Evaluation of Sentinel Lymph Nodes in Complex Atypical Endometrial Hyperplasia
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe authors make an excellent retrospective work.
The authors also submitted to editorial directives while keeping the reader's interest high.
I appreciate all the Appendices.
Some suggestions:
Line 33 abstract:
Please define which type of statistical analysis you have used to calculate the probability of cancer, SLN map rate, and surgical complications.
Line appendix A line 341:
Appendix B: Multiple logistic regression. Predictors of Endometrial cancer. Instead of: "Appendix B: Multiple logistical regression. Predictors of Endometrial cancer."
Comments on the Quality of English Language
Minor editing of English language required.
Author Response
Comment 1: Abstract: define which type of analysis we used to calculate the probability of cancer, SLN map rate, and surgical complications.
Response: The following sentence was added "Descriptive statistics were used to summarize the results, comparative statistics were used to compare cohorts, and logistical regression analysis was used to predict risk. Forty-seven percent of the entire cohort were diagnosed with endometrial cancer" in the abstract.
Comment 2: Change in nomenclature of Appendix B to "Appendix B: Multiple logistical regression. Predictors of Endometrial cancer"
Response: Thank you for this observation. The following changes mentioned have been made to Appendix B.
Reviewer 2 Report
Comments and Suggestions for AuthorsI have reviewed the article titled "Evaluation of Sentinel Lymph Nodes in Complex Atypical Endometrial Hyperplasia" by Al Kallas et al.The article effectively establishes the rationale for the study by highlighting the limitations of intraoperative cancer evaluation in CAH and the potential of SLN sampling. The research question regarding the efficacy and safety of SLN sampling in a robotic setting for CAH patients is clinically significant. The inclusion of a reasonable number of patients (n=113) and information on surgical complications is valuable for assessing the safety profile of SLN sampling.
However, some suggestions could improve the work:
A retrospective study design inherently has limitations in establishing causality. Consider mentioning potential biases and the need for prospective studies for confirmation.
Briefly describing the specific technique used for SLN mapping (e.g., dye, fluorescence) would strengthen the methodology section.
While the study focuses on peri-operative outcomes, mentioning the availability of longer-term follow-up data (if applicable) would be valuable for assessing long-term oncological outcomes.
Specifying the statistical tests used to analyze the data in each table where is applicable (e.g., chi-square, logistic regression) would enhance transparency.
Discussing the limitations of generalizability, such as the study population or surgical approach, would strengthen the conclusions.
Please consider mentioning if any patients had a positive SLN but ultimately a negative hysterectomy specimen.
Exploring the potential cost-effectiveness of SLN sampling in this context would be valuable.
By incorporating these suggestions, the authors can improve their manuscript.
Author Response
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions highlighted in the re-submitted files.
Comment 1: Consider mentioning potential biases and the need for prospective studies for confirmation.
Response: We mentioned how different selection biases, which are inherent to a retrospective study, can affect the results (lines 243-265). We conclude by stating that we support a prospective study for further investigation (lines 270-274).
Comment 2: Briefly describing the specific technique used for SLN mapping (e.g., dye, fluorescence) would strengthen the methodology section.
Response: A detailed explanation of the use of the indocyanine dye is outlined in the methodology (lines 290-300) and a reference cited 24 (Barlin, 2012).
Comment 3: While the study focuses on peri-operative outcomes, mentioning the availability of longer-term follow-up data (if applicable) would be valuable for assessing long-term oncological outcomes.
Response: Thank you for this comment, we are currently abstracting data on oncological outcomes of SLNS in our patients with endometrial cancer and will report in a separate study.
Comment 4: Specifying the statistical tests used to analyze the data in each table where is applicable (e.g., chi-square, logistic regression) would enhance transparency.
Response: The statistical tests used for each table have been added under the description.
Comment 5: Discussing the limitations of generalizability, such as the study population or surgical approach, would strengthen the conclusions.
Response: We have added the following in the discussion section under the limitations “Furthermore, since this study focused on robot assisted sentinel lymph node mapping using ICG dye under the near infrared light our results cannot be generalizable to populations that are not managed using this technique”.
Comment 6: Please consider mentioning if any patients had a positive SLN but ultimately a negative hysterectomy specimen.
Response: Thank you for this very interesting observation. Our population did not include any patients with this pathology.
Comment 7: Exploring the potential cost-effectiveness of SLN sampling in this context would be valuable.
Response: Thank you for this very important question. Our study did not focus on cost because data on charges were unfortunately not available to us. We are working with administration on obtaining data on charges and plan to submit information on the economic impact of SLNS in CAH and EAC in a separate manuscript.
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors have made significant changes that have improved the article.