Author's response to reviews Title: Peripheral pulmonary nodules: relationship between multi-slice spiral CT perfusion imaging and tumor angiogenesis and VEGF expression Authors: Shu-Hua Ma (mashuhua6699@sina.com) Hong-Bo Le (hongbo125@qq.com) Bao-hui Jia (myrrossee@yahoo.com.cn) Zhao-xin Wang (wzx425@gmail.com) Zhuang-Wei Xiao (xiaozhuangweiyxy@sina.com) Xiao-Ling Cheng (chengxiaoling28@126.com) Wei Mei (meiweist@126.com) Min Wu (jwumin@yahoo.com) Zhi-Guo Hu (maxnow_hu@126.com) Yu-Guang Li (liyuguangyxy@sina.com) Version: 2 Date: 29 April 28 Author's response to reviews: see over
Cover letter Dear editor, We thank you and the reviewers very much for your very informative and helpful reviews on our manuscript! All the comments have been addressed with corresponding changes made in the current version, as explained by a point-by-point response letter. Sincerely yours. Ma Shuhua Reviewer 1 Major concerns: Question 1. In discussion, authors insist that immunostaing of VEGF of pulmonary nodule is important for diagnosis. However, it is hard to know the results of immunohistochemical analylsis of VEGF before surgery or biopsy (invasive method). These paragraphs should be deleted from discussion. It is very excellent point. These paragraphs have been deleted accordingly. Question 2. Additional table which shows tumor differentiation of lung tumors (adenocarcinoma and squamous cell carcinoma) and their number (how many are there) is should be added. Thank you. It is a very good point and the table about differentiation of peripheral lung cancer has been added as follows. 1
Table 1: Differentiation of peripheral lung cancer differentiation of lung tumors cases well moderately poorly Adenocarcinoma 24 9 1 5 Squamous cell carcinoma 11 6 4 1 large and small cell carcinoma 4 3 1 Question 3. It would be useful to have mean sizes and range of each group (lung cancer, inflammatory nodule and benign nodules). It is a good point. The mean sizes and range of each group of pulmonary nodules are now added as follows. The 64 patients included 39 cases of peripheral lung cancer (24 adenocarcinoma, 11 squamous cell carcinoma, 2 large cell carcinoma, and 2 small cell carcinoma, long-axis diameters range, 1.7-4.2 cm, mean diameters, 2.7cm), 13 cases of inflammatory nodules (8 active inflammatory granuloma and 5 pneumonia apostematosa, long-axis diameters range, 2.1-3.9 cm, mean diameters, 3.2cm), 12 cases of benign nodules (9 tuberculoma and 3 hamartoma, long-axis diameters range, 1.6-3. cm, mean diameters, 2.5cm). Minor Essential Revisions (The author can be trusted to make these. For example, missing labels on figures, the wrong use of a term, spelling mistakes.) Question 1. Explanation of abbreviations should be written in the abstract. 2
Thank you, the explanations of abbreviations are now added in the abstract as follows. Abstract Background:The aim of this study is to investigate the relationship between16-slice spiral CT perfusion imaging and tumor angiogenesis and VEGF (vascular endothelial growth factor) expression in patients with benign and malignant pulmonary nodules, and differential diagnosis between benign and malignant pulmonary nodules. Methods: Sixty-four patients with benign and malignant pulmonary nodules underwent 16-slice spiral CT perfusion imaging. The CT perfusion imaging was analyzed for TDC(time density curve), perfusion parametric maps, and the respective perfusion parameters. Immunohistochemical findings of MVD (microvessel density) measurement and VEGF expression was evaluated Results: The shape of the TDC of peripheral lung cancer was similar to those of inflammatory nodule. PH(peak height), PHpm /PHa(peak height ratio of pulmonary nodule to aorta), BF(blood flow), BV(blood volume) value of peripheral lung cancer and inflammatory nodule were not statistically significant(all P>.5). Both showed significantly higher PH, PHpm /PHa, BF, BV value than those of benign nodule(all P<.5). Peripheral lung cancer showed significantly higher PS (permeability surface) value than that of inflammatory nodule and benign nodule(all P<.5).. rather than PS and MTT (mean transit time) (all P>.5). Question 2. Table 7, Figure 5, 6 legends. Type I is missing. Thank you, I have added the typeⅠin the Table 7, Figure 5, 6 legends. Question 3. Figure 2, legend. â##lowly differentiated adenocarcinomaâ## should be corrected to â##poorly differentiated adenocarcinomaâ##. 3
Thank you, the phase is now corrected. Question 4. Page 23, para.2 Numbers of the type are not recognized. Thank you, I have added the type.( typeⅠ, type Ⅱ,and type Ⅲ). Discretionary Revisions (These are recommendations for improvement which the author can choose to ignore. For example clarifications, data that would be useful but not essential.) Question 1. It would be helpful to add relationships between tumor differentiations (especially in adenocarcinoma) and parameters. Thank you, relationships between tumor differentiations and parameters are added as follows. Table : Comparison among the perfusion parameters and MVD of adenocarcinoma, squamous cell carcinoma, large and small cell carcinoma parameter cases BV BF MTT PS PH PHpm/PHa MVD Adenocarcinoma 24 1.173 225.46 6.673 17.819 62.329 21.159 27.483 ±3.624 ±83.132 ±3.821 ±8.214 ±8.84 ±3.83 ±14.85 Squamous cell 11 1.244 164.71 8.876 22.217 56.436 19.48 3.828 carcinoma ±3.528 ±11.1 ±3.371 ±6.414 ±8.456 ±3.465 ±15.559 5 large and small 4 13.92 197.63 8.413 24.93 63.525 21.62 35.918 cell carcinoma ±3.925 ±86.943 ±3.969 ±3.389 ±6.52 ±2.758 ±5.683 *BV,BF,PS,MTT, PH, PHpm/PHa, and MVD among adenocarcinoma, squamous cell carcinoma, large and small cell carcinoma were not significantly (all P>.5). 4
Table : Tumor differentiations of adenocarcinoma, squamous cell carcinoma, large and small cell carcinoma parameter differentiat ion cases BV BF MTT PS PH PHpm/ PHa MVD well 9 8.76 ±2.441 25.723 ±77.469 5.422 ±1.591 15.949 ±5.736 61.122 ±6.371 2.718 ±3.1 22.451 ±13.536 Adenocarcinoma (24 cases) moderately 1 9.261 ±3.448 25.193 ±9.827 8.755 ±5. 15.528 ±9.547 59.95 ±6.435 2.69 ±2.478 22.831 ±12.514 poorly 5 14.636 ±2.237 31.518 ±6.29 4.758 ±1.919 25.766 ±4.142 69.26 ±11.132 24.134 ±2.889 45.846 ±4.79 well 6 1.38 ±2.729 182.63 ±15.873 8.362 4.83 2.83 ±7.198 59.717 ±5.138 2.342 ±2.17 28.92 ±16.223 Squamous cell moderately 4 1.393 157.448 9.938 22.993 52.825 17.933 29.693 carcinoma ±5.359 ±11.379 ±2.759 ±3.81 ±12.95 ±4.852 ±16.515 (11 cases) poorly 1 9.26 79.21 7.71 31.92 51.2 15.75 46.93 well 3 13.743 ±4.787 165.83 ±72.129 6.67 ±2.327 23.3 ±3.179 6.567 ±3.356 2.46 ±1.828 34.993 ±6.582 Large and small cell carcinoma (4 cases) moderately poorly 1 14.45 293. 13.64 27.36 72.4 25.1 38.69 Table : Relationships between adenocarcinoma differentiations and parameters. parameter BV (p) BF (p) MTT (p) PS (p) PH (p) PHpm/PHa (p) MVD (p) well (n=9) and moderately(n=1).679 1..198.999.738.615.945 well (n=9) and poorly(n=5).1.18.897.11.66.38.2 poorly(n=5)and moderately(n=1).3.25.13.38.35.14.2 *Because there are fewer cases of squamous cell carcinoma, large and small cell carcinoma, relationships between their differentiations and parameters were not compared. In the case of adenocarcinoma, BV,BF,PS,PHpm/PHa,and MVD between poorly and well differentiation and between poorly and moderately differentiation were statistically significant(all P<.5). 5
Question 2. Histology of three benign nodules which showed positive VGEF expression should be added. Thank you. Only few benign nodules which showed positive VGEF expression are included and there are no statistically meaning with the histology on this condition. We will address this question with a bigger sample size in the future. The first reviewer's report: Quality of written English: Needs some language corrections before being published. The second reviewer's report: Major Compulsory Revisions: However, it must be rewritten in standard English.. The manuscript has been proof read carefully in standard English by professor Grace from Singapore, Junqing Cui, PH.D. from USA. Here are some sample of the manuscript revised by professor Grace from Singapore. 6
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