Association between Inflammatory Markers and Local Recurrence in Patients with Giant Cell Tumor of Bone: A Preliminary Result

Round 1

Reviewer 1 Report (Previous Reviewer 5)

Authors revised the manuscript based on the previous comments and included new figures to understand the concept of their results. However, the inserted figures are not in high quality for publication. Therefore, requesting authors to include high-quality figures to accept for publication. 

Reviewer 2 Report (Previous Reviewer 3)

Authors provided sufficient changes into resubmitted paper.

Reviewer 3 Report (Previous Reviewer 1)

The authors addressed all the point raised by this reviewer and the manuscript overall quality has improved. The paper is suitable for publication.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

The authors of this manuscript investigated the association between several inflammatory markers and clinical outcome in 103 GCTB patients. In particular, they studied the correlation between NLR, mGPS, PNI, LMR, PLR as well as Hb, ALP and LDH levels with rate of local recurrence and pulmonary metastases. They reported an increased risk of local recurrence in distal radius/proximal femur/hand/foot tumors, in patients treated with denosumab or curettage and in presence of low LDH levels. Moreover, they observed that female sex and Campanacci stage III tumors are correlated with an higher risk for lung metastases. However, no correlation was found between any inflammatory marker and clinical outcome.

The manuscript is of interest since it focuses on identifying prognostic markers for GCTB outcome, which is characterized by a high local recurrence rate and a propensity for lung metastases. The authors analyzed several inflammatory markers which are known to be correlated with GCTB outcome and did not find any significant correlation, however discordant results on this topic were previously published in literature, therefore these negative results are in line with some previous findings.

However, some issues should be addressed:

1) in Introduction section, some recent relevant references are missing and should be added. Indeed in a recent work Palmerini and colleagues reported a reduction in  bALP/ALP/OCN and s-CTX levels in GCTB patients treated with denosumab, together with a concomitant increase in sPTH. Importantly, they highlighted that elevated baseline s-CTX levels correlated with an higher risk of progression of the disease. Please discuss thi findings adding the following relevant reference:

- Palmerini E et al. Bone Turnover Marker (BTM) Changes after Denosumab in Giant Cell Tumors of Bone (GCTB): A Phase II Trial Correlative Study. Cancers. 2022; 14(12):2863. https://doi.org/10.3390/cancers14122863

2) In Discussion section, the authors mentioned the role of angiogenesis in tumorigenesis through the release of angiogenic proteins such as vascular endothelial growth factor. This is appropriate, indeed its role in GCTB has been investigated in previous years in several works, in which the involvement of VEGFR  has been described in supporting RANKL-induced osteoclastogenesis. Moreover, VEGFR1 was recently found to be upregulated in patients with distal GCTB, highlighting the potential efficacy of TKI treatment, as it's also emerging from ongoing studies on bone sarcomas (see clinical trial NCT04784247). Please add the following references to deepen the discussion about this topic:

- Kumta, S. et al. Expression of VEGF and MMP-9 in giant cell tumor of bone and other osteolytic lesions. Life Sci. 2003

- Taylor, R.M. et al. VEGF, FLT3 ligand, PlGF and HGF can substitute for M-CSF to induce human osteoclast formation: Implications for giant cell tumour pathobiology. Lab. Investig. 2012

- De Vita, A. et al. A Rationale for the Activity of Bone Target Therapy and Tyrosine Kinase Inhibitor Combination in Giant Cell Tumor of Bone and Desmoplastic Fibroma: Translational Evidences. Biomedicines 2022

3) limitations: the authors indicate that their results may have been affected by the limited sample size of the population studied. However, their sample size does not significantly differ from that of other similar studies in which significant correlation with some markers has been identified. Instead, they should mention other limitations such as the different protocols followed for blood draining and collection (time of the day, fasting, anti-coagulant preservatives, ecc..) as well as patients stratification criteria which may have jeopardized the results. 

Author Response

Reviewer 1

Comment

The authors of this manuscript investigated the association between several inflammatory markers and clinical outcome in 103 GCTB patients. In particular, they studied the correlation between NLR, mGPS, PNI, LMR, PLR as well as Hb, ALP and LDH levels with rate of local recurrence and pulmonary metastases. They reported an increased risk of local recurrence in distal radius/proximal femur/hand/foot tumors, in patients treated with denosumab or curettage and in presence of low LDH levels. Moreover, they observed that female sex and Campanacci stage III tumors are correlated with an higher risk for lung metastases. However, no correlation was found between any inflammatory marker and clinical outcome.

The manuscript is of interest since it focuses on identifying prognostic markers for GCTB outcome, which is characterized by a high local recurrence rate and a propensity for lung metastases. The authors analyzed several inflammatory markers which are known to be correlated with GCTB outcome and did not find any significant correlation, however discordant results on this topic were previously published in literature, therefore these negative results are in line with some previous findings.

However, some issues should be addressed:

1) in Introduction section, some recent relevant references are missing and should be added. Indeed in a recent work Palmerini and colleagues reported a reduction in  bALP/ALP/OCN and s-CTX levels in GCTB patients treated with denosumab, together with a concomitant increase in sPTH. Importantly, they highlighted that elevated baseline s-CTX levels correlated with an higher risk of progression of the disease. Please discuss thi findings adding the following relevant reference:

- Palmerini E et al. Bone Turnover Marker (BTM) Changes after Denosumab in Giant Cell Tumors of Bone (GCTB): A Phase II Trial Correlative Study. Cancers. 2022; 14(12):2863. https://doi.org/10.3390/cancers14122863

Response

Thank you for your valuable comments. We added the following sentence in the “Introduction” section; “Histologically, GCTB comprises neoplastic mononuclear stromal cells with a monoto-nous appearance admixed with macrophages and osteoclast-like giant cells [1]. GCTB stromal cells highly express the receptor activation of nuclear factor-kappa ß (RANK) ligand (RANKL) [6,7]. In osteolytic tumors, similar to GCTB, massive bone resorption is triggered by the RANKL/RANK axis, which stimulates osteoclast-dependent and -independent pathways by activating intracellular mediators [8]. Patients with high carboxyterminal-crosslinked-telopeptide of type I collagen (s-CTX) (≥500 UI/mL), a marker of bone resorption, had significantly worse outcomes compared to those with low s-CTX (<500 UI/mL) [9]. It has also been reported that the median s-CTX was higher in patients with tumor sizes ≥5 cm [9].”

Comment

2) In Discussion section, the authors mentioned the role of angiogenesis in tumorigenesis through the release of angiogenic proteins such as vascular endothelial growth factor. This is appropriate, indeed its role in GCTB has been investigated in previous years in several works, in which the involvement of VEGFR  has been described in supporting RANKL-induced osteoclastogenesis. Moreover, VEGFR1 was recently found to be upregulated in patients with distal GCTB, highlighting the potential efficacy of TKI treatment, as it's also emerging from ongoing studies on bone sarcomas (see clinical trial NCT04784247). Please add the following references to deepen the discussion about this topic:

- Kumta, S. et al. Expression of VEGF and MMP-9 in giant cell tumor of bone and other osteolytic lesions. Life Sci. 2003

- Taylor, R.M. et al. VEGF, FLT3 ligand, PlGF and HGF can substitute for M-CSF to induce human osteoclast formation: Implications for giant cell tumour pathobiology. Lab. Investig. 2012

- De Vita, A. et al. A Rationale for the Activity of Bone Target Therapy and Tyrosine Kinase Inhibitor Combination in Giant Cell Tumor of Bone and Desmoplastic Fibroma: Translational Evidences. Biomedicines 2022

Response

Thank you for your valuable comments. We added the following sentence in the “Discussion” section; “Indeed, in GCTB, vascular epidermal growth factor receptors support RANKL-induced osteoclastogenesis, and vascular epidermal growth factor receptors are upregulated in patients with large and recurrent GCTB [66,67]. Therefore, the multitarget tyro-sine-kinase inhibitor “Lenvatinib,” which acts through the inhibition of vascular en-dothelial growth factor receptors, fibroblast growth factor receptors, platelet-derived growth factor receptor, proto-oncogene receptor tyrosine kinase and rearranged during transfection kinase, have been suggested to be effective against GCTB [68].”

Comment

3) limitations: the authors indicate that their results may have been affected by the limited sample size of the population studied. However, their sample size does not significantly differ from that of other similar studies in which significant correlation with some markers has been identified. Instead, they should mention other limitations such as the different protocols followed for blood draining and collection (time of the day, fasting, anti-coagulant preservatives, ecc..) as well as patients stratification criteria which may have jeopardized the results.

Response

Thank you for your valuable comments. We added the following sentence in the “Discussion” section; “Second, it is possible that the time of blood sampling, whether the patient has fasted, medical history, and comorbidities affected the inflammatory markers, and that effect was not considered.”

Reviewer 2 Report

Thanks for giving this opportunity to review the manuscript entitled “ Association between inflammatory markers and clinical outcomes in patients with giant cell tumor of bone.” By  Shinji Tsukamoto, et al. The authors conducted a retrospective study aiming to investigate whether preoperative systemic inflammatory markers could predict local recurrence or distant metastasis in giant cell tumor of bone (GCTB ). 103 patients with GCTB of the extremities who underwent surgery at the authors’ institutions between 1993 and 2021 were included. Multivariate analysis did not show these inflammatory markers are correlated with the patients ‘ prognosis. They concluded that these markers don’t have prognosis predicting values. Specific comments regarding the manuscript are as below:

1.      The results of this study are not in agreement with the previous studies, such as the reference 18,19,20, etc. Different patient cohort may contribute the difference.

2.      The main drawback to this study is that this is not a prospective randomized controlled study, the size of sample and the retrospective design of this study are not superior to the previous ones, therefore, whether the systemic inflammatory markers can define the local recurrence or metastasis remain controversial .

3.        This study provides few novel clinical findings and less clinical values.

Taken together, we may not recommended this manuscript to be published.

Author Response

Reviewer 2

Comment

Thanks for giving this opportunity to review the manuscript entitled “ Association between inflammatory markers and clinical outcomes in patients with giant cell tumor of bone.” By  Shinji Tsukamoto, et al. The authors conducted a retrospective study aiming to investigate whether preoperative systemic inflammatory markers could predict local recurrence or distant metastasis in giant cell tumor of bone (GCTB ). 103 patients with GCTB of the extremities who underwent surgery at the authors’ institutions between 1993 and 2021 were included. Multivariate analysis did not show these inflammatory markers are correlated with the patients ‘ prognosis. They concluded that these markers don’t have prognosis predicting values. Specific comments regarding the manuscript are as below:

1. The results of this study are not in agreement with the previous studies, such as the reference 18,19,20, etc. Different patient cohort may contribute the difference.

Response

Thank you for your valuable comments. As you said, the patient background is different from the previous reports. As mentioned in the discussion, the results of the previous reports may differ from the results of this study because the tumor site and preoperative denosumab treatment, which are factors strongly associated with local recurrence, have not been investigated in previous reports.

Comment

2. The main drawback to this study is that this is not a prospective randomized controlled study, the size of sample and the retrospective design of this study are not superior to the previous ones, therefore, whether the systemic inflammatory markers can define the local recurrence or metastasis remain controversial .

Response

Thank you for your valuable comments. We agree with you. However, because giant cell tumor of bone is actually a rare tumor, it is difficult to conduct a prospective randomized controlled study with a sufficient number of patients. As we wrote in the conclusion, it is necessary to re-evaluate this result in a multicenter study with a larger number of patients in the future.

Comment

3. This study provides few novel clinical findings and less clinical values. Taken together, we may not recommended this manuscript to be published.

Response

Thank you for your valuable comments. The relationship between inflammatory markers and prognosis has been investigated in many malignant tumors. Even if the result of this study are negative, we think it would be meaningful to increase the literature investigating the relationship between giant cell tumor of bone, which is of intermediate malignancy, and inflammatory markers.

Reviewer 3 Report

Thank you very much for opportunity to review the manuscript “Association between inflammatory markers and clinical outcomes in patients with giant cell tumor of bone”. Inflammatory markers are one of the most commonly used markers and more recently used in cancer patients. Even thus, the manuscript is interesting, it requires some changes.

1)      Introduction section, line 42-43 “GCTB ha a high local recurrence rate… 2-9% of GCTB develop lung metastases”: does this sentence really need 10 references to support? Please provide some minor changes

2)      Material and methods section: line 69 and line 74: Authors in both lines indicate that the information about “lung metastases” was collected from participant.

3)      Material and Methods section: I recommend do exclude these 9 patients with lung metastases – the group is to small perform real able analysis;

4)      Material and Method section, Table 1: please indicate why Authors include these 19 patients who underwent previous surgery.

5)      Even thus this manuscript provide information about group of 103 patients, only on 30 of them were included in the real analysis, thus Authors should provide in the title, that this is a preliminary results.

6)      Conclusion: Authors should rewrite this section, it should not be state that these inflammatory markers are not useful in GCTB, because of a small number of patients in which the analysis was performed.

Author Response

Reviewer3

Comment

Thank you very much for opportunity to review the manuscript “Association between inflammatory markers and clinical outcomes in patients with giant cell tumor of bone”. Inflammatory markers are one of the most commonly used markers and more recently used in cancer patients. Even thus, the manuscript is interesting, it requires some changes.

• Introduction section, line 42-43 “GCTB ha a high local recurrence rate… 2-9% of GCTB develop lung metastases”: does this sentence really need 10 references to support? Please provide some minor changes

Response

Thank you for your valuable comments. I have reduced the references.

Comment

2)      Material and methods section: line 69 and line 74: Authors in both lines indicate that the information about “lung metastases” was collected from participant.

Response

We deleted “lung metastases at presentation”.

Comment

• Material and Methods section: I recommend do exclude these 9 patients with lung metastases – the group is to small perform real able analysis;

Response

Thank you for your valuable comments. We cancelled the analysis of correlations between lung metastases and inflammatory markers.

Comment

• Material and Method section, Table 1: please indicate why Authors include these 19 patients who underwent previous surgery.

Response

Thank you for your valuable comments. We also included patients who were referred to our institutions for local recurrence after initial surgery at the previous hospital. Patients with a history of surgery at the previous hospital may have an increased risk of local recurrence, therefore they were analyzed as a variable.

Comment

• Even thus this manuscript provide information about group of 103 patients, only on 30 of them were included in the real analysis, thus Authors should provide in the title, that this is a preliminary results.

Response

Thank you for your valuable comments. We added “a preliminary results” into the title.

Comment

• Conclusion: Authors should rewrite this section, it should not be state that these inflammatory markers are not useful in GCTB, because of a small number of patients in which the analysis was performed.

Response

Thank you for your valuable comments. We replaced the previous sentence with “In this study, inflammatory markers, such as NLR, mGPS, PLR, LMR, PNI, and Hb, ALP, and LDH levels, did not correlate with local recurrence in patients with GCTB. However, due to the small number of patients included in this study, this result should be re-evaluated in a multicenter study with a larger sample size.” in the “Conclusion” section.

Reviewer 4 Report

With respect to systemic inflammatory markers including neutrophil-lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), prognostic nutritional index (PNI), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), and hemoglobin (Hb), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH) levels, authors described their prediction powers of prognoses in GCTB. 

As background of systemic inflammatory markers, there are many articles that reported as prognostic markers in patients with malignant tumors, currently. Although, regarding GCTB, some articles have reported associations between prognosis and systemic inflammatory markers, these reports have completely not concluded them yet.

In this study, authors employed 103 patients with GCTB of the extremities and they found NLR, mGPS, PNI, LMR, and PLR score were not correlated with local recurrence or distant metastasis rates in patients with GCTB. Finally, they concluded these markers may not be useful in predicting the prognosis of GCTB. I thought this article provides novel clinical information into the treatment of GCTB. As this study has employed the huge cohort of GCTB cases, there is no concern.

Author Response

Reviewer 4

Comment

With respect to systemic inflammatory markers including neutrophil-lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS), prognostic nutritional index (PNI), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), and hemoglobin (Hb), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH) levels, authors described their prediction powers of prognoses in GCTB.

As background of systemic inflammatory markers, there are many articles that reported as prognostic markers in patients with malignant tumors, currently. Although, regarding GCTB, some articles have reported associations between prognosis and systemic inflammatory markers, these reports have completely not concluded them yet.

In this study, authors employed 103 patients with GCTB of the extremities and they found NLR, mGPS, PNI, LMR, and PLR score were not correlated with local recurrence or distant metastasis rates in patients with GCTB. Finally, they concluded these markers may not be useful in predicting the prognosis of GCTB. I thought this article provides novel clinical information into the treatment of GCTB. As this study has employed the huge cohort of GCTB cases, there is no concern.

Response

Thank you for reviewing our manuscript and your valuable comments.

Reviewer 5 Report

Comments for author File: Comments.pdf

Author Response

Reviewer 5

Comment

Manuscript title: Association between inflammatory markers and clinical outcomes in patients with giant cell tumor of bone Manuscript ID: curroncol-2065259

It is an interesting study that investigated the correlation between inflammatory markers and the rates of local recurrence and pulmonary metastasis in patients with GCTB. Multivariate analysis showed that tumor site, preoperative and postoperative denosumab treatment, and surgical procedure were significantly associated with local recurrence-free survival. Multivariate analysis revealed a significant correlation among sex, Campanacci stage, and lung metastasis-free survival. NLR, mGPS, PNI, LMR, and PLR score were not correlated with local recurrence or distant metastasis rates in patients with GCTB. In order to prove that inflammatory markers may not be helpful for predicting the prognosis of GCTB, a multicenter investigation is needed. Additionally, the sample size is too small to determine if the inflammatory markers response prediction is accurate. It would be helpful if the authors addressed the following comments and revised the entire manuscript.

1. The materials and methods section should state the details of each individual treatment, such as curettage, surgery, Enbloc resection, and Denosumab administration as individual methods. In the methods, please explain them as separate subsections.

Response

Thank you for your valuable comments. We added the following sentence in the “materials and methods” section; “(resection of a large bulky tumor and its attached normal structures, virtually without dissection)”, “Denosumab (a fully human monoclonal antibody that inhibits RANKL) was ap-proved by the US Food and Drug Administration in 2013 because its reported efficacy and safety [33]. It was also reported that denosumab had the effect of down-staging to less invasive surgery [34]. Currently, denosumab treatment is indicated for GCTB that is inoperable or where resection will result in severe dysfunction [33].”

Comment

2. In order to understand the entire concept of these categories, a flow diagram is required. Please include this in the results section. Through text, it is difficult to understand how the authors excluded and included the patients in this study. To give readers a clear picture of this study, a figure will be helpful.

Response

Thank you for your valuable comments. We added the flow diagram (Fig.1).

Comment

3. Please provide the multivariate analysis correlation and the significant difference among pre and post operative site of the tumor’s histological examinations data along with the tables.

Response

Thank you for your valuable comments. All blood data were collected from pre-biopsy data. We changed “preoperative blood data” into “pre-biopsy blood data” in the “materials and methods” section.

Comment

4. The results of the Univariate and multivariate analysis could be shown in a figure which will elevate the results of this study. Please show the differences among the study groups and statistical significance in a figure along with the table.

Response

Thank you for your valuable comments. We added figure 2.

Comment

5. Multivariate Cox regression analysis of local recurrence-free survival should be explained in a curve graph with statistical significance among the studied categories.

Response

Thank you for your valuable comments. We added figure 2.

Comment

6. Authors need to show the correlation between serum systemic inflammatory markers, such as NLR, mGPS, PNI, LMR, PLR, and Hb, ALP, and LDH levels, and local recurrence and lung metastasis in patients with GCTB in a detailed figures including the tables.

Response

Thank you for your valuable comments. We added figure 3 and revised Table 4.

Comment

7. Without multicenter investigation on these markers, we cannot conclude that these inflammatory markers, such as NLR, mGPS, PLR, LMR, PNI, and Hb, ALP, and LDH were not useful. Authors need to provide the solid data to prove their claims.

Response

Thank you for your valuable comments. We replaced the previous sentence with “In this study, inflammatory markers, such as NLR, mGPS, PLR, LMR, PNI, and Hb, ALP, and LDH levels, did not correlate with local recurrence in patients with GCTB. However, due to the small number of patients included in this study, this result should be re-evaluated in a multicenter study with a larger sample size.” in the “Conclusion” section.