|Year : 2022 | Volume
| Issue : 2 | Page : 532-544
Microwave ablation of non-small cell lung cancer tumors changes plasma levels of cytokines IL-2 and IFN-γ
Hui Xu1, Xiaojing Tan2, Yongmei Kong1, Yahan Huang1, Zhigang Wei3, Xin Ye3
1 Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong; Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China
2 Department of Oncology, Dongying People's Hospital, Dongying, Shandong Province, China
3 Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China
|Date of Submission||25-Jan-2022|
|Date of Decision||10-Feb-2022|
|Date of Acceptance||11-Feb-2022|
|Date of Web Publication||20-May-2022|
Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China No. 16766, Jingshi Road, Jinan, Shandong Province - 250014
Department of Oncology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China No. 16766, Jingshi Road, Jinan, Shandong Province-250014
Source of Support: None, Conflict of Interest: None
Background: Combined therapy with immune checkpoint inhibitors (ICIs) and microwave ablation (MWA) is known to improve outcome in non-small cell lung cancer (NSCLC). However, the mechanism underlying the synergistic effect of these two treatments is unknown. Tumor immune microenvironment is known to affect the efficacy of ICI. Therefore, in the present study, we evaluated changes in the levels of peripheral cytokines at 48 h and 1-month post-ablation in patients with NSCLC.
Materials and Methods: A total of 44 patients with primary NSCLC were retrospectively enrolled. All patients underwent MWA of the primary tumors. Plasma samples were collected pre- and post-ablation to examine the levels of various cytokines, including interleukin (IL)-2, IL-4, IL-6, IL-10, IL-12, IL-17, tumor necrosis factor (TNF)-α, and interferon-gamma (IFN-γ).
Results: Although the levels of the majority of cytokines remained within normal range, levels of IL-2 and IFN-γ were significantly decreased at 48 h post-ablation and increased at 1-month post-ablation. In the subgroup analyses, changes in IL-2 and IFN-γ levels were commonly identified. Moreover, the Eastern Cooperative Oncology Group status, sex, pathology type, tumor site, and tumor size were associated with cytokines' levels pre-ablation or post-ablation.
Conclusion: MWA of NSCLC tumors influenced the plasma levels of cytokines IL-2 and IFN-γ.
Keywords: Cytokines, IFN-γ, IL-2, microwave ablation, non-small cell lung cancer
|How to cite this article:|
Xu H, Tan X, Kong Y, Huang Y, Wei Z, Ye X. Microwave ablation of non-small cell lung cancer tumors changes plasma levels of cytokines IL-2 and IFN-γ. J Can Res Ther 2022;18:532-44
|How to cite this URL:|
Xu H, Tan X, Kong Y, Huang Y, Wei Z, Ye X. Microwave ablation of non-small cell lung cancer tumors changes plasma levels of cytokines IL-2 and IFN-γ. J Can Res Ther [serial online] 2022 [cited 2022 Jul 7];18:532-44. Available from: https://www.cancerjournal.net/text.asp?2022/18/2/532/345537
Hui Xu, Xiaojing Tan, Yongmei Kong and Yahan Huang contributed equally to
| > Introduction|| |
Lung cancer remains the leading cause of cancer-associated mortality and morbidity in China. Non-small cell lung cancer (NSCLC) accounts for nearly 85% of all lung cancer cases. For patients at the advanced disease stage, the treatment regimen has changed from platinum-based doublet chemotherapy to targeted therapy with inhibitors of the epidermal growth factor receptor, anaplastic lymphoma kinase, or immune checkpoints such as cytotoxic lymphocyte antigen 4 or programmed death-1/programmed death ligand 1.,,
Immune checkpoint inhibitor (ICI) monotherapy has been approved for both initial and subsequent treatment of NSCLC. However, the relatively low efficacy of the monotherapy limits its application., To overcome this limitation, ICI combination regimens such as ICI combined with chemotherapy, ICI combined with ICI, ICI combined with both ICI and chemotherapy, and ICI combined with both targeted therapy and chemotherapy have been explored.,,, Both efficacy and survival following the administration of combination regimens are significantly better than those achieved with ICI monotherapy alone. However, combination therapies are associated with higher incidence of serious adverse events, which leads to treatment delay or even cessation thereof.,,,
The combination of ICI monotherapy with irradiation has also been explored., When patients with oligometastatic NSCLC received ICI monotherapy and radical irradiation of all lesions, the efficacy and survival dramatically improved. We have also demonstrated previously that a combination of ICI monotherapy and microwave ablation (MWA) led to a superior objective response rate.
The mechanism underlying the synergistic effect of ICI and MWA combination has not been clarified. Studies have shown that the tumor immune microenvironment predicts ICI efficacy., MWA induces tumor necrosis, reduces tumor burden, and increases new antigens, which subsequently impacts the immune microenvironment., The effect of MWA on peripheral cytokines has rarely been reported. As the peripheral levels of various cytokines may inform about the status of the tumor immune microenvironment, in the present study, we determined cytokine concentrations in plasma in a relatively large patient cohort before and after MWA.
| > Materials and Methods|| |
Patients with the following criteria were retrospectively enrolled: 1) pathologically verified NSCLC, 2) primary tumors located in the periphery of the lungs, 3) patients who underwent MWA for primary tumors, 4) adequate cardiovascular and pulmonary function reservation, and 5) availability of plasma cytokine measurements pre-ablation and 1 month post-ablation. The exclusion criteria were as follows: 1) secondary tumors other than NSCLC; 2) mixed NSCLC and small cell lung cancer; 3) localization of the primary tumors in the middle of the lungs; and 4) patient lost to follow-up.
The MWA procedure has been described in detail in our previous studies.,, Once the ablation zone surpassed the tumors for 5–10 mm, the ablation procedure was completed.
Cytokine Levels Pre- and Post-ablation
Plasma samples were collected pre- and post-ablation to examine the levels of various cytokines, including interleukin (IL)-2, IL-4, IL-6, IL-10, IL-12, IL-17, tumor necrosis factor TNF-a, and interferon-gamma (IFN-γ). Plasma samples were collected 1 week before MWA to determine pre-ablation cytokine levels. Post-ablation plasma samples were collected at 48 h and at 1 month post-ablation to determine post-ablation cytokine levels. The details of the blood testing procedure are as follows. All reagents were purchased from Raisecare Biological Technology Co. Ltd (Qingdao, Shandong Province, China). Matrix B or the experimental buffer was added to the calibration tube, followed by the addition of the calibrator. After adding the microsphere-based capture antibody and detection antibody, all four materials were mixed. The mixture was incubated at room temperature (25°C ± 1°C) for 2 h (400–500 rpm). Streptavidin phycoerythrin was added to the above mixture and incubated for 0.5 h at room temperature. Thereafter, the washing buffer was added and the tubes were centrifuged. The supernatant was slowly poured out on absorbent paper. According to the flow cytometer loading requirements, 150–300 μL of the washing buffer was added to each tube. After resuspension of the microspheres, they were immediately evaluated on the machine, followed by data analysis.
Statistical package for the Social Sciences (SPSS) ver. 16.0 (SPSS Inc., Chicago, IL, USA) was used for all analyses. Percentages were used to describe the categorical variables. Means, standard deviations, medians, and interquartile ranges were used to describe numerical variables according to the normality test. The correlations between clinical features (sex, age, smoking history, Eastern Cooperative Oncology Group (ECOG) status, pathology, subsequent treatments, tumor size, and tumor site) and cytokine levels were analyzed by the Wilcoxon signed-rank test. The Friedman test for several related samples was applied for the self-comparison of plasma cytokine levels at three different time points: pre-ablation and post-ablation (two points). All statistical analyses were two sided, and the results were considered statistically significant if P < 0.05.
| > Results|| |
Patient Baseline Characteristics
From June 15, 2020 to July 20, 2021, 44 NSCLC patients with primary tumors were retrospectively enrolled in the study. The mean age of the patients was 68.2 years, with the majority (n = 23, 52.3%) being older than 65 years of age. Male patients (n = 27, 61.4%) formed majority of the patient cohort, and 30 patients (68.2%) were nonsmokers. Most patients (n = 36, 81.8%) had an ECOG performance status of 1.
Adenocarcinoma was the most common histological tumor type (n = 37, 84.1%), followed by squamous cell carcinoma (n = 3, 6.8%). In all 44 patients, pulmonary lesions were treated with MWA. Most tumors were located in the left lung (n = 24, 54.5%) and in the upper or middle lobe (n = 29, 65.9%). The mean largest diameter was 2.0 cm, ranging from 0.8 to 4.5 cm. The majority of tumors (n = 29, 65.9%) had a tumor size of 3.0 cm or less. The applied power of MWA was 40 W, and the mean ablation time was 8.7 min [Table 1].
Pre-ablation Cytokine Levels
Pre-ablation levels of IL-2, IL-4, IL-6, IL-10, IL-12, IL-17, TNF-α, and IFN-γ were within their normal ranges (1.4, 0.9, 2.1, 0.9, 1.2, 1.0, 2.3, and 3.5 pg/mL, respectively) [Table 2].
|Table 2: Changes of cytokines of peripheral blood pre- and post-ablation of MWA on lung cancer|
Click here to view
Post-ablation Cytokine Levels
Forty-eight hours post-ablation, plasma levels of IL-2, IL-4, IL-6, IL-10, IL-12, IL-17, TNF-α, and IFN-γ were 1.2, 0.8, 2.1, 0.8, 1.1, 1.0, 2.1, and 2.3 pg/mL, respectively. Thus, although the levels of most cytokines studied remained in the normal range, IL-2 and IL-10 levels decreased significantly [Table 2].
One month post-ablation, the levels of IL-2, IL-4, IL-6, IL-10, IL-12, IL-17, TNF-α, and IFN-γ were 2.2, 0.9, 1.8, 0.9, 1.4, 1.4, 2.3, and 5.3 pg/mL, respectively. The levels of IL-2 and IFN-γ increased significantly, but remained within the normal ranges [Table 2].
The changes in IL-2 and IFN-γ levels were statistically significant (P = 0.001 and P < 0.001, respectively), whereas changes in the levels of other cytokines were not [Table 2].
Changes in Cytokine Levels in Subgroups of Enrolled Patients
We further explored the changes in cytokine levels induced by MWA in subgroups of patients.
In males, changes in levels of IL-2, IL-12, TNF-α, and IFN-γ were observed: the levels of all these cytokines decreased at 48 h post-ablation, but increased at 1 month post-ablation [Table 3]. Similar changes in IL-2 and INF-γ were found regardless of age and smoking history [e Table 1] and [e Table 2]. Patients with an ECOG of 1 had altered levels of IL-2, IL-12, and IFN-γ. In this subgroup, all these cytokines exhibited a decrease at 48 h post-ablation and an increase at 1 month post-ablation [e Table 3].
Compared with patients with adenocarcinoma in situ, those with invasive carcinoma tended to have altered levels of IL-2, TNF-α, and IFN-γ [e Table 4] and [e Table 5]. Patients without subsequent treatments tended to have altered levels of IL-2 and INF-γ [e Table 6].
In addition, in the subgroup of patients with tumor size of 3 cm or less, IL-2, IL-6, and INF-γ levels changed significantly. However, in the subgroup with a tumor size larger than 3 cm, only INF-γ levels were altered [e Table 7].
Interestingly, the presence of tumors in the left lung was associated with changes of IL-2 and INF-γ levels, whereas the presence of tumors in the right lung was associated only with changes in IL-2 levels. In addition, in patients with tumors in the upper and middle lobes, altered levels of IL-2, IL-6, and INF-γ were observed [e Table 8] and [e Table 9].
Correlations Between Cytokine Levels and Baseline Characteristics
The ECOG status correlated with the baseline TNF-α level [Table 4]. Pathology type correlated with IL-2 level at 48 h post-ablation. Tumor sites (upper and middle lobes vs. lower lobe) were associated with IL-6 and TNF-α levels at 48 h post-ablation [Table 5]. Sex correlated with IL-4 level at 1 month post-ablation. Tumor size was associated with IL-6 and INF-γ levels at 1 month post-ablation. Tumor site correlated with IL-17 (right lung vs. left lung) and TNF-α (upper and middle lobes vs. lower lobe) levels [Table 6].
|Table 4: Correlation between peripheral cytokines pre-ablation and clinical characteristics|
Click here to view
|Table 5: Correlation between peripheral cytokines at 48 h post-ablation and clinical characteristics|
Click here to view
|Table 6: Correlation between peripheral cytokine levels at 1 month post-ablation and clinical characteristics|
Click here to view
| > Discussion|| |
To establish if the beneficial effects of MWA in combination with ICI treatment of NSCLC could be explained by modified tumor immune microenvironment, we explored the effect of MWA on peripheral cytokines in patients with NSCLC. We found that IL-2 and INF-γ levels decreased at 48 h post-ablation and increased at 1 month post-ablation. The levels of IL-6, IL-12, and especially of IL-2 and INF-γ, were altered by MWA in multiple subgroups. For all patients, sex, histology type, tumor size, and tumor site had significant effects on IL-2, IL-6, IL-17, TNF-α, and INF-γ levels.
Accumulating evidence has demonstrated that infiltrating lymphocytes, natural killer (NK) cells, macrophages, dendritic cells, eosinophils, mast cells, and myeloid-derived suppressor cells regulate tumor immune microenvironment. It has been previously demonstrated that the levels of tumor-derived biologically active molecules, such as IL-6, IL-10, vascular endothelial growth factor (VEGF), M°CSF (macrophage colony-stimulating factor), GM°CSF (granulocyte-macrophage colony stimulating factor), and gangliosides, correlate with the extent of dendritic cell differentiation.
Several cytokines are functional within the tumor microenvironment. For example, IL-12, as a partner of IFN-γ, reverses the levels of suppressive factors within the tumor microenvironment by enabling antigen-presenting cells to facilitate antitumor response by CD8 + T cells. Moreover, the loss of transforming growth factor (TGF)-β signaling may affect tumor initiation, progression, and metastasis via intrinsic cell signaling and stromal–epithelial interactions in adjacent cells. In our study, the ECOG status correlated with baseline TNF-α level.
Effects of thermal ablation on cytokine levels have been investigated in several studies. When the active variant of CC chemokine ligand 3 was administered post-radiofrequency, the loss of TGF-β signaling may affect tumor initiation, progression, and metastasis via intrinsic cell signaling and stromal–epithelial in teractions in adjacent cell frequency ablation (RFA), RFA-induced antitumor immune responses were augmented in a CCR (CC chemokine receptor) 1-dependent manner.
In the KRAS model, IL-6 expression was upregulated in the lungs. Genetic ablation of either IL-6 or STAT3 (Signal transducer and activator of transcription 3) normalized pulmonary STAT3 activity, which subsequently suppressed lung cancer manifestations. Moreover, the IKK (inhibitor of kappa B kinase)-related kinase TBK1 (TANK Binding Kinase 1) promotes KRAS-driven tumorigenesis by regulating autocrine effects of CCL5 and IL-6. In KRAS and KRAS/LKB1 lung tumors, the levels of chemokines such as CXCL (Chemokine (C-X-C motif) ligand 7), CXCL3, CXCL5, CSF3, G-CSF, IL-33, and IL-1A were increased, but those of CCL5 and CXCL12 were decreased. In our study, although IL-6 levels did not change pre- and post-ablation, they correlated with tumor site and tumor size.
In a systematic review and meta-analysis of multiple studies, IFN-γ treatment was found to be effective in preventing hepatocellular carcinoma (HCC) recurrence after curative surgery or irradiation in hepatitis C virus-related HCC. IL-6 and IL-10 plasma levels were elevated post-ablation compared with those pre-ablation. However, IL-1A, IL-2, and TNF-α levels did not change significantly. As for the definitive local treatment regimen, cryoablation followed by RFA and MWA was more commonly associated with elevated IL-6. As for the primary tumors, individuals with melanomas showed the maximum change in IL-6 levels. Although we did not observe any changes in IL-6 or IL-10 levels, we observed that IL-2 and IFN-γ levels were altered post-ablation. The increased IL-2 level after MWA indicates an increased antitumor effect, as it can promote the proliferation of T cells and NK cells and activate mononuclear macrophages to enhance their killing activity and so on. Increased IFN-γ level after MWA also suggests increased antitumor effects, as it induces the expression of major histocompatibility complex (MHC) class I and class II molecules on different target cells, induces macrophage activity, and increases cytotoxicity of NK and CTL (Cytotoxic T Lymphocyte) cells.
This study had several limitations. First, the sample size was small. Second, several cases of adenocarcinoma in situ were included. Third, the post-ablation sampling intervals included only two time points.
In conclusion, MWA treatment of NSCLC induces changes in plasma levels of several cytokines, especially IL-2 and IFN-γ.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Cao M, Li H, Sun D, He S, Yu Y, Li J, et al
. Cancer screening in China: The current status, challenges, and suggestions. Cancer Lett 2021;506:120-7.
Wang M, Herbst RS, Boshoff C. Toward personalized treatment approaches for non-small-cell lung cancer. Nat Med 2021;27:1345-56.
Kaur J, Elms J, Munn AL, Good D, Wei MQ. Immunotherapy for non-small cell lung cancer (NSCLC), as a stand-alone and in combination therapy. Crit Rev Oncol Hematol 2021;164:103417.
Majeed U, Manochakian R, Zhao Y, Lou Y. Targeted therapy in advanced non-small cell lung cancer: Current advances and future trends. J Hematol Oncol 2021;14:108.
Gandhi L, Rodríguez-Abreu D, Gadgeel S, Esteban E, Felip E, De Angelis F, et al
. Pembrolizumab plus chemotherapy in metastatic non-small-cell lung cancer. N Engl J Med 2018;378:2078-92.
Socinski MA, Jotte RM, Cappuzzo F, Orlandi F, Stroyakovskiy D, Nogami N, et al
. Atezolizumab for first-line treatment of metastatic nonsquamous NSCLC. N Engl J Med 2018;378:2288-301.
Hellmann MD, Ciuleanu TE, Pluzanski A, Lee JS, Otterson GA, Audigier-Valette C, et al
. Nivolumab plus ipilimumab in lung cancer with a high tumor mutational burden. N Engl J Med 2018;378:2093-104.
Paz-Ares L, Ciuleanu TE, Cobo M, Schenker M, Zurawski B, Menezes J, et al
. First-line nivolumab plus ipilimumab combined with two cycles of chemotherapy in patients with non-small-cell lung cancer (CheckMate 9LA): An international, randomised, open-label, phase 3 trial. Lancet Oncol 2021;22:198-211.
Theelen WSME, Peulen HMU, Lalezari F, van der Noort V, de Vries JF, Aerts JGJV, et al
. Effect of pembrolizumab after stereotactic body radiotherapy vs pembrolizumab alone on tumor response in patients with advanced non-small cell lung cancer: Results of the PEMBRO-RT phase 2 randomized clinical trial. JAMA Oncol 2019;5:1276-82.
Bauml JM, Mick R, Ciunci C, Aggarwal C, Davis C, Evans T, et al
. Pembrolizumab after completion of locally ablative therapy for oligometastatic non-small cell lung cancer: A phase 2 trial. JAMA Oncol 2019;5:1283-90.
Wei Z, Yang X, Ye X, Huang G, Li W, Han X, et al
. Camrelizumab combined with microwave ablation improves the objective response rate in advanced non-small cell lung cancer. J Cancer Res Ther 2019;15:1629-34.
Oliver AJ, Davey AS, Keam SP, Mardiana S, Chan JD, von Scheidt B, et al
. Tissue-specific tumor microenvironments influence responses to immunotherapies. Clin Transl Immunology 2019;8:e1094.
Shirasawa M, Yoshida T, Shimoda Y, Takayanagi D, Shiraishi K, Kubo T, et al
. Differential immune°related microenvironment determines pd°1/pd°l1 blockade efficacy in advanced non°small cell lung cancer patients. J Thorac Oncol 2021;16:2078-90.
Stone J, Hartley-Blossom Z, Healey T. The emerging role of percutaneous thermal ablation in the treatment of thoracic malignancies: A review. Surg Technol Int 2020;36:257-64.
Lin M, Eiken P, Blackmon S. Image guided thermal ablation in lung cancer treatment. J Thorac Dis 2020;12:7039-47.
Hausner PF. Image-guided thermal ablation of tumor increases the plasma level of interleukin-6 and interleukin-10: Is plasma level of interleukin-6 a surrogate for immunogenic cell death? J Vasc Interv Radiol 2013;24:1112-3.
Wei Z, Yang X, Feng Y, Kong Y, Yao Z, Ma J, et al
. Could concurrent biopsy and microwave ablation be reliable? Concordance between frozen section examination and final pathology in CT-guided biopsy of lung cancer. Int J Hyperthermia 2021;38:1031-6.
Wei Z, Yang X, Ye X, Feng Q, Xu Y, Zhang L, et al
. Microwave ablation plus chemotherapy versus chemotherapy in advanced non-small cell lung cancer: A multicenter, randomized, controlled, phase III clinical trial. Eur Radiol 2020;30:2692-702.
Wei Z, Ye X, Yang X, Huang G, Li W, Han X, et al
. Efficacy and safety of microwave ablation in the treatment of patients with oligometastatic non-small-cell lung cancer: A retrospective study. Int J Hyperthermia 2019;36:827-34.
Kerkar SP, Restifo NP. Cellular constituents of immune escape within the tumor microenvironment. Cancer Res 2012;72:3125-30.
Bierie B, Stover DG, Abel TW, Chytil A, Gorska AE, Aakre M, et al
. Transforming growth factor–B regulates mammary carcinoma cell survival and interaction with the adjacent microenvironment. Cancer Res 2008;68:1809-19.
Iida N, Nakamoto Y, Baba T, Nakagawa H, Mizukoshi E, Naito M, et al
. Antitumor effect after radiofrequency ablation of murine hepatoma is augmented by an active variant of CC Chemokine ligand 3/macrophage inflammatory protein-1alpha. Cancer Res 2010;70:6556-65.
Zhu Z, Aref AR, Cohoon TJ, Barbie TU, Imamura Y, Yang S, et al
. Inhibition of KRAS-driven tumorigenicity by interruption of an autocrine cytokine circuit. Cancer Discov 2014;4:452-65.
Koyama S, Akbay EA, Li YY, Aref AR, Skoulidis F, Herter-Sprie GS, et al
. STK11/LKB1 deficiency promotes neutrophil recruitment and proinflammatory cytokine production to suppress T-cell activity in the lung tumor microenvironment. Cancer Res 2016;76:999-1008.
Singal AK, Freeman DH Jr, Anand BS. Meta-analysis: Interferon improves outcomes following ablation or resection of hepatocellular carcinoma. Aliment Pharmacol Ther 2010;32:851-8.
Abbas AK, Trotta E, R Simeonov D, Marson A, Bluestone JA. Revisiting IL-2: Biology and therapeutic prospects. Sci Immunol 2018;25:eaat1482. doi: 10.1126/sciimmunol.aat1482.
Ikeda H, Old LJ, Schreiber RD. The roles of IFN gamma in protection against tumor development and cancer immunoediting. Cytokine Growth Factor Rev 2002;13:95-109.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]