1. No category

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Treatment of the Anemia of Myelodysplastic Syndromes Using Recombinant
Human Granulocyte Colony-Stimulating Factor
in Combination With Erythropoietin
By Robert S. Negrin, Richard Stein, James Vardiman, Kathleen Doherty, Jill Cornwell,
Sanford Krantz, and Peter L. Greenberg
We treated myelodysplastic syndrome patients (MDS)
with both recombinant human granulocyte colony-stimulating factor (G-CSF) and recombinant human erythropoietin (EPO) t o determine whether such combination therapy
resulted in improvement of their anemias. Twenty-four of
28 patients begun on study completed the protocol and
were evaluable for erythroid responses. Therapy was initiated with G-CSF at 1 pg/kg administered by daily subcutaneous injection and adjusted to either normalize or double
the neutrophil count. EPO was then administered by daily
subcutaneous injection at a dose of 100 U/kg and doseescalated to 150 and 300 U/kg every 4 weeks while continuing the G-CSF. Changes in absolute reticulocyte count,
hematocrit level, and need for RBC transfusions were compared with pretreatment values as well as other blood cell
T
HE MYELODYSPLASTIC syndromes (MDS) are
characterized by chronic cytopenias that predispose
patients to symptomatic anemias requiring RBC transfusions, infection, bleeding, and a high incidence of conversion to acute myeloid leukemia (AML).14 These patients
have limited treatment options and often respond poorly to
cytotoxic ~hemotherapy.~,~
Recently, a series of studies have been reported using recombinant human colony-stimulating factors (CSFs) to
treat MDS patients. Both granulocyte colony-stimulating
factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) have been used in this patient popul a t i ~ n , ~as- ’well
~ as preliminary studies with interleukin3 . I 5 , l 6 With these growth factors the majority of patients
have improvements in neutrophil counts that in some studies using G-CSF and GM-CSF, has been correlated with a
decrease in infection r i ~ k . ’ ~ , ’ ~
Despite the improvements in myeloid cell numbers in
these patients, the majority of patients who were anemic
and thrombocytopenic remained so. A low proportion of
these patients had erythroid responses to either G-CSF or
GM-CSF.7,L2
Because many patients with MDS have ongoing needs for RBC transfusions and often have serum erythropoietin (EPO) levels that are lower than would be expected relative to the degree of anemia,” investigators have
explored the use of recombinant human EPO treatment in
this patient population. These studies have shown that approximately 10% to 25% of patients demonstrated erythroid
response^.'^-'^ Generally, the doses required for erythroid
responses were high and responding patients had variable
serum EPO levels before treatment. In vitro, marrow erythroid hematopoietic precursor cell (burst-forming unit-erythroid [BFU-E]) responses to EPO in MDS patients have
also been ~ u b o p t i m a l . ~ ~Recent
, ’ ~ studies have demonstrated in vitro synergy between G-CSF and EPO for normal and MDS e r y t h r o p o i e s i ~Thus,
. ~ ~ ~ ~we~ have evaluated
combination therapy with G-CSF and EPO in patients with
MDS to determine whether treatment with both agents resulted in erythroid as well as myeloid responses.
Blood, Vol 82,No 3 (August 1). 1993:pp 737-743
counts. Ten of 24 patients (42%)had erythroid responses,
whereas all patients had neutrophil responses. Six previously transfused patients no longer required RBC transfusions during the treatment period. Erythroid responses
were found to be independent of patient age, FrenchAmerican-British subtype, duration of disease, prior RBC
transfusion requirements, or cytogenetic abnormalities at
presentation. Pretreatment serum EPO levels were lower
in erythroid-responding as compared with nonresponding
patients (median 157 v 600 U/L; P = .05).The combined
treatment modality was generally well tolerated. We conclude that a substantial percentage of MDS patients had
both erythroid and myeloid responses when treated with
the combination of G-CSF and EPO.
0 1993 by The American Society of Hematology.
MATERIALS AND METHODS
Patients. Twenty-eight patients with MDS were enrolled in this
study, 16 at Stanford University Medical Center and 12 at Vanderbilt University Medical Center. All patients had histologically confirmed MDS evaluated both at the treating institution and by central pathology review (by J.V.) at the University of Chicago Medical
Center before entering the study. Bone marrow aspirates were classified according to French-American-British (FAB) criteria as either
refractory anemia (RA), refractory anemia with ringed sideroblasts
(RARS), refractory anemia with excess blasts (RAEB), or refractory
anemia with excess blasts in transformation (RAEB-T).m The clinical characteristics of the patients are shown in Table 1. All 28 patients were evaluable for myeloid responses and toxicity. Four patients did not complete the dose escalation of EPO because of bone
pain (I), splenic pain (I), splenic pain with progression to AML (l),
and gastrointestinal bleeding ( 1). These four patients were therefore
not eligible for evaluation of erythroid responses. Written informed
consent was obtained from all patients according to guidelines established by the Human Experimentation Committees at either
Stanford University or Vanderbilt University.
From The Department of Medicine, Stanford University Medical
Center, Stanford, CA; the Department ofMedicine, Vanderbilt Medical Center, Nashville, TN; the Department of Pathology, University
of Chicago Medical Center, Chicago, IL; the Veterans Administration Medical Center, Nashville, TN; and the Veterans Administration Medical Center, Palo Alto, CA.
Submitted January 4, 1993; accepted March 24, 1993.
Supported in part by research funds j o m AMGEN and Ortho
Biotech.
Presented in part at the International Society of Experimental
Hematology meeting, Providence, RI, August 1992. Exp Hematol
1992, 20:745a (abstr).
Address reprint requests to Robert S. Negrin, MD, Room H1353,
Bone Marrow Transplant Program, Stanford University Medical
Center, Stanford, CA 94305.
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be hereby marked
“advertisement” in accordance with 18 U.S.C.section 1734 solely to
indicate this,fact.
0 1993 by The American Society of Hematology.
0006-4971/93/8203-0003$3.00/0
737
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NEGRIN ET AL
738
Table 1. Characteristicsof MDS Patients Enrolled in the G-CSF
Plus EPO Clinical Trial
No. enrolled
No. evaluable for erythroid responses
Age in years, median (range)
Male/female
FAB subtype:
RA
RARS
RAEB
RAEB-T
Anemic
RBC transfusion dependent
Neutropenic
Thrombocytopenic
Cytogenetic abnormalities
28
24
71 (34-84)
2117
13
8
5
2
28
25
18
12
9/26
Study design. All patients were evaluated before study entry
with complete history and physical examinations. Eligibility criteria included histologically confirmed MDS performed by our central pathology reviewer, hemoglobin level 5 10 g/dL, hematocrit
level 1 3 1% or symptomatic anemia, serum creatinine <2.0 mg/dL,
and bilirubin less than 2.5 times the upper limit of the institutional
normal value. Patients were excluded if they had received cytotoxic
or radiation therapy within 4 weeks of study entry, were receiving
current therapy with lithium, vitamin A or D, steroids or danazol,
or had cardiac disease with decompensated congestive heart failure,
active gastrointestinal bleeding, or uncorrected iron deficiency anemia (defined as absence of marrow iron, transferrin saturation of
<16%,serum iron <40 pg/dL or serum ferritin <20 pg/L. Patients
previously treated with other hematopoietic growth factors within 4
weeks of study entry were also excluded. Eligible patients underwent baseline laboratory evaluation including a complete blood cell
count (CBC) with reticulocytes and platelets, serum EPO, B12 and
RBC folate levels, stool guaiac determinations, chest radiograph,
and electrocardiogram. B 12 and RBC folate levels were normal in
all patients.
G-CSF was administered as a daily subcutaneous (SC) injection
with a starting dose of 1.0 pg/kg. CBC counts were obtained twice
weekly until stabilization of the absolute neutrophil count (ANC)
occurred. The dose of G-CSF was adjusted to normalize the ANC if
the pretreatment ANC value was less than 1,800/pL, or to double
the ANC if above 1,8OO/pL. The dose required to achieve this
ranged from 0.2 to 5.0 pg/kg/d. EPO administration was then begun by daily SC injection while continuing the daily G-CSF injections. The EPO dose was started at 100 U/kg/d and increased every
4 weeks to 150 and finally 300 U/kg/d. The 300 U/kg/d dose was
continued for a total of 8 weeks. CBC counts were obtained weekly
once the EPO was begun and a chemical survey panel was obtained
monthly. Bone marrow aspiration with cytogenetics was performed
at study entry and at either the end of 8 weeks of the 300 U/kg/d
EPO treatment or the time of erythroid response.
Patients were questioned weekly concerning possible adverse
events. Patients were instructed to draw up the appropriate amount
of G-CSF and EPO into a syringe and self-inject the drugs SC.
Treatment was discontinued if severe side effects occurred or at the
patient’s request.
Recombinant human G-CSF was supplied by AMGEN, Thousand Oaks, CA, and recombinant human EPO was supplied by
Ortho Biotech, Raritan, NJ. The factors were provided to the
Cancer Therapy Evaluation Program (CTEP), Investigational Drug
Branch, National Cancer Institute, which then distributed them to
the participating medical centers. Statistical analyses were performed by Student’s t-test.
Response criteria. Erythroid responses were defined as being a
good response (GR), partial response (PR), or no response (NR). A
GR was defined as an increase in untransfused hemoglobin values
of >2 g/dL or a 100%decrease in RBC transfusion requirements
over the treatment period. A PR was defined as an increase in untransfused hemoglobin values of 1 to 2 g/dL or a greater than 50%
decrease in RBC transfusion requirements. NR was defined as responses less than a PR. Pretreatment RBC transfusion requirements were calculated over the months before study entry when
accurate data were available. This ranged from 1 to 36 months
(median 7 months), and was stable for 1 to 2 months before study
entry. Myeloid responses were categorized as being either a complete response (CR), PR, or NR. A CR was defined as normalization of the ANC (>l,800/pL) if initially < 1,8OO/pL, or if the pretreatment ANC was > I ,800/pL then increased by 100%.A PR was
defined as an increase in ANC to between 500 and 1,8OO/pL if
initially <1,8OO/pL, or a 50% to 100% increase in ANC if initially
> 1,80O/fiL.NR was defined as changes in ANC less than a PR.
RESULTS
Patients. The clinical characteristics of the 28 enrolled
patients are shown in Table 1. The median age was 7 1 years
(range 34 to 84) with 2 I males and 7 females. Thirteen patients had RA, 8 RARS, 5 RAEB, and 2 RAEB-T. All patients were anemic and 25 were RBC transfusion dependent. Eighteen patients were neutropenic (tl,800/pL) and
12 were thrombocytopenic. Twenty-six patients had cytogenetic studies performed, of whom 9 patients showed abnormalities, primarily involving chromosomes 5 and 8. All 28
patients were evaluable for toxicity and myeloid responses.
Four patients did not complete the dose escalation of EPO,
and thus, were not evaluable for erythroid responses.
Myeloid responses. Treatment was started with daily SC
G-CSF injections beginning at 1 .O pg/kg. All patients had a
myeloid response (26 CR, 2 PR), with all patients but one
requiring between 0.2 and 1 .O pg/kg/d to maintain this neutrophil level (Table 2). One patient required dose escalation
to 5.0 pg/kg/d. Both PR patients withdrew from the study
early because of toxicity (patients no. 112 and 209).
Erythroid responses. Once a myeloid response occurred, EPO was begun by daily SC injection while continuing the G-CSF injections. The EPO dosage was initially 100
U/kg/d, with escalation every 4 weeks to 150 and finally 300
U/kg/d, which was continued for a total of 8 weeks. A representative responding patient’s course is shown in Fig 1. This
patient (no. 102) had been dependent on approximately
four units of RBCs per month for 12 months and was chronically neutropenic, with an ANC of 1,4OO/pL before therapy. Treatment was initiated with G-CSF at 1.0 pg/kg/d,
which resulted in a prompt increase in a total white blood
cell (WBC) count and ANC to the 6,000 to 12,00O/pL
range. Two weeks later, EPO administration was started at
100 U/kg/d. Increases in absolute reticulocyte counts and
untransfused hematocrit levels were noted at the 150 U/kg/
d EPO dose, although these values were not sustained. At
the 300 U/kg/d EPO dose, a sustained increase in hematocrit level was noted, and the patient did not require any
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G-CSF AND EPO IN MDS
739
Table 2. Hematoloaic Characteristics of MDS Patients Receivina G-CSF Plus EPO
RBC
Patient
No.
Age
(yrs)
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
201
202
203
204
205
206
207
208
209
210
21 1
212
72
78
61
79
72
82
69
69
84
82
82
82
81
77
70
64
64
67
34
61
67
67
70
68
82
84
71
78
Sex
M
M
M
M
M
M
M
M
M
M
M
M
M
F
F
M
F
F
M
M
M
M
F
F
M
F
M
M
FAB
Subtype
Serum
EPO
(U/L)
RA
1,635
RARS
604
RARS
169
92
RARS
RA
948
128
RA
3,010
RA
RA
127
258
RAEB/RS
RA
35
RARS
342
12
RAEB
RARS
157
112.7
RARS
122.3
RARS
RA
312.9
RA
600
RAEB
1,500
ND
RA
ND
RA
ND
RARS
40
RAEBT
RAEBT
960
RA
28
RAEB
120
RAEB
18
RA
950
RA
22.000
Transfusions
(units/month)
Cytogenetics
Before
Before
NN
AN
NN
AN
NN
NN
NN
NN
NN
NN
AN
NN
NN
NN
NN
NN
AA
AA
NN
AA
NN
ND
AA
ND
AN
NN
NN
AA
2.0
4.0
3.4
1.6
2.5
3.0
2.4
2.0
2.5
0.0
1 .o
2.0
2.4
3.1
2.3
0.4
2.4
6
0
6
4
0
2.6
1.3
2.6
1.3
3.3
3.3
After
4.5
0.0
1.0
3.0
1.0
2.5
3.0
1.5
2.0
O+
1.5
Neutrophils
x
Hematocrit (%)
Before
23.6
22.1
25.6
24.2
27.7
30.5
19.2
29.0
26.8
30.6
21.3
NE
30.5
0.0 23.9
3
27.4
0
25.1
0
29.7
2
22.1
6
25.6
0
27.8
2.7 31.2
4
27.8
0
31
4.5 23
0
25
ND
20
0
28
2.8 30
2.5 29
After
25.8
27.2
23.1
27.6
32.2
35.3
19.5
26.2
32.9
50.9-i
24.7
25.8
26.2
34
31.4
45.6
21
26
27.8
27
24.4
41
17
28
ND
35.9
28
26
Erythroid
Response
Before
NR
GR
PR
NR
PR
NR
NR
NR
NR
GR
NR
NE
CR
NR
GR
GR
NR
NR
NE
PR
NR
GR
NR
NE
NE
GR
NR
NR
Platelets
x
1 0 3 ~ ~ G-CSF
2.4
1.4
3.7
0.7
1.6
0.5
1.5
1.3
0.3
1.3
1.3
0.4
1.5
4.4
4
2.2
1
1.4
1.6
1.7
1.2
1.1
7.9
1.5
4.3
5.1
3.2
2.6
After
5.4
7.3
11.3
3.2
10.4
6.6
2.6
4.7
4
7.2
9.7
1.5
4.5
8.5
8.1
9.8
11.8
4.8
7.1
12.9
3.2
4
10.8
3.7
8.7
15.4
12.7
8.5
Dose
Fg/kg
Myeloid
Response
0.2
1
1
0.3
0.3
1
0.3
1
0.3
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
PR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
1
0.3
1
0.3
0.3
0.2
1
1
5
1
1
0.3
0.3
0.3
1
1
0.3
0.3
1
PR
CR
CR
CR
1 0 3 ~ ~
Before
After
344
188
242
420
250
234
124
80
305
60
566
184
287
168
296
22
32
83
105
128
176
50
51
32
472
740
145
197
294
173
198
416
258
103
102
117
238
45
428
125
216
90
246
32
33
16
45
192
187
21
9
19
237
240
79
159
Abbreviations: ND, not done; NE, not evaluable; NN, all normal; AA, all abnormal; AN, mosaic of abnormal and normal karyotypes (by patient no.)
+, patient phlebotomized.
102 +8. 104 +22. 1 1 1 20q-, 201 5q-, 202 5q-, 204 5q-, +8,207 -7, 209 +8,212 1 lq-, -y.
RBC transfusions for 4 months of subsequent treatment.
Platelet counts did not change.
The response of a second patient (no. 1 10)is shown in Fig
2. This patient had a prior diagnosis of idiopathic hemochromatosis with chemical and clinical evidence of iron
overload. His anemia was caused by MDS, which precluded
phlebotomy therapy. At the time of protocol initiation, the
patient had a stable hematocrit level of 30% and was neutropenic, with an ANC of 1,33O/pL. On initiation of G-CSF,
an increase in WBC count and ANC was promptly noted,
with an ANC in the 6,000 to 10,00O/rLrange. EPO administration was begun at 100 U/kg, resulting in an increase in
absolute reticulocytes and hematocrit level from 30% to
51% over a 10-week period. This patient’s treatment was
maintained on 100 U/kg of EPO and did not undergo dose
escalation. The scheduling of EPO administration was decreased to three times weekly and courses of therapeutic
phlebotomies were initiated for his hemochromatosis.
Erythroid responses of the 24 evaluable patients are
shown in Tables 2 and 3. Ten of the 24 patients (42%)had
erythroid responses. Seven patients had a GR and three had
a PR. Of the 10 responding patients, 9 required the 300
U/kg/d dose of EPO, whereas 1 patient (no. 110 discussed
above) responded at a dose of 100 U/kg/d. In all patients the
responses were maintained over the course of the protocol.
Six responding patients of the 22 evaluable patients (27%)
who were previously dependent on RBC transfusions to
control symptoms no longer required transfusions.
A variety of clinical features were compared in an effort
to evaluate retrospectively possible correlations with erythroid responses (Table 4). No correlation was noted between erythroid responses and age, FAB subtype, disease
duration, prior RBC transfusion requirements, reticulocyte,
neutrophil, or platelet counts at study entry, presence of
cytogenetic abnormalities, or the pretreatment or posttreatment relative myeloid or erythroid differentiation indexes
of the bone marrow. The only pretreatment laboratory parameter that was different between the responding and
nonresponding patients was the serum EPO levels. Responding patients had lower levels, with a median value of
157 (range 18 to 948) U/L as compared with nonresponding
patients, with a median value of 600 (range 92 to 3,010)
U/L (P = .05), although there was significant overlap of
these values between the two groups (Fig 3). Platelet counts
were generally unaffected by treatment. However, two patients had significant decreases in platelet counts, one of
whom was found to have evolved to AML. Five patients had
previously received treatment with EPO alone (without re-
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NEGRIN ET AL
740
GCSF & ERYTHROPOIETIN FOR MDS
-e 14
12
2z
0
z
4
4
10
8
6
P
4
E
2
n
MONTHS
Fig 1. Hematologic response of MDS patient no. 102 to combination therapy with G-CSF plus EPO. Baseline hematocrit (a),absolute
reticulocyte count (0);WBC count [e),absolute neutrophil count (0)are shown. RBC transfusions are denoted by the solid bars. G-CSF was
started as a daily SC injection denoted by the arrow. Two weeks later, EPO was begun, initially at 100 U/kg, with doses escalated to 150
and 300 U/kg/d.
tion. One of these patients, who had previously received
1,000 U/kg of EPO IV three times weekly for over 4 weeks,
responded to G-CSF plus EPO.
Serum femtin values were >400 pg/L at study entry in 27
sponses) at least 2 months before enrolling in this study. The
EPO for these patients had been administered in a variety of
doses and schedules, generally between 50 to 1,000 U/kg
three times per week by either intravenous (IV) or SC injec-
*
G-CSF & ERYTHROPOIETIN FOR MDS
46 42 50
a HEMATOCRIT
- 120
383430-
16
12-
- 200
- 160
0 RETICULOCYTES
.LA
- 80
- 40
a
-
a WBC
OANC
a-
-
40
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
Fig
2. Hematologic response of MDS patient no. 110
to G-CSF plus EPO therapy.
€PO was administered by a
daily (hatched area) SC injection of 100 U/kg for 10 weeks
and then decreased to three
times weekly for an additional 4
weeks. Response of blood
counts is demonstrated.
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741
G-CSF AND EPO IN MDS
Table 3. Erythroid Responses of MDS Patients
Treated With G-CSF Plus EPO
FAB
Subtype
GR
PR
NR
RA
RARS
RAE6
RAEE-T
2
3
1
1
2
1
0
0
7
4
2
1
11
8
3
2
Total
7
3
14
24
Total
Overall response rate (GR plus PR) 10/24 (42%)
ofthe patients. Serum ferritin levels increased by >20% in 8
of 13 nonresponding patients, as compared with only 3 of 9
responding patients, probably reflecting their continued
treatment with RBC transfusions. Marrow myeloid and erythroid dysplasia and the presence of ringed sideroblasts persisted in patients who had demonstrated these morphologic
abnormalities, independent of their clinical responses.
Cytogeneticstudies. Twenty-sixpatients had marrow cytogenetic studies performed before study entry. Nine patients had abnormal cytogenetics, of whom five patients had
all abnormal cytogenetics(AA) and four patients had a mixture of normal and abnormal chromosomes (AN). These
cytogenetic abnormalities were either 5q-, monosomy 7 or
trisomy 8 in 6 of these patients. Identical marrow chromosomal patterns were found in all patients tested after the
treatment protocol. Of the patients in whom cytogenetics
were performed, 7 of 9 responders had normal cytogenetics
as compared with 8 of 14 nonresponders (Table 4; P = NS).
The two patients with cytogenetic abnormalities who had
erythroid as well as myeloid responses (patients no. 102 and
204) had trisomy 8 as their karyotypic abnormality, one of
whom also had a 5q- lesion. These two patients had persistence of their karyotypic abnormalities during their responses, suggesting responsiveness of their abnormal hemopoietic clones. Two other patients with the 5q- abnormality
(no. 201 and 202) did not respond.
Toxicity. The combined treatment with G-CSF and
EPO was generally well tolerated. There were no significant
lesions at the injection sites and all patients were treated as
outpatients. Two patients (no. 202 and 208) progressed to
AML over the 4- to 5-month treatment period. In all other
patients bone marrow aspirations at the end of the treatment protocol showed the same FAB classification as that
noted before initiating treatment. As stated above, four patients did not complete the treatment protocol. These individuals were patient no. 112, who developed severe bone
pain shortly after beginning the G-CSF injections before
EPO administration, no. 203, who developed splenic pain,
no. 208, who developed splenicpain and evolution to AML,
and no. 209, who developed gastrointestinal bleeding before
administration of EPO. Patient no. 212 also developed
splenic pain, but was able to continue the protocol after
decreasing the dose of G-CSF. Patient no. 21 1 also developed bone pain following G-CSF administration but completed the protocol.
DISCUSSION
In this report, we have evaluated the clinical efficacy of
combination therapy with G-CSF and EPO in an effort to
improve the anemia in MDS patients. Previous phase 1-11
studies have documented that the majority of MDS patients
had neutrophilic responses to G-CSF”-’3and a small subset
of patients also had erythroid responses when treated with
G-CSF or GM-CSF
In a prior study of G-CSF
treatment of MDS patients, 4 of 18 (22%)patients had erythroid responses,” all of whom would have been classified
as PRs by the criteria used here.
Treatment with EPO alone has also been widely studied
in MDS
In the eight reported trials, a total of 84
patients have been treated with EPO alone, of which there
have been 19 responders (23%).In our current study, 10 of
24 patients (42%) had erythroid responses, a finding that
compares favorably to results with either G-CSF or EPO
alone. However, direct comparisons of results from our
study with those obtained with EPO alone is not possible,
because EPO dose, scheduling, and mode of administration
differed. Further, MDS patients are heterogeneous, and it is
possible that selection factors could contribute to these different response rates.
The rationale for using G-CSF and EPO in combination
Table 4. Comparison of Pretreatment Clinical Characteristics With Erythroid Responses in MDS Patients Treated W i t h G-CSF Plus EPO
Median (Range)
Age, years
Disease duration, months
Prior REC transfusion requirements (units per month)
Reticulocytes X 103/pL
Neutrophils X 103/pL
Platelets x 10 3 / p L
Serum EPO, U/L
Relative erythroid differentiation index’
Relative myeloid differentiation indext
Cytogenetic findings (abnormal/normalkaryotypes)
Responders
n = 10
Nonresponders
n = 14
70 (61-84)
11 (1-84)
2.3 (0-6)
23 (13.6-49.2)
1.6 (1.l-5.1)
188 (22-740)
157 (18-948)
1.8 (0.73-4.44)
10.2 (0.92-15.7)
71 (64-84)
16 (3-102)
2.6 (1-6)
14.1 (2.5-46.9)
1.3 (0.3-7.8)
168 (32-566)
600 (92-3,010)
2.6 (0.16-11)
4.65 (2.87-10.5)
618
217
Results are expressed as medians (range).
Orthochromatic polychromatic normoblastsJbasophilic pronormoblasts.
t Neutrophils bands metamyelocytes myelocytes/promyelocytes myeloblasts.
+
+
+
+
+
+
NS
NS
NS
NS
NS
NS
P = .05
NS
NS
NS
From www.bloodjournal.org by guest on February 11, 2015. For personal use only.
NEGRIN ET AL
742
0
3000
3
E
3
E
v
0
2000
f
;
0
BI
0
I-
>
a
W
I
a
w
v)
low
I
0
8
-0-
0
-f0
RESPONDERS
N=9
0
0
8
NON-RESPONDERS
N = 13
Fig 3. Serum EPO levels obtained before initiation of treatment
in erythroid responding ( 0 )and nonresponding (0)patients. The median value is denoted by a horizontal bar. The median values were
157 U/L for responding patients (range 18 to 948) as compared
with 600 U/L for nonresponding patients (range 92 to 3,010; P =
.05).
was the documented in vitro synergy for erythropoiesis of
these agents, both for normal and MDS erythroid presursors28~29
and the in vivo responses stated above following the
use of either agent alone. Further, the data of Leary et a13'
demonstrated that G-CSF enhanced the development of
early precursors into EPO-responsive progenitor cells, supporting the possibility that clinical responses may reflect in
vivo synergy of these agents. Alternatively, the in vivo responses could relate to the relatively high EPO doses or the
daily dosing used in this study. To distinguish between these
possible explanations we plan to discontinue the G-CSF in
our responding patients to determine the possible persistence of the in vivo erythroid responses. Preliminary evaluation of in vitro-in vivo correlations of patients in whom in
vitro erythroid clonogenicity (ie, marrow BFU-E) were evaluated indicated that patients with responsive marrow BFUE in vitro were the in vivo responders as compared with
those patients lacking detectable in vitro BFU-E growth.32
The persistence of cytogenetic abnormalities in two of the
erythroid and myeloid responders does not support the hypothesis that more responsive normal hemopoietic clones
emerged during treatment. However, for more precise assessment of the issue of clonality evaluation of X-linked
gene homozygosity using restriction-length polymorphisms
analysis is needed.L2,33
The only pretreatment clinical Characteristic of the patients that was predictive of erythroid responses was the
serum EPO level. However, there was substantial overlap of
these values between the responding and nonresponding patients. Other features including age, sex, FAB subtype, duration of disease, duration of RBC transfusional needs, absolute reticulocyte count, ANC, platelet count, marrow
morphology, and cytogenetics did not correlate with erythroid response. Of interest was the general lack of alteration in the qualitative marrow morphologic features (dysplasia, ringed sideroblasts) in the responding patients. This
finding and the persisting cytogenetic abnormalities in two
responders suggests that a quantitative increase of responsive (though abnormal) erythroid precursors occurred in
these patients. The in vitro correlative studies showing increments in BFU-E3*are consistent with this requirement
for adequate numbers of responsive erythroid precursors.
The combination of therapy with G-CSF and EPO was
generally well tolerated. Two patients progressed to AML.
However, it is not known whether G-CSF or EPO impact on
the rate of transformation in this disease, which has a potential for evolution to AML. An ongoing phase 111 study comparing G-CSF with supportive care is aimed at definitively
answering this question. Of interest was the observation that
three patients developed splenic pain without splenomegaly, a finding which has not previously been noted using
either G-CSF or EPO in MDS patients. Splenomegaly has
been reported in a portion of the children with congenital
agranulocytosis (Kostmann's syndrome) who were chronically treated with G-CSF.34
In summary, we have evaluated the utility of combination therapy with G-CSF and EPO in MDS patients. One
important aspect of this study was the determination that it
is possible to administer two cytokines together without a
negative interaction. A substantial proportion of the patients had clinically beneficial erythroid and myeloid responses, possibly related to synergy between these two
agents for stimulating hemopoiesis. The durability of these
responses and determination of factors that are predictive
for both erythroid and myeloid responses are currently
under study. The results would be important to predict
which patients are likely to respond to such therapy because
of the potential relatively high cost of treating such patients
with both cytokines.
ACKNOWLEDGMENT
The committed administrative efforts of Drs Shem Brown (AMGEN), David Gordon (Ortho), and Langdon Miller (CTEP/NCI)
are greatly appreciated. The expert secretarial assistance of Sara
Clarke and Vibeke Cleaver, and the statistical analysis by Byron
Brown, PhD, Stanford University Biostatistics Department, are
also appreciated.
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From www.bloodjournal.org by guest on February 11, 2015. For personal use only.
1993 82: 737-743
Treatment of the anemia of myelodysplastic syndromes using
recombinant human granulocyte colony-stimulating factor in
combination with erythropoietin [see comments]
RS Negrin, R Stein, J Vardiman, K Doherty, J Cornwell, S Krantz and PL Greenberg
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