Review Reports

Round 1

Reviewer 1 Report

This is a case report of pancreatic acinar cell carcinoma (ACC) that perforated the stomach. This is an interesting case, and it is worth reporting, but it needs significant revision. 

The title is "Misunderstood gastric perforation of a pancreatic acinar cell carcinoma: a wolf in sheep's clothing." However, the authors do not describe "misunderstanding" or "a wolf in sheep's clothing" sufficiently. The authors need to describe endoscopic findings and CT images in more detail. 

 

Other points to be improved;

Information that can be used to identify an individual (“A. Costa Hospital” in 35 Alto Reno Terme, Bologna, Italy) should be deleted.

The patient had a gastric ulcer in the past history, and please explain the relationship between this and the current episode. Also, why was this patient given multiple transfusions?

The upper gastrointestinal (GI) endoscopy findings are essential in this patient. The authors should show their image, which is very useful for readers, especially endoscopists. It is difficult to recognize the location of the stomach, pancreas, and tumor in Fig. 1 and 2. I want to point them out with arrows or circles, so we can easily see them. 

The polypoid lesion is not recognized in Fig. 6. The authors need to show a more low-magnified or loupe image. 

Is this tumor true ACC? Unfortunately, these images did not show typical findings. The authors should show more magnified tumor images and more typical ACC images. 

The resolution of Fig. 7 and 8 is poor; please give a clearer image.

Table 1 and 2 are not used in "Discussion" and can be omitted. Instead, the authors should make a table of summary of the reported cases. 

"Discussion" needs to be reconsidered. Normally, "Discussion" includes a summary of the manuscript.

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Summary

Cuoghi et al. reported the case of pancreatic acinar cell carcinoma with gastric perforation. Although the case of pancreatic acinar cell carcinoma with gastric perforation is rare, cannot recommend this article for publication because it has extensive problems.

 

Major points

[Introduction; Line 11-12] The authors mentioned that the pancreatic acinar cell carcinoma (PACC) showed poor prognosis and low resectability. However, there still have some discussion whether PACC is worse prognosis than pancreatic ductal adenocarcinoma. There is also a report that resectable PACC has a favorable prognosis (Takahashi et al. Pancreas. 2021 Jan 1;50(1):77-82; Wisnoski et al. Surgery. 2008 Aug;144(2):141-8.)

[Case report; Line 34-35] The authors showed a CT scan imaging on figure 1 and figure 2. However, the dynamic contrast enhanced CT scan imaging should be performed making a differential diagnosis from solid pseudopapillary neoplasm (SPN) and pancreatic neuroendocrine neoplasms (Wang et al. Acta Radiol. 2019 Oct;60(10):1216-1223.)

[Case report; Line 51-50] It is difficult to diagnose as “undifferentialted duffuse carcinoma associated with necrotic material” from the immunohistochemistry shown in the main text. The authors should making immunohistochemistry with Trypsin, Synaptophysin, Chomogranin A, CD10, CD56, and BCL10 to distinguish the specimen as acinar cell carcinoma (Stelow et al. Diagn Cytopathol. 2006 May;34(5):367-72; Adams et al. Adv Anat Pathol. 2008 Jan;15(1):39-45; La Rosa et al. Virchows Arch. 2009 Feb;454(2):133-42.)

[Case report; Line 59-65] The author showed microscopical findings of the pathology of this tumor. However, the authors should state macroscopical pathologic findings (e.g. morphology of the tumor, size.)

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The authors corrected many points, but some still needed to be modified. It is crucial that there was no endoscopic image. 

According to the WHO classification, no poorly differentiated acinar cell carcinoma exists in the pancreas, as the authors showed in Table 1. 

The polypoid lesion is not recognized in Fig. 6 and is not also shown in Fig. 7a.

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Major points

 

Point 1: English language and style: moderate English changes required.

Response 1: Moderate English changes have been edited.

> The English correction has been made correctly.

 

Point 2: [Introduction; Line 11-12] The authors mentioned that the pancreatic acinar cell carcinoma (PACC) showed poor prognosis and low resectability. However, there still have some discussion whether PACC is worse prognosis than pancreatic ductal adenocarcinoma. There is also a report that resectable PACC has a favorable prognosis (Takahashi et al. Pancreas. 2021 Jan 1;50(1):77-82; Wisnoski et al. Surgery. 2008 Aug;144(2):141-8.)

Response 2: As recommended, we expanded the discussion and the references about the prognosis and resectability of PACC comparing to pancreatic ductal adenocarcinoma.

 

>In lines 22-24, it is stated that PACC has a poor prognosis, yet in lines 28-30, it is written that the prognosis is good if it is resectable. It leads misunderstandings of PACC for readers.

 

 

Point 3: [Case report; Line 34-35] The authors showed a CT scan imaging on figure 1 and figure 2. However, the dynamic contrast enhanced CT scan imaging should be performed making a differential diagnosis from solid pseudopapillary neoplasm (SPN) and pancreatic neuroendocrine neoplasms (Wang et al. Acta Radiol. 2019 Oct;60(10):1216-1223.)

Response 3: As recommended, we expanded the CT scan considerations for differential diagnosis among PACC, SPN and neuroendocrine.

 

> Dynamic contrast-enhanced CT scan imaging is presented, but it is difficult to determine what pathological condition is reflected by this section alone. It is believed that multiple sections should be included. Also, findings suggesting hemorrhage are recognized, but it is necessary to confirm in pathology whether such findings were present as mentioned later.

 

Point 4: [Case report; Line 51-50] It is difficult to diagnose as “undifferentialted duffuse carcinoma associated with necrotic material” from the immunohistochemistry shown in the main text. The authors should making immunohistochemistry with Trypsin, Synaptophysin, Chomogranin A, CD10, CD56, and BCL10 to distinguish the specimen as acinar cell carcinoma (Stelow et al. Diagn Cytopathol. 2006 May;34(5):367-72; Adams et al. Adv Anat Pathol. 2008 Jan;15(1):39-45; La Rosa et al. Virchows Arch. 2009 Feb;454(2):133-42.)

Response 4: As recommended, we added the immunohistochemistry of our patient and expanded the immunohistochemistry aspects of PACC.

> Immunohistochemistry for trypsin, synaptophysin, and chromogranin A, and CD 56 has not been performed, and it is considered insufficient for diagnosis.

 

Point 5: [Case report; Line 59-65] The author showed microscopical findings of the pathology of this tumor. However, the authors should state macroscopical pathologic findings (e.g. morphology of the tumor, size.)

Response 5: We stated macroscopical pathological findings of the tumor; unfortunately we have not images

> Macroscopic images are not available, and it is difficult to determine if there is evidence of perforation in the stomach based on the information provided.

Author Response

Please see the attachment

Author Response File: Author Response.pdf