Dr. med. Menelaos Zafrakas, 1st Department for OBGYN, Aristotle University, Papageorgiou
Hospital, Periferiaki Odos Thessalonikis, N. Efkarpia, 56403 Thessaloniki, Greece,
Tel: +30-2310-693131, Fax: +30-2310992890, email: mzafrakas@gmail.com
Thessaloniki, July 26, 2008
To:
R. Smith
Editor – in – Chief
Cases Journal
Re: Revision letter for MS: 1421096372030151 - “Ultrasound and MR-imaging
in preoperative evaluation of two rare cases of scar endometriosis”
Dear Sir,
The authors would like to thank the Referee for her critical comments, which were
very helpful in revising the manuscript in order to provide more clear messages to the
readers. Changes made in the manuscript have been highlighted and our point-to-point
responses to the Referee’s comments are given in detail below:
Referee Comment 1:
The authors emphasize on the use of three imaging techniques to assist the diagnosis
of scar endometriosis but it is not clear how each has made a difference in the
diagnosis, and whether all three are needed. It is not entirely clear what the key
messages are: did these two cases represent the typical or atypical characteristics of
scar endometriosis? What were the lessons learned?
Authors’ Response:
Scar endometriosis is a rare and by definition an atypical presentation of
endometriosis and thus both cases have atypical characteristics. Τhe imaging
techniques used may assist differential diagnosis, but definitive diagnosis can be
established only after histological examination. The key message or the lesson to be
learned is that imaging techniques are valuable in determining preoperatively the
extent of disease, thus allowing accurate and total excision; this was apparently not
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clear throughout the entire manuscript, and thus appropriate changes have been made
(see below). Though the two cases presented are not the first reported cases of scar
endometriosis, systematic use of imaging techniques in the preoperative evaluation of
this clinical entity in order to ensure its total surgical removal may represent an
important advance in general medical knowledge.
1. The 4th sentence of the Abstract, in lines 4 and 5 (“After 2-D ultrasound, power
Doppler and MRI, the mass was totally excised in both cases.”) was rephrased to
“In both cases, the mass was totally excised, after accurate preoperative
evaluation with 2-D ultrasound, power Doppler and MRI.”
2. The final sentence of the Abstract, in lines 6-8 (“In cases of suspected scar
endometriosis, preoperative diagnostic imaging is valuable in differential
diagnosis from other rare pathologic entities and in determining the extent of
disease, thus enhancing accurate and total excision.“) was changed to “In cases
of suspected scar endometriosis, preoperative diagnostic imaging is valuable in
determining the extent of disease, thus enhancing accurate and total excision. “
3. The following sentences have been added to the Discussion (page 5, lines 17-22
– see also Response to the Referee Comment 2): “At a first glance, the simplest
and less costly approach would be excisional biopsy followed by histological
examination of the lesion, without prior imaging evaluation. However, this may
lead to inadequate excision, and subsequently disease recurrence, necessitating
re-excision. On the other hand, preoperative evaluation with imaging techniques
can facilitate total surgical excision. “
4. The sentence “The extent and biologic behaviour can be further evaluated by
MR-imaging” in the Discussion has been changed to: “If 2D and Doppler
ultrasound studies seem inadequate, the extent and biologic behaviour can be
further evaluated by MR-imaging.” (Discussion, page 6, lines 2-3).
5. The “Conclusions” section has been changed as follows: “In conclusion, use of
diagnostic imaging, including 2-D ultrasound, power Doppler sonography and
MRI, in the preoperative assessment of suspected scar endometriosis lesions is
very helpful for accurate determination of the extent of disease. This approach
enhances total surgical excision, which is crucial for definitive diagnosis and
avoidance of disease recurrence.”
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Referee Comment 2:
From a general practitioner point of view, the most important is whether there are
symptoms and signs that should alert to the diagnosis and what is the simplest and
most cost-effective investigation to support the diagnosis. So it would be nice to know
whether the two patients had the typical symptoms of cylcical pain. The other
information that may be useful is whether biopsy is useful or harmful.
Authors’ Response:
Incisional endometriosis is a rare clinical entity, and thus there is no data available
concerning the cost-effectiveness of different diagnostic methods. The simplest and
less costly approach in order to establish diagnosis appears to be excisional biopsy
followed by histological examination of the lesion, without prior imaging evaluation.
This approach however, may lead to inadequate excision, and subsequently disease
recurrence necessitating re-excision - in any case a costly, and particularly in case of
malignancy a harmful scenario. A needle biopsy could be also useful for diagnosis,
but still preoperative imaging would be needed in order to ensure total surgical
excision of the lesion; thus a needle biopsy appears to be an unnecessary and
avoidable diagnostic step. Appropriate changes have been made in the manuscript,
concerning this issue (see below).
As stated in the Abstract, both patients presented with cyclic pain. However,
this was not “typical” cyclic pain, as it was not always present and did not always
have the same intensity during menses. In any case, if typical or atypical cyclic pain is
present this should alert to suspected diagnosis of endometriosis; this aspect was
indeed not emphasized in our manuscript, as our focus was on preoperative evaluation
with imaging techniques, rather than clinical manifestations, which have been already
described in the literature (appropriate changes have been made now - see below).
1. The word “atypical” (referring to cyclic pain) has been added in the 3rd line of
the Abstract (page 2, line 4), and the 1st line of Case 2 (page 4, line 4).
2. The 1st sentence of “Case 1” (page 3, line 13) “A 28 year-old white woman,
G2P1, presented with a small, painful, firm lump …” was changed to “A 28
year-old white woman, G2P1, presented with atypical cyclic pain on a small,
firm lump…”
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3. The sentence “Cyclic symptoms and signs should alert to clinical diagnosis of
endometriosis.” has been added in the 2nd paragraph of the “Discussion” (page
5, line 10).
4. The following sentences have been added to the Discussion (page 5, lines 1622 – see also Response to the Referee Comment 1): Due to the rarity of
incisional endometriosis, there is no data available concerning costeffectiveness of different diagnostic methods. At a first glance, the simplest
and less costly approach would be excisional biopsy followed by histological
examination of the lesion, without prior imaging evaluation. However, this
may lead to inadequate excision, and subsequently disease recurrence,
necessitating re-excision. On the other hand, preoperative evaluation with
imaging techniques can facilitate total surgical excision.
Yours sincerely
M. Zafrakas
For the authors