Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article is well-written, and the references are up to date. I have found a few errors that need to be corrected.

 

It is advisable to indicate the year of the last oncological follow-up for the patient presented. 

Have additional tests, such as PET - CT, been performed?

It is necessary to specify exactly how long the follow-up period lasted.

In the discussion, it is advisable to include information regarding adjuvant treatment.

It is advisable to supplement the description of the surgical treatment, particularly by indicating whether intraoperative histopathological examination was performed and which reconstruction methods were used to repair the postoperative defect.

 

The specimen size and the size of the tumor infiltration within it are incorrectly reported in lines 60 and 61.

„The initial excision (September 2021) consisted of a cutaneous sample measuring 36 x 10 mm, with a firm, white area of 30 x 24 mm on the cut section” - I think it should be … a cutaneous sample measuring 36 x 24 mm, with a firm, white area of 30 x 10 mm on the cut section ? - Tumor in histopathological examination cannot be larger than the cutaneous sample.

Author Response

We sincerely thank the reviewer for the careful reading of our manuscript and the constructive comments, which have helped us improve the quality and clarity of the article. We will respond to each of the concerns as follows:

-Oncological Follow-up Year
We have indicated the year of the patient's last oncological follow-up in the revised manuscript.
-Additional Tests
We clarified the tests performed during follow-up, and this information has been added to the Case Report section.
-Follow-up Period
We specified the exact duration of the follow-up period in the revised manuscript.
-Adjuvant Treatment
Our patient did not receive adjuvant treatment and remained under surveillance. This has been clarified in both the discussion and report sections.
-Surgical Treatment Details
We mentioned LWD in the discussion section. Frozen sections were not performed during surgery.
-Specimen Size Correction
We thank the reviewer for carefully pointing out the error regarding the specimen and tumor sizes. We clarified this in the manuscript, as the thickness of the specimen was not previously mentioned.

 

Reviewer 2 Report

Comments and Suggestions for Authors

First of all, I would like to thank you for inviting me to review the manuscript entitled “Recurrent cutaneous leiomyosarcoma: a histopathological perspective and the quest for complete excision”.

 

The title accurately reflects the case. The case involves an important area of health and presents a clear and clinically useful message. The manuscript is well written in terms of clarity, style, and use of English and has a logical construction. The discussion section explains the case in the context of published information. The conclusions accurately and clearly explain the main clinical message. The figures are of good quality and relevant to the clinical message. The references are appropriate and current.

There are some minor flaws that should be corrected:

1) In lines 25-26 add citation(s) to the sentence.

2) In lines 37-39 add citation(s) to the sentence.

3) In lines 137-138 add citation(s) to the sentence.

4) In my opinion in the discussion section the differential diagnosis should be expanded to include two more entities: leiomyoma and Kaposi sarcoma.

Author Response

We thank the reviewer for suggesting that we include additional citations to support several statements in our manuscript. For the general statements regarding the rarity of cutaneous sarcomas, their most frequent entities (DFSP, AFX, PDS), and their clinical and histopathological characteristics (lines 25–26), we have cited the WHO Classification of Skin Tumours and Soft tissue tumors, which provides a comprehensive and authoritative overview of these tumors.

Regarding leiomyosarcomas (lines 37–39 and 137–138), we have retained the WHO citation as a primary source, as it covers the origin from smooth muscle, anatomical distribution, and prognosis differences between cutaneous and visceral LMS. To further support these statements, we have now added the following peer-reviewed articles:

-Sakamoto A, et al., 2015, Sarcoma, 2015: Article ID 204031 – providing a single-institution experience and review of cutaneous LMS.

-Helbig D, et al., 2023, J Dtsch Dermatol Ges. 21(12):555–563 – S1-guideline on cutaneous and subcutaneous LMS. 

These additional citations included in this section provide further evidence for the statements in the manuscript while maintaining the WHO as the primary authoritative source. For line 138, the information is covered by Helbig and it was cited.

For the differential diagnosis, we expanded the discussion section, adding the entities suggested. We are grateful for your advice and we hope we fulfilled your requests.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

The manuscript presents a well-documented case of recurrent cutaneous leiomyosarcoma, highlighting the histopathological features, immunohistochemical profile, and the surgical challenges in achieving tumor-free margins. The topic is relevant for dermatology and pathology readers, and the clinical course is clearly described.

That said, several areas could be improved to enhance clarity and scientific rigor. In the introduction, please distinguish more clearly between the aggressive nature of visceral leiomyosarcomas and the generally more favorable prognosis of cutaneous forms, to avoid potential confusion. The methodology section would benefit from additional detail—specifically, standardizing the reporting of mitotic counts (per HPF rather than per mm²), providing the FNCLCC grading breakdown, and listing antibody clones/dilutions when available. Although SMA and desmin positivity is sufficient, mentioning why h-caldesmon was not used would strengthen the immunohistochemical interpretation.

In the discussion, the adequacy of the final 4 mm margin should be addressed in the context of current recommendations, which often advise 5–10 mm for dermal LMS. The section on differential diagnosis is thorough, though adding that CD34 staining could definitively exclude dermatofibrosarcoma protuberans would further reinforce the argument. Finally, while the references are recent and relevant, some claims (incidence rates, survival statistics, prognostic factors) would benefit from more direct linkage to large series or guideline-based evidence.

Overall, this is a solid and educational case report that would be suitable for publication after minor revisions addressing the points above.

Comments on the Quality of English Language

The quality of English is generally good, and the manuscript is clearly understandable. The structure and flow are logical, and technical terms are used correctly. However, there are occasional grammatical slips and minor stylistic issues (e.g., awkward phrasing, inconsistent tense use, and wordiness in some sentences). These do not obscure meaning but could be improved with careful editing. A light language polish—focusing on sentence conciseness, verb tense consistency, and grammar refinement—would enhance readability and overall presentation.

Author Response

We sincerely thank the reviewer for their careful reading and constructive feedback. We have revised the manuscript to address each of the points raised as follows:

Introduction – distinction between visceral and cutaneous LMS
We have clarified the introduction to distinguish visceral leiomyosarcomas, which generally have aggressive behavior, from cutaneous LMS, which typically exhibit a more favorable prognosis. Added a citation to support the statement.

Methodology – mitotic counts, FNCLCC grading, and antibody details

-The mitotic counts are now reported per high-power field (HPF) for standardization.

-AJCC&FNCLCC grading has been added, including the breakdown for differentiation, mitotic activity, and necrosis. Information has been corrected

-Antibody clones and dilutions used for immunohistochemistry have been included. Please tell us if you want the clones for the other markers used.

-We have added a note explaining why h-caldesmon was not used.

Discussion – surgical margins

-The discussion now addresses the final 4 mm margin in light of current recommendations, which generally suggest 5–10 mm for dermal LMS. We have explained the rationale for our surgical approach in this case.

Differential diagnosis
-We have added that CD34 staining can definitively exclude dermatofibrosarcoma protuberans, further supporting the differential diagnosis. We also expanded the discussion by adding two more entities, Kaposi sarcoma and leiomyoma.

References and evidence for claims
-We have added citations from large series and guideline-based evidence, including the WHO Classification of Skin Tumours (5th edition) and relevant case series, to support statements regarding incidence, survival, and prognostic factors.

We thank the reviewer again for their valuable suggestions, which have improved the clarity, scientific rigor, and educational value of the manuscript.