Author response:
Reviewer #1 (Public Review):
This study presents an exploration of PPGL tumour bulk transcriptomics and identifies three clusters of samples (labeled as subtypes C1-C3). Each subtype is then investigated for the presence of somatic mutations, metabolism-associated pathways and inflammation correlates, and disease progression. The proposed subtype descriptions are presented as an exploratory study. The proposed potential biomarkers from this subtype are suitably caveated and will require further validation in PPGL cohorts together with a mechanistic study.
The first section uses WGCNA (a method to identify clusters of samples based on gene expression correlations) to discover three transcriptome-based clusters of PPGL tumours. The second section inspects a previously published snRNAseq dataset, and labels some of the published cells as subtypes C1, C2, C3 (Methods could be clarified here), among other cells labelled as immune cell types. Further details about how the previously reported single-nuclei were assigned to the newly described subtypes C1-C3 require clarification.
Thank you for your valuable suggestion. In response to the reviewer’s request for further clarification on “how previously published single-nuclei data were assigned to the newly defined C1-C3 subtypes,” we have provided additional methodological details in the revised manuscript (lines 103-109). Specifically, we aggregated the single-nucleus RNA-seq data to the sample level by summing gene counts across nuclei to generate pseudo-bulk expression profiles. These profiles were then normalized for library size, log-transformed (log1p), and z-scaled across samples. Using genesets scores derived from our earlier WGCNA analysis of PPGLs, we defined transcriptional subtypes within the Magnus cohort (Supplementary Figure. 1C). We further analyzed the single-nucleus data by classifying malignant (chromaffin) nuclei as C1, C2, or C3 based on their subtype scores, while non-malignant nuclei (including immune, stromal, endothelial, and others) were annotated using canonical cell-type markers (Figure. 4A).
The tumour samples are obtained from multiple locations in the body (Figure 1A). It will be important to see further investigation of how the sample origin is distributed among the C1-C3 clusters, and whether there is a sample-origin association with mutational drivers and disease progression.
Thank you for your valuable suggestion. In the revised manuscript (lines 74-79), Figure. 1A, Table S1 and Supplementary Figure. 1A, we harmonized anatomic site annotations from our PPGL cohort and the TCGA cohort and analyzed the distribution of tumor origin (adrenal vs extra-adrenal) across subtypes. The site composition is essentially uniform across C1-C3—approximately 75% pheochromocytoma (PC) and 25% paraganglioma (PG)—with only minimal variation. Notably, the proportion of extra-adrenal origin (paraganglioma origin) is slightly higher in the C1 subtype (see Supplementary Figure 1A), which aligns with the biological characteristics of tumors from this anatomical site, which typically exhibit more aggressive behavior.
Reviewer #2 (Public Review):
A study that furthers the molecular definition of PPGL (where prognosis is variable) and provides a wide range of sub-experiments to back up the findings. One of the key premises of the study is that identification of driver mutations in PPGL is incomplete and that compromises characterisation for prognostic purposes. This is a reasonable starting point on which to base some characterisation based on different methods. The cohort is a reasonable size, and a useful validation cohort in the form of TCGA is used. Whilst it would be resource-intensive (though plausible given the rarity of the tumour type) to perform RNA-seq on all PPGL samples in clinical practice, some potential proxies are proposed.
We sincerely thank the reviewer for their positive assessment of our study’s rationale. We fully agree that RNA sequencing for all PPGL samples remains resource-intensive in current clinical practice, and its widespread application still faces feasibility challenges. It is precisely for this reason that, after defining transcriptional subtypes, we further focused on identifying and validating practical molecular markers and exploring their detectability at the protein level.
In this study, we validated key markers such as ANGPT2, PCSK1N, and GPX3 using immunohistochemistry (IHC), demonstrating their ability to effectively distinguish among molecular subtypes (see Figure. 5). This provides a potential tool for the clinical translation of transcriptional subtyping, similar to the transcription factor-based subtyping in small cell lung cancer where IHC enables low-cost and rapid molecular classification.
It should be noted that the subtyping performance of these markers has so far been preliminarily validated only in our internal cohort of 87 PPGL samples. We agree with the reviewer that larger-scale, multi-center prospective studies are needed in the future to further establish the reliability and prognostic value of these markers in clinical practice.
The performance of some of the proxy markers for transcriptional subtype is not presented.
We agree with your comment regarding the need to further evaluate the performance of proxy markers for transcriptional subtyping. In our study, we have in fact taken this point into full consideration. To translate the transcriptional subtypes into a clinically applicable classification tool, we employed a linear regression model to compare the effect values (β values) of candidate marker genes across subtypes (Supplementary Figure. 1D-F). Genes with the most significant β values and statistical differences were selected as representative markers for each subtype.
Ultimately, we identified ANGPT2, PCSK1N, and GPX3—each significantly overexpressed in subtypes C1, C2, and C3, respectively, and exhibiting the most pronounced β values—as robust marker genes for these subtypes (Figure. 5A and Supplementary Figure. 1D-F). These results support the utility of these markers in subtype classification and have been thoroughly validated in our analysis.
There is limited prognostic information available.
Thank you for your valuable suggestion. In this exploratory revision, we present the available prognostic signal in Figure. 5C. Given the current event numbers and follow-up time, we intentionally limited inference. We are continuing longitudinal follow-up of the PPGL cohort and will periodically update and report mature time-to-event analyses in subsequent work.
