Review for 10.1186/s12876-021-02009-8 (2021)

Reviewer’s report
Title: 
Pulmonary tumor thrombotic microangiopathy in occult early gastric
cancer that was undetectable on upper endoscopy: a case report and review of
similar cases
Version: 
0 
Date: 
23 Aug 2021
Reviewer's report:
BMGE-D-21-00668
Pulmonary tumor thrombotic microangiopathy in occult early gastric cancer that
was undetectable on upper endoscopy: a case report and review of similar cases
submittede to BMC Gastroenterology
The authors reported a case with a patient with pulmonary tumor thrombotic
microangiopathy and early gastric cancer that are undetectable on endoscopy.
1-1. Generally, early gastric cancer with signet ring cell carcinoma was reported
to have a favorable outcome, with a 5-year survival rate of more than 90%.
Although categorized as undifferentiated histology, early gastric signet ring cell
carcinoma has a low rate of lymph node metastasis similar to the differentiated
cancer. Several studies revealed no lymph node metastasis when signet ring cell
carcinoma lesions were confined to mucosa, without lymphovascular invasion),
and less than 15 or 20 mm [PMID: 27861374; PMCID: PMC5120931.]. Thus,
cases with early gastric signet ring cell carcinoma presenting with 
pulmonary
tumor thrombotic microangiopathy are considered to be infrequent. It is
recommended that these information be included in the Discussion section.
1-2. It should be confirmed that there was no component of poorly differentiated
adenocarcinoma in the gastric cancer lesions.
2. As the authors stated, signet ring cell carcinomas are most often found in the
stomach. Although less frequently, signet ring cell carcinomas arise in the breast,
gallbladder, urinary bladder, and pancreas. How did the authors exclude the
diagnosis of signet ring cell carcinoma of other organs than the stomach?
3. It is recommended that the infection status of Helicobacter pylori be added in
the Case Presentation section.
4. The authors stated that, "Imatinib inhibits PDGF-receptor and PDGF release
from cancer cells and plays a potential role in alleviating pulmonary
hypertension in PTTM [1, 2]. Thus, although specific chemotherapy could not be
delivered until the final pathological report, we suggest that imatinib
administration at an earlier time point when PTTM is suspected (i.e., on day 1)
might provide more favorable outcomes." However, the usefulness of imatinib
was not shown in the presented patient. Since the discussion seems to me to be
based more on speculation than on reported facts, it is recommended that these
sentences be removed from the manuscript.
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