Reviewer’s report
Title: 
Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower
gastrointestinal tract approaches
Version: 
0 
Date: 
04 Aug 2020
Reviewer's report:
Retrospective study that expands the indications of EUS-FNA. In this study, the authors show the
feasibility of EUS-FNA of pelvis lesions via an upper approach (mainly from the duodenum but also from
the stomach) with good results and without complications. Since the patients were recruited after CT
showed the location of the lesions in the aortoiliac bifurcation or lower, the retrospective nature of the
study is not an important limitation. However, the series is short and the results need to be validated in
large-scale, well designed studies.
Comments:
Introduction: 
- EUS-FNA is a well established diagnostic technique. There is no need of describing when it was
introduced. References 1 and 2 are very old and can be replaced by some meta-analysis. There are too
many references to studies about performance of EUS-FNA 
- Reference 18: The cited article is a case report with 6 patients in which EUS-FNA of pelvic lesions with
the upper access allows diagnosis in 5. The statement should be tone down.
- Perirectal colorectal cancer recurrence is not uncommon and that has been assessed in the literature but
there is no mention in the study (neither in the introduction nor in the references section).
Methods:
- Inclusion criteria: do we know how many cases with a pelvic lesion in the CT were not send for EUS-
FNA? And if there are some, what was the reason?
- Acquire and EZ shot plus needles have specific designs that allow to obtain tissue samples and are
considered fine needle biopsy (FNB) needles instead of EUS-FNA needles. See the ESGE guideline by
Polkowski et al "Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology:
European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline -March 2017". Endoscopy
2017 Oct;49(10):989-1006. 
Results:
- Could you give more details about how many cases were performed with each type of needle?
- How do you explain that there are not cases with colorectal cancer recurrence in this series?
- 
The results should be presented in an intention-to-treat analysis.
- No need of presenting results of cytology and histology separately in the tables. These two tables can be
replaced by one table showing the results when using EUS-FNA and EUS-FNB needles separately. 
- No need of figures 1 and 2
- Keep figure 3A and eliminate 3B and 3C
- No need of table 3. Explain the results in the text 
Discussion:
- The two first paragraphs in the discussion are a summary of the results and need to be rewritten
- The authors write "Therefore, the size and type of FNA needle should be chosen considering the location
and shape of the EUS scope, lesion size, and operator's experience". Although this is generally the case,
this study shows that a 19G needle almost always provide a diagnosis. Change the redaction of the
paragraph.
- The results of the meta-analysis by Han et al (reference 15) show a low rate of AEs (1.7%, 2/236) but
are not mild (2 cases of abscesses in cystic lesions, 1 case of gross hematuria and 1 case of hemorrhage).
Do they used antibiotics when sampling cystic lesions? Although Han et al considered that the procedure
is safe, I recommend to tone down this sentence.
REFERENCES:
Replace some of the references by some of the following:
- Fernández-Esparrach G et al. Endoscopic ultrasound-guided fine needle aspiration is highly accurate for
the diagnosis of perirectal recurrence of colorectal cancer. Diseases of the Colon & Rectum Volume 58: 5
(2015):469-73
- Rzouq F, Brown J, Fan F, et al. The utility of lower endoscopic ultrasound-guided fine needle aspiration
for the diagnosis of benign and malignant pelvic diseases. J Clin Gastroenterol. 2014;48:127-130.
- Glesson FC, Clain JE, Karnes RJ, et al. Endoscopic-ultrasoundguided tissue sampling facilitates the
detection of local recurrence and extra pelvic metastasis in pelvic urologic malignancies. Diagnostic and
Therapeutic Endoscopy. 2012;2012:219521.
- Gleeson FC, Larson DW, Dozois EJ, et al. Local recurrence detection following transanal excision
facilitated by EUS-FNA . Hepatogastroenterology. 2012;59:1102-1107.
- Gleeson FC, Clain JE, Rajan E, Topazian MD, Wang KK, Levy MJ. EUS-FNA assessment of
extramesenteric lymph node status in primary rectal cancer. Gastrointest Endosc. 2011;74:897-905.
- Boo SJ, Byeon JS, Park do H, et al. EUS-guided fine needle aspiration and trucut needle biopsy for
examination of rectal andperirectal lesions. Scand J Gastroenterol. 2011;46:1510-1518.
- Maleki Z, Erozan Y, Geddes S, Li QK. Endorectal ultrasoundguided fine-needle aspiration: a useful
diagnostic tool for perirectal and intraluminal lesions. Acta Cytol. 2013;57:9-18.
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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 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
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Do you hold or are you currently applying for any patents relating to the content of the manuscript?
4
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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
Reviewer Publication Consent.
 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
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free from apparent
manipulation?
Yes
Reviewer’s report
Title: 
Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower
gastrointestinal tract approaches
Version: 
0 
Date: 
04 Aug 2020
Reviewer's report:
Retrospective study that expands the indications of EUS-FNA. In this study, the authors show the
feasibility of EUS-FNA of pelvis lesions via an upper approach (mainly from the duodenum but also from
the stomach) with good results and without complications. Since the patients were recruited after CT
showed the location of the lesions in the aortoiliac bifurcation or lower, the retrospective nature of the
study is not an important limitation. However, the series is short and the results need to be validated in
large-scale, well designed studies.
Comments:
Introduction: 
- EUS-FNA is a well established diagnostic technique. There is no need of describing when it was
introduced. References 1 and 2 are very old and can be replaced by some meta-analysis. There are too
many references to studies about performance of EUS-FNA 
- Reference 18: The cited article is a case report with 6 patients in which EUS-FNA of pelvic lesions with
the upper access allows diagnosis in 5. The statement should be tone down.
- Perirectal colorectal cancer recurrence is not uncommon and that has been assessed in the literature but
there is no mention in the study (neither in the introduction nor in the references section).
Methods:
- Inclusion criteria: do we know how many cases with a pelvic lesion in the CT were not send for EUS-
FNA? And if there are some, what was the reason?
- Acquire and EZ shot plus needles have specific designs that allow to obtain tissue samples and are
considered fine needle biopsy (FNB) needles instead of EUS-FNA needles. See the ESGE guideline by
Polkowski et al "Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology:
European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline -March 2017". Endoscopy
2017 Oct;49(10):989-1006. 
Results:
- Could you give more details about how many cases were performed with each type of needle?
- How do you explain that there are not cases with colorectal cancer recurrence in this series?
- 
The results should be presented in an intention-to-treat analysis.
- No need of presenting results of cytology and histology separately in the tables. These two tables can be
replaced by one table showing the results when using EUS-FNA and EUS-FNB needles separately. 
- No need of figures 1 and 2
- Keep figure 3A and eliminate 3B and 3C
- No need of table 3. Explain the results in the text 
Discussion:
- The two first paragraphs in the discussion are a summary of the results and need to be rewritten
- The authors write "Therefore, the size and type of FNA needle should be chosen considering the location
and shape of the EUS scope, lesion size, and operator's experience". Although this is generally the case,
this study shows that a 19G needle almost always provide a diagnosis. Change the redaction of the
paragraph.
- The results of the meta-analysis by Han et al (reference 15) show a low rate of AEs (1.7%, 2/236) but
are not mild (2 cases of abscesses in cystic lesions, 1 case of gross hematuria and 1 case of hemorrhage).
Do they used antibiotics when sampling cystic lesions? Although Han et al considered that the procedure
is safe, I recommend to tone down this sentence.
REFERENCES:
Replace some of the references by some of the following:
- Fernández-Esparrach G et al. Endoscopic ultrasound-guided fine needle aspiration is highly accurate for
the diagnosis of perirectal recurrence of colorectal cancer. Diseases of the Colon & Rectum Volume 58: 5
(2015):469-73
- Rzouq F, Brown J, Fan F, et al. The utility of lower endoscopic ultrasound-guided fine needle aspiration
for the diagnosis of benign and malignant pelvic diseases. J Clin Gastroenterol. 2014;48:127-130.
- Glesson FC, Clain JE, Karnes RJ, et al. Endoscopic-ultrasoundguided tissue sampling facilitates the
detection of local recurrence and extra pelvic metastasis in pelvic urologic malignancies. Diagnostic and
Therapeutic Endoscopy. 2012;2012:219521.
- Gleeson FC, Larson DW, Dozois EJ, et al. Local recurrence detection following transanal excision
facilitated by EUS-FNA . Hepatogastroenterology. 2012;59:1102-1107.
- Gleeson FC, Clain JE, Rajan E, Topazian MD, Wang KK, Levy MJ. EUS-FNA assessment of
extramesenteric lymph node status in primary rectal cancer. Gastrointest Endosc. 2011;74:897-905.
- Boo SJ, Byeon JS, Park do H, et al. EUS-guided fine needle aspiration and trucut needle biopsy for
examination of rectal andperirectal lesions. Scand J Gastroenterol. 2011;46:1510-1518.
- Maleki Z, Erozan Y, Geddes S, Li QK. Endorectal ultrasoundguided fine-needle aspiration: a useful
diagnostic tool for perirectal and intraluminal lesions. Acta Cytol. 2013;57:9-18.
Publons Reviewer Recognition
. Springer Nature can send verification of this review directly to Publons
(a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on
the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted to Publons upon
publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt
of this review and update your profile 
as per your settings and their policy. If you are not registered with
Publons, you will receive an email from them asking you to register in order for them to be able to
recognize your review on your new profile page. Publons may use the Review Data to generate derivative
metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such
information. For example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help editors to identify candidate
reviewers. Please find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
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 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 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
Reviewer Publication Consent.
 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
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free from apparent
manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower
gastrointestinal tract approaches
Version: 
0 
Date: 
04 Aug 2020
Reviewer's report:
Retrospective study that expands the indications of EUS-FNA. In this study, the authors show the
feasibility of EUS-FNA of pelvis lesions via an upper approach (mainly from the duodenum but also from
the stomach) with good results and without complications. Since the patients were recruited after CT
showed the location of the lesions in the aortoiliac bifurcation or lower, the retrospective nature of the
study is not an important limitation. However, the series is short and the results need to be validated in
large-scale, well designed studies.
Comments:
Introduction: 
- EUS-FNA is a well established diagnostic technique. There is no need of describing when it was
introduced. References 1 and 2 are very old and can be replaced by some meta-analysis. There are too
many references to studies about performance of EUS-FNA 
- Reference 18: The cited article is a case report with 6 patients in which EUS-FNA of pelvic lesions with
the upper access allows diagnosis in 5. The statement should be tone down.
- Perirectal colorectal cancer recurrence is not uncommon and that has been assessed in the literature but
there is no mention in the study (neither in the introduction nor in the references section).
Methods:
- Inclusion criteria: do we know how many cases with a pelvic lesion in the CT were not send for EUS-
FNA? And if there are some, what was the reason?
- Acquire and EZ shot plus needles have specific designs that allow to obtain tissue samples and are
considered fine needle biopsy (FNB) needles instead of EUS-FNA needles. See the ESGE guideline by
Polkowski et al "Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology:
European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline -March 2017". Endoscopy
2017 Oct;49(10):989-1006. 
Results:
- Could you give more details about how many cases were performed with each type of needle?
- How do you explain that there are not cases with colorectal cancer recurrence in this series?
- 
The results should be presented in an intention-to-treat analysis.
- No need of presenting results of cytology and histology separately in the tables. These two tables can be
replaced by one table showing the results when using EUS-FNA and EUS-FNB needles separately. 
- No need of figures 1 and 2
- Keep figure 3A and eliminate 3B and 3C
- No need of table 3. Explain the results in the text 
Discussion:
- The two first paragraphs in the discussion are a summary of the results and need to be rewritten
- The authors write "Therefore, the size and type of FNA needle should be chosen considering the location
and shape of the EUS scope, lesion size, and operator's experience". Although this is generally the case,
this study shows that a 19G needle almost always provide a diagnosis. Change the redaction of the
paragraph.
- The results of the meta-analysis by Han et al (reference 15) show a low rate of AEs (1.7%, 2/236) but
are not mild (2 cases of abscesses in cystic lesions, 1 case of gross hematuria and 1 case of hemorrhage).
Do they used antibiotics when sampling cystic lesions? Although Han et al considered that the procedure
is safe, I recommend to tone down this sentence.
REFERENCES:
Replace some of the references by some of the following:
- Fernández-Esparrach G et al. Endoscopic ultrasound-guided fine needle aspiration is highly accurate for
the diagnosis of perirectal recurrence of colorectal cancer. Diseases of the Colon & Rectum Volume 58: 5
(2015):469-73
- Rzouq F, Brown J, Fan F, et al. The utility of lower endoscopic ultrasound-guided fine needle aspiration
for the diagnosis of benign and malignant pelvic diseases. J Clin Gastroenterol. 2014;48:127-130.
- Glesson FC, Clain JE, Karnes RJ, et al. Endoscopic-ultrasoundguided tissue sampling facilitates the
detection of local recurrence and extra pelvic metastasis in pelvic urologic malignancies. Diagnostic and
Therapeutic Endoscopy. 2012;2012:219521.
- Gleeson FC, Larson DW, Dozois EJ, et al. Local recurrence detection following transanal excision
facilitated by EUS-FNA . Hepatogastroenterology. 2012;59:1102-1107.
- Gleeson FC, Clain JE, Rajan E, Topazian MD, Wang KK, Levy MJ. EUS-FNA assessment of
extramesenteric lymph node status in primary rectal cancer. Gastrointest Endosc. 2011;74:897-905.
- Boo SJ, Byeon JS, Park do H, et al. EUS-guided fine needle aspiration and trucut needle biopsy for
examination of rectal andperirectal lesions. Scand J Gastroenterol. 2011;46:1510-1518.
- Maleki Z, Erozan Y, Geddes S, Li QK. Endorectal ultrasoundguided fine-needle aspiration: a useful
diagnostic tool for perirectal and intraluminal lesions. Acta Cytol. 2013;57:9-18.
Publons Reviewer Recognition
. Springer Nature can send verification of this review directly to Publons
(a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on
the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted to Publons upon
publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt
of this review and update your profile 
as per your settings and their policy. If you are not registered with
Publons, you will receive an email from them asking you to register in order for them to be able to
recognize your review on your new profile page. Publons may use the Review Data to generate derivative
metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such
information. For example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help editors to identify candidate
reviewers. Please find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
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 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 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
Reviewer Publication Consent.
 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
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free from apparent
manipulation?
Yes
assistant