Reviewer's report
Title:Management of musculoskeletal tumors during pregnancy: a retrospective
study
Version:2Date:19 February 2015
Reviewer: elYCE CARDONICK
Reviewer's report:
Discretionary Revisions
The primary aim of this paper is to report a single institution’s experience
concerning the diagnosis and treatment of musculoskeletal tumors during
pregnancy. Would the authors consider changing the title to the DIAGNOSIS and
management of musculoskeletal tumors in pregnancy: a retrospective study,
given that part of their message is the unfortunate delay in diagnosis of these
tumors during pregnancy.
Were the methods appropriate to achieve this goal? Given the rarity of cancer
during pregnancy, longer than an 8 year span may have been necessary to
capture more cases. However the treatment for these tumors may have been
different if the authors had searched too many years before 2002. Given the
hesitancy of some women to volunteer a history of elective pregnancy
termination, the incidence of these tumors during pregnancy may be
underestimated. Was there any search of an obstetrical service database at the
same institution, not to rely on patient amnestic annotations of a pregnancy?
Again, there may have been patients who had miscarried very early in pregnancy
or had an elective termination of pregnancy that they did not wish to disclose or
did not recall an early pregnancy loss.
Minor Essential Revisions
Results:
Diagnosis page 5 regarding the patient’s recollection of the onset of symptoms
during pregnancy-were prenatal records obtained concerning the pregnancies to
more accurately report the timing of symptoms? Were these reported to their
obstetrician or midwife with a date which could be compared to their LMP (last
menstrual period).
The gestational age at diagnosis could be accurately documented with biopsy
date and pregnancy dating by ultrasound measurement of the fetus or LMP.
Imaging in pregnancy only 1 patient had an MRI performed, was this because
there was a hesitancy to perform imaging during pregnancy? As this may have
contributed to the delayed diagnosis, this is important to stress. How soon after
delivery was the imaging performed?
Line 200 page 9 Under diagnosis, is the number of doctors and time frame
needed to make the diagnosis of a musculoskeletal tumor unique to pregnancy
or is the diagnosis of such rare tumors often delayed? Is there an average time
known for the non pregnant young reproductive age population?
Was the delay significantly related to a hesitancy to image pregnant women or
perform a biopsy during pregnancy that has been seen for patients presenting
with a breast mass in pregnancy?
Line 207-209
I find it confusing to ask the reader to go back and forth between sections. For
example, under diagnosis it says : “we advise that in cases where the etiology of
a growing tumor mass is not clear, imaging should be arranged with
consideration of the recommendations stated in the diagnostic work-up section
below. Would it read better to say that in in cases where the etiology of a growing
tumor mass is not clear, imaging should be arranged, keeping in mind the
information gained by the study versus the fetal risks of various exposures. Each
imaging modality is discussed in the following sections.
Treatment page 12
Line 259 Mother and fetus, not child.
Line 265 consider change to: procedures should only be used in cases in which
the results would change treatment management during pregnancy
Major Compulsory Revisions
Regarding the Figures/Tables:
Table 1
Why is contraceptive history relevant? Does the use of oral contraceptives
increase the risk for musculoskeletal sarcomas? How is STD history
relevant?Allergies? These inconsequential columns make the table very busy.
Why was iodine taken in several pregnancies? Is this an endemic area of iodine
deficiency? If this refers to iodinated contrast, it should be labeled an “exposure”,
not medication in pregnancy
Table 2
”Gestation at diagnosis “ column heading should be Gravidy And parity or
Pregnancy number, gestation at diagnosis is an unused term
Table 3
What is PVNS?
Next column after first symptoms/sign and week of pregnancy should be
gestational age at diagnosis, then days between symptoms and diagnosis as
separate column to demonstrate the delay between symptoms and diagnosis
Gestational age should be Gestational age at delivery
Page 11-radiation exposure:
Risk of teratogenesis is highest weeks 2-10 of embryonic age, not 2-20. This can
be broken down in even more detail-weeks 2-7 gross malformations/growth
restriction/No increased risk for mental repercussions
Weeks 8-15 highest risk for mental retardation/Still at risk for for gross
malformations/growth restriction
Weeks 16-25 No increased risk for malformations, risk for mental retardation and
growth restriction present
After week 25, no risk for mental repercussions
Line 274 under biopsy
Pregnancy causes maternal changes of physiology is more appropriate under the
next section, surgical treatment during pregnancy. It does not affect a biopsy as
most are under local anesthesia.
Surgical treatment in pregnancy
page 13 line 290 again, referring the reader outside the current paragraph or in
this case outside the actual paper- why say surgery during pregnancy can be
performed relatively safely provided that the possible difficulties that have been
described in the literature are considered (26,27). Just state the difficulties here.
Or state an anesthesiologist familiar with the physiologic changes of pregnancy
should be present. Maternal complications of bleeding, oxygenation,
hypovolemia can affect the fetal well being.
Page 13 line 292-*At end of paragraph, should be a statement that uterine
displacement is suggested after 20 weeks of gestation to avoid aorto-caval
compression by the growing uterus during surgery.
In addition fetal monitoring is recommended after viability in most institutions.
Radiotherapy and chemo page 13
Line 298-it may not be the radiation dose needed for pelvic cancers that is
contraindicated-- it is the PROXIMity to the fetus.
Page 14-Change ‘abortion” to termination of pregnancy
This affects the heading of this paragraph, Line 310, line314, and 320.
Page 14
Line 327 Are limitations of the work clearly stated? The limitations could include
limiting the collection of cases to a single institution as well as relying on the
amnestic annotations of pregnancies voluntarily offered by the patients. Also in
this section, the sentence on line 327 could end after follow up. Lack of
randomization is unnecessary
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I have no conflict of interest