Granulocyte-colony stimulating factor-associated aortitis in cancer: A systematic literature review

Aortitis after switching short-acting granulocyte colony-stimulating factors in a lymphoma patient with HLA-B52

Aortitis is a rare adverse event of granulocyte colony-stimulating factor (G-CSF) treatment. Several previous studies have described recurrent aortitis caused by re-administration of the same G-CSF. However, no previous studies have examined the safety of switching between short-acting G-CSFs in patients who develop aortitis. We report the case of a 55-year-old man with refractory diffuse large B-cell lymphoma, who developed G-CSF-associated aortitis. The aortitis was triggered by filgrastim and recurred after treatment with lenograstim. The patient possessed human leukocyte antigen B52, which has been implicated in Takayasu arteritis. In addition, a drug-induced lymphocyte stimulation test for lenograstim performed upon detection of recurrent G-CSF-associated aortitis produced a positive result. Our case suggests that switching from one short-acting G-CSF to another does not prevent recurrence of G-CSF-associated aortitis. Although the etiology of G-CSF-associated aortitis has not been fully elucidated, our case also suggests that some patients may be genetically predisposed to aortitis.

Granulocyte-Colony Stimulating Factor (G-CSF)-Induced Aortitis: A Case Report

Pegylated granulocyte colony-stimulating factor (G-CSF), commonly used in chemotherapy-induced neutropenia, has been associated with rare instances of aortitis. This study describes a 67-year-old female patient with estrogen receptor (ER)-positive, human epidermal growth factor receptor-2-positive breast cancer, undergoing chemotherapy with an epirubicin/cyclophosphamide (EC) regimen (epirubicin, cyclophosphamide) and pegylated G-CSF for neutropenia prophylaxis. Post-treatment, she developed symptoms including intermittent fever and severe arthralgia. Laboratory tests revealed an elevated white blood cell count, C-reactive protein levels, and erythrocyte sedimentation rate, while a computed tomography scan showed thickening in the aortic arch and descending aorta. Given the clinical presentation and exclusion of other potential causes, pegylated G-CSF-induced aortitis was suspected. The patient's symptoms improved significantly following the cessation of pegylated G-CSF, aiding in the differentiation from other types of aortitis. This study highlights the importance of considering pegylated G-CSF as a potential cause of aortitis in patients presenting with unexplained symptoms of fever and inflammation after chemotherapy. The rapid improvement upon discontinuation of the drug is a key feature distinguishing it from other aortitis causes. In conclusion, while rare, aortitis should be considered in the differential diagnosis of patients treated with pegylated G-CSF who exhibit relevant clinical symptoms. Early detection and management, including the discontinuation of the causative agent, are crucial for patient recovery and prognosis.

Large-vessel vasculitis induced by pegfilgrastim and immune checkpoint inhibitor in a patient with small-cell lung cancer

A 75-year-old woman with stage IVB (cT3N3M1c) extensive disease small-cell lung cancer was treated with carboplatin, etoposide, and atezolizumab. Ten days after pegfilgrastim initiation, during the second chemotherapy cycle, she experienced back pain. Contrast-enhanced computed tomography revealed soft tissue thickening around the descending aorta and brachiocephalic artery. She was diagnosed with atezolizumab and pegfilgrastim-induced large-vessel vasculitis (LVV) and was treated with prednisolone, which was tapered and discontinued after 14 weeks, with no symptom recurrence. LVV should be included in the differential diagnosis of patients with nonspecific body pain when pegfilgrastim and immune checkpoint inhibitors are used in combination.

Comparison of 18 F-FDG PET Findings of Pegfilgrastim-Induced Aortitis With Other Types of Large-Vessel Vasculitis : A Retrospective Observational Study

PURPOSE OF THE REPORT

To elucidate the PET/CT findings of pegfilgrastim-induced aortitis (PFIA) and compare them with those of other large-vessel vasculitis.

METHODS

We enrolled 45 patients diagnosed with the following: PFIA, n = 8; Takayasu arteritis (TA), n = 12; giant cell arteritis (GCA), n = 6; and immunoglobulin G4-related aortitis (IgG4-A), n = 19. Records of PET/CT performed before treatment initiation were collected. The aorta and its branches were divided into 16 anatomic regions. Presence of abnormal 18 F-FDG uptake in each region was determined and measured.

RESULTS

The 18 F-FDG-positive areas of PFIA were distributed in the regions of the ascending aorta to the suprarenal abdominal aorta, cervical branches of the aorta, and external iliac arteries, similar to those of TA. However, TA had a higher proportion of 18 F-FDG-positive areas than PFIA in almost all anatomic regions. These areas of GCA were widespread throughout the entire aorta and the upper and lower limbs, whereas those of IgG4-A were observed from the abdominal aorta to iliac arteries. SUV max , SUV peak , metabolic volume, and total lesion glycolysis were higher in GCA than in PFIA, TA, and IgG4-A.

CONCLUSIONS

Pegfilgrastim-induced aortitis distribution on PET/CT was frequently observed in the aorta, cervical branches, and extra iliac arteries. The low proportion of 18 F-FDG-positive areas in PFIA was different from that of TA, GCA, and IgG4-A. These findings may help identify and differentiate various aortitis types in clinical practice.

Granulocyte Colony-stimulating Factor-associated Aortitis on Gallium Scintigraphy

Aortitis is a rare adverse event associated with granulocyte colony-stimulating factor (G-CSF). Contrast-enhanced computed tomography (CECT) is widely used to diagnose G-CSF-associated aortitis. However, the usefulness of gallium scintigraphy for the diagnosis of G-CSF-associated aortitis is unknown. We herein report a set of pre- and post-treatment gallium scintigrams of a patient with G-CSF-associated aortitis. During the diagnosis, gallium scintigraphy revealed hot spots on the arterial walls that appeared inflamed on CECT. Both the CECT and gallium scintigraphy findings disappeared. Gallium scintigraphy can be a supportive diagnostic tool for G-CSF-associated aortitis, especially in patients with an impaired renal function or allergy to iodine contrast.

Spectrum of Large- and Medium-Vessel Vasculitis in Adults: Neoplastic, Infectious, Drug-Induced, Autoinflammatory, and Primary Immunodeficiency Diseases

PURPOSE OF REVIEW

To provide a comprehensive review of drugs and neoplastic, infectious, autoinflammatory, and immunodeficiency diseases causing medium- to large-vessel vasculitis in adults with emphasis on information essential for the initial diagnostic process.

RECENT FINDINGS

Entities with medium- to large-vessel vasculitis as clinical manifestations have been described recently (e.g., adenosine deaminase-2 deficiency, VEXAS-Syndrome), and vasculitis in established autoinflammatory or immunodeficiency diseases is increasingly being identified. In the diagnostic process of medium- to large-vessel vasculitis in adults, a large variety of rare diseases should be included in the differential diagnosis, especially if diagnosis is made without histologic confirmation and in younger patients. Although these disorders should be considered, they will undoubtedly remain rare in daily practice.

Single-Center Analysis of Pegfilgrastim-induced Aortitis Using a Drug Prescription Database and CT Findings

Background Pegfilgrastim-induced aortitis is a rare but serious adverse event in patients undergoing anticancer therapy with granulocyte colony-stimulating factor analogs. Despite previous case series and systemic reviews, the exact incidence, clinical presentation, and CT manifestations of pegfilgrastim-induced aortitis remain unclear. Purpose To clarify the incidence and clinicoradiologic characteristics of pegfilgrastim-induced aortitis. Materials and Methods Pegfilgrastim administration records from January 2015 to March 2021 were retrospectively collected from the drug prescription database of a single center and were matched with the relevant findings in the CT database. Corresponding CT images within 6 months were available for a total of 1462 doses of pegfilgrastim in 674 patients. Four radiologists reviewed the CT images for the presence of aortitis in two steps. Clinical information and the distribution of aortitis on CT images were examined for patients with a diagnosis of pegfilgrastim-induced aortitis. Results Pegfilgrastim-induced aortitis was observed in 18 of 674 patients (mean age, 62 years ± 13 [SD]; 424 men), resulting in incidence rates of 2.7% per patient (95% CI: 1.6, 4.2) and 1.2% per dose (95% CI: 0.7, 1.9). The most common original primary malignancies were esophageal cancer (n = 10, 9%), breast cancer (n = 3, 4%), and pancreatic cancer (n = 2, 2%). The most common anticancer drugs used at onset were 5-fluorouracil, cisplatin, and docetaxel. Seven cases were symptomatic, while the remaining 11 (61%) were asymptomatic. CT findings indicated that aortitis involved branches of the aortic arch in 13 cases (72%), aortic arch in 10 cases (56%), and abdominal aorta in two cases (11%). Conclusion Pegfilgrastim-induced aortitis may be more prevalent than previously reported and may be more common in patients with esophageal cancer and those who received 5-fluorouracil, cisplatin, and docetaxel as anticancer drugs. The findings also suggest that pegfilgrastim-induced aortitis is often characterized by aortic arch and proximal branch involvement at CT. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Krinsky in this issue.

Aortitis and aortic dissection after administration of pegfilgrastim during adjuvant chemotherapy for early breast cancer

A 70 year-old woman on adjuvant chemotherapy for breast cancer developed acute aortitis after receiving pegfilgrastim. 12 days after pegfilgrastim administration, she presented to our hospital with fever and shoulder pain. White blood cell count and C-reactive protein were elevated. As the computed tomography scan revealed thickening of the walls of the aortic arch and surrounding arteries, we suspected granulocyte colony-stimulating factor-related aortitis. Although steroid treatment administered once improved the general condition, her symptoms and C-reactive protein worsened again. On increasing the steroid dose, her general condition recovered rapidly. On day 85, Stanford type A aortic dissection was incidentally detected by a follow-up computed tomography scan. Physicians should recognize these adverse events of filgrastim.

Combination regimen of granulocyte colony-stimulating factor and recombinant human thrombopoietin improves the curative effect on elderly patients with leukemia through inducing pyroptosis and ferroptosis of leukemia cells

Leukemia ranks as the one of most common causes of death from tumor. 51.4% of patients with leukemia are over 65 years old. However, the median overall survival (OS) of elderly leukemia patients is less than one year. It is urgent to explore more effective treatments for elderly patients with leukemia. Our recent prospective phase II single-arm study has revealed that combination regimen of granulocyte colony-stimulating factor (G-CSF) and recombinant human thrombopoietin (rhTPO) could improve the curative effect on elderly patients with leukemia, yet the precise mechanism remains unknown. This study demonstrated that combination of G-CSF and rhTPO showed greater effect on suppressing leukemia growth than G-CSF or rhTPO alone in vitro and in vivo. Mechanistically, G-CSF induced pyroptosis through ELANE in leukemia cells. Besides, rhTPO triggered ferroptosis by EP300 in leukemia cells. Moreover, rhTPO suppressed glutathione peroxidase 4 (GPX4) expression to induce ferroptosis through blocking the interaction between EP300 and GPX4 gene promoter via associating with EP300. In summary, this study illuminated that combination regimen of G-CSF and rhTPO improved the curative effect on elderly patients with leukemia through inducing pyroptosis and ferroptosis of leukemia cells. Therefore, our results provided a theoretical basis for combination regimen of G-CSF and rhTPO treating leukemia and potential therapeutic targets for leukemia.