Executive Functions in a Patient with Low-Grade Glioma of the Central Nervous System: A Case Report

Round 1

Reviewer 1 Report

In this paper the authors present a case of a 59 yo patient with right temporo-insular low grade glioma in which longitudinal executive functioning assessment was performed with the Wisconsin Card Classification Test.

While the application of this test to LGG could be interesting, the topic of the paper isn't very clear. It lacks novelty and clarity. Authors are encouraged to refer to the current literature, such as:

-van Loon EM, Assessment methods and prevalence of cognitive dysfunction in patients with low-grade glioma: A systematic review. J Rehabil Med. 2015

-Cochereau J, Network-behavior mapping of lasting executive impairments after low-grade glioma surgery. Brain Struct Funct. 2020

-Barzilai O, Improvement in cognitive function after surgery for low-grade glioma. J Neurosurg. 2018

Language needs a carefull review for aboundance of typo errors and lexical redundance.

Author Response

Dear reviewer, thank you for taking the time to review our manuscript. We greatly appreciate your insightful comments and suggestions for improvement. As per your suggestions, we have made changes to the manuscript to make it clearer and more concise. We hope that the revised manuscript meets your expectations and that you find it suitable for publication.

R// Dear Reviewer,

Thank you for your feedback. We have clarified the argument and novelty of our paper. We went ahead and looked over the suggested references. Additionally, the language editing was checked.

Best regards,

Author Response File: Author Response.docx

Reviewer 2 Report

1.     It is not clear why an executive functioning evaluation is needed in the case of an oncological patient. This is the goal of the study, hence I think the authors need to describe the importance of having this kind of evaluation.

2.     As a consequence of my prior suggestion, it is also important the authors explain which are the areas that are involved in executive functioning impairment in patients with tumor. This is necessary as executive functioning entails several cognitive processes different from each other (e.g., updating, inhibition, problem-solving) allowing people to perform several tasks and everyday activities. Also, the prevalence of this phenomenon in this specific type of population is another relevant data to describe.

3.     I miss also a section where it clearly describes the objective of the study and possible hypotheses.

4.     I encourage the authors to split the case presentation into different sections referring to the different sources consulted to have a clinical overview of the patient. For instance, Medical Records, Psychological Interview, etc. A brief summary of the sources used at the beginning of the section could be a nice addendum to the paper. A better description of the neuropsychological evaluation carried out is fundamental to understand the data.

5.     Similarly, graphically speaking, I believe it is important to have a Results section where data are discussed clearly.

6.     I believe the authors failed to take into consideration the possibility that the patient was malingering his/her condition. This is an important aspect that needs to be ruled out during neuropsychological evaluation as it is a very common phenomenon not only in forensic contexts but also in clinical and medical ones.

Author Response

Dear reviewer, thank you for taking the time to review our manuscript. We greatly appreciate your insightful comments and suggestions for improvement. As per your suggestions, we have made changes to the manuscript to make it clearer and more concise. We hope that the revised manuscript meets your expectations and that you find it suitable for publication.

1. It is not clear why an executive functioning evaluation is needed in the case of an oncological patient. This is the goal of the study, hence I think the authors need to describe the importance of having this kind of evaluation. 

R/ Thank you for the feedback, we have made explicit the relevance of the assessment for the neurological clinic, as well as the role of executive functions in everyday life.

2. As a consequence of my prior suggestion, it is also important the authors explain which are the areas that are involved in executive functioning impairment in patients with tumor. This is necessary as executive functioning entails several cognitive processes different from each other (e.g., updating, inhibition, problem-solving) allowing people to perform several tasks and everyday activities. Also, the prevalence of this phenomenon in this specific type of population is another relevant data to describe.

 R// Thanks for the comment, we have incorporated the prevalence of the phenomenon as well as the areas involved in executive functioning and affected in patients with brain tumors.

1. I miss also a section where it clearly describes the objective of the study and possible hypotheses.

R// Thank you again, we have explained the objective and hypothesis of the study.

4. I encourage the authors to split the case presentation into different sections referring to the different sources consulted to have a clinical overview of the patient. For instance, Medical Records, Psychological Interview, etc. A brief summary of the sources used at the beginning of the section could be a nice addendum to the paper. A better description of the neuropsychological evaluation carried out is fundamental to understand the data.

 R// Thank you for the comment We have subdivided the presentation of the case into different sections, with a brief description at the beginning, along with looking for reproducibility detailing the neuropsychological evaluation process followed.

5. Similarly, graphically speaking, I believe it is important to have a Results section where data are discussed clearly.

R// Thanks for the comment, we have discussed the data obtained in more detail in a results subheading.

6. I believe the authors failed to take into consideration the possibility that the patient was malingering his/her condition. This is an important aspect that needs to be ruled out during neuropsychological evaluation as it is a very common phenomenon not only in forensic contexts but also in clinical and medical ones.

R// Thank you for the comment, due to the basic biological condition, we do not contemplate the possibility that the observed results were due to the fact that you are faking your condition and therefore, a consistent result in the test. However, we believe that both his story and that of his wife, the pre- and post-evaluation carried out by the neurologist, the psychologist, and the neuropsychologist allow us to say that the risk that he is faking it is minimal, due to the consistency between the different data collection instruments used (interview, neuroimaging, psychometric tests).

Author Response File: Author Response.docx

Reviewer 3 Report

Dear Authors,

The present research article, entitled “Executive Functions in Patient with Low Degree Glioma of the Central Nervous System: Case Report”, aims to describe the executive function of a 59-year-old adult neuro-oncological patient.

The main strength of this manuscript is that it aims to analyze what are the main characteristics of the executive function of a particular patient with a low-grade glioma, something that has not been studied in detail in previous studies.

In general, I believe that the topic and approach of this article is timely and of interest to the readers of Tomography. However, I believe that some issues should be included to improve the quality of the manuscript.

Abstract:

·         A brief discussion or relevant aspects should be included at the end of the abstract. This would help to give visibility to the importance of the study.

Introduction

·         I believe that more emphasis should be placed on the various clinical effects and/or consequences that central nervous system tumors have on people.

·         It would be advisable to briefly include the importance of executive functions in people's daily functioning.

·         Although the objective is in the summary, it would be appropriate to include it at the end of the introduction. This would help the reader to understand the study.

·         Please add the study hypothesis, which was missing in the manuscript.

Case Presentation

·         The measuring instruments used should be briefly explained and cited.

Discussion

·         I recommend starting the discussion with the objective of the study.

·         Can some limitations of the study be included?

Conclusions

·         Again, in the conclusions, I consider it necessary to emphasize the relevance of this study. This will allow readers to give due importance to determining the level of executive function performance of patients with low-grade glioma and, consequently, to establish intervention guidelines in relation to it.

I declare no conflict of interest regarding this manuscript.

 Best regards.

Author Response

Dear reviewer, thank you for taking the time to review our manuscript. We greatly appreciate your insightful comments and suggestions for improvement. As per your suggestions, we have made changes to the manuscript to make it clearer and more concise. We hope that the revised manuscript meets your expectations and that you find it suitable for publication.

Abstract:

• A brief discussion or relevant aspects should be included at the end of the abstract. This would help to give visibility to the importance of the study.

R//Thanks for the comment, the abstract was adjusted.

Introduction

• I believe that more emphasis should be placed on the various clinical effects and/or consequences that central nervous system tumors have on people. 

R//Thanks for the comment, the introduction was adjusted.

• It would be advisable to briefly include the importance of executive functions in people's daily functioning.

R//Thank you, it was incorporated.

• Although the objective is in the summary, it would be appropriate to include it at the end of the introduction. This would help the reader to understand the study.

R//Thank you was incorporated

• Please add the study hypothesis, which was missing in the manuscript.

R// Again thanks, we've adjusted including the hypothesis.

Case Presentation

• The measuring instruments used should be briefly explained and cited.

R// Thank you we have incorporated the suggestion.

Discussion

• I recommend starting the discussion with the objective of the study.

R//Thank you. We've adjusted

• Can some limitations of the study be included?

R//Thanks, we've included some limitations.

Conclusions

• Again, in the conclusions, I consider it necessary to emphasize the relevance of this study. This will allow readers to give due importance to determining the level of executive function performance of patients with low-grade glioma and, consequently, to establish intervention guidelines in relation to it.

R// Thank you, we have incorporated these suggestions.

I declare no conflict of interest regarding this manuscript.

 Best regards.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

At line 199 the BANFE-II score is cited but never applied. Please clarify.

A graphic scheme depicting cognitive deterioration could be usefull for readers comprehension.

A carefull check is advised to provide a concise and clear text. The style is redundant.

Author Response

Dear reviewer, thank you for the valuable annotations. With regard to Banfe II, what we point out is the use of a questionnaire that is included in this instrument, which is taken up in line 199 “The frontal neuropsychological damage questionnaire provided by the second edition of the Neuropsychological Battery of Executive Functions and Frontal Lobes (BANFE-II), developed by Flores, Ostrosky and Lozano (2014), was used. It is a behavioral scale applied to the caregiver with 40 items composed of a Likert-type scale from 0 to 5 (1: almost never; 2: rarely; 3: sometimes; 4: frequently; 5: almost always)”. which is taken up in line 244: "In this sense, the frontal lobe inventory seeks to objectify the behaviors of the patient by inquiring with the caregiver about it and receives 13 points out of 40 possible, which places it close to the minimum global functional commitment. Therefore, we consider the possibility that there was a falsified result in the WCST unlikely, given the contrasting sources of information mentioned on the existence of cognitive impairment. These are related to neuroimaging, the caregiver's testimony, and the frontal damage questionnaire." We also made a graph to show cognitive impairment and make it easier for readers to understand. And we have revised the manuscript for concise and clear language.

Reviewer 2 Report

Thank you for replying to all my prior concerns. I do not have any further comment

Author Response

Thank you

Reviewer 3 Report

Dear Authors,

I believe that the changes made in the paper are quite timely.

Best regards.

Author Response

Thank you.