EURA-D-24-04209
Efficacy and Safety of Thermal Ablation for Treatment of Recurrent and Persistent Secondary Hyperparathyroidism: A Multicenter Retrospective Study
热消融治疗复发性和持续性继发性甲状旁腺功能亢进症的疗效与安全性：一项多中心回顾性研究


Dear Dr Liang,
尊敬的梁医生，

Peer-review of your manuscript has now been completed. Major Revisions are requested before a final decision can be reached. Please find the comments below.
您的手稿已经完成同行评审。在做出最终决定之前，要求进行重大修订。请查看以下评论。

"Manuscript requirements for submissions"
提交手稿的要求
Before you revise your manuscript, please carefully read the updated requirements as they outline the must-haves and show how to further improve your manuscript:
在您修订手稿之前，请仔细阅读更新的要求，因为它们概述了必备条件，并展示了如何进一步改进您的手稿：
https://www.european-radiology.org/for-authors/submission-guidelines/

Pay attention to:
注意：
- Correctly structure your key points as outlined below:
- 正确地按照下面列出的方式组织你的关键点：
1. Question (20-25 words) - Explain the unmet need/clinical problem your study addresses
1. 问题（20-25 个字）- 解释您的研究所解决的未满足需求/临床问题
2. Findings (20-25 words) - Objectively summarize your main result
2. 发现（20-25 个字） - 客观总结你的主要结果
3. Clinical Relevance Statement (maximum 40 words) - summarize the benefit for the patient and/or clinical
临床相关性声明（最多 40 个字）- 总结对患者和/或临床的益处
- Correctly format the bibliography
- 正确格式化参考书目
- Check that all keywords are exactly as they appear in the MeSH database
- 检查所有关键词是否与 MeSH 数据库中显示的完全一致
- Delete all geographical information (city, country) for commercial names
- 删除商业名称中的所有地理信息（城市、国家）

Make sure to adhere to these and the following instructions to facilitate the processing and decision process of your revised manuscript!
确保遵循这些及后续指示，以便于处理和决策您修改后的手稿！

* * * * * * *
Your revision *must* contain the following items:
您的修订*必须*包含以下项目：

1) Author's Response to Reviewers' Comments:
作者对审稿人意见的回应：
A file (Author's Response to Reviewers' Comments) containing the editor's and reviewers' suggestions with your specific responses to each of the comments. This file must be editable (preferred format: MS Word)
一个文件（作者对评审意见的回复），包含编辑和评审的建议以及您对每条评论的具体回复。该文件必须可编辑（最佳格式：MS Word）

2) Revised & Clean Main document:
2) 修订及整理主文件：
One document with visible changes to the previous version, highlighted by using the 'track changes' option ("Main text_marked"). One document with all changes accepted ("Main text_clean")
一个带有可见更改的文档，使用“跟踪更改”选项进行了高亮处理（“主要文本_标记”）。一个已接受所有更改的文档（“主要文本_干净”）

3) Other revised & clean documents:
其他修订和清晰的文件：
Any other document you made changes to (e.g. tables, supplementary material) in two versions - one with visible highlights and one with all changes accepted.
您对其他任何文件所做的更改（例如表格、补充材料）的两个版本 - 一个显示高亮，另一个接受所有更改。

When uploading your revised manuscript:
上传修订后的手稿时：
- Select from the previous submission all files that haven't changed and include it in the revision.
从之前的提交中选择所有未更改的文件，并将其包含在修订中。
- Delete/de-select any redundant files.
- 删除/取消选择任何多余的文件。
- Upload all new (revised & clean) files and use a clear file name (e.g. "Main text_marked", "Main text_clean" or "Table 1_marked", "Table 1_clean").
- 上传所有新的（修订过的和干净的）文件，并使用清晰的文件名（例如“主文本_标记”，“主文本_干净”或“表 1_标记”，“表 1_干净”）。

* * * * * * *

We look forward to receiving your revised submission through https://www.editorialmanager.com/eura/
我们期待通过 https://www.editorialmanager.com/eura/ 收到您修订后的提交。
before 27 Dec 2024
2024 年 12 月 27 日之前

Please note: When uploading your revised manuscript files, please make sure only to submit your editable source files (i.e. Word). PDF is not allowed at this stage.
请注意：在上传您修订后的手稿文件时，请确保仅提交可编辑的源文件（即 Word）。在此阶段不允许使用 PDF。

Kind regards,
此致敬礼，

Dr. Roh-Eul Yoo
Deputy Editor, European Radiology
副编辑，欧洲放射学

Prof. Bernd Hamm
Editor-in-Chief, European Radiology
欧洲放射学主编

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COMMENTS TO AUTHORS:
对作者的评论：

Reviewer #1: The authors of this retrospective study summarize the results from repeated treatment with thermal ablation (TA) of patients with recurrent/persistent secondary hyperparathyroidism (SHPT), previously treated with surgery or TA. The number is significant for this category of patients and the results support the conclusions. However there are some shortcomings in the study design and in the description of the results. The manuscript needs serious English editing.
审稿人#1：这项回顾性研究的作者总结了对既往接受过手术或热消融（TA）治疗的复发/持续性继发性甲状旁腺功能亢进症（SHPT）患者进行重复热消融治疗的结果。对于这一类别的患者，这个数字是显著的，结果支持结论。然而，研究设计和结果描述上存在一些缺陷。手稿需要认真进行英语编辑。
The Abstract effectively summarize the manuscript but in the Materials and Methods the follow-up period is missing.
摘要有效地概括了手稿，但在材料与方法中缺少随访期间。
Page 1, line 48: "Compared to baseline, significant reduction in PTH, calcium, phosphorus and ALP levels (P ＜ 0.05)." - the verb is missing!
与基线相比，PTH、钙、磷和 ALP 水平显著降低（P ＜ 0.05）。

Keywords: "achievement rate" could be skipped.
关键词：“完成率”可以跳过。

Introduction
介绍
Page 3, line 34: "…persistent SHPT nodules" - the authors have to skip "nodules", because in SHPT we talk about hyperplasic parathyroid glands.
第 3 页，第 34 行：“…持续的 SHPT 结节” - 作者必须跳过“结节”，因为在 SHPT 中我们讨论的是增生性甲状旁腺。
Page 4, line 31: Here the authors state that the purpose is to use TA as an alternative to repeat surgery, but it is not clear what the previous treatment was. In the abstract, the objective is better formulated.
第 4 页，第 31 行：在这里，作者指出其目的是将 TA 作为重复手术的替代方案，但之前的治疗是什么并不清楚。在摘要中，目标表述得更清楚。

Materials and Methods
材料与方法
In the inclusion criteria, Page 5, line 17, is mentioned: "(e) At least one parathyroid gland is enlarged and >0.6 cm in diameter on ultrasound examination;" The active tip of the RFA electrode is 7 mm. If the gland diameter is 7 or 8 mm, the treatment will be not safe. The inclusion criteria should be corrected.
在纳入标准中，第 5 页，第 17 行提到：“(e) 至少有一个甲状旁腺在超声检查中增大且直径超过 0.6 厘米；” RFA 电极的有效尖端为 7 毫米。如果腺体直径为 7 或 8 毫米，治疗将不安全。纳入标准应进行修正。

There is not sufficient information about the follow-up after TA. In the follow-up protocol (page 6, line 47) is written 1 year. In the Results section (page 9, line39) it is mentioned "median follow-up of 30 months", without min/max data. The figure 4 gives data for 24 months. Finally, it is not clear what the minimal and maximal follow-up periods are and how many patients reached the different follow-up points.
关于 TA 后续的资料不足。在后续协议（第 6 页，第 47 行）中写道为一年。在结果部分（第 9 页，第 39 行）提到“中位随访 30 个月”，没有最小/最大数据。图 4 提供了 24 个月的数据。最后，不清楚最小和最大随访期是多少，以及有多少患者达到了不同的随访时间节点。

Subgroup Analysis
亚组分析
In the Comparison of initial treatment modalities (page 12, line 9), it is not clear about the TA group, if the retreatment was performed on the same gland or on a new one - please give more information about the baseline number of hyperplasic glands and how many patients were with one or more glands to be treated. Also, it will be useful to compare the efficacy rate according to the number of treated glands.
在初始治疗方式的比较中（第 12 页，第 9 行），有关 TA 组的信息并不清楚，重新治疗是针对同一腺体还是新的腺体 - 请提供有关增生腺体基线数量的更多信息，以及有多少患者需要治疗一个或多个腺体。此外，比较根据治疗腺体数量得出的疗效率也将是有用的。

Discussion
讨论
Page 13, line 9: "Recurrent group is 44 of 55 (80.0%) and persistent group is 43 of 48 (89.6%) (P = 0.18)." - Please explain the meaning of this sentence.
第 13 页，第 9 行：“复发组为 44/55（80.0%），持续组为 43/48（89.6%）（P = 0.18）。”
Page 14, line 59: "The hydrodissection technique is an important protective measure used to minimize thermal damage …" - in the Materials and Methods section the authors have not described the use of this technique.
第 14 页，第 59 行：“水剥离技术是一种重要的保护措施，旨在尽量减少热损伤……” - 在材料和方法部分，作者没有描述使用这种技术。

Tables and figures
表格和图形

Table 3: Major and Minor Complications
表 3：主要和次要并发症
"Severe hypocalcium" - should be "hypocalcaemia"
"严重低钙血症" - 应该是 "低钙血症"
"Persistent hoarseness" - a major complication that should be marked as paralysis of n. recurrence
“持续的嘶哑” - 应标记为神经瘫痪的主要并发症。
"Cough" - how long is this symptom? It could be also consequence of n. recurrence damage. Is there an ORL exam?
“咳嗽” - 这个症状持续多久？它也可能是 n.复发损伤的结果。是否有耳鼻喉科检查？



Reviewer #2: General Comments
审稿人 #2：一般评论

The manuscript describes a review of a multicentric series of patients with recurrent or persistent secondary hyperparathyroidism after previous treatment by surgery or ablation.
该手稿描述了对一系列多中心患者的回顾，这些患者在前期接受手术或消融治疗后出现复发或持续性继发性甲状旁腺功能亢进。
Ablation in secondary hyperparathyroidism is a matter of debate in the community performing parathyroid ablation because of the higher risk of failure or recurrence due to the higher possibility of letting some hyperplasic gland untreated. In this context, this study is of the utmost interest because places ablation as a main challenger to the accepted surgical treatment and, also, as an alternative in case of failure of the surgery. It is also a multicentric study what avoid the criticism of being a study dependent on the personal skills of a group.
在继发性甲状旁腺功能亢进症中，消融疗法在进行甲状旁腺消融的社区中存在争议，因为由于可能未治疗某些增生腺体，导致失败或复发的风险较高。在这种背景下，这项研究具有极大的意义，因为它将消融作为接受的外科治疗的主要挑战者，同时也作为手术失败时的替代方案。这也是一项多中心研究，避免了依赖于某个团队的个人技能的批评。
The article is comprehensive and well-written, and the study addresses the main issues of the procedure. The only drawbacks can be the relatively poor description of the procedure, probably due to the variations among centres.
这篇文章内容全面且写得很好，研究解决了手术的主要问题。唯一的缺点可能是对手术的描述相对较差，这可能是由于各个中心之间的差异。


Specific Comments:
具体评论：
Title
标题
No remarks.
没有备注。

Keywords
关键词
No remarks.
没备注。

Key points.
要点。
No remarks.
没有备注。

Abstract
摘要
1. P1, l 48. The sentence "Compared to baseline, significant reduction in PTH, calcium, phosphorus and ALP levels(P ＜ 0.05)" lacks a verb. May be you can add "was achieved"
与基线相比，PTH、钙、磷和 ALP 水平显著降低（P ＜ 0.05）缺少动词。也许你可以加上“达成”。
2. I miss in the conclusions a reference to the PTH as a predictor of treatment failure. I know that you include this in the results, but, as you have included identifying predictors of treatment failure among your objectives, you should include a comment on this in the conclusions. Conclusions here should be similar to the last paragraph of the discussion section of the article.
我在结论中缺少对 PTH 作为治疗失败预测因子的引用。我知道你在结果中提到了这一点，但由于你在目标中列出了识别治疗失败的预测因子，你应该在结论中对此进行评论。这里的结论应类似于文章讨论部分的最后一段。

Introduction
介绍
3. The last paragraph should be similar to the Objectives section of the abstract. I miss here "Identify possible predictors associated with treatment failure"
最后一段应与摘要的目标部分类似。我在这里缺少“确定与治疗失败相关的可能预测因子”。

Methods
方法
4. P. 5, l. 15. You include among the inclusion criteria "Patients with a potential transplant program". The transplant program is external to the patient, and you do not specify the target organ. I suggest changing into "Patients potential candidates to kidney transplantation".
4. P. 5, l. 15. 您在入选标准中包括“有潜在移植方案的患者”。移植方案是针对患者的外部因素，且您没有具体说明目标器官。我建议改为“潜在肾脏移植的患者”。
5. You have used two different techniques of ablation: RF and MW. Please, describe the reason to choose one or another. I suppose that the reason is the personal preference in every participant centre, but please, disclose it.
5. 你使用了两种不同的消融技术：射频（RF）和微波（MW）。请描述选择其中一种的原因。我想原因在于每个参与中心的个人偏好，但请披露一下。
6. P. 6, l. 20. You say that "The electrode usually adopted the moving shot technique or fixed-applicator technique". But you have used both RFA an MWA. What about the antenna? Have you used a different technique, or you should say "the electrode or the antenna"?
6. P. 6, l. 20. 你说“电极通常采用移动拍摄技术或固定应用器技术”。但是你使用了 RFA 和 MWA。天线呢？你是否使用了不同的技术，或者你应该说“电极或天线”？
7. You say that the ablation was terminated when the entire tumour was covered with hyperechoic microbubbles. So, I understand that you have not used impedance (roll-off) to control the completion of the ablation when using RFA. Is it correct?
您说当整个肿瘤被高回声微气泡覆盖时，消融被终止。所以，我理解您在使用射频消融（RFA）时没有使用阻抗（衰减）来控制消融的完成。这正确吗？
8. P. 7, l. 12. Please, define technical success, or add a reference to explain it (14 maybe).
8. P. 7, l. 12。请定义技术成功，或添加一个参考来解释它（可能是 14）。

Results
结果
9. P. 9, l. 53. Please change "2 patients occurred second relapse" into "2 patients had a second relapse"
9. P. 9, l. 53. 请将“2 patients occurred second relapse”更改为“2 patients had a second relapse”

Discussion
讨论
10. You speak here about the importance of hydrodissection. However, you have not mentioned it when explaining the ablation technique in the methods section. You should not discuss any issue you have not included in the methods or section sections. Please, provide some more information regarding your technique of ablation in the methods section.
10. 您在这里谈论了水解的重要性。然而，您在方法部分解释消融技术时并没有提到它。您不应该讨论您未在方法或部分章节中包含的任何问题。请您在方法部分提供更多关于您的消融技术的信息。

References
参考文献
No remarks..
没有评论。
Tables
表格
Fine.
好的。

Figures
数字
11. In the legend for Figure 2 you say that this is a radiofrequency ablation. However, when describing the procedure, you say that an antenna was inserted into the parathyroid nodule. So, it is a microwave ablation. Please, clarify.
在图 2 的图例中，你说这是射频消融。然而，当描述这个过程时，你说一个天线被插入到甲状旁腺结节中。因此，这是微波消融。请澄清一下。

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