Title: Causes of endoscopic misdiagnosis of gastrointestinal cyst as solid lesion
Version: 2 Date: 02 Jul 2022
Reviewer's report:
Comments to Author:
The author examined the causes of endoscopic misdiagnosis of gastrointestinal cyst and reported
the importance of EUS diagnosis. While this is a novel retrospective study focused on cyst, there
are several serious concerns to be resolved.
Major concerns:
1. This study focused on SMT in which the final diagnosis is the cyst, and examined the
differences in diagnostic performance of each factor, such as EUS and texture. I think this
method can calculate only sensitivity; however, the author calculated the sensitivity, specificity,
PPV, NPV, and accuracy. How did the author calculate these values?
2. This method may provide information on factors that improve the sensitivity to diagnose cysts
but does not reveal any useful factors for differential diagnosis. To solve this issue, it is necessary
to examine the diagnostic performance of each modality for all SMT, including non-cysts.
3. As the author mentioned, cysts do not need to be resected. There are 12 cases that were
correctly diagnosed as cysts preoperatively. What is the reason these lesions were resected?
4. There are many cases in which EUS and forceps palpation are not performed; the evaluation
method is not standardized. Considering that this is a study of a small number of cases, this is
a significant bias.
5. The final diagnosis was made by two definitions: 1. fluid outflow in endoscopic incision of
tumor or postoperative specimen; 2. pathological diagnosis of postoperative specimen was cyst.
Does this mean that there are cases where cysts are diagnosed only by fluid outflow?
6. As preoperative diagnosis, boring biopsy and EUS-FNA are important modality to improve
the diagnostic performance. What is the reason these modalities have not been examined?
7. How many endoscopists were evaluated for these cases? How many cases were excluded?
Please describe Methods in more detail.
8. Since this study does not examine EUS-FNA, this should not be mentioned in Conclusion.  If
you want to describe the usefulness of EUS-FNA from previous studies, you should do in the
Discussion paragraph.
Minor concerns:
1. Please show the flow chart of this study participants for better understanding.
Title: Causes of endoscopic misdiagnosis of gastrointestinal cyst as solid lesion
Version: 2 Date: 02 Jul 2022
Reviewer's report:
Comments to Author:
The author examined the causes of endoscopic misdiagnosis of gastrointestinal cyst and reported
the importance of EUS diagnosis. While this is a novel retrospective study focused on cyst, there
are several serious concerns to be resolved.
Major concerns:
1. This study focused on SMT in which the final diagnosis is the cyst, and examined the
differences in diagnostic performance of each factor, such as EUS and texture. I think this
method can calculate only sensitivity; however, the author calculated the sensitivity, specificity,
PPV, NPV, and accuracy. How did the author calculate these values?
2. This method may provide information on factors that improve the sensitivity to diagnose cysts
but does not reveal any useful factors for differential diagnosis. To solve this issue, it is necessary
to examine the diagnostic performance of each modality for all SMT, including non-cysts.
3. As the author mentioned, cysts do not need to be resected. There are 12 cases that were
correctly diagnosed as cysts preoperatively. What is the reason these lesions were resected?
4. There are many cases in which EUS and forceps palpation are not performed; the evaluation
method is not standardized. Considering that this is a study of a small number of cases, this is
a significant bias.
5. The final diagnosis was made by two definitions: 1. fluid outflow in endoscopic incision of
tumor or postoperative specimen; 2. pathological diagnosis of postoperative specimen was cyst.
Does this mean that there are cases where cysts are diagnosed only by fluid outflow?
6. As preoperative diagnosis, boring biopsy and EUS-FNA are important modality to improve
the diagnostic performance. What is the reason these modalities have not been examined?
7. How many endoscopists were evaluated for these cases? How many cases were excluded?
Please describe Methods in more detail.
8. Since this study does not examine EUS-FNA, this should not be mentioned in Conclusion.  If
you want to describe the usefulness of EUS-FNA from previous studies, you should do in the
Discussion paragraph.
Minor concerns:
1. Please show the flow chart of this study participants for better understanding.
Please review this paper.
user
Title: Causes of endoscopic misdiagnosis of gastrointestinal cyst as solid lesion
Version: 2 Date: 02 Jul 2022
Reviewer's report:
Comments to Author:
The author examined the causes of endoscopic misdiagnosis of gastrointestinal cyst and reported
the importance of EUS diagnosis. While this is a novel retrospective study focused on cyst, there
are several serious concerns to be resolved.
Major concerns:
1. This study focused on SMT in which the final diagnosis is the cyst, and examined the
differences in diagnostic performance of each factor, such as EUS and texture. I think this
method can calculate only sensitivity; however, the author calculated the sensitivity, specificity,
PPV, NPV, and accuracy. How did the author calculate these values?
2. This method may provide information on factors that improve the sensitivity to diagnose cysts
but does not reveal any useful factors for differential diagnosis. To solve this issue, it is necessary
to examine the diagnostic performance of each modality for all SMT, including non-cysts.
3. As the author mentioned, cysts do not need to be resected. There are 12 cases that were
correctly diagnosed as cysts preoperatively. What is the reason these lesions were resected?
4. There are many cases in which EUS and forceps palpation are not performed; the evaluation
method is not standardized. Considering that this is a study of a small number of cases, this is
a significant bias.
5. The final diagnosis was made by two definitions: 1. fluid outflow in endoscopic incision of
tumor or postoperative specimen; 2. pathological diagnosis of postoperative specimen was cyst.
Does this mean that there are cases where cysts are diagnosed only by fluid outflow?
6. As preoperative diagnosis, boring biopsy and EUS-FNA are important modality to improve
the diagnostic performance. What is the reason these modalities have not been examined?
7. How many endoscopists were evaluated for these cases? How many cases were excluded?
Please describe Methods in more detail.
8. Since this study does not examine EUS-FNA, this should not be mentioned in Conclusion.  If
you want to describe the usefulness of EUS-FNA from previous studies, you should do in the
Discussion paragraph.
Minor concerns:
1. Please show the flow chart of this study participants for better understanding.
assistant