Reviewer ’s report  
 
Title: Undifferentiated carcinoma with osteoclast -like giant cells of the pancreas harboring 
KRAS  and BRCA mutations: case repo rt and whole exome sequencing analysis  
 
Version: 1 Date: 27 Mar 2020  
 
Reviewer: Alessia Nottegar  
 
Reviewer's report:  
 
I read with interest such paper, which contains useful information for the readers, but at the same 
time must be improved in several parts, before re -considering it for publication.  
 
-The Authors' statament in the Abstract: "To date, although sporadic cases worldwide had been 
reported, it is still lack of comprehensive research about it, especially on molecular features from 
whole exome sequencing analysis." must be changed, since the paper of Luchini C., et al 
(Journal of Pathology, 2017, PMID: 28722124. Reference n.15 of the current manuscript), is a 
whole -exome sequencing (WES) -based paper, reporting data from 22 tumors, 8 of which 
analyzed with this NGS methodology. Thus, the author s here can just say that "to date, only one 
paper reported data from whole -exome sequencing on this tumor entity"…."and this current 
paper aims at providing novel insights on the molecular landscape of these tumors". Along this 
line, in the discussion the authors stated: "The whole exome sequencing of eight UC -OGC 
patients showed the genetic alterations in UC -OGC were similar to those known to drive 
conventional PDAC[16 -19]". But here the correct reference is number 15 and not 16 -19, which 
are not the repor t of the 8 WES -analyzed tumors, but represent only potential references showing 
the current knowledge on the molecular landscape of pancreatic cancer. Since the previous WES 
paper (Luchini C, et al, J Pathol 2017) also showed the same SERPINA3 mutations in  25% of 
the analyzed cases, the authors should verify the eventual presence of mutations affecting 
SERPINA family -genes and related pathways, and should discuss also this feature in the 
Discussion section. A similar consideration regards GLI3 gene and the related hedgehog 
pathway.  
 
-The statement in the results section: "Also the WES result indicated microsatellite stabilization 
(MSS) and the tumor mutational burden (TMB) was low." should be changed with this or 
similar: "the tumor did not show microsatell ite instability and did not present a high -tumor 
mutational burden.". Microsatellite stabilization is not an existing terminology. These indexes 
(MSI and TMB) and their implications, which are strongly correlated with a good response to 
immunotherapy, shou ld be better discussed in the Discussion section, also in the light of a recent 
paper on this topic, which investigated the very same tumor type (Luchini C. et al, Human Pathol 
2018, PMID: 30031096).  
 
 
 
 
-The role of PARP -inhibitors and platinum -based chemoth erapy in patients with BRCA -mutated 
pancreatic cancer should be better highlighted and discuss in the Discussion section, also in the 
light of the paper by Waddell N. et al., Nature 2015, PMID: 25719666, which is the reference 40 
of the current manuscript,  and of the paper by Golan, et al. New Engl J Med 2019, PMID: 
31157963.  
 
-Please write in italic -uppercase all the name of genes.  
 
-Please change the conclusions, where there is a very controversial and wrong statement: 
"current data regarding this malignant  neoplasm is limited and inconclusive.". Indeed, Muraki et 
al. (Am J Surg Pathol, ref. number 3 of the current paper) and Luchini, et al. (J Pathol, ref. 
number 15 of the current paper) have already clarified that "pure" UCOGC have a better 
prognosis than UCOGC associated with a conventional ductal component. Furthermore, Luchini, 
et al. (J Pathol, ref. number 15 of the current paper) have clarified that UCOGC are a real variant 
of conventional ductal adenocarcinoma, demonstrating their similarities with wh ole-exome 
sequencing. Lastly, Luchini et al. (Human Pathology 2018, PMID: 30031096) have clarified that 
inflammatory cells, like CD163 -positive macrophages, are important in determining the peculiar 
morphology of UCOGC. Thus, current data are not limited a nd not inconclusive. Please change 
this wrong statement, taking advantages from these considerations.  
 
-English language must be drastically improved by a native speaker.  
 
Minor:  
_current reference number 15 appears wrongly written. Please fix it, writing  correctly the 
reference as per Journal requirements.  
 
 
 
 
 
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 co ntrols are required in your comments to the authors.  
 
Yes 
 
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 manuscript or would you recom mend 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:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in t he 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 organisat ion 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 reimbursemen ts, 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 t his 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 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 ag ree 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 as confidential c omments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Undifferentiated carcinoma with osteoclast -like giant cells of the pancreas harboring 
KRAS  and BRCA mutations: case repo rt and whole exome sequencing analysis  
 
Version: 1 Date: 27 Mar 2020  
 
Reviewer: Alessia Nottegar  
 
Reviewer's report:  
 
I read with interest such paper, which contains useful information for the readers, but at the same 
time must be improved in several parts, before re -considering it for publication.  
 
-The Authors' statament in the Abstract: "To date, although sporadic cases worldwide had been 
reported, it is still lack of comprehensive research about it, especially on molecular features from 
whole exome sequencing analysis." must be changed, since the paper of Luchini C., et al 
(Journal of Pathology, 2017, PMID: 28722124. Reference n.15 of the current manuscript), is a 
whole -exome sequencing (WES) -based paper, reporting data from 22 tumors, 8 of which 
analyzed with this NGS methodology. Thus, the author s here can just say that "to date, only one 
paper reported data from whole -exome sequencing on this tumor entity"…."and this current 
paper aims at providing novel insights on the molecular landscape of these tumors". Along this 
line, in the discussion the authors stated: "The whole exome sequencing of eight UC -OGC 
patients showed the genetic alterations in UC -OGC were similar to those known to drive 
conventional PDAC[16 -19]". But here the correct reference is number 15 and not 16 -19, which 
are not the repor t of the 8 WES -analyzed tumors, but represent only potential references showing 
the current knowledge on the molecular landscape of pancreatic cancer. Since the previous WES 
paper (Luchini C, et al, J Pathol 2017) also showed the same SERPINA3 mutations in  25% of 
the analyzed cases, the authors should verify the eventual presence of mutations affecting 
SERPINA family -genes and related pathways, and should discuss also this feature in the 
Discussion section. A similar consideration regards GLI3 gene and the related hedgehog 
pathway.  
 
-The statement in the results section: "Also the WES result indicated microsatellite stabilization 
(MSS) and the tumor mutational burden (TMB) was low." should be changed with this or 
similar: "the tumor did not show microsatell ite instability and did not present a high -tumor 
mutational burden.". Microsatellite stabilization is not an existing terminology. These indexes 
(MSI and TMB) and their implications, which are strongly correlated with a good response to 
immunotherapy, shou ld be better discussed in the Discussion section, also in the light of a recent 
paper on this topic, which investigated the very same tumor type (Luchini C. et al, Human Pathol 
2018, PMID: 30031096).  
 
 
 
 
-The role of PARP -inhibitors and platinum -based chemoth erapy in patients with BRCA -mutated 
pancreatic cancer should be better highlighted and discuss in the Discussion section, also in the 
light of the paper by Waddell N. et al., Nature 2015, PMID: 25719666, which is the reference 40 
of the current manuscript,  and of the paper by Golan, et al. New Engl J Med 2019, PMID: 
31157963.  
 
-Please write in italic -uppercase all the name of genes.  
 
-Please change the conclusions, where there is a very controversial and wrong statement: 
"current data regarding this malignant  neoplasm is limited and inconclusive.". Indeed, Muraki et 
al. (Am J Surg Pathol, ref. number 3 of the current paper) and Luchini, et al. (J Pathol, ref. 
number 15 of the current paper) have already clarified that "pure" UCOGC have a better 
prognosis than UCOGC associated with a conventional ductal component. Furthermore, Luchini, 
et al. (J Pathol, ref. number 15 of the current paper) have clarified that UCOGC are a real variant 
of conventional ductal adenocarcinoma, demonstrating their similarities with wh ole-exome 
sequencing. Lastly, Luchini et al. (Human Pathology 2018, PMID: 30031096) have clarified that 
inflammatory cells, like CD163 -positive macrophages, are important in determining the peculiar 
morphology of UCOGC. Thus, current data are not limited a nd not inconclusive. Please change 
this wrong statement, taking advantages from these considerations.  
 
-English language must be drastically improved by a native speaker.  
 
Minor:  
_current reference number 15 appears wrongly written. Please fix it, writing  correctly the 
reference as per Journal requirements.  
 
 
 
 
 
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 co ntrols are required in your comments to the authors.  
 
Yes 
 
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 manuscript or would you recom mend 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:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in t he 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 organisat ion 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 reimbursemen ts, 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 t his 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 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 ag ree 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 as confidential c omments  
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: Undifferentiated carcinoma with osteoclast -like giant cells of the pancreas harboring 
KRAS  and BRCA mutations: case repo rt and whole exome sequencing analysis  
 
Version: 1 Date: 27 Mar 2020  
 
Reviewer: Alessia Nottegar  
 
Reviewer's report:  
 
I read with interest such paper, which contains useful information for the readers, but at the same 
time must be improved in several parts, before re -considering it for publication.  
 
-The Authors' statament in the Abstract: "To date, although sporadic cases worldwide had been 
reported, it is still lack of comprehensive research about it, especially on molecular features from 
whole exome sequencing analysis." must be changed, since the paper of Luchini C., et al 
(Journal of Pathology, 2017, PMID: 28722124. Reference n.15 of the current manuscript), is a 
whole -exome sequencing (WES) -based paper, reporting data from 22 tumors, 8 of which 
analyzed with this NGS methodology. Thus, the author s here can just say that "to date, only one 
paper reported data from whole -exome sequencing on this tumor entity"…."and this current 
paper aims at providing novel insights on the molecular landscape of these tumors". Along this 
line, in the discussion the authors stated: "The whole exome sequencing of eight UC -OGC 
patients showed the genetic alterations in UC -OGC were similar to those known to drive 
conventional PDAC[16 -19]". But here the correct reference is number 15 and not 16 -19, which 
are not the repor t of the 8 WES -analyzed tumors, but represent only potential references showing 
the current knowledge on the molecular landscape of pancreatic cancer. Since the previous WES 
paper (Luchini C, et al, J Pathol 2017) also showed the same SERPINA3 mutations in  25% of 
the analyzed cases, the authors should verify the eventual presence of mutations affecting 
SERPINA family -genes and related pathways, and should discuss also this feature in the 
Discussion section. A similar consideration regards GLI3 gene and the related hedgehog 
pathway.  
 
-The statement in the results section: "Also the WES result indicated microsatellite stabilization 
(MSS) and the tumor mutational burden (TMB) was low." should be changed with this or 
similar: "the tumor did not show microsatell ite instability and did not present a high -tumor 
mutational burden.". Microsatellite stabilization is not an existing terminology. These indexes 
(MSI and TMB) and their implications, which are strongly correlated with a good response to 
immunotherapy, shou ld be better discussed in the Discussion section, also in the light of a recent 
paper on this topic, which investigated the very same tumor type (Luchini C. et al, Human Pathol 
2018, PMID: 30031096).  
 
 
 
 
-The role of PARP -inhibitors and platinum -based chemoth erapy in patients with BRCA -mutated 
pancreatic cancer should be better highlighted and discuss in the Discussion section, also in the 
light of the paper by Waddell N. et al., Nature 2015, PMID: 25719666, which is the reference 40 
of the current manuscript,  and of the paper by Golan, et al. New Engl J Med 2019, PMID: 
31157963.  
 
-Please write in italic -uppercase all the name of genes.  
 
-Please change the conclusions, where there is a very controversial and wrong statement: 
"current data regarding this malignant  neoplasm is limited and inconclusive.". Indeed, Muraki et 
al. (Am J Surg Pathol, ref. number 3 of the current paper) and Luchini, et al. (J Pathol, ref. 
number 15 of the current paper) have already clarified that "pure" UCOGC have a better 
prognosis than UCOGC associated with a conventional ductal component. Furthermore, Luchini, 
et al. (J Pathol, ref. number 15 of the current paper) have clarified that UCOGC are a real variant 
of conventional ductal adenocarcinoma, demonstrating their similarities with wh ole-exome 
sequencing. Lastly, Luchini et al. (Human Pathology 2018, PMID: 30031096) have clarified that 
inflammatory cells, like CD163 -positive macrophages, are important in determining the peculiar 
morphology of UCOGC. Thus, current data are not limited a nd not inconclusive. Please change 
this wrong statement, taking advantages from these considerations.  
 
-English language must be drastically improved by a native speaker.  
 
Minor:  
_current reference number 15 appears wrongly written. Please fix it, writing  correctly the 
reference as per Journal requirements.  
 
 
 
 
 
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 co ntrols are required in your comments to the authors.  
 
Yes 
 
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 manuscript or would you recom mend 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:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in t he 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 organisat ion 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 reimbursemen ts, 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 t his 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 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 ag ree 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 as confidential c omments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant