Review for 10.1186/s12876-025-04076-7 (2025)

Title: The nomograph predicting the recurrence of Solid Pseudopapillary Neoplasm of the
Pancreas: a study of the SEER database and a Chinese cohort
Version: 4 Date: 06 May 2025
Reviewer's report:
Comments to authors,
The authors have made a good effort to address the reviewers’ comments, and the manuscript
appears close to acceptable. However, it is essential to ensure that only appropriate cases are
included and that the statistical analyses are conducted logically. As mentioned in the minor
comments below, the authors should also be more considerate in presenting their revisions in a
way that facilitates the review process.
Major comments
1. Reviewer is pleased that the authors have revised the definition of “synchronous metastasis.”
Once this definition is understood correctly, the rationale behind the reviewer’s initial comment
during the first revision should become clear. Specifically, if the 16 cases presenting with
synchronous metastasis in the SEER database underwent complete resection of both the primary
pancreatic tumor and all synchronous metastatic lesions, then including synchronous metastasis
as a factor in the analysis of recurrence risk may be acceptable. However, if only the pancreatic
resection was performed and the synchronous metastases were not concurrently resected, thus
failing to achieve at least a clinical R0 resection, then such cases should not be included
in the analysis of recurrence risk factors. If synchronous metastases remained unresected
during pancreatic surgery, any subsequent disease observed should be considered disease
progression, not recurrence. Therefore, such cases cannot be validly analyzed in a recurrence
risk factor analysis. The authors must specify in the Materials and Methods section whether the
synchronous metastatic lesions were resected at the time of pancreatic surgery in the analysis
from the SEER database. If the SEER database does not provide this information, then the 16
cases with synchronous metastasis should be excluded from the cohort of 471 patients in Table
1. The authors should then reanalyze the univariate logistic analysis of recurrence factors for
SPN using the remaining 455 cases, and reconstruct Table 2 and Figure 1 accordingly, excluding
synchronous metastasis from the analyzed variables. Without addressing this issue through one
of the abovementioned approaches, many pancreatic surgeons will likely question the validity
of the statistical analysis regarding “recurrence risk factors” following SPN resection.
2. The authors have appropriately addressed and revised the manuscript in response to Major
Comments #2 and #3 from the previous round of review.
Minor comments
1. The authors have referred to page and line numbers in their response to the reviewers, despite
the manuscript not including any such numbering. This is an inappropriate and unclear way
to indicate revisions. In the next revision, the authors must clearly mark the changes in an
appropriate manner that corresponds with the submitted manuscript.
2. The “U” in “Univariate logistic analysis” should be written in lowercase.
Analysis of recurrence factors
As shown in Table 2, Univariate logistic analysis of recurrence factors for SPN showed that
tumor size (OR=1.02, 95%CI 1.01-1.03, P=0.001), regional nodes positive (OR=15.07, 95%CI
2.65-85.59, P=0.002) and chemoradiotherapy (OR=16.47, 95%CI 2.88-94.37, P=0.002) were
relative factors.