Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia

Antonio Braga; Ana Clara Canelas; Berenice Torres; Izildinha Maesta; Luana Giongo Pedrotti; Marina Bessel; Ana Paula Vieira dos Santos Esteves; Joffre Amim Junior; Jorge Rezende Filho; Kevin M. Elias; Neil S. Horowitz; Ross S. Berkowitz

doi:10.1371/journal.pone.0277892

Peer Review History

Original SubmissionAugust 22, 2022
10 Oct 2022 Decision Letter - Roberto Magalhães Saraiva, Editor PONE-D-22-23500Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasiaPLOS ONE Dear Dr. Braga, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 24 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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[Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Many thanks for asking me to review this retrospective study from an internationally renowned GTD collaborative group. The study aimed to evaluate the relationship between neutrophil/lymphocyte ratios (NLR) and platelet/lymphocyte ratios and the occurrence of gestational trophoblastic neoplasia (GTN) after complete hydatidiform mole (CHM) among Brazilian women. High pre-treatment NLR for example can be associated with poorer outcomes in cancer patients with variation in the size of this association across studies of cancer patients. The paper is well written and clear and involves a larger number of CHM pts. The clear outcome, after adjusting for potential confounders, is that there is no association here with the development of post molar GTN from CHM. This is worthy of publication for the international GTN community as some much smaller series have reported a potential association. I have the following minor comments: Was there a set time frame before evacuation in which the blood count was taken or was it on the day of the evacuation - would this have any influence on the results Are there any subgroups of patients e.g. ethic groups - where there may be stronger associations? Can the authors expand on why they think that Neutrophil/lymphocyte ratio and other blood cell component counts are not predictive the development of postmolar gestational trophoblastic neoplasia from CHM. Is this the fact that CHM is a pre-malignant diagnosis, clearly different from e.g. NLR trying to predict outcome in established cancer? Would it be useful to look at a later stage e.g. NLR prior to treatment in GTN to see if this may have an association with outcome e.g. resistance, survival in high risk disease? Perhaps the authors can add to the discussion at the end some further detail in how they see future development of predicting the development of post-molar GTN e.g. microRNA etc ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0277892.r001
Revision 1
15 Oct 2022 Author Response Rio de Janeiro, Brazil October, 2022. Dr. Emily Chenette, PhD. Editor-in-Chief, PLOS ONE Dear Dr. Emily Chenette and the members of the Editorial Board: Response to reviewers Paper: “Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia” Initially, we would like to highlight that we made a surname correction, changing the original name from Berenice Nogueira to Berenice Torres. In addition, we linked a new institution to the first author: Postgraduate Program in Applied Health Sciences, Vassouras University. Rio de Janeiro – RJ, Brazil. Editor review. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. REPLY: We appreciate the comment and agree with the reviewer. Please note that the necessary corrections have been made. 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. REPLY: We appreciate the comment and agree with the reviewer. Please note that we already presented this declaration in the methods section, in the original submission, as follows: “The study was done with anonymized patient records, so the Ethics Committees waived the need for obtaining individual informed consent.”. 3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. REPLY: We appreciate the comment and agree with the reviewer. We have included the following Data Availability Statement as follows: “Data Availability Statement. Due to ethical issues related to the public disclosure of a database of a disease that is not highly prevalent, coming from a delimited geographical area, with the potential to breach data confidentiality, even in the face of data de-identification, we emphasize that any data referring to the study: “Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia” must be requested directly from the Research Ethics Committee of the Maternity School of Rio de Janeiro Federal University, with due justification analyzed by this institutional review board, in order to preserve the interests of research participants, following compliance with research standards in Brazil (CNS/CONEP/CEP 466/2012). The Research Ethics Committee of the Maternity School of Rio de Janeiro Federal University can be contacted directly through the institutional email: cep@me.ufrj.br or directly by phone: 55.21.2285-7935.”. 4. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary). REPLY: We appreciate the comment and agree with the reviewer. We have made the necessary changes in this revised version. 5. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. REPLY: We appreciate the comment and agree with the reviewer. We emphasize that we do not include in our references any article that has been retracted and have made no changes to our reference list. Reviewer 1. Many thanks for asking me to review this retrospective study from an internationally renowned GTD collaborative group. The study aimed to evaluate the relationship between neutrophil/lymphocyte ratios (NLR) and platelet/lymphocyte ratios and the occurrence of gestational trophoblastic neoplasia (GTN) after complete hydatidiform mole (CHM) among Brazilian women. High pre-treatment NLR for example can be associated with poorer outcomes in cancer patients with variation in the size of this association across studies of cancer patients. The paper is well written and clear and involves a larger number of CHM pts. The clear outcome, after adjusting for potential confounders, is that there is no association here with the development of post molar GTN from CHM. This is worthy of publication for the international GTN community as some much smaller series have reported a potential association. I have the following minor comments: 1. Was there a set time frame before evacuation in which the blood count was taken or was it on the day of the evacuation - would this have any influence on the results. REPLY: We appreciate the comment and agree with the reviewer. The issue is relevant and we added the following sentence in the description of the methods: "In all patients, the blood test was collected within 6 hours before surgery". 2. Are there any subgroups of patients e.g. ethic groups - where there may be stronger associations? REPLY: We appreciate the opportunity to clarify these aspects. Although previous studies have attributed different outcomes of hydatidiform mole, in relation to certain ethnic population groups, no Brazilian study has been carried out in this sense. This is due to the Brazilian ethnic background being extremely mixed, making it difficult to ethnically characterize patients. Furthermore, Brazilian legislation prohibits physicians from establishing the ethnic classification of their patients, which in Brazil is done according to self-declaration, which, in itself, makes it difficult to analyze this variable. 3. Can the authors expand on why they think that Neutrophil/lymphocyte ratio and other blood cell component counts are not predictive the development of postmolar gestational trophoblastic neoplasia from CHM. Is this the fact that CHM is a pre-malignant diagnosis, clearly different from e.g. NLR trying to predict outcome in established cancer? Would it be useful to look at a later stage e.g. NLR prior to treatment in GTN to see if this may have an association with outcome e.g. resistance, survival in high risk disease? REPLY: We appreciate the comment and agree with the reviewer. We have added the following sentences in the Discussion section to contextualize the reviewer's comment, as follows: “Although the NLR and other blood cell component counts were unable to predict the cases of CHM that will develop postmolar GTN, it would be important to evaluate these markers in cases of postmolar GTN, in order to assess whether there is a relationship between these findings and the occurrence of chemoresistance, high risk disease, number of chemotherapy cycles to remission and time to remission, and survival rate or recurrence. Perhaps, studying established neoplasia (GTN), instead of pre-malignant disease (CHM) can provide better prognostic parameters.”. 4. Perhaps the authors can add to the discussion at the end some further detail in how they see future development of predicting the development of post-molar GTN e.g. microRNA etc. REPLY: We appreciate the comment and agree with the reviewer. We have added the following sentences in the Discussion section to contextualize the reviewer's comment, as follows: “Although new modern technologies such as microRNA have shown promising results in predicting the prognosis of CHM, their cost and availability limit their clinical use [34], which contrasts with NLR and other blood cell counts that are simple, inexpensive and widely available laboratory tests, which need to be further evaluated.”. 34. Lin LH, Maestá I, St Laurent JD, Hasselblatt KT, Horowitz NS, Goldstein DP, Quade BJ, et al. Distinct microRNA profiles for complete hydatidiform moles at risk of malignant progression. Am J Obstet Gynecol. 2021;224(4):372.e1-372.e30. doi: 10.1016/j.ajog.2020.09.048. Sincerely, Antonio Braga MD and Ross Berkowitz MD For the authors Attachments Attachment Submitted filename: Response to reviewer.docx https://doi.org/10.1371/journal.pone.0277892.r002
6 Nov 2022 Decision Letter - Roberto Magalhães Saraiva, Editor Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia PONE-D-22-23500R1 Dear Dr. Braga, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Roberto Magalhães Saraiva, MD, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors have responded with appropriate answers and they have made appropriate edits made to the manuscript ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No ******** https://doi.org/10.1371/journal.pone.0277892.r003
Formally Accepted
9 Nov 2022 Acceptance Letter - Roberto Magalhães Saraiva, Editor PONE-D-22-23500R1 Neutrophil/lymphocyte ratio and other blood cell component counts are not associated with the development of postmolar gestational trophoblastic neoplasia Dear Dr. Braga: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Roberto Magalhães Saraiva Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0277892.r004

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