Multiethnic radiogenomics reveals low-abundancy microRNA signature in plasma-derived extracellular vesicles for early diagnosis and subtyping of pancreatic cancer

Reviewer #1 (Public review):

Summary:

The manuscript by Shi et al, has utilized multiple imaging datasets and one set of samples for analyzing serum EV-miRNAs & EV-RNAs to develop an EV miRNA signature associated with disease-relevant radiomics features for early diagnosis of pancreatic cancer. CT imaging features (in two datasets (UMMD & JHC and WUH) were derived from pancreatic benign disease patients vs pancreatic cancer cases), while circulating EV miRNAs were profiled from samples obtained from a different center (DUH). The EV RNA signature from external public datasets (GSE106817, GSE109319, GSE113486, GSE112264) were analyzed for differences in healthy controls vs pancreatic cancer cases. The miRNAs were also analyzed in the TCGA tissue miRNA data from normal adjacent tissue vs pancreatic cancer.

Strengths:

The concept of developing EV miRNA signatures associated with disease relevant radiomics features is a strength.

Weaknesses:

While the overall concept of developing EV miRNA signature associated with radiomics features is interesting, the findings reported are not convincing for the reasons outlined below:

(1) Discrepant datasets for analyzing radiomic features with EV-miRNAs: It is not justified how CT images (UMMD & JHC and WUH) and EV-miRNAs (DUH) on different subjects and centers/cohorts shown in Figures 1 &2 were analyzed for association. It is stated that the samples were matched according to age but there is no information provided for the stages of pancreatic cancer and the kind of benign lesions analyzed in each instance.

(2) The study is focused on low-abundance miRNAs with no adequate explanation of the selection criteria for the miRNAs analyzed.

(3) While EV-miRNAs were profiled or sequenced (not well described in the Methods section) with two different EV isolation methods, the authors used four public datasets of serum circulating miRNAs to validate the findings. It would be better to show the expression of the three miRNAs in the additional dataset(s) of EV-miRNAs and compare the expressions of the three EV-miRNAs in pancreatic cancer with healthy and benign disease controls.

(4) It is not clear how the 12 EV-miRNAs in Figure 4C were identified.

(5) Box plots in Figures 4D-F and G-I of three miRNAs in serum and tissue should show all quantitative data points.

(6) What is the GBM model in Figure 5?

(7) What are the AUCs of individual EV-miRNAs integrated as a panel of three EV-miRNAs?

(8) The authors could have compared the performance of CA19-9 with that of the three EV-miRNAs.

(9) How was the diagnostic performance of the three EV-miRNAs in the two molecular subtypes identified in Figure 6&7? Do the C1 & C2 clusters correlate with the classical/basal subtypes, staging, and imaging features?

Reviewer #2 (Public review):

Summary:

This study investigates a low abundance microRNA signature in extracellular vesicles to subtype pancreatic cancer and for early diagnosis. There are several major questions that need to be addressed. Numerous minor issues are also present.

Strengths:

The authors did a comprehensive job with numerous analyses of moderately sized cohorts to describe the clinical and translational significance of their miRNA signature.

Weaknesses:

There are multiple weaknesses of this study that should be addressed:

(1) The description of the datasets in the Materials and Methods lacks details. What were the benign lesions from the various hospital datasets? What were the healthy controls from the public datasets? No pancreatic lesions? No pancreatic cancer? Any cancer history or other comorbid conditions? Please define these better.

(2) It is unclear how many of the controls and cases had both imaging for radiomics and blood for biomarkers.

(3) The authors should define the imaging methods and protocols used in more detail. For the CT scans, what slice thickness? Was a pancreatic protocol used? What phase of contrast is used (arterial, portal venous, non-contrast)? Any normalization or pre-processing?

(4) Who performed the segmentation of the lesions? An experienced pancreatic radiologist? A student? How did the investigators ensure that the definition of the lesions was performed correctly? Raidomics features are often sensitive to the segmentation definitions.

(5) Figure 1 is full of vague images that do not convey the study design well. Numbers from each of the datasets, a summary of what data was used for training and for validation, definitions of all of the abbreviations, references to the Roman numerals embedded within the figure, and better labeling of the various embedded graphs are needed. It is not clear whether the graphs are real results or just artwork to convey a concept. I suspect that they are just artwork, but this remains unclear.

(6) The DF selection process lacks important details. Please reference your methods with the Boruta and Lasso models. Please explain what machine learning algorithms were used. There is a reference in the "Feature selection.." section of "the model formula listed below" but I do not see a model formula below this paragraph.

(7) In Figure 2, more quantitative details are needed. How are patients dichotomized into non-obese and obese? What does alcohol/smoking mean? Is it simply no to both versus one or the other as yes? These two risk factors should be separated and pack years of smoking should be reported. The details of alcohol use should also be provided. Is it an alcohol abuse history? Any alcohol use, including social drinking? Similarly, "diabetes" needs to be better explained. Type I, type II, type 3c? P values should be shown to demonstrate any statistically significant differences in the proportions of the patients from one dataset to another.

(8) In the section "Different expression radiomic features between pancreatic benign lesions and aggressive tumors", there is a reference to "MUJH" for the first time. What is this? There is also the first reference to "aggressive tumors" in the section. Do the authors just mean the cases? Otherwise there is no clear definition of "aggressive" (vs. indolent) pancreatic cancer. This terminology of tumor "aggressiveness" either needs to be removed or better defined.

(9) Figure 3 needs to have the specific radiomic features defined and how these features were calculated. Labeling them as just f1, f2, etc is not sufficient for another group to replicate the results independently.

(10) It is not clear what Figure 4A illustrates as regards model performance. What do the different colors represent, and what are the models used here? This is very confusing.

(11) Figure 5 shows results for many more model runs than the described 10, please explain what you are trying to convey with each row. What are "Test A" and "Test B"? There is no description in the manuscript of what these represent. In the figure caption, there is a reference to "our center data" which is not clear. Be more specific about what that data is.

(12) Figure 6 describes the subtypes identified in this study, but the authors do not show a multi-variable cox proportional hazards model to show that this subtype classification independently predicts DFS and OS when incorporating confounding variables. This is essential to show the subtypes are clinically relevant. In particular, the authors need to account for the stage of the patients, and receipt of chemotherapy, surgery, and radiation. If surgery was done, we need to know whether they had R1 or R0 resection. The details about the years in which patients were included is also important.

(13) How do these subtypes compare to other published subtypes?

Reviewer #3 (Public review):

Summary:

The authors appear to be attempting to identify which patients with benign lesions will progress to cancer using a liquid biomarker. They used radiomics and EV miRNAs in order to assess this.

Strengths:

It is a strength that there are multiple test datasets. Data is batch-corrected. A relatively large number of patients is included. Only 3 miRNAs are needed to obtain their sensitivity and specificity scores.

Weaknesses:

This manuscript is not clearly written, making interpretation of the quality and rigor of the data very difficult. There is no indication from the methods that the patients in their cohorts who are pancreatic cancer patients (from the CT images) had prior benign lesions, limiting the power of their analysis. The data regarding the cluster subtypes is very confusing. There is no discussion or comparison if these two clusters are just representing classical and basal subtypes (which have been well described).