BRCA1/2 Mutation Types Do Not Affect Prognosis in Ovarian Cancer Patients

Round 1

Reviewer 1 Report

The study addressed the potential value of using BRCA mutation at different coding positions as the biomarkers for HGSOC prognosis. They results show negative correlation. it is worth to report the negative correlation considering the uncertainty before the study.

Comments:

Table 1 is unclear for read. It would be easier to read if it follows the format of Table 2. Besides, why is the “Bevacizumab administration” apart from “PARP inhibitor administration” in Table 1 while they are mentioned at the same time in Line 94?

Table 2, what is meaning for asterisk in the column “p-value*”?

The author needs to explain the meaning of abbreviation “NR” and state them above Table 2.

Line 121, “The only characteristic that showed a correlation with survival outcome was surgical outcome, with patients having no residual disease following debulking surgery exhibiting a significantly higher PFS (p<0.001) and OS (p=0.028) compared to those with optimal or suboptimal surgical results (Table 2).” If the results show significant differences in Table 2, the p-value in Table 2 should be italicized or in bold.

In Line 126, “The results of the analysis of PFS among patients harboring the same mutation are graphically presented in Fig. 3 showing significant differences between carriers of identical mutations in the same BRCA gene.”  It seems not to show any analysis in Fig 3 to prove there has significant differences between the carriers who shares same mutation. It may need to add the asterisk (*) symbol to the row which is significant different from others.

- What are the differences between the “flat bar” and “pointed bar” in Figure 3?

Line 131, “Lines indicate a case that received a PARP inhibitor as first-line therapy.” It is confusing to use “lines” to describe the bar that indicate the case which received a PARP inhibitor. It should change into “bar in red and white stripes”.

The format of the variants should be identical, for example: “BRCA1 c.3375_3376delTC/ BRCA1 c.3375_3376del”, “BRCA1 c.3700_3704delGTAAA/ BRCA1 C.3700_3704DELGTAAA”

In Figure 4, the authors use lollipop plot to show the location and frequencies of germline BRCA1/2 mutations. Why don’t use different color to represent various type of mutation such as nonsense/missense/frameshift?

For the description of the abbreviation, it should add “aa” to indicate the sequence of amino acid. For example: zf-C3HC4: Zinc finger, C3HC4 type (RING finger) (24 - 64) change into zf-C3HC4: Zinc finger, C3HC4 type (RING finger)(aa 24-64)

Minor corrections

Line 37, Line 68, Line 76: The number that over 1,000 should use comma (,) rather than period symbol (.)

Line 90: The majority of patients presented at advanced stages (Stage III/IV: 84.4%).

Line 88, Line 96, Table 1, Line 99, Line 100, …… : BRCA1/2 stands for the gene, it should be italicized except for BRCA1/2 protein.

Line 100: “16 a BRCA2 mutation” change into “16 patients who have a BRCA2 mutation”

Line 118, Line 261: (Supplemental Figure 1) change into (Figure S1)

Line 243, Line 244: “encodes an 1863/3418 amino acid protein” change into “encodes 1863/3418 amino acids”

Line 258, Line 261: (A and b) change into (A and B)

Line 293, Line 311, Line 327……: The author needs to check the format in the References part

Author Response

Response to the reviewers’ comments:

1. REVIEWER 1

• The study addressed the potential value of using BRCA mutation at different coding positions as the biomarkers for HGSOC prognosis. They results show negative correlation. it is worth to report the negative correlation considering the uncertainty before the study.

We thank the reviewer for thoroughly reading our work and for their time and effort in reviewing our manuscript.

Comments:

• Table 1 is unclear for read. It would be easier to read if it follows the format of Table 2. Besides, why is the “Bevacizumab administration” apart from “PARP inhibitor administration” in Table 1 while they are mentioned at the same time in Line 94?

We appreciate your constructive input. Table 1 has been revised to present our data more clearly, according to your suggestions.

• Table 2, what is meaning for asterisk in the column “p-value*”?
• The author needs to explain the meaning of abbreviation “NR” and state them above Table 2.
• Line 121, “The only characteristic that showed a correlation with survival outcome was surgical outcome, with patients having no residual disease following debulking surgery exhibiting a significantly higher PFS (p<0.001) and OS (p=0.028) compared to those with optimal or suboptimal surgical results (Table 2).” If the results show significant differences in Table 2, the p-value in Table 2 should be italicized or in bold.

We thank the reviewer for pointing out these omissions. The suggested modifications in Table 2 have been made and clarifications have been added under Table 2. (*Log-rank test, NR= not reached).

• In Line 126, “The results of the analysis of PFS among patients harboring the same mutation are graphically presented in Fig. 3 showing significant differences between carriers of identical mutations in the same BRCA gene.” It seems not to show any analysis in Fig 3 to prove there has significant differences between the carriers who shares same mutation. It may need to add the asterisk (*) symbol to the row which is significant different from others.

We agree with the reviewer’s interpretation of Fig. 3 and we have thus omitted the wrongfully used word “significant” and changed the sentence in Lines 179-181 as follows: “Interestingly, we observed noteworthy differences, in terms of PFS duration, between carriers of identical mutations in the same BRCA gene, as it is shown with same color bars in the graph of Fig. 3.”

• What are the differences between the “flat bar” and “pointed bar” in Figure 3?

We thank the reviewer for pointing this out. Bars with an arrow at the end of them indicate no disease progression, and this information has been added in the description under Fig.3.

• Line 131, “Lines indicate a case that received a PARP inhibitor as first-line therapy.” It is confusing to use “lines” to describe the bar that indicate the case which received a PARP inhibitor. It should change into “bar in red and white stripes”.

The suggested changes were made in the description under Table 2.

• 8) The format of the variants should be identical, for example: “BRCA1 c.3375_3376delTC/ BRCA1 c.3375_3376del”, “BRCA1 c.3700_3704delGTAAA/ BRCA1 C.3700_3704DELGTAAA”

According to your helpful comment, alterations were made to ensure a uniform presentation of data on Figure 3.

• 9) In Figure 4, the authors use lollipop plot to show the location and frequencies of germline BRCA1/2 mutations. Why don’t use different color to represent various type of mutation such as nonsense/missense/frameshift?

Taking into consideration your thoughtful comment, mutation diagram circles were colored with respect to the corresponding mutation types.

• For the description of the abbreviation, it should add “aa” to indicate the sequence of amino acid. For example: zf-C3HC4: Zinc finger, C3HC4 type (RING finger) (24 - 64) change into zf-C3HC4: Zinc finger, C3HC4 type (RING finger)(aa 24-64)

Changes were made in the description under Figure 4 as per your suggestion.

• Minor corrections

Line 37, Line 68, Line 76: The number that over 1,000 should use comma (,) rather than period symbol (.)

Line 90: The majority of patients presented at advanced stages (Stage III/IV: 84.4%).

Line 88, Line 96, Table 1, Line 99, Line 100, …… : BRCA1/2 stands for the gene, it should be italicized except for BRCA1/2 protein.

Line 100: “16 a BRCA2 mutation” change into “16 patients who have a BRCA2 mutation”

Line 118, Line 261: (Supplemental Figure 1) change into (Figure S1)

Line 243, Line 244: “encodes an 1863/3418 amino acid protein” change into “encodes 1863/3418 amino acids”

Line 258, Line 261: (A and b) change into (A and B)

Line 293, Line 311, Line 327……: The author needs to check the format in the References part

All minor corrections were performed. We believe that the reviewer’s comments are an important addition to our paper and thank you for helping us conceive it.

Reviewer 2 Report

Currently, the standard treatment of advanced ovarian cancer (ROC) is mainly based on surgical and medical treatment chosen according to several clinical parameters; in addition, in the last years, other parameters have been shown to play a major role on clinical outcomes, such as histotype, status of BRCA genes or homologous recombination deficiency (HRD) and pattern of relapse presentation and platinum interval.

Besides the advances in the medical treatments which have integrated bevacizumab and PARP-inhibitors in the chemotherapeutic armamentarium, primary cytoreductive surgery (SCS) has been associated with improved survival in the management of OC

the present study, with very small number of patients shows no significant influence by BRCA status on oncological outcomes. However, should be very important to not draw any definitive conclusion. moreover, should be add in the discussion the potential role of brca status also in the recurrent setting

please add in the references the following studies on this topic

Salvage lymphadenectomy in recurrent ovarian cancer patients: Analysis of clinical outcome and BRCA1/2 gene mutational status. Eur J Surg Oncol. 2020 Jul;46(7):1327-1333. 

Prognostic factors value of germline and somatic brca in patients undergoing surgery for recurrent ovarian cancer with liver metastases. Eur J Surg Oncol. 2019 Nov;45(11):2096-2102. 

Author Response

REVIEWER 2

• Currently, the standard treatment of advanced ovarian cancer (ROC) is mainly based on surgical and medical treatment chosen according to several clinical parameters; in addition, in the last years, other parameters have been shown to play a major role on clinical outcomes, such as histotype, status of BRCA genes or homologous recombination deficiency (HRD) and pattern of relapse presentation and platinum interval.

Besides the advances in the medical treatments which have integrated bevacizumab and PARP-inhibitors in the chemotherapeutic armamentarium, primary cytoreductive surgery (SCS) has been associated with improved survival in the management of OC

We would like to thank the reviewer for his positive feedback and for the time devoted to improving our manuscript.

• the present study, with very small number of patients shows no significant influence by BRCA status on oncological outcomes. However, should be very important to not draw any definitive conclusion.

We would like to thank the reviewer for his thoughtful comment. We agree with the reviewer’s assessment. Therefore, we conclude that “further investigations exploring the genotype–phenotype correlations of specific BRCA1 and BRCA2 mutations that differentiate prognosis among family members who are carriers of the same mutations are needed to clarify the role of other genetic abnormalities and co-contributing risk factors in the clinical course of BRCA-mutated ovarian cancer patients.”.

• moreover, should be add in the discussion the potential role of brca status also in the recurrent setting

We think this is a very thoughtful comment and thus we have added in the Discussion section a sentence drawing attention to the potential role of BRCAmut not only in primary disease, which concerns our study participants, but also in recurrent ovarian cancer (Lines 191-196). Also, the suggested literature has been added to further support our discussion.

• please add in the references the following studies on this topic

Salvage lymphadenectomy in recurrent ovarian cancer patients: Analysis of clinical outcome and BRCA1/2 gene mutational status. Eur J Surg Oncol. 2020 Jul;46(7):1327-1333.

Prognostic factors value of germline and somatic brca in patients undergoing surgery for recurrent ovarian cancer with liver metastases. Eur J Surg Oncol. 2019 Nov;45(11):2096-2102.

We have added the suggested literature in the revised version of our manuscript.

Once again thank you for your consideration and for your careful and thorough reading of the manuscript. We believe that the reviewers’ comments are an important addition to our research paper and thank you for helping us conceive it. We will be happy to address any potential future questions.