Title: Diaphragmatic Endometriosis Associated with Pelvic Endometriosis: A Case Report
Version: 0 Date: 31 Mar 2024
Reviewer's report:
Dear authors,
This a a good case report as it shows the coincidental diagnosis and the following pathway of
diagnosis and treatment. The discussion is rather a mini review than a discussion of your case.
Please be more precise in the description of your decision making process and give reasons for
your decisions.
Please find my comments and suggestions as follows:
- Please add the following recent paper as it also discusses hormonal treatment and outcomes:
Naem A, Andrikos A, Constantin AS, Khamou M, Andrikos D, Laganà AS, De Wilde
RL, Krentel H. Diaphragmatic Endometriosis-A Single-Center Retrospective Analysis of
the Patients' Demographics, Symptomatology, and Long-Term Treatment Outcomes. J Clin
Med. 2023 Oct 11;12(20):6455. doi: 10.3390/jcm12206455. PMID: 37892593; PMCID:
PMC10607902.
- please explain who started the intervention, the general surgeons I guess. This would mean
that your gynecological team was surprised by the surgery.
- Did you know during surgery, if the patient had symptoms? (Only in case of symptoms the
surgical removal would make sense.
- If I understand you right, you performed a partial resection of the diaphragmatic disease. So it
was incomplete, true? Please add a ratio on your decision making process. Why did you opt for
incomplete surgical treatment. (Nodules still visible in the second MRI....)
- Please discuss the option to stop the surgery and pass the patient to a team that is specialized
with diaphragmatic resection.
- Line 52. Please add reference.
- the quality of images is very low. Do you have images with higher resolution?
- Line 78: did you open the pleura? Did you perform thoracoscopy? Which type of scope did
you use? 30 degrees?
- Please discuss the risk of pneumothorax in your patient as MRI describes the openings.
- Line 147-153: this a more appropriate for introduction.
- Please shorten the discussion.
- In the discussion you describe the diagnostic approach. I would suggest that you start as it
should be done in clinical process. VATS would not be the first diagnostic approach. Please
change this part and shorten it and explain your approach.
- I think you should omit the biomarkers part. Focus on your topic.
- Line 201 ff.: I believe you should not explain how GnRHa works.
- I think danazol and aromatase inhibition should not be mentioned.
- Line 227: what do you mean by parenchyma. Usually, when full thickness resection is
performed, the parenchyma of the lung is not involved. In some cases you may find adhesions
to the lung.
-Line 228 what does certain scenario mean. Be more precise here, as there is a relevant group
which is asymptomatic (75%).
- Line 235 ff: this technique is not a recommendable approach in diaphragmatic endometriosis
and should be only offered in very rare occasions.
- What about liver mobilization?
- Line 238:ablation of the larger foci? How large? why not resection? And what happened with
the small foci?
- Line 238 ff: you are repeating the case presentation.
Line 253: How you can be sure that there where no infiltrative lesions?
Kind regards.