Abstract
Background:
Mesothelioma is an aggressive malignancy with poor outcomes, particularly when diagnosed at advanced stages. This study evaluated the prognostic value of tumor-specific biomarkers: soluble mesothelin-related peptide (SMRP), megakaryocyte potentiating factor (MPF) and CA125; inflammatory markers: C-reactive protein (CRP) and fibrinogen; cellular markers: platelet count and neutrophil-to-lymphocyte ratio (NLR) in patients with pleural (MPM) and peritoneal mesothelioma (MPeM).
Methods:
A total of 414 patients including 241 MPM, 153 MPeM and 20 with mesothelioma at other body sites were enrolled in the Natural History Protocol (NCT 01950572) at the National Cancer Institute. Blood samples collected at enrollment were assessed for biomarker levels and based on their expression levels patients were stratified into quartiles. Kaplan-Meier survival curves were plotted, and median overall survival (mOS) was compared between groups.
Results:
For all the biomarkers evaluated, there was a significant decrease in mOS in the high expression cohorts. The mOS in years in low versus high expression cohorts being: SMRP (3 vs. 0.7), MPF (3.7 vs. 0.7), CA125 (1.6 vs. 0.8), CRP (4.1 vs. 0.4), fibrinogen (4.1 vs. 0.6), platelet count (1.4 vs. 0.8) and NLR (2.1 vs. 0.7). When analyzed separately, the pleural and peritoneal cohorts showed similar trends. Strong correlations existed between SMRP and MPF (r = 0.84), as well as CRP and fibrinogen (r = 0.86).
Conclusions:
Biomarkers such as SMRP, MPF, CA125, CRP, fibrinogen, platelet count and NLR can independently predict overall survival in mesothelioma. These biomarkers can therefore provide prognostic information for these patients and help guide treatment strategies.
Keywords: mesothelioma, biomarkers, mesothelin, megakaryocyte potentiating factor, CA125
Microabstrcat
Mesothelioma is an aggressive malignancy with limited treatment options. Identification of biomarkers can help risk stratify patients for treatment and provide prognostic information. In this study we have evaluated tumor specific, inflammatory and cellular biomarkers in patients with both pleural and peritoneal mesothelioma and their impact on overall survival. Patients with elevated levels of these biomarkers had significantly poor overall survival.
INTRODUCTION
Mesothelioma is an aggressive cancer arising from the mesothelial lining of body cavities including the pleura, peritoneum, pericardium, and tunica vaginalis.1 Malignant pleural mesothelioma (MPM) accounts for about 90% of the cases, while malignant peritoneal mesothelioma (MPeM) arising from the serosal membranes of the abdominal cavity accounts for the second most common site of disease.2 The majority of patients with MPM present with advanced disease and therefore are not candidates for surgical resection.2 In addition, recent randomized clinical trials of surgery in MPM have shown limited impact of surgery on overall survival (OS) and therefore is considered only for select patients with early-stage disease.3 In contrast to MPM, the median OS (mOS) of patients with MPeM is longer, and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve OS and is recommended for these patients if they meet criteria for surgical resection.4 For nearly 20 years, treatment with pemetrexed and cisplatin was the only FDA approved therapy for MPM, yielding a median overall survival (mOS) of 12.1 months.5 Recently, immunotherapy using combination of nivolumab and ipilimumab as first line therapy for MPM, has shown a significant improvement in mOS to 18.1 months.6 Despite this improvement in survival with immunotherapy, the majority of patients die within 2 years of diagnosis highlighting the need to develop more effective therapies as well as better prognostic tools to risk stratify patients.
Mesothelin a GPI linked cell surface glycoprotein that is normally expressed on the mesothelial cells lining the pleura and peritoneum is highly expressed in the majority of patients with mesothelioma and other cancers.7, 8 It is synthesized as a 71 kD precursor protein and is cleaved by the endo-protease furin to release the secreted N-terminal region, called megakaryocyte potentiating factor (MPF), while the 40-kD mature mesothelin remains attached to the cell membrane.9 This membrane bound mesothelin is also shed through the action of a variety of proteases and is designated either as soluble mesothelin or soluble mesothelin-related peptide (SMRP).10 Both serum MPF and SMRP have been used as a diagnostic and prognostic markers.11–13 Increase in serum MPF level has been associated with poor survival14 while reduction in MPF level is associated with improved clinical outcome.15 Studies on soluble mesothelin have shown potential value of SMRP as both a prognostic and predictive biomarker as well as for monitoring of treatment response in mesothelioma.16–18
Cancer antigen 125 (CA125), widely used as a predictive tumor marker in ovarian cancer,19 has been less extensively studied in mesothelioma. However, studies have shown that increase in baseline CA125 level was associated with poor prognosis20 and normalization was observed in patients that achieved remission.21
Neutrophil-to-lymphocyte ratio (NLR), an indicator of systemic inflammation and immune dysregulation, has also emerged as a prognostic marker in mesothelioma. Elevated NLR, typically defined as greater than 5, is associated with significantly shorter survival. Kao et al. reported a median overall survival of 5.4 months in mesothelioma patients with NLR ≥5, compared to 15.4 months in those with NLR <5.22 In a meta-analysis of 11 studies comprising 1533 mesothelioma patients, high NLR consistently correlated with poor outcomes, with a pooled hazard ratio for overall survival of 1.63 (P < 0.001).23 In addition to neutrophils, platelet count has also been demonstrated as a prognostic indicator in patients with mesothelioma. In a meta-analysis of 18 studies baseline thrombocytosis prior to treatment predicted poor overall survival (n=3,602 patients; HR 1.56, 95% CI: 1.36–1.77)24 and the CALGB index includes platelet count above 400,000/μL as an adverse factor.25
Other systemic inflammatory markers like CRP and fibrinogen have been linked to poor outcomes in mesothelioma. Elevated CRP (>1 mg/dL) was associated with worse mOS of 6 months compared to 15 months for patients with normal levels.26 More recently the use of CRP to albumin ratio (CAR) has gained traction as albumin adjusts for differences in liver synthetic function and nutritional status.27 Retrospective studies have shown that mesothelioma cohort with increase in CAR, had significantly worse survival outcomes.28, 29 Of 100 patients with MPM, 35 with increased CAR (>0.58) had poor OS and shorter DFS and PFS (p< 0.001).28 A retrospective study on patients with MPM who underwent EPP (n=61) had similar results, with subjects with >0.123 CAR, had poor outcomes.29 Circulating fibrinogen was identified as an independent prognostic marker in patients with MPM, with low levels associated with increased OS (19.1 month vs 8.5 month) in a study with 176 patients.30
Our study describes the prognostic significance of tumor-specific markers (SMRP, MPF, CA125), inflammatory markers (CRP, fibrinogen), and cellular markers (platelet count, NLR) in a large cohort of patients with MPM as well as MPeM and that will be valuable in management of these patients.
MATERIAL AND METHODS
The Natural History Protocol (NCT 01950572) at the National Cancer Institute (NCI), Bethesda, Maryland, enrolled 414 participants with mesothelioma September 2013 to August 2020. The study was conducted in accordance with the principles of the International Conference on Harmonization - Good Clinical Practice (ICH-GCP) guidelines. The Institutional Review Board of the NCI approved the study, and all patients provided written informed consent. Disease was assessed for site of origin per radiographic findings at the NCI or previous treatment institutions. Participants provided blood, urine, and tissue biopsy samples within seven days of enrollment. Biomarker analysis included SMRP (using MESOMARK®), megakaryocyte potentiating factor (MPF), cancer antigen 125 (CA125), CRP, fibrinogen, platelet count, and NLR (calculated from neutrophil and lymphocyte counts).
Serum mesothelin levels were evaluated using the MESOMARK (Fujirebio Diagnostics, Inc., Malvern, PA) enzyme-linked immunosorbent assay (ELISA) kit and following the manufacturer’s instructions.31 Serum MPF levels were evaluated using an ELISA-based assay as previously described.14 All other lab tests were performed by the Department of Laboratory Medicine at the NIH Clinical Center. Neutrophil-to-lymphocyte ratio and platelet count were obtained from complete blood counts.
Demographic data included gender, age at diagnosis, and date of death. The primary outcome was overall survival (OS), calculated from enrollment to death or censoring (March 1, 2021). Patients were stratified into low, medium and high expression cohorts to identify survival differences using Kaplan-Meier curves and log-rank tests assessing statistical significance. The initial groupings for each biomarker were formed by dividing the data into quartiles to arrive at approximately 4 equal sized groups (Table S1). After examining the data, either two, low and high (CA125, platelet count and N:L ratio) or three low, medium and high (SMRP, MPF, CRP, and fibrinogen) groups were formed, if appropriate, to combine groups with similar survival, resulting in clear differences among the remaining groups (Supplementary Table S2). The resulting p-values are presented without adjustment for multiple comparison since they typically demonstrated clear differences among the groups. The median OS of each categorization was reported with 95% confidence intervals. Spearman correlation analysis was performed to define correlation between expressions of the biomarkers.
RESULTS
Patient characteristics are summarized in Table 1. Among the 414 participants, 241 had MPM, 153 had MPeM, and 11 had bi-compartmental disease, 7 had mesothelioma involving the tunica vaginalis and 2 had pericardial mesothelioma. Only patients with MPM and MPeM were included in this analysis given low numbers of patients in other subgroups. Sixty two percent of patients were male (62%) and the median age at diagnosis was 63.5 years for MPM and 52.5 years for MPeM. Median age at the time of enrollment in the study was 65 and 56.7 years for MPM and MPeM, respectively. The majority of patients had epitheliod mesothelioma (87%). At enrollment, 67 participants were treatment-naïve, while others had received chemotherapy (n=347), immunotherapy (n=87), angiogenesis inhibitors (n=43), radiation (n=69), and/or cytoreductive surgery (n=267).
Table 1.
Baseline patient characteristics.
| Patient Characteristics | n (%) | Range |
|---|---|---|
| 414 (100) | ||
| Median Age at Diagnosis (years) | ||
| Pleural | 63.5 | (25 – 85) |
| Peritoneal | 52.5 | (12 – 80) |
| Median Age at Enrollment (years) | ||
| Pleural | 65 | (28.5 – 85.5) |
| Peritoneal | 56.7 | (15.1 – 81) |
| Gender | ||
| Male | 258 (62) | |
| Female | 156 (38) | |
| Disease site | ||
| Pleura | 241 (58) | |
| Peritoneum | 153 (37) | |
| Others* | 20 (5) | |
| Histology | ||
| Epitheliod | 360 (86.9) | |
| Sarcomatoid | 16 (3.9) | |
| Biphasic | 24 (5.8) | |
| Unknown | 14 (3.4) | |
| Prior Treatment | ||
| Naïve | 67 | |
| Chemotherapy | 347 | |
| Immunotherapy | 87 | |
| Other therapies | 92 | |
| Radiation | 69 | |
| Surgery | 267 |
Bi-compartmental 11, tunica vaginalis 7, pericardial 2
Kaplan-Meier survival analysis demonstrated significant survival differences based on biomarker levels. Low SMRP expression was associated with an mOS of 3.0 years (95% CI: 2.0–NE), compared to 0.7 years (95% CI: 0.5–0.9) for high expression (Figure 1A). MPF showed a similar trend, with low expression yielding an mOS of 3.7 years (95% CI: 1.3–NE), while high levels were linked to 0.7 years (95% CI: 0.4–0.9; Figure 1B). Spearman correlation analysis showed strong correlation between the expression of the SMRP and MPF (r=0.084; p <0.0001). For CA125, low expression correlated with an mOS of 1.6 years (95% CI: 1.2–2.0), while high levels were associated with 0.8 years (95% CI: 0.6–1.0; Figure 1C).
Figure 1: Kaplan-Meier curves for overall survival in patients with pleural and peritoneal mesothelioma with varying levels of tumor biomarkers.
(A) SMRP: mOS of patients with low, [3.0 years (95% CI: 2.0 years – not estimable)]; medium, [1.2 years (95% CI: 1.0–1.7 years)] and high levels [0.7 years (95% CI: 0.5–0.9 years)] of SMRP. p<0.0001. (B) MPF: mOS of patients with low, [3.7 years (95% CI: 1.3 years – not evaluable)]; medium, [1.1 years (95% CI: 0.9–2.3 years)] and high [0.7 years (95% CI: 0.4–0.9 years)] levels of MPF. p<0.0001. (C) CA125: mOS of patients with low, [1.6 years (95% CI: 1.2–2.0 years)]; and high [0.8 years (95% CI: 0.6–1.0 years)] levels of CA125. p<0.0001.
Kaplan-Meier curves were calculated from the date of enrolment until the date of death or last censored. The log-rank test was used to determine the statistical significance of the difference among the curves. Numbers of patients at risk of death at bi-annual intervals is charted at the base of each figure. mOS, median overall survival; CI, confidence interval; SMRP, soluble mesothelin related protein; MPF, megakaryocyte potentiating factor; CA 125, cancer antigen 125.
Inflammatory markers also displayed significant survival differences. Patients with low CRP levels (<3.65 mg/L) had an mOS of 4.1 years (95% CI: 2.7–NE), compared to 0.4 years (95% CI: 0.4–0.6) in those with high levels (>68.1 mg/L) (Figure 2A). Similarly, low fibrinogen levels were associated with an mOS of 4.1 years (95% CI: 2.6–6.0), compared to 0.6 years (95% CI: 0.4–0.7) for high levels (Figure 2B). CRP and fibrinogen also showed a strong correlation (r = 0.86; p <0.0001), reflecting their shared role in systemic inflammation. Platelet count also affected survival, with low levels (Supplementary Table S1) correlating to an mOS of 1.4 years (95% CI: 1.1–1.8) compared to 0.8 years (95% CI: 0.5–1.1) for high levels (Figure 2C). The neutrophil-to-lymphocyte ratio (NLR) demonstrated a strong prognostic value, with low NLR associated with a significantly longer mOS of 2.1 years (95% CI: 1.6–2.7), compared to 0.7 years (95% CI: 0.6–0.9) in patients with high NLR (Figure 2D).
Figure 2: Kaplan-Meier curves for overall survival (mOS) in patients with pleural and peritoneal mesothelioma with varying levels of inflammatory and cellular biomarkers.
(A) CRP: mOS of patients with low, [4.1 years (95% CI: 2.7 years – not estimable)]; medium, [1.2 years (95% CI: 1.0–1.6 years)] and high, [0.4 years (95% CI: 0.4–0.6 years)] levels of CRP. p<0.0001. (B) Fibrinogen: mOS of patients with low, [4.1 years (95% CI: 2.6–6.0 years)]; medium, 1.3 years (95% CI: 1.1–1.7 years); and high, [0.6 years (95% CI: 0.4–0.7 years)] levels of Fibrinogen. p<0.0001. (C) Platelet count: mOS of patients with low, [1.4 years (95% CI: 1.1–1.8 years)] and high [0.8 years (95% CI: 0.5–1.1 years)] platelet count. p=0.0004. (D) Neutrophile-to-Lymphocyte ratio mOS with low [2.1 years (95% CI: 1.6–2.7 years)] and high [0.7 years (95% CI: 0.6–0.9 years)] N:L ratio. p<0.0001.
mOS, median overall survival; CI, confidence interval, CRP, C-Reactive Protein, N:L ratio, neutrophil to Lymphocyte ratio.
When analyzed separately for pleural and peritoneal mesothelioma, similar survival trends were observed. Low levels of the biomarkers had longer survivals in patients with MPeM (Figures 3 and 4) and MPM (Figures 5 and 6). Taken together, these findings emphasize that lower levels of tumor-specific, inflammatory and cellular biomarkers are consistently associated with improved survival outcomes.
Figure 3: Kaplan-Meier curves for overall survival in patients with peritoneal mesothelioma with varying levels of tumor biomarkers.
(A) SMRP: mOS of patients with low, [not reached]; medium, [2.3 years (95% CI: 1.7–3.7 years)]; high, [0.7 years (95% CI: 0.4–1.1 years)] levels of SMRP. p<0.0001. (B) MPF: mOS of patients with low, [not reached]; medium [2.1 years (95% CI: 1.5–3.2 years)]; and high, [0.7 years (95% CI: 0.4–0.9 years)] levels of MPF. p<0.0001 (C) CA125: mOS of patients with low [2.6 years (95% CI: 2.0–4.2 years)] and high, [1.1 years (95% CI: 0.4–1.8 years)] CA125 levels. p=0.0063. mOS, median overall survival; CI, confidence interval; SMRP, soluble mesothelin related protein; MPF, megakaryocyte potentiating factor; CA 125, cancer antigen 125.
Figure 4: Kaplan-Meier curves for overall survival in patients with peritoneal mesothelioma with varying levels of inflammatory and cellular biomarkers.
(A) CRP: mOS of patients with low, [not reached]; medium, [2.1 years (95% CI: 1.1 – 3.2 years)]; high, [0.6 years (95% CI: 0.3–1.0 years)] levels of CRP. p<0.0001 (B) Fibrinogen: mOS of patients with low, [not reached]; medium, [2.3 years (95% CI: 1.6–3.7 years)]; high, [0.7 years (95% CI: 0.4–0.9 years)] fibrinogen levels. p<0.0001 (C) Platelet counts: mOS of patients with low [2.6 years (95% CI: 2.0–4.8 years)] and high [1.3 years (95% CI: 0.8–1.9 years)] platelet counts. p=0.01 (D) Neutrophile-to-Lymphocyte ratio: mOS of patients with low, [3.0 years (95% CI: 2.0–5.0 years)] and high, 0.9 years (95% CI: 0.7–1.3 years) N:L ratio. p<0.0001. CRP, C-reactive protein.
Figure 5: Kaplan-Meier curves for overall survival in patients with pleural mesothelioma with varying levels of tumor biomarker.
(A) SMRP: mOS of patients with low, [2.2 years (95% CI: 1.0–4.0 years)]; medium, [0.9 years (95% CI: 0.8–1.1 years)]; high [0.7 years (95% CI: 0.4–1.0 years)] levels of SMRP. p<0.0001. p<0.0001 (B) MPF: mOS of low, [1.8 years (95% CI: 1.0–5.2 years)]; medium, [0.9 years (95% CI: 0.7–1.1 years)] and high, [0.6 years (95% CI: 0.4–1.0 years)] levels of MPF. p<0.0001. p<0.0001 (C) CA125: Patients with low, [1.1 years (95% CI: 0.9–1.6 years)] and high, [0.7 years (95% CI: 0.6–0.9 years)] CA125. p= 0.0013. mOS, median overall survival; CI, confidence interval; SMRP, soluble mesothelin related protein; MPF, megakaryocyte potentiating factor; CA 125, cancer antigen 125.
Figure 6: Kaplan-Meier curves for overall survival in patients with pleural mesothelioma with varying levels of inflammatory and cellular biomarkers.
(A) CRP: mOS of patients with low, [2.7 years (95% CI: 1.3–5.8 years)]; medium, [1.1 years (95% CI: 0.9–1.3 years)]; and high, [0.4 years (95% CI: 0.3–0.6 years)] CRP levels. p<0.0001. (B) Fibrinogen: mOS of patients with low, 2.3 years (95% CI: 1.1–5.2 years); medium, 1.1 years (95% CI: 0.9–1.3 years) and high 0.5 years (95% CI: 0.4–0.7 years) fibrinogen levels. p<0.0001 (C) Platelet count: mOS of patients with low, [1.1 years (95% CI: 0.9–1.3 years)] and high, [0.5 years (95% CI: 0.3–0.8 years)] platelet count. p<0.0001 (D) Neutrophile-to-Lymphocyte ratio: patients with low, [1.5 years (95% CI: 1.1 – 2.1 years)] and high [0.7 years (95% CI: 0.5–0.8 years)] N:L ratio. p<0.0001. CRP, C-reactive protein.
DISCUSSION
This study provides a comprehensive analysis of tumor-specific, inflammatory and cellular biomarkers in mesothelioma, highlighting their individual prognostic significance. This includes mesothelin, a cell surface glycoprotein highly expressed in mesothelioma which is an attractive target for cancer therapy. Different approaches to target mesothelin including immunotoxins (SS1P, LMB-100), antibody drug conjugate (anetumab ravtansine) and mesothelin vaccine (CRS-207) have been tested in clinical trials.32, 33 More recently, mesothelin targeted adoptive cellular therapies are being evaluated in clinical trials, either alone or in combination with checkpoint inhibitors.34–36 Hence, the study of SMRP and MPF as prognostic marker is of interest. In our study both SMRP and MPF were strongly associated with survival outcomes. Patients with low SMRP and MPF levels had significantly longer survival compared to those with elevated levels. Our results are in agreement with multiple studies that demonstrate that elevated SMRP levels are associated with shorter median overall survival. A previous study reported that in patients with mesothelioma with increased SMRP levels (> 3.5 nM), the median OS was 8.4 months with 1 year survival of 32% compared to 17.1 months in patients with SMRP levels less than or equal to 3.5 nM with 1 year survival of 63.1%.16 Similarly, another study demonstrated an 11.7-month difference in mOS (21.5 months vs 9.8 months, p<0.001) based on SMRP below a cutoff of 1.0 nmol/L versus elevated SMRP.17 In a prospective study of 97 patients with MPM treated with chemotherapy, mOS was significantly longer (19 months) for patients with reduction in SMRP levels post treatment compared to those with higher levels (5 months; P<0.001).18 A meta-analysis of eight studies (n=579 patients with MPM, different cutoff values ranging from 1.0 to 15.0 nmol/L in serum and pleural fluid) demonstrated high SMRP was associated with worse survival (HR = 1.96).37 Our study also demonstrates the elevated levels of serum MPF are associated with worse overall survival in patients with both pleural and peritoneal mesothelioma.
Likewise, CA125 showed a significant prognostic association in our study which aligns with the results of multiple studies. A small retrospective study of 41 patients with diffuse malignant mesothelioma (MPM n=23, MPeM n=18) reported worse survival (HR 2.214, 95% CI 1.08–5.09, P=0.045) in patients with elevated baseline levels of CA125 (≥280U/mL).20 In the same study, patients who achieved objective responses and increase in mOS after systemic chemotherapy, also had a decline in their serum CA125 levels. In MPeM, elevated CA125 levels (> 35 U/mL) are often observed and correlate with disease burden. Baratti et al. reported that preoperative CA125 levels were elevated in 73.9% of patients with MPeM, with normalization observed in 95.4% of those who achieved remission after cytoreductive surgery.21 CA125 has been studied along with soluble mesothelin in a larger cohort of patients with MPM who underwent pleurectomy/decortication. The biomarkers were assayed before and after surgery and at time of disease recurrence. While pre-operative CA-125 level was not significantly associated with overall or disease-free survival, it was significantly higher in patients with abdominal (P<0.001) and nodal (P<0.004) recurrences.38
Systemic inflammation plays a critical role in mesothelioma progression.39–42 A recent study by Mosleh and colleagues evaluated the prognostic significance of an inflammation based score, consisting of pretreatment neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP), and fibrinogen in a large cohort of patients with MPM. The study found that higher levels of inflammatory markers were corelated with decreased OS and patients with low levels of inflammatory markers had better outcomes with multimodality treatment including surgery.41 This is reflected in our study as well with patients that had increased levels of the inflammatory biomarkers – NLR, CRP and fibrinogen having worse clinical outcomes. NLR, a cost-effective and easily measurable marker from routine lab work, showed a significant inverse relationship with survival. Elevated NLR has been associated with a pro-inflammatory tumor micro-environment that suppresses immune responses, contributing to disease progression.22, 43 CRP and fibrinogen, both markers of systemic inflammation, further underscored the impact of inflammation on survival. High levels of these markers were consistently linked to poor outcomes, highlighting their value in identifying high-risk patients. Similarly, baseline platelet counts, which are readily available, along with NLR, via complete blood count testing, have demonstrated an inverse relationship with survival,24, 43 which our study results have confirmed.
This study’s retrospective design and single-center cohort leads to several limitations. The results do not include adjustments for prior therapies which may influence biomarker levels. Additionally, TNM staging of patients with pleural mesothelioma, another important prognostic indicator was not available for comparison with the biomarkers we studied. However, since there is no official TNM staging for peritoneal mesothelioma, these biomarkers can provide important prognostic information for these patients. The single study site may not reflect outcomes in broader populations due to selection bias. However, our results are in agreement with results from multiple studies evaluating these biomarkers separately rather than in a comprehensive manner as reported in our study. Although the timing of biomarker collection was standardized to within 7 days of enrollment in our natural history protocol, patients presented with highly variable disease stages and treatments received at the time of enrollment. In addition, inflammatory markers like CRP and fibrinogen can be influenced by non-cancer conditions (e.g., infections) which may reduce their specificity as prognostic tools.44
In summary our study demonstrates the prognostic value of tumor specific, inflammatory, and cellular biomarkers in malignant mesothelioma with elevated levels of the biomarkers associated with decreased overall survival. While prior studies have examined single markers or a narrow set within one class, our study assessed multiple biomarkers drawn at the same time point in a well characterized cohort of patients with mesothelioma. Using a large peritoneal subset and analyzing it identically to the pleural subset, we show that prognostic associations previously reported for pleural mesothelioma can be generalized to peritoneal mesothelioma as well. This enables a single risk-stratification framework to guide personalized treatment strategies and improve outcomes for patients with pleural and peritoneal mesothelioma.
Supplementary Material
CLINICAL PRACTICE POINTS:
Mesothelioma is an aggressive malignancy with limited treatment options.
In this study we evaluated tumor specific, cellular and inflammatory biomarkers in patients with pleural and peritoneal mesothelioma and their impact on patient survival.
Patients with elevated levels of mesothelin-related peptide (SMRP), megakaryocyte potentiating factor (MPF), CA125, neutrophil-to-lymphocyte ratio, C-reactive protein (CRP), fibrinogen, and platelet counts had decreased overall survival.
These biomarker can enable risk stratification in patients with pleural and peritoneal mesothelioma and guide treatment decisions.
Acknowledgements:
This research was supported by the Intramural Research Program of the National Institutes of Health (NIH). The contributions of the NIH author(s) were made as part of their official duties as NIH federal employees, are in compliance with agency policy requirements, and are considered Works of the United States Government. However, the findings and conclusions presented in this paper are those of the author(s) and do not necessarily reflect the views of the NIH or the U.S. Department of Health and Human Services.
This research was also made possible by the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and contributions to the Foundation for the NIH from the Doris Duke Charitable Foundation, Genentech, the American Association for Dental Research, and the Colgate-Palmolive Company. We thank Betsy Morrow and Dr. Liang Cao for sample collection and analysis and Dr. Seth M. Steinberg for statistical analysis of the data.
Funding:
This research was supported by the Intramural Research Program of the NIH, National Cancer Institute, Center for Cancer Research (Z0A-BC-010816) given to R.H.
Disclosures and conflicts of interests:
R.H. has received funding for the conduct of clinical trials via a cooperative research and development agreement between NCI and TCR2 Therapeutics. Other authors have no competing interests to disclose.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
CRediT authorship contribution statement:
Keval Yerigeri: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft.
Manjistha Sengupta: Data curation, Methodology, Writing – review and editing.
Jingli Zhang: Data curation, Methodology, Writing – review and editing
Jeevan Puthiamadathil: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – review and editing
Raffit Hassan: Conceptualization, Funding acquisition, Investigation, Resources, Supervision, Validation, Visualization, Writing – review and editing
REFERENCES
- 1.Robinson BW, Lake RA. Advances in malignant mesothelioma. N Engl J Med. 2005;353:1591–1603. [DOI] [PubMed] [Google Scholar]
- 2.Janes SM, Alrifai D, Fennell DA. Perspectives on the Treatment of Malignant Pleural Mesothelioma. N Engl J Med. 2021;385:1207–1218. [DOI] [PubMed] [Google Scholar]
- 3.Lim E, Waller D, Lau K, et al. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respir Med. 2024;12:457–466. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Kusamura S, Cinquini M, Morris D, et al. Multisocietal Consensus on the Use of Cytoreductive Surgery and HIPEC for the Treatment of Diffuse Malignant Peritoneal Mesothelioma: A GRADE Approach for Evidence Evaluation and Recommendation. J Surg Oncol. 2025;131:810–815. [DOI] [PubMed] [Google Scholar]
- 5.Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21:2636–2644. [DOI] [PubMed] [Google Scholar]
- 6.Baas P, Scherpereel A, Nowak AK, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial. Lancet. 2021;397:375–386. [DOI] [PubMed] [Google Scholar]
- 7.Chang K, Pastan I. Molecular cloning of mesothelin, a differentiation antigen present on mesothelium, mesotheliomas, and ovarian cancers. Proc Natl Acad Sci U S A. 1996;93:136–140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Chang K, Pastan I, Willingham MC. Isolation and characterization of a monoclonal antibody, K1, reactive with ovarian cancers and normal mesothelium. Int J Cancer. 1992;50:373–381. [DOI] [PubMed] [Google Scholar]
- 9.Yamaguchi N, Hattori K, Oh-eda M, Kojima T, Imai N, Ochi N. A novel cytokine exhibiting megakaryocyte potentiating activity from a human pancreatic tumor cell line HPC-Y5. J Biol Chem. 1994;269:805–808. [PubMed] [Google Scholar]
- 10.Hassan R, Bera T, Pastan I. Mesothelin: a new target for immunotherapy. Clin Cancer Res. 2004;10:3937–3942. [DOI] [PubMed] [Google Scholar]
- 11.Onda M, Nagata S, Ho M, et al. Megakaryocyte potentiation factor cleaved from mesothelin precursor is a useful tumor marker in the serum of patients with mesothelioma. Clin Cancer Res. 2006;12:4225–4231. [DOI] [PubMed] [Google Scholar]
- 12.Hassan R, Remaley AT, Sampson ML, et al. Detection and quantitation of serum mesothelin, a tumor marker for patients with mesothelioma and ovarian cancer. Clin Cancer Res. 2006;12:447–453. [DOI] [PubMed] [Google Scholar]
- 13.Robinson BW, Creaney J, Lake R, et al. Mesothelin-family proteins and diagnosis of mesothelioma. Lancet. 2003;362:1612–1616. [DOI] [PubMed] [Google Scholar]
- 14.Yu Y, Ryan BM, Thomas A, et al. Elevated Serum Megakaryocyte Potentiating Factor as a Predictor of Poor Survival in Patients with Mesothelioma and Primary Lung Cancer. J Appl Lab Med. 2018;3:166–177. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Cao L, Yu Y, Thomas A, et al. Megakaryocyte Potentiating Factor as a Predictive Biomarker for Therapies Against Malignant Mesothelioma. JCO Precis Oncol. 2018;2018:1–16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Schneider J, Hoffmann H, Dienemann H, Herth FJ, Meister M, Muley T. Diagnostic and prognostic value of soluble mesothelin-related proteins in patients with malignant pleural mesothelioma in comparison with benign asbestosis and lung cancer. J Thorac Oncol. 2008;3:1317–1324. [DOI] [PubMed] [Google Scholar]
- 17.Cristaudo A, Foddis R, Vivaldi A, et al. Clinical significance of serum mesothelin in patients with mesothelioma and lung cancer. Clin Cancer Res. 2007;13:5076–5081. [DOI] [PubMed] [Google Scholar]
- 18.Creaney J, Francis RJ, Dick IM, et al. Serum soluble mesothelin concentrations in malignant pleural mesothelioma: relationship to tumor volume, clinical stage and changes in tumor burden. Clin Cancer Res. 2011;17:1181–1189. [DOI] [PubMed] [Google Scholar]
- 19.Charkhchi P, Cybulski C, Gronwald J, Wong FO, Narod SA, Akbari MR. CA125 and Ovarian Cancer: A Comprehensive Review. Cancers (Basel). 2020;12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Cheng X, Gou HF, Liu JY, Luo DY, Qiu M. Clinical significance of serum CA125 in diffuse malignant mesothelioma. Springerplus. 2016;5:368. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Baratti D, Kusamura S, Martinetti A, et al. Circulating CA125 in patients with peritoneal mesothelioma treated with cytoreductive surgery and intraperitoneal hyperthermic perfusion. Ann Surg Oncol. 2007;14:500–508. [DOI] [PubMed] [Google Scholar]
- 22.Kao SC, Pavlakis N, Harvie R, et al. High blood neutrophil-to-lymphocyte ratio is an indicator of poor prognosis in malignant mesothelioma patients undergoing systemic therapy. Clin Cancer Res. 2010;16:5805–5813. [DOI] [PubMed] [Google Scholar]
- 23.Chen N, Liu S, Huang L, et al. Prognostic significance of neutrophil-to-lymphocyte ratio in patients with malignant pleural mesothelioma: a meta-analysis. Oncotarget. 2017;8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Zhuo Y, Lin L, Zhang M. Pretreatment thrombocytosis as a significant prognostic factor in malignant mesothelioma: a meta-analysis. Platelets. 2017;28:560–566. [DOI] [PubMed] [Google Scholar]
- 25.Edwards JG, Abrams KR, Leverment JN, Spyt TJ, Waller DA, O’Byrne KJ. Prognostic factors for malignant mesothelioma in 142 patients: validation of CALGB and EORTC prognostic scoring systems. Thorax. 2000;55:731–735. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Ghanim B, Hoda MA, Winter MP, et al. Pretreatment serum C-reactive protein levels predict benefit from multimodality treatment including radical surgery in malignant pleural mesothelioma: a retrospective multicenter analysis. Ann Surg. 2012;256:357–362. [DOI] [PubMed] [Google Scholar]
- 27.Kinoshita A, Onoda H, Imai N, et al. The C-reactive protein/albumin ratio, a novel inflammation-based prognostic score, predicts outcomes in patients with hepatocellular carcinoma. Ann Surg Oncol. 2015;22:803–810. [DOI] [PubMed] [Google Scholar]
- 28.Takamori S, Toyokawa G, Shimokawa M, et al. The C-Reactive Protein/Albumin Ratio is a Novel Significant Prognostic Factor in Patients with Malignant Pleural Mesothelioma: A Retrospective Multi-institutional Study. Ann Surg Oncol. 2018;25:1555–1563. [DOI] [PubMed] [Google Scholar]
- 29.Okita R, Okada M, Inokawa H, Murakami T, Ikeda E. Prognostic values of preoperative C-reactive protein, albumin, and neutrophil ratios in patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy. Surgical Oncology. 2022;43:101813. [DOI] [PubMed] [Google Scholar]
- 30.Ghanim B, Hoda MA, Klikovits T, et al. Circulating fibrinogen is a prognostic and predictive biomarker in malignant pleural mesothelioma. Br J Cancer. 2014;110:984–990. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Hassan R, Sharon E, Thomas A, et al. Phase 1 study of the antimesothelin immunotoxin SS1P in combination with pemetrexed and cisplatin for front-line therapy of pleural mesothelioma and correlation of tumor response with serum mesothelin, megakaryocyte potentiating factor, and cancer antigen 125. Cancer. 2014;120:3311–3319. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Hassan R, Thomas A, Alewine C, Le DT, Jaffee EM, Pastan I. Mesothelin Immunotherapy for Cancer: Ready for Prime Time? J Clin Oncol. 2016;34:4171–4179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Boisgard R, Chames P, Kerfelec B. Mesothelin biology and the evolving landscape of targeted immunotherapy. Molecular Therapy Oncology. 2026;34:201148. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Adusumilli PS, Zauderer MG, Rivière I, et al. A Phase I Trial of Regional Mesothelin-Targeted CAR T-cell Therapy in Patients with Malignant Pleural Disease, in Combination with the Anti-PD-1 Agent Pembrolizumab. Cancer Discov. 2021;11:2748–2763. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Haas AR, Tanyi JL, O’Hara MH, et al. Phase I Study of Lentiviral-Transduced Chimeric Antigen Receptor-Modified T Cells Recognizing Mesothelin in Advanced Solid Cancers. Molecular Therapy. 2019;27:1919–1929. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Hassan R, Butler M, O’Cearbhaill RE, et al. Mesothelin-targeting T cell receptor fusion construct cell therapy in refractory solid tumors: phase 1/2 trial interim results. Nat Med. 2023;29:2099–2109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Tian L, Zeng R, Wang X, et al. Prognostic significance of soluble mesothelin in malignant pleural mesothelioma: a meta-analysis. Oncotarget. 2017;8:46425–46435. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Paajanen J, Sadek A, Richards WG, et al. Circulating SMRP and CA-125 before and after pleurectomy decortication for pleural mesothelioma. Thoracic Cancer. 2024;15:1237–1245. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Fiorilla I, Martinotti S, Todesco AM, et al. Chronic Inflammation, Oxidative Stress and Metabolic Plasticity: Three Players Driving the Pro-Tumorigenic Microenvironment in Malignant Mesothelioma. Cells. 2023;12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Linton A, van Zandwijk N, Reid G, Clarke S, Cao C, Kao S. Inflammation in malignant mesothelioma - friend or foe? Ann Cardiothorac Surg. 2012;1:516–522. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Mosleh B, Sinn K, Cho A, et al. The Mesothelioma Systemic Inflammation Score Is Independently Associated with Overall Survival and Predicts Benefit of Multimodality Treatment in Pleural Mesothelioma. Cancers (Basel). 2025;17:1371. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Yang H, Rivera Z, Jube S, et al. Programmed necrosis induced by asbestos in human mesothelial cells causes high-mobility group box 1 protein release and resultant inflammation. Proc Natl Acad Sci U S A. 2010;107:12611–12616. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Linton A, Pavlakis N, O’Connell R, et al. Factors associated with survival in a large series of patients with malignant pleural mesothelioma in New South Wales. Br J Cancer. 2014;111:1860–1869. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Gulhar R, Ashraf MA, Jialal I. Physiology, Acute Phase Reactants (Updated 2023 April 24). In: StatPearls (Internet). Treasure Island (FL) StatPearls Publishing LLC; 2025. Jan; 2025. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.