Reviewer's report 
 Duodenal Metastases from Renal Cell Carcinoma Presenting as Gastrointestinal Bleeding: Two Case Title: 
Reports and a Review of the Literature 
 1  15 November 2006 Version: Date: 
 Myriam Delhaye Reviewer: 
Reviewer's report: 
General 
The authors report two observations of uncommon presentation of metastatic renal cell carcinoma as upper 
gastrointestinal haemorrhage. 
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Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 1. The authors should be careful in considering the duodenum as the site of metastases rather than the 
more likely pancreatic metastases invading the duodenal wall and causing bleeding. 
Indeed, Figure 1 is inadequate to show a normal head of the pancreas, Figure 2A is showing numerous pancreatic metastases and Figure 3 (case 2) is demonstrating a large mass in the area of the pancreatic head protruding into the duodenum suggesting the diagnosis of pancreatic metastasis. 
Maybe the title should be changed accordingly. 
2. With regard to case 2, the authors should emphasize that surgical resection of pancreatic/duodenal 
metastasis (by duodenopancreatectomy) should be considered when possible (see their reference 17). Indeed, when metastases are limited to the pancreas, surgery can provide 31% 5-year survival rate as 
compared to 9% for metastatic RCC (Faure et al, J Urol 2001; 165: 20-22; Maldazy JD et al, J Urol 1986; 
136: 376-379). ------------------------------------------------------------------------------- Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
1. Introduction, p. 4, l. 2: one or more references could be added at the end of the sentence related to metastasis to the small intestine in RCC, causing gastrointestinal bleeding. 2. Case 1 (p. 5): CLO should be written in full as campylobacter-like organisms the first time it appears in 
the text. 
3. Discussion, p. 11, first sentence: reference 17 reported a case of bleeding due to a pancreatic metastasis 
invading the duodenum and not a duodenal metastasis. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
1. Four upper gastrointestinal endoscopies were necessary during a period of 3 months to achieve the correct diagnosis in case 1 despite the presence of blood in the duodenum. Maybe endoscopy using a lateral viewing duodenoscope would have been useful in such cases when there is suspicion of bleeding 
originating from the periampullary region. 
2. Endoscopic and pathologic (with immunohistochemical staining) pictures could be interesting. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Reviewer's report 
 Duodenal Metastases from Renal Cell Carcinoma Presenting as Gastrointestinal Bleeding: Two Case Title: 
Reports and a Review of the Literature 
 1  15 November 2006 Version: Date: 
 Myriam Delhaye Reviewer: 
Reviewer's report: 
General 
The authors report two observations of uncommon presentation of metastatic renal cell carcinoma as upper 
gastrointestinal haemorrhage. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 1. The authors should be careful in considering the duodenum as the site of metastases rather than the 
more likely pancreatic metastases invading the duodenal wall and causing bleeding. 
Indeed, Figure 1 is inadequate to show a normal head of the pancreas, Figure 2A is showing numerous pancreatic metastases and Figure 3 (case 2) is demonstrating a large mass in the area of the pancreatic head protruding into the duodenum suggesting the diagnosis of pancreatic metastasis. 
Maybe the title should be changed accordingly. 
2. With regard to case 2, the authors should emphasize that surgical resection of pancreatic/duodenal 
metastasis (by duodenopancreatectomy) should be considered when possible (see their reference 17). Indeed, when metastases are limited to the pancreas, surgery can provide 31% 5-year survival rate as 
compared to 9% for metastatic RCC (Faure et al, J Urol 2001; 165: 20-22; Maldazy JD et al, J Urol 1986; 
136: 376-379). ------------------------------------------------------------------------------- Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
1. Introduction, p. 4, l. 2: one or more references could be added at the end of the sentence related to metastasis to the small intestine in RCC, causing gastrointestinal bleeding. 2. Case 1 (p. 5): CLO should be written in full as campylobacter-like organisms the first time it appears in 
the text. 
3. Discussion, p. 11, first sentence: reference 17 reported a case of bleeding due to a pancreatic metastasis 
invading the duodenum and not a duodenal metastasis. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
1. Four upper gastrointestinal endoscopies were necessary during a period of 3 months to achieve the correct diagnosis in case 1 despite the presence of blood in the duodenum. Maybe endoscopy using a lateral viewing duodenoscope would have been useful in such cases when there is suspicion of bleeding 
originating from the periampullary region. 
2. Endoscopic and pathologic (with immunohistochemical staining) pictures could be interesting. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Please review this paper.
user
Reviewer's report 
 Duodenal Metastases from Renal Cell Carcinoma Presenting as Gastrointestinal Bleeding: Two Case Title: 
Reports and a Review of the Literature 
 1  15 November 2006 Version: Date: 
 Myriam Delhaye Reviewer: 
Reviewer's report: 
General 
The authors report two observations of uncommon presentation of metastatic renal cell carcinoma as upper 
gastrointestinal haemorrhage. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 1. The authors should be careful in considering the duodenum as the site of metastases rather than the 
more likely pancreatic metastases invading the duodenal wall and causing bleeding. 
Indeed, Figure 1 is inadequate to show a normal head of the pancreas, Figure 2A is showing numerous pancreatic metastases and Figure 3 (case 2) is demonstrating a large mass in the area of the pancreatic head protruding into the duodenum suggesting the diagnosis of pancreatic metastasis. 
Maybe the title should be changed accordingly. 
2. With regard to case 2, the authors should emphasize that surgical resection of pancreatic/duodenal 
metastasis (by duodenopancreatectomy) should be considered when possible (see their reference 17). Indeed, when metastases are limited to the pancreas, surgery can provide 31% 5-year survival rate as 
compared to 9% for metastatic RCC (Faure et al, J Urol 2001; 165: 20-22; Maldazy JD et al, J Urol 1986; 
136: 376-379). ------------------------------------------------------------------------------- Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author 
can be trusted to correct) 
1. Introduction, p. 4, l. 2: one or more references could be added at the end of the sentence related to metastasis to the small intestine in RCC, causing gastrointestinal bleeding. 2. Case 1 (p. 5): CLO should be written in full as campylobacter-like organisms the first time it appears in 
the text. 
3. Discussion, p. 11, first sentence: reference 17 reported a case of bleeding due to a pancreatic metastasis 
invading the duodenum and not a duodenal metastasis. 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
1. Four upper gastrointestinal endoscopies were necessary during a period of 3 months to achieve the correct diagnosis in case 1 despite the presence of blood in the duodenum. Maybe endoscopy using a lateral viewing duodenoscope would have been useful in such cases when there is suspicion of bleeding 
originating from the periampullary region. 
2. Endoscopic and pathologic (with immunohistochemical staining) pictures could be interesting. 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
assistant