Desmoplastic Fibromas of the Bone: A Systematic Review of Clinical Presentation and Surgical Treatment

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This systematic review addresses a less common but still clinically important entity, desmoplastic fibroma of the bone, and provides a valuable synthesis of its clinical presentation and surgical management. The topic is relevant to orthopedic oncology and pathology specialists, and the authors have made an effort to summarize scattered case reports and small series. Overall, the paper contributes meaningful information, but several aspects require clarification and refinement to strengthen its scientific rigor and readability.

 

1. A PRISMA flow diagram is mentioned; however, it could be expanded to include the precise number of articles screened, duplicates removed, and the reasons for exclusion at each stage.
2. It is also unclear whether the included studies underwent any form of quality or bias assessment. Although most of the data derive from case reports, undertaking a formal appraisal—such as using the CARE guidelines or the Joanna Briggs Institute checklist—would substantially enhance the credibility of the conclusions.
3. The summary tables are informative but could be reorganised for greater clarity. Grouping the data by anatomical site, age group, or surgical approach may help to illustrate underlying trends more effectively.
4. The authors are encouraged to summarise relevant studies that have investigated the pathogenesis of the disease.

Author Response

Dear Reviewer,

 

Thank you for your help and your suggestions to increase the quality of our paper.

 

Please, find reported below our answers to your suggestions:

 

• A PRISMA flow diagram is mentioned; however, it could be expanded to include the precise number of articles screened, duplicates removed, and the reasons for exclusion at each stage.

As required, we updated our PRISMA flow diagram (Figure 2; Lines 143-144).

 

• It is also unclear whether the included studies underwent any form of quality or bias assessment. Although most of the data derive from case reports, undertaking a formal appraisal—such as using the CARE guidelines or the Joanna Briggs Institute checklist—would substantially enhance the credibility of the conclusions.

We agree with you. Therefore, we used the Joanna Briggs Institute (JBI) Critical Appraisal tools to assess the quality of the case series included in our systematic review (Lines 164-168 and Lines 181-191).

 

• The summary tables are informative but could be reorganised for greater clarity. Grouping the data by anatomical site, age group, or surgical approach may help to illustrate underlying trends more effectively.

Although we agree that further stratification of data would be desirable, the majority of the most extensive series did not provide stratified information for each case, thereby limiting our ability to provide a reliable, comprehensive stratification of some data and impeding the identification of significant correlations. However, our results section aimed to highlight the distribution in anatomical sites, age, and surgical approaches in the clearest possible way. As far as we are concerned, all the feasible efforts had already been made in the previous version of our manuscript.

 

• The authors are encouraged to summarise relevant studies that have investigated the pathogenesis of the disease.

We agree that our manuscript would benefit from a focus on the molecular and pathogenetic characteristics of desmoplastic fibromas of the bone. While the pathogenesis remains debated and poorly understood, some data could be added to our introduction (88-95).

 

We also tried our best to improve the quality of our English grammar, removing some typos and rephrasing some sentences that were hard to read. We also used Grammarly Pro to improve our English further.

 

 

We look forward to your response, and we are available for any further change you consider necessary.

 

Best regards

Reviewer 2 Report

Comments and Suggestions for Authors

I appreciated very much this topic. Moreover, I found the structure of the article solid.

I suggest You to enhance/expand the radiological features of this rare entity.

At this aim I suggest tò:

1) in the radiological description in the introduction section, I uggest You tò include a description of the transitional zone/Borders according tò Lodwick and Madewell grading ( Please see this recent ref  PMID: 39718620).

2) Please, briefly report the radiological appearence of the lesions in the included article, if the information Is present. Consider also ti add a column in the summarizing table including main radiological pattern.

3) I suggest to enrich the graphical part of the manuscript with at least One figure (e.g. x.rays and/or mri pattern in One or two cases )

4) I suggest tò refer to the last WHO in introduction for definition of this entity and initial description

Congratulations for the work done.

Author Response

 

Dear Reviewer,

 

Thank you for your help and your suggestions to increase the quality of our paper.

 

Please, find reported below our answers to your suggestions:

 

• In the radiological description in the introduction section, I suggest you to include a description of the transitional zone/Borders according to Lodwick and Madewell grading ( Please see this recent ref  PMID: 39718620).
  As suggested, we provided more information on the radiographic presentation of DFs, also referring to the narrow transitional zone and to the Lodwick and Madewell classification. The provided article was cited.
  
  
• Please, briefly report the radiological appearance of the lesions in the included article, if the information is present. Consider also to add a column in the summarizing table including the main radiological pattern.

Although we respect your point, please note that the focus of our manuscript was on the clinical presentation and surgical treatment. Furthermore, only a few of the included articles were truly informative about the radiographic patterns of the examined lesions. Finally, as orthopedic surgeons, we lack the expertise to manage this information effectively. For all these reasons, we preferred not to add a dedicated column in the summary table.

 

• I suggest enriching the graphical part of the manuscript with at least one figure (e.g. x.rays and/or MRI pattern in One or two cases).

We were pleased to follow your suggestion, including MRI images in our introduction (Lines 77-79)

 

• I suggest to refer to the last WHO in the introduction for the definition of this entity and the initial description.

Referral to the latest WHO classification has been included in the latest version of our manuscript (Lines 48-50)

 

 

We look forward to your response, and we are available for any further change you consider necessary.

 

Best regards

Reviewer 3 Report

Comments and Suggestions for Authors

Interesting and relevant subject.

I would appreciate if the Authors write more about recommended diagnostic tools needed for diagnostics (only x-ray and biopsy ?), potential diagnostic difficulties and errors, and how often it happens?.

In abstract Authors write that the lower limb was the most common localization followed by the lower limb ...

27% of patients with desmoplastic fibroma did not report any pain. If so, so what was the reason that any diagnostics started?

This study is a retrospective one. What was the reason that some doctors choose curettage and some of them resection. Any criteria ?

Comments on the Quality of English Language

Interesting and relevant subject.

I would appreciate if the Authors write more about recommended diagnostic tools needed for diagnostics (only x-ray and biopsy ?), potential diagnostic difficulties and errors, and how often it happens?.

In abstract Authors write that the lower limb was the most common localization followed by the lower limb ...

27% of patients with desmoplastic fibroma did not report any pain. If so, so what was the reason that any diagnostics started?

This study is a retrospective one. What was the reason that some doctors choose curettage and some of them resection. Any criteria ?

Author Response

Dear Reviewer,

 

Thank you for your help and your suggestions to increase the quality of our paper.

 

Please, find reported below our answers to your suggestions:

 

• I would appreciate if the Authors write more about recommended diagnostic tools needed for diagnostics (only x-ray and biopsy ?), potential diagnostic difficulties and errors, and how often it happens?
  X-rays are commonly the first step in the diagnostic pathway, which is generally followed by CT and MRI scans, as already reported in the previous version of our manuscript. To clarify, we provided additional information on the radiological characteristics of DFs (Lines 67-73). While no data on errors in diagnosing DFs were available, we also included the differential diagnosis with radiographically similar lesions in Lines 80-83.
  More details were also provided about the histological and histochemical characteristics of the tumor (Lines 88-95).
  
  
• In abstract Authors write that the lower limb was the most common localization followed by the lower limb ...

We apologize for the mistake. It has been corrected in the new version of our manuscript (Line 29)

 

• 27% of patients with desmoplastic fibroma did not report any pain. If so, so what was the reason that any diagnostics started?

In cases that did not experience any pain, the diagnostic pathway was initiated by either localized swelling, pathologic fractures, or lesions diagnosed incidentally during investigations of trauma or other diseases (Lines 228-230).

 

• This study is a retrospective one. What was the reason that some doctors choose curettage and some of them resection. Any criteria?

In general, curettage is preferred for relatively short-sized lesions, bones without massive cortical thinning or scalloping, or areas where bone reconstructions can be extremely challenging due to their tridimensional shape or anatomical location. In the remaining cases, resections are generally preferred. This information was already reported in our discussion in the dedicated area (Lines 351-375).

 

We also tried our best to improve the quality of our English grammar, removing some typos and rephrasing some sentences that were hard to read. We also used Grammarly Pro to improve our English further.

 

 

We look forward to your response, and we are available for any further change you consider necessary.

 

Best regards

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I am satisfied with the revisions performed.

I agree that, being a clinical and surgical-oriented review, the exact description of imaging findings can be avoided, especially in cases where the literature data are limited.

In Figure 1, please indicate the MRI sequences (they seem fluid-sensitive ones); and I would add into the figure legends that a multi-cystic appearance is present.

Thank You

Author Response

Dear Reviewer,

Thank you for your help and your suggestions to increase the quality of our paper.

Please, find reported below our answer to your suggestion:

In Figure 1, please indicate the MRI sequences (they seem fluid-sensitive ones); and I would add into the figure legends that a multi-cystic appearance is present.
As suggested, we indicated the MRI sequences for both subfigures A and B. We also reported on the multi-cystic appearance of the lesion (Lines 77-78). 

We look forward to your response, and we are available for any further change you consider necessary.

Best regards