Review for 10.1186/s12876-025-03897-w (2025)

Title: Diagnostic challenges of inflammatory submucosal tumor-like lesions: a multicenter
propensity score- matching analysis
Version: 0 Date: 18 Mar 2025
Reviewer:  Mohamed H. Zidan
Reviewer's report:
Dear Author,
Re: Diagnostic challenges of inflammatory submucosal tumor-like lesions: a multicenter
propensity score-matching analysis
Thank you for the opportunity to review your manuscript. Your study provides a valuable
multicenter analysis of inflammatory submucosal tumor-like lesions (I-SMTLs). The use of
propensity score matching (PSM) strengthens the comparability of I-SMTLs and non-I-SMTLs,
and the correlation analysis between endoscopic and pathological characteristics is particularly
insightful. Below are my comments and suggestions for improving the manuscript.
The introduction effectively highlights the clinical challenge posed by I-SMTLs and the need
for improved diagnostic accuracy. The discussion on the limitations of endoscopic ultrasound
(EUS) in differentiating I-SMTLs from true submucosal tumors is relevant and well-supported.
However, it would be beneficial to clarify how this study advances previous work in this field.
While prior studies have noted the existence of inflammatory lesions mimicking SMTs, further
elaboration on how this study provides new insights—such as through a more comprehensive
analysis of EUS features or a larger, multicenter cohort—would enhance the introduction.
The methodology is well-structured and includes detailed descriptions of patient selection,
endoscopic evaluation, and histopathological classification. The inclusion and exclusion criteria
are clearly defined, which is a strength. However, additional clarification on the rationale for
specific statistical choices would be helpful. For instance, the decision to use a caliper value of
0.2 in PSM should be briefly justified. Similarly, while Cramer’s V coefficient is an appropriate
measure of association, discussing why this particular metric was chosen over alternatives
(e.g., logistic regression for multivariable associations) would provide more transparency.
Additionally, a brief mention of interobserver variability in EUS assessment and any measures
taken to mitigate it (e.g., consensus review of images) would strengthen the methodological
rigor.
The results are presented in a logical sequence, with a clear distinction between overall
patient demographics, endoscopic features, and diagnostic efficacy. The figures and tables are
informative, though Figure 3 could benefit from a clearer explanation of how observed and
expected frequencies were calculated.
The discussion does a good job of contextualizing the findings within existing literature. The
emphasis on the poor sensitivity of EUS for I-SMTLs (approximately 4%) and the potential
role of specific EUS features (e.g., submucosal location, mixed echogenicity, heterogeneous
texture) in improving recognition is well-founded. However, a more nuanced discussion of the
clinical implications would be helpful. For instance, while the study suggests that I-SMTLs
are often overdiagnosed as neoplastic lesions, what are the practical implications for clinical
management? Should biopsy techniques such as mucosal incision-assisted biopsy (MIAB) be
more widely employed in suspected cases? Additionally, the discussion could briefly address
the limitations of EUS-guided fine-needle aspiration (FNA) for small submucosal lesions and
whether newer biopsy techniques could improve diagnostic accuracy.
One area that warrants further exploration is the role of lesion size in clinical decision-making.
The study notes that 98.31% of I-SMTLs were #2 cm, which aligns with current guidelines
suggesting that small SMTs may be monitored rather than resected. However, given the high rate
of misdiagnosis, should this threshold be reconsidered? Additionally, while the study suggests
that endoscopic resection may be a reasonable option for I-SMTLs, a discussion of potential risks
(e.g., perforation, bleeding) versus benefits (e.g., definitive diagnosis, reduced patient anxiety)
would be valuable.
The conclusion appropriately summarizes the key findings and their relevance to clinical
practice. However, it would be beneficial to explicitly state that prospective studies are needed
to validate these findings. Additionally, while the study makes a compelling case for the
importance of recognizing I-SMTLs, a brief mention of whether artificial intelligence (AI)-
assisted EUS interpretation or other advanced imaging modalities could improve diagnostic
accuracy in the future would add depth to the conclusion.
Overall, this is a well-executed study that addresses an important gap in the literature.
Best regards,