Thymidylate Synthase and Folyl-polyglutamate synthase (FPGS) Are Not Clinically Useful Markers of Response to Pemetrexed [Pem] in Patients with Malignant Pleural Mesothelioma [MPM]

Abstract

Purpose

Thymidylate synthase (TS) is a potential predictor of outcome after pemetrexed (Pem) in patients with malignant pleural mesothelioma (MPM), and assays measuring TS levels are commercially marketed. The goal of this study was to further evaluate the value of TS and to study another potential biomarker of response, the enzyme, folyl-polyglutamate synthase (FPGS), which activates Pem intracellularly.

Patients and Methods

Levels of TS and FPGS were semi-quantitatively determined immunohistochemically using H-scores on tissue samples from 85 MPM patients receiving Pem as primary therapy. H-score was correlated with radiographic disease control rate (DCR), time to progression (TTP) and overall survival (OS). In addition, expression levels of TS and FPGS in MPM cell lines were determined using immunoblotting and correlated with their sensitivity to Pem-induced cell death.

Results

H-scores from patients with disease control versus progressive disease showed extensive overlap. There were no significant correlations of DCR, TTP, or OS to either TS levels (p = 0.73, 0.93, and 0.59, respectively), FPGS levels (p = 0.95, 0.77 and 0.43 respectively) or the ratio of FPGS/TS using the median scores of each test as cutoffs. There was no correlation between TS or FPGS expression and chemosensitivity of mesothelioma cells to Pem in vitro.

Conclusions

Although previous retrospective data suggest that TS and FPGS expression might be potential markers of Pem efficacy in MPM, our data indicate these markers lack sufficient predictive value in individual patients and should not be used to guide therapeutic decisions in the absence of prospective studies.

Introduction

Malignant pleural mesothelioma (MPM) is a rare, deadly cancer associated with exposure to asbestos. Without treatment, patients with MPM have a median survival of approximately 9 months. In a landmark Phase III trial by Vogelzang et al [1], pemetrexed (Pem) and cisplatin improved outcomes compared to cisplatin alone, with commensurate improvement in progression free survival. Overall survival (OS) improved by 11 weeks when compared to cisplatin alone. This doublet has become the standard of care when systemic therapy is employed.

Pem is an antifolate agent that inhibits multiple folate-dependent enzymes. The main target of Pem is thought to be thymidylate synthase (TS); to a lesser extent, glycinamide ribonucleotide formyltransferase (GARFT), dihydrofolate reductase (DHFR) and 5-aminoimidazole-4-carboxamide ribonucleotide formyltransferase (AICARFT) are also considered targets [2]. As a folic acid analog, Pem enters the cell via the reduced folate carrier and the folate receptor-alpha. Once inside the cell, its activity is dependent on glutamation. Pem is poly-glutamated by the key enzyme folyl-polyglutamate synthase (FPGS). This step increases the intracellular retention of Pem and the affinity for its intracellular targets by 50–100 fold [2].

Although the use of Pem in combination with platinum has fostered a major advance in the treatment of MPM, the objective radiological response rate is only about 40% [1]. Hence, the majority of patients who receive the drug are exposed to its toxic side effects (and considerable costs) without radiographic or clear clinical benefit. Therefore, finding biomarkers that will identify the population of patients most likely to benefit from Pem is an important goal as we enter the era of personalized therapeutic oncology.

In vitro data support a connection between TS expression and Pem response. In colon, breast and lung cancer cell lines, higher gene and protein expression of TS has been associated with resistance to Pem [3, 4]. Induction of resistance to Pem in a colon cancer cell line was associated with TS overexpression [5]. Three Phase III clinical trials have shown Pem to be more efficacious in patients with adenocarcinoma of the lung as opposed to those with squamous cell histology[6–8]. TS expression has been found to be lower in adenocarcinoma than squamous cells [9]. Additionally, low TS levels have been shown to predict better outcomes in patients with non-squamous non-small cell lung cancer treated with Pem [10].

Three recent retrospective studies showed a statistical association between TS expression measured by immunohistochemistry and response to Pem in patients with MPM [11–13]. The later study also showed that patients with high FPGS had better tumor responses and improved disease control rate. However, the clinical utility of measuring TS expression or FPGS to select patients for treatment with Pem has yet to be verified in prospective clinical trials.

The goal of our retrospective study was to validate these findings in a well-characterized set of MPM patients treated with Pem. Since it is postulated that TS and FPGS have an inverse relationship with regard to Pem sensitivity (decreased TS levels have been proposed to predict response to Pem therapy [14], while increased FPGS levels have been proposed to predict sensitivity to Pem therapy [15, 16]), we also tested whether the ratio of FPGS/TS expression could predict clinical responses to Pem in patients with MPM.

METHODS

Study Population

Patient samples were obtained from three sites: the Fondazione IRCCS Policlinico San Matteo in Pavia, Italy (69 cases); the Sir Charles Gairdner Hospital in Perth, Australia (12 cases); and the Hospital of the University of Pennsylvania in Philadelphia (4 cases). Patients were included if they had a diagnosis of MPM, received at least one cycle of a frontline Pem-containing chemotherapy regimen, and had tissue available for immunohistochemical analysis. Patients receiving adjuvant or neoadjuvant Pem in the setting of surgical resection were excluded. All patients were followed with a CT of the chest every 3 months during treatment and up to 2 years after chemotherapy was completed. Patients who survived greater than 2 years had imaging every 6 months.

The primary endpoint was the association between TS, FPGS and FPGS/TS expression measured by immunohistochemistry and: 1) time to progression (TTP), 2) OS and 3) best-achieved radiographic response. Radiographic response was measured according to the modified response evaluation criteria in solid tumors (RECIST) for MPM [17]. Patients were classified as having “disease control” if the best response was complete response (CR), partial response (PR) or stable disease (SD). Otherwise, they were classified as having progressive disease (PD).

Immunohistochemistry (IHC)

IHC was performed on formalin-fixed, paraffin embedded tissue. Samples were first deparaffinized with xylene and rehydrated in serial dilutions of ethanol. Antigen unmasking was performed by heat-induced epitope retrieval method with a 10mM sodium citrate solution buffered at pH 6.0. The samples were then incubated with the primary antibody [anti-thymidylate synthase Ab clone TS106 (Invitrogen) at a dilution of 1:100 for 30 min at room temperature, and an anti-FPGS monoclonal Ab [18] provided by Eli-Lilly and Company at a dilution of 1:1500 at 4°C overnight. Appropriate treatment with 3% hydrogen peroxide and DAKO serum-free protein block were performed prior to incubation with the primary antibody. DAKO anti-mouse HRP polymer solution was used for the detection of the primary antibody and DAB was used as substrate. The germinal centers of normal human tonsils were used as a 3+ positive control for TS (Fig. 1A) and normal human kidney (Fig. 1C) was used as a 3+ positive control for FPGS. To assess non-specific staining, negative controls were stained with isotype control monoclonal antibodies for the anti-TS (Fig. 1B) and anti-FPGS antibodies (Fig. 1D) then processed as above. Both antibodies showed high specificity on immunoblotting (i.e. see Figure 4, FPGS data not shown). Since they were monoclonal antibodies, blocking peptides were not available.

Figure 1.

Examples of Immunohistochemical Staining on Tissues. A) Human tonsil stained with anti-thymidylate synthase Ab clone TS106 (Invitrogen) shows strongly (3+) positive lymphocyte staining. B) Human tonsil stained with a control antibody shows no staining (negative control). C) Human Kidney stained with the anti-FPGS antibody shows strong (3+ staining of the tubules. D) Human Kidney stained with control antibody shows no staining. E) MPM tissue sample stained with anti-TS antibody showing an H score of 20. F) MPM tissue sample stained with anti-TS antibody showing an H score of 90. G) MPM tissue sample stained with anti-TS antibody showing an H score of 130. H. MPM tissue sample stained with anti-TS antibody showing an H score of 190.

Figure 4. Immunoblot of Mesothelioma Cell Lines Correlated with Sensitivity to Pemetrexed.

Equal amounts of protein lysates from nine human mesothelioma cell lines were loaded onto an SDS gel, immunoblotted, and reacted with the anti-TS antibody (top panel) or with an anti-actin antibody (bottom panel) to assure equal loading. Clear variations in TS content were noted. The same nine cell lines were treated with varying concentrations of Pem, ranging from 0.001 to 100 micromolar, and cell viability was assessed 72 hours after treatment. The 50% inhibitory concentrations (IC₅₀) values were then determined in each cell line. There was no clear correlation with sensitivity to Pem and the TS expression level as observed in the immunoblot.

H Score

To determine the H score, the intensity of the cytoplasmic and nuclear staining was compared to a strong positive control and given an intensity score: 0- no staining, 1 - mild intensity, 2 - moderate intensity, 3 - intensity equal to or greater than the positive control. The percentage of cells with each intensity score was estimated. The H score was obtained by adding the product of the intensity score multiplied by the percentage of cells staining at that intensity, thus the H score ranged from 0–300 [19]. All samples were scored by a single lung pathologist (CD) blinded to the patient’s clinical outcome. The H-score was verified by a second pathologist (LL) in the first 40 cases and showed high intra-observer concordance.

In vitro experiments with cell lines

Nine human mesothelioma cell lines were examined for sensitivity to Pem using a colorimetric MTT assay. To perform MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assays to estimate cell numbers, cells were plated in triplicate on 96-well plates (5000 cells/well in their respective culture medium) and were treated with various concentrations (ranging from 0.001 – 100 micromolar) of Pemetrexed. Cell viability was assessed 72 hours post-treatment by developing the reaction assay per manufacturer’s instruction (Promega, Madison, WI). The IC₅₀ values of Pem (the concentration of Pem inhibiting tumor cell growth by 50% in comparison with the untreated control) in our human mesothelioma cell lines were determined from these MTT results.

The expression level of TS and FPGS was determined by immunoblotting. Human mesothelioma cell lines were grown in T75 tissue culture flask until they reached 90–100% confluence. The cells were then harvested and lysed in ice-cold lysis buffer (50mM Tris HCL, pH 7.4, 150mM NaCL, 5mM EDTA, 1% Nonidet P-40, and protease inhibitor cocktail tablets (Roche Diagnostics, Indianapolis, IN) with 1mM PMSF. Equal amounts of protein from whole cell lysate from each sample were electrophoresed on 4–12% NuPAGE Novex Tris Acetate Mini Gels (Invitrogen) and transferred onto nitrocellulose membranes. Monoclonal anti-β-actin antibody (purchased from Sigma). The Anti-TS antibody (clone TS106) was used at a concentration of 2ug/ml (1:100 dilution). The FPGS antibody (see above) was used at a concentration of 0.25 ug/ml (1:5000 dilution).

The human OK4, OK5, OK6 and OK7 MPM cell lines were provided by Dr. Claire Verschaegen (Univ. of Vermont). The I-45 and MSTO-211H MPM lines were purchased from the American Tissue Type Collection (Manassas, VA). The human Pt108, REN, LRK and M30 MPM lines were derived from patient samples at the University of Pennsylvania.

Statistical analysis

OS was calculated from the time the first cycle with a Pem-containing regimen was initiated to the time of death. TTP was calculated from the time the first cycle was initiated to the time disease progression, was documented according to modified RECIST criteria. OS and TTP were evaluated using standard Kaplan-Meier curves, and a log-rank test was used to compare survival between groups. Hazard ratios were obtained using a Cox proportional hazards regression model. A Chi2 test was used to analyze the association between categorical variables. STATA version 11 was used for all analysis, and statistical significance was set at p ≤ 0.05 for all tests.

Results

Clinical Characteristics

Eighty five patients with MPM who were treated with Pem were included; 75 received Pem plus a platinum agent and 10 received Pem alone. Samples with fewer than 100 malignant cells were excluded from the analysis. The characteristics of the study population are summarized in Table 1.

Table 1.

Characteristics of patients with MPM treated with Pemetrexed.

Clinical Characteristic	N	%	Median TTP	Median OS
Total	85
Gender
Male	55	64.7%	7.0 mo	13.25
Female	30	35.3%	6.0 mo	11
(p)			(0.71)	(0.76)
Age (median / range)	68 / (35 – 85)
< 65 years	32	37.7%	10.75 mo	14
≥ 65 years	53	62.3%	6 mo	12
(p)			(0.02)	(0.49)
Histology	70 / 85
Epithelial	50	71.4%	8.0 mo	17mo
Non-Epithelial       (Sarcomatoid)       (Biphasic)	20 (11) (9)	28.6% (15.7%) (12.9%)	5.5 mo	10mo
Treatment
Pemetrexed PLUS platinum	75	88%
Pemetrexed alone	10	12%
(p)			(0.04)	(< 0.001)
NA	15 / 85
Radiographic Response (modified RECIST)	83
Disease Control (CR, PR or SD)	57	68.7%	10 mo	18 mo
Progressive Disease	26	31.3%	4 mo	8.5 mo
(p)			(< 0.0001)	(< 0.0001)
Median Time to Progression (months) (n=61)	6.75 mo
Median Overall Survival (months) (n=81)	13 mo

The clinical outcomes are summarized in Table 1 and are similar to other studies [1, 12]. The overall disease control rate was 69%, PD was documented in 31%. Median TTP was 6.8 months. Median OS time was 13 months.

The effects of clinical characteristics on outcomes are also shown in Table 1. Gender was not predictive of TTP or OS. A non-epithelioid histology was associated with shorter survival (HR 3.03; 95% CI - 1.64 – 5.62; p < 0.001) but not with shortened TTP. Age above 65 years was associated with shorter TTP (p=0.02), but not with worse survival.

Relationship of Thymidylate Synthase to Clinical Outcomes

Of 85 patients, 78 samples were available for TS staining and analysis (some sections were not included due to technical reasons). TS staining was mostly nuclear with variable cytoplasmic expression (Figure 1). In virtually all patients, some degree of staining was seen with a range of H-scores from 10 to 190. The level of TS expression detected by IHC followed a normal distribution (Fig. 2A). The median H-score was 105.

Figure 2.

Levels of Thymidylate Synthase and Folyl-polyglutamate synthase expression detected by IHC. A) frequency distribution of H scores for TS staining in all tumor samples. B) frequency distribution of H scores for FPGS staining in all tumor samples. C) Plot of H scores for anti-TS staining versus best radiographic responses comparing patients with progressive disease versus those with disease control (stable disease plus partial response). D) Plot of H scores for anti-FPGS staining versus best radiographic responses comparing patients with progressive disease versus those with disease control (stable disease plus partial response).

We plotted the H-score from patients with disease progression versus disease control. As shown in Figure 2C, there was extensive overlap between groups with both having the same median score of 105.

We next used the median H-score of 105 to classify samples as having “high” or “low” TS expression (Table 2). When comparing high TS levels to low TS levels, we observed no differences in disease control rates (DCR) (p = 0.73) (Table 2). We performed the same analysis in the subgroup of patients with epithelioid histology and found similar results. Although there was a numerically longer median TTP (8 months vs. 6 months; p=0.93) and OS (14 mo vs. 11.25 mo; p=0.59) in the patients with low TS scores compared to higher TS scores these differences were not statistically significant. The Kaplan-Meier curves are shown in Figure 3A and 3B (online only).

Table 2.

Outcomes of patients with MPM according to biomarker expression

Biomarker	Disease Control Rate	Median TTP	Median OS
TS HScore (median 105)		N= 56	N= 76
Below the median (n = 35)	68.6	8 mo	14 mo
Above the median (n = 43)	72.1	6 mo	11.25 mo
(p)	(0.73)	(0.93)	(0.59)
FPGS HScore (median 120)		N= 54	N = 74
Below the mean	69.4	7 mo	13.75 mo
Above the mean	70.0	6 mo	11 mo
(p)	(0.95)	(0.77)	(0.43)
FPGS/TS ratio (median 1.17)		N = 53	N = 73
Below the mean	64.9	6 mo	12 mo
Above the mean	76.3	7.5 mo	13 mo
(p)	(0.27)	(0.10)	(0.43)

Figure 3. Kaplan-Meier Survival Curves.

A. Overall KM survival according to TS expression, B. KM plot of Time to Progression according to TS expression. C. Overall KM survival according to FPGS expression, D. KM plot of Time to Progression according to FPGS expression.

Relationship of folyl-polyglutamate synthase to clinical outcomes

Of 85 patients, 74 had adequate samples available for FPGS analysis due to technical reasons. FPGS was detected in almost all patients (72/74), again with a normal distribution of H-scores (Fig. 2B). Staining was both nuclear and cytoplasmic (Fig. 1C). The median H-score was 120 (range 0 – 285).

We plotted the H-scores from patients with disease progression versus disease control. As shown in Figure 2D, extensive overlap existed between the groups: the median H-score was 120 in patients with disease progression and 130 in those with disease control.

Using the median H-score of 120, samples were categorized as having “high” or “low” FPGS expression (Table 2). We did not find a significant association between high and low FPGS expression and median TTP (p = 0.77), median OS (p = 0.43) or DCR (p = 0.95). The Kaplan-Meier curves are shown in Figure 3C and 3D (online only).

FPGS / TS ratio

The ratio of FPGS/TS was calculated by dividing the FPGS H-score by the TS H-score for each patient. The data appeared normally distributed. The median ratio was 1.17 and this value was used to classify samples as having high or low FPGS/TS ratios (Table 2). In patients with a high FPGS/TS ratio there was a higher TTP (7.5 months vs. 6 months; p = 0.10), OS (13 months vs. 12 months; p = 0.43), and DCR (76.3% vs. 64.9%; p = 0.27) but these differences were not statistically significant.

Correlation of TS and FPGS expression with in vitro chemosensitivity of human mesothelioma cells to pemetrexed

Given the lack of correlation between TS expression and the clinical response to Pem, we tested whether such a correlation existed in in vitro. Nine human mesothelioma cell lines were treated with varying concentrations of Pem, ranging from 0.001 to 100 micromolar, and cell viability was assessed 72 hours after treatment. The 50% inhibitory concentration (IC₅₀) values were then determined in each cell line and correlated with the TS expression as determined by immunoblotting, (Table 3 –online only and Figure 4). Consistent with our clinical data, we did not observe any correlation between TS expression and chemosensitivity of mesothelioma cells to Pem in vitro. We performed similar in vitro studies evaluating FPGS expression by immunoblotting and again observed no correlation with IC₅₀ values of Pem for each cell line (data not shown).

Discussion

The clinical data supporting the relationship between TS and Pem sensitivity has largely been indirect; based on relatively small retrospective studies that showed an association between lower levels of TS expression and Pem efficacy in mesothelioma and lung cancer [20]. Three recent observational studies [11–13] demonstrated a statistical association between intratumoral TS expression and Pem efficacy in patients with MPM. Table 4 compares these studies to ours. In all studies, TS levels were semi-quantitatively measured by IHC using the same H-score metric that we used. In the Righi study [11], the median H-score was 90 and when used as a cutoff, a significant correlation between TS levels and both TTP and OS was seen. In this study, TS but not ERCC1 expression was associated with TTP and OS. No data on response rates were provided. It should be noted that the overall survival of the entire group (20.9 months) was much longer than the 13 months reported in the large phase III Pem trial by Vogelzang [1], the Zucali study [12], and our cohort, suggesting the selection of a “healthier” and likely less representative cohort of patients than is usually treated. In the Zucali study [12], the median H-score was very low (a value of 21). The progression-free survival (PFS) and OS survival were 7 and 13 months respectively, with a disease control rate of 78%, much more similar to our data and to other data cited in the literature. When the median H score was used as a cutoff, statistically significant differences in disease control rates (92% vs 73%), median PFS (7 months vs 6 months) and OS (18 months vs 9 months) were observed based on TS levels. In the Christoph study [13], the median H-score was very high (a value of 210). Their OS was much longer (23.3 months) compared with other studies, but similar to that seen in the Righi study. They found that median TS was associated with statistically significant differences in OS, but not PFS, objective response rate (OR), or DCR.

Table 4.

Comparison of studies assessing TS as predictor of Pemetrexed efficacy in MPM

	Righi (2010)[11]	Zucali (2011)[12]	Christoph (2012)[13]	Current Study
Study Design	Single institution Observational - Retrospective	Single institution Observational - Retrospective	Single institution Observational - Retrospective	Multicenter Observational - Retrospective
Number of Subjects	60	99	84	85
Primary Endpoint	Association between TS and ERCC1 with TTP and OS in pts treated with Pem and Cis respectively	Association between TS and ERCC1 with PFS, OS and DCR in pts treated with Pem and Cis respectively	Association between TS and FPGS expression and Pem efficacy (PFS, OS, DCR)	Association between TS and FPGS expression and Pem Efficacy (TTP, OS, DCR)
Antibody Type	TS: TS106, (dilution 1:100); Zymed, San Francisco, CA ERCC: clone 8F1, dilution 1:100; LabVision, Fremont, CA	TS: TS106, (dilution 1:100), DAKO ERCC1: clone 8F1, dilution 1:50, Santa Cruz Biotechnology	TS: TS106 antibody (dilution 1:10), Invitrogen, Inc., Carlsbad, CA FPGS: (dilution 1:20), Spring Bioscience, Inc., Pleasanton, CA	TS: TS106 (Invitrogen) at a dilution of 1:100, Zymed, San Francisco, CA FPGS: (dilution1:1500), Eli-Lilly, Indianapolis, IN
Variables Measured	TS and ERCC1 expression measured by IHC and rt-PCR	TS and ERCC1 expression measured by IHC and rt-PCR	TS and FPGS expression measured by IHC only	TS and FPGS expression measured by IHC only
Cutoff Used (H score)	Median H score (90) and lower Tertile (60)	Median H score (21)	Median H score (TS: 210 FPGS: 230)	Median H score (TS: 105 FPGS: 120)
Clinical Characteristics	TTP - 10 mo OS - 20.9 mo Epithelial: 83%	PFS - 7 mo OS - 13 mo Epithelial: 92%	PFS – 7.6 mo OS: 23.3 mo Epithelial: 86%	TTP - 6.5 mo OS - 13 mo Epithelial: 70%
Findings	TS but not ERCC1 expression was associated with TTP and OS	TS but not ERCC1 expression was associated with PFS, OS and DCR.	FPGS was associated with PFS, OR and DCR but not OS TS was associated with OS but not with PFS, OR or DCR	No association between marker expression (TS and FPGS) and either TTP, OS or DCR.

TS: Thymidylate synthase; FPGS: folyl-polyglutamate synthase; TTP: time to progression; OS: overall survival; DCR: Disease control rate (complete response + partial response + stable disease); OR: Objective response (complete response plus partial response); Pem: Pemetrexed; Cis: cisplatin.

Our median H-score was 105, similar to that seen by Righi, but clearly different from that appreciated by Zucali or Christoph [11–13] (Table 4). We observed an overall DCR of 69%, a median TTP of 6.8 months, and a median OS of 13 months (outcomes similar to those of Zucali and previous studies, as well as the established literature [1]. Although the median TTP (8 months vs 6 months) and OS (14 months vs 11 months) were longer in our low TS versus high TS group, these differences did not reach statistical significance. Other cutoffs, beside the median score, were also analyzed (including the highest tertile and highest quartile), but statistical significance was still not reached. The reason why we did not observe statistically significant differences in our study is not entirely clear. One potential explanation could be differences in antibodies or technique. We view this as unlikely for the TS results, as all four studies (see Table 4) used the same anti-TS antibody clone (TS106) and three of the four studies used the antibody at the same dilution (1:100). It is possible we would have reached significance with larger numbers of patients.

Given this limitation in using TS expression alone, we also explored the utility of assessing the expression of FPGS. In vitro studies [15, 16] have suggested that loss of FPGS activity may lead to Pem resistance in cell lines because of decreased intracellular availability of the active poly-glutamated form of Pem. A recent paper suggests there may be some predictive value in FPGS levels in MPM [13]. In that study, the median FPGS H-score was 230 - a relatively high value since 300 is the maximal score. High FPGS (greater than median) expression was associated with response rate and DCR, but not OS. However, as shown in Table 2, we detected no association between FPGS expression and Pem efficacy. Of note, our median H-score was much lower at 120. We also determined if a higher FPGS/TS ratio (i.e. high(er) FPGS with low(er) TS) would correlate with improved outcome on Pem. We noted a trend towards increased TTP (p= 0.10) with higher FPGS/TS ratios, but not with OS (p=0.43). Again, other cutoffs beside the median score were analyzed, but statistical significance was not achieved. Consistent with our clinical findings, we did not find an association between the in vitro Pem sensitivity (measured as the IC₅₀ value) of several mesothelioma cell lines with TS or FPGS expression as measured by immunoblotting. One explanation for the discrepant results may be that we used an antibody different from that used in the Christoph study (13).

The main limitation of this study was its retrospective observational design. Although stage is predictive of survival, this information was not available in the majority of patients and therefore could not be included in our survival analysis as a possible confounder. We also did not have baseline data on performance status or weight loss. The retrospective nature of our study made measurements of radiographic response and TTP less accurate since these were obtained as part of routine clinical care and not as part of a formal study protocol. Although we limited our analysis to patients who received a Pem-containing regimen in the first-line setting, some patients went on to receive second line therapies after disease progression; although benefits from second line therapy have never been proven in randomized phase III studies, it is conceivable that subsequent treatment could have influenced OS. We were also careful to exclude patients who received “adjuvant” chemotherapy for similar reasons, since these patients, by and large, were likely to have earlier stage disease, better overall survival, and no “measurable” tumor after resection.

Even with these limitations in mind, the most important implication of this study relates to the issue of “statistical” versus “clinical” utility of a test. Specifically, even if TS levels ultimately prove to have a statistical association with response and survival in patients with MPM treated with Pem, it seems doubtful this association would have any true clinical utility. This translates to a broader clinical question: should TS levels be used to decide whether Pem should be administered to a specific MPM patient? This is an important issue, since a number of companies are already actively marketing tests to clinicians to measure TS mRNA or protein expression levels in tumors with the obvious, but unstated, implication that this information should be used in therapeutic decision-making. In addition, many clinicians have already made the “leap of faith” that TS levels do, in fact, predict benefit to Pem, both in MPM and in NSCLC, and are using these tests accordingly.

We believe our data indicate that TS expression levels should not be used in such decisions. First, the measurement of TS using IHC is inherently imprecise and rather subjective, even for trained academic lung pathologists. Each of the three studies found a different median H-score value for TS ranging from 21 (an extremely low value) to 210 (an extremely high value). It is unclear which value should be chosen as a cutoff. Carefully standardized positive and negative controls must be used with each staining run. Even with these controls, detecting small differences is difficult. Reliably and reproducibly differentiating an H-score of 90 (a “low” value) and 130 (a “high” value) is challenging (see Figure 1). As a second example, in the Christoph study [13], the median FPGS H-score for responders was 255 and for non-responders was 220, again a very small difference to discern. Secondly, and perhaps even more importantly, even if an H-score can be reliably determined, the sensitivity and specificity of the test appears to be poor. This is shown in Figure 2, where we have plotted individual H-score values versus disease control status. Clearly, the overlap between groups precludes any meaningful prediction at the individual patient level. Accordingly, there were some patients with very low H-scores who did not respond to therapy, just as there were some patients with very high H-scores whose disease was controlled. This key representation of the frequency distributions of H-scores has not been shown in any of the other manuscripts.

In summary, although other data suggest that TS and FPGS expression might be potential markers of Pem efficacy in patients with MPM in a “statistical setting”, our study indicates that these markers lack sufficient predictive value in an individual patient to be used to guide clinical decisions. In fact, basic demographic factors, such as histology and age, are more predictive. Before TS and FPGS expression are used to make treatment selections, additional data are needed. Ideally, a prospective observational study with predetermined diagnostic criteria and standardized treatment, outcome measurements and follow-up would need to be performed. If positive, a prospective trial randomizing patients to treatment based on TS and/or FPGS levels would need to be conducted to show increased efficacy. Until then, we do not recommend the use of these markers as determinants of therapy in the clinical setting.