Article Type : Review Article
Authors : Lissoni P, Rovelli F, Pelizzoni F, Zanandrea G, Galli C, Merli N, Messina G, Codogni R, Lissoni A, Tassoni S and Di Fede G
Keywords : Autoimmunity; Biomarkers; Cancer; Cardiovascular diseases; Cytokines; Lymphocyte-to-monocyte ratio
The evolution of the
medical Sciences corresponded to the discovery of new classes of molecules,
firstly the vitamins, then the hormones, then again the neurotransmitters, and
finally the cytokines, and each discovery of new molecules allowed the
possibility to definitively cure some human diseases. Unfortunately, the last
discovery that of cytokines, has still substantially excluded from the common
clinical practice. Therefore, it becomes essential to clinically introduce the
new science of cytokines, that we could call as cytokinology, before from
either a diagnostic, or a prognostic point of view, and after from a
therapeutic one. This statement is justified by the fact that the cytokines
produced by the activated immune cells do not regulate the only immune system,
but all biological functions, being the main responsible for host biological
response. The most synthetic and less expensive biomarker could be the same
lymphocyte-to-monocyte (LMR), since the evidence of a progressive decline in
LMR has been proven to predict a negative prognosis in both metastatic cancer
and cardiovascular disorders, as well as to be related to the exacerbation
phase of the autoimmune diseases. The occurrence of high blood levels of
TNF-alpha, IL-6 and IL-17A has a negative prognostic significance in both
advanced cancer and autoimmunity. On the contrary, the evidence of high
concentrations of TGF-beta and IL-10 is associated with a negative prognosis in
metastatic cancer and with a disease control in the autoimmune disorders.
Despite its great complexity, the immune
functionless is the end-results of the interactions occurring between
lymphocyte and monocyte-macrophage functions, with the dendritic cells as the
link between old innate and new acquired immunity. Moreover, within the
lymphocyte system, the immune regulation is mainly determined by three major
subsets of T lymphocytes, consisting of TH1 lymphocytes (CD4+CD25-CD17-),
regulatory T lymphocytes (T reg) (CD4+CD25+), and TH17 lymphocytes (CD4+CD17+)
[1-3]. All lymphocyte subpopulations may release several proteins, the
so-called cytokines, but from a clinical point of view it is important to
remember the main factors involved in the regulation of the whole immune
system, which are represented by IL-2 for TH1 cells, IL-17A for TH17 cells, and
IL-10 and TGF-beta for T reg cells. On the other side, the differentiation of
the monocyte-macrophage system into different sub-sets is more controversial
[4-8]. However, it has been shown that monocyte count may reflect the functional
status of the macrophage system [9]. Therefore, because of the great number of
potential immune biomarkers and their different economic cost, it is
fundamental to distinguish the most important ones from a clinical point of
view to monitor the clinical course of the various systemic diseases from those
useful for the only experimental researches. At this proposal and by taking
into consideration that the immune status is depending on the
lymphocyte-macrophage relationships the most simple and less expensive
biomarker from a clinical point of view may be considered the
lymphocyte-to-monocyte ratio (LMR) which has appeared to play a prognostic
significance in all severe human systemic diseases, including cancer autoimmune
diseases and cardiovascular disorders [10-13]. Finally, as far as systemic
disease-related symptomatology is concerned, IL-1 beta would be the main
responsible for fever TNF-alpha for cachexia and anorexia IL-6 for
sepsis-related hypotension and multi-organ failure and IL-31 for pruritus. Unfortunately,
most Clinicians do not seem to be interested in the investigation of the
physiopathology of cytokines [14-17].
Since the pathogenesis of human systemic
diseases may be reinterpreted as depending at least in part on an altered
relation among the different T lymphocyte subsets, it becomes clinically
important to quantify T cell subpopulations. In fact, the alterations in
cytokine secretions occurring in the different systemic diseases would be the
simple consequence of those involving the various T cell subsets. The
progressive decline in TH1 cell count in association with an increase in T reg
cell number and activity is the main advanced cancer-related immune alteration
which would be due to macrophage-mediated chronic inflammatory status. Then,
the progressive decline in TH1/T reg cell ratio occurring during cancer
progression depends either on a diminished TH1 cell count, or an increased T
reg cell number. Moreover, it has been shown that the decline in TH1/ T reg
cell ratio positively correlates with a decline in LMR values. Then, LMR values
could represent an adequate and less expensive biomarker to monitor the
evolution of advanced cancer patents. As fare as the autoimmune diseases are
concerned, until few years ago the increased activity of TH1 cells was
considered the main event responsible for the onset of autoimmune processes. In
contrast, it has been demonstrated that the autoimmune diseases are namely
characterized by an increase in TH17 cell activity in association with a
decline in T reg cell count since the main action of TH17 cells is the
inhibition of T reg cell generation and function. Then, the evidence of an
abnormally high values of TH17/T reg cell ratio, which is due to both TH17 cell
increase and T reg cell decline, may be considered as the main biomarker with
negative prognostic significance to monitor the clinical course of the
autoimmune diseases. LMR values have also appeared to have a prognostic
significance in the autoimmune pathologies, since it has been shown to be
normal or a little increased during the remission phase of disease and
abnormally low during the exacerbation phase in any case not due to a
diminished lymphocyte production as well as in the metastatic neoplasms but
probably to lymphocyte exit from the blood to infiltrate organ tissues. In
addition, at least some autoimmune diseases may be also characterized by a
decline in TH1/TH17 cell ratio, sine the increase in TH17 cell count would be
superior to TH1 enhancement. The occurrence of a diminished TH1/TH17 could also
characterized the advanced neoplastic pathologies, because of cancer-related
decline in TH1 count, as well as a probable increase in TH17 cell number, even
though the TH17 profile in cancer patients has been less investigated up to now
[18,19]. In any case, according to the data available up to now, cancer
progression would be characterized not only by an increased T reg cell
function, but also by an enhanced TH17 cell activation. Moreover, IL-17,
despite its potential favourable effect due to an inhibition of T reg cell
system, may directly stimulate cancer cell proliferation, and IL-17-expression
by cancer cells would enhance their malignant aggressiveness. Finally, a marked
increase in TH17/T reg cell ratio has been shown to predict a risk of acute
respiratory distress syndrome (ARDS) in patients with lung injury, or viral
infections, including coronavirus infection.
In non-metastatic cancer
patients, the immune profile is substantially within the normal range. On the
contrary, the metastatic disease is characterized by an increase in IL-6,
TNF-alpha and TGF-beta blood concentrations in association with a progressive
decline in LMR values and in TH1/T reg cell ratio [20]. On the contrary, IL-17
secretion in cancer needs to be furtherly investigated and understood. The
common immune profile of the autoimmune disorders is depending on the phase of
disease, since the remission phase tends to present LMR values within the
normal range in association with normal blood levels of the main inflammatory
cytokines. On the other hand, the exacerbation phase of disease is
characterized by abnormally high concentrations of IL-17A, IL-6, and TNF-alpha,
in association with a rapid decline in LMR and with an abnormal increase in
TH17/T reg cell ratio while the evidence of high levels of IL-10 and TGF-beta
may reflect a disease control because of their anti-inflammatory action
[21-29]. Finally, the cardiovascular disorders, including myocardial infarction
and brain stroke, are substantially characterized by a decline in LMR values.
Two other important biomarkers for the cardiovascular diseases are represented
by atrial natriuretic peptide-to-endothelin-1 ratio (ANP/ET-1), and by
vasopressin-to-oxytocin ratio (ADH/OT). The evidence of an abnormal decline in
ANP/ET-1 ratio as well as an abnormal increase in ADH/OT ratio would predict a
less favourable prognosis [30]. The occurrence of an abnormal increase in the
blood concentrations of inflammatory cytokines, such as TNF-alpha, has been
proven to be also associated with a more severe prognosis in the myocardial
infarction [31]. These findings would confirm that the functionless of the
cytokine network is not involved only in the regulation of the immune system,
but also of the overall biological systems. On the contrary, the profile of
TGF-beta secretion and lymphocyte and monocyte subsets in the myocardial
infarction, as well as in the other cardiovascular disorders, needs to be
furtherly established. In addition, it seems that the concomitant occurrence of
an abnormally enhanced secretion of IL-18 may furtherly worsen the severity of
systemic disease-related exaggerated host inflammatory response [32]. Finally,
the loss of the physiological light/dark rhythm of the pineal hormone
melatonin, whose fundamental immunoregulatory role has been well demonstrated,
would also be associated with a more negative prognosis either in the
metastatic cancer, or in cardiovascular ischemic diseases [33].
Table 1: The main immune and
neuroendocrine pathological and prognostic biomarkers to monitor the clinical
course of the main systemic human diseases.
Pathology Significance |
Biomarkers |
Prognostic |
Metastatic
Cancer |
Low LMR |
Negative |
Low TH1/T reg
ratio, low TH1/TH17 ratio |
Negative |
|
High TNF-alpha and IL-6 levels |
Negative |
|
High TGF-beta
and IL-10 levels |
Negative |
|
Lack of
light/dark MLT rhythm |
Negative |
|
Autoimmune
Diseases |
Low LMR |
Negative |
High TH17/T
reg ratio, low TH1/TH17 ratio |
Negative |
|
High IL-17A,
TNF-alpha and IL-6 levels |
Negative |
|
High IL-10
and TGF-beta levels |
Positive |
|
Cardiovascular Diseases |
Low LMR |
Negative |
High TNF-alpha,
IL-6, IL-18 levels |
Negative |
|
Low ANP/ET-1
ratio |
Negative |
|
High ADH/OT
ratio |
Negative |
|
Lack of
light/dark MLT rhythm |
Negative |
|
Ards |
Low LMR |
Negative |
High TH17/ T
reg ratio |
Negative |
|
High IL-17A,
TNF-alpha and IL-6 levels |
Negative |
|
High IL-10
levels |
Probably
positive |
The two extreme mistakes are the almost complete
lack of immune evaluation in patients with systemic diseases, including cancer
and autoimmunity, and on the other side the detection of an excessive number of
laboratory immune parameters, including cytokine blood levels and lymphocyte
subsets. Then, the correct clinical behaviour would have to consist of the
measurement of the only essential and synthetic immune biomarkers to establish
the immune status of patients, in particular by avoiding the measurement of
cytokines provided by the same pathological significance, such as the
concomitant detection of IL-1 beta and IL-6, because of their positive
correlation. Obviously, the choice of the fundamental immune parameters to be
clinically detected requires a perfect knowledge of the physiopathology of the
different human systemic diseases. In addition, the synthetic group of
biomarkers to monitor the clinical course of the systemic diseases must include
both parameters provided by physio-pathologic and prognostic significance. The
main cytokine levels and T lymphocyte subsets provided by pathological or
prognostic significance in the most important human systemic diseases are
summarized in (Table 1). LMR: Lymphocyte/monocyte ratio; ANP: Atrial
natriuretic peptide; ET-1: Endothelin-1; MLT: Melatonin, ADH: Vasopressin; OT:
Oxytocin.
A further future evolution of the medical Sciences
will be achieved and realized only when the evaluation of the functionless of
the cytokine network will be included within the commonly laboratory
examinations to monitor the clinical course of the most important severe human
systemic disease.