Review for 10.1186/s12876-021-01641-8 (2021)

Reviewer’s report
Title: 
Lactoferrin amyloid presenting as a mural nodule in a pancreatic cystic
lesion prompting pancreatoduodenectomy: a case report.
Version: 
0 
Date: 
16 Dec 2020
Reviewer: 
Jayanta Samanta
Reviewer's report:
The authors of the manuscript "Lactoferrin amyloid presenting as a mural nodule
in a pancreatic cystic lesion prompting pancreatoduodenectomy: a case report"
have described a case of lactoferrin amyloid deposition, a benign condition, in
the form of a mural nodule giving a picture of suspected neoplastic cystic lesion
warranting pancreatoduodenectomy.
I have the following comments to make:
1) The authors mention of a 1.7 X 1.3 cm cystic lesion in the head of the
pancreas with a mural nodule. No mention of the size of the nodule is present. 
Did the authors look for the vascularity of the mural nodule during EUS?
2) Fukoka guidelines clearly suggest that worrisome are those with cyst >3 cm
with an enhancing mural nodule < 0.5 mm. Mere presence of mural nodule is not
a worrisome feature as the authors here have mentioned. 
3) MPD calibre has not been mentioned. That again will add on to the worrisome
features, but has not been looked into here.
4) And as per Fukoka guidelines, cyst with <3cm size and no worrisome features
should be undergoing surveillance, not surgery. Then why is it different in this
study, and the decision for surgery?
5) In the EUS description, no mention of main pancreatic duct is there. If MPD is
dilated with distal atrophy, then it's a high suspicion case. 
6) Where is the stenosis in the bile duct (level of obstruction.)? This has not been
mentioned and what do the authors think is the cause for this stenosis?
7) The authors have mentioned that "Clinically, the cyst was considered to be an
intraductal papillary mucinous neoplasm." How can IPMN be a clinical
diagnosis?
8) How is the provisional diagnosis of IPMN made? Neither is it in line with the
MPD with focal dilatation (main duct IPMN), nor is it communicating with
MPD (branch duct IPMN). 
9) Extrinsic compression of the CBD with "dark colored urine and acholic
stools" but a serum bilirubin of just 1.2 mg/dL somehow does not match.
10) What was the fluid report of the initial EUS when fluid was aspirated? What
was the CEA levels in the fluid? Without confirming a definite worrisome or
high-risk factor, how was pancreatoduodenectomy carried out?
11) 
what is the authors' view on this unusual isolated focal amyloid deposit
within a cyst of the pancreas without any other place deposition? 
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