Continuous infusion or subcutaneous injection of granulocyte-macrophage colony-stimulating factor: increased efficacy and reduced toxicity when given subcutaneously

The role of colony-stimulating factors and granulocyte transfusion in treatment options for neutropenia in children with cancer

Children with cancer receiving anticancer therapy always experience neutropenia, and as a result often develop serious neutropenic infections that cause morbidity and/or mortality. Intensive chemotherapy with improved supportive care for neutropenia contribute to the recent advances in treatment outcome in children with cancer. Recombinant human granulocyte colony-stimulating factor (G-CSF) and recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) can shorten the duration and decrease the severity of neutropenia, and thus support intensive chemotherapy. Both G-CSF and GM-CSF stimulate proliferation and maturation of myeloid progenitor cells and are thus used to help mobilization of peripheral blood progenitor cells, and after stem-cell transplantation. The American Society of Clinical Oncology 2000 Guidelines recommended that colony-stimulating factors (CSFs) can be administered as a primary prophylaxis with a chemotherapy regimen if previous experiences with chemotherapy regimens have shown that the incidence of febrile neutropenia (neutropenic fever) is > or =40%. The routine use of CSFs for secondary prophylaxis or for patients with afebrile neutropenia is not recommended in order to avoid the overuse of CSFs. The use of a CSF may be considered in children with febrile neutropenia with a neutrophil count <100/microL, uncontrolled primary disease, pneumonia, hypotension, multiorgan dysfunction (sepsis syndrome), or invasive fungal infection. Although these guidelines are generally applicable to children with cancer, further studies on CSFs are certainly needed in pediatric oncology. The recent advances in granulocyte collection, using healthy volunteer donor stimulation with G-CSF and/or dexamethasone to yield large numbers of granulocytes has made granulocyte transfusion a more realistic option. Granulocyte transfusion has shown promising results in treating children with severe neutropenic infection; however, controlled trials are warranted to clarify the efficacy and cost-effectiveness of this procedure.

Intra-arterial infusion of 5-fluorouracil plus granulocyte-macrophage colony-stimulating factor (GM-CSF) and chemoembolization with melphalan in the treatment of disseminated colorectal liver metastases

AIMS

We compared two prospective trials of intra-arterial cytokine/chemotherapeutic infusion plus chemoembolization in the treatment of inoperable colorectal liver metastases.

MATERIALS AND METHODS

One hundred and three patients with disseminated inoperable colorectal liver metastases received intra-arterial chemotherapy with 5-FU and granulocyte-macrophage colony-stimulating factor (GM-CSF) plus chemoembolization via an angiographically positioned hepatic artery catheter. Two different regimens were used in two consecutive studies. Group A: short-term i.a. infusion of 550 mg/m(2)5-FU (days 1-4) plus 80 microg/m(2)GM-CSF (day 1+2) combined with chemoembolization with 25 mg/m(2)melphalan plus Lipiodol and Gelfoam (day 5). Group B: continuous circadian intra-arterially administered 1400 mg/m(2)5-FU infusion plus 60 mg/m(2)i.v. leucovorin and 80 microg/m(2)GM-CSF (day 1+2) combined with chemoembolization with 25 mg/m(2)melphalan plus Lipiodol and Gelfoam (day 3).

RESULTS

One hundred and three patients (62 male/41 female) with a median age of 59.9 and a median Karnofsky index of 88.5 were treated with 447 cycles of immuno-chemoembolization (group A 299, group B 148 cycles). Fifty-seven percent of these patients had received prior systemic chemotherapy. Side-effects were seen in all patients, mainly upper abdominal pain lasting 1-4 days and grade 1 or 2 vomiting. Systemic side-effects were mild and transient with a very low rate of leukopenia. Using World Health Organization response criteria, the following responses could be demonstrated: group A: CR 2.7%, PR 32.4%, MR 21.6%, SD 12.7%, NR 16.2%; group B: CR 1.0%, PR 42.4%, MR 24.2%, SD 18.2%, NR 12.1%. Time to progression was 7 as compared to 8 months. Median survival was 17 months in group A, whereas it has not been reached after 28 months (P=0.0095) in group B. There was no statistically significant difference between chemo-naive patients and patients who had received prior systemic therapy.

CONCLUSION

Immuno-chemoembolization combined with 2-day circadian administration of 5-FU is an effective tool in the treatment of disseminated colorectal liver metastases. This regimen is also effective as second-line treatment.

Haemopoietic growth factors in paediatric oncology: a review of the literature

Recombinant haemopoietic growth factors (HGFs) are an attractive adjunct to reduce morbidity from chemotherapy regimens and their use has become widespread in paediatric oncology. Although patients receiving HGFs often have faster haematological recovery after intensive chemotherapy, this does not always translate into meaningful clinical benefits. This article reviews the clinical effectiveness of HGFs in a variety of different contexts. Most published studies have used granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) as prophylaxis to ameliorate the subsequent neutropenia following intensive chemotherapy. These 2 agents have also been used to mobilise peripheral blood stem cells for autologous transplantation. HGFs specific for anaemia and thrombocytopenia are currently in paediatric clinical trials and it is hoped that the proper context and administration strategy can be found to make their use clinically effective. This article also reviews data on toxicity, specifically focusing on differences between various formulations of growth factors. HGFs are expensive, and cost-benefit analyses reviewed in this article give an important perspective on the financial aspects of paediatric cancer care. Because HGFs do not benefit every child receiving chemotherapy and overuse increases costs and may result in unnecessary adverse effects, evidence-based guidelines for their rational use in paediatric oncology are proposed.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) decreases left ventricular function. An echocardiographic study in cancer patients

To study the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on the heart, echocardiographic assessments of left ventricular (LV) end-diastolic and end-systolic (ES) diameters (D), ejection fraction (EF) and cardiac output (CO) were done in six male patients (28-70 years of age) with advanced sarcoma (Group 1), prior to (day -1-0), during (day 7-9) and after (day 20-21) a first course of i.v. doxorubicin (day 0) without GM-CSF and a second course (3 weeks after the first one) with GM-CSF 250 microg/m(2)subcutaneously and daily from day 1-11. A similar study was done in ten female patients with advanced breast cancer (31-58 years of age, Group 2) for a first course of doxorubicin+cyclophosphamide with GM-CSF (same schedule as in Group 1). As compared to the mean of values prior to and after the course with GM-CSF in Group 1 and 2, the LVESD during GM-CSF administration transiently increased by median 6% (range -19 to 30%, P<0.05) vs -9% (-21 to 6%, not significant) in the first course without GM-CSF in Group 1 (P<0.05 between courses). The CO and EF tended to decrease during GM-CSF. GM-CSF thus causes a small and transient decrease of LV contractility.

Prognostic role of clinical, pathological and biological characteristics in patients with locally advanced breast cancer

Forty-two patients with clinical stage IIIA or IIIB breast cancer were treated with neoadjuvant chemotherapy followed by mastectomy and radiotherapy. The median follow-up was 32 months (range 10-72 months) and the median time to progression was 17 months (range 10-30 months). A multivariate analysis showed that a longer disease-free survival (DFS) was related to more chemotherapy cycles given (P = 0.003), a better pathological response to chemotherapy (P = 0.04) and fewer positive axillary lymph nodes (P = 0.05). A better overall survival (OS) was related to more chemotherapy cycles given (P = 0.03) and better pathological response to chemotherapy (P = 0.04). In patients with residual tumour after neoadjuvant chemotherapy, high levels of staining for Ki-67 was correlated with a worse DFS (P = 0.008). Other biological characteristics, including oestrogen receptor status, microvessel density (CD31 staining), P-glycoprotein (P-gp) staining and nuclear accumulation of p53, were not independent prognostic factors for either DFS or OS. If both P-gp and p53 were expressed, DFS and OS were worse in the uni- and multivariate analysis. The preliminary results of this phase II study suggest that coexpression of P-gp/p53 and a high level of staining for Ki-67 after chemotherapy are associated with a worse prognosis, and that prolonged neoadjuvant chemotherapy and the attainment of a pathological complete remission are important factors in determining outcome for patients with this disease.

Multiple cycles of high-dose doxorubicin and cyclophosphamide with G-CSF mobilized peripheral blood progenitor cell support in patients with metastatic breast cancer

BACKGROUND

In a previous study we applied doxorubicin and cyclophosphamide in a dose-intensive regimen with GM-CSF to patients with metastatic breast cancer (MBC). That treatment failed to prolong the remission duration compared to conventional-dose chemotherapy. In the present study we escalated the dosages of the same agents to: 1) determine the maximum tolerated dosages (MTD) when given for three cycles with G-CSF mobilised peripheral blood progenitor cell (PBPC) reinfusion and 2) evaluate the antitumour effect of this regimen.

PATIENTS AND METHODS

For mobilisation of PBPC, G-CSF 15 microg/kg/day was given subcutaneously (s.c.), and in subsequent cohorts leucapheresis was started on days 3, 4 or 6. The intention was to treat MBC patients with three cycles of doxorubicin and cyclophosphamide at a starting dose of doxorubicin 90 mg/m2 and cyclophosphamide 1000 mg/m2. Dosages were then escalated in subsequent cohorts of at least three patients. In case of dose-limiting mucositis, only the dose of cyclophosphamide was escalated in the next cohort.

RESULTS

Twenty-one patients entered this protocol, of which 18 patients received high-dose chemotherapy. The mobilisation of PBPC using G-CSF only was sufficient for three cycles of high-dose chemotherapy in 10 of 21 (47%) patients. Mucositis precluded dose escalation of doxorubicin beyond 110 mg/m2. The MTD in this combination was 110 mg/m2 for doxorubicin, and 4 g/m2 for cyclophosphamide, with haemorrhagic cystitis being the dose-limiting toxicity. The overall response rate was 78% (95% confidence interval (95% CI): 57%-97%), with 22% (95% CI: 3%-41%) complete responses.

CONCLUSION

The MTD of this three cycle high-dose regimen was doxorubicin 110 mg/m2 and cyclophosphamide 4 g/m2 with mucositis and cystitis being dose-limiting toxicities. Although the primary aim was not the evaluation of antitumour effect, this high-dose regimen does not appear to provide an improvement of treatment results in comparison with our previous study with the same drugs at moderately high-dosages without stem cell support.