Review for 10.1186/1471-230X-11-33 (2011)

Reviewer's report
Title:Polymyositis complicating pancreatic adenocarcinoma treated with
corticosteroids along with cancer specific treatment: case report
Version: 1Date:6 December 2010
Reviewer: Albert Selva-O'Callaghan
Reviewer's report:
This is a well written Case Report of a patient diagnosed with cancer
(adenocarcinoma of the pancreas)-associated myositis with some interesting
messages. Nevertheless, there are some issues that need to be clarified or
corrected before publication.
Major Compulsory Revisions
Abstract
Background
• I am not sure that “complicated” is the correct word, probably it will be more
appropriate “associated”.
• The poor prognosis of cancer associated myositis lies mainly in the tumour, not
in the associated polymyositis. Moreover, it is difficult to ascertain the
glucocorticoids resistance in this setting, because some cases are treated with
chemotherapy which has obviously immunosuppressive effects. Thus, the
sentence “…polymyositis is usually resistant to glucocorticoids and confers poor
outcome” should be rewritten
Case Presentation
• When after 6 months the pancreatic cancer relapsed, did the polymyositis also
relapse? This information will be of great interest and it is, besides the temporal
relationship between cancer and polymyositis (less than 3 years interval),
another issue that reinforce the paraneoplastic nature of myositis.
Introduction
• Pag. 3, line 2. Again in opinion of this reviewer the sentence “In the later setting
(it means malignancy), most patients are refractory to glucocorticoids” is not
absolutely right and should be deleted or may be fully explained (taking into
account that some patients improve after chemotherapy, because its
immunosuppressive effect or because the tumour –trigger- is cured)
Case presentation
• Pag 3, last line. Biopsy of the right quadriceps muscle…It would be of interest to
better describe the lymphocytic infiltrate. It was perymisial and perivascular or
endomyisial? Detection of CD8/MHC-I complex would be also of interest to
confirm the diagnosis of polymyositis. Unfortunately, it is well known that
polymyositis is an overdiagnosed entity, so it is important to be more precise on
histological grounds. Autoantibody screening would be of interest in
dermatomyositis or not paraneoplastic myositis but probably not in
paraneoplastic polymyositis as it seems to be the case herein reported.
• The sentence: “Intravenous methylprednisolone was initiated at dose of 125 mg
daily for two days and then was switched to oral methylprednisolone 16 mg daily”
is confuse. Does it mean that methylprednisolone was switched “immediately”, at
the third day to 16 mg daily or after several months? Please clarify this issue.
Discussion
Page 6, paragraph 2, line 4. In the opinion of the reviewer there is not enough
data to state that “…malignancy being a cause of failed response to
glucocorticoids”. This sentence suggest that if a patient do not respond to
glucocorticoids it means that occult cancer is the cause of polymyositis. It is not
my experience. I suggest deleting this sentence.
• Even the case reported is a polymyositis, not dermatomyositis, authors should
comment the relevance of the recently described autoantibodies against a
protein of 155 KD (anti-p155) which antigen is TIF-1###This autoantibody seems
to a reliable marker of cancer in patients with dermatomyositis
Thus, the main message that “paraneoplastic polymyositis, that usually do not
respond to glucocorticoids, occasionally do as the case reported” has to be
changed to “It is difficult to evaluate the clinical response of paraneoplastic
polymyositis to immunosuppressive therapy i.e. glucocorticoids, because of
chemotherapy (with immunosuppressant effects) or the fact that the cancer
–trigger- improves could also play a role in the response to therapy. Even
though, a trial with glucocorticoids will be of benefit in combination with cancer
specific treatment, as is the case presented ”
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
'I declare that I have no competing interests'