Cytokine 61 (2013) 885–891

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Cytokine
journal homepage: www.journals.elsevier.com/cytokine

Cytokine profiles in acute myeloid leukemia patients at diagnosis: Survival is

inversely correlated with IL-6 and directly correlated with IL-10 levels
Beatriz Sanchez-Correa a, Juan M. Bergua b, Carmen Campos c, Inmaculada Gayoso c, Maria Jose Arcos b,
Helena Bañas b, Sara Morgado a, Javier G. Casado a,d, Rafael Solana c, Raquel Tarazona a,⇑
a
Immunology Unit, Department of Physiology, University of Extremadura, 10003 Caceres, Spain
b
Department of Hematology, Hospital San Pedro de Alcantara, Caceres, Spain
c
Immunology Unit, Instituto Maimonides para la Investigacion Biomedica de Cordoba (IMIBIC), University of Cordoba, Cordoba, Spain
d
Stem Cell Therapy Unit, Minimally Invasive Surgery Centre Jesus Uson, Caceres, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Background: Several evidences support the existence of cytokine deregulation in acute myeloid leukemia
Received 29 August 2012 (AML) patients that may be associated with pathogenesis, disease progression and patient survival.
Received in revised form 19 December 2012 Methods: In the present study, we analyzed plasma levels of pro- and anti-inflammatory cytokines in
Accepted 22 December 2012
AML patients and age-matched healthy donors. TNF-a, IL-6, IL-1b, IL-2, IFN-c, IL-17A, IL-12p70, IL-8,
Available online 26 January 2013
IL-10, IL-4 and IL-5 were analyzed using fluorescent bead-based technology and TGF-b by ELISA tech-
nique. Because age-associated differences in cytokine profiles have been described, patients and healthy
Keywords:
individuals were divided into two age groups: up to 65 years and over 65 years.
Acute myeloid Leukemia
Pro-inflammatory cytokines
Results: Our results showed that plasma TNF-a, IL-6 and IL-10 levels were higher in AML patients from
IL-6 both groups of age. IL-8 was increased in AML patients less than 65 years while the plasma concentra-
Survival tions of IL-4, IL-5 and IL-12p70 were significantly higher only in elderly AML patients compared with
IL-10 aged-matched healthy controls. Moreover, plasma levels of IL-6 and IL-10 were associated with patient
survival and event-free survival.
Conclusions: An aberrant production of the pro-inflammatory cytokines IL-6 and TNF-a and the anti-
inflammatory cytokine IL-10 is observed in AML patients. Low levels of IL-6 and high levels of IL-10 rep-
resent favorable prognostic factors for survival in AML patients. These results support the idea that cyto-
kine deregulation may be useful as a marker for predicting clinical evolution in AML patients.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction In AML patients, cytokines can be produced by both leukemic

Acute myeloid leukemia (AML) represents a group of clonal
hematopoietic stem cell disorders in which both failure to differen-
tiate and overproliferation in the stem cell compartment result in
accumulation of non-functional myeloid cells termed myeloblasts
and loss of normal hematopoietic function. Considerable efforts
have been spent in identifying prognostic markers that might pre-
dict clinical outcomes in AML patients and several characteristics
including older age, cytogenetics and performance status are com-
monly used as predictors of survival [1,2]. Prognosis in AML pa-
tients has also been related to the frequently observed defective
function of their immune system that hampers the development
of an effective response against leukemic blasts [3–8].
Cytokines are secreted by different types of cells in response to
a variety of stimuli such as tissue damage or infection and regulate
the immune response and other biologic processes.
⇑ Corresponding author. Tel.: +34 927257000x51322; fax: +34 927257106.
E-mail address: rtarazon@unex.es (R. Tarazona).
blasts and cells of the immune system and the role of cytokines
in the pathogenesis of acute leukemia has not been fully clarified
[9,10]. Thus, aberrant cytokine signaling is a feature of leukemia
that may contribute to proliferation, blast survival, resistance to
chemotherapy and patients’ prognosis [10–14].
At the tumor site, the presence of pro-inflammatory cytokines
as IL-6 or IL1-b constitutes a hallmark of cancer-associated inflam-
mation. The major sources of IL-6 and IL-1 are activated monocytes
or macrophages and their production is induced by TNF-a, a pleio-
tropic cytokine mainly produced by macrophages but also by acti-
vated NK cells, neutrophils, CD4 T helper 1 (Th1) cell subset and
CD8 T cells [15]. It has been demonstrated that these cytokines
can be produced by AML blasts [16,17]. In the tumor microenviron-
ment, IL-1b promotes angiogenesis and tumor invasiveness [18]
and may suppress immune function by enhancing the accumula-
tion of myeloid-derived suppressor cells [19]. IL-1b may act as an
autocrine growth factor for AML and chronic myeloid leukemia
[20]. IL-6, a cytokine with pleiotropic inflammatory effects, has
demonstrated different effects (stimulatory, inhibitory or neutral)

1043-4666/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.cyto.2012.12.023
886 B. Sanchez-Correa et al. / Cytokine 61 (2013) 885–891
on the growth of leukemic blasts [14,21]. IL-6 may also exert anti-
inflammatory biological activity by enhancing plasma IL-1 receptor
antagonist (IL1ra), IL-10 and cortisol in humans [22].
Interactions between pro- and anti-inflammatory cytokines
regulate cytokine response. Thus, TNF-a and IL-1b can stimulate
their own and each other’s production and also IL-6 secretion
[23,24]. This represents an important amplification loop of the
inflammatory response. On the other hand, IL-6 and TNF-a may in-
duce IL-10 secretion with potential to inhibit IL-6, TNF-a and IL-1b
production. Changes in one of these cytokines lead to compensa-
tory mechanisms that may alter the cytokine network [22,25].
Adverse clinical outcomes in elderly individuals have been asso-
ciated with the increase of pro-inflammatory cytokines [26,27]. It
has been described that the production of several cytokines in
the elderly is clearly influenced by health status and that normal
IL-6 levels may be considered a good overall biomarker of healthy
aging [28–31].
Here, we examined the plasma levels of 12 cytokines in 42 AML
patients and 58 healthy adult volunteers, and analyzed the associ-
ations between the concentration of each cytokine, clinical charac-
teristics, disease progression and survival of AML patients. To avoid
potential confounding effects from age-associated differences in
cytokine profiles, we have analyzed plasma cytokines in AML pa-
tients and healthy controls distributed in two groups according
to their age.
2. Materials and methods
2.1. Patients and healthy donors
Forty-two AML patients (27 males, 15 females) with an age
range of 21–86 years (median age, 62 ± 16 years) newly diagnosed
at the Hospital San Pedro de Alcantara from January 2006 through
April 2010 were included in this study. Patients with acute promy-
elocytic leukemia were not included. Diagnoses were established
according to the French–American–British (FAB) classification sys-
tem. AML samples were collected at diagnosis (M0 = 10, M1 = 5,
M2 = 6, M4 = 4 and M5 = 17).
The control group was population-based and the cases were
age-matched healthy volunteers. Fifty-eight healthy controls (33
males, 25 females) were included as controls. Samples were col-
lected from control subjects only if the subjects had not had fever
within 1 week, were not receiving any medications, were not
known to be pregnant, and did not have a history of any chronic
disease. Due to the potential effects of age in the levels of cyto-
kines, we divided AML patients and healthy controls into two
groups: from 21 to 65 years of age (20 AML patients and 28 healthy
donors) and over 65 years (22 AML patients and 30 healthy
donors).
The study was approved by the local Ethics Committee (2006/
01) and samples collected after written informed consent in accor-
dance with the Declaration of Helsinki.
2.2. Procedures of sample collection and processing
Plasma was obtained by centrifugation of heparinized periphe-
ral blood and stored in aliquots at 80 °C until analysis. All the
analyses were performed on samples that had not been previously
thawed. The time from sample collection to processing was always
lower than 24 months. Samples were kept in a freezer connected to
an uninterruptible power supply to guarantee the maintenance of
optimum temperature.
2.3. Cytokine measurement
The concentrations of TNF-a, IL-6, IL-10, IL-1-b, IL-8, IL-5, IL-4,
IL-2, IL-12, IFN-c and IL-17A in the plasma of AML patients and
healthy controls were determined by using the commercially
available fluorescent bead immunoassay FlowCytomix human
Th1/Th2 11-plex kit (eBiosciences, Vienna, Austria). The cytokine
measurement was performed following the instructions of man-
ufacturers. Four independent sets of experiments were per-
formed. Each Flowcytomix experiment included the kit’s
standards run in triplicate and samples from AML patients and
healthy controls. No significant variations were observed among
the experiments.
Standard curves were determined for each cytokine from a
range of 27.44–20,000 pg/mL. The lower limits of detection for all
cytokines according to the manufacturer are between 0.5 and
20.8 pg/mL. Samples were acquired in a FACScan flow cytometer
(BD Biosciences) and data were analyzed using FlowCytomix Pro
2.2 Software (eBiosciences). The standards used for determining
cytokine levels were measured in triplicate.
TGF-b1 concentrations in the plasma were determined by en-
zyme linked immunosorbent assay (ELISA) using a Human TGF-
b1 kit (eBiosciences), according to the manufacturer’s instructions.
Standards were run in triplicate and samples were run in duplicate.
Four independent sets of experiments were performed. No signifi-
cant variations were observed among the experiments.
2.4. Statistical analysis
Statistical analyses were performed using SPSS V.15 statistical
software (SAS Institute, Cary, NC). The concentrations of each
cytokine were compared among the AML patients and healthy vol-
unteers using the Kruskal–Wallis test. The AML patients were di-
vided into two groups according to the plasma level of each
cytokine; cut-off values for each cytokine were set using Receiver
Operating Characteristic (ROC) curves. The optimal cut-off point
for each cytokine was determined by the point of convergence of
sensitivity and specificity (i.e. by simultaneously maximizing the
two). In our study, P 6 0.05 was considered as significant. Survival
analyses were performed by the Kaplan–Meier method, and
survival curves were compared using the log-rank and Breslow–
Gehan–Wilcoxon tests. The starting time for survival was the date
of blood collection. For survival analysis, all patients who were still
alive were censored at the date of last follow-up. Event free
survival (EFS) was established as the interval of time between
diagnosis and the relapse or death or documented failure of
treatment.
3. Results
3.1. Plasma cytokine concentrations in AML patients and healthy adult
volunteers
Concentrations of plasma cytokines in each group are shown in
Fig. 1. We have observed that the concentrations of TNF-a, IL-6 and
IL-10 were significantly higher in AML patients than in the healthy
volunteers in both groups of age (P = 0.003, P = 0.002 and P = 0.005,
respectively in the younger age group and P = 0.001, P = 0.04 and
P = 0.009 in the elderly donors). TGF-b concentration was signifi-
cantly lower in AML patients than in the healthy volunteers in both
age groups (P = 0.004 and P = 0.0001).
IL-4, IL-5 and IL-12p70 levels were significantly higher in el-
derly AML patients compared to their aged-matched healthy vol-
unteers (P = 0.048, P = 0.002 and P = 0.018 respectively). IL-8 level
was higher in AML patients under 65 years when compared with
 B. Sanchez-Correa et al. / Cytokine 61 (2013) 885–891 887

Fig. 1. Comparison of plasma cytokine concentrations in healthy donors and AML patients. The concentrations of cytokines in plasma samples obtained from 58 healthy
donors (28 6 65 years (d) and 30 (j) elderly) and 42 AML patients (20 patients 6 65 years (o) and 22 elderly (h) patients) are shown. The horizontal bars represent the mean
values. P 6 0.05, P 6 0.01 and P 6 0.001. HD: healthy donor.

their age matched healthy donors (P = 0.006). There were no
significant differences between AML patients and healthy donors
in the plasma concentrations of IL-1b, IL-17A, IFN-c and IL-2.
In relation to the effect of age in healthy donors and AML pa-
tients we observed that IL-6 and IL-8 levels were higher in healthy
elderly than in healthy donors under 65 years (P = 0.001 and
P = 0.001 respectively). The only cytokine that showed statistically
significant age-associated differences in AML patients was IL-8 that
was higher in elderly AML patients compared to AML patients less
than 65 years (P = 0.014).
3.2. Correlations among the cytokines, FAB subtypes, blast and
leukocyte counts
There was no significant correlation between blast or leukocyte
counts with the plasma levels of all cytokines analyzed in our
study. The analysis of the cytokines involved in Th17 differentia-
tion showed that higher IL-1b levels correlated with higher levels
of IL-17A (r = 0.91; P < 0.01). In contrast, IL-6 (r = 0.23) and TGF-b
(r = 0.062) did not show any correlation with the concentration
of IL-17A in AML patients.
888 B. Sanchez-Correa et al. / Cytokine 61 (2013) 885–891
Fig. 2. Kaplan–Meier survival curve for overall survival stratified by cytokine levels. We analyzed cytokine levels and overall survival in 42 AML patients. Kaplan–Meier
curves were performed according to IL-6 (a), IL-17A (b) and simultaneous detection of IL-6 and/or IL-17A (c). Statistical significance was calculated according to the log-rank
method. Values in parenthesis represent total number of patients/number of deaths.
No correlation was found between cytokine levels and FAB sub-
types that may be the consequence of the limited number of pa-
tients in each category.
3.3. Association between plasma cytokine levels and survival among
the AML patients
Overproduction of IL-17 has been associated with elevated pro-
duction of pro-inflammatory mediators such as IL-6 [32]. In AML
patients IL-6 levels have been correlated positively with Th17 fre-
quencies suggesting a positive feedback loop [33].
We have observed that patients with higher levels of IL-6 had
decreased survival compared with those patients with lower levels
(log rank P = 0.05). Low levels of IL-6 were also associated with
longer median event-free survival (EFS). The Kaplan–Meier curves
and results of the log rank tests are shown in Fig. 2a. Plasma levels
of IL-17A were not associated with overall survival (Fig. 2b). Sur-
vival analysis according to the plasma levels of IL-6 and IL-17A
showed that AML patients who had both IL-6 and IL-17A elevated
had a decreased survival (Fig. 2c) compared with patients with no
elevation of these cytokines or with an increase of one of them (log
rank P = 0.017). On the contrary, higher levels of IL-10 were associ-
ated with longer survival and EFS (Table 1).
Age was associated with complete remission (CR), median sur-
vival and median EFS as shown in Table 1. Regarding cytokine con-
centrations, only IL-8 was associated with the achievement of CR.
TNF-a, IL-1b, IL-2, IL-12, IFN-c, IL-5, IL-4 and TGF-b plasma levels
at diagnosis did not correlate with survival of AML patients.
4. Discussion
Cytokine deregulation has been postulated to play a role in the
pathogenesis of several hematological malignances, including
AML, and plasma cytokine levels have been correlated with disease
progression and survival [11–14,34]. Our results agree with previ-
ous authors who reported an increase of IL-6 in AML patients
[33,35,36]. We have found that high levels of IL-6 were correlated
with lower survival and EFS. In addition, AML patients that con-
comitantly exhibited high levels of IL-6 and IL-17A had lower sur-
vival. Recent findings suggest that more than one mechanism is
involved in the promotion of abnormal IL-6 expression in cancer
patients [20], whereas in some cases, high levels of IL-1b have been
found to be responsible of the induction of IL-6, in other patients
no association has been observed between IL-6 and IL-1b. We have
not found statistically significant differences in IL-1b levels in AML
patients compared to healthy donors and no correlation was de-
tected between IL-6 and IL-1b levels. It has been also shown that
TNF-a, IL-1b, and IL-17 interact together to induce massive
amounts of IL-6 and this cytokine has demonstrated a role in mod-
ulating Th17/regulatory T cell balance [24]. In healthy elderly indi-
viduals it has been reported that increased levels of TNF-a, IL-6 and
IL-1ra were associated with increased risk of death [26]. IL-6 has a
key role in the regulation of plasma levels of YKL-40, a glycoprotein
that is elevated during inflammatory conditions [37] and high lev-
els of YKL-40 have been correlated with short survival in AML pa-
tients [38]. In AML patients IL-6 levels have been correlated
positively with Th17 frequencies [33]. It has been suggested that
IL-17 acting on stromal cells sustains NF-kB-mediated IL-6 produc-
tion, which in turn enhances Th17 differentiation in a positive
feedback loop [32].
Pro-inflammatory cytokines as IL-1b and TNF-a can be counter-
balanced by the secretion of antagonist as IL-1ra or soluble TNF
receptors. Another level of cytokine regulation is controlled by
anti-inflammatory cytokines such as IL-10 that shutdown the pro-
duction of inflammatory cytokines [25]. This loop is tightly regu-
lated to govern the level of inflammation in response to a
stimulus. Nevertheless, genetic variations (e.g. IL-10 promoter
polymorphisms) may explain some inter-individual differences
[25]. In accordance with previous reports [14], we have found that
IL-10 levels are increased in AML patients. In our study patients
were stratified according to age and the differences were statisti-
cally significant in both groups of age when compared to age-
matched healthy donors. Here we also described an association
of high IL-10 levels with median survival and median EFS. Kornb-
lau et al. [13] have previously shown that patients who attained
remission were more likely to have higher levels of IL-10. Con-
versely, Tsimberidou et al. [14] described no statistically significant
association of IL-10 levels with CR and disease progression. The
association of high levels of IL-10 with longer survival times can
be explained by its capacity to inhibit granulocyte and granulo-
cyte-macrophage colony stimulating factors (G-CSF and GM-CSF)
production and, consequently, blast proliferation [39]. IL-10 also
inhibits IL-6, IL-1b and TNF-a, cytokines that have been associated
with lower survival in different diseases [14,20,25].
On the other hand, IL-10 displays strong immunosuppressive
effects inhibiting the proliferation of T cells and the production
of IFN-c and IL-2 [40]. Thus, evidences for both tumor promoting
and anti-tumor function of IL-10 have been reported [41,40]. A bet-
ter understanding of the dual biological effects of IL-10 will be
important for dissecting its role in pathology and may provide
new avenues for developing successful therapies against cancer.
 B. Sanchez-Correa et al. / Cytokine 61 (2013) 885–891 889

Table 1
Treatment response, overall survival and event free survival according to cytokine levels.

No. CR (%) P Median survival (mo) P Median EFS (mo) P

Age (years)
665 (range 21–65; median 55) 20 75 0.004 26 <0.001 19.75 <0.001
>65 (range 66–86; median 74) 22 31 5.87 3.74
Cytogenetics (risk)
Favorable 9 88.9 0.06 31.1 0.004 22.67 0.014
Intermediate 10 60 14 11.66
Poor 19 42.1 8.7 5.77
WBC (103/lL)
<10 11 63.6 0.73 17.7 0.85 14.79 0.75
>10 27 55.5 14.5 9.9
Circulating blasts (%)
<50 14 54.3 0.5 17.1 0.9 13.74 0.36
>50 24 54.17 15.1 10.82
TNF-a, pg/ml
<10 10 50 0.71 16.3 0.45 14.1 0.29
>10 32 53.1 15.1 10.3
IL-6 (pg/ml)
<1 22 68.2 0.09 21.1 0.05 15.98 0.003
>1 20 35 8.37 5.57
IL-10 (pg/ml)
<10 11 72.7 0.14 10.6 0.014 8.45 0.023
>10 31 45.16 17.1 12.35
TGF-b (ng/ml)
<4 12 41.7 0.4 18.9 0.21 12.31 0.31
>4 21 23.8 8.9 6.99
IL-8 (pg/ml)
<9 8 87.5 0.014 18.5 0.16 13.36 0.51
>9 34 44.1 14.7 10.86
IL-1b (pg/ml)
<1 9 22.2 0.26 16.8 0.14 14.17 0.06
>1 33 60.6 14.9 10.31
IL-4 (pg/ml)
<5 11 54.5 1 17.7 0.62 15.22 0.32
>5 31 51.6 14.6 9.93
IL-5 (pg/ml)
<1.25 22 50 0.52 14.5 0.47 12.09 0.71
>1.25 20 55 16.4 10.47
IL-12p70 (pg/ml)
<1 25 56 1 14 0.24 10.67 0.14
>1 17 47 17.8 12.44
IFN-c (pg/ml)
<5 18 55.5 1 15.5 0.86 13.78 0.36
>5 24 50 15.3 9.34
IL-17A (pg/ml)
<4 21 57.1 1 15 0.65 12.47 0.79
>4 21 47.6 15.9 10.05
IL-2 (pg/ml)
<20 16 62.5 0.5 19.6 0.06 15.36 0.16
>20 26 46.1 12.7 8.69

CR indicates complete remission; EFS, event-free survival; mo, months; WBC, white blood cell count. Cut-off values were established using ROC curves.

In our study, the only cytokine associated with CR was IL-8.
High plasma levels of IL-8 were associated with a lower percentage
of patients achieving CR. Younger age at diagnosis was also associ-
ated with CR. We have observed an increase in the levels of IL-8 in
AML patients under 65 years. IL-8 is a pro-angiogenic mediator re-
leased by most leukemic blast populations that is involved in leu-
kemogenesis [34]. Previous reports have shown a high percentage
of AML patients with elevated levels of IL-8 [13,35]. Hsu et al. [35]
observed that the level of IL-8 in patients with AML and myelodys-
plastic syndromes (MDSs) was high during diagnosis and de-
creased to the level of healthy controls when patients were
under chemotherapy or in CR. It is interesting to note that we have
found an age-associated increase in the levels of IL-8 in both
healthy donors and AML patients. In elderly AML patients, strati-
fied analysis according to age (patients aged 66–74 years versus
patients over 75 years) did not show statistically significant differ-
ences in the levels of cytokines (data not shown).
Although it has been reported that high serum TNF-a level is an
adverse prognostic factor for survival and event-free survival in pa-
tients with AML or high-risk MDS [14], we have not found statisti-
cally significant correlations. TNF-a can be produced by a wide
variety of tumor cells including solid tumors and hematological
malignances. TNF-a has conflicting roles in cancer, as can act di-
rectly or indirectly as an autocrine tumor growth factor but may
also induce apoptosis of tumor cells [42,43]. We have found that
mean levels of TNF-a were significantly higher in AML patients
than in the healthy volunteers in both age groups. An increase of
TNF-a level was also observed in healthy elderly individuals
890 B. Sanchez-Correa et al. / Cytokine 61 (2013) 885–891
compared with younger donors as previously described [27,44].
Kornblau et al. [13] analyzed the expression of different cytokines
and chemokines profiles in AML and MDS showing that serum
TNF-a was higher in unfavorable and lower in favorable signatures.
On the contrary, in other study, the analysis of AML patients at
diagnosis or during relapsed disease showed that TNF-a was sig-
nificantly elevated in chronic leukemia and acute lymphoblastic
leukemia but not in AML and MDS [45]. The discrepancies ob-
served in the different studies are probably due to the existence
of high inter-individual variations as we observed in our study.
We have observed lower plasma levels of TGF-b1 in AML pa-
tients compared to healthy donors. TGF-b1 constitutes an impor-
tant negative regulatory factor of both normal and neoplastic
hematopoietic progenitor cells [46,47]. Thus, our findings together
with those describing low expression of TGF-b1 high-affinity bind-
ing sites on AML cells suggest that AML cells may escape from the
regulation by TGF-b1 [46]. IL-10 and TGF-b can be produced by
regulatory T cells, a subset of CD4 T cells that mediates immuno-
suppression and is increased in AML patients [6,48].
The analysis of plasma levels of cytokines according to age re-
vealed some statistically significant differences restricted to the el-
derly groups. Thus, IL-12p70, IL-4 and IL-5 levels were significantly
higher in elderly AML patients compared with healthy elderly indi-
viduals. IL-12 may exert potent anti-tumor activity through immu-
nostimulatory and antiangiogenic mechanisms [49,50]. Recently, it
has been reported that age is positively correlated with serum lev-
els of IL-12p70 [27]. A dual biological effect has been reported for
IL-4 in tumor immunity, whereas it can exhibit potent anti-tumor
immunity, numerous reports have shown that IL-4 can also pro-
mote tumor growth [51]. In relation to IL-5, a previous report
showed no statistically significant differences in AML and MDS pa-
tients compared to healthy donors [13]. The role of these cytokines
in the prognosis of elderly patients with AML requires further
studies.
In our study, no statistically significant differences were ob-
served in the plasma levels of IL-17A, IL-2 and IFN-c in AML pa-
tients compared with healthy donors. Our results are consistent
with previous reports [13,52] and differ from those obtained by
Wu et al. [33] that showed higher plasma levels of IL-17 in AML pa-
tients compared with healthy donors. The high variability observed
in cytokine levels among AML patients could explain these
discrepancies.
In the present study the limited number of patients makes dif-
ficult broad generalizations and the potential confounding effect of
age in the survival analysis cannot be excluded. It is difficult to dis-
tinguish between age-associated and disease-associated altera-
tions in cytokine levels. Thus, the analysis of cytokines according
to age in healthy and AML patients showed that IL-6 and IL-8 are
increased in healthy elderly individuals compared with healthy
controls up to 65 years. In AML patients only IL-8 was increased
in elderly patients compared with the younger group of patients
(665 years) supporting that the alterations observed in cytokine
levels are associated to AML rather than to age. The results pre-
sented confirm and extend previous findings by other research
groups regarding cytokine profiles in AML patients and survival.
Further studies are needed to clarify the clinical relevance of these
findings and the role of disturbed cytokine balance (e.g. IL-6, IL-17
and IL-10) in disease progression and patient survival.
In summary, plasma levels of several cytokines are associated
with disease progression and survival in AML patients. We have
observed that CR was associated with age and IL-8 levels. In addi-
tion, older age, cytogenetic risk, low levels of IL-10 and high levels
of IL-6 were found to be correlated with lower survival and EFS.
AML patients that concomitantly exhibited high levels of IL-6
and IL-17A had lower survival. The current findings together with
previous reports showing alterations in different lymphocyte sub-
sets suggest that patients with AML, in general, present a deregu-
lation in their immune system [3–5]. Several cytokines are
aberrantly produced in some AML patients that can be considered
as indicators of tumor development and disease progression con-
tributing to proliferation, survival and resistance to chemotherapy
of leukemic cells. Further research leading to identify the molecu-
lar mechanisms underlying cytokine network deregulation are re-
quired and new approaches to modulate cytokine signaling should
be evaluated.
Disclosure statement
The authors have nothing to disclose.
Acknowledgments
This work was supported by Grants SAF2009-09711 to RT from
the Ministry of Science and Innovation of Spain, PRI09A029 and
Grants to INPATT research group from Junta de Extremadura
(GRU10104) and from University of Extremadura, cofinanced by
European Regional Development Funds (FEDER), and Grants to RS
PS09/00723 from Spanish Ministry of Health and JA0292/07 from
Junta de Andalucia. We thank the technical assistance of J.J.
Gordillo.
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