Reviewer ’s report  
 
Title: Pancreatic hamartoma: A case report and literature review.  
 
Version: 0 Date: 13 Sep 2015  
 
Reviewer: Cindy  Neuzillet  
 
Reviewer's report:  
 
The authors report the case of a 68 year -old man with a pancreatic tumor with initial benign 
presentation, who required surgery due to an increase in tumor size and suspicion of IPMN with 
malignant transform ation. The tumor was classified as a pancreatic hamartoma based on its 
histological description (mature adipose tissue and colonization of dilated pancreatic ducts with 
mild fibrosis).  
The case is clearly exposed and well illustrated.  
However, I have some  concerns regarding the clinical management and the final diagnosis :  
 
MAJOR CONCERNS  
- Regarding the initial case presentation (first paragraph): the authors describe the lesion at 
imaging but do not provide their initial diagnostic hypothesis to justify h ow they managed 
the patient.  
Can the authors indicate what was their initial diagnosis? They indicate in the next paragraph 
that they had a suspicion of IPMN with malignant transformation. Was the lesion compatible 
with benign IPMN at baseline imaging? Wa s there a communication between the cysts and the 
pancreatic ducts at MRI that could have supported this diagnosis? If not, based on what criteria 
did they decide to follow -up the patient? If the nature of the lesion was uncertain and given its 
size > 3 cm , a biopsy under EUS could have been discussed: did the authors considered this 
option and can they explain why they decided not to perform a biopsy at this stage to support 
them in a non -invasive therapeutic strategy?  
- In the second paragraph of case pr esentation: can the authors discussed why they decided to 
go directly to surgery and not to perform a biopsy at this stage (benefit/risk balance of the 
biopsy given the morbidity/mortality of the surgical procedure vs. risk of sample bias, fear of 
biopsy c omplication such as pancreatitis or tumor cell dissemination, typical aspect of the 
lesion on imaging…)?  
- Regarding the final diagnosis of hamartoma: the histological description of the lesion is not 
typical of a hamartoma; it seems very uncommon in other  reported cases to observe such an 
abundant adipose component within the lesion. Can the authors comment on this? Were there 
other cases in the literature of hamartoma with similar aspect of predominant adipose tissue? 
If not, the conclusion should not be so affirmative (when describing pancreatic hamartoma as 
"mature adipose tissue and fibrosis"). We agree that a lipoma does not typically present with 
trapped ducts inside the lesion and is not the most probable diagnosis. However, this 
presentation may be compatible with a lipomatous pseudohypertrophy (example of reported 
cases: Altinel D et al, Pancreas 2010; Shimada M et al, Case Reports in Gastroenterology 
2010), a differential diagnosis that the authors do not discuss. Could the authors comment on 
this?  Can they add a paragraph in the discussion about this differential diagnosis? Can they 
provide the results of the CD34 and CD117 immunostaining that are typically positive in 
hamartoma to reinforce their diagnosis?  
 
MINOR CONCERNS  
- The first paragraph o f the discussion is redundant with the introduction and may be deleted.  
- The table 2 is quite buzzy. It would be valuable if the authors add a bottom line to summarize 
the data (median age, sex ratio, % of cases in the pancreatic head/body/tail, median si ze, % of 
positive cases for each feature…) of each column.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not , please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the man uscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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 s hares 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.  
 
I declare that I have no competing interests  
 
I agree to the open peer r eview policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors'  
responses. 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/ ). I understand that any comments 
which I do not wish to be included in my named report can be included a s confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Pancreatic hamartoma: A case report and literature review.  
 
Version: 0 Date: 13 Sep 2015  
 
Reviewer: Cindy  Neuzillet  
 
Reviewer's report:  
 
The authors report the case of a 68 year -old man with a pancreatic tumor with initial benign 
presentation, who required surgery due to an increase in tumor size and suspicion of IPMN with 
malignant transform ation. The tumor was classified as a pancreatic hamartoma based on its 
histological description (mature adipose tissue and colonization of dilated pancreatic ducts with 
mild fibrosis).  
The case is clearly exposed and well illustrated.  
However, I have some  concerns regarding the clinical management and the final diagnosis :  
 
MAJOR CONCERNS  
- Regarding the initial case presentation (first paragraph): the authors describe the lesion at 
imaging but do not provide their initial diagnostic hypothesis to justify h ow they managed 
the patient.  
Can the authors indicate what was their initial diagnosis? They indicate in the next paragraph 
that they had a suspicion of IPMN with malignant transformation. Was the lesion compatible 
with benign IPMN at baseline imaging? Wa s there a communication between the cysts and the 
pancreatic ducts at MRI that could have supported this diagnosis? If not, based on what criteria 
did they decide to follow -up the patient? If the nature of the lesion was uncertain and given its 
size > 3 cm , a biopsy under EUS could have been discussed: did the authors considered this 
option and can they explain why they decided not to perform a biopsy at this stage to support 
them in a non -invasive therapeutic strategy?  
- In the second paragraph of case pr esentation: can the authors discussed why they decided to 
go directly to surgery and not to perform a biopsy at this stage (benefit/risk balance of the 
biopsy given the morbidity/mortality of the surgical procedure vs. risk of sample bias, fear of 
biopsy c omplication such as pancreatitis or tumor cell dissemination, typical aspect of the 
lesion on imaging…)?  
- Regarding the final diagnosis of hamartoma: the histological description of the lesion is not 
typical of a hamartoma; it seems very uncommon in other  reported cases to observe such an 
abundant adipose component within the lesion. Can the authors comment on this? Were there 
other cases in the literature of hamartoma with similar aspect of predominant adipose tissue? 
If not, the conclusion should not be so affirmative (when describing pancreatic hamartoma as 
"mature adipose tissue and fibrosis"). We agree that a lipoma does not typically present with 
trapped ducts inside the lesion and is not the most probable diagnosis. However, this 
presentation may be compatible with a lipomatous pseudohypertrophy (example of reported 
cases: Altinel D et al, Pancreas 2010; Shimada M et al, Case Reports in Gastroenterology 
2010), a differential diagnosis that the authors do not discuss. Could the authors comment on 
this?  Can they add a paragraph in the discussion about this differential diagnosis? Can they 
provide the results of the CD34 and CD117 immunostaining that are typically positive in 
hamartoma to reinforce their diagnosis?  
 
MINOR CONCERNS  
- The first paragraph o f the discussion is redundant with the introduction and may be deleted.  
- The table 2 is quite buzzy. It would be valuable if the authors add a bottom line to summarize 
the data (median age, sex ratio, % of cases in the pancreatic head/body/tail, median si ze, % of 
positive cases for each feature…) of each column.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not , please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the man uscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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 s hares 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.  
 
I declare that I have no competing interests  
 
I agree to the open peer r eview policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors'  
responses. 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/ ). I understand that any comments 
which I do not wish to be included in my named report can be included a s confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Pancreatic hamartoma: A case report and literature review.  
 
Version: 0 Date: 13 Sep 2015  
 
Reviewer: Cindy  Neuzillet  
 
Reviewer's report:  
 
The authors report the case of a 68 year -old man with a pancreatic tumor with initial benign 
presentation, who required surgery due to an increase in tumor size and suspicion of IPMN with 
malignant transform ation. The tumor was classified as a pancreatic hamartoma based on its 
histological description (mature adipose tissue and colonization of dilated pancreatic ducts with 
mild fibrosis).  
The case is clearly exposed and well illustrated.  
However, I have some  concerns regarding the clinical management and the final diagnosis :  
 
MAJOR CONCERNS  
- Regarding the initial case presentation (first paragraph): the authors describe the lesion at 
imaging but do not provide their initial diagnostic hypothesis to justify h ow they managed 
the patient.  
Can the authors indicate what was their initial diagnosis? They indicate in the next paragraph 
that they had a suspicion of IPMN with malignant transformation. Was the lesion compatible 
with benign IPMN at baseline imaging? Wa s there a communication between the cysts and the 
pancreatic ducts at MRI that could have supported this diagnosis? If not, based on what criteria 
did they decide to follow -up the patient? If the nature of the lesion was uncertain and given its 
size > 3 cm , a biopsy under EUS could have been discussed: did the authors considered this 
option and can they explain why they decided not to perform a biopsy at this stage to support 
them in a non -invasive therapeutic strategy?  
- In the second paragraph of case pr esentation: can the authors discussed why they decided to 
go directly to surgery and not to perform a biopsy at this stage (benefit/risk balance of the 
biopsy given the morbidity/mortality of the surgical procedure vs. risk of sample bias, fear of 
biopsy c omplication such as pancreatitis or tumor cell dissemination, typical aspect of the 
lesion on imaging…)?  
- Regarding the final diagnosis of hamartoma: the histological description of the lesion is not 
typical of a hamartoma; it seems very uncommon in other  reported cases to observe such an 
abundant adipose component within the lesion. Can the authors comment on this? Were there 
other cases in the literature of hamartoma with similar aspect of predominant adipose tissue? 
If not, the conclusion should not be so affirmative (when describing pancreatic hamartoma as 
"mature adipose tissue and fibrosis"). We agree that a lipoma does not typically present with 
trapped ducts inside the lesion and is not the most probable diagnosis. However, this 
presentation may be compatible with a lipomatous pseudohypertrophy (example of reported 
cases: Altinel D et al, Pancreas 2010; Shimada M et al, Case Reports in Gastroenterology 
2010), a differential diagnosis that the authors do not discuss. Could the authors comment on 
this?  Can they add a paragraph in the discussion about this differential diagnosis? Can they 
provide the results of the CD34 and CD117 immunostaining that are typically positive in 
hamartoma to reinforce their diagnosis?  
 
MINOR CONCERNS  
- The first paragraph o f the discussion is redundant with the introduction and may be deleted.  
- The table 2 is quite buzzy. It would be valuable if the authors add a bottom line to summarize 
the data (median age, sex ratio, % of cases in the pancreatic head/body/tail, median si ze, % of 
positive cases for each feature…) of each column.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not , please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the man uscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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 s hares 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.  
 
I declare that I have no competing interests  
 
I agree to the open peer r eview policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors'  
responses. 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/ ). I understand that any comments 
which I do not wish to be included in my named report can be included a s confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant