Review for 10.1186/s12876-024-03193-z (2024)

Title: Characterization of Primary Small Intestinal Lymphoma: A Retrospective Study Based
on Double Balloon Endoscopy
Version: 2 Date: 17 Nov 2023
Reviewer's report:
This study presents a case series of 30 primary small intestinal lymphomas (PSIL), summarizing
their clinical symptoms, laboratory results, imaging, and endoscopy findings. Given the small
sample size, the study primarily focuses on descriptive statistics. However, there are several
aspects of the analysis and presentation that warrant further clarification.
1.Clarification of Patient Source and Inclusion Criteria:
The methodological description raises questions about the patient source and inclusion criteria.
The methods section mentions 255 small intestinal biopsy examinations, resulting in 32 patients
with a pathological diagnosis of PSIL, yet the results only discuss 30 cases. Such a discrepancy,
particularly in a small sample study, is concerning. Additionally, the study lacks clarity regarding
whether all cases originated from the same hospital, whether the pathology findings were
reviewed by an expert pathologist, and if the endoscopies were performed by experienced
endoscopists. There is also a need to address potential influences of pathologist or endoscopic
factors on the diagnosis of PSIL. Similarly, it is unclear if CT findings were confirmed by expert
radiologists. The authors should reevaluate and reconfirm the inclusion and validity of these 30
(or 32) cases and thoroughly document this process in the methods section.
2.Concerns Regarding Presentation of Descriptive Statistics:
The tabular presentation in all tables, with duplicated columns for DLBCL and separate
columns for indolent B-cell lymphoma and T-cell lymphoma, deviates from standard practices.
Additionally, the application of statistical comparisons seems inconsistent, focusing primarily
on comparisons between DLBCL and other types.
2.1) Clarification is needed on whether p-values were adjusted for multiple comparisons, and if
so, the method of adjustment should be detailed in the statistical analysis section.
2.2) The rationale behind using DLBCL as a universal reference for comparisons in symptoms,
signs, endoscopy findings, etc., requires explanation.
3.Interpretation of Clinical and Pathophysiological Implications:
While the study provides descriptive information, it lacks discussion on the clinical or
pathophysiological implications of its findings. For instance, in Table 3, the statistical
significance of CRP, Fib, D-dimer between DLBCL and indolent BCL, or CEA and CA125
between DLBCL and TCL, should be interpreted in terms of their clinical or pathological
relevance. The authors need to distinguish between meaningful findings and potential Type I
errors.
4.Clarity in Multivariate Analysis Reporting:
The reporting of multivariate analysis in the "DBE findings" section is unclear, particularly
concerning the statistical significance of deep ulcers and aneurysmal dilation for prognosis.
4.1) The specific statistical method used in this analysis, including the variable selection process,
should be detailed in the methods section.
4.2) The complete model, including all variables used in the multivariate analysis, should be
presented.
4.3) The definition of "prognosis" used in this analysis should be specified. Does it refer to
mortality, gastrointestinal bleeding, or another outcome?
5.Relevance of Therapy and Clinical Outcome Section:
The section on "Therapy and Clinical Outcome," including the Kaplan-Meier curve in Figure 1,
appears redundant. The authors should consider its relevance or removal from the main text.
6.Reconsideration of the Conclusions:
The conclusion currently does not adequately reflect the study's findings. The authors should
reformulate it to illustrate how the study's results can assist in the diagnosis and identification of
small bowel lymphoma. An example application based on the study's findings would be needed.
For example, How should the result be used in "a 80 y/o lady presented due to occult GI bleeding.
CT showed a 4 cm segment of bowell wall thickening, up to 1.3 cm in thickness with aneurysmal
dilatation. Double balloon enteroscopy showed a large, irregular ulcer with muocal hyperplasia."