Dear Editors,
Thank you very much for your letter and advice. We really sorry, it is too late for
the revised the paper. We would like to re-submit it for your further consideration. We
have addressed each of the comments raised by the reviewers, and the amendments
are highlighted in red in the revised manuscript. We hope that the revision is
acceptable, and we look forward to hearing from you soon.
Sincerely,
Dr. Chaoliu Dai, corresponding author
Department of General Surgery, Shengjing Hospital of China Medical University,
Shenyang 110004, P.R. China
We would like to express our sincere gratitude to the reviewers for their constructive
and positive comments.
Replies to Reviewer 1
Specific Comments:
1. Response to comment: In the present case report, the authors should add the
perioperative picture of the mass location, anatomic structures, etc). for the readers.
Response: We have add the intraoperative pictures of the mass (Fig. 2A, B&C).
2. Response to comment: The authors should add a picture of the removed specimens.
Response: We have add the picture of the removed specimens (Fig. 2D).
3. Response to comment: Did the patient had malign hypertension attack? According
to the patient's parameter, the mass is functional. Moreover, did they cofront malign
hypertension during the operation? Did they use fenoxibenzamine?
Response: The patient don’t have malignant hypertension attack. There was two
sharp rises in blood pressure intra-operatively during manipulation of the tumour
(blood pressure 150-160/90-100 mmHg), which was treated with antihypertensives
(such as, nicardipine hydrochloride, sodium nitroprusside) by anesthetist. On the other
hand, esmolol hydrochloride was used to decrease the heart rate. Fenoxibenzamine
was not used in the operation.
4. Response to comment: Which incision type was selected by the authors? (Chevrone
incision, midline incision?)
Response: A generous right subcostal incision was made.
5. Response to comment: The authors should give information about the
chemotherapy regimens and its contribution on the survival in the metastatic
paraganglioma.
Response: We also use CVD chemotherapy regime (cyclophosphamide 750mg/m2,
vincristine 1.4mg/m2, and dacarbazine 600 mg/m2 on Day 1 and dacarbaine 600
mg/m2 on Day 2; every 21 to 28 days), as partial - and in few cases completeresponse in up to 50-55% of the patients [Reference 18].
6. Response to comment: Please correct some grammar errors in the manuscript.
Response: We fully understand the reviewer’s concern. This revised manuscript was
edited by Medjaden Bioscience Limited, Hong Kong, China.
Replies to Reviewer 2
Specific Comments:
1. Response to comment: The case report is quite long, it will be important if the
length of the manuscript is shortened by avoiding repetitions especially in case
presentation and discussion sections.
Response: As per your advice, the case presentation and discussion sections have
been reduced respectively.
2. Response to comment: Patients had CT and MRI in secondary care centre, why
ultrasound was performed in tertiary care centre. It is not clear if a repeat CT was also
performed in the tertiary hospital – what reason was for this?
Response: In my hospital, ultrasound is routine examination, especially for
abdominal mass patients. The CT in secondary-care centre was without using contrast
medium and contrast-enhanced CT with 3D reconstruction was made in my hospital.
3. Response to comment: Although patient’s preoperative blood pressure was normal,
hence author did not give preoperative alpha blocker, following points need
clarification in the revised version.
- Response to comment: Any reference of not using preoperative alpha blockers in
patients labelled as “functional” extra adrenal paraganglioma?
Response: Alpha blocker is still recommended prior to the resection of
pheochromocytoma or paraganglioma. However, the effect has never been tested in a
randomized clinical trial. The necessity of preoperative alpha blocker remains
uncertain for the normotensive pheochromocytom or paraganglioma. Shao et al.
[Reference 11] considered that preoperative alpha-adrenoceptor antagonist has no
benefit in maintaining intraoperative hemodynamic stability in patients with
normotensive pheochromocytoma. It may increase the use of vasoactive drugs and
colloid infusion. Groeben et al. [Reference 12] also reported that there was no
correlation between the individual dose of phenoxybenzamine and the maximum
blood pressure in 200 consecutive resections of catecholamine-producing tumors.
This present case represented a normotensive paraganglioma and alpha-blocker was
not used. Although the intraoperative blood pressure varied sharply, there was not
malignant hypertension in the operation. The surgery and anaesthesia process were
safe and controllable. Overall it can be concluded that with the improvement of
surgical techniques, diagnostic tools and highly effective short acting substances to
control hemodynamics intraoperatively, the question must be raised whether a
time-consuming, unreliable pretreatment burdened with significant side effects is still
required [Reference 12].
- Response to comment: Was there was any changes in hemodynamic status of the
patients observed intra-operatively (during manipulation of the tumour). If yes, how
these were managed?
Response: There was two changes in hemodynamic status of the patients observed
intraoperatively during manipulation of the tumour (blood pressure 150-160/90-100
mmHg), which was treated with antihypertensives (such as, nicardipine hydrochloride,
sodium nitroprusside) by anesthetist. After the tumor was resected, the blood pressure
dropped to 70/50 mmHg, norepinephrine was pumped continuously one half hour and
blood pressure rose and steadied at 110/85 mmHg.
- Response to comment: What was the rationale of 3 day per-operative volume
expansion, any reference to this practice?
Response: We apologize for that there was not any reference to 3 day per-operative
volume expansion. In most cases, we give 3 to 7 days of volume expansion therapy
for such patients.
- Patients was discharged on day 21, this is quite a long stay in hospital– what
was the reason for this?
Response: By 3 days after surgery, the patient undergone closed thoracic drainage for
the right side of massive pleural effusion and aerothorax with the obviously
compression of the right lung. The closed thoracic drainage tube was removed on
postoperative day 18. Local community medical conditions were underdeveloped, so
the patient decided to discharg on postoperative day 21.
- It is stated that "chemotherapy was offered to patient. What chemotherapy agents
were considered and what are the known response rates?
Response:
The
considered
chemotherapy
regime
is
the
CVD-protocol
(cyclophosphamide 750mg/m2, vincristine 1.4mg/m2, and dacarbazine 600 mg/m2 on
Day 1 and dacarbaine 600 mg/m2 on Day 2; every 21 to 28 days), as partial - and in
few cases complete- response in up to 50-55% of the patients.
General Response: We have tried our best to improve the presentation of our study
and findings. The changes made to the text (marked in red) did not influence the
content or framework of the study itself. We sincerely appreciate the earnest efforts of
the Editors/Reviewers and hope that our corrections/modifications will meet with
approval.
Once again, thank you very much for your dedication to our manuscript and study.