Cytokine & Growth Factor Reviews 23 (2012) 333342

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Cytokine & Growth Factor Reviews

journal homepage: www.elsevier.com/locate/cytogfr

Mini review

The role of interleukin-6 in gynaecological malignancies

Jermaine I.G. Coward a,*, Hagen Kulbe b
a b

Cancer Therapeutics Group, Mater Medical Research Institute, Level 3 Aubigny Place, Mater Hospitals, Brisbane, QLD 4101, Australia Barts Cancer Institute, Centre for Cancer and Inammation, Charterhouse Square, London EC1 6BQ, United Kingdom

A R T I C L E I N F O

A B S T R A C T

Article history: Available online 30 September 2012 Keywords: Interleukin-6 Tumour microenvironment Epithelial ovarian cancer Endometrial cancer Cervical cancer

There are many parallels between gynaecological cancers in relation to cytokine networks within their respective tumour microenvironments and evidence to support interleukin-6 (IL-6) being an appropriate therapeutic target in these diseases. This article provides an overview on IL-6 biology including updates on novel discoveries in IL-6 signalling and then focuses on the role of IL-6 in processes such as cell proliferation, migration, angiogenesis, evasion of tumour immunity and chemoresistance and presents data relating to the abrogation of these processes with anti-IL-6 targeted therapy in preclinical and clinical studies. The overall aim will be to highlight the necessity for further translational studies concentrating on combinations of anti-IL-6/IL-6R therapies with other novel targets in an attempt to signicantly improve overall survival in patients with gynaecological cancers. 2012 Elsevier Ltd. All rights reserved.

1. Introduction Collectively, gynaecological malignancies (i.e. epithelial ovarian (EOC), endometrial and cervical cancers) represent one of the most common causes of female cancer death worldwide. Although advanced presentations of these diseases are amenable to surgery and exhibit modest sensitivity to chemotherapy, resistance invariably occurs and most patients eventually die within 5 years. From research into the biology of gynaecological cancers (GC) during the past few decades, inammation has emerged as a chief orchestrator of processes that underpin disease progression and ultimately poor prognosis. Cancer-related inammation is particularly exemplied by the role of cytokines and chemokines in both the pathogenesis and progression of GC. Indeed, inammatory aetiological factors have been well established in these tumour types, for example; (a) Unopposed oestrogens have profound inammatory effects on the endometrium that can result in the initiation and propagation of neoplastic activity through upregulation of cytokines including interleukin (IL)-1, IL-6, tumour necrosis factor (TNF)-a and matrix metalloproteases (MMPs) [1,2]. These processes are mediated through NF-kB signalling in endometrial adenocarcinoma [3]. (b) Ovulation is characterised by local release of inammatory mediators including the cytokines IL-1b, IL-6, TNF-a, GM-CSF [4], platelet activating factor, prostaglandins, histamine and bradykinin [5]. These substances may inuence the epithelium

in ovulatory tissue by enhancing cell replication and create oxidative stresses that can facilitate the development of malignant cells [5]. (c) Cervical inammation is associated with high-grade cervical neoplasia or invasive cervical cancer [68]. In addition, elevated systemic levels of IL-6, IL-8, TNF-a and CCL3 are associated with persistent human papilloma virus (HPV) infection [9]. As inammation prominently features in normal reproductive processes, it is not surprising that aberrant inammatory signalling is associated with chronic diseases and malignancies in the lower female genital tract [10,11]. It follows that GC appear to share inammatory pathway signatures within their tumour microenvironments that are integral to processes that expedite disease progression (Table 1). However, despite the evidence to support the importance of these networks in disease recurrence, there is a paucity of translational clinical trials that focus on manipulating these pathways in order to prolong survival. Although some studies have shown modest increments in progression free survival (PFS) [1219], the impact on overall survival (OS) has been negligible due to the development of resistance. Furthermore, these limited benets are in some part due to targeting single molecules that consequently induce compensatory pathways leading to relapse. Within the proinammatory cytokine milieu, IL-6 is emerging to be a pivotal mediator of tumourigenesis (Fig. 1) and subsequently a potential therapeutic target. Moreover, the concept of manipulating inammatory mediators in cancer therapeutics is particularly signicant in light of the recent ndings from the Cancer Genome Atlas project in ovarian cancer [20]. The genomic analysis

* Corresponding author. E-mail address: jcoward@mmri.mater.org.au (Jermaine I.G. Coward). 1359-6101/$ see front matter 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.cytogfr.2012.08.005

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Table 1 Cancer-related inammation in gynaecological cancers.  Gene signatures conrm IL-6 upregulation [14,112,113]  Upregulation of JAK-STAT signalling pathway that results in the transcription of anti-apoptotic genes such as bcl-xl, survivin, mcl-1 [36,39]  PTEN and KRAS mutations associated with activation of inammatory signalling and subsequent upregulation of inammatory mediators resulting in tumourogenesis [114121]  Poor prognosis correlating with elevated circulating concentrations of IL-6 [52,62,65] and increased inltration with tumour associated macrophages [100,122,123]  Increased metastatic potential associated with increased expression of the chemokine receptor CXCR4 and its ligand CXCL12 (also known as stromal cell derived factor-1 (SDF-1)) [82,124,125]

This review will summarise the role of IL-6 in GC along with the preclinical and clinical research to support the rationale for targeting this cytokine in conjunction with established cytotoxic regimes and/or other novel therapies in future treatment algorithms. 2. Interleukin-6 signalling IL-6 is a pleiotropic cytokine with a broad spectrum of biological activity relating to regulation of inammation, cell differentiation, cell proliferation, immunomodulation, haematopoiesis and oncogenesis. Human IL-6 consists of 184 amino acids and is produced by multiple host and tumour cells in the tumour microenvironment. It was initially cloned in 1986 and identied as an antigen-nonspecic B-cell differentiation factor that induced Bcell production of immunoglobulins. IL-6 acts through the formation of a high-afnity complex with its receptor that consists of an 80-kDa IL-6 binding glycoprotein gp80 (a-chain, IL-6Ra) and the 130-kDa signal transducer gp130 (b-chain). Both gp80 and gp130 exist in transmembrane and soluble forms (sgp80 and sgp130). The transmembrane domain of gp80 consists of a short

conrmed that high grade serous subtypes (HGSC) consisted predominantly of TP53 mutations (96%) with a low frequency of additional targetable oncogenes. However, Notch signalling, a pathway downstream of TNF-a and IL-6 [14,21], was amplied/ mutated in 11% of HGSC cases [20]. Hence targeting the inammatory microenvironment in this particular disease could prove be benecial in improving clinical outcome.

Fig. 1. IL-6 function and the GC tumour microenvironment IL-6 can exhibit pleiotropy within the GC microenvironment primarily through pSTAT3 signalling and interaction with other cytokine and chemokines. IL-6 contributes to GC with aggressive phenotypes by promoting tumour cell proliferation, angiogenesis and platinum resistance alongside subverting tumour immunity by enhancing dendritic cell tolerogenicity and phenotypic skewing of M1 macrophages to TAM.

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intracytoplasmic region that associates with gp130 as a consequence of IL-6 binding. This leads to gp130 homodimerisation and signal transduction that characterises classic signalling; the predominant mode through which IL-6 orchestrates its homeostatic functions [22] (Fig. 2). Both sgp80 and sgp130 are formed either by cleavage from the cell membrane by transmembrane metalloproteinases (e.g. ADAM17) or translated from alternate mRNA splicing [2326]. Whilst gp80 expression is limited to certain cell types (hepatocytes, monocytes, T cells, B cells, neutrophils and malignant cells) [26], gp130 expression is ubiquitous. However, IL-6 can still exert inuences on cells lacking transmembrane gp80 by forming a complex with sgp80 and membrane bound gp130 to initiate downstream events. This is known as trans-signalling and is critically involved in inammatory diseases (e.g. rheumatoid arthritis, peritonitis, asthma and inammatory bowel disease) and malignancies such as colorectal cancer and AIDS-associated Kaposis sarcoma [22,27,28]. Trans-signalling can be regulated by sgp130 which is able to neutralise IL-6-sgp80 complexes and sgp80 can enhance the antagonistic activity of sgp130 [29]. Although previously thought not to inuence classic signalling effects, a recent study conrms that sgp130 can indeed

inhibit this pathway in addition to trans-signalling [30]. Considering that most pathophysiological conditions are characterised by molar excesses of sgp80 over IL-6 in serum, Garbers et al. demonstrated that sgp130 can indirectly block classic signalling by trapping IL-6sgp80 complexes which subsequently eliminate free IL-6 molecules (Fig. 2) [30]. Gp130 behaves promiscuously in that it acts as a common signal transducer for other cytokines along with IL-6, namely IL-11, IL-27, ciliary neurotrophic factor (CNTF), cardiotropin1 (CT-1), oncostatin M (OSM), neurotrophin-1 and leukaemia inhibitory factor (LIF) [22,31]; each of which have dened physiological roles. This group of cytokines are collectively known as the IL-6 cytokine superfamily [32] and all (with the exception of OSM and LIF that engage directly with gp130) interact with their respective binding receptor leading to gp130 hetrodimerisation. Intracellular signalling is then initiated through activation of gp130 associated cytoplasmic tyrosine kinases, namely the Janus-activated kinases 1 and 2 (JAK1 and JAK2) which phosphorylate signal transducers and activators of transcription (STAT) proteins, Ras/ MAPK and PI3K/Akt [33]. The association between IL-6 and cancer revolves around gp130 activation of IL-6 signalling pathways that ultimately lead to

Fig. 2. IL-6 signalling A. The classic mode of IL-6 signalling involves IL-6 complexing with membrane bound IL-6R. Trans-signalling is mediated via IL-6-sgp80 complexes. Both modes involve association with membrane bound gp130 to induce downstream signalling. B. sgp130 abrogates both classic signalling and trans-signalling by preferentially binding to IL-6-sgp80 complexes.

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evasion of apoptosis which appears to be principally mediated through the aforementioned JAK/STAT pathway. Within normal eukaryotic cells, STATs, particularly STAT3, are involved in the transduction of signals from the cell surface to its nucleus and activation of gene transcription. This results in the inhibition of apoptosis during inammation and cell survival in suboptimal conditions. However, dysregulation of such processes may also promote the development of a number of malignancies and constitutive STAT signalling is prominent in GC [3439]. JAK2 mediated phosphorylation of STAT3 occurs at a single tyrosine residue (Tyr705) [40] which is situated in the Src homologue (SH2) domain and binding between these residues results in the formation of stable STAT dimer complexes that contain an exposed nuclear translocation signal. The complex is then able to translocate to the nucleus where enhancer elements in the promoter and enhancer regions of target genes are recognised leading to the initiation of transcription [41]. Induced genes include acute phase proteins (CRP, haptoglobin and brinogen), the anti-apoptotic bcl-2 family members (e.g. bcl-2, b-1, bcl-xL, XIAP and mcl-1), alongside myc and cyclin D1 that both enhance cellular proliferation [34]. IL-6 also modulates STAT3 signalling via a negative feedback loop through induction of suppressor of cytokine signalling 3 (SOCS3) proteins that bind to the phosphorylated tyrosine residue, Tyr759, on the gp130 receptor [42]. Conversely, recent research in an ulcerative colitis related colorectal cancer model has demonstrated that IL-6 can induce DNA methyltransferase gene 1 (DNMT1) mediated SOCS3 promoter methylation that consequently results in aberrant STAT3 signalling and increased malignant potential [43]. Furthermore, this pathway blunts anti-tumour immunity by tolerising dendritic cells and augments angiogenesis by upregulation of VEGF [44,45]. These effects, which are complemented by other oncogenic events manifesting through parallel Ras/MAPK and PI3/Akt signalling pathways, fuel the malignant repertoire of IL-6 within the tumour microenvironment and hence make this key cytokine an attractive therapeutic target in GC. 3. IL-6 as an autocrine growth factor in GC A number of in vitro and in vivo studies have reported increased IL-6 expression in GC. In EOC, elevated levels of IL-6 have been identied in ovarian tumour cell cultures with cells displaying intracellular IL-6 by immunoperoxidase staining [46]. These concentrations also appear to be considerably higher in subtypes with poor prognosis. This was shown clearly by Anglesio et al., who demonstrated a panel of ovarian clear cell cancer (OCCC) lines (namely TOV21G, RMG1, HAC2, JOHCS5, JOHCS7 and JOHCS9) secreting IL-6 in concentrations several logs higher than other EOC subtypes [47]. Watson et al. have also demonstrated constitutive production of IL-6 in EOC cell lines such as CAOV-3, OVCAR-3 and SKOV-3 and its activity appears to be upregulated by IL-1b, TNF-a and IFN-g [46]. This group also discovered that inhibition of IL-6 gene expression using IL-6 anti-sense oligonucleotides could result in up to 85% inhibition of cellular proliferation [48]; however this effect was not reversed with the addition of exogenous IL-6. Recently, we have shown bi-weekly intraperitoneal (i.p.) injections of the anti-IL-6 monoclonal antibody (mAb), siltuximab (Centocor Ortho Biotech Inc.) into mice xenografted with either IGROV-1 or TOV21G cells, diminished tumour colonisation analysed by bioluminescence imaging and signicantly decreased cellular proliferation as measured by Ki67 expression on tumour sections after 4 weeks of treatment [14]. For endometrial cancer the evidence to support existing IL-6 autocrine networks in this disease requires further exploration. In the normal endometrium, IL-6 promotes proliferation, differentiation and invasion of trophoblast cells [49]. Furthermore, IL-6

modulates the expression of growth hormone (GH) and its receptor [50]; which is also responsible for endometrial cell proliferation. In view of this, a retrospective study by Slater et al. demonstrated that compared to normal uterine cells, GH and IL-6 are increased by 3.8 and 4.4-fold in endometrial adenocarcinoma respectively [51]. They concluded that these two growth factors may act in concert to enhance endometrial cancer progression [51]. Bellone et al. [52] identied detectable levels of IL-6 from the supernatants of endometrioid (EC; Type I) and uterine serous papillary cell lines (UPSC; Type II) with the latter poorer prognostic subtype secreting signicantly higher concentrations of IL-6. In addition, endometrial cell proliferation enhanced through estrogenic G proteincoupled receptor 30 (GPR30) signalling via the MAPK/ERK pathway can result in increased IL-6 production [2]. Although these studies suggest a tenuous association between IL-6 and endometrial cell growth, more focused experiments are required to rmly establish its autocrine function in this disease. In contrast, such effects have been established in cervical cancer cell lines in vitro. IL-6 is secreted in variable quantities from numerous epithelial cervical neoplastic cells cultured on plastic and cell proliferation is inhibited with the addition of anti-IL-6 neutralising agents [5355]; an effect that can be rescued with recombinant human IL-6 (rhIL-6) [54]. Predictably, targeting IL-6 with anti-IL-6/IL-6R mAb also impedes the transcription of pro-survival genes and this effect appears to be specic to certain signalling pathways within GCs. Wei et al. elegantly demonstrated that the anti-apoptotic effects of IL-6 through mcl-1 upregulation occurs preferentially via PI3/Akt signalling [56]; whereas in EOC, the expression of the bcl2 gene family is predominantly inuenced by STAT3 activity [57].

4. Serum and peritoneal uid IL-6 concentrations Several studies have focused on analysing IL-6 levels in blood and ascites from patients with GCs. In healthy human subjects, IL-6 concentrations found in blood greater than 10 pg/ml are considered to be abnormally elevated [58,59] and in patients with newly diagnosed EOC, these levels portend signicantly worse survival (median OS: IL-6 < 10 pg/ml: 5.99 yrs, IL-6 > 10 pg/ml: 3.38 yrs; p < 0.001) [60]. Additionally, there is evidence to suggest a relationship between serum IL-6, tumour burden, disease stage and prognosis in EOC. Berek et al. published data illustrating that high IL-6 levels correlated with bulky disease, elevated CA-125, disease progression and ultimately poorer prognosis [61]. Similarly, the Tempfer study conrmed that elevated serum IL-6 measured prior to treatment (mean 55.6 pg/ml) correlated statistically signicantly with FIGO stage, poorer PFS and OS [62]. There also appears to be inter-subtype variability in IL-6 concentrations [47,63] (Table 2). For example, analysis of serum from the Australian Ovarian Cancer Study (AOCS) dataset, has conrmed patients with OCCC have signicantly higher concentrations of IL-6 than patients with HGSC. These elevated levels were associated with poor PFS and OS in OCCC; and, unlike the HGSC cohort, there was no correlation with increasing tumour stage [47]. However, IL-6 has yet to be validated as a tumour marker in EOC and in combination with CA-125 only marginally increases overall sensitivity compared to CA-125 alone [63]. The in vitro results from the Bellone study were also reected in the analysis of serum from patients with endometrial cancer. Not only were IL-6 levels signicantly higher relative to healthy controls (p < 0.01), but these concentrations were particularly elevated in UPSC as compared to EC (p < 0.03) [52]. These observations conict with an earlier study that showed normal levels of IL-6 throughout all stages of endometrial cancer; however all of these patients had type I disease only [64]. Hence, as with EOC, IL-6 appears to be associated with subtypes exhibiting poor

J.I.G. Coward, H. Kulbe / Cytokine & Growth Factor Reviews 23 (2012) 333342 Table 2 Serum and ascitic/peritoneal uid IL-6 concentrations in GC. GC type Cervical cancer Subtype Squamous cell Adenocarcinoma Squamous cell & adenocarcinoma Specimen Serum Serum Serum Mean IL-6 pg/ml (unless indicated) (range SEM) 83.4 14.1 Stage I: 21.6 9.8 Stage II: 32.8 8.9 Stage III: 27.5 5.7 Stage IV: 42.4 3.6 1222 546 20.43 (2.8682.13) <10.0 (all stages) 125.7 (16.3500.1) 1977 616 0.26 U/ml 0.04 Stage I: 16.1 (0316.3) Stage II: 44.7 (0877.9) Stage IIIIV: 285.3 (66.02869.0) 10.0 (<11221)

337

Reference [55]

[65]

Squamous cell & adenocarcinoma Endometrial cancer Endometrioid Endometrioid Uterine serous papillary Adenocarcinoma, carcinosarcoma & stromal sarcoma Unspecied Serous, mucinous, clear cell and undifferentiated

Peritoneal uid Serum Serum Serum Peritoneal uid

[66] [52] [64] [52] [66]

Ovarian cancer

Serum Serum

[61] [62]

Serous, endometrioid, mucinous, clear cell and undifferentiated Serous Mucinous Endometrioid Undifferentiated Unspecied Serous, endometrioid, mucinous, clear cell and undifferentiated Serous cystadenocarcinoma, endometrioid, mucinous and granulosa cell Serous, mucinous, endometrioid, mixed and unspecied

Serum

[69]

Serum

7.0 1.5 4.4 4.5 7.7

(0.3660) (0.455) (0.420) (0.426) (0.455)

[63]

Ascites Ascites

49,612 (<1680,330) 5572 1266

[69] [66]

Ascites

6419 1409

[70]

prognosis and may serve as a more appropriate therapeutic target in UPSC [52]. Similarly elevated levels of IL-6 are also found in serum from patients with cervical cancer. Takano et al. reported that amongst 66 patients with squamous cell carcinoma (SCC) approximately 33% had IL-6 levels > 20 pg/ml (mean 83.4 pg/ml) [55]. This concentration was substantially higher than in 4 patients with adenocarcinoma (14.1 pg/ml) and 8 healthy controls (4.4 pg/ml). This pattern was also seen when cells from these subtypes were cultured in vitro and IL-6 concentrations correlated with the extent of SCC differentiation [55]. In addition, for both subtypes, increasing IL-6 levels appear to correlate with advancing stages of disease [65]. In comparison with plasma or serum, IL-6 concentrations in ascitic uid are substantially higher; predominantly due to the relative abundance of inammatory cells such as tumour associated macrophages (TAM), neutrophils, lymphocytes and mesothelial cells which are all rich sources of IL-6 [66,67]. These levels have also been attributed to the surge in IL-6 production by EOC cells followed by rapid clearance into the vasculature where IL-6 becomes either protein bound or degraded [68,69]. Plante et al. reported that ascitic IL-6 levels can correlate with increasing volume of ascites (p < 0.0001) and tumour size found at surgery (p = 0.05) but found no relationship with survival or tumour grade and stage [69]. However, a recent study has associated poor PFS with high ascitic levels of IL-6 in patients newly diagnosed with EOC [70]. The subtype variability observed in serum IL-6 concentrations in EOC also applies to peritoneal uid. This was rst intimated by Kutteh et al. who identied that papillary cases had a tendency to secrete higher levels than non-papillary histotypes [71]. A subsequent study by Kryczek et al. observed

substantially higher concentrations in patients with serous and mucinous tumours compared with endometrioid and undifferentiated carcinomas and also noted an inverse correlation between IL-6 and p53 staining on EOC cytospins [72]. In conjunction with IL6, elevated levels of sIL-6R are also evident in ascites. In EOC xenograft models, IL-6 trans-signalling through ERK activation facilitates the development of ascites by enhancing endothelial cell hyperpermeability and transendothelial migration of ovarian cancer cells [73]. Furthermore, ascites formation can be reduced by blocking trans-signalling using the ERK inhibitor PD98059 [73]. Punnonen et al. studied the peritoneal uid cytokine proles from GC patients and discovered that IL-6 levels were elevated amongst all GCs and these concentrations were signicantly higher in patients with benign ovarian tumours and EOC than in patients with endometrial or cervical cancer. Interestingly, amongst the myriad of cytokines and growth factors measured (i.e. IL-2, IL-4, IL10, IFN-g, TNF-a, M-CSF, G-CSF and GM-CSF), IL-6 was the solitary cytokine that exhibited signicant differences amongst the different GCs [66]. The reasons for this observation have yet to be determined. Contrary to the Plante study, which included the same selection of EOC subtypes, there was no correlation between IL-6 levels and volume of ascites; so it remains to be ascertained whether ascitic IL-6 concentrations could be utilised as a reliable marker for tumour response in patients receiving treatment for predominantly ascitic disease. 5. Cell migration and invasion During inammation, IL-6 certainly employs a central role with integrin induction and migration of monocytes [74]; a phenomenon also commonplace within tumorigenic processes in a variety

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of malignancies [7577]. The inuence of IL-6 on ovarian cancer cell motility is also mediated through STAT3 signalling. As previously mentioned, Silver et al. correlated constitutive pSTAT3 production in ovarian cancer cell lines with phenotypically aggressive tumours [37]. By using confocal micrographs of SKOV3 and OVCAR3 cells plated on bronectin, this group detected localisation of pSTAT3 in focal adhesions, structures that enhance cell migration by transducing extracellular signals into changes in the cytoskeleton and hence potentially facilitate invasion of malignant cells. Furthermore, this localisation occurred when these cells were stimulated with IL-6 in vitro [37]. More recently, Colombiere et al. have shown with wound healing assays that IL-6 can induce OVCA 433 cell migration and this can be reversed with a neutralising anti-IL-6R antibody [78]. In addition, in vitro studies have conrmed that IL-6 can enhance EOC cell line invasion and attachment to matrigel [79,80] and targeting IL-6 can effectively suppress MMP-9 secretion [81]. Interestingly, although inammatory mediators related to IL-6 such as CXCL12 [82], TNF-a [83] and PGF2a [84] are known to promote endometrial cancer cell migration and invasion, the direct role of IL-6 in these processes for this disease has yet to be conrmed. Similarly, although nonsignicant trends have been reported between increasing intratumoural IL-6 expression and extent of loco-regional invasion and metastasis in cervical cancer [85], further research is required relating to this issue. 6. IL-6 and angiogenesis

mediated angiogenesis leads to transcription of HIF-1a along with VEGF [92]. Anglesio et al. have recently reported overexpression of the IL-6-STAT3-HIF1 a pathway in OCCC tumours compared to HGSC and evidence of response in patients treated with the antiangiogenic agent; sunitinib [47]. Another mode of IL-6 induced angiogenesis in EOC could occur through its ability to polarize macrophages in ascites to the immunosuppressive M2 phenotype, i.e. TAM [93]. TAM secrete proangiogenic factors such as TGF-b, PDGF, VEGF, FGF and numerous chemokines including CXCL1 and IL-8 (CXCL8) that promote the angiogenic switch [94]. In conjunction with inhibiting angiogenesis in our aforementioned EOC xenograft models, siltuximab also inhibited macrophage inltration in tumour sections as evidenced by signicant decreases in F4/80 IHC staining [14]. Equally, from an immunogenic perspective, IL-6 with TGF-b could also inuence angiogenic effects by mediating the preferential differentiation of CD4+ Th cells to Th17 subsets as opposed to FoxP3+ regulatory T cells [95,96]. Within the EOC tumour microenvironment, IL-6 promotes expansion of Th17 cells [97] that secrete a host of cytokines including IL-17 which is signicantly associated with increased microvascular density in EOC tissue sections [98]. Although TAM, IL-8, VEGF and FGF are well documented to have proangiogenic activity within endometrial cancers [99,100], further studies are required in verify whether IL-6 per se has a profound inuence on angiogenic processes in this disease. 7. IL-6 and chemoresistance

There is ample evidence supporting proangiogenic activity of IL-6 in various tumour types [76,86,87]. With respect to this review, it seems tting that the pivotal work implicating IL-6 as a potent inducer of VEGF was established in a cervical carcinoma model [85,88]. Wei et al. demonstrated that rhIL-6 can induce VEGF in a time- and dose-dependent manner in C33A cells in vitro and at a transcriptional level this effect can be substantially repressed with either anti-IL-6 or anti-IL-6R treatment [85]. This group also highlighted that IL-6 upregulation of VEGF transcription is mediated by STAT-3 [88]; a signalling pathway notorious for promoting tumour angiogenesis through its constitutive activation [44]. Subsequently, using matrigel plugs containing C33A cells overexpressing IL-6, Su et al. have shown that inhibition of IL-6R with S7 peptide can effectively impede angiogenesis and tumour growth in vivo [89]. Within normal ovarian tissue, IL-6 is involved in the formation of new blood vessels that accompany ovarian folliculogenesis [90]. In relation to ovarian cancer and angiogenesis there are a few studies emerging that specically focus on the role of IL-6 in this process. Using IHC analysis, Nilsson et al. showed that IL-6R is expressed on endothelial cells in human ovarian cancer specimens and IL-6 induced pSTAT3 in ovarian and mesenteric endothelial cells. Furthermore, through STAT3 activation, IL-6 promoted endothelial cell migration in vitro [91]. This study also reported potent angiogenic effects associated with IL-6 in vivo. Gel foam sponges previously incubated with IL-6, bFGF or PBS, were implanted into the peritoneum of BALB/c mice for two weeks and then immunostained with CD31 and VEGFR-1 antibodies to estimate microvascular density. The vessel density with IL-6 treated sections was equivalent to bFGF, but signicantly greater than PBS (p < 0.0001) [91]. More recently, using IL-6 producing intraperitoneal IGROV-1 and TOV21G xenograft models, we have shown that siltuximab can signicantly reduce microvascular density on confocal imaging of tumour sections and reduce expression of jagged-1; also known to have angiogenic effects in advanced EOC [14,21]. In addition, VEGF and IL-8 plasma concentrations decrease markedly in platinum resistant patients treated with siltuximab monotherapy for 6 months [14]. In response to hypoxia, IL-6-STAT3

IL-6 behaves as a prominent mediator of chemoresistance in a variety of malignancies [101]. In EOC, Scambia et al. were the rst group to report the association of elevated serum IL-6 concentrations (6 pg/ml) with poor response to chemotherapy [63]. Since then, Wang et al. revealed that both exogenous and endogenous IL-6 increased platinum and paclitaxel resistance in non-IL-6 producing A2760 cell lines and sensitivity to these drugs could be retrieved with IL-6 antisense in IL-6 over-expressing SKOV-3 cells [102]. This group also showed that IL-6 specically promoted such cytotoxic resistance through upregulation of multidrug resistance genes MDR-1 and GSTpi, transcription of anti-apoptotic proteins (bcl-xL and XIAP) and signalling through PI3/Akt and Ras/MEK/ERK signalling pathways [102]. Similar studies conducted by Duan et al. showed that IL-6 is preferentially overexpressed in certain ve paclitaxel-resistant EOC cell lines compared with chemo-na counterparts [103]. Additionally, using paired resistant and sensitive human ovarian cancer cell lines, they demonstrated that STAT3 was overexpressed in some paclitaxel resistant lines and correlated high levels of IL-6 with increased STAT3 expression in the chemoresistant cells [103]. They concluded that chemoresistance could be reversed by STAT3 knockdown using siRNA, and found that apoptosis was enhanced when resistant lines were treated with a STAT3 inhibitor (AG490), paclitaxel or a combination of both drugs [103]. Using siltuximab, on multidrug resistant EOC cell lines, Guo et al. have recently recapitulated these ndings in vitro but witnessed no signicant effect on paclitaxel resistant tumour growth with SKOV-3TR xenograft mouse models [57]. Although fewer reports explicitly focus upon the role of IL-6 and chemoresistance in endometrial and cervical cancers; the pathways that have been implicated in this process appear to be inextricably linked with IL-6. For example, the cytoprotective redox sensitive transcription factor, nuclear factor erythroid-2related factor 2 (Nrf2), is not only a potent inducer of the IL-6 promoter, but is upregulated in a myriad of tumour types [104]. Nrf2 is highly expressed in SPEC-2 (Type II EC) cell lines, confers resistance to platinum and paclitaxel and this resistance can be reversed by Nrf2 siRNA [105]. Nrf2 expression also increases with

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advancing stages of cervical cancer and Nrf2 knockdown with shRNA in CaSki cells can reverse multidrug resistance [106]. Moreover, with respect to IL-6 signalling pathways, isoforms of Akt (Akt2 and Akt3) are involved in mediating cisplatin resistance in KLE endometrial cancer cell lines [107]. Furthermore, IL-6 overexpressed in C33A cervical cancer cells can diminish doxorubicin and cisplatin related apoptosis in a PI3/Akt dependent fashion [56]. 8. Translational anti -IL-6/anti-IL-6R studies in GC With evidence supporting the signicant inuence of IL-6 in numerous cancers, this cytokine is emerging as an attractive therapeutic target in the clinical setting. Several clinical trials using anti-IL-6/IL-6R therapy have been conducted in a range a tumour types with diverse results [101]. These studies have primarily been conducted in patients with poor prognosis disease and clinical benet (stable disease or better) has been achieved with durable response in select cases. The encouraging outcome from these trials has provided a sound rationale for developing further studies with anti-IL-6(R) therapy in GC; however, at the time of writing, only one such study has been reported. We conducted an open label non-randomised phase II clinical trial investigating the effects of siltuximab monotherapy in 20 patients (age 4175) with advanced platinum resistant EOC [14]. All, but one patient with OCCC, had tissue biopsy conrmed HGSC and nearly half of the cohort had an ECOG performance status of 2. Each had radiological evidence of disease progression at the point of study recruitment and received between 2 and 6 prior lines of platinum-based treatment. The primary endpoint was response rate as assessed by combined RECIST and CA125 criteria. One patient of eighteen evaluable had a partial response, whilst seven others had periods of disease stabilization. None of the serious adverse events reported in the study were attributable to siltuximab and it was generally well tolerated. In 4 patients treated for 6 months, there was a signicant decline in plasma levels of IL-6-regulated CCL2, CXCL12 and VEGF. Alongside this, sgp130 receptor concentrations increased 2.5-fold (baseline: 260.4 103 pg/ml; 6-month: 662.4 103 pg/ml); a difference that was statistically signicant (p < 0.05) [108]. This implies that long term response to siltuximab in these patients could be inuenced by inhibition of IL-6 trans-signalling. In addition, gene expression levels of factors that were reduced by siltuximab treatment in the patients signicantly correlated with high IL-6 pathway gene expression and macrophage markers in microarray analyses of ovarian cancer biopsies [14]. The mechanisms of action underlying these phenomena are currently not clear, but it serves as an intriguing avenue for further exploration in order to enhance the efcacy of anti-IL-6 therapies in future combinatorial trials. Together with the in vitro and in vivo studies previously mentioned, we concluded that IL-6 stimulates inammatory cytokine production, tumour angiogenesis and the TAM inltrate in ovarian cancer and both paracrine and autocrine actions can be inhibited by a neutralising anti-IL-6 antibody [14]. Subsequent to this research, Stone et al. have noted an important relationship between IL-6 and the development of paraneoplastic thrombocytosis in ovarian cancer [60]. Targeting either IL-6 or platelets with siltuximab and an anti-platelet antibody (APA; directed against mouse glycoprotein 1ba) respectively, impeded tumour development and reduced circulating platelets in EOC xenograft mouse models. With siltuximab, this effect was particularly enhanced in combination with paclitaxel; however APA signicantly inhibited tumour cell proliferation, microvascular density, pericyte coverage and endothelial apoptosis [60]. Whether the anti-neoplastic/anti-angiogenic effects exerted with APA are an indirect consequence of IL-6 inhibition requires further investigation. In correlation with our Phase II

study data, for all evaluable patients there were signicant and sustained reductions in mean platelet counts after the completion of 3 cycles of siltuximab (p = 0.009) [60]; however there were no statistical differences in these levels between patients attaining clinical benet and those who progressed at this time-point (J. Coward, PhD Thesis, Queen Mary University, London). In light of the potential additive effect of targeting IL-6 in combination with chemotherapy, a recently initiated feasibility study in the Netherlands is investigating the efcacy of varying schedules of carboplatin/caelyx or carboplatin/doxorubicin with anti-IL-6R mAb (Tocilizumab; Roche) and Peg-Intron (interferon-a 2b) in patients with recurrent EOC. The primary objective is to assess the safety and efcacy of these novel regimens. In view of the immunosuppressive effects of IL-6 signalling, the secondary outcomes focus on the inuence of anti-tumour immunity on survival by analyzing changes in dendritic cell subsets and assessing T- and B-cell responses to known ovarian cancer antigens such as NY-ESO and p53 (ClinicalTrials.gov identier: NCT01637532). 9. Future directions Although there have been some signicant improvements in response rates with different combinations of chemotherapy over the past 20 years, it is clear that the therapeutic ceiling is being reached with this approach in treating GC. Naturally, for this reason, attention has turned towards targeting mediators of specic processes intrinsic to tumour progression; a strategy that has had varying degrees of efcacy, both as monotherapy and in combination with cytotoxic agents. Certainly the most convincing approach in this group of diseases to date has centred upon inhibiting angiogenesis through VEGF blockade with bevacizumab (anti-VEGF-A mAb) with signicant PFS benet evident in adjuvant, maintenance and palliative settings. However, despite these recent encouraging results, the goal of attaining a distinct OS survival has yet to be realised in GC and this consequently necessitates the rapid development of further combinatorial clinical trials with novel targeted agents. This review has provided considerable evidence to support the role of IL-6 as a therapeutic target in various GC subtypes and the aforementioned trials with siltuximab and bevacizumab have set the foundation for the incorporation of drugs targeting IL-6(R) and associated signalling pathways into the standard pharmacological management of these diseases. Although the EOC siltuximab trial was conducted on a small cohort, the results are striking in that clinical benet was evident for monotherapy in a heavily pretreated poor prognostic group. Although the exact mechanisms of action have to yet undergo further investigation, the anti-angiogenic effects of this drug are compelling and in view of the recent ICON 7 and OCEANS studies [19,109], it warrants further investigation as both rst-line and salvage treatment in conjunction with chemotherapy. This is a point of particular interest as both platinum and taxane drugs can themselves transiently induce IL-6 in in vitro and in vivo cancer models [110,111]. Hence, theoretically at least, the introduction of anti-IL-6 blockade both in combination and as maintenance therapy could avert the development of chemoresistant clones in addition to suppressing neoangiogenesis. Such trials could also be introduced in the neoadjuvant settings, whereby tissue obtained during debulking surgery could provide a wealth of information on the effects previously exerted by targeting IL-6 on the tumour microenvironment. Moreover, high throughput systematic analysis for the upregulation of compensatory signalling pathways that foster resistance to this therapy could assist in tailoring appropriate adjuvant therapies in order to prolong survival. Not only will it be important to expand translational

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J.I.G. Coward, H. Kulbe / Cytokine & Growth Factor Reviews 23 (2012) 333342 [19] Perren TJ, Swart AM, Psterer J, Ledermann JA, Pujade-Lauraine E, Kristensen G, et al. A phase 3 trial of bevacizumab in ovarian cancer. New England Journal of Medicine 2011;365(26):248496. [20] Integrated genomic analyses of ovarian carcinoma. Nature 2011;474:60915. [21] Kulbe H, Chakravarty P, Leinster DA, Charles KA, Kwong J, Thompson RG, et al. A dynamic inammatory cytokine network in the human ovarian cancer microenvironment. Cancer Research 2012;72:6675. [22] Jones SA, Scheller J, Rose-John S. Therapeutic strategies for the clinical blockade of IL-6/gp130 signaling. Journal of Clinical Investigation 2011;121:337583. [23] Horiuchi S, Koyanagi Y, Zhou Y, Miyamoto H, Tanaka Y, Waki M, et al. Soluble interleukin-6 receptors released from T cell or granulocyte/macrophage cell lines and human peripheral blood mononuclear cells are generated through an alternative splicing mechanism. European Journal of Immunology 1994;24(8): 19458. [24] Mullberg J, Schooltink H, Stoyan T, Gunther M, Graeve L, Buse G, et al. The soluble interleukin-6 receptor is generated by shedding. European Journal of Immunology 1993;23(2):47380. [25] Montero-Julian FA, Brailly H, Sautes C, Joyeux I, Dorval T, Mosseri V, et al. Characterization of soluble gp130 released by melanoma cell lines: A polyvalent antagonist of cytokines from the interleukin 6 family. Clinical Cancer Research 1997;3(8):144351. [26] Jones SA, Horiuchi S, Topley N, Yamamoto N, Fuller GM. The soluble interleukin 6 receptor: mechanisms of production and implications in disease. FASEB Journal 2001;15:4358. [27] Scheller J, Ohnesorge N, Rose-John S. Interleukin-6 trans-signalling in chronic inammation and cancer. Scandinavian Journal of Immunology 2006;63: 3219. [28] Murakami-Mori K, Taga T, Kishimoto T, Nakamura S. The soluble form of the IL6 receptor (sIL-6R alpha) is a potent growth factor for AIDS-associated Kaposis sarcoma (KS) cells; the soluble form of gp130 is antagonistic for sIL-6R alphainduced AIDS-KS cell growth. International Immunology 1996;8:595602. [29] Muller-Newen G, Kuster A, Hemmann U, Keul R, Horsten U, Martens A, et al. Soluble IL-6 receptor potentiates the antagonistic activity of soluble gp130 on IL-6 responses. Journal of Immunology 1998;161(11):634755. [30] Garbers C, Thaiss W, Jones GW, Waetzig GH, Lorenzen I, Guilhot F, et al. Inhibition of classic signaling is a novel function of soluble glycoprotein 130 (sgp130), which is controlled by the ratio of interleukin 6 and soluble interleukin 6 receptor. Journal of Biological Chemistry 2011;286(50):4295970. [31] Muller-Newen G. The cytokine receptor gp130: faithfully promiscuous. In: Sci STKE 2003. 2003. p. PE40. [32] Autissier P, De Vos J, Liautard J, Tupitsyn N, Jacquet C, Chavdia N, et al. Dimerization and activation of the common transducing chain (gp130) of the cytokines of the IL-6 family by mAb. International Immunology 1998;10(12):18819. [33] Hirano T, Nakajima K, Hibi M. Signaling mechanisms through gp130: a model of the cytokine system. Cytokine and Growth Factor Reviews 1997;8:24152. [34] Hodge DR, Hurt EM, Farrar WL. The role of IL-6 and STAT3 in inammation and cancer. European Journal of Cancer 2005;41:250212. [35] Catalano S, Giordano C, Rizza P, Gu G, Barone I, Bonoglio D, et al. Evidence that leptin through STAT and CREB signaling enhances cyclin D1 expression and promotes human endometrial cancer proliferation. Journal of Cellular Physiology 2009;218(3):490500. [36] Huang M, Page C, Reynolds RK, Lin J. Constitutive activation of stat 3 oncogene product in human ovarian carcinoma cells. Gynecologic Oncology 2000;79: 6773. [37] Silver DL, Naora H, Liu J, Cheng W, Montell DJ. Activated signal transducer and activator of transcription (STAT) 3: localization in focal adhesions and function in ovarian cancer cell motility. Cancer Research 2004;64:35508. [38] Takemoto S, Ushijima K, Kawano K, Yamaguchi T, Terada A, Fujiyoshi N, et al. Expression of activated signal transducer and activator of transcription-3 predicts poor prognosis in cervical squamous-cell carcinoma. British Journal of Cancer 2009;101(6):96772. [39] Chen CL, Hsieh FC, Lieblein JC, Brown J, Chan C, Wallace JA, et al. Stat3 activation in human endometrial and cervical cancers. British Journal of Cancer 2007;96(4):5919. [40] Yang J, Chatterjee-Kishore M, Staugaitis SM, Nguyen H, Schlessinger K, Levy DE, et al. Novel roles of unphosphorylated STAT3 in oncogenesis and transcriptional regulation. Cancer Research 2005;65(3):93947. [41] Sasse J, Hemmann U, Schwartz C, Schniertshauer U, Heesel B, Landgraf C, et al. Mutational analysis of acute-phase response factor/Stat3 activation and dimerization. Molecular and Cellular Biology 1997;17(8):467786. [42] Nicholson SE, De Souza D, Fabri LJ, Corbin J, Willson TA, Zhang JG, et al. Suppressor of cytokine signaling-3 preferentially binds to the SHP-2-binding site on the shared cytokine receptor subunit gp130. Proceedings of the National Academy of Sciences of the United States of America 2000;97(12): 64938. [43] Li Y, Deuring J, Peppelenbosch MP, Kuipers EJ, de Haar C, van der Woude CJ. IL6-induced DNMT1 activity mediates SOCS3 promoter hypermethylation in ulcerative colitis-related colorectal cancer. Carcinogenesis 2012. [44] Niu G, Wright KL, Huang M, Song L, Haura E, Turkson J, et al. Constitutive Stat3 activity up-regulates VEGF expression and tumor angiogenesis. Oncogene 2002;21(13):20008. [45] Wang T, Niu G, Kortylewski M, Burdelya L, Shain K, Zhang S, et al. Regulation of the innate and adaptive immune responses by Stat-3 signaling in tumor cells. Nature Medicine 2004;10(1):4854.

studies with agents targeting IL-6(R) amongst all GCs, but exhaustive methods should be adopted to identify appropriate subtypes that can be effectively treated in this fashion. Inevitably, heterogeneity within these subtypes will also exist and hence robust predictive biomarkers for treatment response will require thorough validation. Clearly we are currently in the midst of an exciting era in cancer therapeutics, but there is still a substantial body of research that needs to be executed in order to enable the efcient translation of anti-IL-6(R) therapy into the armamentarium of drugs treating gynaecological cancers. This will require close international collaborations between basic scientists, clinicians and, most importantly, the pharmaceutical industry in order to develop astutely designed combinatorial sub-type specic clinical trials that emanate from focused experiments. Conict of interest statement None declared. References
[1] Modugno F, Ness RB, Chen C, Weiss NS. Inammation and endometrial cancer: a hypothesis. Cancer Epidemiology Biomarkers and Prevention 2005;14:28407. [2] He YY, Cai B, Yang YX, Liu XL, Wan XP. Estrogenic G protein-coupled receptor 30 signaling is involved in regulation of endometrial carcinoma by promoting proliferation, invasion potential, and interleukin-6 secretion via the MEK/ERK mitogen-activated protein kinase pathway. Cancer Science 2009;100: 105161. [3] Seo KH, Lee HS, Jung B, Ko HM, Choi JH, Park SJ, et al. Estrogen enhances angiogenesis through a pathway involving platelet-activating factor-mediated nuclear factor-kappaB activation. Cancer Research 2004;64(18):64828. [4] Makinoda S, Hirosaki N, Waseda T, Tomizawa H, Fujii R. Granulocyte colonystimulating factor (G-CSF) in the mechanism of human ovulation and its clinical usefulness. Current Medicinal Chemistry 2008;15:60413. [5] Espey LL. Current status of the hypothesis that mammalian ovulation is comparable to an inammatory reaction. Biology of Reproduction 1994;50:2338. [6] Castle PE, Hillier SL, Rabe LK, Hildesheim A, Herrero R, Bratti MC, et al. An association of cervical inammation with high-grade cervical neoplasia in women infected with oncogenic human papillomavirus (HPV). Cancer Epidemiology Biomarkers and Prevention 2001;10(10):10217. [7] Yang YC, Chang CL, Huang YW, Wang DY. Possible cofactor in cervical carcinogenesis: proliferation index of the transformation zone in cervicitis. Chang Gung Medical Journal 2001;24:61520. [8] Schwebke JR, Zajackowski ME. Effect of concurrent lower genital tract infections on cervical cancer screening. Genitourinary Medicine 1997;73:3836. [9] Kemp TJ, Hildesheim A, Garcia-Pineres A, Williams MC, Shearer GM, Rodriguez AC, et al. Elevated systemic levels of inammatory cytokines in older women with persistent cervical human papillomavirus infection. Cancer Epidemiology Biomarkers and Prevention 2010;19(8):19549. [10] Goswami B, Rajappa M, Sharma M, Sharma A. Inammation: its role and interplay in the development of cancer, with special focus on gynecological malignancies. International Journal of Gynecological Cancer 2008;18:5919. [11] Jabbour HN, Sales KJ, Catalano RD, Norman JE. Inammatory pathways in female reproductive health and disease. Reproduction 2009;138:90319. [12] Aghajanian C, Sill MW, Darcy KM, Greer B, McMeekin DS, Rose PG, et al. Phase II trial of bevacizumab in recurrent or persistent endometrial cancer: a Gynecologic Oncology Group study. Journal of Clinical Oncology 2011;29(16): 225965. [13] Burger RA. Phase III trial of bevacizumab (BEV) in the primary treatment of advanced epithelial ovarian cancer (EOC), primary peritoneal cancer (PPC), or fallopian tube cancer (FTC): a Gynecologic Oncology Group study. Journal of Clinical Oncology 2010;28. [14] Coward J, Kulbe H, Chakravarty P, Leader D, Vassileva V, Leinster DA, et al. Interleukin-6 as a therapeutic target in human ovarian cancer. Clinical Cancer Research 2011;17(18):608396. [15] Kristensen G. ICON7 phase III randomized trial of bevcacizumab in women with newly diagnosed ovarian cancer. Journal of Clinical Oncology 2011;29(Suppl.). Abstract No: LBA5006. [16] Monk BJ, Sill MW, Burger RA, Gray HJ, Buekers TE, Roman LD. Phase II trial of bevacizumab in the treatment of persistent or recurrent squamous cell carcinoma of the cervix: a gynecologic oncology group study. Journal of Clinical Oncology 2009;27:106974. [17] Madhusudan S, Muthuramalingam SR, Braybrooke JP, Wilner S, Kaur K, Han C, et al. Study of etanercept, a tumor necrosis factor-alpha inhibitor, in recurrent ovarian cancer. Journal of Clinical Oncology 2005;23(25):59509. [18] Burger RA, Brady MF, Bookman MA, Fleming GF, Monk BJ, Huang H, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. New England Journal of Medicine 2011;365(26):247383.

J.I.G. Coward, H. Kulbe / Cytokine & Growth Factor Reviews 23 (2012) 333342 [46] Watson JM, Sensintaffar JL, Berek JS, Martinez-Maza O. Constitutive production of interleukin 6 by ovarian cancer cell lines and by primary ovarian tumor cultures. Cancer Research 1990;50:695965. [47] Anglesio MS, George J, Kulbe H, Friedlander M, Rischin D, Lemech C, et al. IL6STAT3-HIF signaling and therapeutic response to the angiogenesis inhibitor sunitinib in ovarian clear cell cancer. Clinical Cancer Research 2011;17(8):253848. [48] Watson JM, Berek JS, Martinez-Maza O. Growth inhibition of ovarian cancer cells induced by antisense IL-6 oligonucleotides. Gynecologic Oncology 1993;49:815. [49] Das C, Kumar VS, Gupta S, Kumar S. Network of cytokines, integrins and hormones in human trophoblast cells. Journal of Reproductive Immunology 2002;53:25768. [50] Wang P, Li N, Li JS, Li WQ. The role of endotoxin, TNF-alpha, and IL-6 in inducing the state of growth hormone insensitivity. World Journal of Gastroenterology 2002;8:5316. [51] Slater M, Cooper M, Murphy CR. Human growth hormone and interleukin-6 are upregulated in endometriosis and endometrioid adenocarcinoma. Acta Histochemica 2006;108:138. [52] Bellone S, Watts K, Cane S, Palmieri M, Cannon MJ, Burnett A, et al. High serum levels of interleukin-6 in endometrial carcinoma are associated with uterine serous papillary histology, a highly aggressive and chemotherapyresistant variant of endometrial cancer. Gynecologic Oncology 2005;98(1):928. [53] Castrilli G, Tatone D, Diodoro MG, Rosini S, Piantelli M, Musiani P. Interleukin 1alpha and interleukin 6 promote the in vitro growth of both normal and neoplastic human cervical epithelial cells. British Journal of Cancer 1997;75: 8559. [54] Eustace D, Han X, Gooding R, Rowbottom A, Riches P, Heyderman E. Interleukin-6 (IL-6) functions as an autocrine growth factor in cervical carcinomas in vitro. Gynecologic Oncology 1993;50:159. [55] Takano H, Harigaya K, Ishii G, Sugaya Y, Soeta S, Nunoyama T, et al. Interleukin-6 (IL-6) production in carcinoma of the cervix. Archives of Gynecology and Obstetrics 1996;258(1):2533. [56] Wei LH, Kuo ML, Chen CA, Chou CH, Cheng WF, Chang MC, et al. The antiapoptotic role of interleukin-6 in human cervical cancer is mediated by upregulation of Mcl-1 through a PI 3-K/Akt pathway. Oncogene 2001;20(41): 5799809. [57] Guo Y, Nemeth J, OBrien C, Susa M, Liu X, Zhang Z, et al. Effects of siltuximab on the IL-6-induced signaling pathway in ovarian cancer. Clinical Cancer Research 2010;16(23):575969. [58] Song M, Kellum JA. Interleukin-6. Critical Care Medicine 2005;33:S4635. [59] Heikkila K, Ebrahim S, Lawlor DA. Systematic review of the association between circulating interleukin-6 (IL-6) and cancer. European Journal of Cancer 2008;44:93745. [60] Stone RL, Nick AM, McNeish IA, Balkwill F, Han HD, Bottsford-Miller J, et al. Paraneoplastic thrombocytosis in ovarian cancer. New England Journal of Medicine 2012;366(7):6108. [61] Berek JS, Chung C, Kaldi K, Watson JM, Knox RM, Martinez-Maza O. Serum interleukin-6 levels correlate with disease status in patients with epithelial ovarian cancer. American Journal of Obstetrics and Gynecology 1991;164:103842. discussion 10381042. [62] Tempfer C, Zeisler H, Sliutz G, Haeusler G, Hanzal E, Kainz C. Serum evaluation of interleukin 6 in ovarian cancer patients. Gynecologic Oncology 1997;66: 2730. [63] Scambia G, Testa U, Benedetti Panici P, Foti E, Martucci R, Gadducci A, et al. Prognostic signicance of interleukin 6 serum levels in patients with ovarian cancer. British Journal of Cancer 1995;71(2):3546. [64] Chopra V, Dinh TV, Hannigan EV. Serum levels of interleukins, growth factors and angiogenin in patients with endometrial cancer. Journal of Cancer Research and Clinical Oncology 1997;123:16772. [65] Chopra V, Dinh TV, Hannigan EV. Circulating serum levels of cytokines and angiogenic factors in patients with cervical cancer. Cancer Investigation 1998;16:1529. [66] Punnonen R, Teisala K, Kuoppala T, Bennett B, Punnonen J. Cytokine production proles in the peritoneal uids of patients with malignant or benign gynecologic tumors. Cancer 1998;83:78896. [67] Offner FA, Obrist P, Stadlmann S, Feichtinger H, Klingler P, Herold M, et al. IL-6 secretion by human peritoneal mesothelial and ovarian cancer cells. Cytokine 1995;7(6):5427. [68] May LT, Viguet H, Kenney JS, Ida N, Allison AC, Sehgal PB. High levels of complexed interleukin-6 in human blood. Journal of Biological Chemistry 1992;267:19698704. [69] Plante M, Rubin SC, Wong GY, Federici MG, Finstad CL, Gastl GA. Interleukin-6 level in serum and ascites as a prognostic factor in patients with epithelial ovarian cancer. Cancer 1994;73:18828. [70] Lane D, Matte I, Rancourt C, Piche A. Prognostic signicance of IL-6 and IL-8 ascites levels in ovarian cancer patients. BMC Cancer 2011;11:210. [71] Kutteh WH, Kutteh CC. Quantitation of tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 in the effusions of ovarian epithelial neoplasms. American Journal of Obstetrics and Gynecology 1992;167:18649. [72] Kryczek I, Grybos M, Karabon L, Klimczak A, Lange A. IL-6 production in ovarian carcinoma is associated with histiotype and biological characteristics of the tumour and inuences local immunity. British Journal of Cancer 2000;82:6218.

341

[73] Lo CW, Chen MW, Hsiao M, Wang S, Chen CA, Hsiao SM, et al. IL-6 transsignaling in formation and progression of malignant ascites in ovarian cancer. Cancer Research 2011;71(2):42434. [74] Clahsen T, Schaper F. Interleukin-6 acts in the fashion of a classical chemokine on monocytic cells by inducing integrin activation, cell adhesion, actin polymerization, chemotaxis, and transmigration. Journal of Leukocyte Biology 2008;84:15219. [75] Lin MT, Lin BR, Chang CC, Chu CY, Su HJ, Chen ST, et al. IL-6 induces AGS gastric cancer cell invasion via activation of the c-Src/RhoA/ROCK signaling pathway. International Journal of Cancer 2007;120(12):26008. [76] Liu Q, Li G, Li R, Shen J, He Q, Deng L, et al. IL-6 promotion of glioblastoma cell invasion and angiogenesis in U251 and T98G cell lines. Journal of NeuroOncology 2010;100(2):16576. [77] Lederle W, Depner S, Schnur S, Obermueller E, Catone N, Just A, et al. IL-6 promotes malignant growth of skin SCCs by regulating a network of autocrine and paracrine cytokines. International Journal of Cancer 2011;128(12): 280314. [78] Colomiere M, Ward AC, Riley C, Trenerry MK, Cameron-Smith D, Findlay J, et al. Cross talk of signals between EGFR and IL-6R through JAK2/STAT3 mediate epithelial-mesenchymal transition in ovarian carcinomas. British Journal of Cancer 2009;100(1):13444. [79] Obata NH, Tamakoshi K, Shibata K, Kikkawa F, Tomoda Y. Effects of interleukin-6 on in vitro cell attachment, migration and invasion of human ovarian carcinoma. Anticancer Research 1997;17:33742. [80] Wang Y, Li L, Guo X, Jin X, Sun W, Zhang X, et al. Interleukin-6 signaling regulates anchorage-independent growth, proliferation, adhesion and invasion in human ovarian cancer cells. Cytokine 2012. [81] Rabinovich A, Medina L, Piura B, Segal S, Huleihel M. Regulation of ovarian carcinoma SKOV-3 cell proliferation and secretion of MMPs by autocrine IL-6. Anticancer Research 2007;27:26772. [82] Tsukamoto H, Shibata K, Kajiyama H, Terauchi M, Nawa A, Kikkawa F. Uterine smooth muscle cells increase invasive ability of endometrial carcinoma cells through tumor-stromal interaction. Clinical and Experimental Metastasis 2007;24:4239. [83] Choi DS, Kim HJ, Yoon JH, Yoo SC, Jo H, Lee SY, et al. Endometrial cancer invasion depends on cancer-derived tumor necrosis factor-alpha and stromal derived hepatocyte growth factor. International Journal of Cancer 2009;124(11):252838. [84] Sales KJ, Boddy SC, Jabbour HN. F-prostanoid receptor alters adhesion, morphology and migration of endometrial adenocarcinoma cells. Oncogene 2008;27:246677. [85] Wei LH, Kuo ML, Chen CA, Cheng WF, Cheng SP, Hsieh FJ, et al. Interleukin-6 in cervical cancer: the relationship with vascular endothelial growth factor. Gynecologic Oncology 2001;82(1):4956. [86] Karst AM, Gao K, Nelson CC, Li G. Nuclear factor kappa B subunit p50 promotes melanoma angiogenesis by upregulating interleukin-6 expression. International Journal of Cancer 2009;124:494501. [87] Huang SP, Wu MS, Shun CT, Wang HP, Lin MT, Kuo ML, et al. Interleukin-6 increases vascular endothelial growth factor and angiogenesis in gastric carcinoma. Journal of Biomedical Science 2004;11(4):51727. [88] Wei LH, Kuo ML, Chen CA, Chou CH, Lai KB, Lee CN, et al. Interleukin-6 promotes cervical tumor growth by VEGF-dependent angiogenesis via a STAT3 pathway. Oncogene 2003;22(10):151727. [89] Su JL, Lai KP, Chen CA, Yang CY, Chen PS, Chang CC, et al. A novel peptide specically binding to interleukin-6 receptor (gp80) inhibits angiogenesis and tumor growth. Cancer Research 2005;65(11):482735. [90] Motro B, Itin A, Sachs L, Keshet E. Pattern of interleukin 6 gene expression in vivo suggests a role for this cytokine in angiogenesis. Proceedings of the National Academy of Sciences of the United States of America 1990;87: 30926. [91] Nilsson MB, Langley RR, Fidler IJ. Interleukin-6, secreted by human ovarian carcinoma cells, is a potent proangiogenic cytokine. Cancer Research 2005;65:10794800. [92] Lang SA, Moser C, Gaumann A, Klein D, Glockzin G, Popp FC, et al. Targeting heat shock protein 90 in pancreatic cancer impairs insulin-like growth factorI receptor signaling, disrupts an interleukin-6/signal-transducer and activator of transcription 3/hypoxia-inducible factor-1alpha autocrine loop, and reduces orthotopic tumor growth. Clinical Cancer Research 2007;13(21): 645968. [93] Duluc D, Delneste Y, Tan F, Moles MP, Grimaud L, Lenoir J, et al. Tumorassociated leukemia inhibitory factor and IL-6 skew monocyte differentiation into tumor-associated macrophage-like cells. Blood 2007;110(13):431930. [94] Allavena P, Sica A, Solinas G, Porta C, Mantovani A. The inammatory microenvironment in tumor progression: the role of tumor-associated macrophages. Critical Reviews in Oncology/Hematology 2008;66:19. [95] Korn T, Mitsdoerffer M, Croxford AL, Awasthi A, Dardalhon VA, Galileos G, et al. IL-6 controls Th17 immunity in vivo by inhibiting the conversion of conventional T cells into Foxp3+ regulatory T cells. Proceedings of the National Academy of Sciences of the United States of America 2008;105(47):1846065. [96] Bettelli E, Carrier Y, Gao W, Korn T, Strom TB, Oukka M, et al. Reciprocal developmental pathways for the generation of pathogenic effector TH17 and regulatory T cells. Nature 2006;441(7090):2358. [97] Miyahara Y, Odunsi K, Chen W, Peng G, Matsuzaki J, Wang RF. Generation and regulation of human CD4+ IL-17-producing T cells in ovarian cancer. Pro-

342

J.I.G. Coward, H. Kulbe / Cytokine & Growth Factor Reviews 23 (2012) 333342 ceedings of the National Academy of Sciences of the United States of America 2008;105:1550510. Kato T, Furumoto H, Ogura T, Onishi Y, Irahara M, Yamano S, et al. Expression of IL-17 mRNA in ovarian cancer. Biochemical and Biophysical Research Communications 2001;282(3):7358. Fujimoto J. Novel therapeutic strategy for uterine endometrial cancers. International Journal of Clinical Oncology 2008;13:4115. Hashimoto I, Kodama J, Seki N, Hongo A, Miyagi Y, Yoshinouchi M, et al. Macrophage inltration and angiogenesis in endometrial cancer. Anticancer Research 2000;20(6C):48536. Guo Y, Xu F, Lu T, Duan Z, Zhang Z. Interleukin-6 signaling pathway in targeted therapy for cancer. Cancer Treatment Reviews 2012;38(7):90410. Wang Y, Niu XL, Qu Y, Wu J, Zhu YQ, Sun WJ, et al. Autocrine production of interleukin-6 confers cisplatin and paclitaxel resistance in ovarian cancer cells. Cancer Letters 2010;295(1):11023. Duan Z, Foster R, Bell DA, Mahoney J, Wolak K, Vaidya A, et al. Signal transducers and activators of transcription 3 pathway activation in drugresistant ovarian cancer. Clinical Cancer Research 2006;12(17):505563. Wruck CJ, Streetz K, Pavic G, Gotz ME, Tohidnezhad M, Brandenburg LO, et al. Nrf2 induces interleukin-6 (IL-6) expression via an antioxidant response element within the IL-6 promoter. Journal of Biological Chemistry 2011;286(6):44939. Jiang T, Chen N, Zhao F, Wang XJ, Kong B, Zheng W, et al. High levels of Nrf2 determine chemoresistance in type II endometrial cancer. Cancer Research 2010;70(13):548696. Ma X, Zhang J, Liu S, Huang Y, Chen B, Wang D. Nrf2 knockdown by shRNA inhibits tumor growth and increases efcacy of chemotherapy in cervical cancer. Cancer Chemotherapy and Pharmacology 2012;69:48594. Gagnon V, Mathieu I, Sexton E, Leblanc K, Asselin E. AKT involvement in cisplatin chemoresistance of human uterine cancer cells. Gynecologic Oncology 2004;94:78595. Balkwill FR, Coward J, Kulbe H, Milagre C, Gopinathan G, McNeish IA. IL-6 and ovarian cancer response. Clinical Cancer Research 2011;17:7838. Aghajanian C, Blank SV, Goff BA, Judson PL, Teneriello MG, Husain A, et al. OCEANS: a randomized, double-blind, placebo-controlled phase III trial of chemotherapy with or without bevacizumab in patients with platinumsensitive recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. Journal of Clinical Oncology 2012;30(17):203945. Poth KJ, Guminski AD, Thomas GP, Leo PJ, Jabbar IA, Saunders NA. Cisplatin treatment induces a transient increase in tumorigenic potential associated with high interleukin-6 expression in head and neck squamous cell carcinoma. Molecular Cancer Therapeutics 2010;9:24309. Wang TH, Chan YH, Chen CW, Kung WH, Lee YS, Wang ST, et al. Paclitaxel (Taxol) upregulates expression of functional interleukin-6 in human ovarian cancer cells through multiple signaling pathways. Oncogene 2006;25(35): 485766. Santin AD, Zhan F, Cane S, Bellone S, Palmieri M, Thomas M, et al. Gene expression ngerprint of uterine serous papillary carcinoma: identication of novel molecular markers for uterine serous cancer diagnosis and therapy. British Journal of Cancer 2005;92(8):156173. Tartour E, Gey A, Sastre-Garau X, Pannetier C, Mosseri V, Kourilsky P, et al. Analysis of interleukin 6 gene expression in cervical neoplasia using a quantitative polymerase chain reaction assay: evidence for enhanced interleukin 6 gene expression in invasive carcinoma. Cancer Research 1994;54(23):62438. Enomoto T, Inoue M, Perantoni AO, Terakawa N, Tanizawa O, Rice JM. K-ras activation in neoplasms of the human female reproductive tract. Cancer Research 1990;50:613945. Tashiro H, Blazes MS, Wu R, Cho KR, Bose S, Wang SI, et al. Mutations in PTEN are frequent in endometrial carcinoma but rare in other common gynecological malignancies. Cancer Research 1997;57(18):393540. Daikoku T, Hirota Y, Tranguch S, Joshi AR, DeMayo FJ, Lydon JP, et al. Conditional loss of uterine Pten unfailingly and rapidly induces endometrial cancer in mice. Cancer Research 2008;68(14):561927. [117] St-Germain ME, Gagnon V, Parent S, Asselin E. Regulation of COX-2 protein expression by Akt in endometrial cancer cells is mediated through NFkappaB/IkappaB pathway. Molecular Cancer 2004;3:7. [118] Cheung TH, Lo KW, Yim SF, Chan LK, Heung MS, Chan CS, et al. Epigenetic and genetic alternation of PTEN in cervical neoplasm. Gynecologic Oncology 2004;93(3):6217. [119] Rizvi MM, Alam MS, Ali A, Mehdi SJ, Batra S, Mandal AK. Aberrant promoter methylation and inactivation of PTEN gene in cervical carcinoma from Indian population. Journal of Cancer Research and Clinical Oncology 2011;137: 125562. [120] Pappa KI, Choleza M, Markaki S, Giannikaki E, Kyroudi A, Vlachos G, et al. Consistent absence of BRAF mutations in cervical and endometrial cancer despite KRAS mutation status. Gynecologic Oncology 2006;100(3):596600. [121] Shih Ie M, Kurman RJ. Ovarian tumorigenesis: a proposed model based on morphological molecular genetic analysis. American Journal of Pathology 2004;164:15118. [122] Fujimoto J, Sakaguchi H, Aoki I, Tamaya T. Clinical implications of expression of interleukin 8 related to angiogenesis in uterine cervical cancers. Cancer Research 2000;60:26325. [123] Wan T, Liu JH, Zheng LM, Cai MY, Ding T. Prognostic signicance of tumorassociated macrophage inltration in advanced epithelial ovarian carcinoma. Ai Zheng 2009;28:3237. [124] Zhang JP, Lu WG, Ye F, Chen HZ, Zhou CY, Xie X. Study on CXCR4/SDF-1alpha axis in lymph node metastasis of cervical squamous cell carcinoma. International Journal of Gynecological Cancer 2007;17:47883. [125] Milliken D, Scotton C, Raju S, Balkwill F, Wilson J. Analysis of chemokines and chemokine receptor expression in ovarian cancer ascites. Clinical Cancer Research 2002;8:110814.

[98]

[99] [100]

[101] [102]

[103]

[104]

[105]

[106]

[107]

[108] [109]

[110]

[111]

[112]

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Dr Jermaine Coward is a medical oncology specialist in gynaecological malignancies and is the Cancer Therapeutics Group Leader at the Mater Medical Research Institute, Brisbane, Australia. He completed his medical training at Imperial College, London in 1998 and became a member of the Royal College of Physicians in 2002. His interests in oncology began during his tenure as a junior doctor and he subsequently undertook specialist registrar training at Westmead Hospital, Sydney and the Royal Marsden Hospital, London. He has extensive experience in the development and conduct of Phase II clinical trials in addition to clinical management of numerous tumour types. In 2006, he was appointed as a MRC clinical fellow at the Barts Cancer Institute, London and investigated the effects of anti-IL-6 in advanced ovarian cancer which involved the successful translation of laboratory research into a clinical trial in patients with platinum resistant disease. This research culminated in the award of his PhD from Queen Mary, University London in 2010. Since then, he has been involved in a number of international collaborations with a focus on investigating the role of inammatory cytokine networks in gynaecological cancers.

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Dr Hagen Kulbe is a postdoctorate research assistant at the Centre for Cancer and Inammation, Barts Cancer Institute, London. In 2001, he was awarded his PhD in the eld of tumour immunology and genetics from the Max-Delbrueck-Centre, Berlin. Over the past 5 years he has published a number of key articles relating to the effects of targeting inammation in ovarian cancer and is currently involved in several projects focusing on inammatory signalling within tumour microenvironments using novel animal models.