Review for 10.1186/s12876-021-02084-x (2022)

Reviewer’s report
Title: 
Complete pathological response of colorectal peritoneal metastases in Lynch syndrome after
immunotherapy case report: is a paradigm shift in cytoreductive surgery needed?
Version: 
1 
Date: 
08 Aug 2021
Reviewer's report:
I have reviewed for BMC Gastroenterology a case report of what appears to be a revision of the primary
submission and review. The language has been edited substantially and is now sufficient. I think the case is
presented well, and in great detail. I agree with most reasoning, but I would suggest to not give too much
weight on a single case report with respect to suggesting new strategies, rather suggesting studies that
would confirm these findings. Neoadjuvant therapy among other applications seems very promising in
chasing complete responses in MSI cancers, and the studies are ongoing.
Although it is likely that the peritoneal recurrence and subsequent therapy response have been true, it is
noteworthy that there was no histopathological verification of the cancer recurrence (only radiological is
reported), which could be mentioned in the discussion. The patient was in fact treated with chemotherapy,
off-label ICI and CRS without HIPEC for T3N0 radiological peritoneal/local recurrence without
histological evidence of recurrence, and the diagnosis of complete pathological response is based on
comparison of histopathology to radiological diagnosis (and CEA). The immune responses of LS patients
are strong and unconventional. Can you rule out that the radiologically relatively unresponsive and
unchanged masses were not inflammatory to begin with?
It would be fair to acknowledge this as a limitation in the lengthy discussion that currently describes
literature not directly linked to the findings of this manuscript. For the same reason, I would recommend
removing the priority claims of being "the first" to describe response to peritoneal disease. 
Page 3. I would recommend to refer to LS diagnosis with just LS, and remove the "type 2". This language
is no longer commonly used.
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Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free from apparent
manipulation?
No