Analysis of TERT mRNA Levels and Clinicopathological Features in Patients with Peritoneal Mesothelioma

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript presents a single-center retrospective study analyzing 13 patients with peritoneal mesothelioma (PeM), evaluating morphological and molecular parameters and correlating TERT mRNA expression with clinicopathological characteristics and survival. Several changes must be made for the article to be publishable.

Peritoneal mesothelioma (PeM) is a rare disease. For this reason, the reduced number of samples can be accepted. However, authors have to declare the period of samples collection.

Figure 1 needs to be redone. I suggest that it be divided into 2 figures: one containing the histology and the second IHC. In addition, the figures should be large enough to make all the dots visible.

Figure 2 and table 5 can be represented using the color scale and formatting the cells according to their values.

Figures 3-11 should be grouped into 2 figures: one containing all the survival figures and another containing all the correlations. So the results will be much easier to visualize and understand.

Page 6, line 215 – What does 69.2% mean? Is that correct?

Author Response

REVIEWER 1

The manuscript presents a single-center retrospective study analyzing 13 patients with peritoneal mesothelioma (PeM), evaluating morphological and molecular parameters and correlating TERT mRNA expression with clinicopathological characteristics and survival. Several changes must be made for the article to be publishable.

 

Comment 1:

Peritoneal mesothelioma (PeM) is a rare disease. For this reason, the reduced number of samples can be accepted. However, authors have to declare the period of samples collection.

Response 1:

The period of samples collection is now indicated in the M&M section, line 126 (2003-2017).

 

Comment 2:

Figure 1 needs to be redone. I suggest that it be divided into 2 figures: one containing the histology and the second IHC. In addition, the figures should be large enough to make all the dots visible.

Response 2:

According to the Reviewer, we have redone the figure as suggested. Now are Figure 1 and Figure 2.

 

Comment 3:

Figure 2 and Table 5 can be represented using the color scale and formatting the cells according to their values.

Response 3:

Now, Figure 2 is Figure 3. According to the Reviewer, we used the same color scale for the figure and Table 5 as suggested.

 

Comment 4:

Figures 3-11 should be grouped into 2 figures: one containing all the survival figures and another containing all the correlations. So, the results will be much easier to visualize and understand.

Response 4:

According to the Reviewer, we have grouped the figures 3-11 in two. Now, the new two figures are Figure 4 and Figure 5.

 

Comment 5:

Page 6, line 215 – What does 69.2% mean? Is that correct?

Response 5:

There was an error. “Asbestos exposure (occupational and/or environmental) was known in 9 of the 13 patients (69.2%).” Now is line 239.

Reviewer 2 Report

Comments and Suggestions for Authors

General comments:

This is a very interesting and necessary study. Good design and well displayed. Congrats!

Very well resolved discussion. 21 references are included. It’s fantastic!

Conclusions. Maybe you can summarize and be more concise/concrete in this section. However, the rest of the very useful and interesting text could be included in the final part of the discussion.

Specific comments:

.- Introduction. Up to 4 sentences begin with the acronym “TERT”. Please, review.

Several short and independent sentences. Maybe they could merge and make up a paragraph. 36 references included. Congrats!

.- Results.

Lines 214-215. “Asbestos exposure (occupational and/or environmental) was known in 12 of the 13 patients (69.2%)”. Is this dates or percentage correct? Would 12/13 be 92.3%?

.- Tables. Tables 2, 3 and 4. Perhaps the numerical interpretation could be included as text at the bottom of the table.

.- Figures. Perhaps a large number of figures are presented (11 figures). It could be consider including this material as an annex or complementary material.

.- References. 64 quotes are included. Of which 27 (42%) are recent. This is five years or less from its publication. If possible, it would be appreciated to include any additional recent refereneces.

Author Response

REVIEWER 2

Comment 1:

General comments:

This is a very interesting and necessary study. Good design and well displayed. Congrats!

 

Very well resolved discussion. 21 references are included. It’s fantastic!

 

Conclusions. Maybe you can summarize and be more concise/concrete in this section. However, the rest of the very useful and interesting text could be included in the final part of the discussion.

Response 1:

Thanks for the appreciation. We have summarized the conclusions as suggested.

 

Comment 2:

Specific comments:

- Introduction. Up to 4 sentences begin with the acronym “TERT”. Please, review.

Several short and independent sentences. Maybe they could merge and make up a paragraph. 36 references included. Congrats!

Response 2:

The organization of sentences and paragraphs has been revised as suggested.

Now, the introduction is organized into 4 paragraphs regarding information: clinical and epidemiological, pathogenesis, TERT, and purpose.

 

Comment 3:

Specific comments:

- Results.

Lines 214-215. “Asbestos exposure (occupational and/or environmental) was known in 12 of the 13 patients (69.2%)”. Is this dates or percentage correct? Would 12/13 be 92.3%?

Response 3:

There was an error. “Asbestos exposure (occupational and/or environmental) was known in 9 of the 13 patients (69.2%).” Now is line 239.

 

Comment 4:

Specific comments:

- Tables. Tables 2, 3 and 4. Perhaps the numerical interpretation could be included as text at the bottom of the table.

Response 4:

As suggested for Table 1-5 the numerical interpretation is now present as table footer.

 

Comment 5:

Specific comments:

- Figures. Perhaps a large number of figures are presented (11 figures). It could be consider including this material as an annex or complementary material.

Response 5:

According to Reviewers 1&2, we have grouped figures 3-11 in two. Now, the new two figures are Figure 4 (containing all the survival figures ) and Figure 5 (containing all the correlations).

Please note that figures 1-3 have also been modified to make them more readable in agreement with Reviewer 1.

 

Comment 6:

Specific comments:

- References. 64 quotes are included. Of which 27 (42%) are recent. This is five years or less from its publication. If possible, it would be appreciated to include any additional recent refereneces.

Response 6:

As suggested, we have inserted new and more recent references (56% are recent) in the Introduction and Discussion section:

• Introduction section:
• Ref 12: 10.1002/bjs5.50256 (2020)
• Ref 14: 10.3390/cancers15194704 (2023)
• Ref 19: 10.1016/j.esmoop.2023.101600 (2023)
• Ref 31: 10.1002/mc.23822 (2025)
• Ref 35: 10.1158/1078-0432.CCR-20-3044 (2021)
• Ref 40: 10.1001/jamanetworkopen.2023.23500 (2023)
• Ref 41: 10.1097/DAD.0000000000002357 (2023)
• Ref 42: 10.1016/j.labinv.2024.102201 (2024)
• Ref 45: 10.1016/j.heliyon.2023.e18953 (2023)

 

• Discussion section:
  • Ref 53: 10.1530/ERC-24-0058 (2024)
  • Ref 45: 10.1016/j.heliyon.2023.e18953 (2024)
  • Ref 57:10.1158/0008-5472.CAN-19-3068 (2020)
  • Ref 64: 10.1371/journal.pone.0312115 (2024)
  • Ref 67: 10.1016/j.celrep.2024.115035 (2024)
  • Ref 73: 10.1097/COC.0000000000000745 (2020)
  • Ref 78: 10.3390/jpm14040394 (2024)

Reviewer 3 Report

Comments and Suggestions for Authors

Cancers-3391795

Analysis of TERT mRNA Level and Clinicopathological Features in Patients with Peritoneal Mesothelioma

This study analyzed multiple morphological and molecular parameters of 13 patients with PeM to explore the relationship between TERT mRNA expression and clinicopathological features and patient prognosis, providing a new perspective for the research of PeM. However, some methodologies were incomplete, and the logical flow must also be supplemented. Some concerns need to be addressed or clarified before the manuscript can be considered for publication in the journal.

My comments:

1.       It is strongly recommended that the author integrate the "introduction" part, as there are quite a number of paragraphs with only one or two simple sentences. This practice does not conform to the norms of academic writing. Meanwhile, the tables in the text should be presented in the form of three-line tables. And the figures in the text should be integrated into grouped figures.

2.         Although the study found that TERT mRNA expression is correlated with certain morphological and molecular characteristics, what is the specific molecular mechanism behind these correlations? For example, through which signaling pathways does TERT affect the expression or function of BAP1 and p16, and then is associated with the occurrence and development of tumors?

3.         The factors related to the prognosis of PeM found in the study (such as mitotic index, BAP1 and p16/CDKN2A status), how can they be integrated into a comprehensive prognostic model to more accurately predict patient survival and guide individualized treatment? At the same time, can this model be extended to other types of mesothelioma or related tumors?

4.         Could the observed differences in TERT mRNA expression between epithelioid and biphasic peritoneal mesothelioma be exploited for targeted therapies?

Author Response

REVIEWER 3

Analysis of TERT mRNA Level and Clinicopathological Features in Patients with Peritoneal Mesothelioma

This study analyzed multiple morphological and molecular parameters of 13 patients with PeM to explore the relationship between TERT mRNA expression and clinicopathological features and patient prognosis, providing a new perspective for the research of PeM. However, some methodologies were incomplete, and the logical flow must also be supplemented. Some concerns need to be addressed or clarified before the manuscript can be considered for publication in the journal.

My comments:

Comment 1:

1. It is strongly recommended that the author integrate the "introduction" part, as there are quite a number of paragraphs with only one or two simple sentences. This practice does not conform to the norms of academic writing. Meanwhile, the tables in the text should be presented in the form of three-line tables. And the figures in the text should be integrated into grouped figures.

Response 1:

Effectively, several short and independent sentences were present in the Introduction section. According to you and Reviewer 1, the organization of sentences and paragraphs has been revised. Now, the introduction is organized into 4 paragraphs regarding information: clinical and epidemiological, pathogenesis, TERT, and purpose.

Moreover, as suggested, Tables are now in three-line table form, and the Figures are grouped in two. Now, the new two figures are Figure 4 (containing all the survival figures ) and Figure 5 (containing all the correlations).

Please note that figures 1-3 have also been modified to make them more readable in agreement with Reviewer 1.

 

Comment 2:

2. Although the study found that TERT mRNA expression is correlated with certain morphological and molecular characteristics, what is the specific molecular mechanism behind these correlations? For example, through which signaling pathways does TERT affect the expression or function of BAP1 and p16, and then is associated with the occurrence and development of tumors?

Response 2:

Thank you for your insightful comment regarding the molecular mechanisms underlying the correlations between TERT mRNA expression and the characteristics studied, particularly its interaction with BAP1 and p16.

While our study highlights the association of TERT expression with specific morphological and molecular features, the precise signaling pathways mediating these effects are not the focus of our study; hence, they have not been investigated and remain an area requiring further analysis. However, based on existing literature and the context of our findings, we may propose the following mechanisms:

1. TERT and p16:
   • TERT expression has been linked to cell cycle regulation, where it may downregulate tumor suppressors like p16 through the activation of the PI3K/AKT/mTOR pathway. This pathway is known to promote cellular proliferation and bypass senescence mechanisms driven by p16 loss.
   • Additionally, TERT’s role in telomere maintenance can indirectly influence p16 levels by mitigating telomere dysfunction, which otherwise triggers a p16-mediated senescence response.

(PMID:  38908367)

 

2. TERT and BAP1:
   • BAP1, as a tumor suppressor, is involved in chromatin remodeling and gene expression regulation. Emerging evidence (particularly for HCC, hepatocellular carcinoma) suggests that TERT could interact with BAP1 via the WNT/β-catenin signaling pathway, which is often activated in tumors with TERT overexpression. This interaction might disrupt BAP1’s ability to maintain genomic stability, facilitating tumor progression.
   • Furthermore, TERT’s telomerase-independent functions, such as its role in modulating transcriptional networks, could influence BAP1 activity by altering the epigenetic landscape.

(PMID: 34439356; 33338512)

 

3. TERT and Tumor Development:
   • The interplay between TERT, p16, and BAP1 likely creates a permissive environment for tumor development by promoting immortalization (via telomere elongation), evasion of growth suppression (via p16 inhibition), and genomic instability (via BAP1 inactivation).

 

Although these mechanisms are supported by current literature, further experimental studies, such as pathway-specific inhibition or knockdown models, would be required to elucidate the molecular crosstalk definitively.

 

All underlined parts have been included in the text.

 

We appreciate your suggestion to delve deeper into these mechanisms, and we intend to explore this in future work. Thank you again for your valuable feedback.

 

 

Comment 3:

3. The factors related to the prognosis of PeM found in the study (such as mitotic index, BAP1 and p16/CDKN2A status), how can they be integrated into a comprehensive prognostic model to more accurately predict patient survival and guide individualized treatment? At the same time, can this model be extended to other types of mesothelioma or related tumors?

Response 3:

Thank you for your thoughtful comment. To integrate the identified prognostic factors (mitotic index, BAP1, and p16/CDKN2A status) into a comprehensive model for PeM, we might propose, in future studies possibly involving a higher number of cases, these points:

1. Risk Scoring System: Assign weights to each factor based on their impact on survival, using multivariate analysis or machine learning.
2. Nomogram Development: Create a tool combining these factors with clinical data (e.g., age, sex, treatment) to predict individualized survival probabilities.
3. Validation: Test the model internally and on external datasets to ensure accuracy and generalizability.

 

This approach could be extended to other mesothelioma types or tumors sharing molecular features (e.g., BAP1 deficiency or p16 loss), with adjustments for subtype-specific factors. A robust model like this may possibly enhance risk stratification and guide personalized treatment.

 

Thank you again for your valuable feedback, which will guide our future work.

 

 

Comment 4:

4. Could the observed differences in TERT mRNA expression between epithelioid and biphasic peritoneal mesothelioma be exploited for targeted therapies?

Response 4:

Thank you for your insightful question regarding the potential exploitation of TERT mRNA expression differences between epithelioid and biphasic peritoneal mesothelioma for targeted therapies.

With the current data, it is difficult to draw definitive conclusions on whether these differences in TERT expression could be directly targeted for therapeutic purposes. While the observed correlation between TERT expression and tumor subtype suggests a potential avenue for further investigation, more research is needed to fully understand the functional implications and how this could be translated into a therapeutic strategy.

However, it would certainly be valuable to explore this in future studies. A deeper understanding of the role of TERT in different mesothelioma subtypes could potentially open up new avenues for targeted therapies, particularly if specific molecular pathways linked to TERT expression are identified.

Thank you again for your thoughtful suggestion.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Table 6 should be in the form of three-line tables. I have no other comments.

Author Response

Comment 1:

Table 6 should be in the form of three-line tables. I have no other comments.

Response 1:

Sorry for the oversight. Table 6 is now in the form of three-line tables.