Occupational and environmental exposure to asbestos is associated with the development of different asbestos-related diseases. Even though several countries have banned the use of asbestos after it was classified as a carcinogen in 1977, it is still being used in some countries and it is also still present in the environment.1,2 Additionally, there is a long latency period between exposure and development of asbestos-related diseases, which can occur several decades after asbestos exposure even in subjects exposed to relatively low doses.1 Therefore, the incidence of asbestos-related diseases continues to rise in most countries and they remain one of the major public health issues.1
Pleural plaques, diffuse pleural thickening, pleural effusions and asbestosis are classified as benign asbestos-related diseases.1 Exposure to asbestos also increases the risk of various cancers, including malignant mesothelioma (MM). MM is an extremely aggressive cancer affecting serosal membranes, mostly pleura or peritoneum.3,4 Due to non-specific symptoms, diagnosis is usually made in the advanced stages of the disease, leading to poor prognosis and short survival of MM patients.4 Even though the use of chemotherapy increased the survival of MM patients, response rate is still limited.4, 5, 6 Early diagnosis could therefore contribute to a more effective treatment of MM.7,8 Currently, immunohistochemical analysis investigating a panel of markers on tissue samples is required to confirm the MM diagnosis.9 New noninvasive biomarkers that would enable earlier diagnosis of MM are thus extensively studied, particularly in pleural MM.
The most frequently investigated biomarker in MM is mesothelin, as many studies have shown it is frequently increased in both tumor tissue and serum of MM patients, especially in epithelioid histological type.8, 10, 11, 12, 13, 14, 15, 16, 17 Mesothelin is a cell-surface glycoprotein expressed in mesothelial cells and overexpressed in several cancer types. It is involved in important cellular processes, including cell adhesion, proliferation, invasion, and epithelial-to-mesenchymal transition.18,19 Mesothelin is a glycophosphatidylinositol–linked membrane protein, but it also has three isoforms that are present in the circulation.12,15,20 Enzyme-linked immunosorbent assay (ELISA) can detect different isoforms, usually referred to as soluble mesothelin related peptides (SMRP).12,20
Meta-analyses focusing on SMRP as a diagnostic marker of MM showed that high SMRP has high specificity, but limited sensitivity, suggesting that positive results should lead to further diagnostic steps, but negative results do not exclude MM and therefore additional biomarkers are needed.12,14
Several studies also investigated SMRP as a prognostic biomarker in MM.18, 21, 22, 23 SMRP levels were markedly increased at disease progression.21 In a meta-analysis, increased SMRP was associated with shorter overall survival and worse prognosis.18 Numerous studies also noted that serial longitudinal SMRP measurements may be more informative than SMRP levels at diagnosis.22,23 MesomarkTM ELISA kit was already approved by the FDA for the measurement of SMRP and monitoring of MM.20,24
A few previous studies have shown that genetic variability also influences SMRP levels. Single nucleotide polymorphisms (SNPs) in the 5’ and 3’ untranslated region (UTR) of the mesothelin gene (
The aim of our study was to determine serum SMRP levels in patients with asbestos-related diseases and in asbestos-exposed subjects without asbestos-related disease and to assess the association of
The study included 782 subjects with different asbestos-related diseases (pleural plaques, asbestosis and MM) and asbestos-exposed subjects with no asbestos-related disease.
Patients with MM were treated at the Institute of Oncology Ljubljana in the period between 1 January 2004 and 31 December 2012. The diagnosis of pleural MM was performed by thoracoscopy and the diagnosis of peritoneal MM by laparoscopy. In both cases, the diagnosis of MM was confirmed histologically by an experienced pathologist. The MM stage was determined according to the TNM staging system for pleural MM, while performance status was evaluated according to Eastern Cooperative Oncology Group (ECOG) scores.
All patients with pleural plaques, asbestosis and subjects with no asbestos-related disease were occupationally exposed to asbestos and presented at the State Board for the Recognition of Occupational Asbestos Diseases in the period from 1 January 1998 to 31 December 2007. The diagnosis of pleural plaques, asbestosis or “no asbestos-related disease” was based on the Helsinki Criteria for Diagnosis and Attribution of Asbestos Diseases29 and on the American Thoracic Society recommendations30 and was confirmed by two groups of experts each consisting of a skilled occupational physician, a radiologist, and a pulmonologist. Follow-up was performed in all patients in 2018 to confirm they did not develop any other asbestos-related disease.
Demographic and clinical data were obtained from the medical records. Data on smoking were obtained using a standardized questionnaire31,32 and during the interview. Patients were classified as ever/never smokers. All subjects provided written informed consent. The study was approved by the National Medical Ethics Committee of the Republic of Slovenia and was carried out according to the Helsinki Declaration.
Serum samples were collected at diagnosis for patients with MM and at inclusion in the study for all other subjects. Serum samples were prepared within 6 hours after blood sampling, aliquoted and stored at -20°C. For determining serum SMRP levels, sandwich ELISA assay (MesomarkTM) using two monoclonal antibodies (4H3 and OV569) was used according to the manufacturer’s protocol (Fujirebio Europe BV, Breda, The Netherlands).24
Genomic DNA was extracted from peripheral blood leukocytes using Qiagen FlexiGene Kit (Qiagen, Hilden, Germany).
Continuous variables were described using median with interquartile range (25%–75%) or 95% confidence intervals (CIs), while categorical variables were described using frequencies. Fisher’s exact test was used to compare categorical variables among different groups. Nonparametric Mann-Whitney or Kruskal-Wallis tests were used to compare distribution of continuous variables. Pairwise comparisons with
In the survival analysis, progression-free survival (PFS) and overall survival (OS) were assessed. PFS was defined as the time to the day of documented disease progression, or death, whichever occured first and OS was defined as the time to death from any cause. Patients without progression or death at the time of the analysis were censored at the date of the last follow-up. The data on vital status were obtained from medical records or from the Slovenian Cancer Registry. Kaplan-Meier analysis was used to calculate median survival or follow-up time, while Cox regression was used to calculate the hazard ratios (HR) with the 95% CIs.
The statistical analyses were carried out by using IBM SPSS Statistics version 21.0 (IBM Corporation, Armonk, NY, USA). All statistical tests were two-sided and the level of significance was set at 0.05.
Among 782 subjects included in our study, 154 (19.7%) patients had MM. Among 628 non-MM subjects that were occupationally exposed to asbestos, 69 did not develop any asbestos-related disease, 410 subjects had pleural plaques, and 149 patients had asbestosis. Characteristics of each subject group are presented in Table 1. Gender and smoking distributions were similar across all groups (
Clinical characteristics of study groups
Characteristic | All subjects | No disease | Pleural plaques | Asbestosis | MM | MM with SMRP at diagnosis | |
---|---|---|---|---|---|---|---|
Gender | Male, N (%) | 581 (74.3) | 52 (75.4) | 295 (72.0) | 115 (77.2) | 119 (77.3) | 69 (80.2) |
Female, N (%) | 201 (25.7) | 17 (24.6) | 115 (28.0) | 34 (22.8) | 35 (22.7) | 17 (19.8) | |
Age | Years, median 25%–75%) | 56.9 (50.2–64.9) | 52.9 (48.2–59.2) | 54.6 (48.8–62.2) | 59.1 (51.2–65.2) | 65 (57–70) | 66 (59–72) |
Smoking | No, N (%) | 375 (49.0) [17] | 31 (45.6) [1] | 203 (50.9) [11] | 71 (48.0) [1] | 70 (46.7) [4] | 43 (51.2) [2] |
Yes, N (%) | 390 (51.0) | 37 (54.4) | 196 (49.1) | 77 (52.0) | 80 (53.3) | 41 (48.8) | |
SMRP | nmol/l, median (25%-75%) | 0.30 (0.00–0.85) [1] | 0.14 (0.00–0.58) [6] | 0.03 (0.00–0.39) [5] | 2.43 (0.44–8.62) |
Number of missing data is presented in [] brackets.
MM = malignant mesothelioma; SMRP = soluble mesothelin-related peptides
Among 138 patients with pleural MM, 8 (5.8%) had stage 1, 41 (29.7%) stage 2, 43 (31.2%) stage 3, and 41 (29.7%) stage 4 disease, while the stage could not be determined in 5 (3.6%) patients.
Additionally, 16 (10.4%) patients had peritoneal MM. Most patients had epithelioid MM (114, 74.0%), 15 (9.7%) patients had biphasic and 14 (9.1%) patients had sarcomatoid MM. In the remaining 11 (7.1%) patients histological type could not be determined. ECOG performance status at diagnosis was 0 in 4 (2.6%) patients, 1 in 82 (53.2%), 2 in 60 (39.2%) and 3 in 3 (1.9%) MM patients, while no data on performance status were available for 5 (3.2%) patients.
Serum samples of 86 (55.8%) MM patients were available at diagnosis, therefore the SMRP level was measured only in these patients. MM patients with available data on serum SMRP at diagnosis did not differ significantly from the rest of MM patients regarding gender, smoking, stage, location (pleura or peritoneum) and histological type (all
SMRP serum levels differed significantly between subject groups presented in Table 1 (Kruskal-Wallis test statistic = 96.470;
When comparing MM patients with all other subjects, MM patients had significantly higher SMRP levels (2.43 (0.44–8.62) nmol/l compared to 0.13 (0.00–0.55) nmol/l; Mann-Whitney U = 42493;
ROC curve analysis according to
Comparison | AUC (95% CI) | SMRP cutoff | Sensitivity | Specificity | |
---|---|---|---|---|---|
MM | 0.802 | < 0.001 | 1.5 | 0.593 | 0.930 |
1 | 0.651 | 0.864 | |||
1.11a | 0.651 | 0.885 | |||
MM | 0.827 | < 0.001 | 1.5 | 0.593 | 0.967 |
1 | 0.651 | 0.925 | |||
0.87a | 0.686 | 0.911 | |||
MM | 0.765 | < 0.001 | 1.5 | 0.593 | 0.882 |
1 | 0.651 | 0.783 | |||
1.57a | 0.593 | 0.896 | |||
MM | 0.780 | < 0.001 | 1.5 | 0.593 | 0.878 |
1 | 0.651 | 0.780 | |||
1.68a | 0.570 | 0.927 |
a Cutoff with the highest sum of sensitivity and specificity.
AUC = area under the curve; MM = malignant mesothelioma; ROC = receiver operating characteristic; SMRP = soluble mesothelin-related peptides
Serum SMRP was not associated with gender (Mann-Whitney U = 48033.5;
In MM patients, 10 patients with peritoneal MM had significantly higher SMRP levels than patients with pleural MM (8.72 (3.65–12.25) nmol/l
Genotype frequencies of
Odds for MM in subjects with different
No disease | Pleural plaques | Asbestosis | MM | MM vs all other subjects | ||||
---|---|---|---|---|---|---|---|---|
Genotype | (N = 69) | (N = 410) | (N = 149) | (N = 154) | ||||
N (%) | N (%) | N (%) | N (%) | OR (95% CI) | ORadj(95% CI) | |||
GG | 41 (60.3) [1] | 241 (59.1) [2] | 84 (56.8) [1] | 81 (52.6) | reference | reference | ||
GA | 21 (30.9) | 147 (36.0) | 49 (33.1) | 60 (39.0) | 1.25 (0.86–1.82) | 0.243 | 1.28 (0.87–1.90) | 0.215 |
AA | 6 (8.8) | 20 (4.9) | 15 (10.1) | 13 (8.4) | 1.43 (0.73–2.80) | 0.292 | 1.30 (0.64–2.64) | 0.472 |
GA+AA | 27 (39.7) | 167 (40.9) | 64 (43.2) | 73 (47.4) | 1.28 (0.90–1.82) | 0.174 | 1.29 (0.89–1.87) | 0.187 |
Number of missing data is presented in [] brackets.
adj = adjusted for age; CI = confidence interval; MM = malignant mesothelioma; OR = odds ratio
SMRP levels differed significantly between
Serum SMRP levels according to
Group | GG genotype | GA genotype | AA genotype | Kruskal-Wallis test statistic | GA+AA genotype | Mann-Whitney U | ||
---|---|---|---|---|---|---|---|---|
SMRP (nmol/l, median (25%–75%) | SMRP (nmol/l, median (25%–75%) | SMRP (nmol/l, median (25%–75%) | SMRP (nmol/l, median (25%–75%) | |||||
All subjects N = 698 | 0.08 (0.00–0.45) | 0.40 (0.00–1.11) | 0.41 (0.00–1.61) | 31.617 | 0.001 < | 0.40 (0.00–1.15) | 73900 | < 0.001 |
No disease N = 67 | 0.16 (0.00–0.44) | 0.75 (0.19–1.40) | 1.34 (0.98–2.41) | 18.657 | 0.001 < | 0.84 (0.25–2.55) | 836.5 | < 0.001 |
Pleural plaques N = 402 | 0.07 (0.00–0.33) | 0.32 (0.00–0.88) | 0.32 (0.00–0.75) | 18.839 | 0.001 < | 0.32 (0.00–0.88) | 24272.5 | < 0.001 |
Asbestosis N = 143 | 0.00 (0.00–0.21) | 0.18 (0.00–0.64) | 0.00 (0.00–0.37) | 5.817 | 0.055 | 0.14 (0.00–0.55) | 2951 | 0.067 |
No disease or pleural plaques or asbestosis N = 612 | 0.07 (0.00–0.33) | 0.33 (0.00–0.88) | 0.33 (0.00–0.76) | 31.125 | < 0.001 | 0.33 (0.00–0.87) | 56942.5 | < 0.001 |
MM N = 86 | 1.79 (0.34–8.47) | 2.22 (0.52–8.61) | 2.87 (1.80–12.14) | 1.716 | 0.424 | 2.62 (0.88–9.07) | 986 | 0.595 |
a additive model; b dominant model
MM = malignant mesothelioma; SMRP = soluble mesothelin-related peptides
As genetic variability only influenced the SMRP levels in non-MM subjects, we performed separate ROC curve analyses stratified by genotype, comparing all MM patients to non-MM subjects with individual genotypes. The predictive capacity of SMRP was genotype-dependent. The AUC was the highest when comparing the MM patients to all other subjects with
Median PFS of MM patients was 7.8 (5.5–13.6) months, while median OS was 18.0 (9.8–29.6) months. The follow-up time of censored patients was 43.5 (21.8–94.3) months.
Compared to
Compared to
In MM patients whose SMRP levels were available at diagnosis, the serum SMRP level was not significantly associated with PFS or OS in our study group (HR = 0.99, 95% CI = 0.96–1.02;
Using the ROC curve analysis, we assessed how well
In the present study, we evaluated serum SMRP as a biomarker in the context of
Our study showed that serum SMRP is significantly increased in MM patients compared to patients with other asbestos-related diseases or asbestos-exposed subjects without any disease. All available meta-analyses confirmed that SMRP is elevated in the serum of MM patients as compared to healthy individuals, patients with asbestos-related diseases, benign respiratory diseases or lung cancer.12,14,16 Previous studies suggest that serum SMRP levels are the highest in epithelioid MM, which is consistent with our results.12,14 Our present study also included patients with peritoneal MM who were rarely represented in other studies or meta-analyses that focused on pleural MM. Interestingly, we observed that patients with peritoneal MM had significantly higher SMRP than patients with pleural MM. Our results are in agreement with a recent study that also reported elevated serum SMRP in patients with peritoneal MM compared to controls.33 This suggests that studies on a larger numbers of patients with peritoneal MM are needed to elucidate if SMRP could also serve as a diagnostic biomarker in these patients.
Studies therefore suggest that SMRP measurement could be a potential screening tool for the detection of MM, but clinical use is still limited due to the probability of false positive and especially false negative results.12,14,16 Some issues related to sensitivity may be associated with a difficult selection of an appropriate cutoff value and different studies found different optimal thresholds.12,14,16 In our study, the standard cutoff of 1.5 nmol/l had 93% specificity and 59.3% sensitivity for distinguishing MM patients from other subjects. The cutoff with the best sum of specificity and sensitivity was 1.11 nmol/l, with 88.5% specificity and 65.1% sensitivity.
Genetic factors that affect gene expression may account for some of the observed interindividual variability in serum SMRP levels and affect the usefulness of SMRP as a biomarker. In the present study, polymorphic
However, other mechanisms might be more important for the increased SMRP expression seen in MM.28
An important finding is that when rs1057147 genotype was taken into account when determining the serum SMRP cutoff value, the diagnostic predictive value was improved both in our present and in the previously published study.28 Cutoff values with the highest sum of specificity and sensitivity differed in respective genotype groups. Similar results were reported for SNPs in the 5’ UTR of the
We also investigated serum SMRP levels and
On the other hand,
One of the shortcomings of the present study was that we did not include SNPs in
Mesothelin is by far the most studied biomarker in MM; however, other diagnostic and prognostic biomarkers were also reported. Among serum biomarkers, especially fibulin-3 and osteopontin are promising candidates, but novel biomarkers, such as plasma biomarkers, HMGB1, mRNA and microRNA expression, are also emerging.16,39, 40, 41, 42, 43, 44, 45 Additionally, recent studies suggest that a combination of different biomarkers could improve the predictive capacity of SMRP.41,42,44,46,47 Our present results show that genetic variability affecting the expression of these biomarkers should also be taken into account.
In conclusion, our results confirm that