Reviewer’s report
Title: 
Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower
gastrointestinal tract approaches
Version: 
0 
Date: 
17 Aug 2020
Reviewer's report:
In this paper Mita and colleagues discuss about the efficacy of EUS-guided FNA for pelvic lesions using
both an upper and a lower approach. The paper topic is potentially interesting because it highlights the
possibility of these two approaches in a location which is usually uncommon and challenging.
However, even if the topic is interesting, there are some major concerns that should be considered before
eventual publication:
1) As mentioned by the authors limitations of the study are represented by the retrospective design, the
small number of patients and that the final diagnoses were determined according to both surgical and
FNA results. 
2) Other limitations are represented by: the wide period of inclusion (10 years), the use both of FNA and
FNB needles.
3) Authors affirm that, regardless the use of FNA or FNB needle, in the study a high percentage of
hystological specimens were obtained (superior than those reported in literature for FNA).However, over
the years the concept of CORE has changed and only recently has been standardize (Fabbri C, Luigiano C,
Maimone A, et al. Endoscopic ultrasound-guided fine-needle biopsy of small solid pancreatic lesions
using a 22-gauge needle with side fenestration. Surg Endosc. 2015;29(6):1586-1590.
doi:10.1007/s00464-014-3846-6). There was a definition of CORE in the study period? If yes, specify.
4) In methods please indicate: type of technique used for tissue sampling (slow-pull, suction or wet), the
presence/absence of ROSE during the procedure.
5) authors affirmed that the final diagnoses were determined according to both surgical and FNA results.
However, in one patient with a false negative result underwent to mucosal biopsy of the small intestinal
lesion during double-balloon enteroscopy with a final diagnosis of malignant lymphoma. Why in this
patient was decided to perform a second procedure? Specify in the text.
6) The overall technical success in the study was 91.8%. However, the technical success in the upper-GI
route was lower than 90%, while in the lower-GI procedure was up to 95.2%. Can authors explain why
this difference is present? The difference of mean size of the lesions between the two groups can be liked
the technical success? 
7) In two patients EUS-FNA through the upper-GI was not possible because of the presence of vessels in
the puncture route. Why was not performed a second attempt using the lower-GI route?
8) Moreover, in the discussion authors affirmed that "Our high feasibility might be not applicable for
other centers, considering our extensive experience with EUS-FNA using a 19-gauge needle". This
affirmation need to be supported by evidences [see article: Attili F, Fabbri C, Yasuda I, et al. Low
diagnostic yield of transduodenal endoscopic ultrasound-guided fine needle biopsy using the 19-gauge
Flex needle: A large multicenter prospective study. Endosc Ultrasound. 2017;6(6):402-408.
doi:10.4103/eus.eus_54_17].
9) References, especially in the discussion, need to be improved because is lacking of many important
studies that has been recently published on EUS-guided tissue sampling.
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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?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
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: 
17 Aug 2020
Reviewer's report:
In this paper Mita and colleagues discuss about the efficacy of EUS-guided FNA for pelvic lesions using
both an upper and a lower approach. The paper topic is potentially interesting because it highlights the
possibility of these two approaches in a location which is usually uncommon and challenging.
However, even if the topic is interesting, there are some major concerns that should be considered before
eventual publication:
1) As mentioned by the authors limitations of the study are represented by the retrospective design, the
small number of patients and that the final diagnoses were determined according to both surgical and
FNA results. 
2) Other limitations are represented by: the wide period of inclusion (10 years), the use both of FNA and
FNB needles.
3) Authors affirm that, regardless the use of FNA or FNB needle, in the study a high percentage of
hystological specimens were obtained (superior than those reported in literature for FNA).However, over
the years the concept of CORE has changed and only recently has been standardize (Fabbri C, Luigiano C,
Maimone A, et al. Endoscopic ultrasound-guided fine-needle biopsy of small solid pancreatic lesions
using a 22-gauge needle with side fenestration. Surg Endosc. 2015;29(6):1586-1590.
doi:10.1007/s00464-014-3846-6). There was a definition of CORE in the study period? If yes, specify.
4) In methods please indicate: type of technique used for tissue sampling (slow-pull, suction or wet), the
presence/absence of ROSE during the procedure.
5) authors affirmed that the final diagnoses were determined according to both surgical and FNA results.
However, in one patient with a false negative result underwent to mucosal biopsy of the small intestinal
lesion during double-balloon enteroscopy with a final diagnosis of malignant lymphoma. Why in this
patient was decided to perform a second procedure? Specify in the text.
6) The overall technical success in the study was 91.8%. However, the technical success in the upper-GI
route was lower than 90%, while in the lower-GI procedure was up to 95.2%. Can authors explain why
this difference is present? The difference of mean size of the lesions between the two groups can be liked
the technical success? 
7) In two patients EUS-FNA through the upper-GI was not possible because of the presence of vessels in
the puncture route. Why was not performed a second attempt using the lower-GI route?
8) Moreover, in the discussion authors affirmed that "Our high feasibility might be not applicable for
other centers, considering our extensive experience with EUS-FNA using a 19-gauge needle". This
affirmation need to be supported by evidences [see article: Attili F, Fabbri C, Yasuda I, et al. Low
diagnostic yield of transduodenal endoscopic ultrasound-guided fine needle biopsy using the 19-gauge
Flex needle: A large multicenter prospective study. Endosc Ultrasound. 2017;6(6):402-408.
doi:10.4103/eus.eus_54_17].
9) References, especially in the discussion, need to be improved because is lacking of many important
studies that has been recently published on EUS-guided tissue sampling.
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?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
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: 
17 Aug 2020
Reviewer's report:
In this paper Mita and colleagues discuss about the efficacy of EUS-guided FNA for pelvic lesions using
both an upper and a lower approach. The paper topic is potentially interesting because it highlights the
possibility of these two approaches in a location which is usually uncommon and challenging.
However, even if the topic is interesting, there are some major concerns that should be considered before
eventual publication:
1) As mentioned by the authors limitations of the study are represented by the retrospective design, the
small number of patients and that the final diagnoses were determined according to both surgical and
FNA results. 
2) Other limitations are represented by: the wide period of inclusion (10 years), the use both of FNA and
FNB needles.
3) Authors affirm that, regardless the use of FNA or FNB needle, in the study a high percentage of
hystological specimens were obtained (superior than those reported in literature for FNA).However, over
the years the concept of CORE has changed and only recently has been standardize (Fabbri C, Luigiano C,
Maimone A, et al. Endoscopic ultrasound-guided fine-needle biopsy of small solid pancreatic lesions
using a 22-gauge needle with side fenestration. Surg Endosc. 2015;29(6):1586-1590.
doi:10.1007/s00464-014-3846-6). There was a definition of CORE in the study period? If yes, specify.
4) In methods please indicate: type of technique used for tissue sampling (slow-pull, suction or wet), the
presence/absence of ROSE during the procedure.
5) authors affirmed that the final diagnoses were determined according to both surgical and FNA results.
However, in one patient with a false negative result underwent to mucosal biopsy of the small intestinal
lesion during double-balloon enteroscopy with a final diagnosis of malignant lymphoma. Why in this
patient was decided to perform a second procedure? Specify in the text.
6) The overall technical success in the study was 91.8%. However, the technical success in the upper-GI
route was lower than 90%, while in the lower-GI procedure was up to 95.2%. Can authors explain why
this difference is present? The difference of mean size of the lesions between the two groups can be liked
the technical success? 
7) In two patients EUS-FNA through the upper-GI was not possible because of the presence of vessels in
the puncture route. Why was not performed a second attempt using the lower-GI route?
8) Moreover, in the discussion authors affirmed that "Our high feasibility might be not applicable for
other centers, considering our extensive experience with EUS-FNA using a 19-gauge needle". This
affirmation need to be supported by evidences [see article: Attili F, Fabbri C, Yasuda I, et al. Low
diagnostic yield of transduodenal endoscopic ultrasound-guided fine needle biopsy using the 19-gauge
Flex needle: A large multicenter prospective study. Endosc Ultrasound. 2017;6(6):402-408.
doi:10.4103/eus.eus_54_17].
9) References, especially in the discussion, need to be improved because is lacking of many important
studies that has been recently published on EUS-guided tissue sampling.
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?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free from apparent
manipulation?
Yes
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