Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have reviewed the interaction of insulin-like growth factor pathway and immune mechanisms in colorectal cancer. The topic of this manuscript is of fair interest and it is well organized and written. There are some concerns, however.

1. It would be good to make a table that orginizes the key components of IGF pathways.
2. Figures are cut off in the middle of Fig 2 (B) .
3. The nuber of Reference 224 is missing.
4. The explanation about lines 1732 & 1733 on page 40 is needed.

 

Author Response

Thank you very much for taking the time to review this manuscript. We appreciate your positive assessment of the topic and organization, and we have carefully addressed each of your concerns below. 

Comment 1: It would be good to make a table that organizes the key components of IGF pathways.

Response 1: We agree that a summary table would enhance the accessibility of IGF pathways for the readers. We have added Table 1 ("Key Components of the IGF Axis and their Roles in CRC Immunity") at the end of Section 1.2 (line 252). This table organizes all major IGF axis components across three categories (ligands, receptors, and binding proteins), with columns describing their primary function, relevance in CRC, and role in immune regulation. This addition provides readers with a comprehensive resource that connects each component to the bidirectional IGF-immune framework discussed throughout the manuscript.

Comment 2: Figures are cut off in the middle of Fig 2 (B).

Response 2: We apologize for this formatting issue. The original Figure 2 has been regenerated from the source files at high resolution, and all panels (A, B, and C) are now displayed completely.

Comment 3: The number of Reference 224 is missing.

Response 3: We thank the Reviewer for identifying this error. Reference 224 (Roshandel et al. 2024, now 250) was present in the reference list but lacked proper numbering. This has been corrected, and we have verified that the reference is properly cited in the text and numbered sequentially.

Comment 4: The explanation about lines 1732 & 1733 on page 40 is needed.

Response 4: We appreciate the Reviewer drawing attention to this. Lines 1732 & 1733 contained placeholder text from the IJMS manuscript template that was inadvertently retained during final formatting. These template entries (“Author 1, A.B. Title of Thesis…” and “Title of Site. Available online: URL…”) have been removed from the revised manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Centeno-Girona et al. reviewed IGF axis and immune regulation in CRC. Please refer to my comments: 

1) None of the authors appear to have prior research experience in IGF or immune-related studies in CRC. As this is a narrative review, how do the authors ensure that reporting bias, interpretation bias, and omission of relevant literature are minimised? Please justify why a systematic or scoping review was not undertaken.

2) The current format contains too many subsections, which makes it difficult to read. It resembles a student’s thesis rather than a review article

3) Consider to restructure section 2 and 3 as interactions in immune cells are inherently bidirectional, discussing Tumor-Associated Macrophages (TAMs), Regulatory T cells (Tregs), and Myeloid-Derived Suppressor Cells (MDSCs) in two separate sections creates significant repetition. 

4) Please request the publication license for any figure that created from Biorender

5) I assume that most of the content is from CRC. Please specify them if they are not from CRC model.

6) For IGFBP-2 and multi-marker panels in early detection, please discuss further on the clinical translation and try to speculate why most do not work as intended. Kindly include the information from epidermio or human study registry like clinicaltrial.gov to show the ongoing and completed biomarker studies. 

7) What are the strengths and limitations of this review? How does it address existing research gaps, and what is its impact compared with other similar reviews?

Author Response

Thank you very much for taking the time to review this manuscript. Your comments have substantially improved the scientific rigor and readability of this review. We provide detailed point-by-point responses below:

Comment 1: None of the authors appear to have prior research experience in IGF or immune-related studies in CRC. As this is a narrative review, how do the authors ensure that reporting bias, interpretation bias, and omission of relevant literature are minimised? Please justify why a systematic or scoping review was not undertaken.

Response 1: We respectfully clarify that the author team has direct research experience with IGF axis components in CRC. The corresponding author (E.V.C.) and first author (H.C.G.) are co-first authors, and co-author S.N.L.A. is a contributing author, on a published case-control study evaluating the diagnostic accuracy of a blood-based biomarker panel including IGFBP-2 for CRC detection in Hispanic patients (Caraballo et al., 2024 [reference 234 in the revised manuscript]]). This work involved direct measurement of plasma IGFBP-2 levels in 124 CRC cases and 124 controls, evaluation of multi-biomarker panel performance, and analysis of IGF-related biomarker utility across disease stages. The interdisciplinary composition of the team, spanning translational cancer research, immunology, and epidemiology, was assembled to ensure comprehensive and balanced coverage of the IGF-immune interface reviewed in this manuscript.

Regarding the choice of a narrative rather than systematic review, the objective of this manuscript was to synthesize mechanistic evidence on bidirectional interactions between IGF signaling and immune regulation across multiple biological scales, including molecular pathways, cellular phenotypes, metabolic competition, and clinical biomarker applications. Systematic reviews are optimally suited for evaluating the efficacy of specific interventions or the diagnostic accuracy of defined tests using standardized search protocols and meta-analytic methods (Grant MJ & Booth A., 2009; PMID: 19490148). The integrative, multi-pathway scope of our review does not lend itself to the focused, reproducible search strategies required by PRISMA guidelines. Narrative reviews remain the appropriate format for synthesizing heterogeneous evidence across disciplines to generate conceptual frameworks and identify research gaps (Ferrari, 2015; doi: 10.1179/2047480615Z.000000000329).

To minimize reporting and interpretation bias, we employed several safeguards: (1) literature searches were conducted independently by multiple authors across PubMed, Web of Science, Elsevier, and EBSCOHost; (2) evidence from non-CRC models is explicitly identified throughout the manuscript with appropriate caveats (further strengthened in this revision); (3) knowledge gaps and limitations of extrapolated evidence are transparently acknowledged in a new Strengths and Limitations section; and (4) the manuscript underwent critical review by all co-authors representing complementary disciplinary perspectives prior to submission. Additionally, this work was reviewed by an independent editor from our institutional Scientific Editing and Communications Core, with a research background in growth factors and transcriptional co-activator signaling in tumor immunology.

Comment 2: The current format contains too many subsections, which makes it difficult to read. It resembles a student’s thesis rather than a review article

Response 2: We appreciate this feedback regarding readability. In the revised manuscript, we have reduced the depth of subsection numbering by removing fourth-level headings throughout. For example, the individual cytokine subsections in Section 2.1 (formerly 2.1.2.1 through 2.1.3.2) and the T lymphocyte subgroups in Section 3.1.1 (formerly 3.1.1.1 through 3.1.1.3) have been converted to inline bold headings within their respective paragraphs, reducing the hierarchical depth from four levels to three while preserving the organizational clarity for readers navigating specific topics. This change, combined with the structural reorganization described in Point 3 below, substantially improves the readability and flow of the manuscript. See lines 278-694.

Comment 3: Consider to restructure section 2 and 3 as interactions in immune cells are inherently bidirectional, discussing Tumor-Associated Macrophages (TAMs), Regulatory T cells (Tregs), and Myeloid-Derived Suppressor Cells (MDSCs) in two separate sections creates significant repetition.

Response 3: We thank the Reviewer for this constructive observation. We acknowledge that the original organization created redundancy in the discussion of TAMs, Tregs, and MDSCs across Sections 2 and 3. In the revised manuscript, we have restructured these sections to ensure that each immune cell population is discussed primarily in one consolidated location, with the bidirectional nature of the interaction addressed within that discussion. Specifically, Section 2.2 has been refined and renamed "Immune Cells as Regulators of IGF Bioavailability" (line 377) to focus only on mechanisms by which immune cells modify IGF/IGFBP levels (proteolytic cleavage of IGFBPs, cytokine-mediated modulation of IGFBP secretion, oxidative modifications). The effects of IGF signaling on immune cell differentiation, function, and phenotype have been consolidated in Section 3 (line 503). The key consolidations are:

• Former Sections on macrophage-mediated immunosuppression (including M2 polarization and IGFBP-2/STAT3 signaling) have been merged into new Section 3.1.5 (Macrophages) (line 634), removing duplicate M2 polarization descriptions.
• Treg content previously in Section 2 has been consolidated with IGF-Treg signaling into new Section 3.1.2 (Regulatory T Cells) (line 566).
• MDSC content previously in Section 2 has been consolidated with IGF-MDSC signaling into new Section 3.1.6 (MDSCs) (line 681).
• The former separate section on IGF signaling and immunosuppressive cell populations has been removed as a standalone section; all immune cell types are now organized under Section 3.1 by cell type (line 503).

As a result, the revised Section 3 structure is: 3.1 (IGF Signaling Effects on Immune Cell Function, with subsections 3.1.1-3.1.6 by cell type), 3.2 (IGF Axis and Immune Checkpoint Expression), and 3.3 (Impact on TME Architecture). Cross-references between Sections 2 and 3 maintain the bidirectional framework without repeating mechanistic descriptions.

Comment 4: Please request the publication license for any figure that created from Biorender

Response 4: We thank the Reviewer for this observation. Publication licenses for all BioRender-generated figures have been obtained and are available upon request. The appropriate citation and corresponding link are included in the figure legend, along with the access date as recommended by the journal.

Comment 5: I assume that most of the content is from CRC. Please specify them if they are not from CRC model.

Response 5: We agree that transparent identification of evidence sources is essential for a CRC-focused review. In the revised manuscript, we have systematically annotated all instances where evidence is derived from non-CRC models throughout Sections. Key examples include: IGFBP-2/STAT3-driven Treg differentiation demonstrated in pancreatic cancer (Sun et al., 2021 [reference 78 in the revised manuscript]); IGFBP-3-mediated suppression of CD8+ T cell infiltration in murine breast cancer models (Baxter, 2023 [reference 62 in the revised manuscript]); IGF-1R-dependent downregulation of antigen processing machinery in prostate cancer (Nandakumar et al., 2025 [new reference 70 in the revised manuscript]); IGFBP-5 correlation with M2 macrophage infiltration in glioma (Lin et al., 2024 [new reference 88 in the revised manuscript]); and IGFBP-2 inhibition effects on CD8+ T cell infiltration in glioblastoma (Liu et al., 2019 [reference 186 in the revised manuscript]).  In each case, we note the cancer type, and the plausibility of these extrapolated mechanisms in CRC is addressed in the Strengths and Limitations discussion in Section 6 (lines 1262-1295).

Comment 6: For IGFBP-2 and multi-marker panels in early detection, please discuss further on the clinical translation and try to speculate why most do not work as intended. Kindly include the information from epidermio or human study registry like clinicaltrial.gov to show the ongoing and completed biomarker studies.

Response 6: We thank the Reviewer for this important suggestion. We have substantially expanded Section 5.3 (Clinical Translation Challenges) with a new discussion addressing the specific barriers to clinical translation of IGF-derived biomarkers for CRC. The expanded text addresses: (1) the persistent gap between biomarker discovery and clinical implementation, noting that approximately 1% of published cancer biomarkers enter clinical practice (Goossens et al., 2015 [new reference 244 in the revised manuscript]); (2) CRC-specific obstacles including molecular heterogeneity across CMS subtypes, functional decoupling between systemic and local IGF levels, confounding by metabolic comorbidities (obesity, type 2 diabetes, hyperinsulinemia), and inter-assay variability due to proteolytic processing of IGFBPs; (3) the regulatory landscape, including the CMS minimum performance thresholds for blood-based CRC screening tests (sensitivity ≥74%, specificity ≥90%) (van den Puttelaar et al., 2024 [new reference 247 in the revised manuscript]); and (4) reference to a registered prospective observational study (ClinicalTrials.gov) assessing the diagnostic role of serum IGFBP-3 compared to CEA in recently diagnosed CRC patients [new reference 248 in the revised manuscript]. See lines 1159-1200.

Comment 7: What are the strengths and limitations of this review? How does it address existing research gaps, and what is its impact compared with other similar reviews?

Response 7: We have added a Strengths and Limitations section at the end of Section 6 (Conclusion) (lines 1262-1295). The strengths identified include: (1) the systematic mapping of bidirectional IGF-immune interactions, which has not been undertaken in prior reviews that address IGF biology and CRC immunology separately; (2) the analysis across molecular subtypes revealing the disproportionate role of IGF-mediated immunosuppression in MSS and CMS4 tumors; and (3) the integration of biomarker evidence with mechanistic pathways. Limitations explicitly acknowledged include: (1) reliance on extrapolated evidence from non-CRC models for several key mechanisms, with specific examples provided; (2) the narrative rather than systematic approach; (3) the incomplete characterization of IGFBPs beyond IGFBP-2 and IGFBP-3 in CRC immunity; and (4) the predominantly retrospective nature of available clinical biomarker evidence. The section also positions the review relative to existing literature, noting that prior IGF-focused reviews (Gligorijevic et al., 2022 [reference 29 in the revised manuscript] and Kasprzak, 2021 [reference 58 in the revised manuscript]) did not address immune regulation, and prior CRC immune microenvironment reviews (Andac-Aktas & Calibasi-Kocal, 2025 [new reference 106 in the revised manuscript] and Fridman et al., 2012 [reference 92 in the revised manuscript]) did not integrate growth factor signaling networks.

Reviewer 3 Report

Comments and Suggestions for Authors

Very important topic and very intersting area of research but unfortaneutely the authors miss a big part of literature such as

Rahmoon, M. A., Youness, R. A., Gomaa, A. I., Hamza, M. T., Waked, I., El Tayebi, H. M., & Abdelaziz, A. I. (2017). MiR-615-5p depresses natural killer cells cytotoxicity through repressing IGF-1R in hepatocellular carcinoma patients. Growth Factors, 35(2–3), 76–87. https://doi.org/10.1080/08977194.2017.1354859

ZeinElAbdeen, Y.A., AbdAlSeed, A. & Youness, R.A. Decoding Insulin-Like Growth Factor Signaling Pathway From a Non-coding RNAs Perspective: A Step Towards Precision Oncology in Breast Cancer. J Mammary Gland Biol Neoplasia 27, 79–99 (2022).

A summary table highlighting the role of each member of the IGF family in oncology and immunoncology is of great value to be added in this review

The non-coding RNAs regulating those members are important to be mentioned

The downstream signaling cascades drawn downstream the IGF signaling pathway and their crosstalk with immune cells and TME is very important to be highlighted in such review

Author Response

Thank you very much for taking the time to review this manuscript and for bringing important literature to our attention. We have carefully incorporated your suggestions, as detailed below. 

Comment 1: Very important topic and very interesting area of research but unfortunately the authors miss a big part of literature such as: Rahmoon et al. (2017) and ZeinElAbdeen et al. (2022).

Response 1: We thank the Reviewer for bringing these references to our attention. Rahmoon et al. (2017) demonstrates that miR-615-5p represses IGF-1R expression in natural killer cells, diminishing their cytotoxic capacity in hepatocellular carcinoma. Although conducted in an HCC model, the mechanism of miRNA-mediated IGF-1R suppression in NK cells is directly relevant to the IGF-immune interface discussed in our review. We have incorporated this reference in two locations: Section 1.2.4, within the broader context of ncRNA regulation of IGF components (line 194), and Section 3.1.3 (NK Cells, line 587), where we discuss this as a plausible mechanism warranting investigation in CRC (Rahmoon et al., 2017 [new reference 179]). Regarding ZeinElAbdeen et al. (2022), which comprehensively reviews ncRNA regulation of IGF signaling in breast cancer, we acknowledge this as a valuable reference for the broader ncRNA-IGF field. Given our manuscript's specific focus on CRC, we have prioritized CRC-specific ncRNA-IGF literature in the new Section 1.2.4 but recognize the conserved regulatory principles described across cancer types.

Comment 2: A summary table highlighting the role of each member of the IGF family in oncology and immuno-oncology is of great value to be added in this review.

Response 2: We agree with this recommendation. We have added Table 1 ("Key Components of the IGF Axis: Functions, CRC Relevance, and Immune Regulatory Roles," line 252), which organizes all major IGF axis components with their oncological and immuno-oncological roles. The table includes ligands (IGF-I, IGF-II, insulin), receptors (IGF-1R, IGF-2R, IR-A, IR-B), and binding proteins (IGFBP-1 through IGFBP-6), with dedicated columns for primary function, relevance in CRC, and role in immune regulation.

Comment 3: The non-coding RNAs regulating those members are important to be mentioned.

Response 3: We agree that post-transcriptional regulation by non-coding RNAs represents an important layer of IGF axis modulation. We have added a new subsection, Section 1.2.4 ("Post-Transcriptional Regulation of IGF Components by Non-Coding RNAs," line 194), covering: (1) miRNAs targeting IGF-1R cascade components in CRC, including miR-497/IRS-1 and the miR-143/145 cluster/IGF-1R axis; (2) circular RNAs functioning as miRNA sponges, including circHIPK3/miR-7/IGF-1R and circRUNX1/miR-145-5p/IGF-1; (3) miRNAs regulating IGF-II availability; (4) long non-coding RNAs including H19 and CRNDE; (5) IGF2BP1-3 as post-transcriptional regulators; and (6) connections between ncRNA-IGF circuits and immune checkpoint regulation through circRNAs modulating PD-L1 expression in CRC, with cross-references to Sections 3.1.3 and 3.2.1.

Comment 4: The downstream signaling cascades drawn downstream the IGF signaling pathway and their crosstalk with immune cells and TME is very important to be highlighted in such review.

Response 4: We appreciate this comment and note that downstream signaling cascades and their crosstalk with immune cells constitute a central theme of the manuscript. Section 1.2.2 describes the canonical PI3K/AKT/mTOR and MAPK/ERK cascades (Figure 1). Section 3 details how these cascades affect specific immune cell populations: PI3K/AKT drives M2 macrophage polarization (Section 3.1.5, line 634), Treg expansion through mTOR signaling (Section 3.1.2, line 565), and MDSC immunosuppressive function (Section 3.1.6, line 681). Section 3.2 (line 696) describes the convergence of PI3K/AKT, STAT3, NF-κB, and ERK on PD-L1 upregulation, and Section 3.3 addresses TME architectural remodeling. The new Section 1.2.4 adds a post-transcriptional regulatory layer modulating the activity of these cascades. 

Reviewer 4 Report

Comments and Suggestions for Authors

Comments for authors:

 

This review was very well written. I have the following three questions:

 

Q1. I am interested in the relationship between IGF and the senescence-associated secretory phenotype (SASP). I understand that inflammatory cytokines modulate the bioavailability of IGF and promote tumor progression, but could you explain the connection between the IGF axis and SASP?

 

Q2. You mentioned that the specific mechanisms by which gut microbiota-derived signals regulate tumor immunity via the IGF network have not been fully defined. However, since the microbiome is a hot topic, perhaps you could expand on this section a bit more.

 

Q3. Is there any discussion regarding the relationship between hereditary colorectal cancer and IGF? Does IGF influence the pathogenesis of familial adenomatous polyposis or Lynch syndrome?

Author Response

Thank you very much for your positive assessment and for your thoughtful, insightful questions. We have expanded the manuscript in response to each point, as detailed below. 

Comment 1: I am interested in the relationship between IGF and the senescence-associated secretory phenotype (SASP). I understand that inflammatory cytokines modulate the bioavailability of IGF and promote tumor progression, but could you explain the connection between the IGF axis and SASP?

Response 1: We appreciate this insightful question, which highlights an important connection that strengthens the bidirectional framework of our review. Multiple IGF binding proteins, particularly IGFBP-3 and IGFBP-5, are now recognized as components of the SASP (Coppé et al., 2010 [reference 225]), and recent transcriptomic profiling of primary human colon fibroblasts has established that IGFBP-2 is also a universal component of the colon-specific SASP (Hattangady et al., 2024 [reference 75]). Mechanistically, IGFBP-5 induction in senescent cells is mediated by IL-6 through STAT3 activation, while IGFBP-4 propagates senescence through autocrine and paracrine pathways by modulating IGF-II half-life. From an immunological perspective, chronic SASP exposure promotes M2 macrophage polarization and recruitment of Tregs and MDSCs, as observed in prostate, breast, and hepatic malignancies (Xiong et al., 2024 [reference 226]). We have added a new paragraph to Section 4.3.2 (line 948) addressing the SASP-IGF axis connection and its implications for immune remodeling in CRC, and have included SASP-related IGFBP information in Table 1 (line 252).

Comment 2: You mentioned that the specific mechanisms by which gut microbiota-derived signals regulate tumor immunity via the IGF network have not been fully defined. However, since the microbiome is a hot topic, perhaps you could expand on this section a bit more.

Response 2: We agree that the gut microbiota-immunity interface deserves additional attention given its relevance to CRC biology. We have expanded Section 4.3.3 (line 962) to include emerging evidence on specific mechanisms by which the microbiome may intersect with both IGF signaling and tumor immunity. These include short-chain fatty acid-mediated metabolic effects on immune cells (Wong & Yu, 2023 [new reference 227 in the revised manuscript]), microbiota-driven macrophage reprogramming from protumoral SPP1+ phenotypes toward antigen-presenting CD74+ states in colon cancer models (Cao et al., 2025 [new reference 228 in the revised manuscript]), and the demonstrated dependence of immune checkpoint inhibitor efficacy on intact gut microbiota, particularly in melanoma and non-small cell lung cancer (Gopalakrishnan et al., 2018 [new reference 229 in the revised manuscript]; Jiang & Zhang, 2024 [new reference 230 in the revised manuscript]). We also note emerging evidence that intestinal epithelial IGF-1 is essential for maintaining microbiome composition and preventing bacterial translocation (Kasprzak, 2023 [reference 163 in the revised manuscript]). Importantly, we have maintained the caveat that direct mechanistic studies connecting microbiota-derived signals to IGF axis regulation of tumor immunity have not been established, as overstating this connection would misrepresent the current evidence base.

Comment 3: Is there any discussion regarding the relationship between hereditary colorectal cancer and IGF? Does IGF influence the pathogenesis of familial adenomatous polyposis or Lynch syndrome?

Response 3: We thank the Reviewer for raising this question. The primary molecular drivers of FAP and Lynch syndrome operate through pathways that are mechanistically distinct from the IGF axis. While isolated studies have examined associations between IGF1 gene polymorphisms and hereditary nonpolyposis CRC susceptibility (Zecevic et al., 2006 [new reference 252 in the revised manuscript]), these findings have not been consistently replicated, and no mechanistic role for the IGF axis in FAP or Lynch syndrome pathogenesis has yet been established (Gligorijevic et al., 2022 [reference 29 in the revised manuscript]). We have added a brief acknowledgment of this limited evidence in the Strengths and Limitations discussion within Section 6 (line 1294), noting that a comprehensive investigation of IGF axis involvement in hereditary CRC syndromes represents an area warranting dedicated study beyond the scope of this review, which focuses on the bidirectional interactions between IGF signaling and immune regulation in sporadic CRC.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors had addressed most of the comments.

Follow-up comments: 

1. Publishing one or two papers before does not eliminate the risk of reporting and interpretation bias. Please mention the actions or procedures taken (to demonstrate how your team attempted to minimise these biases; as stated in the response), particularly after the Limitations.
2. Avoid using the term “systematic,” as you have not demonstrated a systematic approach to literature search, data extraction, or qualitative analysis.
3. Please move the strengths and limitations of the review to the Discussion section, rather than the Conclusion.
4. The Conclusion should be concise; please remove repetitive and unnecessary statements.

Author Response

We thank the reviewer for the continued engagement with our manuscript. Below we provide a point-by-point response to all R2 comments. Changes in the revised manuscript are highlighted in yellow.

Comment 1: Publishing one or two papers before does not eliminate the risk of reporting and interpretation bias. Please mention the actions or procedures taken to demonstrate how your team attempted to minimise these biases, particularly after the Limitations.

We thank the reviewer for this important observation and agree that prior publications alone do not mitigate bias. A dedicated paragraph has been added at the end of Section 6 (Discussion), immediately following the Limitations subsection [LINE 1287], outlining the methodological safeguards implemented during manuscript preparation.

 

Comment 2: Avoid using the term 'systematic,' as you have not demonstrated a systematic approach to literature search, data extraction, or qualitative analysis."

We thank the reviewer for the observation. The term "systematic" has been removed throughout the manuscript.

Comment 3: Please move the strengths and limitations of the review to the Discussion section, rather than the Conclusion.

We thank the reviewer for this recommendation. The manuscript structure has been revised accordingly. Section 6 (Discussion) now integrates the mechanistic synthesis, strengths and contributions, limitations, and the bias-mitigation procedures described in Comment 1. Section 7 (Conclusions) has been condensed to a single focused paragraph.

Comment 4: The Conclusion should be concise; please remove repetitive and unnecessary statements.

The Conclusion has been streamlined [LINE 1363] to include only the central synthesis of the IGF-immune bidirectional framework, its key translational implications for CRC biomarker development, and next steps. Redundant and overlapping content has been removed.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors still did not include all relevant publications relevant to their literature review and with mentioning alot of information with wrong citations or with no citations

Author Response

We thank the reviewer for their continued engagement. Below we provide a point-by-point response to all R2 comments. Changes in the revised manuscript are highlighted in yellow.

Comment 1: The authors still did not include all relevant publications relevant to their literature review and with mentioning a lot of information with wrong citations or with no citations.

Thank you for your comment. To address this concern constructively, we have expanded two sections of the Introduction to incorporate additional literature directly relevant to the IGF-immune framework developed in this review:

• Section 1.2.2 (Downstream Signaling Pathways) has been expanded [LINE 128] to explicitly connect IGF-1R-activated PI3K/AKT/mTOR and MAPK/ERK cascades to their downstream effects on the immune microenvironment, including M2 macrophage polarization, Treg expansion, MDSC-mediated immunosuppression, and convergence on the PD-L1 promoter.
• Section 1.2.4 (Post-Transcriptional Regulation of IGF Components by Non-Coding RNAs) has been expanded [LINE 205] to incorporate additional ncRNA regulators of the IGF axis with documented roles in colorectal cancer, strengthening the mechanistic bridge between post-transcriptional IGF regulation and immune evasion in CRC.

Regarding the comprehensiveness of our review’s coverage, the convergence between IGF signaling and the immune system in colorectal cancer is an emerging field. We have taken care to include the literature’s top cited articles at this nexus, including Stefani, et al. (2021) and Zhou, et al. (2021), while summarizing connections between IGF signaling and tumor immunity to capture the current state of the field.

With respect to the concern regarding incorrect or missing citations, we have examined the manuscript and made targeted refinements where appropriate, including the addition of supporting references in Section 4.3.2 and minor citation and wording adjustments in select passages to improve precision. Unnecessary citations were removed from Table 1. We would also note that, consistent with the conventions of narrative reviews, certain passages represent integrative synthesis and authorial interpretation connecting the cited literature rather than restatements of a single primary source; in these cases, the absence of an adjacent citation is intentional, as the sentence functions as a connective or interpretive bridge between the works cited on either side. Should the reviewer wish to identify specific publications they consider essential to the framework developed here, we would welcome the opportunity to incorporate them in a subsequent revision.

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

The authors fulfilled all the required reviewers comments