Lung (2012) 190:327–332
DOI 10.1007/s00408-011-9364-6
RESPIRATORY SYSTEM MALIGNANCY
Adipokines and Systemic Inflammation in Weight-Losing Lung
Cancer Patients
Sule T. Gulen • Fisun Karadag • Aslihan B. Karul •
Naciye Kilicarslan • Emel Ceylan • Nilgun K. Kuman •
Orhan Cildag
Received: 3 October 2011 / Accepted: 22 December 2011 / Published online: 14 January 2012
Ó Springer Science+Business Media, LLC 2012
Abstract
Background Cancer cachexia is a devastating condition
leading to loss of function and independence, decreased per-
formance status, decreased quality of life, and poor prognosis.
Adipokines play a role in a wide variety of physiological or
pathological processes, including immunity and inflamma-
tion, in addition to having significant effects on metabolism
and lipogenesis. The objective of the present study was to
investigate the relationship of adipokines and systemic
inflammation in weight-losing advanced-stage non-small-cell
lung cancer (NSCLC) patients.
Methods Sixty-three male NSCLC patients (stages III and
IV) and 25 age- and sex-matched controls were included.
NSCLC patients were further divided into subgroups as those
with a [ 5% weight loss in last 6 months and those who did
not. Serum leptin, adiponectin, and TNF-a concentrations
were measured by ELISA using commercially available kits.
Results The positive acute-phase reactants (APR) CRP,
leukocyte, ferritin, thrombocyte, and fibrinogen were higher in
the NSCLC group. Serum albumin level (which is a negative
APR) was lower in the cancer group, whereas there was no
difference in transferrin level between the groups. TNF-a and
leptin concentrations were similar in the cancer group and the
S. T. Gulen
F. Karadag (&)
E. Ceylan
O. Cildag
Department of Chest Diseases, School of Medicine,
Adnan Menderes University, 09100 Aydin, Turkey
e-mail: fisunkaradag@yahoo.com
A. B. Karul
N. Kilicarslan
Department of Biochemistry, School of Medicine,
Adnan Menderes University, Aydin, Turkey
N. K. Kuman
Department of Thoracic Surgery, School of Medicine,
Adnan Menderes University, Aydin, Turkey
control group, whereas adiponectin was lower in the cancer
group. There was a difference in thrombocyte and transferrin
levels between patients with and without weight loss, whereas
CRP, TNF-a, and adiponectin levels were similar. Leptin was
lower in weight-losing cancer patients. However, there was no
correlation between adipokines and markers of systemic
inflammation.
Conclusion These results revealed a lack of association
between adipokine levels and systemic inflammation with
cancer cachexia.
Keywords Adipokines
Lung cancer
Systemic
inflammation
Weight loss
Introduction
Cancer cachexia is a devastating condition leading to loss
of function and independence, decreased performance
status, decreased quality of life, and poor prognosis and
may account for up to 20% of cancer deaths [1, 2]. The
exact mechanisms of cancer cachexia remain unclear but
are almost certainly multifactorial. To a large degree
development of cancer cachexia is related to a chronic,
low-grade, tumor-induced activation of the host’s immune
system. The systemic inflammatory response, as evidenced
by elevated circulating concentrations of APP, including
C-reactive protein (CRP), and cytokines, including tumor
necrosis factor alpha (TNF-a), is shown to be an important
factor in the progressive nutritional decline of these
patients and is a poor prognostic factor independent of
stage, performance status, and treatment [2, 3].
White adipose tissue (WAT) is currently considered an
endocrine organ that is an active contributor to body
homeostasis rather than just being a fat depot, producing
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more than 50 cytokines and other molecules [4]. These
adipokines play a role in a wide variety of physiological or
pathological processes, including immunity and inflam-
mation, in addition to having significant effects on
metabolism and lipogenesis [5].
Leptin, the product of the ob gene, is a protein syn-
thesized and secreted mainly by WAT in proportion to fat
stores, and it is considered an adipokine that belongs to
the class I cytokine superfamily [4, 6]. It decreases food
intake and increases energy consumption by inducing
anorexigenic factors and suppressing orexigenic neuro-
peptides [4]. Leptin production is regulated mainly by
food intake; fasting reduces leptin levels while food
consumption is associated with a transient increase in ob
gene expression [6]. However, leptin levels can be influ-
enced by other factors as well. Leptin expression is
upregulated by various proinflammatory cytokines,
including TNF-a, IL-1, and IL-6 [7]. However, in contrast
to acute stimulation of the inflammatory system, chronic
inflammation causes a reduction in leptin levels [8].
Leptin has emerged in the literature as a multifunctional
hormone with versatile activities and complex counter-
actions with other cytokines and adipokines [6]. A
remarkable aspect of the effects of leptin on the immune
system is its action as a proinflammatory cytokine itself.
Leptin can therefore be described as a cytokine-like
hormone with pleiotropic actions [4].
Adiponectin, a protein produced largely by WAT,
increases fatty acid oxidation and reduces the synthesis of
glucose in the liver and its serum level is associated with
body mass index (BMI) and insulin resistance [4]. In
addition to its role in protection against obesity and
obesity-related disorders, adiponectin has a wide range of
effects in pathologies with inflammatory components.
Adiponectin exerts relevant actions on innate and adaptive
immunity and its secretion is inhibited by proinflamma-
tory cytokines such as IL-6 and TNF-a [9]. The objective
of the present study was to investigate the relationship of
adipokines and systemic inflammation in weight-losing
advanced-stage non-small-cell lung cancer patients.
Methods
Subjects
Sixty-three male lung cancer patients (age range = 52–84
years) were admitted to the study consecutively. All patients
were histopathologically confirmed to have NSCLC. None of
the patients had undergone surgical resection or had received
chemotherapy or radiotherapy at the time of sampling.
NSCLC patients were further divided into subgroups as those
with a [ 5% weight loss in preceding 6 months (n = 33) and
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Lung (2012) 190:327–332
those who had not (n = 30). Twenty-five male volunteers,
participants at the Chest Diseases Outpatients Clinic, in the
same age range were admitted as the control group. Both
patients and controls with comorbidities that affect weight
maintenance (diabetes, thyroid dysfunction, alcoholism,
malabsorption, renal, and hepatic diseases) or that lead to
systemic inflammation (infection, heart failure, collagen
vascular diseases) and those who did not have precise infor-
mation on his body weight status in the preceding 6 months
were excluded from the study.
Staging of the NSCLC patients was established by
clinical findings, chest X-ray, bronchoscopy, thorax CT,
brain MR, and PET-CT on the basis of the latest TNM
staging system [10]. BMI was calculated as weight/height2
(kg/m2). The study was approved by the institutional ethics
committee and all subjects gave written consent to
participate.
Measurement of Acute-Phase Reactants, Cytokine,
and Adipokines
Fasting blood samples were collected for routine laboratory
analysis of acute-phase reactants (APR) between 8 and 10 a.m.
Another blood sample was taken and centrifuged at
4,0009g for 7 min at room temperature. The samples were
stored in aliquots at -80°C until analysis. Serum leptin
(pg/ml) and adiponectin (ng/ml) concentrations were mea-
sured by solid-phase sandwich enzyme-linked immunosor-
bent assay (ELISA) using Bender MedSystems Human Leptin
kit (No. BMS2039INST; Vienna, Austria) and BioVendor
Human Adiponectin kit (No. RD191023100, Candler, NC,
USA) according to the manufacturers’ instructions. Serum
TNF-a concentration (pg/ml) was also measured by ELISA
using a Bender MedSystems Human TNF-a kit (No.
BMS223INSTCE). Serum CRP concentration (mg/L) was
measured by a commercially available kit using the turbidi-
metric method (Prestige 24i, kit No. 81067HWOO, Tokyo
Boeiki, Tokyo, Japan).
Statistical Analysis
Statistical tests were done with the SPSS software program
(SPSS, Inc., Chicago, IL, USA). Results are given as
mean ± SD. Correlations between parameters were evalu-
ated using Pearson’s rank correlation analysis. Nonparametric
data of the study groups were compared by Mann–Whitney
U test. A significance level of P = 0.05 was used.
Results
Demographic data of the study groups and tumor charac-
teristics of NSCLC patients admitted to the study are given
Lung (2012) 190:327–332 329

in Table 1. The study groups were age- and sex-matched; Serum leptin, adiponectin, CRP, and TNF-a concentra-
they were all male and the mean age was 65.63 ± tions of the study groups are given in Table 2. Adiponectin
9.87 years for the NSCLC group and 63.52 ± 11.54 for the concentrations were significantly lower in lung cancer
control group. Thirty-three (52.4%) NSCLC patients had patients compared to controls (P = 0.020), whereas leptin
weight loss in preceding 6 months. BMI of the NSCLC (P = 0.528) and TNF-a concentrations were similar in the
group was lower than that of the controls (P = 0.026). The cancer group and the control group (P = 0.063).
smoking history of the groups was similar (P = 0.079). There were 33 NSCLC patients (52.4%) who had lost
Forty-three percent of NSCLC patients were classified as weight in the 6 months before entry into the study. The
stage III and 57% as stage IV. comparison of leptin, adiponectin, CRP, and TNF-a concen-
The positive APR CRP, leukocyte, ferritin, thrombo- trations in patients with and without weight loss are given in
cyte, and fibrinogen were higher in the NSCLC group. Table 3. Serum leptin concentration was found to be lower in
Serum albumin (which is a negative APR) was lower in the the weight-losing group (P = 0.006). Adiponectin and CRP
cancer group, whereas there was no difference in trans- concentrations were higher in weight-losing group but the
ferrin level between the groups. There were differences in difference was not statistically significant (P = 0.700 and
thrombocyte and transferrin levels between patients with P = 0.242, respectively). TNF-a concentrations were similar
and without weight loss (Tables 2, 3). in both subgroups (P = 0.094).
In correlation tests, CRP was correlated with transferrin
(r = -0.499, P \ 0.001), ferritin (r = 0.390, P = 0.004),
thrombocyte (r = 0.295, P = 0.019), and fibrinogen (r =
0.523, P \ 0.001) in NCSLC patients. There was a positive
Table 1 Demographic data of study groups and tumor characteristics correlation between leptin and BMI in NSCLC patients
of NSCLC patients (r = 0.473, P = 0.001). However, there was no correlation
NSCLC Controls P between adipokines and markers of systemic inflammation
(n = 63) (n = 25) (APR and TNF-a) (P [ 0.05 for all).
Age (years) 65.63 ± 9.87 63.52 ± 11.54 0.063
Gender M/F (%) 100 100 –
Discussion
Smoking 63.84 ± 30.29 60.72 ± 27.34 0.079
(pack-years)
Weight loss, n (%) 33 (52.4) 0 – Cancer is a systemic inflammation where multiple cyto-
BMI (kg/m ) 2
23.51 ± 4.58 27.76 ± 3.90 0.026
kines are involved. Systemic inflammation is driven by
Stage, n (%)
proinflammatory cytokines, which exert their role on
IIIa–IIIb 27 (43%) – –
catabolism, gluconeogenesis, and acute-phase protein pro-
duction [1]. Although these cytokines have a protective
IVa–IVb 36 (57%)
role in the first steps of inflammation, the unlimited con-
Data are mean ± SD tinuation of inflammation has deleterious effects resulting
NSCLC non-small-cell lung carcinoma, BMI body mass index in poor outcome in advanced cancer [1, 11].

Table 2 Acute-phase reactants,

NSCLC patients (n = 63) Controls (n = 25) P
cytokine, and adipokines in
NSCLC patients and controls Acute phase reactants
CRP (mg/l) 44.57 ± 36.09 6.10 ± 14.94 \0.001
Leucocyte (mkrL) 9815.87 ± 3166.67 8442.86 ± 1923.95 0.042
Thrombocyte (mkrL) 368936.51 ± 134528.43 243952.38 ± 104813.39 \0.001
Ferritin (ng/ml) 252.59 ± 212.40 110.31 ± 86.22 0.009
Fibrinogen (mg/dl) 436.13 ± 158.64 240.00 ± 93.26 \0.001
Albumin (g/dl) 4.26 ± 0.49 4.68 ± 0.41 \0.001
Transferrin (lg/dl) 178.71 ± 51.06 190.00 ± 38.21 0.339
Values are mean ± SD Cytokine and adipokines
NSCLC non-small-cell lung TNF-a (pg/ml) 5.50 ± 2.19 5.63 ± 1.54 0.063
carcinoma, CRP C-reactive Leptin (pg/ml) 187.46 ± 98.14 186.97 ± 66.95 0.528
protein, TNF-a tumor necrosis Adiponectin (ng/ml) 51.70 ± 24.43 68.20 ± 29.82 0.020
factor a

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Table 3 Acute-phase reactants,
NSCLC patients with
cytokine, and adipokines in
weight loss (n = 33)
NSCLC patients with or without
weight loss Acute-phase reactants
CRP (mg/l)
Leucocyte (mkrL)
Thrombocyte (mkrL) 405515.15 ± 144739.66
Ferritin (ng/ml)
Fibrinogen (mg/dl)
Albumin (g/dl)
Transferrin (lg/dl)
Values are mean ± SD Cytokine and adipokines
NSCLC non-small-cell lung TNF-a (pg/ml)
carcinoma, CRP C-reactive Leptin (pg/ml)
protein, TNF-a tumor necrosis Adiponectin (ng/ml)
factor a
Adipokines exert significant effects on metabolism and
lipogenesis as well as in regulation of human inflammatory
responses. Leptin suppresses food intake and stimulates
energy expenditure, while serum levels of adiponectin and
resistin are associated with BMI and insulin resistance [4,
5]. Moreover, they participate in the systemic inflammatory
response with strong reciprocal influences on other cyto-
kines like TNF-a, IL-10, and IL-6, regulating in this way
systemic inflammatory response and cell proliferation,
differentiation, and migration [4–9].
Besides systemic inflammation, advanced cancer is
associated with weight loss [12]. Cancer cachexia is a
complex metabolic status not very well elucidated.
Decreased food intake, hypermetabolism, and acute-phase
response with metabolic disturbances partly due to host and
tumor-derived substances, including various cytokines, and
are considered important wasting factors leading to loss of
skeletal mass and adipose tissue [11, 13]. Although adi-
pokines are strongly associated with BMI, their role in this
complicated situation is not clear.
Whether leptin acts as an acute-phase reactant leading to
anorexia and malnutrition, or if it is only a simple marker of fat
mass in cancer-associated malnutrition is not clear. Leptin
concentrations are increased during cytokine-induced
inflammatory response in sepsis patients, suggesting that
raised leptin levels may be related to anorexia [14]. However,
in many chronic diseases leading to cachexia, in which there is
also an inflammatory status caused by raised proinflammatory
cytokines, serum leptin levels are decreased. This is the case of
wasting associated with chronic obstructive pulmonary dis-
ease and chronic heart failure cachexia in which, despite an
increase in TNF-a and IL-1 levels, there are low leptin levels
that have a relationship with decreased fat mass [15, 16]. The
reasons for this are still unclear, but probably the effects of
acute inflammation differ from those of chronic inflammation.
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Lung (2012) 190:327–332
NSCLC patients without P
weight loss (n = 30)
48.60 ± 36.35 40.13 ± 35.89 0.242
10136.36 ± 3611.6 9463.33 ± 2607.74 0.685
328700.00 ± 111256.20 0.027
280.69 ± 243.55 214.27 ± 158.05 0.379
430.13 ± 136.43 443.65 ± 184.53 0.829
4.25 ± 0.45 4.28 ± 0.54 0.060
162.33 ± 53.02 197.13 ± 42.71 0.015
5.08 ± 1.27 5.95 ± 2.84 0.094
146.60 ± 84.36 217.73 ± 97.99 0.006
53.25 ± 28.56 50.00 ± 19.24 0.700
In the present study we investigated the relationship of
adipokines and systemic inflammation in advanced-stage
NSCLC patients. Most studies have reported lower leptin
and adiponectin levels in cancer patients than in healthy
controls [17–19]. We also found lower serum adiponectin
levels in our NSCLC patients, whereas leptin levels were
similar in lung cancer cases and healthy volunteers.
We also examined the role of adipokines in cancer-asso-
ciated weight loss. Serum leptin concentration was decreased
in weight-losing cancer patients and had no correlation with
inflammatory markers. Our results do not support the
hypothesis that high serum leptin levels, produced by an
intense acute-phase reaction, were involved in anorexia and
cachexia associated with cancer. In response to weight loss,
adiponectin levels are expected to increase. Serum adipo-
nectin concentration of our weight-losing patients was
increased but the difference with that of the controls did not
reach statistical significance. Adipokines are regulated mainly
by changes in adipose tissue. Unlike starvation and other
cachectic states, cancer cachexia is often characterized by
preferential loss of skeletal mass rather than adipose tissue
[20]. Thus, the lack of association between adipokine levels
and weight loss may simply reflect the preservation of adipose
tissue. Another explanation may be their neutralization or
inhibition of secretion due to unknown interactions with other
proinflammatory cytokines. As a matter of fact, some studies
describe the inhibition of adiponectin production due to ele-
vated levels of other cytokines, including TNF-a [9, 21].
Similar to our results, lower serum leptin levels were
reported in cachectic lung cancer patients [19, 22, 23].
Published data suggested that leptin does not play an
important role in cancer cachexia development and chan-
ges of serum leptin concentration should rather be regarded
as a result of cachexia rather than being the cause of it
because its concentration depends on the total body fat
Lung (2012) 190:327–332
mass [18]. We also found a positive correlation between
leptin and BMI in NSCLC patients, as reported in previous
studies, which is compatible with normal functioning of the
afferent loop of the leptin feedback mechanism. In fact, a
decrease in leptin concentration should increase the appe-
tite and decrease energy utilization, resulting in increased
fat stores. However, this is not the case in cancer patients,
which may suggest a block in the hypothalamic response to
low circulating leptin concentrations.
Jamieson et al. [23] examined the relationship between
adiponectin and the systemic inflammatory response in
weight-losing patients with non-small-cell lung cancer.
Compared with the controls, the cancer group had a lower
BMI and circulating concentrations of albumin, free and total
leptin, and adiponectin. In contrast, the cancer group had
elevated circulating concentrations of IL-6 and CRP con-
centrations. However, weight loss, IL-6, or CRP concentra-
tions were not correlated with either adiponectin or free and
total leptin concentrations in the cancer group. They con-
cluded that adipokine production is normal and is unlikely to
play a major role in the abnormal fat metabolism in weight-
losing cancer patients. Likewise, in the present study, the
cancer group had lower BMI and circulating concentrations of
albumin and adiponectin. However, the systemic inflamma-
tory response, as evidenced by an increase in circulating
concentrations of acute-phase proteins (CRP, leucocyte, fer-
ritin, thrombocyte, and fibrinogen) was not accompanied by
an increase in leptin or adiponectin concentrations. Besides,
we could not find any correlation between adipokines and
markers of systemic inflammation, indicating the lack of
adipose tissue participation in generalized inflammation and
weight loss of NSCLC patients.
Conclusion
Our study revealed that leptin and adiponectin are neither
major contributors to weight loss nor related to cancer-
related systemic inflammatory response in patients with
advanced lung cancer. Whether leptin remains low in
weight-losing cancer patients as a compensatory mecha-
nism to preserve body fat content should be assessed in
further studies.
Acknowledgment The study was funded by the Adnan Menderes
University Research Foundation.
Conflict of interest None.
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