 line 28. Add the phrase "a typical" before the word "endoscopic" and
add the word "mucosal" after the word "endoscopic".
3. Page 4 line 22 change to 5.5 X 3.8 ". 
One cannot measure endoscopically with
such precision
4. Page 4 line 28 do you really think this had the features of a lymphangioma?
These neoplasms usually have very thin walls. Why not say that it resembled a
GIST tumor with necrosis?
5. Page 4 line 36. I suggest strongly that you reword this section about
performing a Billroth II gastrectomy and say "because of the size, the unknown
pathology, and it's involvement of the antrum whereby an attempt at local
resection would have markedly narrowed the antrum, a decision was made to
perform a distal gastrectomy.
6. Page 4 line 39. I would change this to say that clear transparent fluid was
found in this cystic mass when opened in the pathology laboratory."
7 page 4 line 42 change the word "specimen" to " mass" and line 45 change the
word "in" to "involving"
8. Page 5 lines 6-9. See #1 above - the fact that ref 8 may have said this does not
make it correct!
9. Page 5 lines 34-42 I will again state that this description of the possible origin
of the pain is not in any way evidence based- no matter what ref 10 says. Why
would the patient not have had this pain before? I would just say. "One possible
explanation for the pain was the associated inflammation of the involved tissue"
but remember did the pathologist describe inflammation in histology ? You
haven't mentioned inflammation in the preceding section AND I see no
inflammation on the histology slides you show . If there is no obvious
inflammation I would just say that the cause of the pain is unknown rather than
trying to involve hormones and enzymes as the cause of the pain- honestly I
unless you can demonstrate true inflammation , I do not think you can blame the
pain on the role of enzymes and hormones causing "inflammation ".
10. Page 5 line 50 change the word "stretching" to " involving"
11. Page 6 line 28 did you biopsy the lesion for frozen section BEFORE you did
the gastrectomy? If so what did the biopsy show? If you had a good biopsy you
would have seen the typical small non- mucous columnar epithelial lining of the
cystic lesion. I would delete any reference to frozen section for several reasons.
1).You do not show the histology and 2) it seems like you would not have been
able to do a local resection without narrowing the antral lumen - thus you had to
perform a gastrectomy.
12. Page 6 line 44 this is frankly ridiculous sorry these oligocystic serous
cystadenomas are NOT premalignant and do not require a cancer type operation.
One rare report may have described a malignant cyst adenocarcinoma but 99%
are benign.
13. Page 7 line 20 delete the words "mixed serous" from the phrase "mixed
serous-neuroendocrine tumors" and call them "cystic neuroendocrine neoplasms"
14. Page 7 line 28 there is no such thing as a solid serous cystadenoma- indeed
the last word "cystadenoma" means a cyst ( the CT imaging may appear to show
a solid lesion but on EUS it will have obvious small cystic changes delete this
claim of a "solid cystadenoma". You must be careful and be precise with your
terms
15.page 7 line 34. No the fluid is not similar to serum! The word serous means
clear and neither mucinous, bilious, nor hemorrhagic. Again the words must be
precise
16. Page 8 lime 39 Whalen you say can also present with the above phenomena,
what phenomena are you referring to? A large serous cyst lined by cuboidal
cells- NO. I would delete all of this and just say that gastric lymphomas can
present with pain
17 page 4 line 3 NO! look at the CT--- this is a posterior lesion not an anterior
lesion you need to change this
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
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and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
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 publication 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 currently 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 reviewer has been recruited by a partner organization, Research Square.
Reviewers with declared or apparent competing interests are not utilized for
these reviews. This reviewer has agreed to publication of their comments online
under a Creative Commons Attribution License attributed to Research Square
and was paid a small honorarium for completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
Ectopic pancreas 
appearing as a giant gastric cyst mimicking gastric
lymphangioma: a case report and a brief review
Version: 
2 
Date: 
04 Feb 2021
Reviewer's report:
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER: 
Has the author addressed your concerns sufficiently for you to now recommend
the work as a technically sound contribution? No
Reviewer comments: HAVE THE AUTHORS RESPONDED ADEQUATELY
TO EACH OF THE QUESTIONS YOU RAISED IN YOUR COMMENTS
Yes they have answered most but certainly not all the queries
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE
MANUSCRIPT 
I am afraid that many of my suggested changes were either ignored or not
accepted ( inappropriately)
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED
MANUSCRIPT 
This is an interesting case of an EP with an associated oligocystic serous
cystadenoma but too much of the text is meaningless and in many places
incorrect. To be publishable, it will take some serious editing.
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD
MAKE
1. Page 2 line 6. I would delete the last part of the sentence starting from the
word "but". The function is NOT identical (no pancreatic duct etc.) and the local
environment also is not identical. Deleting this part at the send of the sentence
does not in any way alter your report
2. Page 3 line 28. Add the phrase "a typical" before the word "endoscopic" and
add the word "mucosal" after the word "endoscopic".
3. Page 4 line 22 change to 5.5 X 3.8 ". 
One cannot measure endoscopically with
such precision
4. Page 4 line 28 do you really think this had the features of a lymphangioma?
These neoplasms usually have very thin walls. Why not say that it resembled a
GIST tumor with necrosis?
5. Page 4 line 36. I suggest strongly that you reword this section about
performing a Billroth II gastrectomy and say "because of the size, the unknown
pathology, and it's involvement of the antrum whereby an attempt at local
resection would have markedly narrowed the antrum, a decision was made to
perform a distal gastrectomy.
6. Page 4 line 39. I would change this to say that clear transparent fluid was
found in this cystic mass when opened in the pathology laboratory."
7 page 4 line 42 change the word "specimen" to " mass" and line 45 change the
word "in" to "involving"
8. Page 5 lines 6-9. See #1 above - the fact that ref 8 may have said this does not
make it correct!
9. Page 5 lines 34-42 I will again state that this description of the possible origin
of the pain is not in any way evidence based- no matter what ref 10 says. Why
would the patient not have had this pain before? I would just say. "One possible
explanation for the pain was the associated inflammation of the involved tissue"
but remember did the pathologist describe inflammation in histology ? You
haven't mentioned inflammation in the preceding section AND I see no
inflammation on the histology slides you show . If there is no obvious
inflammation I would just say that the cause of the pain is unknown rather than
trying to involve hormones and enzymes as the cause of the pain- honestly I
unless you can demonstrate true inflammation , I do not think you can blame the
pain on the role of enzymes and hormones causing "inflammation ".
10. Page 5 line 50 change the word "stretching" to " involving"
11. Page 6 line 28 did you biopsy the lesion for frozen section BEFORE you did
the gastrectomy? If so what did the biopsy show? If you had a good biopsy you
would have seen the typical small non- mucous columnar epithelial lining of the
cystic lesion. I would delete any reference to frozen section for several reasons.
1).You do not show the histology and 2) it seems like you would not have been
able to do a local resection without narrowing the antral lumen - thus you had to
perform a gastrectomy.
12. Page 6 line 44 this is frankly ridiculous sorry these oligocystic serous
cystadenomas are NOT premalignant and do not require a cancer type operation.
One rare report may have described a malignant cyst adenocarcinoma but 99%
are benign.
13. Page 7 line 20 delete the words "mixed serous" from the phrase "mixed
serous-neuroendocrine tumors" and call them "cystic neuroendocrine neoplasms"
14. Page 7 line 28 there is no such thing as a solid serous cystadenoma- indeed
the last word "cystadenoma" means a cyst ( the CT imaging may appear to show
a solid lesion but on EUS it will have obvious small cystic changes delete this
claim of a "solid cystadenoma". You must be careful and be precise with your
terms
15.page 7 line 34. No the fluid is not similar to serum! The word serous means
clear and neither mucinous, bilious, nor hemorrhagic. Again the words must be
precise
16. Page 8 lime 39 Whalen you say can also present with the above phenomena,
what phenomena are you referring to? A large serous cyst lined by cuboidal
cells- NO. I would delete all of this and just say that gastric lymphomas can
present with pain
17 page 4 line 3 NO! look at the CT--- this is a posterior lesion not an anterior
lesion you need to change this
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
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 publication 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 currently 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 reviewer has been recruited by a partner organization, Research Square.
Reviewers with declared or apparent competing interests are not utilized for
these reviews. This reviewer has agreed to publication of their comments online
under a Creative Commons Attribution License attributed to Research Square
and was paid a small honorarium for completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
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