Reviewer's report 
 A case of sigmoid endometriosis difficult to differentiate from colon cancer Title: 
Authors: 
Philippos Dimoulios ( fdimoul@hotmail.com )
Dr Ioannis E Koutroubakis ( ktjohn@her.forthnet.gr )
Maria Tzardi ( tzardi_maria@yahoo.uk )
Dr Pavlos Antoniou ( pantoniou_gr@yahoo.com )
Ioannis M Matalliotakis ( matalliotakis@hotmail.com )
Prof Elias A Kouroumalis ( kouroum@med.uoc.gr )
 1  5 Jun 2003 Version: Date: 
 Tatsuya Harada Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Major concerns 
The paper showed the difficulties to differentiate between colonal endometriosis and colon cancer, 
and the successful treatment for colonal endometriosis by GnRH analogue. Unfortunately, there are significant problems in this case report as described below. 
1) Authors should clearly provide what are similar or different findings of this case compared to 
typical colon cancer. That is to say what kind of findings obtained from various examinations, CT, MRI, ultrasonograph, colonoscopy and blood sample data, containing tumor markers, blood cell 
counts and biochemical study, are important to diagnose. I think it has not been clarified. You have 
to emphasize the differences between this case and colon cancer. 2) Therefore, the reason you have chosen GnRHa analogue for treatment of endometriosis in this case is not clear. Although a GnRH analogue is one of popular treatment methods for 
endometriosis, the recurrence rate is not low. Authors have to generalize your opinions about the 
treatments for intestinal. 
Minor concerns 
3) P4, L2: What kind of pain did the patient have as "dysmenorrhea"? You should write that. 
4) P4, L3: You have written " Her mother and her brother were healthy", but you should clarify 
whether or not her mother has complicated with endometriosis or myoma uteri. 
5) P4, L7-8: I think laboratory data proved inflammatory status in the patient because of an 
increased white blood cell count and ESR. Do you think what is the cause of inflammation? I'd like to 
hear your thought about this problem. 
6) P4, L4-18: What time of menstrual cycle date you obtained the records, especially serum level of 
CA125 and biopsies by colonoscopy, is not shown. You have to show that. 
7) P4, L22: If you examined, you should show other tumor markers, like CA19-9 and CEA, which are 
thought to be elevated in patients with colon cancer. 
8) P4, L23: The details of laparoscopic findings were not shown. Was this patient diagnosed as 
"Stage IV endometriosis" according to American Fertility Society classification? You have to show 
more detailed information. Therefore, most of cases with stage IV endometriosis have chocolate 
cysts. In this case, whether are chocolate cysts present or not? If this patient was complicated with 
chocolate cysts, you should write the findings of CT, MRI and ultrasonograph about this disease. 
9) P4: You have to show the gynecological findings you have investigated by vaginal examination and ultrasonograph. 10) P4: You should provide the pictures of barium enema in figures. 
11) P5, L3-6: You did not demonstrate whether the serum CA125 level was decreased or not after 
GnRHa treatment. If you think the increase of serum CA125 level was caused by endometriosis, you should produce the data after treatment. 12) P6, L20-21: Although You have written "... that was finally confirmed during the laparoscopy", 
you can comfirm only serosal endometriosis. Do you think whether endometriosis invade from 
serosa to mucosal layer through colonal wall or metastasize to mucosa, like neoplasm, in this case? 
You should write your thought about this problem in discussion. 
Compulsory revisions:1,2,6,8,10,11,12 
Discretionary revisions:3,4,5,7,9 
Competing interests: 
None declared. 
Reviewer's report 
 A case of sigmoid endometriosis difficult to differentiate from colon cancer Title: 
Authors: 
Philippos Dimoulios ( fdimoul@hotmail.com )
Dr Ioannis E Koutroubakis ( ktjohn@her.forthnet.gr )
Maria Tzardi ( tzardi_maria@yahoo.uk )
Dr Pavlos Antoniou ( pantoniou_gr@yahoo.com )
Ioannis M Matalliotakis ( matalliotakis@hotmail.com )
Prof Elias A Kouroumalis ( kouroum@med.uoc.gr )
 1  5 Jun 2003 Version: Date: 
 Tatsuya Harada Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Major concerns 
The paper showed the difficulties to differentiate between colonal endometriosis and colon cancer, 
and the successful treatment for colonal endometriosis by GnRH analogue. Unfortunately, there are significant problems in this case report as described below. 
1) Authors should clearly provide what are similar or different findings of this case compared to 
typical colon cancer. That is to say what kind of findings obtained from various examinations, CT, MRI, ultrasonograph, colonoscopy and blood sample data, containing tumor markers, blood cell 
counts and biochemical study, are important to diagnose. I think it has not been clarified. You have 
to emphasize the differences between this case and colon cancer. 2) Therefore, the reason you have chosen GnRHa analogue for treatment of endometriosis in this case is not clear. Although a GnRH analogue is one of popular treatment methods for 
endometriosis, the recurrence rate is not low. Authors have to generalize your opinions about the 
treatments for intestinal. 
Minor concerns 
3) P4, L2: What kind of pain did the patient have as "dysmenorrhea"? You should write that. 
4) P4, L3: You have written " Her mother and her brother were healthy", but you should clarify 
whether or not her mother has complicated with endometriosis or myoma uteri. 
5) P4, L7-8: I think laboratory data proved inflammatory status in the patient because of an 
increased white blood cell count and ESR. Do you think what is the cause of inflammation? I'd like to 
hear your thought about this problem. 
6) P4, L4-18: What time of menstrual cycle date you obtained the records, especially serum level of 
CA125 and biopsies by colonoscopy, is not shown. You have to show that. 
7) P4, L22: If you examined, you should show other tumor markers, like CA19-9 and CEA, which are 
thought to be elevated in patients with colon cancer. 
8) P4, L23: The details of laparoscopic findings were not shown. Was this patient diagnosed as 
"Stage IV endometriosis" according to American Fertility Society classification? You have to show 
more detailed information. Therefore, most of cases with stage IV endometriosis have chocolate 
cysts. In this case, whether are chocolate cysts present or not? If this patient was complicated with 
chocolate cysts, you should write the findings of CT, MRI and ultrasonograph about this disease. 
9) P4: You have to show the gynecological findings you have investigated by vaginal examination and ultrasonograph. 10) P4: You should provide the pictures of barium enema in figures. 
11) P5, L3-6: You did not demonstrate whether the serum CA125 level was decreased or not after 
GnRHa treatment. If you think the increase of serum CA125 level was caused by endometriosis, you should produce the data after treatment. 12) P6, L20-21: Although You have written "... that was finally confirmed during the laparoscopy", 
you can comfirm only serosal endometriosis. Do you think whether endometriosis invade from 
serosa to mucosal layer through colonal wall or metastasize to mucosa, like neoplasm, in this case? 
You should write your thought about this problem in discussion. 
Compulsory revisions:1,2,6,8,10,11,12 
Discretionary revisions:3,4,5,7,9 
Competing interests: 
None declared. 
Please review this paper.
user
Reviewer's report 
 A case of sigmoid endometriosis difficult to differentiate from colon cancer Title: 
Authors: 
Philippos Dimoulios ( fdimoul@hotmail.com )
Dr Ioannis E Koutroubakis ( ktjohn@her.forthnet.gr )
Maria Tzardi ( tzardi_maria@yahoo.uk )
Dr Pavlos Antoniou ( pantoniou_gr@yahoo.com )
Ioannis M Matalliotakis ( matalliotakis@hotmail.com )
Prof Elias A Kouroumalis ( kouroum@med.uoc.gr )
 1  5 Jun 2003 Version: Date: 
 Tatsuya Harada Reviewer: 
 A paper of limited interest Level of interest: 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
Major concerns 
The paper showed the difficulties to differentiate between colonal endometriosis and colon cancer, 
and the successful treatment for colonal endometriosis by GnRH analogue. Unfortunately, there are significant problems in this case report as described below. 
1) Authors should clearly provide what are similar or different findings of this case compared to 
typical colon cancer. That is to say what kind of findings obtained from various examinations, CT, MRI, ultrasonograph, colonoscopy and blood sample data, containing tumor markers, blood cell 
counts and biochemical study, are important to diagnose. I think it has not been clarified. You have 
to emphasize the differences between this case and colon cancer. 2) Therefore, the reason you have chosen GnRHa analogue for treatment of endometriosis in this case is not clear. Although a GnRH analogue is one of popular treatment methods for 
endometriosis, the recurrence rate is not low. Authors have to generalize your opinions about the 
treatments for intestinal. 
Minor concerns 
3) P4, L2: What kind of pain did the patient have as "dysmenorrhea"? You should write that. 
4) P4, L3: You have written " Her mother and her brother were healthy", but you should clarify 
whether or not her mother has complicated with endometriosis or myoma uteri. 
5) P4, L7-8: I think laboratory data proved inflammatory status in the patient because of an 
increased white blood cell count and ESR. Do you think what is the cause of inflammation? I'd like to 
hear your thought about this problem. 
6) P4, L4-18: What time of menstrual cycle date you obtained the records, especially serum level of 
CA125 and biopsies by colonoscopy, is not shown. You have to show that. 
7) P4, L22: If you examined, you should show other tumor markers, like CA19-9 and CEA, which are 
thought to be elevated in patients with colon cancer. 
8) P4, L23: The details of laparoscopic findings were not shown. Was this patient diagnosed as 
"Stage IV endometriosis" according to American Fertility Society classification? You have to show 
more detailed information. Therefore, most of cases with stage IV endometriosis have chocolate 
cysts. In this case, whether are chocolate cysts present or not? If this patient was complicated with 
chocolate cysts, you should write the findings of CT, MRI and ultrasonograph about this disease. 
9) P4: You have to show the gynecological findings you have investigated by vaginal examination and ultrasonograph. 10) P4: You should provide the pictures of barium enema in figures. 
11) P5, L3-6: You did not demonstrate whether the serum CA125 level was decreased or not after 
GnRHa treatment. If you think the increase of serum CA125 level was caused by endometriosis, you should produce the data after treatment. 12) P6, L20-21: Although You have written "... that was finally confirmed during the laparoscopy", 
you can comfirm only serosal endometriosis. Do you think whether endometriosis invade from 
serosa to mucosal layer through colonal wall or metastasize to mucosa, like neoplasm, in this case? 
You should write your thought about this problem in discussion. 
Compulsory revisions:1,2,6,8,10,11,12 
Discretionary revisions:3,4,5,7,9 
Competing interests: 
None declared. 
assistant