New Biopsy Techniques and Imaging Features of Transrectal Ultrasound for Targeting PI-RADS 4 and 5 Lesions
Round 1
Reviewer 1 Report
In this study the authors tried to introduce new techniques and imaging features of TRUS for targeting PI-RADS 4 and 5 lesions in patients with clinical suspicious of PCa.
The concept is not totally novel. Despite that the study seems well conducted and I do not have major concerns.
Author Response
Authors’ Responses to R#1 Comments and Suggestions
Point 1. In this study the authors tried to introduce new techniques and imaging features of TRUS for targeting PI-RADS 4 and 5 lesions in patients with clinical suspicious of PCa. The concept is not totally novel. Despite that the study seems well conducted and I do not have major concerns.
Response: We understand what you mean. However, we have introduced new TRUS techniques and imaging features, which were not dealt with any original article. First, fundamental US was used instead of harmonic US. Second, the dynamic range of TRUS was maintained less than 50. Third, prostate was not compressed until PI-RADS 4 or 5 was detected. Fourth, a TRUS lesion was located more superiorly than an MRI lesion as it was closer to the posterior capsule (Fig. 2). Fifth, a TRUS lesion was located more inferiorly than an MRI lesion as it was closer to the anterior capsule (Fig. 3). Sixth, peripheral and transition cancers appeared to be hypoechoic and hyperechoic, respectively (Figs. 2 and 3). Finally, higher-scoring PI-RADS lesions became more hypoechoic or hyperechoic (Figs. 2 and 3). Using only conventional TRUS techniques cannot depict clearly PI-RADS 4 or 5 lesion. Accordingly, being familiar with our techniques and imaging features can improve cancer detection rate.
Please let me know if there are another papers using our TRUS techniques and imaging features.
Author Response File: 
Author Response.docx
Reviewer 2 Report
In their manuscript, Byung Kwan Park and Sung Yoon Park determine cancer detection rates from TRUS biopsies in patients with PI-RADS 4/5 MRI lesions. Looking at detection rates from TRUS and not from fusion biopsies after MRI appears interesting not only in a dialectical manner. Their retrospective analysis seems well conducted in many aspects.
However, there are some limitations / problems:
Major issues:
Although the authors also mention their comparison of target and systematic biopsies within their limitations section – these data appear seriously biased due to the authors´ own guidelines: target biopsies in cases of clear visibility - target and systematic biopsies in cases of worse visibility. As a result, the authors cannot claim to independently assess target versus systematic biopsies. When addressing this question, they compare good and bad visibility in TRUS. While cancer detection rates shown here seem to be in line with data previously published: yet, is there a follow-up for the PI-RADS 4/5 patients with no proof of PCa – how many did receive MRI/TRUS fusion biopsy afterwards – with which results? Regarding the complication rates: no information whether these complications were caused by target or systematic biopsies. Within the Discussion section, the authors show kappa values that are not demonstrated in the Results section.
Minor issues / typos:
Methods section: page numbers missing Methods / line 83: to detect focal lesions previously characterized as PI-RADS 4 or 5 on MRI Discussion / line 127: difficultyAuthor Response
Authors’ Responses to R#2 Comments and Suggestions
In their manuscript, Byung Kwan Park and Sung Yoon Park determine cancer detection rates from TRUS biopsies in patients with PI-RADS 4/5 MRI lesions. Looking at detection rates from TRUS and not from fusion biopsies after MRI appears interesting not only in a dialectical manner. Their retrospective analysis seems well conducted in many aspects.
However, there are some limitations / problems:
Major issues:
Point 1. Although the authors also mention their comparison of target and systematic biopsies within their limitations section – these data appear seriously biased due to the authors´ own guidelines: target biopsies in cases of clear visibility - target and systematic biopsies in cases of worse visibility. As a result, the authors cannot claim to independently assess target versus systematic biopsies. When addressing this question, they compare good and bad visibility in TRUS.
Response: Definitely, I agree with you. Our study had a serous limitation in that target and systematic biopsies could not be compared in PI-RADS 4 or 5 which was clearly seen on TRUS. This PI-RADS group underwent target biopsy alone. Further investigation is necessary to show how systematic biopsies influence on cancer detection rate in PI-RADS 4 or 5 which is clearly visible on TRUS. We will add it in the limitation section.
Point 2. While cancer detection rates shown here seem to be in line with data previously published: yet, is there a follow-up for the PI-RADS 4/5 patients with no proof of PCa – how many did receive MRI/TRUS fusion biopsy afterwards – with which results?
Response: Thank you for your good comment. This is another topic for my future investigation. Preliminary results show that negative cases proved to be inflammation, mis-targeting, and mis-interpretation of MRI or TRUS. Still, we have not checked out exactly how many cases are followed or lost for follow up.
Point 3. Regarding the complication rates: no information whether these complications were caused by target or systematic biopsies.
Response: I agree with your comment. Unfortunately, we could not determine whether these complications were caused by target or systematic biopsies. Target and systematic biopsies were performed in the same session and thus we were not able to figure out if it came from target or systematic biopsy.
Point 4. Within the Discussion section, the authors show kappa values that are not demonstrated in the Results section.
Response: I am very sorry to confuse you. Description for kappa values will be deleted.
Minor issues / typos:
Point 5. Methods section: page numbers missing Methods / line 83: to detect focal lesions previously characterized as PI-RADS 4 or 5 on MRI Discussion / line 127: difficulty
Response: Thank you for your comments. We have checked out the page or line numbers again, but there is no problem on it. We need the technical check before our manuscript moves to your review process.
Author Response File: Author Response.docx
Round 2
Reviewer 2 Report
From my perspective, the manuscript can be accepted for publication after addressing several previous suggestions.
Author Response
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