Title: Primary pelvic retroperitoneal smooth muscle tumor with cystic degeneration: A case
report and review of the literature
Version: 4 Date: 13 May 2025
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
No - there are minor issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
N/A - there are no statistics in this study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: This case report presents a rare instance of a primary pelvic
retroperitoneal smooth muscle tumor with a clear and structured description. The introduction
effectively frames the rarity and diagnostic challenge of such tumors. The clinical details,
imaging findings, and surgical approach are comprehensive, though some sections would benefit
from more concise and integrated presentation. Histopathological and immunohistochemical
analyses are clearly reported and strengthen the diagnosis. The discussion contextualizes the
case well within the existing literature, although some parts require better logical flow and direct
relevance to the presented case. The report appropriately emphasizes the importance of histology
in differential diagnosis, given imaging limitations. There is some redundancy and vagueness
in describing potential tumor origins and diagnostic approaches. The elevated AFP finding is
insufficiently discussed, leaving its clinical implication ambiguous. The conclusion reinforces
the case’s rarity and value but could be more focused on practical takeaways. Overall, the study is
informative and relevant, with minor revisions needed to improve clarity, structure, and clinical
impact.
For the sake of clarity, I declare that I am a reviewer for the revised version of the manuscript,
although I was not a reviewer for the first version.
REQUESTED REVISIONS:
I recommend to take into account the following suggestions:
- Introduction: The definition of primary retroperitoneal masses is introduced abruptly without
providing a broader clinical or anatomical context. Begin the paragraph with a brief description
of the retroperitoneal space and its clinical significance to help orient the reader.
- Introduction: The incidence rate for primary retroperitoneal tumors is mentioned but lacks
recent references or population data. Support the incidence data with a more current and clearly
cited epidemiological study to strengthen its validity.
- Introduction: The transition between retroperitoneal sarcomas and uterine smooth muscle
tumors is unclear, potentially confusing the reader about the main focus. Improve the flow by
clearly distinguishing between retroperitoneal and uterine origins and specifying the relevance
of each to the case.
- Introduction: The statement “Isolated extrauterine smooth muscle tumors are very rare” is too
brief and lacks contextual explanation. Elaborate on what “isolated” entails and how such tumors
differ from metastatic or uterine-derived cases.
- Introduction: The phrase “1.2% incidence of retroperitoneal smooth muscle tumors” is unclear
about the population or total case denominator. Clarify whether the percentage refers to all
retroperitoneal tumors or another subset.
- Introduction: The association between retroperitoneal tumors and prior uterine fibroids/
myomectomy is mentioned but not explained in terms of possible pathophysiological links.
Include a brief discussion or hypothesis about why such a history might be relevant to tumor
development.
- Introduction: The claim that these tumors have “no specific clinical manifestations” could be
supported with examples or citations to increase its reliability. Provide at least one reference or
example to validate the nonspecific symptomatology claim.
- Introduction: The discussion about diagnostic difficulty lacks detail about which imaging
techniques are typically used and their limitations. Mention commonly used imaging modalities
(e.g., CT, MRI) and explain why they fall short in differentiating benign from malignant lesions.
- Introduction: The purpose of the case report is stated at the end, but it lacks emphasis on what
makes this case particularly noteworthy or different. Strengthen the conclusion by highlighting
what makes this case uniquely valuable to clinical practice or literature.
- Introduction: Some references are not well integrated into the text, making it unclear which
claims they support. Link references more precisely to specific statements or data to enhance
traceability and academic rigor.
- Case presentation: The initial description of the patient’s medical history and clinical findings is
overly detailed and includes redundant negative findings. Condense this section by summarizing
non-contributory negatives to enhance clarity and focus on pertinent clinical information.
- Case presentation: The phrasing “complete medical check-up” is vague and does not explain
the context of the ultrasound discovery. Specify whether the imaging was part of a routine
gynecologic exam or conducted for another reason.
- Case presentation: The use of “insidious onset” and “unknown disease course” is ambiguous
given the patient was asymptomatic. Rephrase to clarify that the lesion was asymptomatic and
discovered incidentally.
- Case presentation: The statement “appropriate abdominal physical examination was
performed” is vague and unnecessary. Remove or replace it with a brief summary of the relevant
findings.
- Case presentation: The tumor marker AFP is elevated, but this result is not interpreted or
discussed in the clinical context. Briefly explain the potential implications of elevated AFP and
its relevance (or irrelevance) to the diagnosis.
- Case presentation: The imaging descriptions are detailed but somewhat repetitive and lack
interpretive guidance. Streamline this section and integrate CT and ultrasound findings to offer
a cohesive clinical impression.
- Case presentation: The phrase “the possibility of ovarian cancer could not be ruled out” is
accurate but would benefit from clarification regarding the differential diagnosis considered.
Expand briefly on how imaging and surgical findings helped narrow down the diagnosis.
- Case presentation: The intraoperative findings are clear, but the anatomical relationships could
be more precisely described. Specify how the tumor’s relationship with critical structures (e.g.,
ureter, vessels) influenced the surgical approach.
- Case presentation: The histopathological findings are well-documented, but the transition
between gross, microscopic, and immunohistochemical results is abrupt. Improve flow by
grouping and logically sequencing the diagnostic findings.
- Case presentation: The follow-up section is informative but redundant in parts. Eliminate
repeated statements about the patient’s health status and instead focus on the long-term follow-
up plan and rationale for ongoing monitoring.
- Discussion: The first sentence introduces smooth muscle tumors in general without clearly
linking the discussion to retroperitoneal tumors. Start the paragraph with a clear reference to
retroperitoneal smooth muscle tumors to maintain focus and consistency with the case.
- Discussion: The classification of benign smooth muscle tumors is presented without defining
or contextualizing the categories for clinical relevance. Briefly describe each category’s typical
presentation or location to clarify their distinction and relevance to the current case.
- Discussion: The pathogenesis section lists multiple speculative origins without discussing their
plausibility or prevalence. Indicate which theories are more widely accepted or supported by
current evidence to guide the reader.
- Discussion: The phrase “under specific conditions” regarding mesenchymal differentiation
is vague and lacks explanation. Clarify or give an example of such conditions to make the
mechanism more informative.
- Discussion: The discussion of tumor degeneration types is informative but disconnected from
the presented case. Explicitly link these degeneration types to the findings in the current patient
(e.g., cystic degeneration).
- Discussion: The physical examination finding that 90% of pelvic masses can be palpated is
not directly relevant to retroperitoneal tumors, which are often deep-seated. Clarify that while
some masses are palpable, retroperitoneal tumors may be more difficult to detect clinically.
- Discussion: The section on misdiagnosis could benefit from a concrete example or brief
elaboration of how misdiagnosis affects clinical outcomes. Add a sentence explaining the risks
or consequences of incorrect preoperative assumptions.
- Discussion: The statement “a single examination is often inadequate for an accurate diagnosis”
is vague and needs clarification. Specify which combinations of tests improve diagnostic
accuracy.
- Discussion: The discussion on imaging modalities lacks coherence and could be better
organized by grouping similar tools (e.g., standard imaging vs. advanced imaging). Reorganize
and contrast standard imaging techniques with newer modalities like diffusion-weighted MRI
for clarity.
- Discussion: The sentence beginning “intraoperative comminution should not be employed…”
is awkward and unclear. Rephrase for clarity, such as: “Intraoperative fragmentation of the tumor
should be avoided when malignancy cannot be excluded preoperatively.”
- Discussion: The summary of the present case appears abruptly in the middle of the general
discussion. Move this paragraph to a separate “case relevance” subsection or clearly transition
into it to preserve logical flow.
- Discussion: The discussion of AFP lacks references or comparative data and does not offer
alternative hypotheses. Mention potential non-tumoral causes of AFP elevation or state clearly
that this may represent an incidental finding.
- Discussion: The conclusion restates many points already discussed but lacks synthesis. Refocus
the conclusion on implications for clinical practice, such as raising awareness and improving
differential diagnosis strategies.
- Discussion: The importance of regular follow-up is mentioned but not detailed. Recommend a
follow-up protocol or duration based on existing literature to support clinical decision-making."