Inter-Rater Agreement for Diagnosing Adenomyosis Using Magnetic Resonance Imaging and Transvaginal Ultrasonography

Round 1

Reviewer 1 Report

The authors presented Inter-rater agreement for diagnosing adenomyosis using Magnetic Resonance Imaging and Transvaginal Ultrasonography. Imaging examinations show “impression” for lesions but not definite diagnosis. Without definite diagnosis, it could be hard to be recognized. I suggest images correlated to pathology study should be mentioned in this article.

 Minor editing of English language required

Author Response

Thanks for your valuable comments,

As this is a consecutive series of women with a clinical suspicion of adenomyosis, we do not have histological assessment in all women as the vast majority did not undergo surgery. Moreover, we did not aim to correlate MRI and TVS to histololgy as this have been investigated elsewhere, while instead focus on assessing inter-rater agreement, and for this comparison, god standard should not be considered obligatory. This have been clarified in the discussion section. "

It is important to point out that we included consecutive women with a clinical suspicion of adenomyosis, representing a real-life setting, where image quality was not optimal in all cases, and histological outcome not available in the majority of women, as they underwent medical treatment. As our aim was not to correlate TVS and MRI to histology, but to assess inter-rater agreement, is a clinical setting, therefore we find it acceptable not to have a gold standard for comparison."

You are indeed right that it would be valuable if the sonographic and radiographic findings could be correlated to a histological diagnosis

Reviewer 2 Report

The authors of this study report higher inter inter-rater agreement for diagnosing adenomyosis for TVS compared to MRI. It is a well written manuscript. In the methods section the authors should explain whether this is a prospective study or a retrospective analsis of prospectively collected data. In addition, the authors should explain why the recruitment period is only 3 years. Why did the authors not choose longer recruitment period in order to include higher number of patients. Apart from that I have no specific comments.

Author Response

Thanks you for your valuable questions.

Indeed this was a prospective study including consecutive women with a clinical suspicion of adenomyosis, while the off-line analysis by the external reviewers was undertaken, retrospectively. This has been clarified both in the abstract section and in the methods section.

With regard to sample size. Prior to starting the study we consulted a statistician that recommended us to include at least 50 women and at least 4-5 MRI and TVS examiners respectively, as this would suffice for an inter-observer reproducibility study.