http://informahealthcare.com/bmk ISSN: 1354-750X (print), 1366-5804 (electronic) Biomarkers, 2014; 19(4): 287–290 ! 2014 Informa UK Ltd. DOI: 10.3109/1354750X.2014.908954
RESEARCH ARTICLE
Serum interleukin-17 as a diagnostic and prognostic marker for non-small cell lung cancer Chunhua Xu1#, Keke Hao1#, Like Yu1, and Xiuwei Zhang2 Department of Respiratory Medicine, Nanjing Chest Hospital, Nanjing, China and 2Department of Respiratory Medicine, Nanjing Jiangning Hospital, Nanjing, China
Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
1
Abstract
Keywords
Objective: The aim of this study was to explore the clinical role of serum interleukin (IL)-17 in patients with non-small-cell lung cancer (NSCLC). Materials and method: Serum specimens from 128 patients with NSCLC and 60 healthy controls were collected. The concentrations of IL-17 were measured using enzyme-linked immunosorbent assay. Results: Serum IL-17 levels were higher in the NSCLC group in comparison with the control group (p50.01). With a cut-off value of 16 pg/ml, IL-17 showed a good diagnostic performance for NSCLC. Multivariate survival analysis indicated that IL-17 was an independent prognostic factor in NSCLC. Conclusion: Measurement of IL-17 might be a useful diagnostic and prognostic value for patients with NSCLC.
Diagnosis, interleukin-17, non-small cell lung cancer, prognosis
Introduction Lung cancer is the leading cause of cancer-related death worldwide (Chen et al., 2012). Non-small-cell lung cancer (NSCLC) accounts for 80–85% of total lung malignancies (Smith et al., 2009). Although advances in noninvasive methods have improved our ability to detect lung cancer, more than 75% of patients with lung cancer present at an advanced stage of disease (Oguz et al., 2013), so that patients have little prospect of effective and curative treatment, with 5-year survival rates of less than 15% (Jemal et al., 2010). Tumor markers play a key role in patient management for many malignancies. The potential uses of serum tumor markers include aiding early diagnosis and determining prognosis. Tumor markers that are currently available for lung cancer, such as carcinoembryonic antigen, cytokeratin 19 fragment and neuron-specific enolase, are not satisfactory for diagnosis at an early stage or for monitoring the disease because of their relatively low sensitivity and specificity in detecting the presence of cancer cells (Grunnet & Sorensen, 2010; Nisman et al., 2009; Okamura et al., 2013; Tufman & Huber, 2010). Therefore, more studies are required to discover novel biomarkers to diagnose or screen early NSCLC.
#
Chunhua Xu and Keke Hao are responsible for statistical design/ analysis. E-mail: [email protected] (C. Xu); Haokk73@ yeah.net (K. Hao) Address for correspondence: Li-ke Yu, Department of Respiratory Medicine, Nanjing Chest Hospital, 215 Guangzhou Road, Nanjing 210029, China. Tel/Fax: +86-25-8372-8558. E-mail: yulike_doctor@ 163.com
History Received 21 February 2014 Revised 22 March 2014 Accepted 24 March 2014 Published online 14 April 2014
Serum tumor markers are non-invasive tools for identifying malignant tumors, and are commonly used as a prognostic factor and an indicator of therapeutic efficacy in clinical practice. Interleukin (IL)-17 is a pro-inflammation cytokine mainly produced by CD4+T lymphocytes and may be important in tumor cell growth and contribute to the aggressiveness of human tumors (Garley et al., 2009; Moseley et al., 2003; Prabhala et al., 2010). IL-17 was significantly increased in the lung cancer (Numasaki et al., 2005). However, it is uncertain to date whether serum IL-17 has clinical significance in NSCLC. Therefore, this study investigated the baseline serum levels of IL-17 in patients with NSCLC to determine its potential diagnostic and prognostic roles.
Methods Patients A total of 128 patients with NSCLC who examined at the Nanjing Chest Hospital between January 2006 and May 2007 were included in this study. The cohort of patients included 77 (60.2%) male and 51 (39.8%) female subjects, with a median age of 54 years. All patients were not affected by inflammatory disease, chronic liver disease, asthma, allergies or other concomitant diseases capable of interfering with IL-17 assay. As control subjects, 60 healthy volunteers (36 males and 24 females with a median age of 56 years) were enrolled in the same period. They were all healthy, had no clinical signs or symptoms of cancer, inflammatory disease, liver or kidney disease. The clinical features of the patients are summarized in Table 1. Follow-up lasted through December 2012, with a
288
C. Xu et al.
Biomarkers, 2014; 19(4): 287–290
Table 1. Clinical characteristics of patients with NSCLC and controls. Variables Subject, No. Age, year Male/female Histology AC SCC
NSCLC
Control
p Value
128 58.5 ± 11.2 77/51
60 56.3 ± 12.5 36/24
0.843 0.716
68 60
AC, adenocarcinoma and SCC, squamous cell carcinoma.
median follow-up period of 24 months for living patients (range, 3–81 months). The overall survival was defined as the time from the date of diagnosis to the date of death. The study protocol was approved by the ethics committee of Nanjing Chest Hospital. All patients provided written informed consent before enrollment.
Figure 1. Levels of IL-17 in NSCLC. The levels of IL-17 were significantly higher in patients with NSCLC than in those with the controls. *p50.01.
Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
Sample collection and determination of IL-17 levels Serum samples from each individual were obtained at the time of diagnosis before any therapeutic measures were started (surgery, chemotherapy or radiation). Samples were centrifuged at 1500 g for 10 min at 4 C. The supernatant were stored at 80 C for assessment of the levels of IL-17 and C-reactive protein (CRP). The IL-17 concentration was determined by enzyme-linked immunosorbent assay (ELISA) with the commercial human IL-17 ELISA Ready-SET-Go kit (eBioscience, San Diego, CA). CRP was analyzed by routine clinical laboratory test protocols using an automated chemical analyzer (BECKMAN SYNCHRON-LX20, Beckman Coulter, Brea, CA). All assays were run in duplicate, with dilutions as appropriate, and the technicians were blinded to clinical data. Statistical analysis Statistical software (SPSS for Windows, version 18, SPSS Inc., Chicago, IL) was used for the analysis. Differences between independent groups were examined by the Mann– Whitney U test. To determine the diagnostic accuracy of IL17, receiver operating characteristic (ROC) curves were retrieved from logistic regression analysis, and the area under the curve was calculated. Significance testing of correlations was evaluated using Spearman rank correlation analysis. Univariate survival analysis was performed using the Kaplan–Meier method and the log-rank test. Multivariate analysis was conducted to determine an independent impact on survival using the Cox proportional hazard method. p50.05 was considered statistically significant.
Results Comparison of serum IL-17 levels between patients with NSCLC and the controls As shown in Figure 1, the levels of IL-17 were significantly higher in patients with NSCLC (21.34 ± 9.26 pg/ml) than in those with the controls (11.12 ± 2.83 pg/ml) (p50.01). Diagnostic value of IL-17 in NSCLC To explore the diagnostic value of IL-17 in NSCLC, we calculated which concentration corresponded to 95% specificity in the controls. IL-17 cut-off value was found to be
Figure 2. ROC of IL-17 for the diagnosis of NSCLC. Serum levels of IL-17 among 128 patients with NSCLC and 60 healthy controls were determined. The diagnostic potentials of IL-17 were assessed by ROC curves. The AUC value was 0.894.
16 pg/ml. The area under the ROC curve was 0.894 (95% confidence interval: 0.846–0.942). With a cut-off value of 16 pg/ml, IL-17 had a sensitivity of 70.3%, a specificity of 95.0%, an accuracy of 78.2%, a positive predictive value of 96.8% and a negative predictive value of 60.0% (Figure 2). Relationship between serum IL-17 levels and clinicopathological characteristics The relationships between serum IL-17 levels and clinicopathological characteristics of patients with NSCLC are listed in Table 2. The levels of IL-17 were significantly correlated with tumor-node-metastasis (TNM) stage (p ¼ 0.001), lymph node metastases (p ¼ 0.002) and distant metastases (p ¼ 0.008), not differ with age (p ¼ 0.108), gender (p ¼ 0.734) or histology (p ¼ 0.166). Correlation between serum IL-17 and CRP levels in NSCLC The level of serum CRP in patients with NSCLC was 10.15 ± 3.56 mg/l. There is no significant correlation between serum IL-17 and CRP levels in NSCLC (r ¼ 0.093, p ¼ 0.614).
Serum IL-17 as a diagnostic and prognostic marker for NSCLC
DOI: 10.3109/1354750X.2014.908954
Table 2. The clinicopathological factors of NSCLC and the association with IL-17 levels.
Table 3. Multivariate Cox proportional hazards analysis for survival in NSCLC.
Factors
p Value
Parameters
0.108
Age, year 60 1 560 1.415 Gender Male 1 Female 1.118 Histology AC 1 SCC 0.932 TNM stage I–II 1 III–IV 1.019 Lymph node metastases Absent 1 Present 1.135 Distant metastases Absent 1 Present 3.175 IL-17 (pg/ml) 16 1 516 0.378
Age, year 60 560 Gender Male Female Histology AC SCC TNM stage I–II III–IV Lymph node metastases Absent Present Distant metastases Absent Present Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
289
n
IL-17 (pg/ml)
65 63
21.67 ± 9.26 21.86 ± 9.63 0.734
77 51
22.96 ± 9.89 23.58 ± 9.14 0.166
68 60
24.32 ± 8.91 21.98 ± 9.36 0.001a
85 43
21.07 ± 9.28 27.43 ± 8.52 a
0.002 74 54
21.41 ± 9.68 26.13 ± 8.57
88 40
21.73 ± 8.67 26.52 ± 9.73
0.008a
a
Significant difference. AC, adenocarcinoma and SCC, squamous cell carcinoma.
HR
95% CI
p Value
0.496–4.035
0.517
0.476–2.628
0.798
0.231–3.769
0.922
1.007–1.031
0.002a
0.499–2.581
0.762
1.365–7.403
0.007a
0.170–0.842
0.017a
a Significant difference. HR, hazard ratio and CI, confidence interval.
Figure 3. Kaplan–Meier survival curves for IL-17 in patients with NSCLC. Survival of patients with NSCLC with IL-17 levels of 516 pg/ml was significantly longer than survival of patients with levels of 16 pg/ml (p ¼ 0.024).
Association of serum IL-17 levels with survival Finally, we determined whether the baseline serum concentration of IL-17 would be a prognostic marker in lung cancer. Patients with NSCLC were dichotomized using the same cut-off value. Median overall survival of patients with IL-17 16 pg/ml (n ¼ 90) was 16 months in comparison with 28 months in cases with IL-17516 pg/ml (n ¼ 38) (logrank p ¼ 0.024) (Figure 3). Multivariate Cox regression analysis confirmed that levels of IL-17 was independent prognostic factors for overall survival in patients with NSCLC (Table 3).
Discussion To the best of our knowledge, this is the first study on NSCLC in which serum IL-17 levels were simultaneously investigated for their diagnostic and prognostic power of lung cancer. Our findings suggest that profoundly elevated serum concentrations of IL-17 ( 16 pg/ml) correlated with shorter survival
in patients with NSCLC. Furthermore, multivariate analysis of prognostic factors identified serum IL-17 concentration as an independent prognostic factor for overall survival in lung cancer. These results suggest that IL-17 is an indicator not only for presence of lung cancer but also subsequent survival outcome. IL-17 is a pro-inflammatory cytokine mainly produced by activated T cells. IL-17-producing CD4+ T helper cells have potent pro-inflammatory properties and play a role in cancers (Dong, 2008). Recently, accumulating evidence has shown that IL-17-positive cells are frequently resent in multiple cancers, including prostate cancer (Steiner et al., 2002), colorectal cancer (Le Gouvello et al., 2008), hepatocellular carcinoma (Zhang et al., 2009), breast cancer (Zhu et al., 2008), ovarian cancer (Miyahara et al., 2008) as well as NSCLC (Numasaki et al., 2005). Most of the literature report that IL-17 promotes angiogenesis in tumor models and IL-17 expression correlates well with the numbers of blood vessels in human ovarian cancer (Droeser et al., 2013), hepatocellular carcinoma (Zhang et al., 2009) and NSCLC (Numasaki et al., 2005); although some reports indicated that IL-17 may protect against tumors by promoting immune systemmediated tumor rejection (Benchetrit et al., 2002). These results suggest importance for IL-17 in immune evasion by tumors. One inference from this is that IL-17 in serum could be a good indicator for follow-up of patients with lung cancer, as was supported by our results. In this study, serum IL-17 level were significantly elevated in patients with NSCLC compared with control subjects, making them potential adjunctive tools for diagnosis of lung cancer. Furthermore, at a cut-off value of 16 pg/ml, IL-17 had a sensitivity of 70.3% and a specificity of 95.0% for the prediction of lung cancer. Importantly, the serum IL-17 levels were significantly correlated with TNM stage, the presence of lymph node and distant metastases, which was consistent with previous findings in other cancer types
290
C. Xu et al.
(Liao et al., 2013). However, statistical analysis revealed no significant correlations between serum IL-17 and CRP levels in NSCLC. In conclusion, our results suggest that serum IL-17 may be a useful diagnostic biomarker and shows a promising potential as prognostic marker in patients with NSCLC. More large-scale prospective studies are warranted to confirm the findings.
Declaration of interest
Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
The authors declare that they have no competing interests. This work was supported, in part, by a grant from ‘‘Twelve-Five Plan’’ the Major Program of Nanjing Medical Science and Technique Development Foundation (Molecular Mechanism Study on Metastasis and Clinical Efficacy Prediction of Non-small Cell Lung Cancer) (LK-Yu). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
References Benchetrit F, Ciree A, Vives V, et al. (2002). Interleukin-17 inhibits tumor cell growth by means of a T-cell-dependent mechanism. Blood 99:2114–21. Chen Z, Wang T, Cai L, et al. (2012). Clinicopathological significance of non-small cell lung cancer with high prevalence of Oct-4 tumor cells. J Exp Clin Cancer Res 31:10. Dong C. (2008). TH17 cells in development: an updated view of their molecular identity and genetic programming. Nat Rev Immunol 8: 337–548. Droeser RA, Gu¨th U, Eppenberger-Castori S, et al. (2013). High IL-17positive tumor immune cell infiltration is indicative for chemosensitivity of ovarian carcinoma. J Cancer Res Clin Oncol 139:1295–302. Garley M, Jabłon´ska E, Grabowska SZ, Piotrowski L. (2009). IL-17 family cytokines in neutrophils of patients with oral epithelial squamous cell carcinoma. Neoplasma 56:96–100. Grunnet M, Sorensen JB. (2010). Carcinoembryonic antigen (CEA) as tumor marker in lung cancer. Lung Cancer 76:138–43.
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Jemal A, Siegel R, Xu J, Ward E. (2010). Cancer statistics, 2010. CA Cancer J Clin 60:277–300. Le Gouvello S, Bastuji-Garin S, Aloulou N, et al. (2008). High prevalence of Foxp3 and IL17 in MMR-proficient colorectal carcinomas. Gut 57:772–9. Liao R1, Sun J, Wu H, et al. (2013). High expression of IL-17 and IL-17RE associate with poor prognosis of hepatocellular carcinoma. J Exp Clin Cancer Res 32:3. Miyahara YK, Odunsi K, Chen W, et al. (2008). Generation and regulation of human CD4+ IL-17-producing T cells in ovarian cancer. Proc Natl Acad Sci USA 105:15505–10. Moseley TA, Haudenschild DR, Rose L, Reddi AH. (2003). Interleukin17 family and IL-17 receptors. Cytokine Growth Factor Rev 14: 155–74. Nisman B, Biran H, Ramu N, et al. (2009). The diagnostic and prognostic value of ProGRP in lung cancer. Anticancer Res 29: 4827–32. Numasaki M, Watanabe M, Suzuki T, et al. (2005). IL-17 enhances the net angiogenic activity and in vivo growth of human non-small cell lung cancer in SCID mice through promoting CXCR-2-dependent angiogenesis. J Immunol 175:6177–89. Oguz A, Unal D, Tasdemir A, et al. (2013). Lack of any association between blood groups and lung cancer, independent of histology. Asian Pac J Cancer Prev 14:453–6. Okamura K, Takayama K, Izumi M, et al. (2013). Diagnostic value of CEA and CYFRA 21-1 tumor markers in primary lung cancer. Lung Cancer 80:45–9. Prabhala RH, Pelluru D, Fulciniti M, et al. (2010). Elevated IL-17 produced by TH17 cells promotes myeloma growth and inhibits immune function in multiple myeloma. Blood 115:5385–92. Smith RA, Cokkinides V, Brawley OW. (2009). Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin 59:27–41. Steiner GE, Newman ME, Paikl D, et al. (2002). Expression and function of pro-inflammatory interleukin IL-17 and IL-17 receptor in normal, benign hyperplastic, and malignant prostate. Prostate 56:171–82. Tufman A, Huber RM. (2010). Biological markers in lung cancer: a clinician’s perspective. Cancer Biomark 6:123–35. Zhang JP, Yan J, Xu J, et al. (2009). Increased intratumoral IL-17producing cells correlate with poor survival in hepatocellular carcinoma patients. J Hepatol 50:980–9. Zhu X, Mulcahy LA, Mohammed RA, et al. (2008). IL-17 expression by breast-cancer-associated macrophages: IL-17 promotes invasiveness of breast cancer cell lines. Breast Cancer Res 10:R95.
RESEARCH ARTICLE
Serum interleukin-17 as a diagnostic and prognostic marker for non-small cell lung cancer Chunhua Xu1#, Keke Hao1#, Like Yu1, and Xiuwei Zhang2 Department of Respiratory Medicine, Nanjing Chest Hospital, Nanjing, China and 2Department of Respiratory Medicine, Nanjing Jiangning Hospital, Nanjing, China
Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
1
Abstract
Keywords
Objective: The aim of this study was to explore the clinical role of serum interleukin (IL)-17 in patients with non-small-cell lung cancer (NSCLC). Materials and method: Serum specimens from 128 patients with NSCLC and 60 healthy controls were collected. The concentrations of IL-17 were measured using enzyme-linked immunosorbent assay. Results: Serum IL-17 levels were higher in the NSCLC group in comparison with the control group (p50.01). With a cut-off value of 16 pg/ml, IL-17 showed a good diagnostic performance for NSCLC. Multivariate survival analysis indicated that IL-17 was an independent prognostic factor in NSCLC. Conclusion: Measurement of IL-17 might be a useful diagnostic and prognostic value for patients with NSCLC.
Diagnosis, interleukin-17, non-small cell lung cancer, prognosis
Introduction Lung cancer is the leading cause of cancer-related death worldwide (Chen et al., 2012). Non-small-cell lung cancer (NSCLC) accounts for 80–85% of total lung malignancies (Smith et al., 2009). Although advances in noninvasive methods have improved our ability to detect lung cancer, more than 75% of patients with lung cancer present at an advanced stage of disease (Oguz et al., 2013), so that patients have little prospect of effective and curative treatment, with 5-year survival rates of less than 15% (Jemal et al., 2010). Tumor markers play a key role in patient management for many malignancies. The potential uses of serum tumor markers include aiding early diagnosis and determining prognosis. Tumor markers that are currently available for lung cancer, such as carcinoembryonic antigen, cytokeratin 19 fragment and neuron-specific enolase, are not satisfactory for diagnosis at an early stage or for monitoring the disease because of their relatively low sensitivity and specificity in detecting the presence of cancer cells (Grunnet & Sorensen, 2010; Nisman et al., 2009; Okamura et al., 2013; Tufman & Huber, 2010). Therefore, more studies are required to discover novel biomarkers to diagnose or screen early NSCLC.
#
Chunhua Xu and Keke Hao are responsible for statistical design/ analysis. E-mail: [email protected] (C. Xu); Haokk73@ yeah.net (K. Hao) Address for correspondence: Li-ke Yu, Department of Respiratory Medicine, Nanjing Chest Hospital, 215 Guangzhou Road, Nanjing 210029, China. Tel/Fax: +86-25-8372-8558. E-mail: yulike_doctor@ 163.com
History Received 21 February 2014 Revised 22 March 2014 Accepted 24 March 2014 Published online 14 April 2014
Serum tumor markers are non-invasive tools for identifying malignant tumors, and are commonly used as a prognostic factor and an indicator of therapeutic efficacy in clinical practice. Interleukin (IL)-17 is a pro-inflammation cytokine mainly produced by CD4+T lymphocytes and may be important in tumor cell growth and contribute to the aggressiveness of human tumors (Garley et al., 2009; Moseley et al., 2003; Prabhala et al., 2010). IL-17 was significantly increased in the lung cancer (Numasaki et al., 2005). However, it is uncertain to date whether serum IL-17 has clinical significance in NSCLC. Therefore, this study investigated the baseline serum levels of IL-17 in patients with NSCLC to determine its potential diagnostic and prognostic roles.
Methods Patients A total of 128 patients with NSCLC who examined at the Nanjing Chest Hospital between January 2006 and May 2007 were included in this study. The cohort of patients included 77 (60.2%) male and 51 (39.8%) female subjects, with a median age of 54 years. All patients were not affected by inflammatory disease, chronic liver disease, asthma, allergies or other concomitant diseases capable of interfering with IL-17 assay. As control subjects, 60 healthy volunteers (36 males and 24 females with a median age of 56 years) were enrolled in the same period. They were all healthy, had no clinical signs or symptoms of cancer, inflammatory disease, liver or kidney disease. The clinical features of the patients are summarized in Table 1. Follow-up lasted through December 2012, with a
288
C. Xu et al.
Biomarkers, 2014; 19(4): 287–290
Table 1. Clinical characteristics of patients with NSCLC and controls. Variables Subject, No. Age, year Male/female Histology AC SCC
NSCLC
Control
p Value
128 58.5 ± 11.2 77/51
60 56.3 ± 12.5 36/24
0.843 0.716
68 60
AC, adenocarcinoma and SCC, squamous cell carcinoma.
median follow-up period of 24 months for living patients (range, 3–81 months). The overall survival was defined as the time from the date of diagnosis to the date of death. The study protocol was approved by the ethics committee of Nanjing Chest Hospital. All patients provided written informed consent before enrollment.
Figure 1. Levels of IL-17 in NSCLC. The levels of IL-17 were significantly higher in patients with NSCLC than in those with the controls. *p50.01.
Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
Sample collection and determination of IL-17 levels Serum samples from each individual were obtained at the time of diagnosis before any therapeutic measures were started (surgery, chemotherapy or radiation). Samples were centrifuged at 1500 g for 10 min at 4 C. The supernatant were stored at 80 C for assessment of the levels of IL-17 and C-reactive protein (CRP). The IL-17 concentration was determined by enzyme-linked immunosorbent assay (ELISA) with the commercial human IL-17 ELISA Ready-SET-Go kit (eBioscience, San Diego, CA). CRP was analyzed by routine clinical laboratory test protocols using an automated chemical analyzer (BECKMAN SYNCHRON-LX20, Beckman Coulter, Brea, CA). All assays were run in duplicate, with dilutions as appropriate, and the technicians were blinded to clinical data. Statistical analysis Statistical software (SPSS for Windows, version 18, SPSS Inc., Chicago, IL) was used for the analysis. Differences between independent groups were examined by the Mann– Whitney U test. To determine the diagnostic accuracy of IL17, receiver operating characteristic (ROC) curves were retrieved from logistic regression analysis, and the area under the curve was calculated. Significance testing of correlations was evaluated using Spearman rank correlation analysis. Univariate survival analysis was performed using the Kaplan–Meier method and the log-rank test. Multivariate analysis was conducted to determine an independent impact on survival using the Cox proportional hazard method. p50.05 was considered statistically significant.
Results Comparison of serum IL-17 levels between patients with NSCLC and the controls As shown in Figure 1, the levels of IL-17 were significantly higher in patients with NSCLC (21.34 ± 9.26 pg/ml) than in those with the controls (11.12 ± 2.83 pg/ml) (p50.01). Diagnostic value of IL-17 in NSCLC To explore the diagnostic value of IL-17 in NSCLC, we calculated which concentration corresponded to 95% specificity in the controls. IL-17 cut-off value was found to be
Figure 2. ROC of IL-17 for the diagnosis of NSCLC. Serum levels of IL-17 among 128 patients with NSCLC and 60 healthy controls were determined. The diagnostic potentials of IL-17 were assessed by ROC curves. The AUC value was 0.894.
16 pg/ml. The area under the ROC curve was 0.894 (95% confidence interval: 0.846–0.942). With a cut-off value of 16 pg/ml, IL-17 had a sensitivity of 70.3%, a specificity of 95.0%, an accuracy of 78.2%, a positive predictive value of 96.8% and a negative predictive value of 60.0% (Figure 2). Relationship between serum IL-17 levels and clinicopathological characteristics The relationships between serum IL-17 levels and clinicopathological characteristics of patients with NSCLC are listed in Table 2. The levels of IL-17 were significantly correlated with tumor-node-metastasis (TNM) stage (p ¼ 0.001), lymph node metastases (p ¼ 0.002) and distant metastases (p ¼ 0.008), not differ with age (p ¼ 0.108), gender (p ¼ 0.734) or histology (p ¼ 0.166). Correlation between serum IL-17 and CRP levels in NSCLC The level of serum CRP in patients with NSCLC was 10.15 ± 3.56 mg/l. There is no significant correlation between serum IL-17 and CRP levels in NSCLC (r ¼ 0.093, p ¼ 0.614).
Serum IL-17 as a diagnostic and prognostic marker for NSCLC
DOI: 10.3109/1354750X.2014.908954
Table 2. The clinicopathological factors of NSCLC and the association with IL-17 levels.
Table 3. Multivariate Cox proportional hazards analysis for survival in NSCLC.
Factors
p Value
Parameters
0.108
Age, year 60 1 560 1.415 Gender Male 1 Female 1.118 Histology AC 1 SCC 0.932 TNM stage I–II 1 III–IV 1.019 Lymph node metastases Absent 1 Present 1.135 Distant metastases Absent 1 Present 3.175 IL-17 (pg/ml) 16 1 516 0.378
Age, year 60 560 Gender Male Female Histology AC SCC TNM stage I–II III–IV Lymph node metastases Absent Present Distant metastases Absent Present Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
289
n
IL-17 (pg/ml)
65 63
21.67 ± 9.26 21.86 ± 9.63 0.734
77 51
22.96 ± 9.89 23.58 ± 9.14 0.166
68 60
24.32 ± 8.91 21.98 ± 9.36 0.001a
85 43
21.07 ± 9.28 27.43 ± 8.52 a
0.002 74 54
21.41 ± 9.68 26.13 ± 8.57
88 40
21.73 ± 8.67 26.52 ± 9.73
0.008a
a
Significant difference. AC, adenocarcinoma and SCC, squamous cell carcinoma.
HR
95% CI
p Value
0.496–4.035
0.517
0.476–2.628
0.798
0.231–3.769
0.922
1.007–1.031
0.002a
0.499–2.581
0.762
1.365–7.403
0.007a
0.170–0.842
0.017a
a Significant difference. HR, hazard ratio and CI, confidence interval.
Figure 3. Kaplan–Meier survival curves for IL-17 in patients with NSCLC. Survival of patients with NSCLC with IL-17 levels of 516 pg/ml was significantly longer than survival of patients with levels of 16 pg/ml (p ¼ 0.024).
Association of serum IL-17 levels with survival Finally, we determined whether the baseline serum concentration of IL-17 would be a prognostic marker in lung cancer. Patients with NSCLC were dichotomized using the same cut-off value. Median overall survival of patients with IL-17 16 pg/ml (n ¼ 90) was 16 months in comparison with 28 months in cases with IL-17516 pg/ml (n ¼ 38) (logrank p ¼ 0.024) (Figure 3). Multivariate Cox regression analysis confirmed that levels of IL-17 was independent prognostic factors for overall survival in patients with NSCLC (Table 3).
Discussion To the best of our knowledge, this is the first study on NSCLC in which serum IL-17 levels were simultaneously investigated for their diagnostic and prognostic power of lung cancer. Our findings suggest that profoundly elevated serum concentrations of IL-17 ( 16 pg/ml) correlated with shorter survival
in patients with NSCLC. Furthermore, multivariate analysis of prognostic factors identified serum IL-17 concentration as an independent prognostic factor for overall survival in lung cancer. These results suggest that IL-17 is an indicator not only for presence of lung cancer but also subsequent survival outcome. IL-17 is a pro-inflammatory cytokine mainly produced by activated T cells. IL-17-producing CD4+ T helper cells have potent pro-inflammatory properties and play a role in cancers (Dong, 2008). Recently, accumulating evidence has shown that IL-17-positive cells are frequently resent in multiple cancers, including prostate cancer (Steiner et al., 2002), colorectal cancer (Le Gouvello et al., 2008), hepatocellular carcinoma (Zhang et al., 2009), breast cancer (Zhu et al., 2008), ovarian cancer (Miyahara et al., 2008) as well as NSCLC (Numasaki et al., 2005). Most of the literature report that IL-17 promotes angiogenesis in tumor models and IL-17 expression correlates well with the numbers of blood vessels in human ovarian cancer (Droeser et al., 2013), hepatocellular carcinoma (Zhang et al., 2009) and NSCLC (Numasaki et al., 2005); although some reports indicated that IL-17 may protect against tumors by promoting immune systemmediated tumor rejection (Benchetrit et al., 2002). These results suggest importance for IL-17 in immune evasion by tumors. One inference from this is that IL-17 in serum could be a good indicator for follow-up of patients with lung cancer, as was supported by our results. In this study, serum IL-17 level were significantly elevated in patients with NSCLC compared with control subjects, making them potential adjunctive tools for diagnosis of lung cancer. Furthermore, at a cut-off value of 16 pg/ml, IL-17 had a sensitivity of 70.3% and a specificity of 95.0% for the prediction of lung cancer. Importantly, the serum IL-17 levels were significantly correlated with TNM stage, the presence of lymph node and distant metastases, which was consistent with previous findings in other cancer types
290
C. Xu et al.
(Liao et al., 2013). However, statistical analysis revealed no significant correlations between serum IL-17 and CRP levels in NSCLC. In conclusion, our results suggest that serum IL-17 may be a useful diagnostic biomarker and shows a promising potential as prognostic marker in patients with NSCLC. More large-scale prospective studies are warranted to confirm the findings.
Declaration of interest
Biomarkers Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
The authors declare that they have no competing interests. This work was supported, in part, by a grant from ‘‘Twelve-Five Plan’’ the Major Program of Nanjing Medical Science and Technique Development Foundation (Molecular Mechanism Study on Metastasis and Clinical Efficacy Prediction of Non-small Cell Lung Cancer) (LK-Yu). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
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