The Role of Imaging Techniques in the Evaluation of Extraglandular Manifestations in Patients with Sjögren’s Syndrome

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This radiological summary provides useful and up-to-date systematic diagnostic tools for the investigation of different organ involvement in Sjögren's syndrome and patient follow-up. Since Sjögren's syndrome is not a rare disease, this summary will be of interest to general practitioners, also other specialists. The article highlights the growing role of the ultrasound examination in organ diagnostics and patient follow-up.

The authors have not followed the PRISMA guidelines recommended by the Diagnostics journal for reviews. There is no Methods” part at all in the manuscript, however, this narrative description is easier to understand. A brief methods part is still badly missing.  

The presented organ diagnostics of the manifestations of Sjögren’s sy. are understandable and clear. The figures would require more detailed descriptions and/or arrows for non-radiologist medical professionals in captions of the ultrasound photos and MRI photos.

English language and style are fine. The references are appropriate.

Author Response

Comment 1: This radiological summary provides useful and up-to-date systematic diagnostic tools for the investigation of different organ involvement in Sjögren's syndrome and patient follow-up. Since Sjögren's syndrome is not a rare disease, this summary will be of interest to general practitioners, also other specialists. The article highlights the growing role of the ultrasound examination in organ diagnostics and patient follow-up.

Response 1: We thank the Reviewer for the positive and encouraging evaluation of our manuscript and for recognizing its clinical relevance for both general practitioners and other specialists. We are pleased that the growing role of ultrasound in organ diagnostics and patient follow-up in Sjögren’s syndrome was clearly highlighted.

Comment 2: The authors have not followed the PRISMA guidelines recommended by the Diagnostics journal for reviews. There is no “Methods” part at all in the manuscript, however, this narrative description is easier to understand. A brief methods part is still badly missing.

Response 2: We thank the Reviewer for this critical comment. We agree that a Methods section was missing in the original submission. Although the manuscript is intended as a narrative review, we have now added a brief Methods section that describes the literature search strategy, the databases consulted, the key search terms, and the selection approach. This section has been added to the revised manuscript on page 2, paragraphs 6-7, lines 64-78.

This narrative review was based on a focused literature search conducted in PubMed/MEDLINE to identify publications addressing the role of imaging in systemic (extraglandular) manifestations of Sjögren’s syndrome. The search combined Medical Subject Headings (MeSH) and free-text terms related to Sjögren’s syndrome with imaging modalities, including ultrasonography, elastography, computed tomography/high-resolution computed tomography, and magnetic resonance imaging, as well as organ-specific terms referring to musculoskeletal, pulmonary, neurological, and lymphoproliferative involvement. Additional relevant articles were identified through manual screening of reference lists from selected publications. The retrieved evidence was qualitatively analyzed and synthesized, and the results are presented in a narrative format.

All diagnostic imaging figures (ultrasound, elastography, computed tomography, and magnetic resonance imaging) are original and belong to the authors; they were acquired during routine clinical care and fully anonymized before inclusion. The images are presented for illustrative purposes in this narrative review.

 

Comment 3: The presented organ diagnostics of the manifestations of Sjögren’s sy. are understandable and clear. The figures would require more detailed descriptions and/or arrows for non-radiologist medical professionals in captions of the ultrasound photos and MRI photos.

Response 3: We thank the Reviewer for this constructive suggestion and fully agree. In response, we have revised all figure legends, particularly those related to ultrasound and MRI, by:

• Expanding the descriptions to explain imaging findings in a manner accessible to non-radiologist medical professionals
• Clearly indicating pathological findings using arrows and symbols, where appropriate
• Specifying imaging modalities, sequences, and planes
• Adding brief explanatory context to each legend

These changes can be found throughout the revised figure legends on pages 5 (Figure 1 - lines 139-143), 6 (Figure 2 - lines 166-169), 8 (Figure 3 - lines 209-212 and Figure 4 - lines 214-217), 9 (Figure 5 - lines 219-221), 10 (Figure 6 - lines 242-244), 11 (Figure 7 - lines 250-252), 12 (Figure 8 - lines 273-276 and Figure 9 – lines 278-281), 13 (Figure 10 - lines 295-298).

In addition, we corrected the MRI sequence description in Figure 7 legend from fluid-attenuated inversion recovery (FLAIR) to short tau inversion recovery (STIR) to ensure technical accuracy (page 11, Figure 7 legend).

Comment 4: English language and style are fine. The references are appropriate.

Response 4: We thank the Reviewer for this positive assessment. In addition, during revision, we made minor language and terminology corrections to improve clarity and consistency further, including:

• Changing "Departament" to "Department"
• Changing “muscular involvement” to “muscle involvement” in a subtitle
• Replacing “pseudotumoral cerebral lesions” with “pseudotumoral brain lesions”

These minor edits did not alter the scientific content and are available on page 1, line 13 ("Departament" to "Department"), page 3, line 101 (“muscular involvement” to “muscle involvement”) and page 11, line 253 (“pseudotumoral cerebral lesions” to “pseudotumoral brain lesions”) of the revised manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

The article offers a review of the role of imaging techniques in the diagnosis of Sjögren’s Syndrome. It presents the contribution of techniques such as ultrasonography, elastography, computed tomography and magnetic resonance imaging in the diagnosis of certain symptoms resulting from the syndrome.

As a review article it is based on adequate and recent references on the subject with an explicit analysis of the methods used to diagnose different symptoms categories. It will certainly be useful as a concise guide to support diagnosis protocols.

In my opinion it would be useful to enrich the article with tables summarising data e.g. prevalence of symptoms, imaging technique used, diagnostic accuracy, sensitivity, specificity.

I would also suggest the addition of more explicit legends to the figures with the source of the figure cited in the legend. 

Would the authors consider adding a paragraph on the methodology of literature searching?

In conclusion I believe that the paper is interesting, contains useful information and would benefit from the above changes regarding the organisation of the presented information.

 

Author Response

Comment 1: The article offers a review of the role of imaging techniques in the diagnosis of Sjögren’s Syndrome. It presents the contribution of techniques such as ultrasonography, elastography, computed tomography and magnetic resonance imaging in the diagnosis of certain symptoms resulting from the syndrome.

Response 1: We thank the Reviewer for this positive assessment of our manuscript and for recognizing the comprehensive overview of imaging techniques used in the evaluation of organ involvement in Sjögren’s syndrome.

Comment 2: As a review article it is based on adequate and recent references on the subject with an explicit analysis of the methods used to diagnose different symptoms categories. It will certainly be useful as a concise guide to support diagnosis protocols.

Response 2: We thank the Reviewer for these encouraging comments. We are pleased that the manuscript was found to be supported by appropriate and up-to-date references and to be a valuable, concise guide to diagnostic protocols.

Comment 3: In my opinion it would be useful to enrich the article with tables summarising data e.g. prevalence of symptoms, imaging technique used, diagnostic accuracy, sensitivity, specificity.

Response 3:  We thank the Reviewer for this valuable suggestion. We agree that summary tables can enhance the clarity and accessibility of information. Accordingly, we have added summary tables that consolidate key data regarding organ involvement, imaging modalities used, and their diagnostic value, where available in the literature. As a result of these additions, the numbering of tables in the manuscript has been updated accordingly. These tables have been added to the revised manuscript on page 3 (Table 1 - lines 95-96), page 3 (Table 2 - lines 97-100), page 5 (Table 4 - lines 152-153), page 7 (Table 6 - lines 189-192).

Comment 4: I would also suggest the addition of more explicit legends to the figures with the source of the figure cited in the legend.

Response 4: We fully agree with this comment. All figure legends have been expanded and revised to provide more precise explanations for non-radiologist readers, including descriptions of imaging modalities, pathological findings, arrows/symbols, and clinical relevance. Furthermore, we have clarified in the Methods section that all imaging figures included in the manuscript are original, belong to the authors, were acquired during routine clinical care, and were fully anonymized before inclusion. These changes can be found throughout the revised figure legends on pages 5 (Figure 1 - lines 139-143), 6 (Figure 2 - lines 166-169), 8 (Figure 3 - lines 209-212 and Figure 4 - lines 214-217), 9 (Figure 5 - lines 219-221), 10 (Figure 6 - lines 242-244), 11 (Figure 7 - lines 250-252), 12 (Figure 8 - lines 273-276 and Figure 9 – lines 278-281), 13 (Figure 10 - lines 295-298).

Comment 5: Would the authors consider adding a paragraph on the methodology of literature searching?

Response 5: We thank the Reviewer for this vital suggestion and agree with it. A brief Methods section describing the literature search methodology has now been added to the manuscript on page 2, paragraphs 6-7, lines 64-78.

This narrative review was based on a focused literature search conducted in PubMed/MEDLINE to identify publications addressing the role of imaging in systemic (extraglandular) manifestations of Sjögren’s syndrome. The search combined Medical Subject Headings (MeSH) and free-text terms related to Sjögren’s syndrome with imaging modalities, including ultrasonography, elastography, computed tomography/high-resolution computed tomography, and magnetic resonance imaging, as well as organ-specific terms referring to musculoskeletal, pulmonary, neurological, and lymphoproliferative involvement. Additional relevant articles were identified through manual screening of reference lists from selected publications. The retrieved evidence was qualitatively analyzed and synthesized, and the results are presented in a narrative format.

All diagnostic imaging figures (ultrasound, elastography, computed tomography, and magnetic resonance imaging) are original and belong to the authors; they were acquired during routine clinical care and fully anonymized before inclusion. The images are presented for illustrative purposes in this narrative review.

Comments 6: In conclusion I believe that the paper is interesting, contains useful information and would benefit from the above changes regarding the organisation of the presented information.

Response 6: We thank the Reviewer for this positive overall evaluation. We believe that the revisions made—including the addition of a Methods section, summary tables, and expanded figure legends—have significantly improved the organization, clarity, and educational value of the manuscript.

In addition, during revision, we made minor language and terminology corrections to improve precision and consistency, including:

• Changing "Departament" to "Department"
• Changing “pseudotumoral cerebral lesions” to “pseudotumoral brain lesions”
• Revising “muscular involvement” to “muscle involvement” in a subtitle
• Correcting an MRI sequence description in a figure legend from fluid-attenuated inversion recovery (FLAIR) to short tau inversion recovery (STIR)

These changes are on page 1, line 13 ("Departament" to "Department"), page 3, line 101 (“muscular involvement” to “muscle involvement”), page 11, lines 250-252 [(fluid-attenuated inversion recovery (FLAIR) to short tau inversion recovery (STIR)] and page 11, line 253 (“pseudotumoral cerebral lesions” to “pseudotumoral brain lesions”) of the revised manuscript.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The new Method section adequately presents the clarified literature research. The revised figures represent a major improvement. The use of arrows, labels, and expanded captions highly increased clarity and educational impact. The figures are now well integrated into the text and effectively support the corresponding descriptions. The addition of summary tables (e.g., prevalence of systemic manifestations, imaging techniques by organ system, and diagnostic performance metrics) improves readability and allows for quick comparison across modalities and disease domains.