Title: A case of gigantic ovarian thecoma with normal estrogen during puberty
Version: 1 Date: 08 Jul 2024
Reviewer's report:
Evaluation of the Manuscript Entitled: A Case of Gigantic Ovarian Thecoma with Normal
Estrogen during Puberty.
Prof. Zhilian Hu, Ph.D.
Editorial Board, Associate Editor
BMC Women’s Health
Dear Professor Zhilian Hu,
Subject: Evaluation of Manuscript
Thank you very much for the opportunity to evaluate the manuscript entitled: "A Case of
Gigantic Ovarian Thecoma with Normal Estrogen during Puberty."
Comments to the Author
I would like to thank the authors for this manuscript. Jiahui Dai and colleagues present a case
study of ovarian thecoma tumors in a 16-year-old girl who presented with abdominal pain and a
large abdominal mass. This is a rare case at puberty, presenting numerous challenges, including
vague and diverse symptoms, contrasting radiological results, and the presence of ascites with
unelevated estrogen levels. Surgical intervention, tumor markers, and pathological examination
were primarily used to diagnose ovarian thecoma tumors. These findings are of great interest.
The authors should however consider the following points below:
MAJOR ISSUES
1. In the patient description, please add information concerning ‘pain’ – where was it located?
OT is usually without pain, except in cases of torsion due to the tumor size or the large tumor
causing compressions or pressure. Was this the cause of the pain? Can you describe the pain’s
location, duration, if dull, constant, etc? How could other differentials be misdiagnosed, for
example, if it was at the right iliac fossa, similar to appendicitis?
2. In Keywords, it would be better to replace "axillary inspection" with "unelevated estradiol
levels."
3. Can you give more details on the histopathology results from lines 113-118?
(Spindle cell tumor in the right tumor...) What type of reticular fiber pattern was found? What
stain was it positive for? Did you analyze the specimen using histochemistry stain antibodies
such as SF1, FOXL2, inhibin, Oil red O, calretinin, vimentin, CD10, EMA, cytokeratins, and
CD99?
4. It is important to make a differential diagnosis with other thecomas or similar SCSTs:
o If it is not a luteinized thecoma associated with sclerosing peritonitis observed at a younger age,
presenting with symptoms including abdominal pain, ascites, and bowel obstruction with bland
spindle cell proliferation circumferentially involving the ovarian cortex, sparing the medulla.
o Why is it not an adult granulosa cell tumor?
o Check (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10741682/)
# If the reticulin stain is of a peri-cellular pattern or shows a nest pattern and if the sex cord
element is >10%.
# If the reticulin stain shows a monocellular tumor and if it is benign with <3 mitosis per 10
high-power fields (HPF) or malignant fibrosarcoma/fibrothecomas if nuclear atypia is present
and/or >4 mitotic figures per 10 HPF.
# If the reticulin stain pattern is ambiguous and there is the presence of DICER1 /FOXL2
mutation.
5. Attach references for statements between lines 128-133.
6. State study limits -  I suggest you add this study limit - Being a rare case, and difficult to
diagnose, only one patient was available in this study, but it is a worthy addition to the literature.
7. On lines 165-173, the Conclusion can be rewritten as:
We reported a rare atypical benign OT, the clinical findings revealed abdominal distention
for a year, menstrual disorder, bleeding, ascites, abdominal fluid, a solid mass of size
24/15.6/10.7 cm, and frequent urination suggesting malignancy. Also, estrogen was atypically
unelevated; however, tumor markers were unelevated. Benign ovarian thecomas should not
be ruled out in adolescents presenting with a large pelvic mass and other findings typical
of malignant ovarian tumors. A differential diagnosis of OT based on the imaging results
was difficult to obtain since the CT and the US examinations provided conflicting results.
Abdominal US could be used to facilitate the differentiation between fluid-filled and solid
masses.                                                                                                                            Did you
discover the cause of frequent urination? Was it due to tumor compression or obstruction?
MINOR ISSUES
8. The author stated on line 109 that "the right side of the oviduct and tumor were performed."
I believe you meant to say "were resected." Can you please correct it?
9. Some ovarian thecomas have been reported to be related to anticonvulsant therapy.
Do you know if she was ever on any anticonvulsant therapy? Was there any follow-up or any
relapse?
10. In addition to the statement on lines 148-149, "Since the mass was too large and the density
was uniform, the lesion appeared as a cystic mass on CT,"
I suggest you also add that "CT scan is usually more fluid sensitive, unlike ultrasound."
11. The statement on lines 159-160, to make a fair comparison, I suggest rewriting as:
"Malignant OT differs from other ovarian malignant tumors since it lacks specific oncological
markers."
Dear Editorial Board, I hope with these changes the authors will be able to improve the
manuscript to a high standard.
Yours sincerely,
Doctor.