International Journal of
Molecular Sciences Article
IL-6 and IL-8 Serum Levels Predict Tumor Response and Overall Survival after TACE for Primary and Secondary Hepatic Malignancies Sven H. Loosen 1,† ID , Maximilian Schulze-Hagen 2,† , Catherine Leyh 3 , Fabian Benz 3 , Mihael Vucur 3 , Christiane Kuhl 2 , Christian Trautwein 1 , Frank Tacke 1 , Philipp Bruners 2,‡ , Christoph Roderburg 1,‡ and Tom Luedde 1,3, *,‡ 1
2
3
* † ‡
Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
[email protected] (S.H.L.);
[email protected] (C.T.);
[email protected] (F.T.);
[email protected] (C.R.) Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
[email protected] (M.S.-H.);
[email protected] (C.K.);
[email protected] (P.B.) Division of Gastroenterology, Hepatology and Hepatobiliary Oncology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
[email protected] (C.L.);
[email protected] (F.B.);
[email protected] (M.V.) Correspondence:
[email protected]; Fax: +49-(0)241-8082-455 These authors share first authorship. These authors share senior authorship.
Received: 3 May 2018; Accepted: 11 June 2018; Published: 14 June 2018
Abstract: While surgical resection represents the standard potentially curative therapy for liver cancer, transarterial chemoembolization (TACE) has evolved as a standard therapy for intermediate-stage hepatocellular carcinoma (HCC) as well as liver metastases. However, it is still not fully understood which patients particularly benefit from TACE. Cytokines represent a broad category of signaling molecules that might reflect concomitant inflammation as an adverse prognostic factor. Here, we evaluated the role of interleukin (IL)-6, IL-8, and CC-chemokine ligand (CCL)22 as biomarkers in the context of TACE treatment. Cytokine serum levels were analyzed by multiplex immunoassay in 54 patients (HCC: n = 44, liver metastases: n = 10) undergoing TACE as well as 51 healthy controls. Patients with primary and secondary liver cancer showed significantly elevated levels of IL-6 and IL-8 but not CCL22 compared to healthy controls. Interestingly, low pre-interventional levels of IL-6 and IL-8 were predictors for an objective response after TACE in binary logistic regression. In contrast, patients with high pre-interventional IL-6 and IL-8 serum levels not only poorly responded to TACE but had a significantly impaired overall survival. Serum levels of IL-6 and IL-8 represent promising biomarkers for patients undergoing TACE and might help to pre-interventionally identify patients who particularly benefit from TACE regarding objective treatment response and overall survival. Keywords: cancer; TACE; cytokines; HCC
1. Introduction Hepatocellular carcinoma (HCC), the most common primary liver malignancy, shows an increasing incidence and is associated with an unfavorable prognosis [1]. Liver metastases frequently arise in the clinical course of various gastrointestinal malignancies such as colorectal cancer (CRC) and represent a limiting factor for long-term survival [2,3]. For both primary and secondary liver tumors, surgical resection represents the standard potentially curative treatment option in daily practice but Int. J. Mol. Sci. 2018, 19, 1766; doi:10.3390/ijms19061766
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is often not feasible due to advanced tumor stage or limited liver function at time of diagnosis [3]. Transarterial chemoembolization (TACE) has evolved as a standard therapeutic option for patients with intermediate-stage, irresectable HCC (Barcelona Clinic Liver Cancer (BCLC) stage B), and several studies have confirmed the general therapeutic benefit of TACE for these patients [4]. While systemic chemotherapy represents the standard of care for irresectable liver metastases, e.g., from CRC, TACE is increasingly applied in patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy [5]. However, response rates to TACE are heterogeneous and it is not fully understood which patients benefit most from TACE therapy in terms of tumor response and overall survival [4,6]. As multimodal therapeutic approaches for both primary and secondary liver cancer are gaining complexity in terms of treatment timing as well as potential treatment alternatives (e.g., selective internal radiation therapy (SIRT) or radiofrequency ablation (RFA)), pre-interventional stratification algorithms are of increasing importance to identify patients who represent particularly good candidates for TACE therapy. Several predictive algorithms such as the ART or SNACOR score have been suggested but are mainly based on imaging techniques and the patients’ liver function while aspects of the individual tumor biology only play a minor role [7,8]. Cytokines could potentially reflect distinct inflammatory mechanisms during tumor progression and might therefore serve as prognostic biomarkers in cancer patients [9,10]. As such, CCL22 has been described as a pro-malignant cytokine, and high serum levels of CCL22 were associated with advanced stage of disease as well as an impaired prognosis in patients with gastric cancer and breast cancer [11,12]. Interleukin (IL)-8 and IL-6 both play an important role in various cancer signaling pathways [13,14]. Elevated circulating levels of IL-6 and IL-8 are associated with a reduced overall survival in patients with lung cancer and pancreatic adenocarcinoma [15,16]. However, only little is known about circulating cytokine levels in the context of TACE treatment. Here, we aimed at evaluating circulating levels of IL-6, IL-8, and CCL22 as serum markers for patients undergoing TACE for primary and secondary liver cancer. 2. Results 2.1. Serum Levels of IL-8 and IL-6 Are Elevated in Patients with Primary or Secondary Liver Cancer We first compared the baseline serum level of IL-8, IL-6, and CCL22 in patients who underwent TACE for primary and secondary liver tumors as well as healthy controls. Here, pre-interventional serum concentrations of IL-8 and IL-6 were significantly elevated in patients with liver cancer compared to healthy controls (Figure 1A,B, Table 1), while serum levels of CCL22 were unaltered between these groups (Figure 1C). In line with this, receiver operating characteristic (ROC) curve analyses revealed area under the curve (AUC) values of 0.944 and 0.931 for IL-8 and IL-6 for the discrimination between liver cancer patients and healthy controls (Figure 1D). Table 1. Serum levels of laboratory markers. Parameter Interleukin (IL)-8 pre-TACE (pg/mL) IL-8 day 1 post-TACE (pg/mL) IL-8 day 2 post-TACE (pg/mL) IL-6 pre-TACE (pg/mL) IL-6 day 1 post-TACE (pg/mL) IL-6 day 2 post-TACE (pg/mL) CC-chemokine ligand (CCL) 22 pre-TACE (pg/mL) CCL22 day 1 post-TACE (pg/mL) CCL22 day 2 post-TACE (pg/mL) Bilirubin (mg/dL)
TACE Patients Median (Range)
Healthy Controls Median (Range)
35.96 (7.69–381.77) 40.17 (12.48–323.73) 39.76 (12.39–332.86) 12.17 (3.49–187.88) 31.67 (7.90–164.59) 31.29 (10.34–566.03)
7.78 (0–158.05) 3.59 (0–17.57) -
835.12 (101.57–1872.29)
934.48 (101.57–1925.91)
780.66 (110.19–1516.91) 644.16 (203.83–1167.72) 0.73 (0.26–2.43)
0.41 (0.1–1.46)
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Figure 1. Serum ofIL-6 IL-6 IL-8notbut notare CCL22 are elevated inhepatic patients with hepatic Figure 1. Serumlevels levels of andand IL-8 but CCL22 elevated in patients with malignancies. (A,B) Pre-interventional serum concentrations IL-8 and IL-6 areof significantly in patients malignancies. (A,B) Pre-interventional serumofconcentrations IL-8 andelevated IL-6 are significantly withinprimary and secondary (C) Serum levels of(C) CCL22 arelevels unaltered between elevated patients with primaryliver andcancer; secondary liver cancer; Serum of CCL22 arethese unaltered patients and healthy controls; (D) ROC curve analysis shows AUCs of 0.944 and 0.931 for IL-8 and 0.931 between these patients and healthy controls; (D) ROC curve analysis shows AUCs of 0.944 and IL-6 regarding the discrimination between TACE patients and healthy controls. (* p < 0.05; ** p < 0.01; for IL-8 and IL-6 regarding the discrimination between TACE patients and healthy controls. (* p < *** p < 0.001; n.s.: p > 0.05). 0.05; ** p < 0.01; *** p < 0.001; n.s.: p > 0.05). 2.2. Pre-Interventional Serum Levels of IL-8 and IL-6 Predict an Objective Response to TACE Therapy
2.2. Pre-Interventional Serum Levels of IL-8 and IL-6 Predict an Objective Response to TACE Therapy We next investigated if pre-interventional cytokine serum levels have a predictive value regarding
We next investigated pre-interventional cytokine serum a predictive the individual response toif TACE therapy. We therefore divided ourlevels cohort have into patients with an value regarding theresponse individual TACE with therapy. We therefore ourand cohort intowho patients objective (OR;response includingtopatients a complete or partialdivided remission) patients showed a non-objective response (non-OR; including with or stable or progressive with an objective response (OR; including patients withpatients a complete partial remission) disease) and patients after TACE [17]. who showed a non-objective response (non-OR; including patients with stable or progressive disease) In this analysis, pretreatment levels of IL-8 were significantly lower in patients who showed an after TACE [17]. OR after TACE compared to non-responding (non-OR) patients (Figure 2A). Median pre-interventional In this analysis, pretreatment levels of IL-8 were significantly lower in patients who showed an IL-6 levels were also lower in OR patients, though statistical significance was not reached (p = 0.126, OR after TACE compared to non-responding (non-OR) patients (Figure 2A). Median preFigure 2B), while circulating levels of CCL22 before TACE were unaltered between OR and non-OR interventional IL-6 levels alsothis, lower OR analysis patients, statistical significance was not patients (Figure 2C). In were line with ROCin curve forthough the discrimination between OR and reached (p = 0.126, Figure 2B),AUC while circulating of CCL22 TACE were unaltered between non-OR patients revealed values of 0.782levels and 0.717 for IL-8before and IL-6 serum levels, which were OR and non-OR patients (Figure line with this, function ROC curve analysis for of the discrimination superior to bilirubin serum levels2C). as aIn surrogate for liver (AUC: 0.549), size target lesion (AUC: and the patients’ (AUC: 0.500, On the contrary, circulating levels between OR0.646), and non-OR patientsage revealed AUC Figure values2D). of 0.782 and 0.717 for IL-8 and IL-6ofserum CCL22 could notsuperior discriminate between OR and levels non-ORaspatients (AUC: for 0.527, Figure 2D). (AUC: 0.549), levels, which were to bilirubin serum a surrogate liver function size of target lesion (AUC: 0.646), and the patients’ age (AUC: 0.500, Figure 2D). On the contrary, circulating levels of CCL22 could not discriminate between OR and non-OR patients (AUC: 0.527, Figure 2D). To further substantiate a potential predictive value of IL-8 and IL-6 for discrimination between OR and non-OR patients, we next performed univariate binary logistic regression analysis. Importantly, in this analysis, pre-interventional serum levels of IL-8 and IL-6 below our defined ideal cut-off values (IL-8: 36.36 pg/mL, IL-6: 13.51 pg/mL) were significant predictors for an OR following
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respectively (Figure 2E). Of note, serum levels of CCL22 had no predictive value for an OR (odds Int. J. Mol. Sci. 2018, 19, 1766 4 of 13 ratio: 0.432, p = 0.190, 95% CI: 0.123–1.515, Figure 2E).
Figure 2. Pre-interventional Pre-interventional serum serum levels levels of of IL-8 IL-8 and and IL-6 IL-6 predict predict an an objective objectiveresponse responseafter afterTACE. TACE. (A) Pre-treatment serum levels of IL-8 are significantly lower in patients who showed an objective response (OR) to TACE compared to non-responding (non-OR) patients; (B) Initial serum IL-6 levels similarly similarly show show aa strong trend towards lower serum concentrations concentrations in OR patients; (C) Circulating levels of of CCL22 CCL22 are unaltered between between OR and non-OR patients; patients; (D) (D) ROC ROC curve curve analysis analysis for for the levels discrimination between between OR OR and and non-OR non-OR patients; patients; (E) (E) Univariate Univariate binary binary logistic logistic regression analysis discrimination reveals circulating IL-6 and IL-8 IL-8 but but not not CCL22 CCL22 levels levels as as predictors predictors of of an an objective objective response response to to TACE TACE 0.01; *** *** pp
