A pleomorphic carcinoma of the lung producing multiple cytokines and forming a rapidly progressive mass-like opacity
© Matsumoto et al.; licensee BioMed Central Ltd. 2014
Received: 11 March 2014
Accepted: 5 August 2014
Published: 13 August 2014
Lung cancer cells have been reported to produce cytokines, resulting in systemic reactions. There have been few reports showing that these cytokines induced the formation of an inflammatory mass around lung cancers.
We encountered a patient with a pleomorphic carcinoma of the lung. This tumor produced interleukin (IL)-8, granulocyte colony-stimulating factor and IL-6, which in turn recruited inflammatory cells, such as CD8 positive lymphocytes, around the tumor, resulting in a rapidly growing tumor shadow.
18 F-fluoro-deoxy-glucose positron emission tomography, in addition to a conventional radiological approach such as computed tomography, may detect immunological responses around a tumor.
KeywordsLung cancer FDG-PET G-CSF IL-6 IL-8 Neutrophilia
Lung cancer cells have been reported to produce several cytokines and growth factors, especially granulocyte colony-stimulating factor (G-CSF), resulting in various systemic reactions [1–12]. We encountered a lung cancer patient with a peritumoral permeation shadow, which increased rapidly due to recruitment of cells by interleukin (IL)-8/CXCR1.
Laboratory data on admission
Hb 10.7 g/dl
BUN 10.5 mg/dl
V.B 12 1208 pg/ml
Cr 0.59 mg/dl
Ferritin 1750 ng/ml
WBC 36000/μ l
T-pro 6.8 g/dl
sIL-2R 2370 U/ml
Alb 2.7 g/dl
CEA 4.5 ng/ml
CRP 19.6 mg/dl
CYFRA ≤1.0 ng/ml
HbA1c 6.0 g/dl
proGRP 14.8 pg/ml
NSE 4.5 ng/ml
IgG 2418 mg/dl
IgA 607 mg/dl
Mycoplasma IgM Negative
AST 44 U/l
IgM 85 mg/dl
C. pneumoniae IgM 0.95
ALT 65 U/l
IgE 1103 IU/ml
C. Psittaci Ab Negative
LDH 1144 U/l
C3 220 mg/dl
Legionella Ag in urine Negative
ALP 1571 U/l
C4 36 mg/dl
Cryptococcus Ag Negative
γ-GTP 497 U/l
CH50 69 U/ml
T-Bil 0.7 mg/dl
Cytokine concentrations before and after tumor resection
Since the rapid growth of the mass-like shadow likely resulted from the infiltration of neutrophils and lymphocytes, we assessed the mechanisms underlying the infiltration of these cells.
Materials & methods
Lung cancer and control tissue
Frozen lung tissues containing cancerous and surrounding non-cancerous areas were obtained from this patient and from three other patients with lung cancer. All control tumors were adenocarcinomas. As the tumor and non tumor areas could be distinguished clearly, they were isolated macroscopically.
Reverse transcription-polymerase chain reaction
Tissues samples were homogenized, and total RNAs were prepared using TRIzol reagent (Invitrogen Life Technologies, Carlsbad, CA, USA) and further purified using RNeasy Kit (Qiagen, Hilden, Germany). Total RNAs (1 μg) were reverse transcribed using oligo(dT)18 primer and SuperScript II reverse transcriptase (Invitrogen Life Technologies). The expression of mRNAs encoding chemokine receptors was assessed by reverse transcription-polymerase chain reaction (RT-PCR). First-strand complementary deoxyribonucleic acids (cDNAs), equivalent to 20 ng total RNA were amplified in a final volume of 20 μl containing 10 pmol of each primer [13, 14] and 1 U Ex-Taq polymerase (Takara Bio, Kyoto, Japan).
The amplification conditions consisted of an original denaturation at 94°C for 5 min, followed by 27 to 35 cycles of denaturation at 94°C for 30 sec, annealing at 60°C for 30 sec, and extension at 72°C for 30 sec, and a final extension at 72°C for 5 min. Chemokine cDNAs were amplified for 33 cycles, chemokine receptor cDNAs for 35 cycles, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) cDNA for 27 cycles. The amplification products (10 μl each) were electrophoresed on 2% agarose gels, which were stained with ethidium bromide.
Immunohistochemistry was performed using an automated immunostainer (Ventana BenchMark AutoStainer, Ventana Medical Systems, Tucson, AZ) with antibodies against CD4 (1:20, IF6, Novocastra), CD8 (1:20, 4B11, Novocastra), IL-8 (1:50, NYR-HIL8, Santa Cruz), IL-8R/CXCR1 (1:100, polyclonal, GeneTex, Inc.), G-CSF (1:100, FL-207, Santa Cruz) and IL-6 (1:20,000, polyclonal, R&D Systems). Neutrophils were recognized by morphological analysis.
This study was approved by the Kitano Hospital research ethics committee, and all subjects provided written informed consent.
Analysis of chemokines and chemokine receptors
Because there are fewer chemokine receptors than chemokine ligands, we first assessed the levels of expression of mRNAs encoding all 18 types of chemokine receptors (CXCR1-6, CCR1-10, XCR1, and CX3CR1) in the inflammatory cells located around the tumor in our patient. RT-PCR showed that CXCR1 mRNA was strongly expressed in the non-cancerous area around the tumor.
We encountered a rare patient with a pleomorphic carcinoma and rapidly growing tumor shadow in the apex of the right lung. This patient presented with a high-grade fever and marked inflammatory responses. The excised tumor consisted of a carcinomatous lesion in the center, surrounded by the intense infiltration of inflammatory cells. FDG-PET showed that FDG uptake was localized to the center of the mass-like lesion, along with diffuse uptake in the bone marrow, liver and spleen.
In addition to high grade fever, neutrophilia, and elevated serum CRP concentration, our patient presented with elevated serum concentrations of G-CSF and IL-6. Following right upper lobectomy, however, these elevated concentrations became normalized. In addition, immunohistochemical examination showed that the cancer cells were positive for G-CSF and IL-6. The elevated IL-6 levels in this patient may have contributed to his high-grade fever and increased CRP levels , whereas the increased serum G-CSF levels may have contributed to neutrophilia and hematopoietic activation, as indicated by diffuse bone marrow uptake of FDG [1, 16]. These cytokines have been reportedly produced by lung cancers, especially by large cell carcinomas [2–11, 17]. Many lung cancers previously diagnosed as large cell carcinomas have been reclassified as pleomorphic carcinomas . Additional studies are needed to determine the mechanism by which pleomorphic carcinomas produce cytokines.
The tumor shadow in this patient rapidly increased in size prior to surgery. Examination of the excised lung tissue showed that the area around the tumor consisted of non-cancerous tissue intensely infiltrated by lymphocytes and neutrophils. The formation of this inflammatory outer zone around the tumor was likely not due to the production by tumor cells of IL-6 or G-CSF. Rather, the tumor may have produced chemotactic factors, which in turn recruited the infiltration by inflammatory cells. To analyze this mechanism, we assessed the expression of several chemokines using RT-PCR and immunohistochemistry.
Although both CD8+ lymphocytes and neutrophils express the same IL-8R , CD8+ lymphocytes predominated around the tumor. This surrounding area was also positive for CXCR3, while mRNAs encoding Mig and IP-10, the ligands of CXCR3 and T-cell chemoattractants , were strongly expressed in the tumor itself. Because CD8 lymphocytes were recruited not only by IL-8 but also by Mig and IP-10, whereas neutrophils were recruited only by IL-8, these findings suggested that the imbalance between CD8 positive lymphocytes and neutrophils surrounding the tumor may be due to differences in the concentrations of these chemokines .
FDG-PET examinations have occasionally shown a pattern, in which FDG accumulates on the periphery of a tumor shadow, but not in the center of the lung tumor, owing to central necrosis and lung abscesses. The preoperative pattern of FDG uptake was unique in this patient, being localized to the center, but not the periphery, of the mass in the right lung apex. These finding suggest that FDG accumulated strongly in the cancerous lesion, but not in the outer inflammatory zone. Similar images on FDG-PET examination should suggest a tumor together with a local immunological response induced by the tumor.
We encountered a patient with a pleomorphic carcinoma of the lung. This tumor produced several cytokines and chemokines, including G-CSF, IL-6, and IL-8, resulting in several systemic responses and a rapidly growing tumor surrounded by inflammatory cells. FDG-PET, in addition to a conventional radiological approach such as CT scanning, may distinguish between tumor-induced immunological responses and the tumor itself.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Granulocyte colony-stimulating factor
18 F-fluoro-deoxy-glucose positron emission tomography
Messenger ribonucleic acid
Reverse transcription-polymerase chain reaction
The authors would like to thank Richard Alexander for editing the manuscript.
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