A Novel Case of Recurrent Mucinous Borderline Ovarian Tumor: Early Relapse and Fatal Outcome

Round 1

Reviewer 1 Report

The authors describe a case of recurrent mucinous borderline ovarian tumor (BOT). The authors claim that this is a novel case of mucinous BOT. However, this report lacks some critical pathological findings. 

First, liver tumors were diagnosed as metastatic tumors from mucinous BOT. However, in the discussion section the authors say, “a biopsy was not performed and a conclusive diagnosis was not made.” Then, why the authors can state that this case was a recurrent mucinous BOT? 

Second, primary mucinous tumors are necessary to distinguish from ovarian metastases of digestive organ cancers. Did the authors perform immunohistochemical staining? In Figure 2, high magnification photomicrographs are necessary. 

Third, mucinous BOTs are sometimes accompanied by anaplastic carcinoma or signet ring cell carcinoma [J Ovarian Res 2013, Gynecol Oncol Rep 2020]. These highly aggressive carcinomas arise in mural nodules. Are there any mural nodules in the tumor? What is the number of sections per centimeter of tumor diameter? 

Why was this case stage IC? What substage?

Figure 3(c) is the same as Figure 3(d).

In paragraph 3 of the Discussion, the authors say, “the time between successful treatment and recurrence.” What is the meaning of ‘successful’ in this sentence? 

Author Response

Responses to the comments made by Reviewer 1:

We are grateful for your insightful comments. Our responses are listed below.

General comment) The authors describe a case of recurrent mucinous borderline ovarian tumor (BOT). The authors claim that this is a novel case of mucinous BOT. However, this report lacks some critical pathological findings. 

Response) We are grateful for your critical comments. Our responses to individual comments are listed below.

Comment 1) liver tumors were diagnosed as metastatic tumors from mucinous BOT. However, in the discussion section the authors say, “a biopsy was not performed and a conclusive diagnosis was not made.” Then, why the authors can state that this case was a recurrent mucinous BOT? 

Response 1) Thank you for your pertinent comments. We apologize for presenting the inaccurate fact. Liver biopsy was performed after the fourth course of TC+BEV. However, no malignant tissue was detected. Honestly, we had difficulty in reaching the diagnosis. We considered the recurrence to be BOT based also on the clinical course. We have deleted some sentences and included additional text in the case presentation and discussion sections. Please see page 5, line 108- page 5 line 112 and page 6, lines 188-189.

Comment 2) primary mucinous tumors are necessary to distinguish from ovarian metastases of digestive organ cancers. Did the authors perform immunohistochemical staining? In Figure 2, high magnification photomicrographs are necessary. 

Response 2) Thank you for your valuable comments. No cancerous lesions were detected at upper and lower gastrointestinal endoscopy. Immunohistochemical staining was not performed. We have included additional text in the case presentation section in the revised manuscript. Please see　page 2, lines 72 and 73.

We have also presented high magnification photomicrographs. Please see Figure 2.

Comment 3) mucinous BOTs are sometimes accompanied by anaplastic carcinoma or signet ring cell carcinoma [J Ovarian Res 2013, Gynecol Oncol Rep 2020]. These highly aggressive carcinomas arise in mural nodules. Are there any mural nodules in the tumor? What is the number of sections per centimeter of tumor diameter? 

Response 3) Thank you very much for your invaluable comments. We detected no mural nodules. We have included additional text in the case presentation section in the revised manuscript. Please see　page 2, lines 79 and 80.

The total number of samplings was 22. Pathological sections were obtained at an interval of about 1 cm in this tumor.　 Please see　page 6, lines 178 and 179.

Comment 4) Why was this case stage IC? What substage?

Response 4) This case was Stage IC1 because it was limited to the left ovary and intraoperative rupture was observed. We have included additional; text in the case presentation section in the revised manuscript. Please see　page 2, lines 78 and 79.

Comment 5) Figure 3(c) is the same as Figure 3(d).

Response 5) Thank you for your careful review. We sincerely apologise for the careless mistake. We have presented a more appropriate Figure 3(d).

Comment 6) In paragraph 3 of the Discussion, the authors say, “the time between successful treatment and recurrence.” What is the meaning of ‘successful’ in this sentence? 

Response 6) Thank you for your insightful comment. We have replaced “successful treatment” with “standard of care.” Please see page 5, line 126.

Reviewer 2 Report

An interesting case report about a rare, borderline ovarian tumor that was associated with a fatal outcome. I feel the article may be eligible to be published after minor revisions:

• An English check would be appropriate, as some expressions are difficult to understand.

Good luck!

Author Response

Responses to the comments made by Reviewer 2:

We are grateful for your insightful comments. Our responses are listed below.

General comment)

An interesting case report about a rare, borderline ovarian tumor that was associated with a fatal outcome. I feel the article may be eligible to be published after minor revisions:

• An English check would be appropriate, as some expressions are difficult to understand.

Good luck!

Response) Thank you for your helpful recommendation. The manuscript has been reviewed by a scientific native English-speaking editor.

Reviewer 3 Report

The authors presented a very interesting and rare Case of Recurrent Mucinous Borderline Ovarian Tumor. 

The paper describes the theoretical information regarding BOT comprehensively.

The case description is detailed and includes all relevant information. The figures included by the authors facilitate its understanding.

The discussion comprehensively discusses the issue. 

The authors have drawn accurate conclusions.

The article can be published in its current form in MDPI Reports in the reviewer's opinion.

Author Response

Responses to the comments made by Reviewer 3:

We are grateful for your pertinent comments. Our responses are listed below.

General comment)

The authors presented a very interesting and rare Case of Recurrent Mucinous Borderline Ovarian Tumor. 

The paper describes the theoretical information regarding BOT comprehensively.

The case description is detailed and includes all relevant information. The figures included by the authors facilitate its understanding.

The discussion comprehensively discusses the issue. 

The authors have drawn accurate conclusions.

The article can be published in its current form in MDPI Reports in the reviewer's opinion.

Response) Thank you for your encouraging comments.

Round 2

Reviewer 1 Report

I　think　immunohistochemical　studies　are　necessary　to　make　a　correct　diagnosis. The diagnosis (mucinous borderline tumor) based only on H&E staining may not be adequate, as pathological diagnosis is the issue of this case report,

Author Response

Responses to the comments made by Reviewer 1:

Thank you very much for providing important comments. We are thankful for the time and energy you expended. Our responses are listed below.

comment)

I　think　immunohistochemical　studies　are　necessary　to　make　a　correct　diagnosis. The diagnosis (mucinous borderline tumor) based only on H&E staining may not be adequate, as pathological diagnosis is the issue of this case report,

Response) Thank you for your valuable comments. We have performed immunohistochemical staining; CK7, CK20 and PAX-8. CK7 was strong positive, CK20 was weakly positive and PAX-8 was moderate positive. These results were consistent with that this tumor was primary ovarian mucinous tumor. We have added some sentences in the case presentation section in the revised manuscript. Please see page 2, line 80- page 3 line 84.

Reviewer 2 Report

The paper improved...it is now eligible to be published.

Author Response

Responses to the comments made by Reviewer 2:

We are grateful for your insightful comments. Our responses are listed below.

Comment)

The paper improved...it is now eligible to be published.

Response) Thank you for your encouraging comments.

Round 3

Reviewer 1 Report

As the authors state, immunohistological studies indicate that the ovarian tumor is of ovarian origin.