PONE-D-21-29914

Diagnostic yield, complications, pathology and anatomical features in CT-guided percutaneous needle biopsy of mediastinal tumours.

PLOS ONE

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: Thank you for the opportunity to review the article entitled “Diagnostic yield, complications, pathology and anatomical features in CT-guided percutaneous needle biopsy of mediastinal tumors”. The authors retrospectively describe their experience using CT-guided needle biopsy to sample mediastinal tumors. While the data is interesting, there are major limitations to this study that needs to be clarified by the authors, some of which are inherent to the nature of the study. While the authors did mention the small number and retrospective nature of their study as a limitation further elaboration is required.

The authors rightfully describe other ways of sampling mediastinal tumors, such as endoscopic and surgical techniques. The authors should describe whether these techniques are used at their institution. As this is a retrospective study, it is important to have a sense of whether the percutaneous approach is used for all patients with mediastinal tumor or a carefully selected subset.

Along the same lines, most of the lesions sampled were in the inferior anterior mediastinum (30 lesions, %63 of procedures), with no cases in the inferior middle mediastinum. It would be helpful for the reader to know what the risk of complications with each compartment as the concern would be that the data may only reflect the safety of sampling lesions in the inferior anterior mediastinum rather than the whole mediastinum.

The authors should clearly state the risk of pneumothorax. The overall risk of pneumothorax was (25%, 12 cases) with intervention required in 4 cases (8%). Arguably, the risk of pneumothorax and the need for intervention should be calculated purely for the transpulmonary approach (60% of cases had pneumothorax, 20% required intervention)

Selection bias may explain why there were no mediastinal lesions sampled in the inferior middle mediastinum. Assuming that the institution has an endoscopy/bronchoscopy service, the lesions in the inferior middle mediastinum may have been sampled endoscopically given the proximity to major vascular structures. This again affects the way the results should be interpreted. Similarly, the recommendation to use compartment system vs the Felson system as result may not necessarily be accurate.

I do not believe that the statement that the likelihood of malignant diagnosis is higher the further anteriorly the lesion is located in the mediastinum is valid unless all the mediastinal lesions at the institution are sampled via the percutaneous approach. Otherwise the conclusion is biased toward the lesions that were easier to access via the percutaneous approach compared to other approaches (endoscopic/Surgical)

The authors mention that two procedures were initially inconclusive and had to be re-biopsied. However, only one re-biopsy was included in the study. Can the authors explain why the other re-biopsy was not included (out of the study timeframe vs another sampling approach was used)?

Minor comment

Introduction, 5th paragraph. As the authors are referencing more than 3 studies, would suggest changing the sentence to state that the complication rates range between 3-17%.

Reviewer #2: Dear Authors,

Thank You for an interesting article. The theme of this article is radiological, yet in the article, I do not find an explanation why is the CT imaging method of choice for percutaneous needle biopsy of this region and what are the advantages of this method in comparison with other imaging methods. In Figure 1. You show the needle tip in the lung window and the pathology in a mediastinal window. Is there any practical explanation for it (considering that the size of the lesion depending on the window can be underrated or overrated, the target components of the lesion during the biopsy are poorly discriminated in the lung window)? How do You define the specific low-dose CT examination You used in the study? Postinterventional control radiography was performed. Is the sensitivity of this method in comparison to CT a limitation for the detection of postinterventional complications? In which cases were chest drainage and surgical drainage performed? Regarding the diagnostic yield and adequate tissue material, did You find any statistical difference related to the tissue structure of the lesion (solid vs. cystic-solid)? How was adequate tissue material defined?

In the discussion, much information pertains to results. Therefore, I would suggest rewriting the discussion and comparing more in detail the study results with current literature.

The text also needs some language adaptation and consistency in writing numbers (for instance - 2 or two).

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Reviewer #1: Yes: Ala Eddin Sagar

Reviewer #2: No

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Diagnostic yield, complications, pathology and anatomical features in CT-guided percutaneous needle biopsy of mediastinal tumours.

PONE-D-21-29914R1

Dear Dr. Ashraf,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Luka Brcic

Academic Editor

PLOS ONE

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