Title: Risk factors for pathological upgrading and noncurative resection in patients with gastric
mucosal lesions after endoscopic submucosal dissection
Version: 1 Date: 03 Jun 2024
Reviewer:  Georgia Lazaraki
Reviewer's report:
To the authors:
Gastric cancer (GC) being one of the most common types of cancer, remains a leading cause of
cancer-related deaths. An early diagnosis significally improves 5years survival rates allowing
for curative resection. Thus it is important for endoscopists to recognize and diagnose lesions in
the early stage. In this retrospective study with real world data, the authors report their experience
from ESD for early gastric cancer and they investigate the histopathological diagnostic
agreement rate between preoperative biopsy and postoperative ESD, explore risk factors for
postoperative pathological upgrading and noncurative resection, and gather experience in
clinical and pathological diagnosis.
Major comments:
• Data collection and grouping methods: “From March 2016 to November 2023, 262 patients
with 292 ESD specimens were retrospectively analyzed”.  Do the authors mean all 262
patients that underwent ESD during this period had 292 ESD specimens and relative data
were retrospectively retrieved and analyzed? If so, this should be included in the manuscript;
otherwise eligibility criteria should be described with details. If these were the eligible patients
after implementation of the exclusion criteria that are described in later in the manuscript, then
the authors should include the number of gastric ESD performed in their center during the same
period.
• Indications for ESD: please provide a reference for e-cura in this section of the manuscript.
• Discussion 2nd paragraph: the results that are reported here, are in my opinion, irrelevant with
the flow of the discussion. The authors should add here a summary of their findings regarding
with the histological upgrading.
• Discussion, line 297: what do authors mean by LGD administration? Same for “According to
recent expert agreement in China, a biopsy alone is not sufficient for LGD patients who have
noticeable lesions during endoscopy with clear boundaries.” Do the authors mean that LGD
diagnosis in one forceps biopsy specimen is not enough to safely characterize a lesion, and
thus the China experts consensus advise a diagnostic ESD resection? If so, the authors should
consider a manuscript English revision.
• Number of forceps biopsies taken: the authors make an analysis based on the number of
biopsies taken and in table 3 they report that in 103 patients only 1 biopsy was taken. This is a
serious limitation of the study since, in my opinion, it is to be expected that with such a small
tissue sample, histology can be upgraded or doungraded in the surgical sample. What is the
common practice in the endoscopy department regarding biopsies? Do they take biopsies from
all lesions before planning treatment or just in cases that there is diagnostic doubt? Since there
is always the fear of fibrosis subsequent to biopsies is this taken in to account?
• What is the common practice in the endoscopy department about the use of virtual
chromoendoscopy when spotting suspicious gastric lesions? The authors report that only a
minority of patients underwent NBI. The NBI system is available in the Olympus endoscopes
whereas in the patients of this study a Pentax endoscpe was used. However in the Pentax
endoscopes also, virtual chromoendoscopy can be performed with the Pentax i-scan system.
• There is a table after table 2 that does not have a heading describing the subject of the table
Minor comments:
• Introduction, end of first paragraph: “Previously, gastrectomy was the conventional treatment
for GC, but endoscopic submucosal dissection (ESD) is currently the preferred treatment…”. I
believe that GC should be replaced with EGC in this context.
Title: Risk factors for pathological upgrading and noncurative resection in patients with gastric
mucosal lesions after endoscopic submucosal dissection
Version: 1 Date: 03 Jun 2024
Reviewer:  Georgia Lazaraki
Reviewer's report:
To the authors:
Gastric cancer (GC) being one of the most common types of cancer, remains a leading cause of
cancer-related deaths. An early diagnosis significally improves 5years survival rates allowing
for curative resection. Thus it is important for endoscopists to recognize and diagnose lesions in
the early stage. In this retrospective study with real world data, the authors report their experience
from ESD for early gastric cancer and they investigate the histopathological diagnostic
agreement rate between preoperative biopsy and postoperative ESD, explore risk factors for
postoperative pathological upgrading and noncurative resection, and gather experience in
clinical and pathological diagnosis.
Major comments:
• Data collection and grouping methods: “From March 2016 to November 2023, 262 patients
with 292 ESD specimens were retrospectively analyzed”.  Do the authors mean all 262
patients that underwent ESD during this period had 292 ESD specimens and relative data
were retrospectively retrieved and analyzed? If so, this should be included in the manuscript;
otherwise eligibility criteria should be described with details. If these were the eligible patients
after implementation of the exclusion criteria that are described in later in the manuscript, then
the authors should include the number of gastric ESD performed in their center during the same
period.
• Indications for ESD: please provide a reference for e-cura in this section of the manuscript.
• Discussion 2nd paragraph: the results that are reported here, are in my opinion, irrelevant with
the flow of the discussion. The authors should add here a summary of their findings regarding
with the histological upgrading.
• Discussion, line 297: what do authors mean by LGD administration? Same for “According to
recent expert agreement in China, a biopsy alone is not sufficient for LGD patients who have
noticeable lesions during endoscopy with clear boundaries.” Do the authors mean that LGD
diagnosis in one forceps biopsy specimen is not enough to safely characterize a lesion, and
thus the China experts consensus advise a diagnostic ESD resection? If so, the authors should
consider a manuscript English revision.
• Number of forceps biopsies taken: the authors make an analysis based on the number of
biopsies taken and in table 3 they report that in 103 patients only 1 biopsy was taken. This is a
serious limitation of the study since, in my opinion, it is to be expected that with such a small
tissue sample, histology can be upgraded or doungraded in the surgical sample. What is the
common practice in the endoscopy department regarding biopsies? Do they take biopsies from
all lesions before planning treatment or just in cases that there is diagnostic doubt? Since there
is always the fear of fibrosis subsequent to biopsies is this taken in to account?
• What is the common practice in the endoscopy department about the use of virtual
chromoendoscopy when spotting suspicious gastric lesions? The authors report that only a
minority of patients underwent NBI. The NBI system is available in the Olympus endoscopes
whereas in the patients of this study a Pentax endoscpe was used. However in the Pentax
endoscopes also, virtual chromoendoscopy can be performed with the Pentax i-scan system.
• There is a table after table 2 that does not have a heading describing the subject of the table
Minor comments:
• Introduction, end of first paragraph: “Previously, gastrectomy was the conventional treatment
for GC, but endoscopic submucosal dissection (ESD) is currently the preferred treatment…”. I
believe that GC should be replaced with EGC in this context.
Please review this paper.
user
Title: Risk factors for pathological upgrading and noncurative resection in patients with gastric
mucosal lesions after endoscopic submucosal dissection
Version: 1 Date: 03 Jun 2024
Reviewer:  Georgia Lazaraki
Reviewer's report:
To the authors:
Gastric cancer (GC) being one of the most common types of cancer, remains a leading cause of
cancer-related deaths. An early diagnosis significally improves 5years survival rates allowing
for curative resection. Thus it is important for endoscopists to recognize and diagnose lesions in
the early stage. In this retrospective study with real world data, the authors report their experience
from ESD for early gastric cancer and they investigate the histopathological diagnostic
agreement rate between preoperative biopsy and postoperative ESD, explore risk factors for
postoperative pathological upgrading and noncurative resection, and gather experience in
clinical and pathological diagnosis.
Major comments:
• Data collection and grouping methods: “From March 2016 to November 2023, 262 patients
with 292 ESD specimens were retrospectively analyzed”.  Do the authors mean all 262
patients that underwent ESD during this period had 292 ESD specimens and relative data
were retrospectively retrieved and analyzed? If so, this should be included in the manuscript;
otherwise eligibility criteria should be described with details. If these were the eligible patients
after implementation of the exclusion criteria that are described in later in the manuscript, then
the authors should include the number of gastric ESD performed in their center during the same
period.
• Indications for ESD: please provide a reference for e-cura in this section of the manuscript.
• Discussion 2nd paragraph: the results that are reported here, are in my opinion, irrelevant with
the flow of the discussion. The authors should add here a summary of their findings regarding
with the histological upgrading.
• Discussion, line 297: what do authors mean by LGD administration? Same for “According to
recent expert agreement in China, a biopsy alone is not sufficient for LGD patients who have
noticeable lesions during endoscopy with clear boundaries.” Do the authors mean that LGD
diagnosis in one forceps biopsy specimen is not enough to safely characterize a lesion, and
thus the China experts consensus advise a diagnostic ESD resection? If so, the authors should
consider a manuscript English revision.
• Number of forceps biopsies taken: the authors make an analysis based on the number of
biopsies taken and in table 3 they report that in 103 patients only 1 biopsy was taken. This is a
serious limitation of the study since, in my opinion, it is to be expected that with such a small
tissue sample, histology can be upgraded or doungraded in the surgical sample. What is the
common practice in the endoscopy department regarding biopsies? Do they take biopsies from
all lesions before planning treatment or just in cases that there is diagnostic doubt? Since there
is always the fear of fibrosis subsequent to biopsies is this taken in to account?
• What is the common practice in the endoscopy department about the use of virtual
chromoendoscopy when spotting suspicious gastric lesions? The authors report that only a
minority of patients underwent NBI. The NBI system is available in the Olympus endoscopes
whereas in the patients of this study a Pentax endoscpe was used. However in the Pentax
endoscopes also, virtual chromoendoscopy can be performed with the Pentax i-scan system.
• There is a table after table 2 that does not have a heading describing the subject of the table
Minor comments:
• Introduction, end of first paragraph: “Previously, gastrectomy was the conventional treatment
for GC, but endoscopic submucosal dissection (ESD) is currently the preferred treatment…”. I
believe that GC should be replaced with EGC in this context.
assistant