PONE-D-23-13935Age-associated mortality is partially mediated by TERT promoter mutation status in differentiated thyroid carcinomaPLOS ONE

Dear Dr. Kim,

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Some potential articles in this field are not cited and are worth to cite the following articles as they contributed to the development of this field (PMID: 23766237; PMID: 25024077; PMID: 26354077; PMID: 26711586; PMID: 26902827).

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Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Age-associated mortality is partially mediated by TERT promoter mutation status in differentiated thyroid carcinoma

[Overall]

This study examined the relationship between age, TERT promoter mutations, and mortality in differentiated thyroid carcinoma (DTC). The findings revealed that age was associated with increased mortality in all DTC patients and those without TERT promoter mutations. A significant interaction was identified between age and TERT promoter mutation in relation to the mortality rate in DTC. Furthermore, this study revealed that the impact of age on the mortality rate in DTC was partially influenced by the presence of TERT promoter mutation using multiple analysis. The authors emphasize the influence of TERT promoter mutation on cancer-specific outcomes based on these analyses. They also highlight the importance of incorporating this critical nonanatomical variable into future stage classifications to enhance the development of personalized prediction models for thyroid cancer.

[Critique]

Overall, the authors addressed evidence about the partial correlation between morality rate and TERT promoter mutation, showing that TERT promoter mutation contributes to age-associated mortality by 36% in TERT mutant DTC. This interaction was theoretically considered as factor of poor outcome in DTC patients with older age and this paper confirmed the theory by analyzing patient samples. This work is logically addressed and appropriately presented in general, but the following points should be addressed or discussed before further consideration for the publication. Especially, many of the details about the figures are missing or incomplete.

[Major comments]

1. Many of the figure legends are missing or have lack of the information. For example, figure 2, 3, 4, and 5 have only title and there are no figure legend which can explain about detail of the figure. It would be better to have abbreviation, statistic information, explanation about each subfigure (such as A, B, and C), etc. in the legend. Especially, in the case of dual axis graph, like figure 4, detailed figure legend should be needed to prevent confusion.

2. In figure 2 and related manuscript, the authors addressed that “The mortality rates were low in all patients with DTC and in the WT-TERT group before the age of 55 years compared with the high mortality rate in the M-TERT group”. To conclude more precisely, the author need to add statistical analysis with comparison between “all vs M-TERT” and “WT-TERT vs M-TERT” and provide information in the figure 2.

3. 2. Based on the mutation analysis, the authors could see two different type of promoter mutations, C228T and C250T. Have there been any previous studies conducted on which mutation is a more risk factor or more frequent in diseases other than DTC (for example, glioblastoma multiforme, GBM)? If so, it would be great to do more discussion in addition to line 429-434.

[Minor comments]

1. In Table 4 and related manuscript, the authors showing result of mediation analysis. Even though they mentioned in the introduction part (line 272) that “natural direct effect (NDE), a synonym for PDE, and the natural indirect effect (NIE), a synonym for TIE”, it would be great to understand for the reader using unified term. In addition, please add abbreviation as well in the table; for example, Total effect (TE), Pure direct effect (PDE), etc. It makes the easier to follow.

Reviewer #2: The manuscript submitted by Jung Heo et al., is a retrospective study that examines the interaction between age and TERT promoter mutation in 393 patients with differentiated thyroid carcinoma and its effect on mortality. The authors subtracted DNA from FFPE tissue and identified TERT promoter mutations and mutant enrichment in those patients. The authors then applied a series of statistical analyses including multivariable Cox regression and mediation analysis to investigate the weight of various factors such as age, treatment and TERT promoter mutation on the survival rate of this group of patients. The examination of interaction between age and TERT promoter mutation is appraisable and the results are interesting.

In addition to the drawbacks of the study mentioned by the authors in the discussion part, I have few more comments about the data analysis and presentation.

1. Most of the patients in this cohort has papillary thyroid cancer, which occurs more frequently in women. It seems that gender is an unneglectable factor associated to the differentiated thyroid carcinoma.

In table 1 and S1, the authors listed the numbers of females and males of the patient cohort and the number of patients with TERT promoter mutations. However, they did not specify the number of female and male in the M-TERT group. Is there a difference in the incidence of TERT promoter mutations between males and females? Moreover, what is the incidence of TERT promoter mutations in different age groups?

As presented in figures 2, 3B, and 3E, there is a clear linear association between mortality rate and age in patients with WT-TERT promoters, whereas this linear association is not found in patients with mutated TERT promoters. The mortality rate is lower in the 55-64y age group as compared to that in the 45-54y age group in patients with mutated TERT promoters. Have the authors examined the mortality rate separately in males and females in different age groups? Females go through menopause between 45 and 55, and there is a decline of estradiol production during this period. It has been reported that 17beta-estradiol significantly increased telomerase activity in human endothelial cells (Grasselli et al., Circ Res. 2008 Jul 3;103(1):34-42), therefore, it is worthwhile and crucial to explore the interaction of age, gender and TERT promoter mutations in this cohort of patients.

2. Figure 3:

To make it clear and easier for reading, please put subtitles to each graph to indicate the group of patients.

Reviewer #3: Aging and TERT promoter mutations have been previously shown as prognostic factors in Differentiated Thyroid Carcinoma (Tae Hyuk Kim et al., 2016). In this study, authors used their previous Differentiated Thyroid Carcinoma (DTC) cohort to elucidate the interaction of aging and TERT promoter mutations. They found that the effect of aging on mortality of mutant TERT patients were not significant, while aging caused higher mortality rate in Wild type TERT patients. In addition, Heo J et al., found that TERT promoter mutation contributes to 36% of age-related mortality rate in this DTC cohort. Next, authors concluded that TERT promoter mutations should be considered in a stage classification of DTC. Although these finding are interesting observations, but the conclusion of this study is similar to their previous study (Tae Hyuk Kim et al., 2016).

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PONE-D-23-13935R1Age-associated mortality is partially mediated by TERT promoter mutation status in differentiated thyroid carcinomaPLOS ONE

Dear Dr. Kim,

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 17 2023 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.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Avaniyapuram Kannan Murugan, M.Phil., Ph.D.

Academic Editor

PLOS ONE

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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.

Additional Editor Comments:

Kindly address the pending reviewer comments which has merit and to be addressed before acceptance.

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

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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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

Reviewer #2: Partly

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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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

Reviewer #2: No

Reviewer #3: Yes

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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

Reviewer #2: Yes

Reviewer #3: 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: In this revised iteration, the authors have conscientiously addressed the majority of the questions that I had raised. The current manuscript has been rendered more lucid and accessible, thereby facilitating a better understanding of its content. It is worth noting that in addition to the modifications to the advice I suggested, additional modifications allowed the author to further emphasize differences in relation to existing research results. Overall, it is evident that this manuscript has undergone substantial enhancements compared to its original submission. These improvements confirmed previously published research results and suggested additional direction to academics and readers by suggesting the need for additional research in elucidating the relationship between aging, TERT promoter mutation, and DTC diagnosis. As the author mentioned, there are limitations such as the possibility of unmeasured confounders and a small cohort, but the limitations and the need for additional research are appropriately described.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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Reviewer #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: comments to manuscript PONE-D-23-13935-revised.docx

Age-associated mortality is partially mediated by TERT promoter mutation status in differentiated thyroid carcinoma

PONE-D-23-13935R2

Dear Dr. Kim,

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Kind regards,

Avaniyapuram Kannan Murugan, M.Phil., Ph.D.

Academic Editor

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