Biotechnological

Communication

Biosci. Biotech. Res. Comm. 10(3): 514-517 (2017)

Interleukin-17 concentration as a biomarker in diagnosis

of exudative pleural effusion compared with benign

pleural effusion

Ali Arian Nia*

and Saeid Mehrabi

Clinical Research Development Unit (CRDU) Golestan University of Medical Sciences Gorgan Iran

MD Golestan University of Medical Sciences Gorgan Iran

ABSTRACT

Pleural effusion is one of signs and complications resulting from malignant disease such as lung and breast cancer, and

also tuberculosis and infective lung disease by cytological analysis of pleural  uid we can use of tumor marker and other

biomarkers to better diagnose malignant pleural effusion.in this study we examined the concentration of interleukin-17 in

pleural  uid with causes of exudative pleural effusion in the patients referred to hospital of 2015-2016.This is a descriptive-

analytical and case-control study and 130 patients with exudative pleural effusion were enrolled in the study after an

informed consent samples collected from the patients divide into two main group including 88 patients with malignant

pleural effusion and 42 patient with benign effusion. in the next step by using of the same previous pleural  uid samples,

the concentration of interleukin-17 was measured with ELISA by speci c kit after entering to computer through SPSS-

18 statistical software, description of data was done into frequency and percentage.Interleukin-17 concentration was

(69.73±64.58) in patients with malignant causes and (55.32±43.60) in benign causes.The results showed that this differ-

ent was statistically signi cant (P=0.02) and interleukin -17 rate, is higher in the malignant pleural effusion.According

to higher levels of interleukin-17 in malignant pleural effusion maybe we can achieve important result in differentiating

between malignant and non-malignant pleural exudate, without the need for invasive procedures, by putting together the

clinical symptoms, the interleukin-17 concentration in pleural  uid and pleural  uid cytology results.

KEY WORDS: INTERLEUKIN-17, EXUDATIVE PLEURAL EFFUSION, MALIGNANT PLEURAL EFFUSION, BENIGN PLEURAL EFFUSION, BIOMARKER

514

ARTICLE INFORMATION:

*Corresponding Author: Aliariannia@gmail.com

Received 27

Nov, 2017

Accepted after revision 26

Sep, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF: 4.006

reserved.

Online Contents Available at:

http//www.bbrc.in/

DOI: 10.21786/bbrc/10.3/26

Ali Arian Nia and Saeid Mehrabi

INTRODUCTION

Pleural effusion is an excessive accumulation of  uid

in the pleural space, which affects annually about one

million people around the world. There are a range of

causes for the disease; benign diseases such as infec-

tions, heart and liver failures, rheumatic diseases and

drugs on the one hand and fatal cancers of lung and

other visceral organs on the other hand are placed in

this spectrum (Esther et al 1997).

Plain chest pleurography is a simple diagnostic meas-

ure to detect pleural effusion, which appears as  at-

tening and displacement between costophrenic angles.

With the presence of less  uid or abnormal localiza-

tion, ultrasound or CT scan can be used to conduct pleu-

ral tap (Heffner et al 1997, Light et al 1972, Ryland et

al1998). Cytologic analysis of pleural  uid is the most

common method for diagnosis of malignancy; while the

speci city of cytologic  ndings is 100%, unfortunately

only about 60% of malignant effusions can be detected

through this technique (Alema’n et al 2010). For undi-

agnosed exudative effusions with suspicion of malig-

nancy but negative cytology, more invasive approaches

are necessary (Hooper et al 2010 Chun Hua et al., 2017).

Closed pleural biopsy has less additional diagnostic

value and thoracoscopy is the preferred method, since

it is diagnostic in 90% of patients (Light 2006, Roberts

2010 and Neragi-Miandoab 2006). However, there is no

possibility of access to this invasive procedure in all

centers. Many investigations have assessed the ability

of tumor markers and other biomarkers to improve the

diagnosis of MPE (Botana-Rial et al 2011, Kremer et al

2010).The combined use of different markers has also

been proposed in some studies ( Kremer et al 2010, 2013).

Unfortunately, none of these markers has shown the

sensitivity and speci city enough to select as a diagnos-

tic marker of MPE (Hooper et al 2010). In a study, a type

of chemical safety approach has been used to search

for non-invasive markers of lung cancer in PE (Porcel

et al 2004). In this regard, several chemical biomark-

ers of in ammation were found that were differentially

expressed in MPE vs. BPE. Among these biomarkers,

IL-17 and CEA were expressed at higher quantities in

MPE than BPE. Interleukin 17 is a potential in amma-

tory cytokine produced by Th17 cells; it is expected to

be used as a marker for the diagnosis of pleural effusion.

The aim of this study is to determine the concentra-

tion of IL-17 in pleural  uid to facilitate differentiation

between MPE and BPE.

MATERIALS AND METHODS

The Deputy of Science and Technology of Golestan Uni-

versity of Medical Sciences and Research Ethics Com-

mittee approved study design and implementation pro-

tocol. All actions taken, had no physical, psychological

or  nancial losses for the participants in the research.

This descriptive and analytical study was performed on

130 patients with exudative pleural effusion who were

admitted to Shahid Sayyad Shirazi Teaching Hospital

in Gorgan during 2015-2016, and enrolled in the study

after obtaining informed consent.Routine diagnostic

procedures such as X-ray, CT scan and ultrasound, if

necessary, were performed for all patients before start-

ing the study. After history taking and exact physical

examination, thoracentesis was carried out to prepare

pleural  uid samples that were frozen at -20°C after cen-

trifugation for 15 min.

The samples were analyzed for biochemical proper-

ties, pH, glucose and proteins; accordingly, exudative

pleural effusion was differentiated from transudative

type and patients with transudative pleural effusion

were excluded from the study. Malignancy of pleural

effusion was diagnosed according to our and previous

studies using VATS technique; such that, after insert-

ing VATS instruments through 1 to 2 incisions and after

viewing the parietal and visceral pleura as well as evi-

dence of metastases, biopsy was performed from the

parietal pleura and pleural  uid for cytology testing.

The samples were sent to the pathology laboratory for

detecting malignancy and its type.

In terms of etiology and based on the  ndings of the

gold standard of pleural  uid analysis (microbiology

and cytology testing, including cell differential count),

exudative pleural effusion were classi ed into two main

MPE and BPE groups. According to previous studies,

since between 40 and 50 percent of the cases showed

malignant exudative pleural effusion, so the samples

were divided almost with the same proportion. At a later

stage, by using the same previous pleural  uid samples,

the IL-17 levels were measured via ELISA kit accord-

ing to the manufacturer’s protocol and the samples were

stored at -80°C until testing.Having pleural effusion dis-

ease was inclusion criterion. Exclusion criteria included

transudative pleural effusion, diabetes, autoimmune dis-

eases and rheumatic diseases.

Data were analyzed using statistical SPSS V.18 soft-

ware. Normal distribution and data homogeneity were

assessed using the Kolmogorov-Smirnov test.

In addition, the mean IL-17 level was compared

between the two groups using independent t-test. Mann-

Whitney test was applied for normal distribution of IL-17

concentration. Signi cance level of the tests was 0.05.

RESULTS AND DISCUSSION

After examining, 130 patients were divided into two

groups of malignant pleural effusion (n=88, 67.7%) and

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS INTERLEUKIN-17 CONCENTRATION AS A BIOMARKER IN DIAGNOSIS OF EXUDATIVE PLEURAL EFFUSION 515

Ali Arian Nia and Saeid Mehrabi

benign pleural effusion (n=42, 32.3%) with a mean age

of 57 and 59 years respectively. There was no statistically

signi cant difference between IL-17 level and age of the

patients. The patients in MPE group included 44 males

(50%) and 44 females (50%), but the patients in BPE group

consisted of 26 males (61.9%) and 16 females (38.1%).

In the MPE and BPE groups, 41 and 21 people were

smokers respectively. Among the patients in MPE group,

22 (25%) had primary lung cancer, 31 (35.2%) secondary

breast cancer, 11 (12.5%) secondary esophageal cancer,

11 (12.5%) metastatic cancer and 13 (14.77 %) secondary

stomach cancer.

The IL-17 level was 36.43±56.719 in males and

74.838±76.42 in females; and as a result of statistical

analysis, no signi cant difference was observed for IL-17

levels in pleural  uid between males and female. Analysis

of the mean pleural  uid protein levels was respectively

4373.8± 419.3 mg and 4411.7 ± 493 mg in the patients of

MPE and BPE groups. There was a correlation between

IL-17 and pleural  uid protein levels, but it was not

statistically signi cant (r = 0.15). The mean IL-17 level

was compared in smokers and nonsmokers, and statisti-

cal analysis showed no signi cant difference (P = 0.35).

The results showed that 66 patients (50.8%) had a history

of previous malignancy; 31 (46.97%) secondary to breast

cancer, 11 (16.67%) secondary to esophageal cancer, 11

(16.67%) secondary to metastasis due to other causes and

13 (19.7%) secondary to stomach cancer had experienced

MPE, and the mean IL-17 level was 63.9±36.6 in these

subjects. In people who had no history of previous malig-

nancy, including 22 (34.38%) with primary lung cancer

and 42 (65.63%) with TB (totally 64 patients, 49.2%), the

mean IL-17 level was 66.2 ± 75.5 in these people. Con-

sidering the higher mean IL-17 level in the group with

no history of previous malignancy compared with the

 rst group as well as P= 0.001, no statistically signi -

cant difference was observed for IL-17 levels between the

two groups. The IL-17 level in pleural  uid of patients

with MPE and BPE was respectively 69.73± 64.58 and

55.32±43.60; there was a statistically signi cant differ-

ence between the two groups (P = 0.02).

Differentiating between benign pleural effusion (BPE)

and malignant pleural effusion (MPE) has remained

controversial as a diagnostic issue. The majority of

malignant pleural effusion (90% to 97%) is exudative

type that occurs because of pleural membrane damage

(Esther et al 1997). MPE can be seen as a complication

in most malignancies, particularly in breast and lung

cancer, while lung infections and tuberculosis cause the

development of BPE.The gold standard for diagnosis of

malignant pleural effusion is clinically the presence of

malignant cells in pleural cells. Dif culty in differentiat-

ing between malignant and benign is the negative result

of malignant cells in pleural  uid cytology. In these cir-

cumstances, differentiation from benign is problematic

and the need for invasive measures such as thoracentesis

is essential for the patient.

Closed pleural biopsy has less additional diagnostic

value and thoracoscopy is the preferred method, since

it is diagnostic in 90% of patients. However, there is

no possibility of access to this invasive procedure in all

centers. According to this issue, 130 patients with exu-

dative pleural effusions were examined in this study. In

the present study, 88 patients with malignant pleural

effusion were compared with 42 patients with benign

pleural effusion in terms of pleural  uid levels of IL-17.

The patients were also evaluated for age, gender, his-

tory of previous cancer, smoking and pleural  uid pro-

tein levels. The mean age of subjects was close to each

other in two age groups and no signi cant difference

was found between the two groups. In addition, there

was no statistically signi cant difference between IL-17

level and age of the patients.

In 2014, Chun Hua et al. examined a new biomark-

ers of interleukin 17 among 123 patients with exuda-

tive pleural effusion to determine the causes of pleural

effusion. They showed that IL-17 level was signi cantly

higher in MPE group compared with BPE group, similar

to our results, and also stated that IL-17 can be used as

a biomarker to differentiate MPE from BPE.

Since only one study has so far examined the level

of IL-17 in pleural  uid, in addition to our study; so in

the following discussion, we will consider similar studies

closer to the present study, (Chun Hua et al., 2017).

Wang et al. in 2013 examined the levels of superox-

ide dismutase (SOD) in TPE and MPE, which was mark-

edly higher in the TPE than the MPE. The results showed

that SOD is not a suitable biomarker for these two types

of pleural effusion (Xin-Feng Wang et al, 2013) In 2014,

Chun Hua et al. examined serum levels of IL-17 in 128

patients with Non-small cell lung cancer (NSCLC). The

results showed that higher levels of IL-17 in NSCLC group

compared with the control group, which can be applied as

diagnostic and prognostic value in patients with NSCLC.

Many studies have been conducted in the  eld of

diagnostic value of cytology and the diagnostic value

for diagnosing malignancies have been reported up to

70% in Iran. More invasive procedures such as biopsy,

thoracoscopy or thoracotomy despite high sensitivity

are not accepted through patients and physicians for

diagnosis of tuberculosis and malignancies.

Therefore, researches in recent decades have led to

 nd markers in pleural effusion and blood plasma to dif-

ferentiate between tuberculosis and malignancies with-

out invasion and with high-value and effectiveness of

diagnosis and differentiation.

So far, only one study has examined the level of

IL-17 in pleural effusion and high sensitivity has been

516 INTERLEUKIN-17 CONCENTRATION AS A BIOMARKER IN DIAGNOSIS OF EXUDATIVE PLEURAL EFFUSION BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS INTERLEUKIN-17 CONCENTRATION AS A BIOMARKER IN DIAGNOSIS OF EXUDATIVE PLEURAL EFFUSION 517

Ali Arian Nia and Saeid Mehrabi

able to differentiate MPE than BPE. Like what mentioned

above, other studies have been done on other biomark-

ers that some of them have been useful for the study. In

our study, according to the signi cant differences for

IL-17 levels in the two groups, its usability can be seen

to differentiate between MPE and BPE. In addition, since

the patients with primary lung cancer were in the group

with no history of previous malignancy and the mean

IL-17 was higher in these patients than in patients with

secondary cancer as well as than TB, so signi cant dif-

ference was found between the two groups regarding

history of previous cancer, though given limited studies

done in this area and the lack of de ned cut-off points,

it de nitely cannot be used as the only reference and

diagnostic methods. Nevertheless, due to the apparent

signi cant difference between the two groups, there is

the possibility of using IL-17 beside other methods for

differentiating malignant from benign diseases.

CONCLUSION

The results obtained from the present study demon-

strated that age, gender, smoking, history of previous

cancer and pleural effusion protein levels have no sig-

ni cant effect on IL-17 level. The IL-17 level was signif-

icantly higher in pleural effusion caused by malignant

diseases than in exudative pleural effusion caused by

benign diseases, especially tuberculosis.

Since the differentiation between malignant pleural

effusion and benign pleural effusion, especially tuber-

culosis, sometimes needs to invasive procedures such as

pleural biopsy or thoracoscopy, so it can be concluded

that the IL-17 level regarding the signi cant difference

can be used as a diagnostic approach in differentiating

between the two types of pleural effusion.

It is recommended that the similar study should be

conducted in different centers with larger sample size, as

well as a variety of malignant and benign diseases can

be studied separately.

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