Diagnostic Accuracy of CT Texture Analysis in Adrenal Masses: A Systematic Review

Round 1

Reviewer 1 Report

The use of texture analysis of CT or MR images in the differential diagnosis of various lesions is a very popular topic of research. Hence, 
apart from the original research, numerous reviews appear. The differential diagnosis of lesions in adrenal glands is not a frequently 
discussed topic, which results, inter alia, from the high sensitivity and specificity of MR and CT methods used in everyday clinical practice, especially in the differentiation of benign and malignant lesions. It should be remembered that apart from CT and MR methods, we have a molecular imaging technique, i.e. PET with the use of 18F-FDG, or other more specific markers.
Reliable methods of preparing the review were appropriately applied in the study.
Ultimately, 9 works, which differed in methodology, were analyzed. Their review, comparison and description is very cursory and does not bring much substantive value, which of course results from the literature available for analysis. The very conclusion of the study, that the data for the review is heterogeneous and sparse, seems to be important, but I am not sure, if it is sufficient for publication in the form of an article.
I suggest mentioning the PET technique as one of the methods of differentiating lesions in the adrenal glands, mainly in order to exclude the metastatic nature.

To sum up, it should be considered whether the analysis of 9 such different publications covering different purposes and methods, and which only share the topic of texture analysis in the adrenal glands (and the changes can be very different), is sufficient for publication in the journal.

Author Response

The use of texture analysis of CT or MR images in the differential diagnosis of various lesions is a very popular topic of research. Hence, apart from the original research, numerous reviews appear. The differential diagnosis of lesions in adrenal glands is not a frequently discussed topic, which results, inter alia, from the high sensitivity and specificity of MR and CT methods used in everyday clinical practice, especially in the differentiation of benign and malignant lesions. It should be remembered that apart from CT and MR methods, we have a molecular imaging technique, i.e. PET with the use of 18F-FDG, or other more specific markers.

Reliable methods of preparing the review were appropriately applied in the study.

Ultimately, 9 works, which differed in methodology, were analyzed. Their review, comparison and description is very cursory and does not bring much substantive value, which of course results from the literature available for analysis. The very conclusion of the study, that the data for the review is heterogeneous and sparse, seems to be important, but I am not sure, if it is sufficient for publication in the form of an article.

I suggest mentioning the PET technique as one of the methods of differentiating lesions in the adrenal glands, mainly in order to exclude the metastatic nature.

To sum up, it should be considered whether the analysis of 9 such different publications covering different purposes and methods, and which only share the topic of texture analysis in the adrenal glands (and the changes can be very different), is sufficient for publication in the journal.

[Reply to reviewer 1]: we thank you for such a careful, in-depth and extensive review for our manuscript that has improved our paper by a huge margin. The modifications made as a result of your (and other reviewers) comments will make the paper much clearer for the learned readers of this esteemed journal and make the information in it more cutting-edge and clinically relevant.

We agree that the final conclusion of our review is that the use of adrenal texture need to be clarified, and we think that our literature analysis could help the next researchers to design a proper study, considering either imaging features and endocrine secretion. At the end of our research, we selected 9 articles, however only two were able to respond to the clinical question “the distinction between adrenal cortical adenoma and carcinoma”. We remarked it in the discussion.

Finally, we agree that PET technique is useful to differentiate lesions in the adrenal glands, nonetheless it is not a gold-standard, it is considered a second-line imaging (the number of PET is reduced than that of CT), and on the contrary a texture analysis validated software in CT can be largely used.

Author Response File: Author Response.docx

Reviewer 2 Report

The authors have clearly demonstrated that the texture analysis is a promising diagnostic tool for the distinction between benign and malignancy of adrenal incidentalomas. 

Author Response

The authors have clearly demonstrated that the texture analysis is a promising diagnostic tool for the distinction between benign and malignancy of adrenal incidentalomas.

[Reply to reviewer 2]: We thank you for the positive review which has instilled confidence in us and helped us to revise the article, in order to make it more relevant for the readers of this esteemed journal.

Author Response File: Author Response.docx

Reviewer 3 Report

The authors performed a systematic review to provide texture analysis in adrenal incidentalomas (AIs). Following analysis in 9 papers (median 125 patients), they found high accuracy of the textural parameters in discriminating benign from malignant lesions. So, they concluded texture analysis appears as a new promising diagnostic tool in the adrenal tumoral pathologies. The manuscript is well written, and to be sure contributes to helping our understanding of this important finding. I have the following comments:

1. As the authors described in the limitation section, the huge heterogeneity would influence the results. How do you think of adequacy as a methodology?
2. A graphical abstract summarizing the manuscript would help readers understand your findings.

Round 2

Reviewer 1 Report

Thank You for Your answer to my review report. I don't have any major comments.