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GM-CSF: biology and appropriate clinical applications

Graham J. Lieschke

Abstract

Granulocyte-macrophage colony stimulating factor (GM-CSF) was one of the first haemopoietic growth factors to be purified, molecularly cloned, and evaluated for clinical use. Recent studies have better defined the usual physiological roles of GM-CSF and better evaluated the efficacy of recombinant GM-CSF to ameliorate the myelotoxicity and infective sequelae of anticancer chemotherapy. GM-CSF-deficient mice were generated by targeted gene disruption in embryonal stem cells. GM-CSF is not physiologically essential for baseline granulopoiesis since GM-CSF-deficient mice have normal blood leukocyte levels and marrow progenitor cell levels. Emergency granulopoiesis has not yet been experimentally evaluated in GM-CSF- deficient mice, but GM-CSF is not essential for haemopoietic reconstitution following myeloablation, and GM-CSF-deficient mice sporadically have elevated granulocyte levels, indicating at least that GM-CSF is not mandatory for emergency granulopoiesis under all circumstances. GM-CSF plays an indispensable role in pulmonary physiology and defences, since GM-CSF-deficient mice develop a lung disease analogous to the human disorder alveolar proteinosis, characterized by accumulation of surfactant phospholipid and proteins, lipid-laden alveolar macrophages, occasional pulmonary bacterial and fungal infections, and peribronchovascular lymphoid hyperplasia. Randomized clinical studies during standard dose anticancer chemotherapy have evaluated the efficacy and safety of several GM-CSF (molgramostim or sargramostim) scheduling approaches: to prevent post-chemotherapy infective events; as a supplementary treatment for established febrile neutropenic events once antibiotic treatment has commenced; and following induction chemotherapy for acute myeloid leukaemia in elderly patients.

Introduction

Granulocyte-macrophage colony stimulating factor (GM-CSF) was purified in 1977,(1) was molecularly cloned in 1984, (2) and was one of the first granulopoietic factors to be available for clinical use. Comprehensive recent reviews cover the molecular and cellular biology of GM-CSF (3) and its initial clinical evaluation. (4) Two areas of recent study about GM-CSF are covered in this discussion: 1) new insights about the usual physiological role of GM-CSF, particularly those revealed by the study of GM-CSF- deficient mice, and 2) data from randomized phase III clinical studies evaluating the efficacy and safety of GM-CSF when it is used following anticancer chemotherapy to ameliorate the neutropenia and associated clinical sequelae.

A. Physiological Roles of GM-CSF

Much of our knowledge about the actions of GM-CSF comes from in vitro studies of its effects to support the proliferation, differentiation, survival and function of cells of the granulocytic and monocyte/macrophage lineages. The capacity of GM-CSF to act in vivo as a regulator of haemopoietic cells in mice was demonstrated by the generation of GM-CSF-transgenic mice, (5) the reconstitution of lethally irradiated mice with marrow cells infected with a recombinant retrovirus overexpressing GM-CSF, (6) and by the administration of pharmacological doses of recombinant GM-CSF protein to mice. (7) However, although such studies demonstrate the capacity of GM-CSF to act in diverse roles as a haemopoietic regulator in vivo, they do not define its usual physiological role. Recently, significant new insights into the physiological roles of GM-CSF in vivo have resulted from the analysis of GM-CSF-deficient mice that we and others generated by disruption of the GM-CSF gene using gene targeting in embryonal stem cells (Table

1). (8,9)

Table 1. Features of GM-CSF-deficient mice (8,9,13-15,17)

Feature

Status in GM-CSF-deficient mice

survival

normal one-year survival

fertility & fecundity

normal

haemopoiesis

blood - normal leukocyte numbers (wide range of neutrophil levels) marrow - normal progenitor cell numbers spleen - increased progenitor cell numbers (possibly infection-related)

lungs

hronic alveolar proteinosis -surfactant lipid and protein accumulation -numerous lipid-laden macrophages -impaired surfactant clearance occasional bacterial and fungal infections rare pulmonary abscess formation

endotoxin tolerance

induced cytokine production

increased

spleen conditioned medium - ØIL-3 plasma after endotoxin - normal TNF-a

Role of GM-CSF in Haemopoiesis A useful distinction can be drawn between baseline and emergency granulopoiesis. Baseline granulopoiesis refers to a steady state when neutrophil production and clearance rates are equal and neutrophil numbers in all compartments are constant. Emergency granulopoiesis refers to scenarios when augmented neutrophil

production is required. Two types of emergency granulopoiesis can be distinguished: 1) “overdrive” emergency granulopoiesis, in which suprabasal levels of neutrophils are generated (such as occurs in a bacterial infection), and 2) “restoring normality” emergency granulopoiesis, in which basal levels of neutrophils are restored from a state of neutrophil depletion (such as occurs following myeloablation due to cytotoxic drug administration). Surprisingly, GM-CSF-deficient mice show no significant perturbation of baseline haemopoiesis: they have normal peripheral blood leukocyte numbers and normal numbers of marrow progenitor cells. (8) This indicates that despite its potent granulopoietic actions in vitro, GM-CSF is not essential for baseline granulocyte or monocyte/macrophage production in vivo. It is either not normally required for this process in vivo or, if it is, its absence can be fully compensated by those factors that remain in its absence. The role of GM-CSF in emergency “overdrive” granulopoiesis has not yet been formally tested in GM-CSF-deficient mice. “Overdrive” granulopoiesis can be evaluated using experimental infection models (we have reported results from such experiments for G-CSF-deficient mice (10) but not yet for GM-CSF-deficient mice). However, baseline neutrophil levels in GM-CSF-deficient mice include sporadic elevated values, (8) which are possibly due to occasional subclinical pulmonary infections in the diseased lungs of these mice, suggesting at least that GM-CSF may not be essential for “overdrive” emergency granulopoiesis in all circumstances. Although the kinetics of leukocyte recovery following myeloablation have not been reported in detail, GM-CSF-deficient mice showed normal reconstitution following lethal irradiation and transplantation of GM-CSF-deficient marrow cells, (9) suggesting that GM-CSF is also not essential for “restoring normality” in emergency granulopoiesis. In contrast, G-CSF-deficient mice have chronic neutropenia, depletion of several subtypes of progenitor cells, and an impaired granulopoietic and monocyte/macrophage response to Listeria monocytogenes infection, (10) which indicates that G-CSF is critically important for granulopoietic homeostasis and demonstrates an important difference between the physiological roles of G-CSF and GM-CSF. Similarly, M-CSF-deficient mice (11) have a deficiency of monocytes and macrophages (12) in contrast to the normal levels of these cells in GM-CSF-deficient mice, (8,13) indicating that M-CSF and GM-CSF have different roles in monocyte/macrophage lineage development.

Other Physiological Roles of GM-CSF Unexpectedly, GM-CSF-deficient mice develop a pulmonary disorder characterized by accumulation of surfactant lipoprotein in alveoli, large numbers of surfactant-laden alveolar macrophages and occasional pulmonary infection, which is analogous to the human disorder alveolar proteinosis. (8,9) Lungs of GM-CSF-deficient mice are morphologically normal at birth, but accumulation of lipoproteinaceous material in pulmonary alveoli is evident by 3 weeks of age. (8,14) Since the accumulation of lipoproteinaceous material can be demonstrated in lungs of GM-CSF-deficient mice in the absence of infection, (8,14) impaired surfactant metabolism is likely to be the primary defect. This presumption is supported by studies showing normal levels of surfactant protein A, B and C mRNA expression (9) and impaired phospholipid clearance in GM- CSF-deficient mice. (15) The lungs of GM-CSF-deficient mice held in a conventional

animal house contain occasional foci of bacterial bronchopneumonia, subclinical foci of fungal pathogens, and, rarely, pulmonary abscesses. (8) Together, these observations define an essential role for GM-CSF in pulmonary physiology and host defences. However, despite their lung disorder, the one-year survival of GM-CSF-deficient mice is normal. (13) Although GM-CSF-gene expression and protein production has been demonstrated in uterine epithelial cells, (16) GM-CSF-deficient mice have apparently normal fertility and fecundity. (8) Hence, GM-CSF is not essential for these processes. Mice unable to make GM-CSF show marked tolerance of the effects of endotoxin; preliminary results of these studies have been reported. (17) When given a non-lethal dose of endotoxin, GM-CSF-deficient mice are protected from its usual effects - acute weight loss, hypothermia and behavioural modification. Interestingly, the acute endotoxin-related leukopenia occurs in GM-CSF-deficient mice, and hence GM-CSF is not essential for this acute haematological response; since endotoxin-treated GM-CSF-deficient mice had comparable serum levels of TNF-a, the protective consequences of GM-CSF deficiency are not mediated directly through this proinflammatory cytokine. It will be interesting to measure the production profiles of other cytokines in endotoxin-treated GM-CSF- deficient mice. By interbreeding GM-CSF-deficient mice with M-CSF (CSF-1)-deficient op/op mice or G-CSF-deficient mice, we generated mice deficient in both GM-CSF and M- CSF, (13) and also mice deficient in both GM-CSF and G-CSF. (18) Mice deficient in G-CSF or M-CSF alone have normal lungs, but mice deficient in these combinations of factors have markedly exacerbated forms of the GM-CSF-deficiency alveolar proteinosis, indicating that although both G-CSF and M-CSF are not themselves critical in pulmonary physiology, they are available for pulmonary host defenses and responsible for ameliorating the severity of lung disease in the face of GM-CSF deficiency. However, the haemopoietic profile of the double-factor-deficient mice resembles that of mice deficient in either G-CSF or M-CSF alone, indicating that even in the absence of each of these factors, GM-CSF is not essential for supporting haemopoiesis. Mice lacking the bc subunit shared by the heterodimeric GM-CSF, interleukin-3 and interleukin-5 receptors show a similar pulmonary disorder, (19,20) confirming that this receptor component is critical for delivering the GM-CSF-signal in physiologically relevant cells. These mice combine features of GM-CSF-deficiency with an additional defect of eosinophil production, which is probably due to absent interleukin-5 signaling since this defect parallels that seen in interleukin-5 deficient mice. (21)

B. Use of GM-CSF to Support Anticancer Chemotherapy

Clinical studies have used three different forms of recombinant human GM-CSF (rhGM-CSF): molgramostim, sargramostim and regramostim, synthesized in bacterial, yeast and mammalian cell expression systems respectively. These different expression systems necessitate or result in minor differences in the final amino acid sequence of the rhGM-CSF and differences in the nature of its glycosylation. (4) However, there are no side-by-side comparisons evaluating whether or not any clinically significant consequences result from these molecular differences. Initial studies defined the pharmacobiology of rhGM-CSF in cancer patients and demonstrated biological activity of

pharmacological doses of rhGM-CSF to accelerate haemopoietic recovery after myeloablative therapy, but did not assess clinical benefits that may accompany this accelerated haemopoietic recovery. To justify the use of rhGM-CSF in patients, it is important to demonstrate that tangible clinical benefits accompany its much more readily measurable effects on haematological parameters. Randomized studies first established the efficacy of rhGM-CSF (sargramostim and molgramostim) to accelerate myeloid recovery and to reduce morbidity following autologous bone marrow transplantation for lymphoid malignancies. (22,23) More recent studies have evaluated various approaches to the use of rhGM-CSF to ameliorate post-chemotherapy myelotoxicity and associated morbidity.

Standard Dose Chemotherapy for Non-Myeloid Malignancies Useful guides to the appropriate use of CSFs with standard-dose cancer

chemotherapy include guidelines from the American Society of Clinical Oncology (24) and

a European Consensus Conference. (25) Several recent reports of randomized studies

provide further information for evaluating the clinical utility of rhGM-CSF for supporting

standard chemotherapy regimens. (This use of rhGM-CSF is distinct from its use in studies evaluating the feasibility of delivering high-dose or other investigative chemotherapy regimens with rhGM-CSF as haematological support.)

Prevention of Post-Chemotherapy Infectious Events with GM-CSF

One approach to rhGM-CSF use with standard dose chemotherapy is to administer

it preventively to all patients receiving chemotherapy in an attempt to reduce the

incidence of post-chemotherapy infectious events or febrile neutropenic episodes. Several randomized studies assessed the efficacy of rhGM-CSF (molgramostim) used in this manner. (26,27)

A randomized double-blind study of subcutaneously administered rhGM-CSF

(molgramostim) compared to placebo in patients undergoing modified COP-BLAM chemotherapy for high-grade lymphoma documented rhGM-CSF to be efficacious at reducing the incidence of infectious events in a subgroup that completed at least 5 or 6 cycles of therapy and > 70% of the planned study drug (68% of enrolled patients). (26)

Infectious events were defined on the basis of physician management practices rather than exclusively on criteria such as the concurrence of fever and neutropenia. However, overall benefit was not demonstrated in an intention-to-treat analysis that included all eligible enrolled patients. Injection site reactions and rash occurred in 51% and 29% of rhGM-CSF-treated patients respectively, and 24% of rhGM-CSFÐtreated patients discontinued rhGM-CSF because of adverse effects. This study indicates that rhGM-CSF is effective compared to placebo in those patients who receive ongoing rhGM-CSF therapy and that, although adverse events accompany rhGM-CSF therapy in some patients, it is tolerated by the majority of patients.

A randomized open-label study of subcutaneous rhGM-CSF (molgramostim)-

treated patients compared to conventionally-supported patients undergoing chemotherapy for relapsed germ cell tumours documented a reduction in infectious complications in the first but not second cycle of therapy. (27) This efficacy analysis was based on an intention- to-treat population. Fatigue, pruritus, rash and injection site reactions were the

commonest rhGM-CSF-related side effects, and 24% of rhGM-CSFÐtreated patients discontinued rhGM-CSF therapy prematurely. The other myelopoietic agent widely used to support standard-dose chemotherapy is rhG-CSF (filgrastim or lenograstim). Randomized studies document the efficacy of rhG-CSF at preventing febrile neutropenia and infectious complications after chemotherapy in patients with small cell lung cancer, (28,29) lymphoma, (30) and inflammatory breast cancer. (31) Most of these studies share a placebo-treated group as a common reference point with the rhGM-CSF studies. However, across-study comparisons may be unreliable, particularly because there are no direct side-by-side randomized comparisons of rhG-CSF and rhGM-CSF in identical patient groups treated with the same chemotherapy regimen. In drawing comparisons between studies, or in relating the results of studies to local clinical practice, study design and analysis issues that should be considered include: (1) the precise definition of primary febrile or infectious endpoints, particularly their objectivity, reproducibility and relationship to local management practices; (2) the comparability of the analyses, particularly whether they were based on an intention-to-treat population or on other subgroups of enrolled patients; (3) the relative magnitude of the clinical benefits, taking account of the myelosuppressive nature of the chemotherapy treatment regimen; (4) the dropout rate and unblinding event rate; and (5) the CSF-related toxicity profile as defined during blinded treatment.

GM-CSF Therapy for Established Post-Chemotherapy Infectious Events An alternative approach to haemopoietic growth factor support of standard chemotherapy regimens is to restrict CSF administration to those patients who develop febrile neutropenic episodes, rather than to administer it with preventive intent to all patients at risk as in the studies discussed above. Two recently reported randomized studies have recruited heterogeneous groups of adult patients with febrile neutropenic episodes after a range of chemotherapy regimens for various malignancies and evaluated the efficacy of rhGM-CSF (molgramostim) as a supplement to conventional antibiotic therapy. One study was an open-label study (32) and the other was double-blinded. (33) Both studies documented accelerated neutrophil recovery with rhGM-CSF therapy. A reduction in the duration of hospitalization was observed in one study. (32) Both studies reported a calculation of the cost impact of rhGM-CSF therapy, but the formulae used for these calculations differed considerably in their complexity. A randomized study of rhGM-CSF (molgramostim) used in this manner in paediatric patients also demonstrated a reduction in the duration of hospitalization. (34) One of these studies (32) compared rhG-CSF (filgrastim) and rhGM-CSF (molgramostim) side-by-side to placebo in the treatment of febrile neutropenia. The primary intent of this study was the comparison of CSF-treated groups with the placebo- treated group, and this was reflected in the statistical design (sample sizes were calculated to have a statistical power of 0.80 [0.05 one-sided significance level] given an expected 30% difference between groups in the primary efficacy endpoint). Also, the open label design used was not an optimal basis for a comparison between rhG-CSF and rhGM-CSF. However, subject to these caveats, no major difference in efficacy or toxicity was observed between the two CSF-treated groups. (32) A separate placebo-controlled study of rhG-CSF (filgrastim) in this clinical setting demonstrated a reduction in the relative risk

of prolonged hospitalization but not a reduction in the duration of hospitalization

overall. (35) Comparisons between studies in this particular clinical setting are significantly complicated not only by the general study design factors mentioned above but also by major differences in the criteria for stopping antibiotics and the policies governing the minimum duration of antibiotic therapy and the timing of hospital discharge.

A double-blind randomized comparison of rhG-CSF (filgrastim) and rhGM-CSF

(sargramostim) in 156 chemotherapy patients has been reported in an abstract,(36) but in this study the CSF therapy was commenced with preventive intent at the onset of neutropenia, rather than at the onset of febrile neutropenia. Hence this study is not exactly analogous to either treatment approach under discussion. Also, although some studies have used rhG-CSF or rhGM-CSF for the treatment of established febrile and/or neutropenic episodes after chemotherapy, results from these studies should not be extrapolated to guide rhG-CSF or rhGM-CSF use to prevent chemotherapy-related infection. This extrapolation is inappropriate because, when a CSF is given to prevent infective episodes, a significant proportion of the CSF treatment occurs before the patient is neutropenic, infected or febrile, and in fact much of the

benefit occurs in patients who do not develop infection or fever whilst neutropenic at all. Hence, those studies that treat only febrile and/or neutropenic patients with CSF therapy evaluate the efficacy and safety of the supplementary CSF therapy for only a small and possibly unrepresentative portion of the total period of CSF exposure experienced by patients treated with preventive intent.

Chemotherapy of Acute Myeloid Leukaemia When myelopoietic factors such as rhGM-CSF are used in acute myeloid leukaemia (AML) patients, the potential stimulatory effects of rhGM-CSF on the myeloid leukemia cells must also be considered. Several randomized studies are now reported in

full that address the efficacy and safety or rhGM-CSF in AML patients, (37,38) and several others reported as abstracts present additional data. (39-41)

In elderly patients with de novo AML, rhGM-CSF (sargramostim) reduced overall

treatment-related toxicity including infectious morbidity, and this translated into a survival advantage for rhGM-CSFÐtreated patients. (37) In this placebo-controlled double- blind study, rhGM-CSF was started three days after cessation of chemotherapy if a marrow aspirate was aplastic without leukaemia. Low-grade skin toxicity was more common in the rhGM-CSF-treated group, but no patients withdrew because of perceived study-drugÐrelated toxicity. The remission rate was not significantly affected by rhGM- CSF therapy, and the relapse rate in complete responding patients was similar whether or not patients had received rhGM-CSF or not. On the basis of such results, rhGM-CSF (sargramostim) is currently widely promoted for use in these patients. Another randomized double-blind placebo-controlled study in elderly patients with de novo AML evaluated the efficacy of rhGM-CSF (molgramostim), which was started the day following cessation of chemotherapy. (38) No difference was seen in treatment-related or infective morbidity or mortality although a statistically significant acceleration of neutrophil was documented. Study-drug treatment was discontinued in a similar proportion of patients in each study arm overall; the reasons were similar in each group except that rash was more common in rhGM-CSF-treated patients.

Although some differences between these two studies can be identified in their design and execution (e.g., different doses of daunorubicin and cytosine arabinoside, different intervals between cessation of chemotherapy and commencing rhGM-CSF, different forms of rhGM-CSF, different rates of study drug discontinuation, different definitions of “elderly”), it is not clear why benefit was documented in one study and not the other. It is improbable that this discrepancy will be clarified with certainty unless a side-by-side comparison were to be undertaken. (A study of rhG-CSF [lenograstim] in elderly AML patients also did not show a survival advantage, despite a higher complete remission rate in the rhG-CSF-treated group. (42) ) The important issues to consider in appraising the studies in this clinical setting have been recently reviewed. (43)

Conclusion

Whereas previously the similarities between GM-CSF and the other granulopoietic factors have received prominent attention, (44) recent work has clarified some distinctions between the granulopoietic factors, both in their basic physiology and in their appropriate clinical use. GM-CSF-deficient mice have led to new insights into the physiological role of GM-CSF and the other granulopoietic factors, permitting reappraisal of their separate and interacting in vivo roles. (45,46) In clinical practice settings such as the haematological support of patients undergoing anticancer chemotherapy with rhGM-CSF, well-designed randomized controlled clinical studies contribute the most helpful data to guide appropriate clinical use.

Acknowledgements

Most of the author’s work with CSF-deficient mice described here was conducted at the Ludwig Institute for Cancer Research (Melbourne Tumour Biology Branch, Victoria, Australia). I thank my collaborators for their ongoing contributions to this work:

Dianne Grail, Cathy Quilici, Sunanda Basu, John Seymour, Mike Marino, George Hodgson, Edouard Stanley and Ashley Dunn. GL is currently a Howard Hughes Medical Institute Postdoctoral Physician Fellow.

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