{'fraction_non_alphanumeric': 0.03353927625772286, 'fraction_numerical': 0.01412180052956752, 'mean_word_length': 5.01085121774777, 'pattern_counts': {'":': 0, '<': 4, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Following Chemotherapy: Serum Cytokine (Tumor Necrosis Factor, Interleukin-2, Interleukin-11), Immunoglobulin, Complement, Vascular Endothelial Growth Factor Levels, and the Systemic Symptoms like Capillary Leak Syndrome

Several problems such as myalgia, arthralgia, fever, dyspnea, generalized edema, and pleural effusion can occur in cancer patients following the chemotherapy, especially at the first cycle of the first chemotherapy treatment. Although it is assumed that some cytokines are associated with the development of these symptoms and signs, their pathophysiology has not been discovered completely yet. They are usually mild, but they may rarely progress to the severe stage of “Systemic Capillary Leak Syndrome” with a high mortality rate. The objective of this study was to investigate the association between the serum levels of interleukin-2 (IL-2), interleukin-11 (IL-11), tumor necrosis factor alpha (TNF-α), vascular endothelial growth factor (VEGF), and these symptoms and signs. A total of 44 cancer patients who had neither heart, lung, liver, renal, or thyroid disease were recruited into this study. Their symptoms and signs were examined and questioned before the first cycle of the first chemotherapy treatment and the 24 h after this chemotherapy. All participant’s serum samples were taken, and the VEGF, TNF, IL-2, and IL-11 levels were studied. There was no association between the chemotherapeutic drugs, and the symptoms and signs such as edema, dyspnea, coughing, and flu-like symptoms. There was a significant decrease in IL-11 levels in the other treatment group compared with the group receiving paclitaxel, docetaxel, gemcitabine, and vinorelbine in the first day following chemotherapy (P = .006). However, no relation was observed between the symptoms and signs, the response to the chemotherapy, and the serum levels of VEGF, TNF, IL-2, and IL-11. These symptoms and life-threatening syndrome have been a current topic between the clinicians. Although some drugs and mediators are accused, its pathophysiology has not been discovered completely yet. In this study, we could not detect any association between the symptoms, signs, and the cytokine levels following the chemotherapy.


2
Biomarkers in Cancer syndrome and these symptoms and signs. [4][5][6] When deciding on the cytokines to be studied, previous literature has been analyzed and it has been decided to study interleukin (IL)-2, IL-11, tumor necrosis factor alpha (TNF-α), and vascular endothelial growth factor (VEGF). These molecules have been previously accused that they cause similar side effects to symptoms and signs mentioned before during immunotherapy usage. 1,[4][5][6]12,13 Although these symptoms and signs (generalized edema, hypotension, shortness of breath, fatigue, widespread muscle and joint pain, numbness, and skin rash) are not as severe as those in the systemic capillary leak syndrome, the clinical symptoms and signs are similar to each other. From this point, we hypothesized that the pathophysiology of the symptoms and signs are similar to the pathophysiology of the systemic capillary leak syndrome. In this study, the relation between these symptoms and signs and the serum levels of the cytokine such as IL-2, IL-11, TNF-α, and VEGF was investigated. It was also investigated the changes of the cytokine level and the response to the chemotherapy treatment.

Patients and Methods
A total of 44 cancer patients (26 males and 18 females) who had a tissue diagnosis were recruited into this study. All of these cases did not previously receive any treatment (chemotherapy/radiotherapy) for cancer disease. All of them were chosen from Ankara University Hospital, Department of Medical Oncology Clinic. Some cases were selected from hospitalized patients and the other ones were selected from ambulatory cases who were resident in Ankara city. Cases who had heart, lung, liver or kidney disease, ongoing infection, any chronic inflammatory disease, autoimmune disease, and used of steroid or any other drug that is affecting on immunoreaction were excluded from the study.
The previous clinical studies and the clinical experiences have shown that these symptoms and signs can be seen after the second and third chemotherapy but they occur more common followed by the first chemotherapy. 14 For this reason, in our study, considering the cost and the difficulty of following-up due to the prospective design, it was considered more appropriate to examine only the first cycle of the first chemotherapy treatment where these symptoms and signs were most frequently observed according to the results of these previous studies. In addition, considering the cost again, IL-2, IL-11, TNF-α, and VEGF levels were measured only in the first-day serum samples. Since the blood half-life of the cytokines is short, the blood samples were obtained in 24 h follow of the chemotherapy. These blood samples were delivered to the nearest laboratory in 20 min. Then, the serum samples were separated by centrifugation at 5000 r/min for 5 min. These serum samples were placed in Eppendorf tube and stored at -°75 C. Hemoglobin, hematocrit, sedimentation, blood urea nitrogen, creatinine, total protein, albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), complement C3 and C4, immunoglobulins IgG, IgA, IgM, protein electrophoresis, spot urine protein, spot urine density, urine osmolarity, and serum osmolarity also measured before the chemotherapy treatment and on the first day after this treatment. Free-T3, free-T4, and TSH were also measured before the treatment. All of these parameters were analyzed at Ankara University Medical Faculty Hospital Laboratories. Besides the blood samples were obtained from all participants, a questionnaire and a physical examination were also simultaneously applied to all participants to observe whether there are lower extremity edema, weakness, shortness of breath, fever, rash-itch on the skin, voice misery, cough, muscle, and joint pain.
All serum samples were removed from -75°C, and they were put in dry ice to be transported to the laboratory where the cytokines were studied. Then, all samples were allowed to stand at room temperature for melting before being analyzed. The samples were run in duplicate, and the results were evaluated as picogram/milliliter. The measurements of VEGF, TNF, IL-2, and IL-11 were made using the enzyme-linked immunosorbent assay (ELISA) method on the device named "Medispec ESR-200 Microplate Reader" which belongs to "IBM."

Statistical analysis
Kolmogorov-Smirnov normality test was used to analyze the normality of the distribution. Then, the paired sample t test was used for the normal distributions while the Wilcoxon test was used for the non-normal distributions. If one of the two dependent variables showed a normal distribution, the paired sample t test was used in the analysis. The results were reported with 95% confidence interval. The P-value of <.05 was considered significant. All statistical analyses in this study were performed using SPSS 20.0 software program (SPSS Inc., Chicago, IL). Written informed consent was obtained from all participants, and the study was approved by the ethical committee of Erzurum Training and Research Hospital, Turkey (2818/16-154).

Results
Serum cytokine levels, survey records, and physical examinations records were analyzed in 44 patients (26 males, 18 females; mean age: 52 ± 12 years, and age range: 26-73 years). The study participants were heterogeneous for the diagnoses, treatment protocols, and age ranges. Patients with lung cancer (27 cases with 8 small cells, 19 non-small cells; mean age: 57.7 ± 9.7 years, and age range: 35-73 years) were in the majority of the study participants. The other cases (3 males, 14 females; mean age: 47.2 ± 11.2 years, and age range: 26-63 years) were consisted of 11 operated breast cancer, 2 operated gastric carcinoma, 1 operated colon carcinoma, 1 operated ovarian cancer, 1 metastatic gastric carcinoma patient who had neoadjuvant chemotherapy, 1 local advanced gastric, and 1 pancreatic carcinoma. All the operated patients were under adjuvant chemotherapy medication. The demographic and Keskin et al 3 clinical characteristics of the patients can be seen in Table 1. There was no tumor tissue in the lungs of any patient except lung cancer cases (no lung metastasis in any patient).
There were not enough cases to separate into the 5 groups as the patient who takes paclitaxel, docetaxel, gemcitabine, or vinorelbine and the other agents because the diagnoses and the treatment protocols of the patients were quite heterogeneous. Therefore, all the participants were divided into two groups. One of the groups (paclitaxel, docetaxel, gemcitabine, or vinorelbine [PDGV]) included patients who had paclitaxel, docetaxel, gemcitabine, or vinorelbine therapy, which we expect most symptoms and signs would be developed in. The other group of patients were received the chemotherapy drugs other than paclitaxel, docetaxel, gemcitabine, vinorelbine. According to the treatment protocols, there were 21 patients in PDGV treatment group and 23 patients in the other treatment group. More detailed information about the treatment procedures can be seen in more detail in Table 1.
There was no difference in both treatment groups for the sedimentation, serum protein electrophoresis, complement, and immunoglobulin levels. The decreasing of hematocrit was significant in the other treatment group (P = .013) while the hemoglobin levels were not changing (P = .157) in the same group (Table 2). When the symptoms and signs were compared from the baseline to the first-day, regardless of the treatment protocols, there were significant differences between the baseline and the first-day values of the body weight. The increase of the leg circumferences was significant in the other treatment group than the PDGV group. When it was evaluated according to the treatment protocols, the systolic blood pressure was increased (P = .025) after taking the PDGV treatment while the diastolic blood pressure was not changed (P = .331) in the same group (Table 3). According to the PDGV group which was formed with the patients who had the paclitaxel, docetaxel, gemcitabine, and vinorelbine therapy, there was a more significant decrease in serum IL-11 levels after the chemotherapy treatment in the other treatment group (P = .006) ( Table 4). However, there was no significant difference in the VEGF, TNF, and IL-2 levels in the whole study group and the two treatment subgroups (Table 4).
There was no statistical difference in both treatment groups for the weakness, shortness of breath, fever, rash-itch on the skin, voice misery, cough, muscle, and joint pain. However, the skin rash and the hoarseness were appeared in 2 patients in the PDGV group, and in 1 patient in the other treatment group. The shortness of breath was detected in 1 patient in PDGV group and in 4 patients in the other treatment group. Also, after 10-12 hours the chemotherapy, 3 patients who received vinorelbine reported shortness of breath which it took half an hour and spontaneously recovered. It was detected cough in 2 patients who one of them received vinorelbine and the other one received gemcitabine in the PDGV group. The cough was also detected in 4 patients in the other treatment group. When assessed the muscle and joint pain, these symptoms were observed in 2 patients. One of them was in the vinorelbine therapy subgroup of the PDGV group, and the other one was in the other treatment group. They can be seen in Table 3.
It was not found any relation between the cytokine level changes and the chemotherapy response. Also, it was not seen any association between the developing signs and symptoms and the response of the chemotherapy.

Discussion
In the present study, it was investigated the relationship between the serum cytokine levels (VEGF, TNF-α, IL-2, and IL-11) and some symptoms and signs before and after the chemotherapy treatment. It was also investigated whether there is a relationship between the changing of the cytokine levels, symptoms, and signs and the chemotherapy response in these cases. Previous chemotherapy experiences have been shown that patients who were treated with paclitaxel, docetaxel, gemcitabine, or vinorelbine had the symptoms and signs such as a cough, flu-like symptoms, edema, and pain more frequently than the patients who were treated with other chemotherapeutic agents. [15][16][17][18] Based on our clinical observation and the previous chemotherapy experiences, in this study, patients who took the paclitaxel, docetaxel, gemcitabine, or vinorelbine were grouped into one group (PDGV group), and the other chemotherapy protocols were evaluated as "the other group." However, no patients with clinical symptoms and signs of capillary escape syndrome were found in neither group. Since it is known that this syndrome is rarely observed, the symptoms and signs suspected of being similar to the pathophysiology were questioned, but there was also no difference between the groups in terms of symptoms and signs. 15,17,19 Amoura et al 16 , and Kawabe et al 20 evaluated 69 patients with systemic capillary leak syndrome, retrospectively. They detected an elevation of hemoglobin, hematocrit, blood urea nitrogen, creatinine, and monoclonal IgG levels while a decreased of serum total protein and albumin levels without proteinuria, and also the changes in serum complement C3 and C4 levels (increased in some cases, decreased in some other cases). 11,16,20 In addition, Amoura et al 16 reported that 4 out of 13 patients had upper respiratory tract infection history in 2 weeks before receiving the chemotherapy treatment. 16 In our study, it was not questioned whether the participants had any infection before the treatment period. We asked whether there was any infection at that moment. If there was an infection at that moment, the patient was not enrolled in the study. We detected also decrease in hematocrit, especially in the other treatment group. The fell in hematocrit could be based on the serum dilution due to the water retention. Increased the body weight and the leg circumferences were also supporting the water retention hypothesis. It was not found a significant change in other parameters in our study.
The relationship between IL-11 and the prognosis of patients with various cancers have been investigated in several studies. One of them was carried out by Berry et al. 21 They observed that tumor cells which metastasized to bone in patients with breast cancer were more likely to overexpressed IL-11. And this overexpressed IL-11 was a poor prognostic indicator. In our study, there was no significant change in serum IL-11 levels before and after the chemotherapy in PDGV group (P = .821) while there was a significant decrease in the Abbreviations: ALT, alanine aminotransferase; AsT, aspartate aminotransferase; GGT, gamma-glutamyltransferase; pDGV, paclitaxel, docetaxel, gemcitabine, or vinorelbine. p 1 denotes difference before and after the treatment in the pDGV group. p 2 denotes difference before and after the treatment in the other treatment group. a patients who have been administered any of the paclitaxel, docetaxel, gemcitabine, and vinorelbine. b X ± sD: mean ± standard deviation. Med (IQR): median ± interquartile range. c patients who have been administered chemotherapy drugs other than paclitaxel, docetaxel, gemcitabine, and vinorelbine. d P-value < .05 was accepted as statistically significant.
other treatment arm (P = .006). We could not find any relation between the prognosis and levels of IL-11 in both groups in 8 months. This result in our study is thought to be due to the short follow-up period and the low number of cases. As with other cytokines, there was also no correlation between serum IL-11 levels and the symptoms of the patients. Maybe the reason was that 15 of 44 patients (34% of all patients) received adjuvant chemotherapy in our patient group, while the recent Weakness Muscle and joint pain -1 -1 --Abbreviation: pDGV, paclitaxel, docetaxel, gemcitabine, or vinorelbine. p 1 denotes difference before and after the treatment in the pDGV group. p 2 denotes difference before and after the treatment in the other treatment group. no one had the fever, voice misery, and rash-itch on the skin before and after receiving the chemotherapy. a patients who have been administered any of the paclitaxel, docetaxel, gemcitabine, vinorelbine. b X ± sD: mean ± standard deviation. c patients who have been administered chemotherapy drugs other than paclitaxel, docetaxel, gemcitabine, and vinorelbine. d P-value < .05 was accepted as statistically significant. Abbreviations: IL, Interleukin; pDGV, paclitaxel, docetaxel, gemcitabine, or vinorelbine; Tnf, tumor necrosis factor; VEGf, vascular endothelial growth factor. p 1 denotes difference before and after the treatment in the pDGV group. p 2 denotes difference before and after the treatment in the other treatment group. a patients who have been administered any of the paclitaxel, docetaxel, gemcitabine, and vinorelbine. b X ± sD: Mean ± standard deviation. Med (IQR): median ± interquartile range. c patients who have been administered chemotherapy drugs other than paclitaxel, docetaxel, gemcitabine, and vinorelbine. d P-value < .05 was accepted as statistically significant.
No relationship between the serum cytokine levels and the symptoms and signs after the chemotherapy treatments arose from the short serum half-lives of cytokines. 4,30,31 Therefore, we could not catch the peak of serum cytokines levels at the 24th hour of the treatment. We observed "shortness of breath that develops after 12 h of chemotherapy and lasts for about half an hour" in three patients who received vinorelbine in the PDGV group. That can be explained by the short serum halflives of these cytokines. In this respect, for an objective assessment, the serum cytokine levels in those patients may need to be assessed with serum samples taken every 15 min after treatment. It is clear that the application of this working order would not be suitable for a clinical trial on humans.
There was also no correlation between changes in serum cytokine levels, symptoms and signs, and response to the chemotherapy treatment protocols in our study. This result can be dependent on three parameters: the heterogeneous patient group for the cancer types, the malign cell burdens, and the heterogeneous treatment protocols. When it was looked at the previous studies, if a study group was composed of heterogeneously patient groups in terms of these parameters, it was reported that there is no relationship between the changes in serum cytokine levels and these parameters, and vice versa. 32,33 It is seen that the low number of patients was in our study, as well as the heterogeneous patient group for cancer type and treatment protocols. The fairly high standard deviation values of serum VEGF, TNF-α, IL-2, and IL-11 were the most important indicator that patient heterogeneity greatly influenced the results of our study. The reason for the heterogeneity of our patient group was that all patients were chosen randomly at the outpatient and inpatient clinics.
VEGF level in circulation is consisted of VEGF released from tumor tissue, as well as VEGF released from platelets or leukocytes during normal blood clotting. One of the important points to note is that the majority of the previous studies evaluated the VEGF levels in frozen tumor tissue, tumor cytosol, or paraffin embedded tumor tissues [34][35][36][37] not in the serum samples. As can be expected, VEGF level is the higher in the hypoxic tumor tissue and its neighboring tissues than the serum. However, we measured the VEGF levels in serum samples in our study. If a study in which VEGF level was measured in serum sample, similar to our study, the increased in circulating VEGF levels was particularly associated with large tumor burden and metastatic disease. 23,28,29,38 All of the breast cancer patients in our study received adjuvant chemotherapy (VEGFreleasing tumor tissue is theoretically absent). Therefore, it was not surprising that our patients serum VEGF levels were lower than the similar previous studies. 23,28,29,[34][35][36][37][38] There was also no significant changes in serum VEGF levels before and 24 h after the chemotherapy treatment.
When it is looked at the previous publications about the levels of complement and immunoglobulin in cancer patients, the pre-chemotherapy treatment period has been evaluated to find out whether there is a relation between these marker levels and the prognosis. One of the exception of these previous studies, Tsavaris et al 19 evaluated levels of complement and immunoglobulin in 100 colorectal cancer patients at pre and post period of the receiving chemotherapy treatment. They detected increasing IgG and IgM levels before the chemotherapy treatment was correlated with prolonged life-span. 19 In our study, we evaluated the differences in Ig and complement levels before and 24 h after the first cycle of the first chemotherapy treatment. In our study, there was no difference between immunoglobulin and complement levels in pre-chemotherapy and post-chemotherapy treatment periods, either in the lung cancer group or in the other group which includes the patients with breast cancer. In addition, there was no correlation between Ig and complement levels and prognosis. The patient group who had adjuvant chemotherapy treatment (who had no tumor tissue is theoretically) was not considered responsible for this result, because 29 patients (65.9%) who had neoadjuvant treatment had also the same result.
Previous studies have shown that there is a triad becoming of hypotension, hemoconcentration, and serum hypoalbuminemia in the systemic capillary leak syndrome. 4 We did not detect any systemic capillary leak syndrome case in our patient group. After the treatment, we identified some symptoms and signs only. However, we hypothesized that the pathophysiology of the symptoms and signs (generalized edema, hypotension, shortness of breath, fatigue, widespread muscle and joint pain, numbness, and skin rash) can have similar pathophysiology of this syndrome. We look at this aspect, the differences between the results of our study and the previous studies may arose the characteristics of the patient groups (cancer type, treatment protocols, and the tumor burden). [4][5][6] In our study, the systolic blood pressure was increased (P = .032) after taking the treatment in PDGV group while the diastolic blood pressure was not changed (P = .286) in the same group. The albumin level, and serum and urine osmolarity were not changed before and after the treatment in both groups.
In the present study, we could not determined any correlation between the serum cytokine levels, symptoms and signs, chemotherapy response, and chemotherapeutic drugs which is thought to be responsible for capillary leak follow-up the chemotherapy treatment. We also did not detect any systemic capillary leak syndrome because the syndrome is appeared very rare and our case number was low. We did not detect any significant change of the serum IL-2, TNF, and VEGF levels before and after the treatment. The result could be dependent on the small sample size and the short half-life of cytokine. We collected the serum samples before and 24 h after the 8 Biomarkers in Cancer chemotherapy treatment, so we could not catch the peak-time of these cytokines.

Conclusions
The topic is a current topic between the clinicians. These symptoms and life-threatening syndrome is a sudden and unexplained leakage of plasma into the tissues. It can appear in patients who have heart disease, lung disease, kidney disease, and hypothyroidism. It can appear in patients who take a chemotherapy treatment, too. If a chemotherapy treatment contains paclitaxel, docetaxel, gemcitabine, or vinorelbine, these symptoms and signs can occur more often than the chemotherapy treatment not containing these drugs, but the pathophysiology is still not clear. In this study, there was no association between edema, dyspnea, cough, flu-like symptoms, and signs suggesting the cytokine effect associated with the chemotherapy drugs administered. According to the group receiving PDGV treatment, there was a significant decrease in IL-11 levels (P = .006) in the other treatment group, but no correlation was found between the drugs applied and the mentioned symptoms, the chemotherapeutic response, the level of serum TNF, IL-2, L-11, and VEGF. The result could be dependent on the small sample size and the short half-life of cytokine. However, this study can raise awareness about this topic, and it can lead to larger and well-planned studies.