SHORT REPORT

Serum interleukin-6 (IL-6) and interleukin-4 (IL-4)in patients with multiple myeloma (MM)

MARIA-CHRI STINA KYRSTSONIS,† GEORGES DEDOUSSIS,* CONSTANTIN BAXEVANIS,* MARINA STAMATELOU AND

ALICE MANIATIS† Division of Haematology, Department of Medicine, *Department of Immunology, Anticancer Institute,Athens, †Laboratory Haematology and Transfusion Medicine, University of Patras Medical School, Patras, Greece

Received 3 August 1995; accepted for publication 18 September 1995

Summary. In this study we determined, in patients withmultiple myeloma (MM), serum levels of IL-4 and IL-6 atdiagnosis and during the course of the disease, seeking acorrelation with disease activity and prognosis. We studied 54MM patients, 41 of whom responded to chemotherapy whilst11 were resistant. At diagnosis, IL-6 was increased in 66% ofpatients (median 35.5 pg/ml) whereas IL-4 was low (median

4 pg/ml) in 75% of patients. In responding patients, IL-4increased in remission (median 25 pg/ml), whereas IL-6decreased (median 4 pg/ml). In chemotherapy-resistantpatients, IL-6 and IL-4 values remained stable during thecourse of the disease.

Keywords: multiple myeloma, interleukin-6, interleukin-4.

Multiple myeloma is a plasma cell neoplasm of unknownaetiology. Recent studies have shown that cytokines play animportant stimulatory or inhibitory role in myeloma cellgrowth. The study of serum cytokine levels in monoclonalgammopathies has attracted the interest of a number ofinvestigators in an effort to understand the pathogenesis ofthese disorders and to better define prognostic factors. IL-6 isan essential growth factor for myeloma cells (Klein et al,1989) and increased IL-6 serum levels have been correlatedwith poor prognosis (Klein et al, 1995). IL-4 was shown tohave an antitumour effect on several B haematologicalmalignancies including multiple myeloma (Defrance et al,1992; Taylor et al, 1990). In the present study we examinedwhether serum levels of IL-6 and IL-4 in patients with MMcan be correlated with prognosis.

PATIENTS AND METHODS

We studied 54 previously untreated MM patients (three stageI, 34 stage II, and 17 stage III, according to the Durie &Salmon classification) and 25 normal controls (healthy blooddonors). All MM patients were treated initially with VAD(vincristine–adriamycin–dexamethasone) if <65 years andwith MP (melphalan–prednisone) if >65 years old. 43patients responded (R) to initial treatment and 11 wereresistant (NR). We defined partial remission (PR) as a

decrease by 550% of the paraprotein level with concurrentstability of bone disease. Blood samples of patients with MMwere drawn before therapy and during the course of thedisease, for a period of 10–76 months. Cytokine levels weremeasured by ELISA (endogen for IL-6 and quantiquine for IL-4). Differences in levels between diagnosis and remission inthe same patients were tested with the Wilcoxon test andbetween responding and non-responding patients with theMann-Whitney U-test. Correlation was evaluated by the non-parametric Spearman rank correlation coefficient.

RESULTS

Serum levels of IL-6 and IL-4 in NC and MM patients atdiagnosis are shown in Table I. IL-6 serum levels weresignificantly higher in MM patients compared to normalcontrols. Stage III MM patients had higher IL-6 levels thanstage I and II patients. �2-microglobulin (�2M) was availableat diagnosis in 45 MM patients and C-reactive protein (CRP)in 41 MM patients. Table II shows the correlation of these twoparameters and IL-6, in MM patients, at diagnosis. There wasno correlation between IL-4, �2M or CRP levels. Nocorrelation was found between IL-6 or IL-4 levels andsurvival.

In remission, IL-6 levels decreased (median 0 pg/ml range0–30) becoming undetectable in most patients, while at thesame time IL-4 serum levels increased (median 24 pg/ml,range 4–95). The difference in serum levels, both for IL-6 andIL-4, between diagnosis and remission in responding patients

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Correspondence: Professor A. Maniatis, University of Patras School ofMedicine, Laboratory Haematology and Transfusion Medicine,Patras, Greece.

is statistically significant (P < 0:001). There is an inversecorrelation between IL-6 and IL-4 at diagnosis and during thecourse of the disease in responding patients (R � ÿ0:25,P < 0:0008). Non-responding patients had essentially stablelevels of serum IL-6 or IL-4 during the course of the disease.

During a follow-up from 12 to 76 months, 23/43responding patients relapsed. In 17/20 relapsing patientsIL-6 levels were measured and were found to be increased(median 40 pg/ml, range 0–1000), whereas IL-4 decreased in14 of them (median 10 pg/ml, range 0–38). The difference inserum levels, both for IL-6 and IL-4, between remission andrelapse is statistically significant (P < 0:01).

DISCUSSION

In our series, most of our patients had stage II and III MM and66% of them had increased serum IL-6 levels (median35.5 pg/ml). Our findings are in agreement with otherinvestigators (Bataille et al, 1989; Tienhaara et al, 1994;Pelliniemi et al, 1995). In responding patients, IL-6 serumlevels reflected the fluctuations of disease activity (high atdiagnosis, low in remission, increasing again at relapse) butthe difference in IL-6 levels between responding and non-responding patients at diagnosis was not statistically sig-nificant (P � 0:35). Thus IL-6 serum levels seem to have aclose relationship with disease activity but do not addanything in terms of prognosis to the Durie & Salmon stagingsystem. Interleukin-4 has been studied in a number of B-cell

malignancies and found to have an inhibitory effect on IL-6production as well as antineoplastic activity (Taylor et al,1990; Hermann et al, 1991), but there are no publishedstudies of IL-4 serum levels in MM that we could find in theliterature. IL-4 serum levels were low at diagnosis in most ofour patients. This low level may relate to a low absolutenumber of CD4(�) lymphocytes which has been reported inMM (San Miguel et al, 1992), because IL-4 is secreted mainlyby T4 lymphocytes and more specifically by type 2 helper Tcells (TH2). In responding MM patients the initially low IL-4level increased at the time of remission, coincidentally with alowering of IL-6, suggesting that endogenous IL-4 may play arole in myeloma by decreasing the secretion of IL-6 and thusreducing plasma cell growth. The reciprocal relation betweenIL-6 and IL-4 was observed in all patients but one, though themagnitude of reciprocal change was not related to the degreeor the duration of remission. IL-4 levels were higher atdiagnosis in non-respondingcompared to responding patients(median 16 pg/ml versus 4 pg/ml) but the difference was ofborderline significance (P < 0:05). Furthermore, the patternof an inverse relationship between IL-6 and IL-4 serum levelswas not found in non-responding patients, in the majorityof whom both cytokines remained stable. Based on findingsthat showed antineoplastic properties on IL-4 on B-cellmalignancies and the important role of IL-6 as a growthfactor for myeloma cells, preliminary efforts at exploiting theadministration of IL-4 (Vesole et al, 1993) and anti-IL-6antibodies therapeutically, have been undertaken (Klein &Brailly, 1995).

REFERENCES

Bataille, R., Jourdan, M., Zhang, X-G. & Klein, B. (1989) Serum levelsof interleukin-6, a potent myeloma cell growth factor, as a reflect ofdisease severity in plasma cell dyscrasias. Journal of ClinicalInvestigation, 84, 2008–2011.

Defrance, T., Fluckiger, A-C., Rossi, J-F., Magaud, J-P., Sotto, J-J. &Banchereau, J. (1992) Antiproliferative effects of interleukin-4 onfreshly isolated non-Hodgkin malignant B-lymphoma cells. Blood,79, 990–996.

Hermann, F., Andreeff, M., Gruss, H-J., Bach, M.A., Lubbert, M. &Mertelsmann, R. (1991) Interleukin-4 inhibits growth of multiple

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# 1996 Blackwell Science Ltd, British Journal of Haematology 92: 420–422

Table I. Value of IL-6 and IL-4 in NC and MM patients at diagnosis.

IL-6 (pg/ml): IL-4 (pg/ml):n median (range) P median (range) P

NC 25 5 (0–13) 10 (0–24)All MM patients 54 25 (0–800*) < 0:001 0† (0–80) � 0:27

Stage I MM patients 3 10 (0–30) � 0:05 10 (0–18) � 0:24Stage II MM patients 34 30 (0–85) 0† (0–34)Stage III MM patients 17 40 (0–800*) (St I � II/St III) 13 (0–32) (St I � II/St III)

R 43 23 (0–800*) � 0:35 0† (0–34) < 0:05NR 11 32 (0–94) 16 (0–80)

* The patient with very high value of IL-6 was suffering from pneumonia at that time.† In more than half the subjects the level was below the sensitivity of the detection method.

Table II. Relationship of serum levels of IL-6 with �2M and CRP inMM patients at diagnosis.

Parameter n IL-6: median (range) Statistical significance

�2M (mg/l)< 4 35 16.5 (0–45) P < 0:01> 4 10 52 (22–94)

CRP (mg/l)< 8:5 25 14 (0–85) P < 0:05> 8:5 16 34 (0–94)

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Pelliniemi, T.T., Irjala, K., Mattila, K., Pulkki, K., Rajamaki, A.,Tienhaara, A., Laakso, M. & Lahtinen, R. (1995) Immunoreactiveinterleukin-6 and acute phase proteins as prognostic factors inmultiple myeloma. Blood, 85, 765–771.

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Tienhaara, A., Pulkki, K., Mattila, K., Kerttu, I. & Pelliniemi, T-T.(1994) Serum immunoreactive interleukin-6 and C-reactiveprotein levels in patients with multiple myeloma at diagnosis.British Journal of Haematology, 86, 391–393.

Vesole, D., Kornbluth, J., Jagannath, S., Mattox, S., Vaugt, L.,Tricot, G. & Barlogie, B. (1993) Biological response modifiers(BRM) in refractory multiple myeloma (MM): lack of clinicalefficacy of recombinant human interleukin-4 (rhIL-4) and all-trans retinoic acid (ATRA). Blood, 10, (Suppl. 1), 263a, no.1037.

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# 1996 Blackwell Science Ltd, British Journal of Haematology 92: 420–422