Possible Role for Tocilizumab, an Anti–Interleukin-6 Receptor Antibody, in Treating Cancer Cachexia
Authors: Katsutoshi Ando, Fumiyuki Takahashi, Shinji Motojima, Kei Nakashima, Norihiro Kaneko, Kazuei Hoshi, Kazuhisa Takahashi
Journal: Journal of Clinical Oncology (2012)

Case ReportA 75-year-old man with no significant past medical history presented with a 3-week period of fever, fatigue, and a 7-kg weight loss.Physical examination revealed a poor performance status (PS; Eastern Cooperative Oncology Group score 3), emaciation, and anemia of palpebral conjunctiva.Laboratory data included a WBC count of 15.7 K/L, moderate anemia (hemoglobin concentration of 7.2 g/dL), and a platelet count of 757 K/L.Serum chemistry showed total protein, albumin, and C-reactive protein (CRP) of 8.5 g/dL, 1.7 g/dL (␥globulin was 50% in the protein fraction), and 24.51 mg/dL, respectively.In addition, serum immunoglobulin G was increased (4.3 g/dL) as was interleukin-6 (IL-6; 172 pg/mL).A computed tomography (CT) scan of the thorax showed a 3-cm mass in the right hilum and swelling of mediastinal lymph nodes, although there was no evidence of metastasis in remote organs.Accordingly, we considered a differential diagnosis of lung cancer, Castleman's disease, or tuberculosis.Subsequent endobronchial ultrasound-guided transbronchial needle aspiration resulted in the detection of a large-cell carcinoma and a final diagnosis of primary lung cancer at clinical stage T2aN2M0 (stage IIIA) with cancer cachexia.Because it was difficult to start chemotherapy and radiotherapy as a result of the poor PS of the patient, we started prednisolone 0.5 mg/kg (a total of 30 mg) for cachexia.After 2 weeks, his symptoms and PS diminished slightly including a decrease of serum IL-6 level to 112 mg/mL.Consequently, we performed systemic chemotherapy (pemetrexed 500 mg/m 2 once every 3 weeks, two courses) and sequential radiotherapy.These treatments produced no adverse events and were completed.However, the PS of the patient deteriorated to an Eastern Cooperative Oncology Group score of 4, with a decrease in serum albumin to 0.8 g/dL as a result of the recurrence of cancer cachexia and an increase of the serum IL-6 level to 173 pg/mL.Accordingly, we diagnosed his condition as progressive cancer cachexia, which was resistant to treatment with prednisolone, and realized that supportive care is usually considered the best choice of treatment.However, on the basis of the clinical findings, we theorized that the cachexia might be controlled by inhibiting the IL-6 mediated inflammatory response with tocilizumab anti-IL-6 receptor antibody.After approval by the institutional review boards of our institution, agreement by the patient and his family, and receipt of a written informed consent, we began tocilizumab therapy for the patient at 8 mg/kg (a total of 400 mg) every 4 weeks.Soon after this treatment began, the symptoms of the patient rapidly lessened, his appetite improved, and his CRP levels normalized in 2 weeks (Table 1).His overall physical condition recovered enough so that he could walk short distances after 4 weeks; after 8 weeks, he was able to live at home without nursing support.The body weight and albumin level of the patient improved dramatically to 46 kg (from