REVIEW 1 major objections 1 minor
Computer Aided Detection of Deep Inferior Epigastric Perforators in Computed Tomography Angiography scans
T0 review · 1 major / 1 minor · reviewed 2026-05-24 · grok-4.3
Pith's one-line read A semi-automatic method extracts perforator paths in CTA scans with average errors of 0.64 mm subcutaneously and 0.50 mm intramuscularly.
desk verdict The semi-automatic DIEAP extraction gives tight error numbers on 21 scans but the single-observer reference standard is the weak point. read the letter →
The pith
A machine-rendered reading of the paper's core claim, the machinery that carries it, and where it could break.
The reading
What carries the argument
A tracking procedure for the subcutaneous region of each perforator combined with a minimum-cost approach for the intramuscular portion.
What would settle it
A comparison of the semi-automatic paths against annotations performed independently by two or more radiologists on the same 21 scans; if the method's average deviation exceeds the typical disagreement between human annotators, the accuracy claim is undermined.
Extended reading notes
Core claim
In 21 CTAs from patients proposed for breast reconstruction with DIEAP flaps, the semi-automatic procedure was able to correctly detect the course of the DIEAPs with a minimum error (average error of 0.64 mm and 0.50 mm regarding the extraction of subcutaneous and intramuscular paths, respectively).
Load-bearing premise
The radiologist manual annotations provide a reliable and unbiased reference standard against which the semi-automatic detections are evaluated.
Editorial extensions
If this is right
- The procedure can reduce the time required for preoperative perforator mapping in DIEAP flap planning.
- It supplies an objective record of vessel course that may decrease observer-to-observer variation in identifying optimal perforators.
- The extracted paths can be used to generate vascular maps for the surgical team with less manual drawing.
- The method demonstrates feasibility for automated support in CTA analysis for breast reconstruction patients.
Reading between the lines
- Integration into existing radiology workstations could allow real-time feedback during scan review.
- The same tracking-plus-minimum-cost logic might apply to perforator detection in other anatomical regions or flap types.
- Quantitative error metrics from the method could be tracked over time to monitor consistency of imaging protocols.
Editorial analysis
A structured set of objections, weighed in public.
Referee Report
Summary. The paper proposes a semi-automatic method to detect the course of deep inferior epigastric artery perforators (DIEAPs) in CTA scans for breast reconstruction planning. Subcutaneous paths are extracted via a tracking procedure and intramuscular paths via a minimum-cost approach; both are compared to manual radiologist annotations on 21 patient CTAs, yielding average errors of 0.64 mm (subcutaneous) and 0.50 mm (intramuscular). The work aims to reduce time and subjectivity relative to fully manual mapping.
Significance. If the validation is robust, the approach offers a concrete quantitative step toward automating perforator mapping, with reported error metrics on a relevant clinical cohort of 21 cases. This could support reduced human effort in preoperative CTA analysis for DIEAP flaps.
major comments (1)
- [Abstract] Abstract: The headline claim that the method 'correctly detect[s] the course of the DIEAPs with a minimum error' rests on direct comparison to annotations by a single radiologist. No inter-observer variability, multi-rater consensus, or independent validation of the reference standard is reported. Because the motivation is precisely to reduce subjectivity in manual annotation, the absence of any quantification of reference variability leaves the 0.64 mm / 0.50 mm error figures unanchored and difficult to interpret as evidence of correctness.
minor comments (1)
- [Abstract] Abstract: The description of error measurement (e.g., whether Euclidean point-to-curve distance, maximum deviation, or another metric) and patient selection criteria is absent, limiting assessment of the reported averages.
Simulated Author's Rebuttal
We thank the referee for the constructive feedback. We address the major comment below.
read point-by-point responses
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Referee: [Abstract] Abstract: The headline claim that the method 'correctly detect[s] the course of the DIEAPs with a minimum error' rests on direct comparison to annotations by a single radiologist. No inter-observer variability, multi-rater consensus, or independent validation of the reference standard is reported. Because the motivation is precisely to reduce subjectivity in manual annotation, the absence of any quantification of reference variability leaves the 0.64 mm / 0.50 mm error figures unanchored and difficult to interpret as evidence of correctness.
Authors: We agree the reference standard consists of annotations from a single radiologist (as stated in the methods section). The reported errors measure deviation from this expert annotation, which is the clinical reference used for preoperative planning. We acknowledge that inter-observer variability data would help contextualize whether the observed errors fall within typical human variation. Because the study dataset contains only single-rater annotations, we cannot supply such variability metrics. We will revise the abstract to replace the phrasing 'correctly detect[s] the course of the DIEAPs with a minimum error' with language that explicitly states the errors are relative to manual annotation by one radiologist, thereby clarifying the reference standard without overstating the results. revision: yes
Circularity Check
No circularity; empirical validation against external manual annotations
full rationale
The paper describes a semi-automatic tracking and minimum-cost detection pipeline for DIEAP paths in CTA, then reports average Euclidean errors (0.64 mm subcutaneous, 0.50 mm intramuscular) against a single radiologist's manual tracings on 21 cases. No equations, parameters, or uniqueness claims are presented; the central result is a direct empirical comparison whose reference standard is external to the algorithm. No self-citations, fitted-input renamings, or self-definitional steps appear in the derivation chain.
Assumptions & free parameters
Cite this review
Pith. "Pith review of Computer Aided Detection of Deep Inferior Epigastric Perforators in Computed Tomography Angiography scans." pith.science (2026). https://pith.science/paper/X5VV6BJP
@misc{pith2026190710354,
author = {Pith},
title = {Pith review of: Computer Aided Detection of Deep Inferior Epigastric Perforators in Computed Tomography Angiography scans},
year = {2026},
howpublished = {\url{https://pith.science/paper/X5VV6BJP}},
note = {Machine review of arXiv:1907.10354}
}
read the original abstract
The deep inferior epigastric artery perforator (DIEAP) flap is the most common free flap used for breast reconstruction after a mastectomy. It makes use of the skin and fat of the lower abdomen to build a new breast mound either at the same time of the mastectomy or in a second surgery. This operation requires preoperative imaging studies to evaluate the branches - the perforators - that irrigate the tissue that will be used to reconstruct the breast mound. These branches will support tissue viability after the microsurgical ligation of the inferior epigastric vessels to the receptor vessels in the thorax. Usually through a Computed Tomography Angiography (CTA), each perforator, diameter and direction is manually identified by the imaging team, who will subsequently draw a map for the identification of the best vascular support for the reconstruction. In the current work we propose a semi-automatic methodology that aims at reducing the time and subjectivity inherent to the manual annotation. In 21 CTAs from patients proposed for breast reconstruction with DIEAP flaps, the subcutaneous region of each perforator was extracted, by means of a tracking procedure, whereas the intramuscular portion was detected through a minimum cost approach. Both were subsequently compared with the radiologist manual annotation. Results showed that the semi-automatic procedure was able to correctly detect the course of the DIEAPs with a minimum error (average error of 0.64 mm and 0.50 mm regarding the extraction of subcutaneous and intramuscular paths, respectively). The objective methodology is a promising tool in the automatic detection of perforators in CTA and can contribute to spare human resources and reduce subjectivity in the aforementioned task.
Reviewed May 24, 2026 · model on record in the stance chip above.
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