Precision-Oriented Reconstruction After Spinal Sarcoma Resection: Integrating Surgical Strategy, Biologic Risk, and Emerging Technologies

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors propose a Precision-Oriented Reconstructive Decision Framework, integrating tumor biology, host environment, and anatomic level, and recommend selecting reconstructive strategies based on a Precision-Oriented Reconstructive Ladder for Spinal Soft Tissue Sarcoma (STS).

However, the current manuscript raises several important concerns.

First, there is a critical issue regarding terminology and cohort definition. The title refers to “spinal sarcoma,” which is generally understood to indicate primary bone sarcomas arising in the spine. In contrast, the main text repeatedly uses the term “spinal soft tissue sarcoma.” Furthermore, the study cohort appears to include not only soft tissue sarcomas but also bone sarcomas, and possibly even cases of bone metastases and infection. This inconsistency in terminology and case definition is highly problematic, as it creates substantial confusion for readers and undermines the scientific rigor of the manuscript. A thorough and systematic revision is required to ensure consistency between the title, definitions, and study population.

Second, while the authors present multiple reconstructive options—such as hybrid patient-specific implants (PSI) combined with vascularized bone grafts (VBG), free VBG, pedicled VBG, implant-based reconstruction, structural reconstruction, and foundation techniques—the manuscript lacks sufficient granularity regarding clinical decision-making. Specifically, it remains unclear under which combinations of tumor biology, host environment, and anatomic level each reconstructive modality should be selected. The current description remains overly conceptual and does not provide actionable guidance for clinical practice.

To enhance the clinical applicability of the proposed framework, the authors should provide more detailed stratification or decision algorithms. For example, clearly defined scenarios or representative cases illustrating how specific biological, host-related, and anatomical factors lead to particular reconstructive choices would be highly valuable.

Finally, several statements are overly vague and should be revised for clarity and precision. For instance, the assertion that “the timing of systemic therapy (chemotherapy or immunotherapy) influences the viability of the reconstructive environment” lacks sufficient specificity. The authors should explicitly describe the mechanisms, clinical contexts, and practical implications of such interactions, rather than relying on general or ambiguous phrasing.

In summary, while the concept of a precision-oriented reconstructive framework is potentially valuable, substantial revisions are necessary to ensure terminological consistency, clarify the study population, and improve the specificity and clinical utility of the proposed decision-making strategy.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses a clinically relevant and challenging topic, and the integration of tumor biology, host factors, and reconstructive strategy is conceptually valuable. The figures and overall structure are clear. However, several important issues need to be addressed.

First, there is a major inconsistency in scope. The review is presented as focusing on “spinal soft tissue sarcomas,” but it extensively includes chordoma, chondrosarcoma, osteosarcoma, and Ewing sarcoma. These entities are primarily bone tumors or mixed categories. The title, inclusion criteria, and discussion should be aligned accordingly.

Second, the methodology of the narrative review is not sufficiently reproducible. The authors should provide detailed search strategies, timeframes, and a clearer description of study selection.

Third, the proposed “precision-oriented reconstructive ladder” is interesting but remains a conceptual framework. This should be explicitly emphasized in the abstract and conclusions to avoid implying a validated clinical algorithm.

Finally, the reference list appears somewhat unbalanced, with over-representation of narrative and affiliated publications. Inclusion of more independent systematic reviews and guideline-level evidence would strengthen the manuscript.

Overall, major revision is recommended to improve conceptual clarity, methodological rigor, and balance of the literature.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Editor, dear authors,

 

thank you very much for giving me the opportunity to review the article “Precision-Oriented Reconstruction After Spinal Sarcoma Resection: Integrating Surgical Strategy, Biologic Risk, and Emerging Technologies“ submitted to the journal “Cancers”. This is an interesting article addressing the important field of soft tissue reconstruction after spinal sarcoma resection.

 

However, there are several points that should be addressed.

 

Major concerns:

1. Results of the review should be presented in a separate paragraph.
2. Conclusion should be shortened.

 

Minor concerns:

1. Page 5, line 155-159: “The landmark O'Sullivan et al. randomized trial comparing. “
   1. Should be changed into: Randomized trial by O’Sullivan et al. comparing…
2. Figure 2 is not readable. Colors should be changed.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have appropriately revised the manuscript in response to the reviewers’ comments and improved it.

Author Response

Comments 1: The authors have appropriately revised the manuscript in response to the reviewers’ comments and improved it.

Response 1: Thank you for your time in reviewing our work.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors, thank you very much for revising the article. However, figure 2 is still not readable. Quality should be improved and colours may be changed.

Author Response

Comments 1: Dear authors, thank you very much for revising the article. However, figure 2 is still not readable. Quality should be improved and colours may be changed.

Response 1: Figure 2 has been updated so that the text is larger and has higher contrast against the background, unnecessary colors have been removed though the content of the ladder is unchanged. Thank you for these suggestions.