Title: Threshold of Main Pancreatic Duct for Malignancy in Intraductal Papillary  Mucinous
Neoplasm at Head-neck and Body-tail
Version: 2 Date: 26 Oct 2022
Reviewer's report:
In this manuscript titled “Threshold of main pancreatic duct for malignancy in intrapapillary
mucinous neoplasm at head-neck and body-tail”, Li et al described that different threshold of
MPD diameter was determined to discriminate malignant IPMN from benign one in both head/
neck and body/tail in the pancreas. Although I think highly of their massive efforts to revise
this manuscript, you did not adequately reply to my suggestions. Therefore, I suppose some
revisions are needed in this manuscript. My suggestions are described below:
1) Your conclusion was quite ambiguous.  To determine surgical indication in the case
with MPD-involved IPMNs in the pancreatic head and/or neck, which threshold of the main
pancreatic duct would you recommend 6.5 mm or 8.5 mm? More clear description is needed.
2) You showed threshold of the MPD is 6.5 mm and 8.5 mm to identify malignant IPMNs in all
IPMN patients and MPD-involved IPMN cases, respectively. However, in the cases with branch
duct (BD)-IPMNs, the threshold would be smaller than 6.5 mm because the MPD diameter
is generally small in BD-IPMNs. In addition, Yoshioka et al [10] showed that MPD diameter
more than 3 mm as a risk factor of pancreatic ductal adenocarcinoma in the patients with BD-
IPMN, as you described. Therefore, I concern that some patients with malignant IPMN would
be excluded from surgical treatment if you use 6.5 mm as a threshold in the patients with BD-
IPMN. Therefore, it would be better to show thresholds of the MPD also in case of BD-IPMN.
3) In multivariate analysis, factors should be determined by univariate analysis. However, in
this study, only specific factors were included in multivariate analysis. For example, univariate
analysis in Table 4 should include the factors which have significant statistical significance in
Table 2 such as extra-pancreas extension and the presence of mural nodule.
4) In Table 2, diabetes mellitus should also be analyzed.
5) In table 3 and 4, it would be better to show data of the pancreatic head-neck and those of the
body-tail in separate tables.
Title: Threshold of Main Pancreatic Duct for Malignancy in Intraductal Papillary  Mucinous
Neoplasm at Head-neck and Body-tail
Version: 2 Date: 26 Oct 2022
Reviewer's report:
In this manuscript titled “Threshold of main pancreatic duct for malignancy in intrapapillary
mucinous neoplasm at head-neck and body-tail”, Li et al described that different threshold of
MPD diameter was determined to discriminate malignant IPMN from benign one in both head/
neck and body/tail in the pancreas. Although I think highly of their massive efforts to revise
this manuscript, you did not adequately reply to my suggestions. Therefore, I suppose some
revisions are needed in this manuscript. My suggestions are described below:
1) Your conclusion was quite ambiguous.  To determine surgical indication in the case
with MPD-involved IPMNs in the pancreatic head and/or neck, which threshold of the main
pancreatic duct would you recommend 6.5 mm or 8.5 mm? More clear description is needed.
2) You showed threshold of the MPD is 6.5 mm and 8.5 mm to identify malignant IPMNs in all
IPMN patients and MPD-involved IPMN cases, respectively. However, in the cases with branch
duct (BD)-IPMNs, the threshold would be smaller than 6.5 mm because the MPD diameter
is generally small in BD-IPMNs. In addition, Yoshioka et al [10] showed that MPD diameter
more than 3 mm as a risk factor of pancreatic ductal adenocarcinoma in the patients with BD-
IPMN, as you described. Therefore, I concern that some patients with malignant IPMN would
be excluded from surgical treatment if you use 6.5 mm as a threshold in the patients with BD-
IPMN. Therefore, it would be better to show thresholds of the MPD also in case of BD-IPMN.
3) In multivariate analysis, factors should be determined by univariate analysis. However, in
this study, only specific factors were included in multivariate analysis. For example, univariate
analysis in Table 4 should include the factors which have significant statistical significance in
Table 2 such as extra-pancreas extension and the presence of mural nodule.
4) In Table 2, diabetes mellitus should also be analyzed.
5) In table 3 and 4, it would be better to show data of the pancreatic head-neck and those of the
body-tail in separate tables.
Please review this paper.
user
Title: Threshold of Main Pancreatic Duct for Malignancy in Intraductal Papillary  Mucinous
Neoplasm at Head-neck and Body-tail
Version: 2 Date: 26 Oct 2022
Reviewer's report:
In this manuscript titled “Threshold of main pancreatic duct for malignancy in intrapapillary
mucinous neoplasm at head-neck and body-tail”, Li et al described that different threshold of
MPD diameter was determined to discriminate malignant IPMN from benign one in both head/
neck and body/tail in the pancreas. Although I think highly of their massive efforts to revise
this manuscript, you did not adequately reply to my suggestions. Therefore, I suppose some
revisions are needed in this manuscript. My suggestions are described below:
1) Your conclusion was quite ambiguous.  To determine surgical indication in the case
with MPD-involved IPMNs in the pancreatic head and/or neck, which threshold of the main
pancreatic duct would you recommend 6.5 mm or 8.5 mm? More clear description is needed.
2) You showed threshold of the MPD is 6.5 mm and 8.5 mm to identify malignant IPMNs in all
IPMN patients and MPD-involved IPMN cases, respectively. However, in the cases with branch
duct (BD)-IPMNs, the threshold would be smaller than 6.5 mm because the MPD diameter
is generally small in BD-IPMNs. In addition, Yoshioka et al [10] showed that MPD diameter
more than 3 mm as a risk factor of pancreatic ductal adenocarcinoma in the patients with BD-
IPMN, as you described. Therefore, I concern that some patients with malignant IPMN would
be excluded from surgical treatment if you use 6.5 mm as a threshold in the patients with BD-
IPMN. Therefore, it would be better to show thresholds of the MPD also in case of BD-IPMN.
3) In multivariate analysis, factors should be determined by univariate analysis. However, in
this study, only specific factors were included in multivariate analysis. For example, univariate
analysis in Table 4 should include the factors which have significant statistical significance in
Table 2 such as extra-pancreas extension and the presence of mural nodule.
4) In Table 2, diabetes mellitus should also be analyzed.
5) In table 3 and 4, it would be better to show data of the pancreatic head-neck and those of the
body-tail in separate tables.
assistant