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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 82-86

Evaluation of interleukin-35 and interleukin-10 in adult acute myeloid leukemia patients before and after induction chemotherapy

1 Department of Pathology, College of Medicine, Mustansiriyah University, Baghdad, Iraq
2 Department of Laboratory, Al-Yarmouk Teaching Hospital, Baghdad, Iraq

Date of Submission10-Mar-2020
Date of Acceptance06-Jul-2020
Date of Web Publication10-Nov-2020

Correspondence Address:
Dr. Eman Fadhil Mahmood
Department of Pathology, College of Medicine, Mustansiriyah University, Baghdad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijh.ijh_17_20

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BACKGROUND: Acute myeloid leukemia (AML) is a clonal proliferation of hemopoietic cells. Interleukin-35 (IL-35) is a pro-inflammatory cytokine expressed in T regulatory (Treg) and B regulatory cells. IL-35 promotes the proliferation of AML blasts and lessens apoptosis. Hence, IL-35-derived from Tregs promotes the growth of adult AML blasts, suggesting that IL-35 has an important role in the pathogenesis of AML. IL-10 is anti-inflammatory cytokines with immune-stimulatory activities and is formed by CD4 and CD8 T-cells and activated B-lymphocytes.
OBJECTIVES: The aim of th study was to estimate the levels of IL-10 and IL-35 in the sera of patients with AML before and after chemotherapy induction and to correlate levels with blast cells percentage and other hematological parameters.
PATIENTS, MATERIALS AND METHODS: This study was conducted on thirty newly diagnosed (ND), de novo adult AML patients, 15 males and 15 females with a age range between 19 and 75 years for a period from September 20, 2017, to March 15, 2018. It included 18 healthy (9 males and 9 females) individuals who were taken as a control group. Diagnosis of AML was established according to the morphology, cytochemistry and flow cytometry study of both peripheral blood and bone marrow aspiration as well as biopsy reports. ILs-35 and 10 levels were measured at diagnosis and after induction chemotherapy when achieving complete remission based on Cheson et al. definition.
RESULTS: Serum IL-35 and IL-10 were significantly higher in ND AML patients than controls and were reduced after induction chemotherapy (P < 0.001). In patients with remission, IL-10 was significantly reduced compared with non-remission group, while the reduction in IL-35 level in remitted compared to nonremitted patients did not reach the level of significance (P > 0.001). No correlations were found between hemoglobin, platelet counts, white cell count, and blast percentage with IL-35 and 10 levels in de novo AML patients.
CONCLUSIONS: Both ILs-35 and 10 levels were elevated in de novo AML patients and lowered following induction chemotherapy. Both ILs have no correlation with hemoglobin level, platelet count, white blood cell count, and blast percentage.

Keywords: Acute myeloid leukemia, interleukin-10, interleukin-35, induction chemotherapy

How to cite this article:
Mahmood EF, Ahmed AA. Evaluation of interleukin-35 and interleukin-10 in adult acute myeloid leukemia patients before and after induction chemotherapy. Iraqi J Hematol 2020;9:82-6

How to cite this URL:
Mahmood EF, Ahmed AA. Evaluation of interleukin-35 and interleukin-10 in adult acute myeloid leukemia patients before and after induction chemotherapy. Iraqi J Hematol [serial online] 2020 [cited 2021 Jun 14];9:82-6. Available from: https://www.ijhonline.org/text.asp?2020/9/2/82/300406

  Introduction Top

Acute myeloid leukemia (AML) is defined as a neoplastic clonal disorder that is characterized by low production and alterations of normal hematopoietic cells; such changes may constrain the differentiation of cells and trigger the proliferation or buildup of blasts. These blasts will substitute normal hematopoietic elements, eliciting the appearance of cytopenias. The buildup of immature cells starts in the bone marrow (BM), but in most cases, rapidly, it builds up in the peripheral blood (PB).[1]

AML has an immune suppressive microenvironment, represented by defects in the number and function of T-cells.

These defects are described to influence the effect of regulatory T regulatory cells (Tregs), which suppress the proliferation and function of T helper (Th) cells.[2]

Both accurate diagnosis and classification in AML are essential for both treatment plans and evaluation of prognosis. Preliminary assessment necessitates a careful history, physical examination, complete blood count with PB smear review, BM examination, flow cytometry (FC), cytogenetics, and selected molecular genetic analyses.[3]

Interleukin 35 (IL-35) was lately recognized heterodimeric inhibitory cytokine secreted by Treg cells and contributes to their immune suppressive activity by limitation of antitumor effect and contribution in dysfunction of T-cell.[4]

IL-10 is an anti-inflammatory cytokine secreted by immune cells including macrophages, natural killer (NK) cells, and T-lymphocytes. IL-10 still has an unclear role in the pathogenesis of cancer; some studies exhibited that IL-10 participates in both development and progression of cancer in humans as a tumor promoting (promote cancer potentially) with immune stimulating and immune suppressive (inhibit cancer potentially).[5]

The leukemias signify exceptional models regarding the effect of cancer on the host immune system. Both immune cells and cancer cells in BM and in PB are in close relation and originate from the same hematopoietic elements.[6]

The malignant clone in AML is promptly expanded and seemingly controlled by cellular immunity, including subsets of cytotoxic (CD8+) T–cells, and NK (NK) cells. In patients with AML, cytokines can be produced by both cells of the immune system and leukemic blasts. Despite that, an increased level of cytokine is a feature of leukemia that may subsidize blast survival, proliferation, resistance to chemotherapy, and patients' prognosis.[7]

  Patients, Materials and Methods Top

This case–control study was conducted on thirty newly diagnosed (ND), de novo AML patients; they included 15 males and 15 females with an age range between 19 and 75 years. Along with 18 healthy age and sex-matched individuals including 9 males and 9 females were taken as a control group.

The study was carried out at the National Hematology Center at Al Mustansiriyah University/college of medicine and Baghdad Teaching Hospital for a period from September 20, 2017, to March 15, 2018.

Ethical approval to conduct the research was obtained from the National Center of Hematology and Medical City as well as verbal consent from all participants in this study was attained.

Diagnosis of AML was established according to the morphology, cytochemistry, and immunophenotype (cluster of differentiation or CD profile) measured by FC of both PB and BM aspiration as well as studying biopsy reports. Since there is no genetic study done for classification of AML, therefore according to the WHO 2016 classification, the “AML not otherwise specified” subgroup was adopted for classification of AML cases included in this study.

Patients included in our study were assessed for complete remission (CR) achievement within 14–28 days from the onset of their induction chemotherapy. CR was based on Cheson et al. definition (<5% blasts in BM aspirate samples, with no persistence of extramedullary disease, no blast cells with  Auer rods More Details, and have a platelet count of ≥100 × 109/L and an absolute neutrophil count of >1 × 109/L).[8]

Four milliliters of blood was taken by a clean, aseptic venipuncture from each patient and controls.

The drawn sample was then put in serum separator tube and samples were permitted to clot at room temperature for about 2 h or overnight at 4°C prior to centrifugation at 1000 ×g for 15 min.

The serum was collected in Eppendorf tubes in 4 aliquot for each sample. The serum stored at −80°C for a maximum of 5 months and used for measuring serum IL-35 and IL-10 level for control subjects and for AML patients (on two occasions: at diagnosis and after the patients had completed their remission induction therapy) by enzyme-linked immunosorbent assay using the CUSABIO Human IL-35 and IL-10 Immunoassay Kit, China.

Hematological parameters including hemoglobin level, white cell count, platelet count, and blast percentage in the PB and BM were obtained from the patients' records.

Statistical analysis

Data were analyzed using SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp.

Categorical data represented by percentages and frequencies and their relations were evaluated using the Pearson's Chi-square test. Data were evaluated for normality of distribution and then tested by Student's t-test for differences between cases and controls as well as the response to treatment. On the other hand, ILs were skewed data thus represented by median and interquartile range, then tested by Mann–Whitney nonparametric test and also tested by the Wilcoxon rank test for differences according to the treatment. Spearman's correlation was used.

P value considered significant at 0.05 level.

  Results Top

This study was conducted on 30 AML patients along with 18 healthy age- and sex-matched individuals who served as a control group. The mean age and range with gender incidences are shown in [Table 1].
Table 1: Age and sex comparison according to the study groups

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Classification according “AML not otherwise specified” subgroup showed that 2 patients had M0 subtype (6.6%); 6 patients had M1 (20.0%); 6 patients had M2 (20%); 7 patients had M3 subtype (23.3%); 5 patients had M4 (16.6%); 3 patients had M5a (10.0%), and 1 patient had M5b (3.3%), as shown in [Figure 1].
Figure 1: Subtypes of acute myeloid leukemia cases n = 30

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At presentation, there was a highly significant increase in the mean level of IL 35 and IL 10 in AML patients compared to their mean level in the control group (P < 0.001) [Table 2].
Table 2: Comparison of laboratory markers according to the study groups before induction chemotherapy

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Moreover, the mean level of IL-10 decreased significantly among patients who had a remission after induction chemotherapy as compared to non-remitted patients and the majority of non-remitted patients showed even increased IL-10 levels (P < 0.001), whereas IL-35 level showed similar changes after induction therapy but did not reach the level of significance, as shown in [Table 3].
Table 3: Comparison of interleukins difference after induction chemotherapy according to response

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The current study revealed that there were no significant correlations between white blood cell count (WBC) count, platelet count, hemoglobin concentration, and blast percentage in PB and BM and the mean level of both ILs before treatment [Table 4] and [Table 5].
Table 4: Spearman's correlation between interleukin 35 and hematological parameters of acute myeloid leukemia cases (n=30)

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Table 5: Spearman's correlation between interleukin 10 and hematological parameters of acute myeloid leukemia cases (n=30)

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  Discussion Top

The mean age of patients with AML included in this study was 46.9 ± 14.6 years with a range of 18–70 years. Those results were comparable to other Iraqi studies in 2009,[9] 2017,[10] and an Egyptian study in 2016.[11]

Of the studied 30 cases, M3 was the most frequent (23.3%) followed by M1 (20%) and M2 (20%). This result was comparable with other studies done in Baghdad by Almohsen and Al-Mudallal [12] and by Hussein et al.[13] in which M3 was the most frequent subtype (26% and 28%, respectively).

However, other studies done by Poul.[14] conducted in Erbil over a period from 2006 to 2009 showed that M2 was the most common subtype (24%), this may be attributed to our smaller sample size and shorter period of observation.

Hemoglobin level estimation in this study primarily showed low mean hemoglobin concentration 7.2 ± 1.7 g/dL, which are analogous with other Iraqi studies reported by Al-Maaroof et al.[15] and Hasan et al.[16]

The mean WBC count in this study was 35.9 ± 23.2 × 109/L which was closely comparable to the result reported by Assem et al.[17] (38.6 × 10[9]/L) and less than that reported by Colovic et al.[18] (53 × 109/L).

The mean platelet count in this study was 53.1 ± 27.6 × 109/L comparable to Hasan et al.'s[16] result (51 × 109/L) and Thomas et al.'s[19] result (60 × 109/L).

The PB blast percentage mean was 58% ± 22.1% (range: 11–97) and the BM blast percentage mean was 70.6% ± 18.8% (range: 30–95). These results were consistent with those described by other studies in 2011 and 2016.[14],[20]

Both ILs showed a significantly higher level in ND AML patients compared with their level in the control group. These findings totally agree with studies done by Binder et al.[21] in 2018 and Wu et al. in 2012[4] which showed higher levels of serum IL-35 and IL-10 in ND adult AML patients compared with the healthy control group.

According to the response to induction chemotherapy, IL-10 was significantly reduced in patients with remission, compared with nonremission (NR) group, while the level of IL35 was lower among those with CR compared to those with NR, but this reduction did not reach the level of significance. Whereas Tao et al.[22] reported that IL-35 level was high in ND and NR AML groups as compared to control and CR AML groups; moreover, it was believed that IL-35 positively correlated to adult AML occurrence and development. This disparity in findings may be due to the differences in sample sizes.

  Conclusions Top

In conclusion, both IL-35 and IL-10 were elevated in ND adult Iraqi patients with AML. There is propensity for serum level of IL10 to be reduced following induction chemotherapy. There was no significant correlation of IL-35 and IL-10 with platelet count, hemoglobin level, blast percentage, and WBC count.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Wang M, Zhang C, Tian T, Zhang T, Wang R, Han F, et al. Increased regulatory T cells in peripheral blood of acute myeloid leukemia patients rely on tumor necrosis factor (TnF)-α–TnF receptor-2 Pathway. Frontiers Immunol 2018;9:1274.  Back to cited text no. 2
Head D, Thompson MA. Diagnosis and classification of the acute myeloid leukemias (with discussion of the role of the myelodysplastic syndromes in AML pathogenesis). In: Estey EH, Faderl SH, Kantarjian HM, editors. Hematologic Malignancies: Acute Leukemias. Vol. 2. Germany: Springer; 2008. p. 21-46.  Back to cited text no. 3
Wu H, Li P, Shao N, Ma J, Ji M, Sun X, et al. Aberrant expression of Treg-associated cytokine IL-35 along with IL-10 and TGF-β in acute myeloid leukemia. Oncol Lett 2012;3:1119-23.  Back to cited text no. 4
Alyaqubi KJ, AL-kaabi AJ, AL-kaabi SJ. Plasma IL-10 Concentration and its role in the pathogenesis of acute myeloid Leukemia: A prospective study. Iraqi J Biotechnol 2016;15:61-7.  Back to cited text no. 5
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Sanchez-Correa B, Bergua JM, Campos C, Gayoso I, Arcos MJ, Bañas H, et al. Cytokine profiles in acute myeloid leukemia patients at diagnosis: Survival is inversely correlated with IL-6 and directly correlated with IL-10 levels. Cytokine 2013;61:885-91.  Back to cited text no. 7
Cheson BD, Bennett JM, Kopecky KJ, Büchner T, Willman CL, Estey EH, et al, Revised recommendations of the international working group for diagnosis, standardization of response criteria, treatment outcomes, and reporting standards for therapeutic trials in acute myeloid leukemia. Journal of clinical oncology. 2003:15;21:4642-9.  Back to cited text no. 8
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Abdulateef S, Almothaffar A, Al-Khafaji KR. Molecular study of FLT3-ITD mutation in Iraqi adult acute myeloid leukemia patients: Its correlation with clinicopathological parameters. Pathol Lab Med 2017;1:14.  Back to cited text no. 10
Nasreldin E, Safwat DM, Hamed HB, Mohamed SA. T-regulatory and T-helper type 17 cells associated cytokines (IL-35, IL-17) as potential diagnostic and prognostic biomarkers in Egyptian acute myeloid leukemia patients. J Clin Cell Immunity 2016;7:478.  Back to cited text no. 11
Almohsen FS, Al-Mudallal SS. Relationship between the expression of CD34, CD123 and myeloperoxidase markers by flow cytometry and response to induction therapy in acute myeloid leukemia. Iraqi JMS 2014;12:161-7.  Back to cited text no. 12
Hussein SH, AL-Rubaie HA. Survey of Adult de novo Acute Myeloid Leukemia Cases Reported in the Medical City in Baghdad Through the Years (2005-2011). M. Sc. Thesis (Pathology). University of Baghdad; 2013.  Back to cited text no. 13
Muhammed NS, Shamoon RP, Pouls RK. Clinical and haematological parameters in adult AML patients: a four year experience at Nanakaly Hospital for blood diseases. Zanco Journal of Medical Sciences. 2012;16:199-20.  Back to cited text no. 14
Al-Maaroof ZW, Yahya DH, Hassoon AF. Evaluation of leukemia inhibitory factor, interleukin-6 and leptin in acute and chronic myeloid leukemia in Babylon province. Med J Babylon 2016;2:513-21.  Back to cited text no. 15
Hasan KM, AL-allawi NA, Badi AI. Multilineage dysplasia in Iraqi Kurds with acute myeloid leukemia: A retrospective study on 105 patients. Duhok Med J 2017;11:1-10.  Back to cited text no. 16
Assem M, Osman A, Kandeel E, Elshimy R, Nassar H, Ali R. Clinical impact of overexpression of FOXP3 and WT1 on disease outcome in egyptian acute myeloid leukemia patients Asian Pac J Cancer Prev 2016;17:4699-711.  Back to cited text no. 17
Colovic N, Tomin D, Vidovic A, Suvajdzic N, Jankovic G, Palibrk V, et al. Pretreatment prognostic factors for overall survival in primary resistant acute myeloid leukemia. Biomed Pharmacother 2012;66:578-82.  Back to cited text no. 18
Thomas X, Chelghoum Y, Cannas G, Elhamri M, Labussière H, Tigaud I, et al. Leukocytosis and circulating blasts in older adults with newly diagnosed acute myeloid leukemia: Are they valuable factors for therapeutic decision-making? Clin Lymphoma Myeloma Leuk 2011;11:342-9.  Back to cited text no. 19
Rockova V, Abbas S, Wouters BJ, Erpelinck CA, Beverloo HB, Delwel R, et al. Risk stratification of intermediate-risk acute myeloid leukemia: Integrative analysis of a multitude of gene mutation and gene expression markers. Blood 2011;118:1069-76.  Back to cited text no. 20
Binder S, Luciano M, Horejs-Hoeck J. The cytokine network in acute myeloid leukemia (AML): A focus on pro- and anti-inflammatory mediators. Cytokine Growth Factor Rev 2018;43:8-15.  Back to cited text no. 21
Tao Q, Pan Y, Wang Y, Wang H, Xiong S, Li Q, et al. Regulatory T cells-derived IL-35 promotes the growth of adult acute myeloid leukemia blasts. International journal of cancer. 2015 Nov 15;137:2384-93.  Back to cited text no. 22


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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