Use of Recombinant Canine Granulocyte Colony-Stimulating Factor to Decrease Myelosuppression Associated with the Administration of Mitoxantrone in the Dog

Toxicity, outcome, and management of anthracycline overdoses in 16 dogs

Background

Despite multiple reports of chemotherapy overdoses (ODs) in human and veterinary medicine, anthracycline ODs have been described infrequently.

Hypothesis/Objectives

Describe toxicities, treatments, and overall outcome after anthracycline OD in dogs.

Animals

Twelve mitoxantrone (MTX) and 4 doxorubicin (DOX) ODs were evaluated.

Methods

Multicenter retrospective analysis. The American College of Veterinary Internal Medicine oncology and internal medicine listservs were solicited for cases in which a chemotherapy OD occurred.

Results

Sixteen anthracycline cases were collected. Anthracycline ODs occurred because of an error in chemotherapy preparation (n = 9), or dose miscalculation (n = 7). The overall median OD was 1.9× (range, 1.4‐10×) the prescribed amount. Most ODs were identified immediately after drug administration (n = 11), and the majority of patients were hospitalized on supportive care (n = 11) for an average of 8 days (range, 3‐34 days). Adverse events after the OD included neutropenia (94%), thrombocytopenia (88%), anemia (63%), diarrhea (63%), anorexia (56%), vomiting (38%), lethargy (31%), and nausea (25%). Two patients did not survive the OD. High grade neutropenia was common and did not appear to be mitigated by the administration of filgrastim.

Conclusions and Clinical Importance

All patients received supportive care after identifying the OD and death was uncommon. Further evaluation is needed to determine ideal therapeutic guidelines anthracycline OD.

Review of oncological emergencies in small animal patients

Oncological emergencies can occur at any time during the course of a malignancy and need to be recognized promptly to maximize successful outcomes. Emergencies are characterized as chemotherapy-induced, paraneoplastic syndromes, or directly related to the neoplasm. Prompt identification with treatment of these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This review aims to educate the reader on the pathophysiology, clinical presentation and treatment of some of these emergencies, and to review the current veterinary literature to help educate veterinarians in primary and tertiary facilities to know how to diagnose and treat these serious conditions.

Use of recombinant canine granulocyte-colony stimulating factor to increase leukocyte count in dogs naturally infected by canine parvovirus

Canine parvovirus (CPV) is one of the most important cause of mortality in young dogs and no specific treatment exists. Since prolonged leukopenia greatly increases the risk of death in infected pups, strategies to counteract this decline were investigated. The outcomes of CPV naturally infected pups treated with the recombinant canine granulocyte-colony stimulating factor (rcG-CSF), in combination with the routine therapy, were compared with similarly-managed infected pups not treated with rcG-CSF. A non-randomized prospective clinical trial was performed on 62 CPV infected pups with WBC counts <3000 cells/μL and two different groups were selected based on a non-randomized approach. Group A dogs (31/62) received 5 μg/Kg of rcG-CSF daily from the hospitalization day until WBC reached the reference range (3-5 days) and group B (31/62) received 1 ml of placebo injection. All dogs in group A recovered, while five dogs in group B died. The rcG-CSF treatment demonstrated a statistically significant effect on WBC counts (p < 0.0001) and, surprisingly, also on lymphocytes and monocytes counts (p < 0.0001). There was no significant effect of treatment on neutrophil count (p = 0.5502). Although lymphocytes and monocytes are not a specific target for rcG-CSF, our study highlights that rcG-CSF is able to improve haematological parameters compared to untreated dogs and a clear increase in their number was detected, as previously described for humans treated with the homologous molecule.

Correlation Between Body Weight and Mitoxantrone-Associated Neutropenia in Dogs

Thirty-seven dogs with histologically or cytologically confirmed malignant tumors treated with single-agent mitoxantrone at 5 mg/m2 were evaluated in a retrospective study assessing the correlation between body weight and neutropenia associated with a single dose of mitoxantrone in dogs. Overall, eight dogs (21%) experienced grade 3 neutropenia and five dogs (14%) experienced grade 4 neutropenia on day 7 following mitoxantrone chemotherapy. Dogs ≤10 kg body weight were significantly more likely to develop grade 3 or 4 neutropenia (5.8 relative risk; 95% confidence interval, 2.6–12.9; P &lt; .0001) than dogs &gt;10 kg. Dogs ≤15 kg body weight were significantly more likely to develop grade 3 or 4 neutropenia (8.1 relative risk; 95% confidence interval, 2.1–31.3; P &lt; .0001) than dogs &gt;15 kg. Of the 13 patients who developed grade 3 or 4 neutropenia, 6 (46%) were hospitalized for clinical signs related to neutropenia. Based on the severity of neutropenia and the resulting hospitalization seen in dogs ≤10 kg, a dose reduction could be considered for the initial dose of mitoxantrone, and clinicians should be aware of the increased risk of neutropenia in patients 10.1 to ≤15 kg.

Serial evaluation of neutrophil function in tumour-bearing dogs undergoing chemotherapy

We hypothesized that neutrophil function in tumour-bearing dogs is negatively impacted by chemotherapy. Flow cytometric techniques were used to assess neutrophil oxidative burst and phagocytic activities at baseline, 7 and 21 days after induction chemotherapy in 20 dogs with lymphoma. Dogs had a lower percentage of neutrophils exhibiting oxidative burst activity after stimulation with Escherichia coli (day 7; P = 0.009) and phorbol 12-myristate 13-acetate (PMA) (days 7 and 21; P = 0.0003 and P = 0.01, respectively), compared with healthy controls. From day 0 to 7, the percentage of neutrophils exhibiting oxidative burst activity decreased after stimulation with E. coli (P = 0.016) and PMA (P = 0.0006). Induction chemotherapy suppresses the percentage of neutrophils capable of oxidative burst in dogs with lymphoma, with improvement in phagocytic activity over time (P = 0.03). The impact of neutrophil dysfunction on incidence and severity of sepsis in dogs receiving chemotherapy should be investigated.

Hematologic improvement in dogs with parvovirus infection treated with recombinant canine granulocyte-colony stimulating factor

Previously, dogs with canine parvovirus-induced neutropenia have not responded to treatment with recombinant human granulocyte-colony stimulating factor (rhG-CSF). However, recombinant canine G-CSF (rcG-CSF) has not been previously evaluated for treatment of parvovirus-induced neutropenia in dogs. We assessed the effectiveness of rcG-CSF in dogs with parvovirus-induced neutropenia with a prospective, open-label, nonrandomized clinical trial. Endpoints of our study were time to recovery of WBC and neutrophil counts, and duration of hospitalization. 28 dogs with parvovirus and neutropenia were treated with rcG-CSF and outcomes were compared to those of 34 dogs with parvovirus and neutropenia not treated with rcG-CSF. We found that mean WBC and neutrophil counts were significantly higher (P < 0.05) in the 28 dogs treated with rcG-CSF compared to disease-matched dogs not treated with rcG-CSF. In addition, the mean duration of hospitalization was reduced (P = 0.01) in rcG-CSF treated dogs compared to untreated dogs. However, survival times were decreased in dogs treated with rcG-CSF compared to untreated dogs. These results suggest that treatment with rcG-CSF was effective in stimulating neutrophil recovery and shortening the duration of hospitalization in dogs with parvovirus infection, but indicate the need for additional studies to evaluate overall safety of the treatment.

Supporting the veterinary cancer patient on chemotherapy: neutropenia and gastrointestinal toxicity

The application of effective chemotherapy protocols in companion animals with sensitive tumors may result in return to a good quality of life and extended long-term survival. However, the potential for adding adverse events that impact overall quality of life in veterinary cancer patients is an important consideration. To ensure the experience is a positive one for our clients and patients alike, the practicing veterinary oncologist must ensure clients are appropriately educated as to the type and likelihood of adverse events that may occur in their companions and should plan for appropriate preventative and therapeutic protocols to manage them. Such attention to detail will help guarantee their clients' experience with medical treatment is positive and worthwhile, and will result in improvement in the well-being of their companion.

Evaluation of dexamethasone as a chemoprotectant for CCNU-induced bone marrow suppression in dogs

In mice and people, administering corticosteroids before chemotherapy can reduce the severity of myelosuppression without reducing antitumour effects. This study investigated whether pretreatment with dexamethasone would reduce the incidence of grade 4 neutropenia in dogs receiving CCNU. Twenty-five dogs received dexamethasone [0.1 mg kg(-1) per os (PO) every 12 h] for 5 days and on the sixth day received CCNU (90 mg m(-2) PO). Historical dogs (n = 67) received CCNU alone (90 mg m(-2) PO). Forty-five percent of historical dogs had grade 4 neutropenia, while 64% of dogs pretreated with dexamethasone had grade 4 neutropenia (P = 0.16). Dexamethasone plasma levels were quantified by enzyme-linked immunosorbent assay in three healthy dogs. Peak plasma concentrations after a single oral 0.1-mg kg(-1) dose were <80 ng mL(-1), the minimum level associated with chemoprotective effects of dexamethasone in people. Pretreatment with dexamethasone did not reduce the incidence of grade 4 neutropenia in dogs receiving CCNU.

Expression and purification of canine granulocyte colony-stimulating factor (cG-CSF)

Canine granulocyte colony-stimulating factor (cG-CSF) with modification of cysteine at position 17 to serine was expressed in Brevibacillus choshinensis HPD31. cG-CSF secreted into the culture medium was purified by ammonium sulfate precipitation and consecutive column chromatography, using butyl sepharose and DEAE sepharose. Biological activity of the recombinant cG-CSF was 8.0 x 10(6) U/mg protein, as determined by its stimulatory effect on NFS-60 cell proliferation. Purified cG-CSF was subcutaneously administered once a day for two successive days to dogs (1, 5, 25, or 125 microg). Neutrophil count increased the following day in all dogs except those administered the lowest dose (1 microg). No severe side effects were observed in dogs after administration of cG-CSF.

Preventive and therapeutic effects of gene therapy using silica nanoparticles-binding of GM-CSF gene on white blood cell production in dogs with leukopenia

OBJECTIVE

Our previous study has shown that granulocyte-macrophage colony-stimulating factor (GM-CSF) gene/silica nanoparticles have a leukocytosis effect in normal dogs. Therefore, this study was conducted to determine whether treatment of canine GM-CSF gene/silica nanoparticles has preventive or therapeutic effects in dogs with leukopenia.

MATERIALS AND METHODS

To induce leukopenia, vinblastine was administered intravenously at a dose of 2 mg/m(2) of body surface area on day 0. Then 7.5 microg GM-CSF/nanoparticles (1:100, w/w) were administered intravenously to each of four dogs in the prevention group on day 2 and an equivalent amount of GM-CSF/nanoparticles was administered to the post-nadir group on day 4 (other groups were administered phosphate-buffered saline intravenously).

RESULTS

Therapeutic GM-CSF gene was expressed in peripheral blood mononuclear cells for 10 days and both the prevention and post-nadir groups showed significant increases in white blood cell counts when compared with the control group, as confirmed by complete blood count, differential count, and flow cytometry.

CONCLUSIONS

GM-CSF/nanoparticles can be useful for correction of acute leukopenia, such as chemotherapy-induced myelosuppression, without developing neutralizing antibodies.

Carboplatin and doxorubicin combination chemotherapy for the treatment of appendicular osteosarcoma in the dog

Twenty-four client-owned dogs with histologically diagnosed appendicular osteosarcoma (OSA) and no evidence of gross metastatic disease were treated with amputation or limb salvage followed by combination chemotherapy consisting of carboplatin (175mg/ m2 IV, day 1) and doxorubicin (15 mg/m2 IV, day 2) given on a 21-day cycle for a maximum of 4 cycles. Hematologic and gastrointestinal adverse effects were graded according to National Cancer Institute guidelines. Thoracic radiographs were obtained before the 3rd chemotherapy cycle and then every 2 months. Median disease-free interval was 195 days (95% confidence interval 111-228 days) and median survival was 235 days (95% confidence interval 150-283 days). Two patients required dose reductions: 1 for grade 3 thrombocytopenia and 1 for grade 3 adverse gastrointestinal effects. Patients with a longer duration of clinical signs before definitive diagnosis and surgery (greater than 30 days) were more likely to develop progressive disease and to die or be euthanized because of progressive disease on any day; hazard ratios were 3.0 (P = .02) and 3.7 (P .02), respectively. In conclusion, although this combination chemotherapy protocol was well tolerated, it did not provide any improvement over historical single-agent protocols.

Expression in Escherichia coli and purification of the functional feline granulocyte colony-stimulating factor

Feline granulocyte colony-stimulating factor (G-CSF) with an N-terminal histidine hexamer tag was expressed as inclusion bodies in E. coli. The G-CSF solubilized in 6 M guanidine solution was absorbed onto a Ni-NTA column and, after washing with decreasing concentrations of guanidine, eluted with imidazole in a soluble and apparently pure form. The activity of the recombinant feline G-CSF was 3 x 10(6)U/mg protein, as assayed by its stimulatory effect on NFS-60 cell proliferation. When a low level of purified feline G-CSF was administered once a day for two successive days to cats, the number of neutrophil increased 4-fold while the levels of other blood cell types remained virtually unchanged. Daily administration of G-CSF for a total of 11 days led to a more than 10-fold increase in neutrophils, an 8-fold increase in the number of monocytes and 2-fold increase in lymphocytes. No severe side effects or antibody production was observed in cats after administration of G-CSF.

Effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on leukocyte count and survival rate of dogs with parvoviral enteritis

Dogs with clinical signs consistent with parvoviral enteritis and leukopenia (total leukocyte count < 5.0 x 10(9) l(-1)) were included in this randomised double-blind study (treatment group: n = 22; control group: n = 21). The dogs in the treatment group received a subcutaneous daily injection of 10 microg kg(-1) of recombinant human granulocyte colony-stimulating factor (rhG-CSF) for 5 days. Clinical and blood investigations were performed prior to the first injection, daily during the treatment period and on the day after treatment ended, and then once more, 26 days after the first injection. During the study, no significant differences were found between the two groups with respect to survival rate (treatment group: 68 per cent; control group: 71 per cent, P > 0 4, Fisher-Test) and other clinical findings. Similarly the total leukocyte count, neutrophil count and other haematologic and biochemical parameters did not differ significantly between the groups, based on differences from initial values (P > 0 05). Consequently, the use of rhG-CSF in the treatment of dogs with parvoviral enteritis cannot be recommended.

Evaluation of single-agent mitoxantrone as chemotherapy for relapsing canine lymphoma

Many chemotherapeutic regimens will induce remission in dogs with lymphoma, but almost all dogs suffer relapse. Mitoxantrone was selected for evaluation as single-agent chemotherapy for relapsing canine lymphoma based on its use in humans undergoing salvage chemotherapy for non-Hodgkin's lymphoma and its tumoricidal effect against canine lymphoma. Dogs entered into study had multicentric lymphoma, and all had been treated solely with a standard combination chemotherapy protocol. At 1st relapse, all dogs were again staged and underwent lymph node biopsy. Mitoxantrone was administered IV at 6 mg/m2 every 21 days. Dogs were evaluated for lymphadenopathy before each dose of mitoxantrone. Fifteen dogs were entered into study. The average age (+/- SEM) of the dogs studied was 7.7 +/- 0.91 years, and most dogs were large (mean +/- SEM weight, 24.44 +/- 2.15 kg). Twelve dogs (80%) had B-cell lymphoma, and 3 had T-cell lymphoma. Dogs were staged IV (n = 12) or V (n = 3). The median duration of chemotherapy before entry into the study was 98 days. Overall median duration of response after mitoxantrone chemotherapy was 21 days. Complete responses were attained in 7 of 15 dogs (47%) with a median response duration of 84 days. Nine of 15 (60%) dogs attained a complete remission with additional chemotherapy after failing mitoxantrone chemotherapy. Mild toxicities were observed after mitoxantrone administration. No adverse reactions were observed during mitoxantrone infusions. The results of this study demonstrate that mitoxantrone, as a single agent, has limited value for dogs with lymphoma at 1st relapse after conventional multidrug chemotherapy.

Biological response modifiers: interferons, interleukins, recombinant products, liposomal products

The concept of enhancing the normal immune response against infections and neoplasms has been considered for decades. The administration of various natural and synthetic products to simulate systemic infections has largely given over to the idea that specific cytokines can be used effectively when administered systemically. Interferons, interleukins, and hematopoietic growth factors may offer substantial clinical benefit in chronic viral infections, and cancers such as osteosarcoma, melanoma, and lymphosarcoma. Erythropoietin has been shown to have great utility in the management of chronic renal failure. At this point in time, only recombinant products derived from humans are commercially available, and they are expensive and not licensed for use in companion animals. Nevertheless, these products may have significant clinical impact on several highly fatal disorders of dogs and cats. When administered systemically, cytokines perturb complex regulatory pathways, and serious side effects may occur. Innovative delivery methods, such as liposomes, gene therapy, and even oral administration may increase the therapeutic index of these molecules. Biological response modification, cytokine biology, and associated delivery systems are rapidly changing fields, and the small animal veterinarian will need to watch for significant advances in these areas over the next several years.

Effect of orally administered heat-killed Enterococcus Faecalis FK-23 preparation on neutropenia in dogs treated with cyclophosphamide

Dogs injected intravenously for 3 days with cyclophosphamide (CY) at a dose of 10 mg/kg were given 100 mg/kg of Enterococcus faecalis FK-23 preparation (FK-23) perorally for 14 days to confirm the beneficial effects of the latter drug in neutropenic dogs when orally administered. Although FK-23 treatment did not inhibit CY-induced neutropenia, it augmented neutrophil-reconstituting capacity in these dogs. Increases in the myeloid/ erythroid ratio and neutrophilic lineages were found in the bone marrow of FK-23 administered dogs. The oral administration significantly restored the reduced activity of neutrophil phagocytosis and chemiluminescence in dogs treated with CY. These findings indicate that FK-23 administered perorally not only augments neutrophil reconstitution through the activation of bone marrow but also functions in dogs treated with CY. It may thus be a useful supportive agent to reduce the adverse side-effects associated with the administration of chemotherapeutic agents such as CY.

The role of blood component therapy in the management of canine and feline patients with cancer

Blood component therapy may be required for a variety of pathologic reasons in the cancer patient. The tumor itself not only affects various cell lines, but treatment with chemotherapeutic agents can induce cytopenias. In addition, chronic and acute hemorrhage can be caused by tumor erosion and rupture or by paraneoplastic coagulopathies. Component replacement will depend on the underlying hematologic deficiencies and should be performed in conjunction with treating the cause of the deficiency.

Hematopoietic growth factors: frontiers for cure

Hematopoietic growth factors are cytokines that regulate the growth, development, and function of hematopoetic lineages. These hematopoietic growth factors have great potential for improving the quality of life and for reducing toxicity. This article reviews some of the most clinically relevant hematopoietic growth factors and what is known about their use in veterinary medicine. In particular, the following hematopoietic growth factors are discussed: erythropoietin, stem-cell factor, interleukin-3, interleukin-5, granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, and macrophage colony-stimulating factor.

Myeloid and megakaryocytic hypoplasia in related standardbreds

Myeloid and megakaryocytic bone marrow hypoplasia in association with moderate to profound neutropenia was observed in 8 young Standardbred horses sired by the same stallion; 7 horses were intermittently thrombocytopenic. Evaluation of serial neutrophil counts in 2 horses suggested that a cyclic variation in neutrophil numbers was present, that lymphocyte numbers increased when neutrophil counts decreased, and that platelet counts decreased when neutrophil counts decreased. Preliminary bone marrow cultures indicated that myeloid progenitor cells were present and that these cells were able to respond to exogenous growth factors by differentiating. A bone marrow microenvironment or growth factor defect is suspected. Seven of 8 horses died or were euthanized. One horse with moderate neutropenia and a normal platelet count has been racing for 3 years. Necropsies in 4 horses did not reveal a cause for the myeloid hypoplasia. A familial basis for the disease is suspected.

Antibodies to canine granulocyte colony-stimulating factor induce persistent neutropenia

A severe persistent neutropenia developed in a rabbit that was injected intradermally with 120, 60, 60, and 120 micrograms of recombinant canine granulocyte colony-stimulating factor (cG-CSF) on days 1, 22, 31, and 44, respectively. The neutropenia was present from day 44 to day 205. The nadir of the neutropenia (60 cells/microliters) occurred in conjunction with peak antibody titer (640,000) to cG-CSF on day 58. The immune antiserum from this rabbit reacted positively for cG-CSF on Western blot analysis. The immune antiserum also neutralized the activity of cG-CSF. On day 160, examination of the bone marrow showed marked granulocytic hypoplasia and mild erythroid hyperplasia. On day 205, the rabbit was still neutropenic (430 cells/microliters), even though the last injection of cG-CSF was given 161 previously. Necropsy on day 205 showed that there was still mild granulocytic hypoplasia with mild erythroid hyperplasia. Because of the lack of any inflammatory foci found at necropsy and the granulocytic hypoplasia, it was thought that the neutropenia was most likely due to decreased production and was not a consumptive process. It is hypothesized that the antibody that was produced to cG-CSF neutralized the effect of endogenous rabbit granulocyte colony-stimulating factor and prevented the normal proliferation and maturation of the rabbit neutrophils.

Perioperative management of paraneoplastic syndromes

This discussion of paraneoplasia is by no means exhaustive, but it does represent the more common conditions seen in the surgical oncology patient. A thorough understanding of biologic behavior of different tumor types allows the surgeon to recognize cases in which special attention is needed for the management of paraneoplastic syndromes. In this way, problems are averted, minimizing risk to the patient and increasing the likelihood of a successful surgical outcome.

Effects of perioperative granulocyte colony-stimulating factor on horses with ascending colonic ischemia

Granulocyte colony-stimulating factor (G-CSF) is a glycoprotein that regulates the proliferation and maturation of hematopoietic progenitor cells and modulates the function of mature neutrophils. The responses to administration of G-CSF alone, and in combination with antimicrobials, were studied in an equine model of ascending colon ischemia. Complete segmental colonic ischemia (3.75 hours) with pelvic flexure enterotomy was created in four treatment groups. Group 1 horses received recombinant canine G-CSF (10 micrograms/kg, every 24 hours, intramuscularly), gentamicin sulfate (2.2 mg/kg, every 8 hours, intravenously), and potassium penicillin G (40,000 IU/kg, every 6 hours, intravenously). Group 2 horses were treated with the G-CSF vehicle and antimicrobials as for group 1. Group 3 horses received G-CSF and the antimicrobial drug vehicles, and group 4 horses served as the untreated control receiving G-CSF vehicle and antimicrobial vehicles. The results for 20 horses, five horses in each group, were compared. Treatment with G-CSF was associated with an increased concentration of white blood cells, band neutrophils, neutrophils, lymphocytes, and monocytes in the peripheral blood after surgery. Antimicrobial administration had no detectable effect on cell concentrations after surgery. Administration of G-CSF was associated with an increased concentration of nucleated cells in the peritoneal fluid including neutrophils, small mononuclear cells and large mononuclear cells. Horses that developed incisional infections had lower neutrophil concentrations in the peripheral blood on postoperative day 2 than horses without infected incisions. These results suggested that the prophylactic administration of G-CSF may be useful in the treatment of patients at risk for developing neutropenia after surgery.