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1149
Phase II Trial of Subcutaneously Administered
Granulocyte-Macrophage Colony-Stimulating Factor in
Patients with Metastatic Renal Cell Carcinoma
Edward WOS, D.0.’
Thomas Olencki, D.O.’,~
Laurie Tuason, M.S?
G. Thomas Budd, M.D.’
David Peereboom, M.D.”*
Kate Sandstrom, A.N.’
Denise McLain, B.S?
James Finke, P ~ . D . * , ~
Ronald M. Bukowski, M . D . ’ ~ ~ ~ ~
’
Department of Hematology and Medical Oncology, The Cleveland Clinic Foundation, Cleveland. Ohio.
Cancer Center Experimental Therapeutics Program, The Cleveland Clinic Foundation, Cleveland. Ohio.
Department of Biostatistics and Epidemiology,
The Cleveland Clinic Foundation, Cleveland,
Ohio.
Department of Immunology. The Cleveland
Clinic Foundation, Cleveland, Ohio.
This work was supported in part by a grant from
the Schering Plough Corporation.
Address for reprints: Ronald M. Bukowski,
MI.,The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.
Received October 18,1995;accepted December
a, 1995.
0
1996 American Cancer Society
BACKGROUND. Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a
cytokine that is involved in the differentiation and proliferation of various hematopoietic precursors. It also has been reported to enhance the antitumor activity of
various mature effector cells. Previous reports have noted preclinical antitumor
activity in a murine model utilizing genetically engineered tumor cells and instances of tumor regression in patients with solid tumors receiving GM-CSF. In
the present study, a Phase I1 trial of human recombinant GM-CSF (GM-CSF,,,) in
patients with metastatic renal cell carcinoma (RCC) was conducted to investigate
further the potential antitumor activity of this cytokine.
METHODS. Twenty-six eligible patients with metastatic RCC received 3 pglkg of
GM-CSF,,, subcutaneously for 14 days, with cycles repeated every 28 days.
RESULTS. Two of 26 patients (8%; 95% confidence interval 1-25%) demonstrated
partial tumor responses during GM-CSF,,, therapy. Both individuals who responded
had received prior therapy. A median of three cycles per patient were administered,
and toxicity was mild.
CONCLUSIONS. GM-CSFrhmay mediate tumor regression in patients with metastatic
RCC; however, the level of activity in previously treated patients is low. Cancer
1996; 7 2 1 149-53. 0 1996 American Cancer Society.
KEYWORDS: renal cell carcinoma, metastatic, GM-CSF, Phase II.
G
ranulocyte-macrophage colony stimulating factor (GM-CSF)is a cytokine that is responsible in part for differentiation and proliferation of
various hematopoietic precursors. Specifically, GM-CSF stimulates clonal
growth of CFU-GEMM,’ promotes granulocyte and macrophage differentiation and proliferation,* stimulates erythroid burst activity,‘ and may
initiate eosinophil and megakaryocytic differentiation.’ It is secreted primarily by activated CD4’ lymphocytes but also is produced by a wide
variety of cells including CD8’, B lymphocytes, endothelial cells, fibroblasts, and mast
Human CM-CSF is a homodimeric glycoprotein consisting of two
identical protein chains linked by disulfide bonds.’ When it is administered to either hematologically normal or leukopenic cancer patients,
there is a reversible, dose-dependent leukocytosis consisting of functionally normal granulocytes, monocytes, and eosin~phils.~-”
In addition,
this cytokine can enhance various activities of mononuclear effector cells.
In vitro studies have demonstrated that GM-CSF-treated monocytes display increased adherence, increased production of superoxides, interferon (IFN)a, interleukin (IL)-lp,1L-6,’*-I4 and tumoricidal activity.I3.l5
In vitro cytotoxic effects of GM-CSF have been demonstrated on
various human tumor cell lines,I6 including the U937 monoblast cell
1150
CANCER March 15,1996 I Volume 77 I Number 6
line.I7Finally, Dranoff et al.” have demonstrated in murine models that tumor cells genetically engineered to
produce GM-CSF can stimulate development of specific
antitumor immunity. Based on these findings and the
enhanced in vitro effector functions found in our recent
Phase I trial of GM-CSF in lung cancer patients,” a Phase
I1 trial of GM-CSF in patients with renal cell carcinoma
was initiated. This tumor was selected in view of reports
documenting responses to various cytokines, such as
IFNaL9and IL-2.” Our results demonstrate brief antitumor responses to systemically administered GM-CSF in
2 of 26 patients.
MATERIALS AND METHODS
Schering Plough Corporation (Kenilworth,NJ). GM-CSFm
was supplied as a lyophilized powder formulated with
mannitol, human serum albumin, polyethylene glycol,
and citratelphosphate buffer. The vials each contained
400 pg or 700 pg and were reconstituted with 0.25-1.0
ml of sterile water.
CM-CSFrhwas given subcutaneously at a dose of 3
pglkglday on days 1-14. Cycles were repeated every 4
weeks, unless excessive toxicity occurred or progressive
disease developed. Dose escalation was not permitted.
Patients who required corticosteroids, hormone therapy,
chemotherapy, or radiation therapy during GM-CSF,h
treatment were removed from the study.
Patient Selection
Patients were eligible if they had metastatic or surgically
unresectable renal cell carcinoma with objectively measurable disease and no clinically evident central nervous
system metastases. Eligibility criteria included histologically proven renal cell carcinoma with an Eastern Cooperative Oncology Group Performance Status of 0-2, age 2
18 years, and a minimum life expectancy of 3 months.
Adequate hematopoietic, renal, and hepatic function
were required and were defined as follows: white blood
cell W C ) count 2 3,500lp1, hemoglobin (Hgb) 2 9.5
gmldl, platelet count 2 100,000lp1, serum creatinine s
1.8 mgldl, and a total bilirubin of 51.5 mgldl. Normal
cardiovascular and pulmonary function were also required and were defined as the absence of a previous
history of serious cardiac arrhythmia, myocardial infarction, or congestive heart failure, and a New York Heart
Association classification of 4 1 . In addition, the absence
of significant effusions or ascites and a carbon monoxide
diffusing capacity D L o z 50% predicted were required.
Prior therapy with cytokines was allowed, but patients who had received prior GM-CSF were excluded.
One prior chemotherapy regimen or radiation therapy
was allowed, but it must have been completed >28 days
prior to the start of therapy, and prior surgery must have
been completed > 14 days before study entry. Patients
with recent infections requiring systemic antibiotics
within 21 days prior to study entry were ineligible.
Women of child-bearing age must have had a negative
pregnancy test or be using a method of contraception.
Informed consent, consistent with federal and institutional guidelines, was obtained from all patients. Exclusion criteria included history of malignancy other than
basal cell carcinoma or carcinoma in situ of the cervix
within the past 3 years, positive HIV or hepatitis serology,
or a requirement for corticosteroids.
Dose Modifications
The NCI common clinical toxicity criteria was employed
to assess side effects. In patients who developed Grade
I11 toxicity (with the exception of a fever), treatment was
withheld until there was a return to Grade I or normalization. GM-CSFrhwas then resumed at 1.5 pglkglday. Following reinstitution of treatment, recurrence of the identical Grade 111 toxicity required removal from the study.
Development of Grade IV toxicity required discontinuatiOn O f GM-CSF,h.
Dose modifications for leukocytosis were also employed. In patients with a total WBC = 75,000lp1, GMCSF,,, was withheld and was resumed at 1.5 pglkglday
when the WBC decreased to <75,OOO/pl. Recurrence of
leukocytosis after an initial dose reduction required a second 50% dose reduction of GM-CSFrh,and subsequent
recurrence required removal from the study. Dose modifications for thrombocytosis were also developed, but
they were not required during the trial.
Treatment
Human recombinant GM-CSF (GM-CSF,h) was obtained
from the National Cancer Institute and supplied by the
Statistical Considerations
A standard Phase I1 trial design was employed. Initially,
14 eligible patients were entered. If no responses were
Study Monitoring
AU studies were performed within 14 days prior to study
entry. These included a complete physical examination,
biochemical studies [total protein, albumin, calcium,
phosphorous, glucose, uric acid, total bilirubin, alkaline
phosphatase, serum lactic dehydrogenase (LDH),serum
glutamic oxaloacetic transaminase, sodium, potassium,
chloride, C02, blood urea nitrogen, and creatininel, a
complete blood count with differential, a chest x-ray, and
imaging studies to assess measurable disease. A head CT
scan was performed if it was clinically indicated.
Oral temperatures were obtained at baseline and
then daily (by the patient) during GM-CSF,h therapy.
Complete blood counts and biochemical studies were obtained weekly, and tumor measurements were obtained
prior to each cycle of GM-CSFrh.Previously reported response criteria and definitions were utilized.2’
Phase I1 Trial GM-CSF In Metastatic Renal Cell Carcinoma/Wos et al.
observed, then a response rate of <20% at the 95% confidence level would be estimated. In the presence of one
response, accrual was to continue until 25 evaluable patients had been treated. This allowed estimation of the
true response with a standard error of at most 10%. Summary statistics were calculated for all biochemical and
hematologic data. Response duration was defined as the
initial time of documented response to time of progressive disease.
RESULTS
From February, 1991, through June, 1994, 28 patients
were enrolled. Two patients were ineligible: one secondary to a positive hepatitis serology and the second because of excessive prior chemotherapy. The characteristics of the 26 eligible patients included a sex distribution
of 10 females and 16 males, a median age of 58.5 years
(range 31-80), and 22 patients with an Eastern Cooperative Oncology Group Performance Status of 0-1. The median performance status was 1, and 20 of 26 (77%) eligible
patients had received prior therapy. This included rIL-2
c I F N a (75%),IL-6 or IL-4 (30%), chemotherapy (25%),
or radiation therapy (15%).Of 26 patients, 19 (73%) had
undergone a prior nephrectomy. Sites of metastases included lungs (77%), liver (15%), and soft tissuellymph
nodes (23%).
The median number of cycles of GM-CSF,,, administered to patients was three (range 1-11), and 2 of 26
patients had partial responses (response rate 8%; 95%
confidence interval, 1-25%) during therapy. One patient
was a 49-year-old male with lung metastases who had
previously received IFNa. The second was a 31-year-old
male with lung metastases who had previously received
radiation therapy and the combination of fluorouracil, IL2, and IFNa. The response durations in these two patients
were 1 and 2 months, respectively.
The most common adverse events seen included
mild-to-moderate arthralgias (69%), feverlchills (81%),
and erythema and/or rash (69%).Several Grade 111-IV toxicities occurred during GM-CSFrhadministration, including neutropenia (two patients), elevated partial thromboplastin time (one patient), alkaline phosphatase (two patients), total bilirubin (two patients), serum glutamic
pyruvic transaminase (one patient), as well as hypercalcemia (two patients) and hyperglycemia (one patient).
These toxicities did not require dose modifications or
postponement of GM-CSFrhadministration, and the majority were disease related.
The hematologic effects of GM-CSF,,, were observed
in all patients and included leukocytosis and neutrophilia. In addition, most patients had transient eosinophilia. During cycle 1, the median peak neutrophil level
was 19,3OO/p1and occurred between days 11- 14. Monocytosis was also noted, with a median peak value of 1,250/
1151
occurring between days 8- 19 (median day 15). Thrombocytosis associated with GM-CSFrhadministration was
not seen.
p1
DISCUSSION
The potential antitumor effects of GM-CSF have been
demonstrated both in vitro and in murine tumor models.” The present study was the first Phase I1 trial to address this issue in patients with metastatic malignancy.
Our results demonstrate minimal antitumor activity in a
population comprised predominantly of previously
treated patients with metastatic RCC. Both individuals
who responded had lung lesion(s) and a performance
status of 51. These latter characteristics have been associated with response to other biologic response modifiers.‘‘ The hematopoietic effects of GM-CSFrhwere similar
to those reported by previous investigators.””
The toxicity of E. coli-derived GM-CSFrhin this trial
was mild, and repetitive administration was well tolerated. The majority of the Grade I11 and IV adverse events
were disease related and were concentrated in a few individuals. One patient with liver involvement and a prior
history of hypercalcemia developed increasing alkaline
phosphatase (Grade 111) and recurrent hypercalcemia
(Grade IV)while in the study. A second patient with progressive liver involvement developed Grade 111 elevation
of alkaline phosphatase, serum glutamic pyruvic transaminase, and total bilirubin. An additional two patients
developed transient neutropenia on day 1 of GM-CSF,,,
therapy, which resolved by day 4 of the cycle. This was
likely secondary to margination and has been described
previously secondary to GM-CSF.23
Reports of tumor regression associated with GM-CSF
administration have been uncommon. A Phase I study
utilizing daily short infusions of GM-CSFrhnoted one objective response in a patient with metastatic sarco~na.’~
In a Phase I1 trial of concomitant subcutaneous IFN-a2b
and GM-CSFrh,two partial responses in 15 patients were
reported.” In a recent report by Edmonson et al,‘“ 15
patients with advanced and refractory sarcomas receiving
chemotherapy (ifosfamide, mesna, doxorubicin, and cisplatin, withlwithout mitomycin C) received GM-CSF,,,
post-therapy, and, in several individuals, it was also administered prior to treatment. Responses occurred in 10
of 15 (66%)patients, and the authors speculate that GMCSF,, may have played a role in producing this unexpectedly high response rate in this group of patients, who are
generally refractory to chemotherapy.
The antitumor effects of GM-CSF have been best
demonstrated in murine tumor models in which mice
were vaccinated with irradiated tumor cells transduced
with the GM-CSF gene.” Paracrine production of this cytokine appeared to mediate protection from secondary
challenge with wild type tumor cells and produced tumor
1152
CANCER March 15,1996 I Volume 77 / Number 6
mononuclear cell infiltrates consisting of b o t h CD4' and
CD8' lymphocytes. These vaccinated animals developed
specific and long-lasting antitumor immunity. In a subseq u e n t report," gelatin-chondroitin sulfate microspheres
containing GM-CSF had effects similar t o genetically altered t u m o r cells. These investigators have speculated
that the antitumor effects seen were related t o t h e enh a n c e m e n t of dendritic cell numbers and function by
GM-CSF." Phase I trials in human malignancies, including renal cell carcinoma, are now underway utilizing genetically altered autologous t u m o r cells.
In the present study, clear but short-lived antitumor
effects were seen in several patients receiving GM-CSF,,,.
It is possible that these responses were unrelated to GMCSFrh administration and were instances of s p o n t a n e o u s
r e g r e s s i ~ n . *The
~ ~ ~rarity
~
of this phenomenon3' makes
this unlikely, however. The mechanisms responsible for
t h e t u m o r regressions observed in GM-CSF-treated patients are unclear. Preclinical studies suggest that CD8'
and CD4' lymphocytes andlor monocytes'8 may be involved. In addition, t h e possibility that GM-CSF enhances
t h e numbers andlor function of dendritic or antigen-processing cells is also a c o n ~ i d e r a t i o n . Systemic
~'
administration of GM-CSF,h t o patients with large t u m o r burdens
is clearly different than t h e murine model of paracrine
GM-CSF production reported by Dranoff et al." It is of
interest, however, that clinical t u m o r responses were seen
in the present study and developed in patients with prior
therapy. The responses were brief, b u t t h e toxicity of GMCSF,h, even in patients receiving repetitive cycles, was
mild. The antitumor activity of this cytokine appears minimal, b u t additional trials of GM-CSF in previously untreated patients, as a part of combination regimens or
administered with autologous t u m o r vaccines, may be
avenues worthy of exploration.
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