|
|
 Previous Article | Table of Contents | Next Article 
Blood, Vol. 95 No. 1 (January 1), 2000:
pp. 56-61
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
Improvement in Castleman's disease by humanized
anti-interleukin-6 receptor antibody therapy
Norihiro Nishimoto,
Mitsuko Sasai,
Yoshihito Shima,
Masashi Nakagawa,
Tomoshige Matsumoto,
Toshikazu Shirai,
Tadamitsu Kishimoto, and
Kazuyuki Yoshizaki
From the Department of Medical Science I, School of Health and Sport
Sciences, Osaka University, Suita-city, Osaka, Japan; Department of
Medicine III, Osaka University Medical School, Suita-city, Osaka,
Japan; Department of Pathology II, Juntendo University School of
Medicine, Tokyo, Japan.
 |
Abstract |
Castleman's disease, an atypical lymphoproliferative disorder, can
be classified into 2 types: hyaline-vascular and plasma cell types
according to the histologic features of the affected lymph nodes. The
plasma cell type is frequently associated with systemic manifestations
and is often refractory to systemic therapy including corticosteroids
and chemotherapy, particularly in multicentric form. Dysregulated
overproduction of interleukin-6 (IL-6) from affected lymph nodes is
thought to be responsible for the systemic manifestations of this
disease. Therefore, interference with IL-6 signal transduction may
constitute a new therapeutic strategy for this disease. We used
humanized anti-IL-6 receptor antibody (rhPM-1) to treat 7 patients with
multicentric plasma cell or mixed type Castleman's disease. All
patients had systemic manifestations including secondary amyloidosis in
3. With the approval of our institution's ethics committee and the
consent of the patients, they were treated with 50 to 100 mg
rhPM-1 either once or twice weekly. Immediately after
administration of rhPM-1, fever and fatigue disappeared, and anemia as
well as serum levels of C-reactive protein (CRP), fibrinogen, and
albumin started to improve. After 3 months of treatment,
hypergammaglobulinemia and lymphadenopathy were remarkably alleviated,
as were renal function abnormalities in patients with amyloidosis.
Treatment was well tolerated with only transient leukopenia.
Histopathologic examination revealed reduced follicular
hyperplasia and vascularity after rhPM-1 treatment. The
pathophysiologic significance of IL-6 in Castleman's disease was thus
confirmed, and blockade of the IL-6 signal by rhPM-1 is thought
to have potential as a new therapy based on the pathophysiologic mechanism of multicentric Castleman's disease. (Blood.
2000;95:56-61)
© 2000 by The American Society of Hematology.
| |
Introduction |
Castleman's disease is a lymphoproliferative disorder
with benign hyperplastic lymph nodes characterized histologically by follicular hyperplasia and capillary proliferation with endothelial hyperplasia.1 Castleman's disease has been classified,
according to the histopathologic findings, as either hyalinevascular or plasma cell type.2,3 Patients with plasma cell type or a mixed hyaline-vascular and plasma cell type frequently have systemic manifestations such as fever, anemia, hypergammaglobulinemia, hypoalbuminemia, and an increase in acute phase
proteins.2-4 In cases of localized Castleman's disease,
these clinical abnormalities may resolve after excision of the affected
lymph nodes.3-5 On the other hand, the multicentric form of
Castleman's disease is often refractory to treatment even with
corticosteroids or chemotherapy, and consequently the prognosis for
such patients is poor. Infections are a common cause of death in
multicentric Castleman's disease, as well as renal failure and other
malignancies including malignant lymphoma and Kaposi's
sarcoma.6 Recently, Kaposi's sarcoma-associated herpesvirus (also called human herpesvirus type 8, KSHV/HHV-8) was
reported to be an etiologic agent of Castleman's disease, especially
in patients infected with human immunodeficiency virus (HIV).7-9
Interleukin-6 (IL-6) is a pleiotropic cytokine with a wide range of
biologic activities, such as support of hematopoiesis, regulation of
immune responses, and generation of acute phase reactions.10 We previously demonstrated the generation of
large quantities of IL-6 from the germinal centers of hyperplastic
lymph nodes of patients with plasma cell type Castleman's
disease.5 We also showed a correlation between serum IL-6
concentration and clinical features, suggesting that dysregulated IL-6
production from affected lymph nodes may be responsible for the
systemic manifestations of this disease. On the basis of these
findings, Beck et al11 showed that the in vivo
administration of murine anti-IL-6 monoclonal antibody (mAb) to a
patient with Castleman's disease seemed to be therapeutically
effective, thus confirming the in vivo function of IL-6 in this
disease. However, such a therapeutic effect was transient, because of
either the emergence of neutralizing human antibodies against murine
anti-IL-6 mAb or the inability to attain serum concentrations of
anti-IL-6 mAb sufficient to neutralize increasing IL-6
levels.12 The therapeutic value of murine anti-IL-6 mAb for
human patients thus remains limited. We therefore attempted to block
IL-6 signal transduction by using mAb against the IL-6 receptor
(IL-6R). Furthermore, to be effective as a therapeutic agent
administered to patients in repeated doses, murine anti-IL-6R mAb,
PM-1, was engineered to be a human antibody by grafting the
complimentarity-determining regions from the murine anti-IL-6R mAb into
human IgG, thereby creating a functioning antigen-binding site in a
reshaped human antibody, rhPM-1.13 We used this humanized
anti-IL-6R mAb to treat 7 patients with the multicentric form of plasma
cell or mixed type Castleman's disease.
| |
Patients and methods |
Patients
Seven patients in Osaka University Hospital were recruited, each of
whom had lymphadenopathy at multiple sites, mild splenomegaly, and
constitutional symptoms such as fever and fatigue. Laboratory findings
included anemia, polyclonal hypergammaglobulinemia, hypoalbuminemia, and increased acute phase proteins. All patients had plasma cell or
mixed type Castleman's disease, based on histologic examination of the
biopsy specimens. The clinical characteristics of the patients are
shown in Table 1. All patients had active
disease at the start of anti-IL-6R mAb treatment, and 4 of them had
previously been treated with prednisolone or immunosuppressive therapy
for more than 3 months. Three patients had amyloidosis secondary to Castleman's disease, and 5 had lymphocytic interstitial pneumonia, based on histologic examination of the lung biopsy specimens. None of
the patients had autoimmune disorders, such as rheumatoid arthritis or
Sjögren syndrome, or malignancies. Both HIV and KSHV/HHV-8 were
undetectable by serologic assays and polymerase chain reaction (PCR).
All patients gave their informed consent for the anti-IL-6R mAb therapy
under the auspices of an approval approved by the ethics committee of
Osaka University.
View this table:
[in this window]
[in a new window]
|
Table 1.
Clinical profiles of 7 patients with multicentric form
of Castleman's disease who received humanized anti-IL-6R Ab
therapy
|
|
PCR/Southern hybridization and serologic analysis of KSHV/HHV-8
The PCR/Southern hybridization analysis of KSHV/HHV-8 was performed
as follows. Genomic DNA was extracted from peripheral blood mononuclear
cells or frozen specimens of lymph nodes or both. The DNA extracted
from peripheral blood mononuclear cells of a Japanese patient with
acquired immunodeficiency syndrome-Kaposi's sarcoma (AIDS-KS) with
KSHV/HHV-8 infection was also used as a positive control for
KSHV/HHV-8. Each 50-µL reaction mixture for PCR contained 0.4 to 0.6 µg total DNA, 2.5 U Ex Taq DNA polymerase (Takara, Kyoto, Japan),
dNTP (0.25 mM each), 25 mM TAPS buffer (pH 9.3), 50 mM KCl, 2 mM
MgCl2, 1 mM 2-mercaptoethanol, and the primers (10 pmol
each) the sequences of which were as follows: outer forward primer:
5'-atggcactcgacaagagtatagtgg-3'; outer reverse primer:
5'-cgttagcgtggggaataccaacagg-3' (from nucleotide 633 to nucleotide 1552 in KSU 18 551)14; inner forward primer:
5'-ctatccaagtgcacactcgctgtcc-3'; inner reverse
primer: 5'-ggaaccaaggctgataggatacaaagg-3' (from nucleotide
828 to nucleotide 1288 in KSU 18 551). The PCR procedure consisted of
1 cycle at 94°C for 2 minutes, then 40 cycles at 94°C for 1 minute, at 58°C for 1 minute, and at 72°C for 2 minutes, and 1 cycle at 72°C extension for 5 minutes with a DNA thermal cycler,
Gene Amp PCR system 2400® (Perkin Elmer, Norwalk, CT). First, the
DNA samples were amplified with the pair of outer primers and then with
the pair of inner primers. The PCR products (10 µL) were then
electrophoresed in a 2.0% agarose gel containing ethidium bromide and
visualized with UV light. The PCR products were transferred to a hybond
N+ (Amersham Inc., Arlington Heights, IL), hybridized with a
DIG-labeled KSHV/HHV-8 specific probe: 5'-tgttggtgtaccacatctactccaaaatat-3', and colorimetrically
detected using a DIG DNA Labeling and Detection Kit (Boehringer
Mannheim, Germany) in accordance with the manufacturer's instructions.
Immunofluorescence assay was performed as previously
described.15 Briefly, BCBL-1 cells (106/mL),
the body cavity-based lymphoma cell line that is latently infected with
KSHV/HHV-8 but not Epstein-Barr virus, were treated with 20 ng/mL
phorbol ester (TPA: Sigma, St. Louis, MO) for 48 hours to induce the
viral lytic antigen. Uninduced and TPA-induced BCBL-1 cells were then
washed in phosphate-buffered saline (PBS), spotted on slides
(2 × 104 cells/well), air dried in a laminar flow
hood, and fixed in acetone at  20°C for 10 minutes. All sera
from the patients with Castleman's disease and the Japanese patient
with AIDS-KS were stored at 20°C and heat inactivated at
56°C for 30 minutes before use. Fixed cells were incubated at
37°C for 30 minutes with human sera serially diluted 1:2 beginning
at 10-fold dilution. After washing rigorously in PBS, the slides were
incubated with fluorescein isothiocyanate-conjugated goat anti-human
IgG (Dako, Copenhagen, Denmark) at 37°C for 30 minutes. The slides
were counterstained with a 1:20 000 dilution of Evan's blue (Sigma)
at room temperature for 5 minutes, washed, mounted with 50% (vol/vol)
glycerol in PBS, and examined under a fluorescence microscope.
Administration of humanized anti-IL-6R mAb, rhPM-1
Humanized anti-IL-6R mAb, rhPM-1, (IgG1 class) was produced in
Chinese hamster ovary cells and purified on protein A.13 rhPM-1 retains its specificity for natural and recombinant human IL-6R
with the same affinity as possessed by the original murine anti-IL-6R
mAb, PM-1, and inhibits IL-6 function both in vitro and in
vivo.13,16 rhPM-1 was dissolved in PBS and stored at 20°C until administration. The appropriate amount of rhPM-1
was then diluted to a volume of 50 mL in saline and administered
intravenously over a period of 1 hour only after a skin test using 100 µL of the antibody was negative. Increasing doses (1, 10, 50, and 100 mg/patient) of rhPM-1 were administered intravenously twice weekly to
establish the maximal tolerated dose in every patient. The dose of 100 mg/patient was chosen as the maximal dose because higher doses exceeded
permitted levels of contaminating DNA after purification, in compliance
with the guideline for the manufacture and testing of mAb products for
human use suggested by the Ministry of Health and Welfare, Japan,
although no dose-limiting toxicity was observed. Fifty to 100 mg rhPM-1
was then administered either once or twice weekly for 5 to 42 weeks as
maintenance therapy until completion of the study and cessation of
rhPM-1 production. Total amounts of rhPM-1 administered, the number of
administrations, and the duration of rhPM-1 therapy for each patient
are summarized in Table 1.
Serum IL-6 and soluble IL-6R (sIL-6R) levels
Serum IL-6 levels were determined with a chemiluminescent enzyme
immunoassay (CLEIA).17 The principle of this assay is based on 2-site immunometric reverse sandwich reaction with the aid of a
Lumipulse 1200 (Fujirebio Inc., Tokyo, Japan). Briefly, the mixture of
the sample and mouse anti-IL-6 mAb conjugated with alkaline phosphatase
was incubated at 37°C for 10 minutes, and then added to particles
covalently linked to a murine anti-IL-6 mAb that recognizes a different
epitope than that recognized by the original mAb. After a 10-minute
incubation at 37°C, the particles were separated magnetically and
washed in buffer. Subsequently, the substrate solution,
3-(2'-spiroadamantane)-4-methoxy-4-(3 -phosphoryloxy) phenyl-1, 2-dioxetane disodium salt was added at 37°C, and the chemiluminescent signal was photoncounted after 5 minutes. The detection limit for serum IL-6 was 0.1 pg/mL.
sIL-6R was measured by means of a dissociation-enhanced
fluoroimmunoassay (DELFIA® Pharmacia, Uppsala, Sweden),
as previously described.18 Briefly, 200 µL of sample was
added to microstrips coated with 200 µL anti-human IL-6R mAb (MT18)
(1 µg/mL), and incubated at 4°C, followed by a reaction with
200 µL europium-labeled PM-1 mAb (100 ng/mL) at room temperature for
15 minutes. Fluorescence in each well was measured with a 1230 ARCUS
fluorometer (Pharmacia).
Serum rhPM-1 and anti-rhPM-1 antibody levels
Serum rhPM-1 levels were assessed by enzyme-linked immunosorbent
assay (ELISA). Briefly, 100 µL recombinant human sIL-6R (1 µg/mL)
was added to the wells of an immunoplate precoated with MT18 and
incubated at room temperature for 2 hours. After washing, 100 µL
serum was added and incubated for additional 2 hours. After washing,
bound rhPM-1 was measured using alkaline phosphatase-conjugated goat
anti-human IgG. The calorimetric reaction was measured with a
microplate reader.
Serum anti-rhPM-1 antibody levels were also determined by ELISA. Serum
was added to the wells coated with 100 µL rhPM-1 (5 µg/mL) and
incubated for 2 hours. After washing, biotin-conjugated rhPM-1 was
added and developed with alkaline phosphatase-conjugated to streptavidin.
| |
Results |
Efficacy of humanized anti-IL-6R mAb, rhPM-1
Data representative of patients with Castleman's disease treated
with rhPM-1 are shown in Figure 1. The
patient was a 51-year-old man who suffered from amyloidosis secondary
to Castleman's disease (patient 5 in Table 1). His disease was
refractory to steroid therapy and chemotherapy consisting of melphalan,
vincristine, and doxorubicin hydrochloride. Immediately after the
administration of 20 mg rhPM-1, fever and malaise disappeared, whereas
CRP and fibrinogen started to decrease within 24 hours, but this
treatment was insufficient to obtain a satisfactory therapeutic effect. Treatment with repeated doses of 50 mg rhPM-1 twice a week completely normalized serum CRP levels within 4 weeks; 8 weeks of therapy was
required to increase hemoglobin and albumin levels. After 2 months of
treatment, hypergammaglobulinemia and lymphadenopathy also improved.
Extension of the interval between administrations caused a slight
increase in CRP and a decrease in hemoglobin levels, but constitutional
symptoms did not reappear. Two weeks after termination of the therapy,
fever, malaise, and anemia recurred, and treatment with increased doses
of prednisolone had little effect on his symptoms. Readministration of
rhPM-1, however, was as effective as the first treatment course,
evidenced by improvements in CRP and hemoglobin levels. The data
confirmed that the improvement was due to rhPM-1 therapy but not
influenced by concomitant therapy. A similar therapeutic effect was
obtained by treatment with 100 mg rhPM-1 once a week, without any
significant adverse events. Thus, a total dose of 100 mg rhPM-1 per
week was determined to be an effective therapy.
View larger version (31K):
[in this window]
[in a new window]
| Fig 1.
Representative changes in CRP, hemoglobin, and IgG
concentrations in a patient with multicentric Castleman's disease
during treatment with anit-IL-6R (rhPM-1).
Arrows and shadings indicate the administration of rhPM-1. Note that
treatment with rhPM-1 improved the clinical abnormalities, but that
these recurred 2 weeks after the cessation of the rhPM-1 regimen.
Readministration of rhPM-1 was as effective as the first treatment.
|
|
The patterns of response to rhPM-1 therapy are shown in Figure
2. Improvements in thrombocytosis, serum
levels of CRP, fibrinogen, and serum amyloid A (SAA) protein were
observed within 1 month in most cases, whereas hemoglobin, albumin, and
immunoglobulin levels more gradually improved over a 3- to 4-month
period. Two of the 7 patients showed increased levels of IgE (patient
2, 5300 IU/mL; patient 7, 650 IU/mL) before treatment, which were also reduced by rhPM-1 therapy (1100 IU/mL and 310 IU/mL, respectively). Autoantibodies (antinuclear antibody, anti-DNA antibody) observed in
patients 2 and 6 disappeared after rhPM-1 therapy. Platelet counts and
fibrinogen and immunoglobulin levels decreased only to the low-normal
range. Similar therapeutic effects were observed in patients both with
and without concomitant therapy. As a result of decrease in disease
activity, it was possible to discontinue concomitant therapy in some
patients. Importantly, these therapeutic effects did not diminish even
after continuous 11-month treatment (patient 1). Therapy with rhPM-1
remarkably improved lymphadenopathy in all patients. Only in patient 4 were a few residual lymph nodes palpable, although their sizes were
significantly reduced by the treatment. Computed tomography scanning
confirmed the disappearance of pathologically significant visceral
lymph nodes (> 1 cm in diameter) in all patients. During the
treatment of patients 3, 4, and 5, who had secondary amyloidosis,
constitutional symptoms such as appetite loss, constipation, and
diarrhea (in all 3 patients) gradually improved. Bradyphasia and
bradypragia, which might not be directly caused by the deposition of
amyloid in the brain, also improved in patient 3. Furthermore,
improvements in serum creatinine and daily urine protein levels were
also observed after 4-month therapy in patient 3: before treatment, the
serum creatinine level was 1.8 mg/dL, urine protein 3.1 g/d, serum
 2m 7.1 mg/L, and urine 2 microglobulin
55.5 mg/d; after treatment, the corresponding values were 1.1 mg/dL, 0.9 g/d, 5.3 mg/L, and 7.4 mg/d. No major side
effects of rhPM-1 therapy were observed, except for a transient and
mild decrease in granulocyte counts on the day following mAb administration in 2 patients, which spontaneously recovered within 2 days. No decrease in T-cell function was observed, assessed either by a
skin test with purified protein derivative of tuberculin or by a mixed
lymphocyte culture test with allogeneic T cells.
View larger version (18171813K):
[in this window]
[in a new window]
| Fig 2.
Clinical response patterns in 7 patients treated with
rhPM-1.
CRP indicates C-reactive protein; Fib, fibrinogen; Alb, albumin; IgG,
immunoglobulin G; IgA, immunoglobulin A; IgM, immunoglobulin M; WBC,
white blood cells; Hb, hemoglobin; Plt, platelets; and SAA, serum
amyloid A.
|
|
Histologic examinations of affected lymph nodes
Therapy with rhPM-1 remarkably improved lymphadenopathy in all
patients, and a few small residual lymph nodes remained palpable only
in patient 4. To examine the histologic changes in the affected lymph
nodes resulting from rhPM-1 therapy, a cervical lymph node that
decreased in size on therapy was resected after 3 months of therapy in
patient 4 and compared to pretreatment histopathologic appearance.
Lymph nodes before rhPM-1 treatment showed features of a mixed
hyaline-vascular and plasma cell type: (1) follicular hyperplasia with
a large germinal center penetrated by branching hyaline blood vessels,
(2) concentric appearance of mantle zone lymphocytes, and (3)
proliferation of hyaline capillaries and numerous plasma cells in the
interfollicular areas (Figure 3A and C).
However, after treatment there was (1) a reduction in the size of lymph
nodes, (2) a reduction in both the number and the size of follicles,
resulting in a relative increase in the interfollicular areas (Figure
3B), and (3) a reduction in the vascularity of germinal centers with
residual eosinophilic deposits (Figure 3D). However, the number of
plasma cells and the extent of vascularity in the interfollicular areas
did not show significant changes (Figure 3B).
View larger version (179K):
[in this window]
[in a new window]
| Fig 3.
Serial histopathologic changes with rhPM-1 therapy.
Hyperplastic lymph follicle with hyalinous capillary vessels penetrates
into the germinal center before rhPM-1 treatment (A and C). Note
reduction in both the size of lymph follicles and in the vascularity of
germinal centers with residual eosinophilic deposits after rhPM-1
therapy (B and D). (Hematoxylin-eosin, A and B, original magnification
×100; C and D, original magnification ×400).
|
|
Quantification of these changes was attempted by measuring both the
longitudinal and transverse diameters of the germinal centers. As shown
in Figure 4, both the longitudinal
(210 ± 76 µm, mean ± SD, n = 109) and transverse
diameters (150 ± 45 mm, n = 109) of the germinal centers before
therapy were markedly reduced (133 ± 48 mm, and 98 ± 27 mm,
n = 15, respectively) after therapy (P < 0.005 and
P < 0.001, respectively, assessed by Mann-Whitney's U
test).
View larger version (16K):
[in this window]
[in a new window]
| Fig 4.
Changes in longitudinal and transverse diameters of the
germinal centers.
Open circles indicate mean diameters of germinal centers before
treatment (n = 109) and closed circles indicate those after treatment
(n = 15). The points and vertical bars indicate mean and SDs,
respectively. Both the longitudinal and transverse diameters
significantly decreased (P < 0.005, P < 0.001,
respectively).
|
|
Serum IL-6 and sIL-6R levels
Serum IL-6 levels did not change essentially, although they showed
fluctuations unrelated temporally to the rhPM-1 treatment, whereas
sIL-6R levels increased in the first month after the administration of
rhPM-1, with peak serum levels of up to 700 ng/mL. Repeated administration of rhPM-1 uniformly and rapidly reduced the sIL-6R levels to normal in all patients. The maximum concentrations of serum
sIL-6R did not increase with rhPM-1 maintenance therapy.
Serum rhPM-1 and anti-rhPM-1 antibody levels
The trough level of serum rhPM-1 was 10 µg/mL during maintenance
therapy using 50 mg rhPM-1 twice a week and decreased to 5 µg/mL
using treatment at 100 mg rhPM-1 once a week. Because a slight increase
in CRP was observed with the latter regimen, the former schedule was
considered to be more effective. There were no differences in responses
in terms of constitutional symptoms observed between the 2 regimens.
Ten µg/mL rhPM-1 had previously been proven to inhibit the
IL-6-induced proliferation of myeloma/plasmacytoma cells in
vitro.16
No serum anti-rhPM-1 antibodies were detected during the course of
therapy of these 7 patients.
| |
Discussion |
The clinical course of multicentric Castleman's disease is
unpredictable, but the prognosis is generally poor.4,6 The accompanying constitutive inflammatory state may result in
complications such as pneumonia, amyloidosis, and malignancies, and
treatment should therefore be introduced as early as possible. Although spontaneous remissions are observed in some patients,4,6 in
other patients the disease is refractory to conventional therapies such
as corticosteroids, cytotoxic agents, or radiation. Thus, a new
therapeutic strategy for multicentric Castleman's disease is needed.
The present study showed that the humanized anti-IL-6R mAb, rhPM-1, can
achieve marked responses in the refractory form of this disease without
significant adverse reactions or development of neutralizing
antibodies. Furthermore, rhPM-1 therapy also improved the symptoms and
biochemical abnormalities of secondary amyloidosis, which is often
otherwise untreatable at present, although successful therapy to reduce
the supply of amyloid fibril protein precursors is followed by
substantial regression of amyloid.19 Although re-biopsy of
the kidney was not performed after rhPM-1 therapy, reduced serum
creatinine and urine protein levels suggest that rhPM-1 therapy may
alleviate renal amyloidosis. In addition, rhPM-1 therapy improved the
hydronephrosis in patient 3 who, before therapy, required nephrostomy
due to ureterostenosis resulting from amyloidosis of the ureter. These
findings suggest that visceral amyloid deposition in organs may also be
reversible, if SAA production is inhibited by blocking IL-6 signaling.
rhPM-1 may also reduce the likelihood of malignant lymphoma and
Kaposi's sarcoma because IL-6 is a potent growth factor for these
malignancies.20,21
The fact that the blockade of the IL-6 signal by humanized anti-IL-6R
mAb improved the systemic manifestations of Castleman's disease
confirms a central role for IL-6 in the pathogenesis of this disease.
In particular, overproduction of IL-6 causes inflammatory symptoms,
such as low-grade fever and generalized malaise, as well as laboratory
findings, such as leukocytosis, anemia, thrombocytosis, hypergammaglobulinemia, hypoalbuminemia, and an increase in CRP, fibrinogen, and SAA levels. The observation that elevation in serum IgE
levels also resolved provides further evidence that IL-6 plays some
role in regulating IgE production in vivo and supports the view that
IL-6 induces differentiation of naive T cells into Th2 cells in
vitro.22 Autoantibodies frequently observed in this disease
also disappeared during rhPM-1 treatment, suggesting that IL-6 may also
mediate autoimmune phenomena.
Histologic changes observed in the lymph nodes after treatment imply an
important pathogenic mechanism of this disease. That is, IL-6 may be
involved in the follicular hyperplasia of affected lymph nodes because
blockade of the IL-6 signal reduced both their number and size. Because
IL-6 is mainly produced by activated B cells in the germinal center of
lymph follicles,5,11 an autocrine growth mechanism may be
mediated by IL-6 in follicular B cells of patients with this disease.
The disappearance of hyaline capillaries in the follicles after
treatment with rhPM-1 indicates that IL-6 may also play a role in
angiogenesis, although it remains to be determined whether or not IL-6
acts directly on endothelial cells. IL-6 may promote angiogenesis
through the induction of other factors such as vascular endothelial
growth factor,23 because patients with a typical
hyaline-vascular variant of Castleman's disease do not always show an
increase in serum IL-6 levels.
We have shown the efficacy of humanized antibodies for anti-cytokine
therapy because no anti-rhPM-1 antibodies were detectable, even in the
patient who received multiple injections (67 doses) for 11 months.
Klein et al12 reported that anti-IL-6 mAb therapy induced a
continuous increase in IL-6 production in vivo, and consequently was
unable to administer sufficient anti-IL-6 mAb to neutralize IL-6
activity. A similar phenomenon was observed during anti-IL-6R mAb
therapy as serum sIL-6R increased after administration of rhPM-1.
However, this tendency did not continue, and the highest concentration
observed was about 700 ng/mL, with trough levels of the serum rhPM-1
concentration of 5 to 10 µg/mL. Moreover, maximum sIL-6R levels
gradually decreased with repeated administrations of rhPM-1 over 2 months. This may be the reason the efficacy of humanized anti-IL-6R mAb
therapy did not diminish over time. On the other hand, serum IL-6
levels did not change essentially although they showed some
fluctuations. This is probably because rhPM-1 reacts with IL-6R and
interferes with IL-6-binding to IL-6R, but does not react with IL-6
itself. It may also be the reason a relatively prompt relapse occurred
(after 2 weeks) when the treatment was stopped. Two weeks is consistent
with the period when rhPM-1 was detectable in blood after termination
of the therapy. However, serum IL-6 levels may decrease if we continue the treatment further, because lymphadenopathy improved during the
treatment and a reduction in both the number and size of the follicles,
which are the main sources of IL-6 in this disease,5,11 was
observed in a lymph node.
Although rhPM-1 therapy improved the symptoms associated with
Castleman's disease and reduced lymphadenopathy, recurrence of the
disease was observed after termination of this therapy. Our data
indicate that overproduction of IL-6 causes most of the abnormalities
of Castleman's disease, but the cause of the constitutive overproduction of IL-6 is at present unknown. This may be due to a lack
of NF-IL6, resulting from genetic abnormalities,24 although
familial aggregation has not been reported. Because Castleman's disease is frequently associated with HIV infection6 and
HIV infection also causes overproduction of IL-6,25
infection with a retrovirus may also play a role in pathogenesis. In
this regard, KSHV/HHV-8 was recently reported to be frequently positive
in multicentric Castleman's disease, especially in HIV-infected
patients.7-9 Because a homologue to human IL-6, viral IL-6
(vIL-6), has been identified in the KSHV/HHV-8 genome,26,27
which retains biologic activities similar to human IL-6, KSHV/HHV-8 is
suspected of being involved in the pathogenesis of Castleman's
disease. Although serologic and PCR assays in our patients were
negative for HIV and KSHV/HHV-8, infection with another organism that
can promote IL-6 production might be involved in this disease.
Further studies will be required to identify the etiology of the
deregulated production of human IL-6 in Castleman's disease. It is
also necessary to examine the effect of rhPM-1 therapy on IL-6 gene,
steroid-responsive gene, and multidrug-resistant gene expression in
germinal center cells because incorporation of immunotherapy may cause
the emergence of drug resistance as a consequence of perturbations in
intracellular signaling and the population kinetics of tumor cell
adaptation and selection. Nevertheless, the pathophysiologic significance of human IL-6 is confirmed by this study because the
clinical manifestations of Castleman's disease are alleviated by
blockade of human IL-6R. The present study, therefore, demonstrates a
novel and promising therapy, based on blockade of IL-6 signaling with a
humanized anti-IL-6R antibody, which may also be effective for other
diseases characterized by overproduction of IL-6.
| |
Acknowledgments |
We wish to thank Dr R. Inagi for performing the KSHV/HHV-8 assay, Ms C. Aoki and Ms M. Ohno for their outstanding technical assistance, and Ms
T. Nakao for preparing the manuscript.
| |
Footnotes |
Submitted February 12, 1999; accepted August 9, 1999.
Supported by grants from the Ministry of Education, Science, Sports and
Culture of Japan, and from the Osaka Foundation for Promotion of
Clinical Immunology.
Reprints: Norihiro Nishimoto, Department of Medical Science I,
School of Health and Sport Sciences, Osaka University, 2-1 Yamada-oka,
Suita-city, Osaka 565-0871 Japan; e-mail:
norihiro{at}imed3.med.osaka-u.ac.jp.
The publication costs of this
article were defrayed in part by
page charge payment. Therefore,
and solely to indicate this fact,
this article is hereby marked
"advertisement"
in accordance with 18 U.S.C.
section 1734.
| |
References |
1.
Castleman B, Iverson L, Menendez VP.
Localized mediastinal lymph-node hyperplasia resembling thymoma.
Cancer.
1956;9:822-830[Medline]
[Order article via Infotrieve].
2.
Flendrig JA, Schillings PHM.
Benign giant lymphoma: the clinical signs and symptoms.
Folia Med Neerl.
1969;12:119.
3.
Keller AR, Hochholzer L, Castleman B.
Hyaline-vascular and plasma-cell types of giant lymph node hyperplasia of the mediastinum and other locations.
Cancer.
1972;29:670-683[Medline]
[Order article via Infotrieve].
4.
Frizzera G, Peterson BA, Bayrd ED, Goldman A.
A systemic lymphoproliferative disorder with morphologic features of Castleman's disease: clinical findings and clinicopathologic correlations in 15 patients.
J Clin Oncol.
1985;3:1202-1216[Abstract/Free Full Text].
5.
Yoshizaki K, Matsuda T, Nishimoto N, et al.
Pathogenic significance of interleukin-6 (IL-6/BSF-2) in Castleman's disease.
Blood.
1989;74:1360-1367[Abstract/Free Full Text].
6.
Peterson BA, Frizzera G.
Multicentric Castleman's disease.
Semin Oncol.
1993;20:636-647[Medline]
[Order article via Infotrieve].
7.
Soulier J, Grollet L, Oksenhendler E, et al.
Kaposi's sarcoma-associated herpesvirus-like DNA sequences in multicentric Castleman's disease.
Blood.
1995;86:12761280.
8.
Dupin N, Gorin I, Deleuze J, Agut H, Huraux JM, Escande JP.
Herpes-like DNA sequences, AIDS-related tumors, and Castleman's disease [letter].
N Engl J Med.
1995;333:798discussion 798-799.
9.
Gessain A, Sudaka A, Briere J, et al.
Kaposi sarcoma-associated herpes-like virus (human herpesvirus type 8) DNA sequences in multicentric Castleman's disease: is there any relevant association in non-human immunodeficiency virus-infected patients?
Blood.
1996;87:414-416[Free Full Text].
10.
Kishimoto T.
The biology of interleukin-6.
Blood.
1989;74:1-10[Free Full Text].
11.
Beck JT, Hsu SM, Wijdenes J, et al.
Alleviation of systemic manifestations of Castleman's disease by monoclonal anti-interleukin-6 antibody.
N Engl J Med.
1994;330:602-605[Free Full Text].
12.
Klein B, Wijdenes J, Zhang XG, et al.
Murine anti-interleukin-6 monoclonal antibody therapy for a patient with plasma cell leukemia.
Blood.
1991;78:1198-1204[Abstract/Free Full Text].
13.
Sato K, Tsuchiya M, Saldanha J, et al.
Reshaping a human antibody to inhibit the interleukin-6-dependent tumor cell growth.
Cancer Res.
1993;53:851-856[Abstract/Free Full Text].
14.
Chang Y, Cesarman E, Pessin MS, et al.
Identification of herpesvirus-like DNA sequences in AIDS-associated Kaposi's sarcoma.
Science.
1994;266:1865-1869[Abstract/Free Full Text].
15.
Na Ayuthaya PI, Inagi R, Auwanit W, et al.
The association of skin diseases with human herpesvirus 8 infection in HIV carriers.
Arch Virol.
1998;143:1881-1892[Medline]
[Order article via Infotrieve].
16.
Nishimoto N, Ogata A, Shima Y, et al.
Oncostatin M, leukemia inhibitory factor, and interleukin 6 induce the proliferation of human plasmacytoma cells via the common signal transducer, gp130.
J Exp Med.
1994;179:1343-1347[Abstract/Free Full Text].
17.
Nishizono I, Iida S, Suzuki N, et al.
Rapid and sensitive chemiluminescent enzyme immunoassay for measuring tumor markers.
Clin Chem.
1991;37:1639-1644[Abstract/Free Full Text].
18.
Ogata A, Tagoh H, Lee T, et al.
New highly sensitive immunoassay for cytokines by dissociation-enhanced lanthanide fluoroimmunoassay (DELFIA).
J Immunol Methods.
1992;148:15-22[Medline]
[Order article via Infotrieve].
19.
Lovat LB, Persey MR, Madhoo S, Pepys MB, Howkins PN.
The liver in systemic amyloidosis: insights from 1231 serum amyloid P component scintigraphy in 484 patients.
Gut.
1998;42:727-734[Abstract/Free Full Text].
20.
Yee C, Biondi A, Wang XH, et al.
A possible autocrine role for interleukin-6 in two lymphoma cell lines.
Blood.
1989;74:798-804[Abstract/Free Full Text].
21.
Miles SA, Rezai AR, Salazar-Gonzales JF, et al.
AIDS Kaposi sarcoma-derived cells produce and respond to interleukin 6.
Proc Natl Acad Sci U S A.
1990;87:4068-4072[Abstract/Free Full Text].
22.
Rincon M, Angurita J, Nakamura T, Fikrig E, Flavell RA.
Interleukin (IL)-6 directs the differentiation of IL-4-producing CD4+ T cells.
J Exp Med.
1997;185:461-469[Abstract/Free Full Text].
23.
Cohen T, Nahari D, Cerem LW, Neufeld G, Levi BZ.
Interleukin 6 induces the expression of vascular endothelial growth factor.
J Biol Chem.
1996;271:736-741[Abstract/Free Full Text].
24.
Screpanti I, Musiani T, Bellavia D, et al.
Inactivation of the IL-6 gene prevents development of multicentric Castleman's disease in C/EBP beta-deficient mice.
J Exp Med.
1996;184:1561-1566[Abstract/Free Full Text].
25.
Nakajima K, Martinez-Maza O, Hirano T, et al.
Induction of IL-6 (B cell stimulatory factor-2/IFN-beta2) production by HIV.
J Immunol.
1989;142:531-536[Abstract].
26.
Moore PS, Boshoff C, Weiss RA, Chang Y.
Molecular mimicry of human cytokine and cytokine response pathway genes by KSHV.
Science.
1996;274:1739-1744[Abstract/Free Full Text].
27.
Nicholas J, Ruvolo VR, Burns WH, et al.
Kaposi's sarcoma-associated human herpesvirus-8 encodes homologues of macrophage inflammatory protein-1 and interleukin-6.
Nature Med.
1997;3:287-292[Medline]
[Order article via Infotrieve].
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
L. Gerard, A. Berezne, L. Galicier, V. Meignin, M. Obadia, N. De Castro, C. Jacomet, R. Verdon, I. Madelaine-Chambrin, E. Boulanger, et al.
Prospective Study of Rituximab in Chemotherapy-Dependent Human Immunodeficiency Virus Associated Multicentric Castleman's Disease: ANRS 117 CastlemaB Trial
J. Clin. Oncol.,
August 1, 2007;
25(22):
3350 - 3356.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. J. Wood, L. M. Nail, N. A. Perrin, C. R. Elsea, A. Fischer, and B. J. Druker
The Cancer Chemotherapy Drug Etoposide (VP-16) Induces Proinflammatory Cytokine Production and Sickness Behavior-like Symptoms in a Mouse Model of Cancer Chemotherapy-Related Symptoms.
Biol Res Nurs,
October 1, 2006;
8(2):
157 - 169.
[Abstract]
[PDF]
|
|
|
|
|
|
|
T. Peters, W. Bloch, C. Wickenhauser, S. Tawadros, T. Oreshkova, D. Kess, T. Krieg, W. Muller, and K. Scharffetter-Kochanek
Terminal B cell differentiation is skewed by deregulated interleukin-6 secretion in {beta}2 integrin-deficient mice
J. Leukoc. Biol.,
September 1, 2006;
80(3):
599 - 607.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Maggio, J. M. Guralnik, D. L. Longo, and L. Ferrucci
Interleukin-6 in aging and chronic disease: a magnificent pathway.
J. Gerontol. A Biol. Sci. Med. Sci.,
June 1, 2006;
61(6):
575 - 584.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Montani, L. Achouh, A. G. Marcelin, J-P. Viard, O. Hermine, D. Canioni, O. Sitbon, G. Simonneau, and M. Humbert
Reversibility of pulmonary arterial hypertension in HIV/HHV8-associated Castleman's disease
Eur. Respir. J.,
November 1, 2005;
26(5):
969 - 972.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Nishimoto, Y. Kanakura, K. Aozasa, T. Johkoh, M. Nakamura, S. Nakano, N. Nakano, Y. Ikeda, T. Sasaki, K. Nishioka, et al.
Humanized anti-interleukin-6 receptor antibody treatment of multicentric Castleman disease
Blood,
October 15, 2005;
106(8):
2627 - 2632.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Guihot, L-J. Couderc, F. Agbalika, L. Galicier, P. Bossi, E. Rivaud, A. Scherrer, D. Zucman, C. Katlama, and E. Oksenhendler
Pulmonary manifestations of multicentric Castleman's disease in HIV infection: a clinical, biological and radiological study
Eur. Respir. J.,
July 1, 2005;
26(1):
118 - 125.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
Top
Abstract
Introduction