Review for 10.1186/s12876-020-01582-8 (2021)

Reviewer’s report
Title: 
Endoscopic ultrasound-guided fine-needle aspiration of pelvic lesions via the upper and lower
gastrointestinal tract approaches
Version: 
0 
Date: 
04 Aug 2020
Reviewer's report:
Retrospective study that expands the indications of EUS-FNA. In this study, the authors show the
feasibility of EUS-FNA of pelvis lesions via an upper approach (mainly from the duodenum but also from
the stomach) with good results and without complications. Since the patients were recruited after CT
showed the location of the lesions in the aortoiliac bifurcation or lower, the retrospective nature of the
study is not an important limitation. However, the series is short and the results need to be validated in
large-scale, well designed studies.
Comments:
Introduction: 
- EUS-FNA is a well established diagnostic technique. There is no need of describing when it was
introduced. References 1 and 2 are very old and can be replaced by some meta-analysis. There are too
many references to studies about performance of EUS-FNA 
- Reference 18: The cited article is a case report with 6 patients in which EUS-FNA of pelvic lesions with
the upper access allows diagnosis in 5. The statement should be tone down.
- Perirectal colorectal cancer recurrence is not uncommon and that has been assessed in the literature but
there is no mention in the study (neither in the introduction nor in the references section).
Methods:
- Inclusion criteria: do we know how many cases with a pelvic lesion in the CT were not send for EUS-
FNA? And if there are some, what was the reason?
- Acquire and EZ shot plus needles have specific designs that allow to obtain tissue samples and are
considered fine needle biopsy (FNB) needles instead of EUS-FNA needles. See the ESGE guideline by
Polkowski et al "Technical aspects of endoscopic ultrasound (EUS)-guided sampling in gastroenterology:
European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline -March 2017". Endoscopy
2017 Oct;49(10):989-1006. 
Results:
- Could you give more details about how many cases were performed with each type of needle?
- How do you explain that there are not cases with colorectal cancer recurrence in this series?
- 
The results should be presented in an intention-to-treat analysis.
- No need of presenting results of cytology and histology separately in the tables. These two tables can be
replaced by one table showing the results when using EUS-FNA and EUS-FNB needles separately. 
- No need of figures 1 and 2
- Keep figure 3A and eliminate 3B and 3C
- No need of table 3. Explain the results in the text 
Discussion:
- The two first paragraphs in the discussion are a summary of the results and need to be rewritten
- The authors write "Therefore, the size and type of FNA needle should be chosen considering the location
and shape of the EUS scope, lesion size, and operator's experience". Although this is generally the case,
this study shows that a 19G needle almost always provide a diagnosis. Change the redaction of the
paragraph.
- The results of the meta-analysis by Han et al (reference 15) show a low rate of AEs (1.7%, 2/236) but
are not mild (2 cases of abscesses in cystic lesions, 1 case of gross hematuria and 1 case of hemorrhage).
Do they used antibiotics when sampling cystic lesions? Although Han et al considered that the procedure
is safe, I recommend to tone down this sentence.
REFERENCES:
Replace some of the references by some of the following:
- Fernández-Esparrach G et al. Endoscopic ultrasound-guided fine needle aspiration is highly accurate for
the diagnosis of perirectal recurrence of colorectal cancer. Diseases of the Colon & Rectum Volume 58: 5
(2015):469-73
- Rzouq F, Brown J, Fan F, et al. The utility of lower endoscopic ultrasound-guided fine needle aspiration
for the diagnosis of benign and malignant pelvic diseases. J Clin Gastroenterol. 2014;48:127-130.
- Glesson FC, Clain JE, Karnes RJ, et al. Endoscopic-ultrasoundguided tissue sampling facilitates the
detection of local recurrence and extra pelvic metastasis in pelvic urologic malignancies. Diagnostic and
Therapeutic Endoscopy. 2012;2012:219521.
- Gleeson FC, Larson DW, Dozois EJ, et al. Local recurrence detection following transanal excision
facilitated by EUS-FNA . Hepatogastroenterology. 2012;59:1102-1107.
- Gleeson FC, Clain JE, Rajan E, Topazian MD, Wang KK, Levy MJ. EUS-FNA assessment of
extramesenteric lymph node status in primary rectal cancer. Gastrointest Endosc. 2011;74:897-905.
- Boo SJ, Byeon JS, Park do H, et al. EUS-guided fine needle aspiration and trucut needle biopsy for
examination of rectal andperirectal lesions. Scand J Gastroenterol. 2011;46:1510-1518.
- Maleki Z, Erozan Y, Geddes S, Li QK. Endorectal ultrasoundguided fine-needle aspiration: a useful
diagnostic tool for perirectal and intraluminal lesions. Acta Cytol. 2013;57:9-18.
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Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
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Yes
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Yes
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manipulation?
Yes