Title:   Upfront Surgery in Patients with Epithelial Ovarian Cancer and Enlarged
Supradiaphragmatic Lymph Nodes Associated with Comparable to Neoadjuvant Chemotherapy
Version: 0 Date: 31 Oct 2022
Reviewer:  Carmine Conte
Reviewer's report:
This is a single-center institutional study involving 71 patients with a histologic diagnosis of
advanced epithelial ovarian cancer (EOC) with or without Supradiaphragmatic lymph nodes
(SDLN).
The authors investigated the overall outcomes of SDLN. As secondary outcome they evaluate
whether the different approach (NACT vs upfront surgery) impacted on the outcome.
The work focuses on a critical topic that will play a central role in the next future to lead the
therapeutic management of ovarian cancer.
Findings are interesting. However, I suggest some revisions to improve the quality of the
manuscript and to be suitable for publication on this Journal.
MAJOR REVISION:
Introduction:
The introduction section Is well conducted. However, I suggest implementing the literature data,
including a large Italian study on resectability of lymphnodal metastasis:
Tinelli G, et al. Anticancer Res. 2017 Dec;37(12):6899-6906.
Material And Methods:
-please verify the period of the study (2012 -2020 in the methods, lines 65-66; 2006-2016 in the
discussion section, see line 169).
-Please, I suggest better specifying the inclusion and exclusion criteria.
-I suggest adding information about the tumor burden score system used in the method section
of the study.
Results:
-Result section is not easy to be followed and the manuscript, in terms of data presentation
should be improved.
-median PFS reported in the manuscript does not correspond to the Kaplan-Meyer curves (see
figures 1-2).
-Lines 118 – 119: please, add recurrence rate of both groups.
-Lines 120-121: please verify:  the number of total recurrence (N=35) did not correspond to the
type of recurrence described (N=34; 29 peritoneal, 2 para-aortic, 2 brain, 1 chest)
-Lines 127-128: please add median PFS of NACT and upfront surgery of enlarged SDLN
population: in the table 2 the Authors reported a 9.3 vs. 14.7 months respectively (but it does not
seem the same in the figure 3. Moreover, add a comment in discussion about this huge difference
between the two approaches in this setting of population (it not in line with 3 randomized trials
that compared NACT vs upfront surgery; e.g. SCORPION trial, EORTC 55971 and CHORUS
trials).
-Add median follow-up and overall survival of both groups
-I suggest improving the graphics of table 1.
-Table1 : At which variable is relative the “* at completion of cytoreductive surgery”?
DISCUSSION:
Limits: it s a very small sample study to do a subgroup analysis. Moreover, you included 76
consecutive cases in 8 years of your centre, and there is a very high rate of SDLN in your series:
66% of SDLN vs 34% without. Add a comment.
In your series there Is a high rate of NACT approach vs upfront surgery. Please, add a comment.
I suggest discussing the role of PET/CT scan in detection of lymph-nodal metastasis.
I suggest discussing the lack of overall survival data in the limitations.
Include data about maintenance therapy of both groups (bevacizumab; PARPi?).
The literature analysis is not extensive.
The authors should conclude giving a message to the readers.