ROLE OF INTERLEUKIN-6 IN THE PARANEOPLASTIC INFLAMMATORY SYNDROME ASSOCIATED WITH RENAL-CELL CARCINOMA Jean-Yves BLAY 1 *, Jean-Franc ¸ois ROSSI 2 , John WIJDENES 3 , Christine MENETRIER-CAUX 1 , Ste ´phane SCHEMANN 1 , Sylvie NE ´ GRIER 1 , Thierry PHILIP 1 and Marie FAVROT 1 1 Unite ´ Cytokine et Cancer et De ´partement de Me ´decine, Centre Le ´on Be ´rard, Lyon, France 2 Hopital Lapeyronie, Montpellier, France 3 Diaclone, Besanc ¸on, France W e investigated the possible causative role of interleukin 6 (IL-6) in the paraneoplastic inflammatory syndrome and in paraneoplastic cholestasis (Stauffer syndrome) associated with renal-cell carcinoma in a series of 119 patients with metastases. IL-6 levels were found significantly higher in patients with paraneoplastic fever and weight loss. Patients with detectable serum IL-6 (n 5 90, 76%) had significantly higher serum CRP, haptoglobin, and serum alkaline-phospha- tase and gammaglutamyl-transferase levels. Platelets, poly- morphonuclear neutrophil (PMN ) and monocyte countswere also significantly higher in patients with detectable serum IL-6; in contrast, hemoglobin levelswere significantly lower in patients with serum IL-6 over 80 pg/ml. Three of these patients were included in a phase-II trial of an anti-IL-6 monoclonal antibody given daily during 21 days. Reductions of CRP, haptoglobin and serum alkalin phosphatases were observed in all 3 patientsduring anti-IL-6 administration, with a subsequent increase up to or above pre-treatment levels after the end of anti-IL-6. Decrease of platelets, PMN and monocyte counts were also observed in the 3 patients during anti-IL-6 administration, with a normalization of cell counts in a patient with increased platelets, PMN and monocyte counts. H emoglobin concentration, serum albumin concentra- tion and lymphocyte counts remained stable in the 3 patients during and after anti-IL-6 administration. Serum IL-6, as evaluated by IRMA, decreased in the 3 patients during anti-IL-6 administration, but increased above pre-treatment levels after the end of anti-IL-6 administration. These results demonstrate that IL-6 is involved in the physiopathology of paraneoplastic syndromes observed in patients with meta- static renal-cell carcinoma, in particular CRP and haptoglobin increase, paraneoplastic cholestasis, also paraneoplastic thrombocytosis, neutrophilia and monocytosis. Int. J. Cancer 72:424–430, 1997. r 1997 Wiley-Liss, Inc. Renal-cell carcinoma is frequently associated with paraneoplas- tic symptoms, in particular cholestasis (Stauffer’s syndrome) and an inflammatory syndrome with fever, increased erythrocyte sedi- mentation rate (ESR) and serum acute-phase protein levels, decreased serum-albumin concentration, thrombocytosis and ane- mia (Ritchie and Chisholm, 1983; Stauffer, 1961; Boxer et al., 1979). The biological mechanisms responsible for these paraneo- plastic syndromes remain poorly understood. Renal-carcinoma cell lines express interleukin 6 (IL-6) receptor and produce IL-6 in vitro (Miki et al., 1988; Takenawa et al., 1991; Blay et al., 1994). Fifty percent or more of patients with metastatic renal carcinoma have increased levels of circulating IL-6, which correlate to increased C-reactive protein levels (Blay et al., 1992a,b; Tsukamoto et al., 1992; Dosquet et al., 1994). Patients with detectable serum IL-6 have poor survival and a poor response rate to immunotherapy with IL-2 and/or interferon alpha (Blay et al., 1992a,b). IL-6 is a pleiotropic cytokine with potent pro-inflammatory activities. It exerts pyrogenic activity and induces the production of acute-phase proteins, including C-reactive protein (CRP) and haptoglobin by liver cells in vitro (Gauldie et al., 1987; Heinrich et al., 1990; Oliviero and Cortese, 1989). IL-6, alone or in combination with other cytokines, also modulates the proliferation and differentiation of multipotent hematopoietic progenitor cells in the human and murine models (Ikebuchi et al., 1987; Rennick et al., 1989; Jacobsen et al., 1992). IL-6 induces the expression of receptors for hematopoietic growth factors on progenitor cells, and accelerates their entry into the cell cycle (Jacobsen et al., 1992). IL-6 stimulates the proliferation and maturation of megakaryocyte progenitors and the proliferation of monocytes and polymorpho- nuclear neutrophil (PMN) progenitors (Lotem et al., 1989; Ishiba- shi et al., 1989; Caracciolo et al., 1989; Bot et al., 1989; Jansen et al., 1992). The administration of recombinant IL-6 induces an increase of serum acute-phase protein levels and thrombocyte counts and a decrease in hemoglobin level in vivo in humans (Weber et al., 1993; Chatelain et al., 1995). In the present study, we investigated the possible role of circulating IL-6 in the physiopathology of paraneoplastic inflamma- tory syndrome and cholestasis associated with metastatic renal-cell carcinoma. PATIENTS, MATERIALAND METHODS: Patients Serum samples were collected prior to chemotherapy and/or immunotherapy in 119 patients with metastatic renal carcinoma who were treated at the Centre Le ´on Be ´rard between 1988 and 1992. The characteristics of the patients are shown in Table I. For each individual patient, serum IL-6, blood cell counts, serum CRP (normal values , 5 mg/L), haptoglobin (normal values: 100–300 mg/dL), albumin (normal values: 38–50 g/L), erythrocyte sedimen- tation rate (normal value ,20 mm/hr), liver enzymes, i.e., gamma glutamyl transferase (normal values: 7–64 U/mL) and alkaline phosphatases (normal values: 26–88 U/mL) were determined on the same day prior to the initiation of a systemic treatment. Anti-IL-6 antibody administration Three patients in relapse after immunotherapy (interferon alpha and/or IL-2) were included in a phase-II trial of a monoclonal antibody anti-IL-6 (BE-8,IgG1, Diaclone, Besanc ¸on, France) after written informed consent. This trial was performed after agreement by an ethic committee, according to French law in force at the time of the clinical trial. BE-8 is a murine IgG1 which neutralizes IL-6 bioactivity. It has been used therapeutically in patients with multiple myeloma and HIV-related non-Hodgkin’s lymphoma (Klein et al., 1991; Emilie et al., 1994; Bataille et al., 1995). Anti-IL-6 was given at a daily dose of 20 mg in 100 ml of normal saline serum with 0.5% human serum albumin, in 1-hr infusions daily during 21 days. None of these patients received glucocorti- coids or non-steroidal anti-inflammatory agents during the 21 days Contract grant sponsor: Comite ´ de Savoie de la Ligue contre le Cancer; Contract grant sponsor: Comite ´ de la Dro ˆme de la Ligue contre le Cancer; Contract grant sponsor: Comite ´ de la Sao ˆne et Loire de la Ligue contre le Cancer; Contract grant sponsor: Fe ´de ´ration des Centres de Lutte contre le Cancer; Contract grant sponsor: Re ´gion Rho ˆne-Alpes. *Correspondence to: Laboratoire de biologie cellulaire, Centre Le ´on Be ´rard, 28, rue Lae ¨nnec, 69373 Lyon ce ´dex 08, France. Fax: (33)78782717. E-mail: blay@lyon.fnclcc.fr Received 29 January 1997; revised 4 April 1997 Int. J. Cancer: 72, 424–430 (1997) r 1997 Wiley-Liss, Inc. Publication of the International Union Against Cancer Publication de l’Union Internationale Contre le Cancer