nterleukin 6 (IL-6) plays a central role in the pathogenesis of Castleman disease (CD), 1 an ultrarare lymphoproliferative disorder. Castleman disease may involve a single lymph node (unicentric) or multiple sites (multicentric). Multicentric CD is associated with excessive release of proinflammatory cytokines, hyperproliferation of immune cells, cutaneous manifestations, ascites, pleural effusions, and can result in multiorgan system impairment. 1,2 Clinical and preclinical models have established a central role for IL-6 in symptomatology of multicentric CD. 1,3 These observations have led to development of antibodies targeting IL-6 and IL-6 receptor (IL-6R). 4 Siltuximab, a chimeric monoclonal antibody against human IL-6, has now been approved in the United States for treatment of CD.Even though IL-6 is a central figure in CD, the mechanisms by which IL-6 mediates the activation of the IL-6/ IL-6R/gp130/JAK1 machinery are not completely understood. The current model proposes that the IL-6-mediated signaling cascade is initiated as 2 IL-6 molecules bind to either 2 membrane-bound IL-6Rs or 2 soluble IL-6Rs (sIL-6R). These receptor-ligand (or soluble receptor-ligand) complexes (acting as agonists) then bind to 2 gp130 signaling subunits to form a complete hexameric complex, to which Janus Kinases (JAKs) are constitutively bound. Through an unidentified mechanism, gp130 homodimerization leads to conformational changes and activation of JAK1, presumably through the release of inhibitory intramolecular interactions (Figure 1). 5 Herein, to our knowledge, we report for the first time genomic characterization of CD, identifying a somatic mutation in JAK1 in a patient with CD who attained a long-term complete remission (CR) after siltuximab treatment and discuss the mechanism by which this alteration may potentiate IL-6 signaling. IMPORTANCE Castleman disease (CD) is an ultrarare, interleukin-6 (IL-6)-driven lymphoproliferative disorder whose underlying molecular alterations are unknown. Siltuximab (anti-IL-6 antibody) is approved for treatment of this disease. To our knowledge, genomic sequencing of CD has not been reported. OBJECTIVE To investigate and identify molecular aberration(s) that help explain the exceptional response to siltuximab in a patient with cutaneous CD.
DESIGN, SETTING, AND PARTICIPANTSThis case study examines data from comprehensive genomic profiling (using targeted next-generation sequencing) of tissue from a patient with cutaneous CD who demonstrated an exceptional response to siltuximab treated at a National Cancer Institute-designated Comprehensive Cancer Center.INTERVENTIONS Intravenous siltuximab 12 mg/kg every 3 weeks. Tissue from the patient was interrogated by next-generation sequencing (405 genes). Serum was evaluated for IL-6 levels by enzyme-linked immunoassay.MAIN OUTCOMES AND MEASURES Identification of pretreatment serum IL-6 levels and somatic variants that may explain the exceptional response to siltuximab in this patient with cutaneous CD.RESULTS Patient pretreatment serum I...