Reviewer’s report
Title: 
Primary Ovarian Endometrioid Stromal Sarcoma Presenting with Reno-
Ureteral Colic
Version: 
2 
Date: 
27 Jan 2022
Reviewer: 
Filippo Alberto Ferrari
Reviewer's report:
Dear Respectable Editor, I am grateful to give me the opportunity to review the
manuscript entitled "Primary Ovarian Endometrioid Stromal Sarcoma Presenting
with Reno-Ureteral Colict" by Bueno Moral et al. The authors presented an
interested case report addressed the ovarian endometrioid stromal sarcoma. It is
an unusual presentation of a rare histotype and it could help to improve the
evidence on this topic. Nonetheless some reflections are needed.
I advice to provide a shorter Background Section. In particular to move in the
Discussion the literature findings about recurrence and risk factors (reported
from line 50). If possible add some brief information about treatment in the
Background.
When the authors reported past medical history any previous surgery had to be
checked. Did the last gynecological examination comprehend a gynecological
ultrasound?. 
The description of the intraoperative findings and the surgical procedure is not
adequately clear and described (Type of incision? relation with the ureter?
superficial vascularization of the mass?) and it must supply to the lack of
intraoperative images. When the authors refered to a multidisciplinary discussion
I advice to provide a complete and precise description of the collegial
conclusion.
In the discussion section the literature evidence was poorly analyzed and
discussed. First of all it could be interesting to describe histological features of
ESS. Actually the traditional classification in low-grade and high-grade groups
had been exceeded and high-grade 
now is 
termed undifferentiated endometrial
sarcomas (UES). At line 149 the authors reported the 5-years overall survival
only for low-grade ESS but is not clear if there is a particular reason or data are
not available about high-grade ESS. Nonetheless, following a rigorous
succession, data on PFS and overall survival need to be move further in the
section.
When you provide the possible diagnostic approach to a such rare type of cancer
you should summarize the literature evidence. It could be helpful to describe the
most common MRI findings or if there is a specific markers panel for the
diagnosis. I suggest to briefly analyze the difference with uterine PEComa (see
doi: 10.1097/PAS.0000000000001119). Unusual cases, as the here reported, lead
always to difficult clinical scenarios both for not easy diagnosis and for lack of
evidence in the practice management. For this reason, as in other delicate
gynecological situation (see doi: 10.1111/jog.15038; doi:
10.2174/1573404817666210224150839) summarize of the literature is requiered
to provide a practical and useful tool for everyday clinical practice. I suggest to
produce a Table of the reported treatment in literature, underlining the role of
radiotherapy and adjuvant therapy in other authors experience. As
aforementioned, the diagnosis of a rare histological entity is challenging and I
advice to considered possible differential diagnosis. Moreover, most frequently
ovarian ESS is a secondary localization of primary uterine localization and the
aspect had to be ruled out. Relation with endometriosis is reported in literature
and I suggest to introduce in discussion the correlation (see PMID: 8253545 and
doi: 10.1002/1097-0142(19840301)53:5<1143::aid-cncr2820530521>3.0.co;2-f).
Some authors reported in early stages the possibility of medical therapy, some
reflections are needed when treatment options are considered (See PMID:
6198065).
I suggest to specify in the description of Figure 1 if the provided image is T1 or
T2-weighted
In the descriptions of Figure 3 sizes are reported in centimeters and not
millimeters
In figure 4 mark each image with the correspondent letter (a or b)
Line 59 " A 54 years old woman". 
At line 79 "palpation" may be more appropriate than "to touch". 
Line 86: no free fluid in the pouch of Douglas.
When the dimensions are reported it is preferred to use the symbol "X" instead
of the asterisk
Finally an English language revision of the paper is necessary before publication.
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing
interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
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
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes