Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Sellar Solitary Fibrous Tumor Mimicking Pituitary Adenoma: Diagnostic Pitfalls 2
and Radiological–Pathological Correlation

Abstract:

Define “NAB2–STAT6 and STAT6”.

Keywords: pituitary adenoma mimic is not a popular keyword. I would suggest to change it pituitary adenoma.

Case presentation:

Table 1: Design it with horizontal lines top and below the first row and also one additional bottom horizontal line like ISI standard tables with three horizontal lines.

I am not sure this is a correct terminology “binostril”.

Figure 1: The coronal images are not labeled.

Figure 4: Again coronal images should be labeled properly. I guess we do not need multiple postop images to prove there is no residual disease.

Discussion:

I believe radiological explanation is not enough since readers need to have a better idea how these lesions would be differentiated from adenoma. I believe there is at least few advanced MRI sequences for differentiating or at least suggest the diagnosis of SFT on MRI such as SWI and DCE and MRS.

Conclusion:

Please summarize it and be more concise. Just talk about the take home message for the reader here.

Table 2: Table design is not appropriate. Please redesign it with three bold horizontal lines.

 

 

 

Author Response

Response to Reviewer 1 Comments

We sincerely thank the reviewer for the constructive overall assessment of our manuscript. We carefully considered all comments and have comprehensively revised the manuscript accordingly. Specifically, the Introduction has been expanded and updated with additional background information and recent references, including the molecular basis of SFT and the 2021 WHO classification. The Case Presentation and Methods have been clarified with additional clinical, radiological, surgical, and pathological details. The Discussion has been substantially strengthened by incorporating contemporary evidence from larger intracranial SFT series, current risk stratification models, and updated management considerations. The Conclusions have also been revised to more accurately reflect the findings and avoid overinterpretation. We believe these revisions have significantly improved the scientific quality, clarity, and clinical relevance of the manuscript.

 

Point-by-point response to Comments and Suggestions for Authors

 

Comments 1: Abstract: Define “NAB2–STAT6 and STAT6”.

Response: We thank the reviewer for this helpful suggestion. The Abstract and Introduction have been revised to clarify that nuclear STAT6 expression represents the most reliable immunohistochemical surrogate marker for the NAB2–STAT6 fusion, which is the molecular hallmark of solitary fibrous tumor.

 

Comments 2: Keywords: pituitary adenoma mimic is not a popular keyword. I would suggest to change it pituitary adenoma.

Response: Thank you for the suggestion. The keyword "pituitary adenoma mimic" has been replaced with "pituitary adenoma" to improve indexing and consistency with the manuscript.

 

Comments 3: Case presentation: Table 1: Design it with horizontal lines top and below the first row and also one additional bottom horizontal line like ISI standard tables with three horizontal lines.

Response: Table 1 has been reformatted according to the journal style using a three-line table format.

 

Comments 4: I am not sure this is a correct terminology “binostril”.

Response: We appreciate this comment. The terminology has been revised throughout the manuscript to "binostril endoscopic endonasal transsphenoidal resection", which more accurately reflects the surgical approach.

 

Comments 5: Figure 1: The coronal images are not labeled. Figure 4: Again coronal images should be labeled properly. I guess we do not need multiple postop images to prove there is no residual disease.

Response: Figure 1 and Figure 4 have been revised. Coronal images are now appropriately labeled, and arrows have been added to highlight the cavernous sinus involvement and the postoperative enhancing focus, respectively.

 

Comments 6: Discussion: I believe radiological explanation is not enough since readers need to have a better idea how these lesions would be differentiated from adenoma. I believe there is at least few advanced MRI sequences for differentiating or at least suggest the diagnosis of SFT on MRI such as SWI and DCE and MRS.

Response: We thank the reviewer for this valuable suggestion. The Discussion has been substantially expanded to include advanced MRI techniques, including susceptibility-weighted imaging (SWI), dynamic contrast-enhanced MRI, diffusion-weighted imaging, and magnetic resonance spectroscopy. We also discuss their potential diagnostic contribution and current limitations in differentiating sellar SFT from pituitary adenoma.

 

Comments 7: Conclusion: Please summarize it and be more concise. Just talk about the take home message for the reader here.

Response: The Conclusion has been completely revised and condensed to emphasize the principal diagnostic and clinical take-home messages while avoiding overinterpretation of the present findings.

 

Comments 8: Table 2: Table design is not appropriate. Please redesign it with three bold horizontal lines.

Response: Table 2 has been completely redesigned using the journal's recommended three-line format. In addition, the table has been expanded into a diagnostic and management matrix by incorporating new columns for Initial Clinical Diagnosis, Extent of Resection, Adjuvant Therapy, and Follow-up/Recurrence, substantially increasing its clinical utility.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I have reviewed this manuscript . . Overall, this is a solid, well-written case report with a focused literature synthesis that adds value to the sparse body of knowledge on sellar solitary fibrous tumors (SFTs). The case is representative, the radiological–pathological correlation is nicely presented, and the emphasis on intraoperative clues and STAT6 immunohistochemistry is clinically relevant. I recommend minor to moderate revisions before acceptance.

Major Comments

1.  Novelty and Timing
The topic is not entirely new, but the timing is good. With the 2021 WHO classification now more widely adopted and STAT6 staining becoming routine in many centers, this paper arrives at a useful moment. However, you should explicitly acknowledge in the Discussion (perhaps in the first or second paragraph) that several recent 2024–2025 cases (which you already cite) are also using modern terminology and STAT6. This would strengthen rather than weaken your contribution by positioning your work as part of an emerging, better-characterized cohort.

2.  Table 2 – Literature Review
This is the strongest part of the paper and deserves polishing. Several entries still list “NA” for STAT6 and WHO grade even in relatively recent cases where this information is likely available in the original publications. I suggest you make another pass through the more recent references (2020 onward) and fill in missing data where possible, or clearly note that you attempted to extract it but it was not reported. Also, consider adding a column for “Extent of Resection” and “Adjuvant Therapy / Recurrence” — this would make the table far more useful for surgeons deciding on management.

3.  Management Discussion – Adjuvant Therapy
Your decision to observe after GTR in a grade 3 SFT is reasonable and courageously stated, but it needs more nuance. Many neurosurgeons (myself included) would still lean toward early adjuvant radiosurgery or fractionated RT for grade 3 lesions given the known metastatic potential of CNS SFT/HPC, even after apparent GTR. You should expand this section with a short paragraph discussing:

•  Reported recurrence rates after GTR vs STR in high-grade SFT.

•  The role of Ki-67 (yours was 15% — relatively high) and mitotic count in risk stratification.

•  Current NCCN or EANO guidance (if any) or at least reference larger CNS SFT series beyond the sellar literature.
Your 1-year follow-up is too short to confidently support a “surveillance only” approach as a general recommendation. Frame it more cautiously as “may be considered in select cases with close imaging surveillance.”

Minor Comments

•  Abstract: Very good, but the sentence “Nuclear STAT6 expression has become a key diagnostic marker for this entity” could be strengthened to “…and is now considered the gold-standard immunohistochemical surrogate for the NAB2–STAT6 fusion.”

•  Case Presentation:
The intraoperative description is excellent and one of the most valuable parts for practicing surgeons. Consider adding a brief comment on whether you used any specific hemostatic techniques beyond what is mentioned (e.g., bipolar, flowable hemostats, or temporary packing strategies) that might be helpful for readers facing similar bleeding.

•  Figures:
Image quality is adequate. Figure 1 and 4 would benefit from arrows highlighting the cavernous sinus involvement and the small residual nodular enhancement at follow-up, respectively. This helps readers who are not neuroradiologists.

•  Pathology:
Nice correlation. It would be helpful to mention whether CD34, BCL-2, or vimentin staining was performed (even if only briefly) as these are classically positive in SFT and sometimes useful when STAT6 staining is equivocal.

•  Language and Style:
The English is generally clear and professional. A few awkward phrasings:

•  Page 3: “its reliability was limited due to suboptimal patient cooperation” → consider “visual field testing was unreliable due to poor patient cooperation.”

•  Several instances of “n the present case” (typo, missing “I”).

•  “Intraoperatively, the lesion was noted to be unexpectedly hypervascular and firm” — excellent sentence; keep it.

•  References:
Mostly up-to-date. Reference 16 (Persico et al. 2025) is appropriately recent. Ensure all DOIs are active and formatting is consistent with journal style.

Author Response

Response to Reviewer 2 Comments

We sincerely thank the reviewer for the careful evaluation of our manuscript and for the encouraging comments regarding its scientific merit and clinical relevance. We are grateful for the positive assessment of the radiological–pathological correlation, the emphasis on intraoperative diagnostic clues, and the discussion of STAT6 immunohistochemistry. We also appreciate the constructive suggestions for improvement.

In response to the reviewer's comments, we have thoroughly revised the manuscript. The Introduction has been expanded to include additional background on the molecular basis of solitary fibrous tumors, the NAB2–STAT6 fusion, and the current WHO classification. The Case Presentation has been clarified with additional radiological, surgical, and pathological details. The Discussion has been substantially strengthened by incorporating recent literature, larger intracranial SFT series, contemporary risk stratification models, and updated considerations regarding postoperative management and adjuvant radiotherapy. The figures, tables, and figure legends have also been revised to improve clarity, and the entire manuscript has undergone comprehensive English language editing to improve readability and scientific precision.

We believe these revisions have substantially improved the quality, clarity, and clinical relevance of the manuscript, and we sincerely appreciate the reviewer's thoughtful suggestions, which have strengthened our work.

files.

 

Comments 1: 1.  Novelty and Timing: The topic is not entirely new, but the timing is good. With the 2021 WHO classification now more widely adopted and STAT6 staining becoming routine in many centers, this paper arrives at a useful moment. However, you should explicitly acknowledge in the Discussion (perhaps in the first or second paragraph) that several recent 2024–2025 cases (which you already cite) are also using modern terminology and STAT6. This would strengthen rather than weaken your contribution by positioning your work as part of an emerging, better-characterized cohort.

Response: We appreciate this important suggestion. The Discussion has been revised to acknowledge recent reports published after implementation of the 2021 WHO classification. The manuscript now places the present case within the context of this emerging cohort of STAT6-confirmed sellar SFTs and discusses the impact of contemporary pathological classification on diagnosis and management.

Comments 2: Table 2 – Literature Review. This is the strongest part of the paper and deserves polishing. Several entries still list “NA” for STAT6 and WHO grade even in relatively recent cases where this information is likely available in the original publications. I suggest you make another pass through the more recent references (2020 onward) and fill in missing data where possible, or clearly note that you attempted to extract it but it was not reported. Also, consider adding a column for “Extent of Resection” and “Adjuvant Therapy / Recurrence” — this would make the table far more useful for surgeons deciding on management.

Response: Thank you for recognizing Table 2 as a strength of the manuscript. We carefully re-reviewed all available publications, particularly those published from 2020 onward, and updated the table wherever additional information could be extracted from the original reports. We also redesigned Table 2 as a comprehensive diagnostic and management matrix by adding columns for Initial Clinical Diagnosis, Extent of Resection, Adjuvant Therapy, and Follow-up/Recurrence. When information was unavailable in the original publication, this is now explicitly indicated as NR (not reported) in both the table and the accompanying notes.

 

Comments 3: Management Discussion – Adjuvant Therapy. Your decision to observe after GTR in a grade 3 SFT is reasonable and courageously stated, but it needs more nuance. Many neurosurgeons (myself included) would still lean toward early adjuvant radiosurgery or fractionated RT for grade 3 lesions given the known metastatic potential of CNS SFT/HPC, even after apparent GTR. You should expand this section with a short paragraph discussing:

• Reported recurrence rates after GTR vs STR in high-grade SFT.
• The role of Ki-67 (yours was 15% — relatively high) and mitotic count in risk stratification.
• Current NCCN or EANO guidance (if any) or at least reference larger CNS SFT series beyond the sellar literature.
  Your 1-year follow-up is too short to confidently support a “surveillance only” approach as a general recommendation. Frame it more cautiously as “may be considered in select cases with close imaging surveillance.”

Response: We thank the reviewer for this insightful recommendation. The Discussion has been substantially expanded. We corrected the pathological grading according to the 2021 WHO classification, incorporated discussion of Ki-67 as a complementary prognostic marker, added the validated risk stratification model proposed by Demicco et al., and included evidence from larger intracranial SFT series (including Fargen et al., Rutkowski et al., and Schiariti et al.) regarding recurrence patterns and postoperative radiotherapy. In addition, the wording regarding postoperative surveillance has been revised to a more cautious interpretation, emphasizing that surveillance may be considered in carefully selected patients following gross total resection rather than representing a general recommendation.

 

Comments 4: Abstract: Very good, but the sentence “Nuclear STAT6 expression has become a key diagnostic marker for this entity” could be strengthened to “…and is now considered the gold-standard immunohistochemical surrogate for the NAB2–STAT6 fusion.”

Response: The Abstract has been revised accordingly. The description of STAT6 has been strengthened and now emphasizes its role as the principal immunohistochemical surrogate marker for the NAB2–STAT6 fusion.

 

Comments 5: Case Presentation: The intraoperative description is excellent and one of the most valuable parts for practicing surgeons. Consider adding a brief comment on whether you used any specific hemostatic techniques beyond what is mentioned (e.g., bipolar, flowable hemostats, or temporary packing strategies) that might be helpful for readers facing similar bleeding.

Response: Additional intraoperative details have been included in the Case Presentation. The manuscript now specifies the hemostatic techniques used during surgery, including oxidized regenerated cellulose, gelatin–thrombin matrix, oxidized cellulose polymer, and meticulous bipolar coagulation.

 

Comments 6: Figures: Image quality is adequate. Figure 1 and 4 would benefit from arrows highlighting the cavernous sinus involvement and the small residual nodular enhancement at follow-up, respectively. This helps readers who are not neuroradiologists.

Response: Arrows have been added to Figure 1 and Figure 4 to improve visualization of the cavernous sinus involvement and postoperative imaging findings, respectively.

 

Comments 7: Pathology: Nice correlation. It would be helpful to mention whether CD34, BCL-2, or vimentin staining was performed (even if only briefly) as these are classically positive in SFT and sometimes useful when STAT6 staining is equivocal.

Response: The pathology section has been expanded. In addition to STAT6, we now report the results of SSTR2, TTF-1, synaptophysin, and S-100 immunohistochemistry to better document the differential diagnostic process. We also discuss the complementary role of CD34, BCL-2, and CD99 in the Discussion.

 

Comments 8: Language and Style:The English is generally clear and professional. A few awkward phrasings: •  Page 3: “its reliability was limited due to suboptimal patient cooperation” → consider “visual field testing was unreliable due to poor patient cooperation.” •  Several instances of “n the present case” (typo, missing “I”). •  “Intraoperatively, the lesion was noted to be unexpectedly hypervascular and firm” — excellent sentence; keep it.

Response: The manuscript has undergone comprehensive language editing. The suggested wording has been adopted where appropriate, typographical errors have been corrected, and the manuscript has been carefully revised for grammar, clarity, and readability throughout.

 

Comments 9: References: Mostly up-to-date. Reference 16 (Persico et al. 2025) is appropriately recent. Ensure all DOIs are active and formatting is consistent with journal style

Response: The reference list has been thoroughly updated. Citation formatting has been standardized according to the journal style, DOIs have been verified, and several recent publications relevant to diagnosis, pathological classification, prognostic stratification, and postoperative management have been incorporated.

Reviewer 3 Report

Comments and Suggestions for Authors

I believe this is a well-presented case report that effectively illustrates a very rare entity.

I have no other major issues; however, since line 106 states that there is no necrosis, according to the 2021 WHO classification:

CNS WHO grade 1: < 2.5 mitoses/mm² (< 5 mitoses/10 HPF)
CNS WHO grade 2: ≥ 2.5 mitoses/mm² (≥ 5 mitoses/10 HPF) without necrosis
CNS WHO grade 3: ≥ 2.5 mitoses/mm² (≥ 5 mitoses/10 HPF) with necrosis

Based on this updated classification, I understand that this SFT would be more appropriately classified as CNS WHO grade 2.

Author Response

Response to Reviewer 3 Comments

We sincerely thank the reviewer for the careful evaluation of our manuscript and for the positive comments regarding its presentation and clinical relevance.

 

Comments 1: I have no other major issues; however, since line 106 states that there isno necrosis, according to the 2021 WHO classification: CNS WHO grade 1: < 2.5 mitoss/mm² (< 5 mitoses/10 HPF), CNS WHO grade 2: ≥ 2.5 mitoses/mm² (≥ 5 mitoses/10 HPF) without necrosis, CNS WHO grade 3: ≥ 2.5 mitoses/mm² (≥ 5 mitoses/10 HPF) with necrosis. Based on this updated classification, I understand that this SFT would be more appropriately classified as CNS WHO grade 2.

Response: We sincerely thank the reviewer for identifying this important issue. We fully agree with the comment. Following the 2021 WHO Classification of Tumors of the Central Nervous System, the tumor has been reclassified from CNS WHO grade 3 to CNS WHO grade 2, as the lesion demonstrated six mitoses per 10 high-power fields in the absence of tumor necrosis. This correction has been implemented consistently throughout the manuscript, including the Abstract, Case Presentation, Discussion, Conclusions, Table 2, and Figure legends where applicable.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors
Thank you for your careful revisions. I have reviewed the updated manuscript, and I am pleased to confirm that it is now in its most complete and refined
form.
Congratulations on the excellent work!
Best regards,