Reviewer ’s report  
 
Title: Endoscopic ultrasonography with fine -needle aspiration for histological diagnosis of solid 
pancreatic masses: A meta -analysis of diagnostic accuracy studies  
 
 
Version: 0 Date: 17 Nov 2015  
 
 
Reviewer: Giovanni  Maconi  
 
Reviewer's report:  
 
The metanalysis is focused on endoscopic ultrasonography with fine -needle aspiration b iopsy for 
diagnosis of pancreatic masses  
 
1) The term "diagnosis" of pancreatic masses is generic and should be better clarified. Does it 
mean detection or histological diagnosis?  
The authors have collected the data of accuracy for each study (false posit ive, false negative, true 
positive and true negative results), but of what? This should be specified.  
The accuracy of EUS -FNA should be differentiated according to the type of lesion (e.g. accuracy 
in detecting adenocarcinoma, neuroendocrine tumors, masse s in chronic pancreatitis, ...)  
 
2) As acknowledged by the authors, the studies included in the meta -analysis are very 
heterogenous, and the accuracy in each study is associated with specific conditions, such as the 
site of the lesions, the operator experience, the technological advanceme nt (the year of study), 
availability cyto pathologist on -site. All these conditions should be analyzed in the meta -
analysis.  
And, if available, the results presented accordingly  
 
3) The authors have excluded the diagnosis of the cysts from the analysis. T his should be clearly 
stated in the method section and possibily also the reasons for this exclusion. Moreover, it should 
be stated how have been managed the results of those studies where the accuracy of EUS -FNA 
has considered mixed lesions (cysts and mas ses) 
4) Regarding the inclusion criteria the authors considered as the reference standard the "final 
diagnosis obtained by surgical biopsy, histological examination of surgically resected specimen 
or a follow -up period of at least six months"  
This is a ve ry heterogenous reference standard.  
In particular using the follow up at six months, this could have been useful to have a idea about 
some malignant lesions, but in my opinion cannot distinguish clearly between malignan and 
benign lesions, and cannot give  information on histology.  
 
5) The quality of the studies should be analyzed and reported according to the criteria of the 
literature, using standard reference (QUADAS criteria).  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
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 supporte d by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please spe cify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections befo re being published  
 
Declaration of competing interests  
Please comp lete 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 t his 
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 apply ing 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 y es to any, please give details below.  
 
I declare that I have no competing interests . 
 
I agree to the open peer review 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 th at any comments  
which I do not wish to be included in my named report can be included as 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: Endoscopic ultrasonography with fine -needle aspiration for histological diagnosis of solid 
pancreatic masses: A meta -analysis of diagnostic accuracy studies  
 
 
Version: 0 Date: 17 Nov 2015  
 
 
Reviewer: Giovanni  Maconi  
 
Reviewer's report:  
 
The metanalysis is focused on endoscopic ultrasonography with fine -needle aspiration b iopsy for 
diagnosis of pancreatic masses  
 
1) The term "diagnosis" of pancreatic masses is generic and should be better clarified. Does it 
mean detection or histological diagnosis?  
The authors have collected the data of accuracy for each study (false posit ive, false negative, true 
positive and true negative results), but of what? This should be specified.  
The accuracy of EUS -FNA should be differentiated according to the type of lesion (e.g. accuracy 
in detecting adenocarcinoma, neuroendocrine tumors, masse s in chronic pancreatitis, ...)  
 
2) As acknowledged by the authors, the studies included in the meta -analysis are very 
heterogenous, and the accuracy in each study is associated with specific conditions, such as the 
site of the lesions, the operator experience, the technological advanceme nt (the year of study), 
availability cyto pathologist on -site. All these conditions should be analyzed in the meta -
analysis.  
And, if available, the results presented accordingly  
 
3) The authors have excluded the diagnosis of the cysts from the analysis. T his should be clearly 
stated in the method section and possibily also the reasons for this exclusion. Moreover, it should 
be stated how have been managed the results of those studies where the accuracy of EUS -FNA 
has considered mixed lesions (cysts and mas ses) 
4) Regarding the inclusion criteria the authors considered as the reference standard the "final 
diagnosis obtained by surgical biopsy, histological examination of surgically resected specimen 
or a follow -up period of at least six months"  
This is a ve ry heterogenous reference standard.  
In particular using the follow up at six months, this could have been useful to have a idea about 
some malignant lesions, but in my opinion cannot distinguish clearly between malignan and 
benign lesions, and cannot give  information on histology.  
 
5) The quality of the studies should be analyzed and reported according to the criteria of the 
literature, using standard reference (QUADAS criteria).  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
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 supporte d by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please spe cify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections befo re being published  
 
Declaration of competing interests  
Please comp lete 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 t his 
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 apply ing 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 y es to any, please give details below.  
 
I declare that I have no competing interests . 
 
I agree to the open peer review 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 th at any comments  
which I do not wish to be included in my named report can be included as 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: Endoscopic ultrasonography with fine -needle aspiration for histological diagnosis of solid 
pancreatic masses: A meta -analysis of diagnostic accuracy studies  
 
 
Version: 0 Date: 17 Nov 2015  
 
 
Reviewer: Giovanni  Maconi  
 
Reviewer's report:  
 
The metanalysis is focused on endoscopic ultrasonography with fine -needle aspiration b iopsy for 
diagnosis of pancreatic masses  
 
1) The term "diagnosis" of pancreatic masses is generic and should be better clarified. Does it 
mean detection or histological diagnosis?  
The authors have collected the data of accuracy for each study (false posit ive, false negative, true 
positive and true negative results), but of what? This should be specified.  
The accuracy of EUS -FNA should be differentiated according to the type of lesion (e.g. accuracy 
in detecting adenocarcinoma, neuroendocrine tumors, masse s in chronic pancreatitis, ...)  
 
2) As acknowledged by the authors, the studies included in the meta -analysis are very 
heterogenous, and the accuracy in each study is associated with specific conditions, such as the 
site of the lesions, the operator experience, the technological advanceme nt (the year of study), 
availability cyto pathologist on -site. All these conditions should be analyzed in the meta -
analysis.  
And, if available, the results presented accordingly  
 
3) The authors have excluded the diagnosis of the cysts from the analysis. T his should be clearly 
stated in the method section and possibily also the reasons for this exclusion. Moreover, it should 
be stated how have been managed the results of those studies where the accuracy of EUS -FNA 
has considered mixed lesions (cysts and mas ses) 
4) Regarding the inclusion criteria the authors considered as the reference standard the "final 
diagnosis obtained by surgical biopsy, histological examination of surgically resected specimen 
or a follow -up period of at least six months"  
This is a ve ry heterogenous reference standard.  
In particular using the follow up at six months, this could have been useful to have a idea about 
some malignant lesions, but in my opinion cannot distinguish clearly between malignan and 
benign lesions, and cannot give  information on histology.  
 
5) The quality of the studies should be analyzed and reported according to the criteria of the 
literature, using standard reference (QUADAS criteria).  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
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 supporte d by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please spe cify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections befo re being published  
 
Declaration of competing interests  
Please comp lete 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 t his 
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 apply ing 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 y es to any, please give details below.  
 
I declare that I have no competing interests . 
 
I agree to the open peer review 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 th at any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant