Thoracoscopy for Pediatric Thoracic Neurogenic Tumors—A European Multi-Center Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor and Authors,

Thank you for asking me to review this manuscript titled “Thoracoscopy for Pediatric Thoracic Neurogenic Tumours. A European Multi-Center Study”

This is quite an interesting study, albeit retrospective, spanning a period of 10 years and involving 15 European Centers. It has a good size patient sample of 116 cases although as a case series presentation no statistical comparisons were made.

I have a number of comments as follows.

Comments:

1.  The title needs some editing. Please see the titled I written above and adjust please.

2. The manuscript needs extensive language editing both in terms of expressions and syntax. For example the abstract the authors write “119 pts aged 4 years old [3 months-17 years]” do they mean 119 patients with an average age of 4 years old [3 months – 17 years].

3. I would not give so much emphasis as the main reason to avoid thoracotomy (see introduction) on the “On the other hand, long[1]term postoperative thoracotomy complications include scoliosis, shoulder elevation, winged scapula, and asymmetric nipples” as these are long term and relatively rare complications. Rather as a thoracic surgeon myself I would mention pain, reduced respiratory function, reduced mobilization, longer post-operative recovery and hospital length of stay, and I would even throw in (as these are young kids) better cosmetic effect!

4. I am not sure the “shorter duration of chest tube” is applicable in these kind of resections given that no lung parenchyma resection is performed! How do the authors justify this? There is a difference reported in the literature but for lung resection surgery!

5. I am not sure what the purpose of figure 1 is? How does it aid the manuscript as this is not a review paper?

6. Looking at the medical groups that were involved this reviewer wondered if  only pediatric surgeons were involved and performed these procedures or if thoracic surgeons also participated?

7. I don’t understand (it is not clearly explained) why multivariable logistic regression was used ? Can the authors better explain it in their methods/statistics section.

8. A statistics section is missing from the methods and needs to be reported.

9. The ethical statement of approval needs to be moved on the top of the methods section as well as the protocol approval number needs to be mentioned. Also, the need or not for informed consent needs to be reported.

10. What is “uncontrollable vascular attachment”? What do the authors mean by this term?

11. The results section is quite lengthy! Can’t the authors report some of their finding in tables? It would reduce the size of the text and make it easier for readers to get the information!

13. Since a number of patients underwent conversion to thoracotomy why was not a 2 group comparison of surgical outcomes performed?

12. As previously mentioned the reason the authors performed a multivariable analysis is unclear. They report oncological results i.e. “On multivariate analysis, neither the preoperative IDRFS (excluding T9-T12), nor prior chemotherapy, nor dumbbell tumor was associated with the presence of a residue (p=0.053, p=0.120, and p=0.788 respectively” but if they wanted to do this then a Kaplan Meier survival analysis should also be performed and reported both for overall survival and recurrence free survival.  However, this would shift the focus of the manuscript from a surgical outcomes to oncological outcomes!!

13. Figure 2 is also not needed as it is unclear what the authors are trying to demonstrate!

14. The discussion also focuses on oncological outcomes! This is inconsistent as mentioned with the focus of the manuscript, the title and reported results!! That section on the discussion needs to be reduced/eliminated and a more focused discussion on the benefits of a minimally invasive surgical technique such as VATS on outcomes!

In conclusion, this study needs some major reworking and editing before it is ready to be presented. It feels scattered in different topics and different focuses (surgery/oncology).

Thank you again and kind regards to all.

Comments on the Quality of English Language

Needs significant editing.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

 

 I would like to congratulate the authors of the interesting article titled: “Thoracoscopy for pediatric thoracic neurogenic tumour. A European multicentric study”.

The authors included a large number of patients in this retrospective multicenter study. The manuscript is written in quite good English, but professional proofreading could improve its quality.

I have a few comments on the manuscript.

1. Abbreviations should not be used in the abstract. Instead of "pts" I suggest using "patients".

2. Simple Summary should be included before Abstract.

3. The authors should mention that this was a retrospective study.

4. The method of performing the surgical procedure should be described in more detail in the methodology section, so as to enable its repetition in other centers based on the description alone. operation should be described in more detail in the methodology section. What method of anesthesia was used? How was the lung isolated - using a double-lumen bronchial tube or bronchial blockers? What was the positioning of the patients? What was the position and size of the trocars? Was utility approach used? What electrosurgical devices were used? How many chest tubes? What kind of chest drainage was used – electronic or 4-chamber? Was passive or active drainage used? What were the criteria for chest tube removal? I understand that due to the large number of centers and the large age range of patients, treatment methods may vary. I would therefore propose a rather general description of the methods used, taking into account the individual subpoints mentioned above (for example, in “in most patients one chest tube was used”).

5. In addition, tumor tissue should always be removed from the pleural cavity in a bag to avoid implants in the wound. If so, please include it in the methodology in the section describing the course of the operation.

6. The description of statistical methods should be more detailed. I propose separating a separate subsection in the methodology section.

7. My personal preference is to present most of the less important results in tables. The authors presented the vast majority of the results in the text, which makes their analysis difficult for readers. I would suggest including most of the results in tables instead of in the text, but this obviously depends on the authors' preferences.

8. The discussion is interesting, but I would suggest including a more thorough review of the literature. It would also be worth mentioning future directions of research and development of this type of surgical operations, for example the possibility of using uniportal VATS accesses or robotic surgery.

9. Limitations of the study should be presented at the end of the discussion.

10. According to the Cancers template, “5. Conclusions” should be included as a separate section.

11. I believe that, unfortunately, it is not possible to conclude from the current study that thoracoscopy is associated with a low rate of complications, residual disease, and recurrence. Such conclusions could only be drawn in a study comparing thoracoscopy and thoracotomy groups. Given the small number of patients operated on for this type of cancer, a prospective study is practically impossible to conduct. However, it would be very valuable to perform a retrospective study with some attempt to control bias, for example propensity score matching. The methodology of this type of research has been very well developed in the case of minimally invasive lung cancer surgery; there are many publications that the authors could refer to when designing this type of study in the future.

12.   According to the Cancers template, “Author Contributions”, “Funding”, “Institutional Review Board Statement”, “Informed Consent Statement”, “Data Availability Statement”, “Acknowledgments” and “Conflicts of Interest” should follow the Conclusions.

13.   References should adhere to the Caners template.

 

 

Comments on the Quality of English Language

Minor editing required.

Author Response

PLEASE SEE ATTACHMENT

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor and Authors,

I reviewed the now marked and highlighted version of the re-submitted manuscript so that I could better elucidate the responses and changes the authors have made.

The authors have very kindly implemented almost all of my suggestions or were able to adequately defend their choices and approach in issues raised regarding the discussion ect. I therefore thank them for this as I am now quite satisfied! I only have some very minor remaining issues:

1.       The title has not been changed even though Centric is not correct English! In other parts of the manuscript it has been corrected.

2.       The abstract has not been changed and the authors still have not mentioned that the average age of the patients was 4 years old and that they were not all age 4!!

However, these issues can be modified - changed in the proofreading stage of the manuscript, which I cannot see why it should not be accepted now. Therefore, my recommendation is to accept the manuscript for publication. I wish everyone well and good job!

 

Comments on the Quality of English Language

Dear Editor,

Please ask the authors to resubmit a clearly marked document with the changes they made. It is impossible to assess a revised work without knowing what and which sections were modified.

Thank you,

Author Response

We thank the reviewer for his very encouraging comments. We changed both the title and abstract,  but the submission system only allows us to do it in the new WORD manuscript file. 

If you upload the revised PDF, you can't see the changed title and abstract, although you can see the rest of the changes in the new manuscript.

if you upload the Word file, you can see all the changes (including title and abstract).

I, therefore, uploaded, as a response to the reviewer, the revised submission with track changes (see below comment to the editorial office), with the changes made according to the previous reviewer's comments.

I want to alert the editorial office on this issue.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Once again, congratulations on an interesting study. 

Author Response

Thank you for your valuable comments and time, which improved the manuscript.