G-CSF and GM-CSF in Hrishikesh M. Mehta, Michael Malandra and Seth J. Corey J Immunol 2015; 195:1341-1349; ; This information is current as doi: 10.4049/jimmunol.1500861 of September 27, 2021. http://www.jimmunol.org/content/195/4/1341 Downloaded from References This article cites 114 articles, 50 of which you can access for free at: http://www.jimmunol.org/content/195/4/1341.full#ref-list-1

Why The JI? Submit online. http://www.jimmunol.org/ • Rapid Reviews! 30 days* from submission to initial decision

• No Triage! Every submission reviewed by practicing scientists

• Fast Publication! 4 weeks from acceptance to publication

*average by guest on September 27, 2021 Subscription Information about subscribing to The Journal of Immunology is online at: http://jimmunol.org/subscription Permissions Submit copyright permission requests at: http://www.aai.org/About/Publications/JI/copyright.html Email Alerts Receive free email-alerts when new articles cite this article. Sign up at: http://jimmunol.org/alerts

The Journal of Immunology is published twice each month by The American Association of Immunologists, Inc., 1451 Rockville Pike, Suite 650, Rockville, MD 20852 Copyright © 2015 by The American Association of Immunologists, Inc. All rights reserved. Print ISSN: 0022-1767 Online ISSN: 1550-6606. Th eJournal of Translating Immunology Immunology

G-CSF and GM-CSF in Neutropenia Hrishikesh M. Mehta,* Michael Malandra,† and Seth J. Corey*,‡ G-CSF and GM-CSF are used widely to promote the differentiation of hematopoietic stem, progenitor, and precursor production of granulocytes or APCs. The U.S. Food cells to a terminally differentiated, functional cell type. Colony- and Drug Administration approved G-CSF (filgrastim) forming assays identified the ability of first crude supernatants, for the treatment of congenital and acquired neutrope- and then highly purified cytokines, to drive multi-lineage and nias and for mobilization of peripheral hematopoietic single-lineage differentiation. After coculturing for 7–14 d, col- progenitor cells for stem cell transplantation. A polyeth- onies from mononuclear cells obtained from the mouse spleen or ylene glycol–modified form of G-CSF is approved for were measured in semisolid medium. Based on the the treatment of neutropenias. Clinically significant characteristics of cells within a single colony, the lineage(s) governed by the cytokine was determined. Granulocytes make

neutropenia, rendering an individual immunocompro- Downloaded from mised,occurswhentheirnumberis,1500/ml. Current up the majority of WBCs in human circulation and play an guidelines recommend their use when the risk for febrile integral role in innate and adaptive immunity. In granulopoi- neutropenia is .20%. GM-CSF (sargramostim) is ap- esis, their production is mediated by a number of growth fac- proved for neutropenia associated with stem cell trans- tors, especially G-CSF and GM-CSF (3, 4). Due to asymmetric division, some daughter cells of the hematopoietic stem cell plantation. Because of its promotion of APC function, (HSC) remain as HSCs, preventing the depletion of the stem http://www.jimmunol.org/ GM-CSF is being evaluated as an immunostimulatory cell pool (5). Multiparameter immunophenotyping has trans- adjuvant in a number of clinical trials. More than 20 formed our ability to identify different cell types in hemato- . 2 1 1 million persons have benefited worldwide, and $5 bil- poiesis. Murine HSCs are characterized as lin sca1 c-kit ,and lion in sales occur annually in the United States. The human HSCs display CD34 in the absence of lineage markers. Journal of Immunology, 2015, 195: 1341–1349. The differentiation pathway from HSCs to granulocytes is de- pendent on G-CSF and, less so, on GM-CSF. The HSC gives ew physician-scientists have made as great an impact on rise to a common myeloid progenitor and a common lymphoid our understanding of hematology or improved the lives progenitor cell (6). The common myeloid progenitor cells dif- by guest on September 27, 2021 F of patients, estimated at .20 million (1), with blood ferentiate into myeloblasts, erythrocytes, and megakaryocytes via and cancer disorders as Don Metcalf, who died in December at least two intermediates: the granulocyte/monocyte progenitor of 2014. Laboring at the Walter and Eliza Hall Institute in cell and the erythrocyte/megakaryocyte progenitor cell. In the granulocytic series, myeloblasts (15–20 mm) are the first rec- Melbourne, Australia throughout his 50-year career, Metcalf ognizable cells by their scant cytoplasm, absence of granules, used semisolid medium and cell culture supernatants to and fine nucleus with nucleoli in the bone marrow clearly discover hematopoietic progenitor cells (e.g., granulocyte/ committed to differentiation to granulocytes. Myeloblasts dif- macrophage colonies) and their growth factors (e.g., G-CSF ferentiate into promyelocytes, which are larger (20 mm) and and GM-CSF). Increased purification of these and related begin to possess granules (Fig. 1B). Promyelocytes give rise to growth factors, sometimes from hundreds of mice injected neutrophilic, basophilic, and eosinophilic precursor cells. Cell with endotoxin, led to the molecular characterization and division continues through the promyelocyte stage. Fine specific cloning of G-CSF, GM-CSF, M-CSF, stem cell factor, and granules containing inflammatory-related proteins appear dur- IL-3 in the 1980s (2). ing myelocyte maturation. For , their size and Hematopoiesis is a highly proliferative (∼1010 cells/d) dy- nuclei become increasingly more condensed as the cells namic process driven by multiple hematopoietic growth mature through myelocyte, metamyelocyte, band, and the ter- factors/cytokines (Fig. 1A). The hematopoietic growth factors minally differentiated (polymorphonuclear and ∼15 are multifunctional and are critical for proliferation, survival, and mm). During episodes of stress, such as , band cells can

*Division of Hematology, Oncology and Stem Cell Transplantation, Department of 1101 East Marshall Street, P.O. Box 980121, Richmond, VA 23298. E-mail address: Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago and Robert H. [email protected] Lurie Comprehensive Cancer Center, Chicago, IL 60611; †Division of Gastroenterol- Abbreviations used in this article: AML, acute myeloid leukemia; ANC, absolute neu- ogy, Hepatology, and Nutrition, Department of Pediatrics, Ann and Robert H. Lurie ‡ trophil count; ASCO, American Society of Clinical Oncology; FDA, U.S. Food and Children’s Hospital of Chicago, Chicago, IL 60611; and Department of Cell and Drug Administration; HSC, hematopoietic stem cell; IBD, inflammatory bowel disease; Molecular Biology, Northwestern University Feinberg School of Medicine, Chicago, IST, immunosuppressive therapy; MDS, myelodysplastic syndrome; NHL, non-Hodgkin’s IL 60611 lymphoma; PAP, pulmonary alveolar proteinosis; SAA, severe aplastic anemia; SCN, severe This work was supported by the National Institutes of Health, the American Society of congenital neutropenia. Hematology, the Leukemia and Lymphoma Society, and the Cures Within Reach Foun- dation (all to S.J.C.). Copyright Ó 2015 by The American Association of Immunologists, Inc. 0022-1767/15/$25.00 Address correspondence and reprint requests to Dr. Seth J. Corey at the current address: Virginia Commonwealth University Massey Cancer Center Sanger Hall, Room 12-024,

www.jimmunol.org/cgi/doi/10.4049/jimmunol.1500861 1342 TRANSLATING IMMUNOLOGY: G-CSF AND GM-CSF IN NEUTROPENIA Downloaded from http://www.jimmunol.org/ by guest on September 27, 2021

FIGURE 1. (A) Schematic diagram of hematopoiesis from the multipotential HSC to fully differentiated cell types. Principal cytokines that determine dif- ferentiation patterns are shown in red. (B) The stages of granulopoiesis from myeloblast to the mature granulocyte. During neutrophil maturation, which is driven primarily by G-CSF, granulocytic cells change shape, acquire primary and specific granules, and undergo nuclear condensation. Epo, erythropoietin; SCF, stem cell factor; SDF-1, stromal cell–derived factor-1; TPO, thrombopoietin. be found in the peripheral blood and are used as a measure of nies containing both granulocytes and macrophages. Gener- inflammation. The above process is complex, dynamic, and ation of G-CSF (Csf3)- and G-CSFR (Csf3r)-knockout mice orchestrated by multiple cytokines and their receptors, most confirmed that G-CSF critically drives granulopoiesis (7). The notably G-CSF and GM-CSF. cognate receptor for G-CSF is a single-transmembrane receptor Following Ag stimulation or activation by cytokines, such that homodimerizes upon G-CSF binding. Unlike G-CSF, as IL-1, IL-6, and TNF-a, macrophages, T cells, endothelial GM-CSF functions via a two-receptor system involving a spe- cells, and fibroblasts produce and secrete G-CSF and GM- cific a-chain and a common b-chain shared by IL-3 and IL-5 CSF. Of unknown significance, a variety of tumor cells also (8). However, GM-CSF–knockout mice did not display a per- produce these paracrine growth factors. Glycoproteins with turbation in hematopoiesis (9, 10). Both G-CSF and GM-CSF a molecular mass ∼ 23 kDa, G-CSF and GM-CSF, are now signal through pathways involving JAK/STAT, SRC family produced through recombinant technology in either Escher- kinases, PI3K/AKT, and Ras/ERK1/2. The receptor complexes ∼ ichia coli or yeast. G-CSF induces the appearance of colonies are characterized by high-affinity (apparent KD 100–500 pM) containing only granulocytes, whereas GM-CSF gives colo- and low-density (50–1000 copies/cell). Interestingly, human The Journal of Immunology 1343

G-CSF is functionally active on murine myeloid cells, but formation of SCN to myelodysplastic syndromes (MDSs) or human GM-CSF is not. The signaling specificity likely involves AML, associated with acquired mutations in G-CSFR. nuances in the proximal postreceptor phosphoprotein networks and the distal gene regulatory networks. The molecular path- G-CSF and GM-CSF signaling pathways and functional consequences ways and their cross-interactions in determining lineage speci- The receptors for both GM-CSF and G-CSF belong to the ficity are critical to the development of more specific therapies. hematopoietin/cytokine receptor superfamily. G-CSFR acts as a Cloning of human GM-CSF and its expression in bacterial homodimer, whereas GM-CSFR is a heterodimer with a shared and eukaryotic cells were achieved in 1985 at the Genetics b-chain with the IL-3R and IL-5R complexes. G-CSFR is Institute (11), and cloning of G-CSF and its expression in expressed primarily on neutrophils and bone marrow precursor E. coli was achieved a year later at Amgen (12). Commercial- cells, which undergo proliferation and eventually differentiate ized by these biotechnology start-ups, G-CSF and GM-CSF into mature granulocytes. G-CSF binds to G-CSFR, resulting revolutionized the treatment of patients with congenital or in its dimerization, with a stoichiometry of 2:2 and with a 5 acquired neutropenias and those undergoing stem cell trans- high affinity (KD 500 pM) (14, 15). Among the activated plantation. Sidelined from the treatment of neutropenias by its downstream signal-transduction pathways are JAK/STAT, Src toxicity profile, GM-CSF is now undergoing a renaissance as kinases, such as Lyn, Ras/ERK, and PI3K (16). The cytoplas- an immunomodulatory agent. mic domain of G-CSFR possesses four tyrosine residues (Y704, G-CSF is approved by the U.S. Food and Drug Adminis- Y729, Y744, Y764) serving as phospho-acceptor sites (17, 18). tration (FDA) for use to decrease the incidence of infection in Src homology 2–containing proteins STAT5 and STAT3 bind Downloaded from patients with nonmyeloid malignancies receiving myelosup- to Y704 and Gab2 to Y764. Grb2 couples to both Gab2 and to pressive anticancer drugs associated with a significant incidence SOS, permitting signaling diversification, such as Ras/ERK, of severe neutropenia with ; reduce the time to neutrophil PI3K/Akt, and Shp2 (19, 20). An alternatively spliced iso- recovery and the duration of fever following induction or form of G-CSFR elicits activation of a JAK/SHP2 pathway consolidation treatment of patients with acute (15). The precise physiological roles of protein kinases and myeloid leukemia (AML); reduce the duration of neutropenia their downstream events in G-CSF–induced signaling remain http://www.jimmunol.org/ and febrile neutropenia in patients with nonmyeloid malig- unclear, although some clues are beginning to emerge (21, 22). nancies undergoing myeloablative chemotherapy followed by GM-CSF binds to the a-chain of the GM-CSFR with a 5 5 stem cell transplantation; mobilize hematopoietic progenitor low affinity (KD 0.2–100 nM), but a higher affinity (KD cells into the peripheral blood for collection by leukapheresis; 100 pM) occurs in the presence of both subunits. GM-CSF and reduce the incidence and duration of complications of signaling involves the formation of dodecameric supercomplex severe neutropenia in symptomatic patients with congenital that is required for JAK activation (23). In addition to the JAK/ neutropenia, , or idiopathic neutropenia. STAT pathway, GM-CSF activates the ERK1/2, PI3K/Akt,

Forms of G-CSF available worldwide include filgrastim, and IkB/NF-kB pathways. Although the a-chain is primarily by guest on September 27, 2021 pegfilgrastim, and lenograstim. considered a ligand-recognition unit, it interacts with Lyn, GM-CSF is approved by the FDA to accelerate myeloid resulting in JAK-independent Akt activation of the survival recovery in patients with non-Hodgkin’s lymphoma (NHL), pathway (24). Thus, differences in receptor expression patterns acute lymphoblastic leukemia, and Hodgkin’s disease under- and known and unknown nuances in signaling pathway circuits going autologous stem cell transplantation; following induction account for the functional differences between G-CSF and chemotherapy in older adult patients with AML to shorten GM-CSF. time to neutrophil recovery and reduce the incidence of life- G-CSF and GM-CSF are pleiotropic growth factors, with threatening ; to accelerate myeloid recovery in overlapping functions. GM-CSF also shares properties with patients undergoing allogeneic stem cell transplantation from M-CSF on monocyte function (25). Both GM-CSF and G-CSF HLA-matched related donors; for patients who have undergone increase chemotaxis and migration of neutrophils, but response allogeneic or autologous stem cell transplantation in whom kinetics may differ. GM-CSF may be considered to be more engraftment is delayed or failed; and to mobilize hemato- proinflammatory than G-CSF. GM-CSF increases cytotoxic poietic progenitor cells into peripheral blood for collection killing of Candida albicans, surface expression of Fc- and by leukapheresis. Forms of GM-CSF available worldwide are complement-mediated cell-binding (FcgR1, CR-1, CR-3), sargramostim and molgramostim. and adhesion receptor (14). Yet, both cytokines promote The recommended dosage for G-CSF is 5 mg/kg/d and for neutrophil phagocytosis (26). More extensive reviews on GM-CSF is 250 mg/m2/d. Both drugs may be given s.c. or G-CSF and GM-CSF function in neutrophils may be found i.v., although randomized clinical trials demonstrate greater (27, 28). efficacy (i.e., decreased duration of neutropenia) without a dif- ference in toxicity for the s.c. route (13). For chemotherapy- Acquired and congenital neutropenia induced neutropenia, G-CSF is administered until there are An absolute neutrophil count (ANC) , 1500/ml is defined as .1000 neutrophils/ml. For congenital neutropenias, the goal is neutropenia, which is graded on the severity of decreased to maintain neutrophil counts ∼ 750/ml. G-CSF is well toler- ANC (Table I). Causes for neutropenia may be congenital ated. Transient fever and bone pain are more commonly ob- or, more commonly, acquired. Neutropenia may be asymp- served in those receiving GM-CSF. Pleural and/or pericardial tomatic until an infection occurs. Benign neutropenia exists, effusions can also occur in those receiving GM-CSF. Long-term and the individuals are not at risk for serious infection. side effects of G-CSF administration, such as osteopenia, are However, onset of fever with neutropenia, termed febrile being monitored in patients with severe congenital neutropenia neutropenia, commonly occurs as a potentially life-threatening (SCN). One concern is that G-CSF may accelerate the trans- complication of chemotherapy and involves considerable cost as 1344 TRANSLATING IMMUNOLOGY: G-CSF AND GM-CSF IN NEUTROPENIA

Table I. Correlation of neutropenia with absolute neutrophil count displayed a restoration of ANC from grade 4 to normal levels. The increase in ANC resulted from increased production of Neutropenia Grade Absolute Neutrophil Count neutrophils in bone marrow. Infection-related incidents were Grade 1 $1.5 to ,2 3 109/ml reduced by ∼50% (p , 0.05), and use was reduced Grade 2 $1to,1.5 3 109/ml by 70%. , 3 9 Grade 3 $0.5 to 1 10 /ml One particular form of inherited neutropenia is WHIM Grade 4 ,0.5 3 109/ml (warts, hypogammaglobulinemia, infections, and myeloka- thexis) syndrome (40). Myelokathexis refers to a build-up of a result of treatment with i.v. and prolonged hospi- mature neutrophils in the bone marrow. Mutations in CXCR4 talization. In addition, febrile neutropenia prevents continuation result in the syndrome (41). CXCR4 and its ligand SDF-1 of chemotherapy until recovery from it occurs. According to the mediate the retention of neutrophils. G-CSF administration Norton–Simon hypothesis (29), the efficacy of chemotherapy is leads to upregulation of SDF-1 and the subsequent release of reduced if stopped midway. A pause in treatment allows re- neutrophils into the peripheral circulation (42). A recently covery of the cancer cells and facilitates the emergence of chemo- published phase 1 study demonstrated the safety and efficacy resistant clones (29–31). Neutropenia also occurs secondary to of low-dose plerixafor, a CXCR4 antagonist (43). One widely bone marrow infiltration with leukemic or myelodysplastic cells. used indication for G-CSF is to mobilize and harvest hema- Neutropenia results from a growing list of germline mu- topoietic progenitor cells into the periphery for stem cell tations in genes, such as ELANE, HAX1, GFI1, G6PC3, WAS, transplantation (44), and the concomitant use of plerixafor Downloaded from and CSF3R (32). Soon after birth, children with SCN develop enhances the mobilization (45). a grade 4 neutropenia. SCN is a lifetime condition resulting Neutropenia associated with aplastic anemia from increased apoptosis of granulocytic progenitors in the marrow. As a result of the severity and chronic nature of Severe aplastic anemia (SAA) is a disease in which stem cells SCN, individuals are prone to recurrent infections, especially residing in the bone marrow are damaged, leading to a defi- from the endogenous flora in the gut, mouth, and skin. Most ciency in all hematopoietic cell lines. SAA has a high mortality, http://www.jimmunol.org/ cases of SCN are due to de novo mutations. Transmission but the 5-y mortality is reduced to ,10% with matched sibling may be autosomal dominant, recessive, or X-linked. The most stem cell transplantation or to 30% with immunosuppressive common mutation involves ELANE and is autosomal domi- therapy (IST) (46). IST includes antithymocyte globulin, cy- nant (33, 34). Mutations in ELANE encode the neutrophil closporine, and glucocorticoids. The addition of G-CSF to IST elastase, a serine protease. ELANE is expressed during gran- was studied in a number of randomized studies. It was shown ulopoiesis, maximally at the promyelocyte stage. It is hy- that G-CSF reduces the number of infectious complications pothesized that mutations in ELANE cause neutropenia via and hospital days compared with standard therapy alone; improper folding of the protein that triggers the unfolded however, its addition did not affect overall survival rates (47, by guest on September 27, 2021 protein response. Unfolded protein response–generated stress 48). Although treatment with G-CSF or GM-CSF results in drives apoptosis due to an overload of unfolded protein, and a neutrophil response, a sustained trilineage response was un- an arrest in differentiation at the promyelocyte stage is ob- common when used alone or in combination with other he- served. Fascinatingly, ELANE mutations are also associated matopoietic growth factors (49, 50). The response to G-CSF with cyclic neutropenia. Cyclic neutropenia is characterized may have prognostic value. Patients treated with IST plus by granulocyte nadirs , 200/ml occurring every 21 d. G-CSF who did not achieve a WBC count $ 5000/mlhada Patients with SCN are always at risk for life-threatening low probability of response and high mortality (51–53). Sim- infections. Early phase 1 clinical trials held in 1989 (35, 36) ilarly, GM-CSF was studied as a potential adjunct to IST with evaluated G-CSF therapy for SCN and cyclic neutropenia. similar results (48). These finding suggest that G-CSF and Both trials demonstrated a $10-fold increase in neutrophil GM-CSF may be useful adjuncts to standard IST for SAA. counts, reducing the severity of neutropenia from grade 4 to grade 1 to normal counts. A reduction in the days of cyclic Neutropenia associated with chemotherapy for solid tumors neutropenia from 21 to 14 d was observed, and a consistent In 1991, the FDA approved the use of recombinant human increase in ANC was observed in SCN. In 1990, two studies G-CSF (filgrastim) to treat cancer patients undergoing mye- explored the benefit of G-CSF versus GM-CSF in treating lotoxic chemotherapy. Multiple factors affect the severity of congenital neutropenia. Gray collie dogs with cyclic neu- neutropenia, with the most important being the type and tropenia due to mutations in the endocytosis gene AP3B1 severity of chemotherapy dosage and the underlying disease (37) were studied with three cytokines: G-CSF, GM-CSF, (54, 55). In 1994, the American Society of Clinical Oncology and IL-3. GM-CSF and G-CSF showed an expansion of (ASCO) recommended primary prophylaxis with G-CSF or neutrophil counts, but only G-CSF prevented the cycling of GM-CSF for the expected incidence of neutropenia $ 40% hematopoiesis (10). Similar to the dog study, G-CSF therapy (56). The purpose of the guidelines was to reduce the inci- increased ANC, whereas GM-CSF therapy increased eosino- dence and length of neutropenia and, thus, the time of hos- phil counts but not neutrophil counts (38). Following the pitalization, which would reduce costs significantly. Three beneficial effects of G-CSF in the above phase 1/2 studies, prospective, randomized, placebo-controlled trials formed the a phase 3 clinical trial was performed in 1993 (39). Patients basis of the recommendations. The first phase 3 trial tested the with SCN, cyclic neutropenia, and idiopathic neutropenia applicability of G-CSF as an adjunct to chemotherapy in (n 5 123) were included in the study. Patients were randomly patients treated for small cell lung cancer with cyclophospha- treated immediately or after a 4-mo observation period. Al- mide, doxorubicin, and etoposide (57). A major outcome of most all of the patients (108/120) receiving G-CSF therapy the study was the significant reduction by at least one episode The Journal of Immunology 1345 of febrile neutropenia in 77% of those treated with G-CSF similar or greater improvement in the ANC after chemotherapy versus 40% in the placebo group. A reduction in the median compared with daily doses of filgrastim (68). The randomized, duration of grade 4 neutropenia was observed in all cycles of placebo-controlled trial conducted with 928 patients demon- chemotherapy (1 d in the G-CSF group versus 6 d in the strated a lower incidence of febrile neutropenia in patients placebo group). From a cost-benefit perspective, the data receiving pegfilgrastim (1%) compared with placebo (17%). translated into a reduction in the 50% incidence of infection, Hospitalization also was reduced in the pegfilgrastim group antibiotic treatment, and days of hospitalization with G-CSF (1%) compared with the placebo group (14%). In 2005 and treatment versus placebo. A similar study performed in Europe 2006, the National Comprehensive Cancer Network (http:// in patients with small cell lung cancer also found that pro- www.nccn.org) and ASCO changed the risk threshold for phylactic G-CSF treatment reduced the incidence of febrile contracting neutropenia from 40 to 20% to justify the use neutropenia (53% in placebo group versus 26% in G-CSF of myeloid growth factors as an adjuvant to chemotherapy group) (58). A reduction in chemotherapy dose by 15% was in treating neutropenia (69). The use of myeloid growth indicated in 61% of the placebo group versus 29% of the G-CSF factors, their cost effectiveness, and the duration of their use group. A gap $ 2 d in the chemotherapy treatment group during chemotherapy remain of great interest to clinical oncol- was observed for 47% of patients in the placebo group and ogists. A randomized phase 3 study with a noninferiority design 29% of the patients in the G-CSF group. The third trial in- demonstrated the efficacy of G-CSF prophylaxis against febrile vestigated G-CSF therapy in NHL treated with vincristine, neutropenia in women with breast cancer for the entirety of doxorubicin, prednisolone, etoposide, cyclophosphamide, and their myelosuppressive treatment (70). Current guidelines Downloaded from bleomycin (59). The incidence of neutropenia was reduced for from ASCO, the National Comprehensive Cancer Network, the G-CSF group (23%) versus the placebo group (44%), with and the European Organization for Research and Treatment fewer delays and shorter duration of treatment in the G-CSF– of Cancer recommend the use of myeloid growth factors when treated group. In comparison, GM-CSF trials provided less the risk for febrile neutropenia is $20% (71, 72). convincing data. In a trial for cyclophosphamide, vincristine, procarbazine, bleomycin, prednisolone, doxorubicin, and Neutropenia associated with leukemia http://www.jimmunol.org/ mesna administered as therapy for NHL, the use of mol- Neutropenia in patients with leukemia results from both the gramostim (GM-CSF) resulted in faster recovery from neu- underlying disease and aggressive chemotherapy. The ASCO tropenia and reduced hospitalization, but the benefit was guidelines developed in 1994, like for solid tumors, considered limited to only 72% of the patients that could tolerate GM- data obtained from three large randomized trials. Unlike the CSF (60). Another trial with small cell lung cancer did not solid tumor trials, two of the three trials used GM-CSF versus show any significant effect with molgramostim treatment (61). G-CSF. The two GM-CSF trials reported conflicting findings, The development of better chemotherapeutic regimens that with some statistical significance in the recovery of ANC but no were less myelotoxic provided more cost-effective options significant reduction in hospitalization or the incidence of serious by guest on September 27, 2021 compared with CSF therapy. In many cases, the incidence of infections (73, 74). The G-CSF trial showed a recovery in ANC, neutropenia was reduced to #10%. However, the advantage reduction in days of neutropenia, and a trend toward better of CSF therapy in both increasing the intensity and mainte- recovery rates. However, like the GM-CSF trials, no improve- nance of dose versus the cost of the growth factors was actively ment in days of hospitalization or usage of antibiotics was ob- debated. In 2003, a large randomized study showed the served (75). Thus, a beneficial response by the growth factors benefit of G-CSF therapy with dose-dense chemotherapy was not observed in leukemia. However at the time of ASCO’s (cyclophosphamide, paclitaxel, and doxorubicin) in patients 2000 guidelines, newer placebo-controlled trials demonstrated with node-positive breast cancer (62). Significantly improved a reduction in neutrophil recovery time from 6 to 2 d and re- disease-free survival (risk ratio 5 0.74; p 5 0.01) and overall duced hospitalization times in the setting of induction chemo- survival (risk ratio 5 0.69, p 5 0.013) were observed in therapy (76). The 2000 ASCO guidelines also identified a patients receiving G-CSF. Fewer patients reported grade 4 potential benefit for growth factor therapy in consolidation neutropenia in the G-CSF group (6%) compared with the chemotherapy. The 2006 update did not introduce any signif- non–G-CSF group (33%). In 2004, two additional studies icant changes and recommended the application of CSF therapy with old (60–75 y) and young (,60 y) NHL patients ob- postinduction and consolidation therapy (69). served a reduction in chemotherapy regimens from 3 to 2 wk Unlike chemotherapy-induced neutropenia, congenital neu- combined with an improvement in the rate of progressive tropenia patients experience neutropenia for life and require disease and overall survival (63, 64). In 2005, two large trials long-term treatment with G-CSF. The long-term effects of supported the use of G-CSF in reducing the incidence of fever G-CSF therapy have become important in the management of and neutropenia and suggested its use with the first cycle of congenital neutropenia. Patients receiving G-CSF therapy for as chemotherapy (65, 66). The first study compared the effect of long as 8 y were evaluated for safety and efficacy (77). Neu- antibiotics versus antibiotics 1 G-CSF in small cell lung trophil counts were maintained without exhaustion of myelo- cancer patients undergoing cyclophosphamide, doxorubicin, poiesis. A significant improvement in the quality of life was and etoposide treatment. A significant reduction in the inci- achieved by the reduction in antibiotic treatment and hospi- dence of febrile neutropenia was observed for the antibiotics 1 talization time, allowing for normal growth, development, and G-CSF group (10%) compared with the antibiotics-only participation in normal daily activities. The SCN international group (24%) (66). The second study investigated the effect registry was formed in 1994 to further assess the progress of of pegfilgrastim in breast cancer patients treated with docetaxel SCN patients being treated with G-CSF. A 10-y report that (65). Approved in 2001, pegfilgrastim was developed to im- followed patients with SCN (n 5 526) who were being treated prove the renal clearance rate (67), and a single dose provided with G-CSF was released in 2006 (78). Consistent with pre- 1346 TRANSLATING IMMUNOLOGY: G-CSF AND GM-CSF IN NEUTROPENIA vious reports, an increase in ANC was observed in majority of G-CSF and/or GM-CSF may improve chemotherapy and the patients with an overall improvement in quality of life. immunotherapy of hematologic malignancies and nonblood Leukemia transformation is significantly higher in SCN cancers. For instance, these myeloid growth factors can recruit patients, and the SCN international registry reported that 21% quiescent leukemic cells into the cell cycle for enhanced killing of patients with SCN developed leukemia while being treated from cell cycle–specific chemotherapy (74, 97). As a proin- with G-CSF. Although leukemic transformation has been flammatory cytokine, GM-CSF is being used to promote reported in SCN patients before the development of G-CSF dendritic cell activity in a variety of anticancer trials. Indeed, therapy (79), the precise role of G-CSF therapy in leukemic GM-CSF is approved as part of the sipuleucel-T regimen for transformation remains unknown. Almost all SCN patients the treatment of hormone-resistant prostate cancer. There, undergo G-CSF therapy; thus, it is difficult to assess leukemic dendritic cells are incubated with a fusion protein consisting of transformation in the absence of G-CSF treatment. However, prostatic acid phosphatase and GM-CSF. Although sipuleucel- patients who require higher doses of G-CSF are at a higher T has been underused, in part because of its expense, GM-CSF risk for developing MDS/AML (80). is being studied in the context of other immunotherapeutic Germline mutations in CSF3R, which encodes G-CSFR, are interventions (https://clinicaltrials.gov). infrequent causes of SCN and result in refractoriness to fil- G-CSF has immunomodulatory effects on immune cells. grastim (81). Acquired nonsense mutations in CSF3R were ob- G-CSF enhances Ab-dependent cellular cytotoxicity and cyto- served in ∼80% of SCN patients who progressed to secondary kine production in neutrophils (98). However, it also inhibits

MDS/AML (82–86). The nonsense mutations result in deletion TLR-induced proinflammatory cytokines produced by mono- Downloaded from 1 of the C terminus of G-CSFR, resulting in the loss of one to all cytes and macrophages (99). CD34 monocytes that inhibit four tyrosine residues and the inability to undergo normal graft-versus-host disease are mobilized in response to G-CSF ligand-induced internalization and endosomal routing (87, 88). (100). In addition, G-CSF inhibits LPS-induced IL-12 pro- The truncated receptor mutants produce a phenotype of en- duction from bone marrow–derived dendritic cells cultured in hanced proliferation and impaired differentiation in response to vitro (101). Interestingly, administration of GM-CSF has the

G-CSF. Furthermore, knock-in mice harboring a similar mu- opposite effect, inducing cytokine production in the circulation http://www.jimmunol.org/ tation showed hyperproliferative responses to G-CSF adminis- in response to LPS (102). tration and strongly prolonged activation of STAT5, which are GM-CSF pathways may be high-value targets in autoim- implicated in increased hematopoietic progenitor stem cell ex- mune diseases. For example, inflammatory bowel disease pansion in vivo (89). This prediction was validated in a patient (IBD) is a chronic inflammatory condition of the gastroin- with SCN who developed secondary AML concomitant with testinal tract caused by a combination of environmental and a nonsense mutation of G-CSFR. Upon discontinuation of genetic factors. Crohn’s disease and ulcerative can be G-CSF and without chemotherapy, the blast count in the blood difficult to treat, and relapse of disease can occur at any time.

and bone marrow disappeared, although the mutation remained Biochemical markers identifying patients at risk for relapse are by guest on September 27, 2021 detectable (90). The tight correlation between the acquisition currently lacking. GM-CSF signaling was recently implicated of G-CSFR mutations and progression of SCN to secondary in the pathogenesis of Crohn’s disease. GM-CSF is required MDS/AML and the abnormal signaling features in vitro and in for myeloid cell antimicrobial functions and homeostatic re- vivo strongly suggested that mutated CSF3R could be a driver sponses to tissue injury in the intestine (103). Preliminary of myelodysplasia. Data from recent studies, which showed that studies found that GM-CSF reduces chemically induced gut the CSF3R T595I mutation is the most prevalent mutation found injury in mice (104). In human studies, higher concentrations in chronic neutrophilic leukemia and that treatment with the Jak2 of circulating Abs against GM-CSF are found in patients with inhibitor ruxolitinib resulted in marked clinical improvement, active IBD compared with those with inactive disease (103). support the hypothesis that mutations in G-CSFR are indeed Currently, several studies and clinical trials are looking at the drivers of myeloproliferative disease (91, 92). A low frequency of use of GM-CSF in the treatment of IBD and anti–GM-CSF CSF3R mutations also occurs in AML and chronic myelomo- Ab for the monitoring of disease activity and assessing the risk nocytic leukemia (93). for recurrence (105, 106). Pulmonary alveolar proteinosis (PAP) is a rare disorder 1 Future developments characterized by accumulation of periodic acid–Schiff lipo- More than 20 y after its registration by the FDA, biosimilars proteinaceous material in the alveoli of the lung, leading to (94) of G-CSF are being developed (95). (Amgen lost its impaired gas exchange, respiratory insufficiency, and, in severe patent protection for filgrastim in 2008, after developing cases, respiratory failure (107). Autoimmune PAP accounts for worldwide sales ∼$4.5 billion.) The European Medicine Agency 90% of cases and is due to the presence of autoantibodies against approved six biosimilars to G-CSF, and in February 2015, the GM-CSF. Hereditary PAP is caused by mutations in the genes FDA approved the first biosimilar, filgrastim-sndz, in the CSF2RA and CSF2RB that code for the a and b subunit of United States since passage of the Biologics Price Competition GM-CSFR, respectively (108, 109). In autoimmune PAP, the and Innovation Act. Teva’s tbo-filgrastim was approved in the presence of anti–GM-CSF Abs leads to aberrant in vivo GM- United States in 2012 before that legislation. These drugs must CSF signaling that is required for the macrophage-mediated demonstrate “high similarity” in the molecular characterization, clearance, but not uptake, of pulmonary surfactant. This purity, stability, pharmacokinetics, pharmacodynamics, clinical results in the progressive accumulation of foamy surfactant- efficacy, tolerability, and safety to the original agent (69). laden macrophages and intra-alveolar surfactant in the alveoli Pricing analysis suggests that that use of biosimilars to fil- of the lung (110). The gold standard of therapy has been whole- grastim, bevacizumab, trastuzumab, and rituximab may save up lung lavage. Although an effective therapy, it often needs to be to $44.2 billion over the next 10 y (96). repeated as a result of reaccumulation of lipoproteinaceous The Journal of Immunology 1347 sediment and is not without complications. Newer therapies 21. Jack, G. D., L. Zhang, and A. D. Friedman. 2009. M-CSF elevates c-Fos and phospho-C/EBPalpha(S21) via ERK whereas G-CSF stimulates SHP2 phosphor- have been studied, including pulmonary macrophage trans- ylation in marrow progenitors to contribute to myeloid lineage specification. Blood plantation, plasmapheresis to remove the GM-CSF autoanti- 114: 2172–2180. body, and inhaled GM-CSF (111–113). Inhaled GM-CSF is of 22. Laslo, P., C. J. Spooner, A. Warmflash, D. W. Lancki, H. J. Lee, R. Sciammas, B. N. Gantner, A. R. Dinner, and H. Singh. 2006. Multilineage transcriptional particular interest because it was shown to be safe and effective priming and determination of alternate hematopoietic cell fates. Cell 126: 755– in animal studies and phase 1 and 2 clinical trials (114, 115). 766. 23. Hansen, G., T. R. Hercus, B. J. McClure, F. C. Stomski, M. Dottore, J. Powell, H. Ramshaw, J. M. Woodcock, Y. Xu, M. Guthridge, et al. 2008. The structure of Disclosures the GM-CSF receptor complex reveals a distinct mode of cytokine receptor acti- vation. Cell 134: 496–507. The authors have no financial conflicts of interest. 24. Perugini, M., A. L. Brown, D. G. Salerno, G. W. Booker, C. Stojkoski, T. R. Hercus, A. F. Lopez, M. L. Hibbs, T. J. Gonda, and R. J. D’Andrea. 2010. Alternative modes of GM-CSF receptor activation revealed using activated mutants References of the common beta-subunit. Blood 115: 3346–3353. 1. Hilton, D. J., N. A. Nicola, W. S. Alexander, A. W. Roberts, and A. R. Dunn. 25. Hamilton, J. A., and A. Achuthan. 2013. Colony stimulating factors and myeloid 2015. Donald Metcalf (1929-2014). Cell 160: 361–362. cell biology in health and disease. Trends Immunol. 34: 81–89. 2. Metcalf, D. 1988. The Molecular Control of Blood Cells. Harvard University Press, 26. Pitrak, D. L. 1997. Effects of granulocyte colony-stimulating factor and Cambridge, MA. granulocyte-macrophage colony-stimulating factor on the bactericidal functions of 3. Kawamoto, H., T. Ikawa, K. Masuda, H. Wada, and Y. Katsura. 2010. A map for neutrophils. Curr. Opin. Hematol. 4: 183–190. lineage restriction of progenitors during hematopoiesis: the essence of the myeloid- 27. Kolaczkowska, E., and P. Kubes. 2013. Neutrophil recruitment and function in based model. Immunol. Rev. 238: 23–36. health and inflammation. Nat. Rev. Immunol. 13: 159–175. 4. Theilgaard-Mo¨nch, K., L. C. Jacobsen, R. Borup, T. Rasmussen, 28. Manz, M. G., and S. Boettcher. 2014. Emergency granulopoiesis. Nat. Rev.

M. D. Bjerregaard, F. C. Nielsen, J. B. Cowland, and N. Borregaard. 2005. The Immunol. 14: 302–314. Downloaded from transcriptional program of terminal granulocytic differentiation. Blood 105: 1785– 29. Simon, R., and L. Norton. 2006. The Norton-Simon hypothesis: designing more 1796. effective and less toxic chemotherapeutic regimens. Nat. Clin. Pract. Oncol. 3: 5. Morrison, S. J., and J. Kimble. 2006. Asymmetric and symmetric stem-cell divi- 406–407. sions in development and cancer. Nature 441: 1068–1074. 30. Norton, L., R. Simon, H. D. Brereton, and A. E. Bogden. 1976. Predicting the 6. Doulatov, S., F. Notta, E. Laurenti, and J. E. Dick. 2012. Hematopoiesis: a hu- course of Gompertzian growth. Nature 264: 542–545. man perspective. Cell Stem Cell 10: 120–136. 31. Norton, L., and R. Simon. 1986. The Norton-Simon hypothesis revisited. Cancer 7. Lieschke, G. J., D. Grail, G. Hodgson, D. Metcalf, E. Stanley, C. Cheers, Treat. Rep. 70: 163–169. K. J. Fowler, S. Basu, Y. F. Zhan, and A. R. Dunn. 1994. Mice lacking granulocyte 32. Glaubach, T., A. C. Minella, and S. J. Corey. 2014. Cellular stress pathways in colony-stimulating factor have chronic neutropenia, granulocyte and macrophage pediatric bone marrow failure syndromes: many roads lead to neutropenia. Pediatr. http://www.jimmunol.org/ progenitor cell deficiency, and impaired neutrophil mobilization. Blood 84: 1737– Res. 75: 189–195. 1746. 33. Gilman, P. A., D. P. Jackson, and H. G. Guild. 1970. Congenital agranulocytosis: 8. Geijsen, N., L. Koenderman, and P. J. Coffer. 2001. Specificity in cytokine signal prolonged survival and terminal acute leukemia. Blood 36: 576–585. transduction: lessons learned from the IL-3/IL-5/GM-CSF receptor family. Cyto- 34. Welte, K., and D. Dale. 1996. Pathophysiology and treatment of severe chronic kine Growth Factor Rev. 12: 19–25. neutropenia. Ann. Hematol. 72: 158–165. 9. Stanley, E., G. J. Lieschke, D. Grail, D. Metcalf, G. Hodgson, J. A. Gall, 35. Hammond IV, W. P., T. H. Price, L. M. Souza, and D. C. Dale. 1989. Treatment D. W. Maher, J. Cebon, V. Sinickas, and A. R. Dunn. 1994. Granulocyte/ of cyclic neutropenia with granulocyte colony-stimulating factor. N. Engl. J. Med. macrophage colony-stimulating factor-deficient mice show no major perturba- 320: 1306–1311. tion of hematopoiesis but develop a characteristic pulmonary pathology. Proc. 36. Bonilla, M. A., A. P. Gillio, M. Ruggeiro, N. A. Kernan, J. A. Brochstein, Natl. Acad. Sci. USA 91: 5592–5596. M. Abboud, L. Fumagalli, M. Vincent, J. L. Gabrilove, K. Welte, et al. 1989. 10. Hammond, W. P., T. C. Boone, R. E. Donahue, L. M. Souza, and D. C. Dale.

Effects of recombinant human granulocyte colony-stimulating factor on neu- by guest on September 27, 2021 1990. A comparison of treatment of canine cyclic hematopoiesis with recombinant tropenia in patients with congenital agranulocytosis. N. Engl. J. Med. 320: 1574– human granulocyte-macrophage colony-stimulating factor (GM-CSF), G-CSF 1580. interleukin-3, and canine G-CSF. Blood 76: 523–532. 37. Benson, K. F., F. Q. Li, R. E. Person, D. Albani, Z. Duan, J. Wechsler, K. Meade- 11. Wong, G. G., J. S. Witek, P. A. Temple, K. M. Wilkens, A. C. Leary, White, K. Williams, G. M. Acland, G. Niemeyer, et al. 2003. Mutations associated D. P. Luxenberg, S. S. Jones, E. L. Brown, R. M. Kay, E. C. Orr, et al. 1985. with neutropenia in dogs and humans disrupt intracellular transport of neutrophil Human GM-CSF: molecular cloning of the complementary DNA and purification elastase. Nat. Genet. 35: 90–96. of the natural and recombinant proteins. Science 228: 810–815. 38. Welte, K., C. Zeidler, A. Reiter, W. Muller,€ E. Odenwald, L. Souza, and 12. Souza, L. M., T. C. Boone, J. Gabrilove, P. H. Lai, K. M. Zsebo, D. C. Murdock, H. Riehm. 1990. Differential effects of granulocyte-macrophage colony- V. R. Chazin, J. Bruszewski, H. Lu, K. K. Chen, et al. 1986. Recombinant human stimulating factor and granulocyte colony-stimulating factor in children with se- granulocyte colony-stimulating factor: effects on normal and leukemic myeloid vere congenital neutropenia. Blood 75: 1056–1063. cells. Science 232: 61–65. 39. Dale, D. C., M. A. Bonilla, M. W. Davis, A. M. Nakanishi, W. P. Hammond, 13. Paul, M., R. Ram, E. Kugler, L. Farbman, A. Peck, L. Leibovici, M. Lahav, J. Kurtzberg, W. Wang, A. Jakubowski, E. Winton, P. Lalezari, et al. 1993. A M. Yeshurun, O. Shpilberg, C. Herscovici, et al. 2014. Subcutaneous versus in- randomized controlled phase III trial of recombinant human granulocyte colony- travenous granulocyte colony stimulating factor for the treatment of neutropenia in stimulating factor (filgrastim) for treatment of severe chronic neutropenia. Blood hospitalized hemato-oncological patients: randomized controlled trial. Am. J. 81: 2496–2502. Hematol. 89: 243–248. 40. Gorlin, R. J., B. Gelb, G. A. Diaz, K. G. Lofsness, M. R. Pittelkow, and 14. Horan, T., J. Wen, L. Narhi, V. Parker, A. Garcia, T. Arakawa, and J. Philo. 1996. Dimerization of the extracellular domain of granuloycte-colony stimulating factor J. R. Fenyk, Jr. 2000. WHIM syndrome, an autosomal dominant disorder: clinical, receptor by ligand binding: a monovalent ligand induces 2:2 complexes. Bio- hematological, and molecular studies. Am. J. Med. Genet. 91: 368–376. chemistry 35: 4886–4896. 41. Hernandez, P. A., R. J. Gorlin, J. N. Lukens, S. Taniuchi, J. Bohinjec, F. Francois, 15. Mehta, H. M., M. Futami, T. Glaubach, D. W. Lee, J. R. Andolina, Q. Yang, M. E. Klotman, and G. A. Diaz. 2003. Mutations in the chemokine receptor gene Z. Whichard, M. Quinn, H. F. Lu, W. M. Kao, et al. 2014. Alternatively spliced, CXCR4 are associated with WHIM syndrome, a combined immunodeficiency truncated GCSF receptor promotes leukemogenic properties and sensitivity to JAK disease. Nat. Genet. 34: 70–74. inhibition. Leukemia 28: 1041–1051. 42. Semerad, C. L., F. Liu, A. D. Gregory, K. Stumpf, and D. C. Link. 2002. G-CSF 16. Touw, I. P., and G. J. van de Geijn. 2007. Granulocyte colony-stimulating factor is an essential regulator of neutrophil trafficking from the bone marrow to the and its receptor in normal myeloid cell development, leukemia and related blood blood. Immunity 17: 413–423. cell disorders. Front. Biosci. 12: 800–815. 43. McDermott, D. H., Q. Liu, D. Velez, L. Lopez, S. Anaya-O’Brien, J. Ulrick, 17. Hermans, M. H., G. J. van de Geijn, C. Antonissen, J. Gits, D. van Leeuwen, N. Kwatemaa, J. Starling, T. A. Fleisher, D. A. Priel, et al. 2014. A phase 1 clinical A. C. Ward, and I. P. Touw. 2003. Signaling mechanisms coupled to tyrosines in trial of long-term, low-dose treatment of WHIM syndrome with the CXCR4 the granulocyte colony-stimulating factor receptor orchestrate G-CSF-induced antagonist plerixafor. Blood 123: 2308–2316. expansion of myeloid progenitor cells. Blood 101: 2584–2590. 44. Greenbaum, A. M., and D. C. Link. 2011. Mechanisms of G-CSF-mediated 18. Akbarzadeh, S., A. C. Ward, D. O. McPhee, W. S. Alexander, G. J. Lieschke, and hematopoietic stem and progenitor mobilization. Leukemia 25: 211–217. J. E. Layton. 2002. Tyrosine residues of the granulocyte colony-stimulating factor 45. To, L. B., J. P. Levesque, and K. E. Herbert. 2011. How I treat patients who receptor transmit proliferation and differentiation signals in murine bone marrow mobilize hematopoietic stem cells poorly. Blood 118: 4530–4540. cells. Blood 99: 879–887. 46. Scheinberg, P., and N. S. Young. 2012. How I treat acquired aplastic anemia. 19. Zhu, Q. S., L. J. Robinson, V. Roginskaya, and S. J. Corey. 2004. G-CSF-induced Blood 120: 1185–1196. tyrosine phosphorylation of Gab2 is Lyn kinase dependent and associated with 47. Tichelli, A., H. Schrezenmeier, G. Socie´, J. Marsh, A. Bacigalupo, U. Duhrsen,€ enhanced Akt and differentiative, not proliferative, responses. Blood 103: 3305– A. Franzke, M. Hallek, E. Thiel, M. Wilhelm, et al. 2011. A randomized con- 3312. trolled study in patients with newly diagnosed severe aplastic anemia receiving 20. Futami, M., Q. S. Zhu, Z. L. Whichard, L. Xia, Y. Ke, B. G. Neel, G. S. Feng, and antithymocyte globulin (ATG), cyclosporine, with or without G-CSF: a study of S. J. Corey. 2011. G-CSF receptor activation of the Src kinase Lyn is mediated by the SAA Working Party of the European Group for Blood and Marrow Trans- Gab2 recruitment of the Shp2 phosphatase. Blood 118: 1077–1086. plantation. Blood 117: 4434–4441. 1348 TRANSLATING IMMUNOLOGY: G-CSF AND GM-CSF IN NEUTROPENIA

48. Jeng, M. R., P. E. Naidu, M. D. Rieman, C. Rodriguez-Galindo, K. A. Nottage, 68. Johnston, E., J. Crawford, S. Blackwell, T. Bjurstrom, P. Lockbaum, L. Roskos, D. T. Thornton, C. S. Li, and W. C. Wiang. 2005. Granulocyte-macrophage B. B. Yang, S. Gardner, M. A. Miller-Messana, D. Shoemaker, et al. 2000. colony stimulating factor and immunosuppression in the treatment of pediatric Randomized, dose-escalation study of SD/01 compared with daily filgrastim in acquired severe aplastic anemia. Pediatr. Blood Cancer 45: 170–175. patients receiving chemotherapy. J. Clin. Oncol. 18: 2522–2528. 49. Kojima, S. 1996. Use of hematopoietic growth factors for treatment of aplastic 69. Smith, T. J., J. Khatcheressian, G. H. Lyman, H. Ozer, J. O. Armitage, anemia. Bone Marrow Transplant. 18(Suppl. 3): S36–S38. L. Balducci, C. L. Bennett, S. B. Cantor, J. Crawford, S. J. Cross, et al. 2006. 2006 50. Marsh, J. C. 2000. Hematopoietic growth factors in the pathogenesis and for the update of recommendations for the use of growth factors: an treatment of aplastic anemia. Semin. Hematol. 37: 81–90. evidence-based clinical practice guideline. J. Clin. Oncol. 24: 3187–3205. 51. Bacigalupo, A., G. Broccia, G. Corda, W. Arcese, M. Carotenuto, A. Gallamini, 70. Aarts, M. J., J. P. Grutters, F. P. Peters, C. M. Mandigers, M. W. Dercksen, F. Locatelli, P. G. Mori, P. Saracco, G. Todeschini, et al. 1995. Antilymphocyte J. M. Stouthard, H. J. Nortier, H. W. van Laarhoven, L. J. van Warmerdam, globulin, cyclosporin, and granulocyte colony-stimulating factor in patients with A. J. van de Wouw, et al. 2013. Cost effectiveness of primary pegfilgrastim pro- acquired severe aplastic anemia (SAA): a pilot study of the EBMT SAA Working phylaxis in patients with breast cancer at risk of febrile neutropenia. J. Clin. Oncol. Party. Blood 85: 1348–1353. 31: 4283–4289. 52. Bacigalupo, A., B. Bruno, P. Saracco, E. Di Bona, A. Locasciulli, F. Locatelli, 71. Crawford, J., J. Armitage, L. Balducci, P. S. Becker, D. W. Blayney, A. Gabbas, C. Dufour, W. Arcese, G. Testi, et al; European Group for Blood and S. R. Cataland, M. L. Heaney, S. Hudock, D. D. Kloth, D. J. Kuter, et al; Na- Marrow Transplantation (EBMT) Working Party on Severe Aplastic Anemia and tional comprehensive cancer network. 2013. Myeloid growth factors. J. Natl. the Gruppo Italiano Trapianti di Midolio Osseo (GITMO). 2000. Antilymphocyte Compr. Canc. Netw. 11: 1266–1290. globulin, cyclosporine, prednisolone, and granulocyte colony-stimulating factor for 72. Dinan, M. A., B. R. Hirsch, and G. H. Lyman. 2015. Management of severe aplastic anemia: an update of the GITMO/EBMT study on 100 patients. chemotherapy-induced neutropenia: measuring quality, cost, and value. J. Natl. Blood 95: 1931–1934. Compr. Canc. Netw. 13: e1–e7. 53. Kojima, S., T. Matsuyama, Y. Kodera, H. Nishihira, K. Ueda, T. Shimbo, and 73. Rowe, J. M., J. W. Andersen, J. J. Mazza, J. M. Bennett, E. Paietta, F. A. Hayes, T. Nakahata. 1996. Measurement of endogenous plasma granulocyte colony- D. Oette, P. A. Cassileth, E. A. Stadtmauer, and P. H. Wiernik. 1995. A ran- stimulating factor in patients with acquired aplastic anemia by a sensitive chemi- domized placebo-controlled phase III study of granulocyte-macrophage colony- . luminescent immunoassay. Blood 87: 1303–1308. stimulating factor in adult patients ( 55 to 70 years of age) with acute myelogenous leukemia: a study of the Eastern Cooperative Oncology Group (E1490). Blood 86: 54. Bodey, G. P., M. Buckley, Y. S. Sathe, and E. J. Freireich. 1966. Quantitative Downloaded from relationships between circulating leukocytes and infection in patients with acute 457–462. leukemia. Ann. Intern. Med. 64: 328–340. 74. Stone, R. M., D. T. Berg, S. L. George, R. K. Dodge, P. A. Paciucci, P. Schulman, 55. Talcott, J. A., R. D. Siegel, R. Finberg, and L. Goldman. 1992. Risk assessment in E. J. Lee, J. O. Moore, B. L. Powell, and C. A. Schiffer, Cancer and Leukemia cancer patients with fever and neutropenia: a prospective, two-center validation of Group B. 1995. Granulocyte-macrophage colony-stimulating factor after initial a prediction rule. J. Clin. Oncol. 10: 316–322. chemotherapy for elderly patients with primary acute myelogenous leukemia. N. 56. American Society of Clinical Oncology. 1994. Recommendations for the use of Engl. J. Med. 332: 1671–1677. hematopoietic colony-stimulating factors: evidence-based, clinical practice guide- 75. Ohno, R., M. Tomonaga, T. Kobayashi, A. Kanamaru, S. Shirakawa, T. Masaoka, lines. J. Clin. Oncol. 12: 2471–2508. M. Omine, H. Oh, T. Nomura, Y. Sakai, et al. 1990. Effect of granulocyte colony- 57. Crawford, J., H. Ozer, R. Stoller, D. Johnson, G. Lyman, I. Tabbara, M. Kris, stimulating factor after intensive induction therapy in relapsed or refractory acute http://www.jimmunol.org/ J. Grous, V. Picozzi, G. Rausch, et al. 1991. Reduction by granulocyte colony- leukemia. N. Engl. J. Med. 323: 871–877. stimulating factor of fever and neutropenia induced by chemotherapy in patients 76. Ozer, H., J. O. Armitage, C. L. Bennett, J. Crawford, G. D. Demetri, P. A. Pizzo, with small-cell lung cancer. N. Engl. J. Med. 325: 164–170. C. A. Schiffer, T. J. Smith, G. Somlo, J. C. Wade, et al; American Society of 58. Trillet-Lenoir, V., J. Green, C. Manegold, J. Von Pawel, U. Gatzemeier, Clinical Oncology. 2000. 2000 update of recommendations for the use of he- B. Lebeau, A. Depierre, P. Johnson, G. Decoster, D. Tomita, et al. 1993. matopoietic colony-stimulating factors: evidence-based, clinical practice guidelines. Recombinant granulocyte colony stimulating factor reduces the infectious com- J. Clin. Oncol. 18: 3558–3585. plications of cytotoxic chemotherapy. Eur. J. Cancer 29A: 319–324. 77. Bonilla, M. A., D. Dale, C. Zeidler, L. Last, A. Reiter, M. Ruggeiro, M. Davis, 59. Pettengell, R., H. Gurney, J. A. Radford, D. P. Deakin, R. James, B. Koci, W. Hammond, A. Gillio, et al. 1994. Long-term safety of treatment with recombinant human granulocyte colony-stimulating factor (r-metHuG-CSF) in P. M. Wilkinson, K. Kane, J. Bentley, and D. Crowther. 1992. Granulocyte patients with severe congenital neutropenias. Br. J. Haematol. 88: 723–730. colony-stimulating factor to prevent dose-limiting neutropenia in non-Hodgkin’s 78. Dale, D. C., A. A. Bolyard, B. G. Schwinzer, G. Pracht, M. A. Bonilla, L. Boxer,

lymphoma: a randomized controlled trial. Blood 80: 1430–1436. by guest on September 27, 2021 M. H. Freedman, J. Donadieu, G. Kannourakis, B. P. Alter, et al. 2006. The 60. Gerhartz, H. H., M. Engelhard, P. Meusers, G. Brittinger, W. Wilmanns, Severe Chronic Neutropenia International Registry: 10-Year Follow-up Report. G. Schlimok, P. Mueller, D. Huhn, R. Musch, W. Siegert, et al. 1993. Ran- Support. Cancer Ther. 3: 220–231. domized, double-blind, placebo-controlled, phase III study of recombinant human 79. Rosen, R. B., and S. J. Kang. 1979. Congenital agranulocytosis terminating in granulocyte-macrophage colony-stimulating factor as adjunct to induction treat- acute myelomonocytic leukemia. J. Pediatr. 94: 406–408. ment of high-grade malignant non-Hodgkin’s lymphomas. Blood 82: 2329–2339. 80. Rosenberg, P. S., B. P. Alter, A. A. Bolyard, M. A. Bonilla, L. A. Boxer, B. Cham, 61. Bajorin, D. F., C. R. Nichols, H. J. Schmoll, P. W. Kantoff, C. Bokemeyer, C. Fier, M. Freedman, G. Kannourakis, S. Kinsey, et al; Severe Chronic Neu- G. D. Demetri, L. H. Einhorn, and G. J. Bosl. 1995. Recombinant human tropenia International Registry. 2006. The incidence of leukemia and mortality granulocyte-macrophage colony-stimulating factor as an adjunct to conventional- from sepsis in patients with severe congenital neutropenia receiving long-term dose ifosfamide-based chemotherapy for patients with advanced or relapsed germ G-CSF therapy. Blood 107: 4628–4635. cell tumors: a randomized trial. J. Clin. Oncol. 13: 79–86. 81. Sinha, S., Q. S. Zhu, G. Romero, and S. J. Corey. 2003. Deletional mutation of 62. Citron, M. L., D. A. Berry, C. Cirrincione, C. Hudis, E. P. Winer, the external domain of the human granulocyte colony-stimulating factor receptor W. J. Gradishar, N. E. Davidson, S. Martino, R. Livingston, J. N. Ingle, et al. in a patient with severe chronic neutropenia refractory to granulocyte colony- 2003. Randomized trial of dose-dense versus conventionally scheduled and se- stimulating factor. J. Pediatr. Hematol. Oncol. 25: 791–796. quential versus concurrent combination chemotherapy as postoperative adjuvant 82. Germeshausen, M., M. Ballmaier, and K. Welte. 2007. Incidence of CSF3R treatment of node-positive primary breast cancer: first report of Intergroup Trial mutations in severe congenital neutropenia and relevance for leukemogenesis: C9741/Cancer and Leukemia Group B Trial 9741. J. Clin. Oncol. 21: 1431–1439. Results of a long-term survey. Blood 109: 93–99. € € 63. Pfreundschuh, M., L. Trumper, M. Kloess, R. Schmits, A. C. Feller, C. Rube, 83. Dong, F., R. K. Brynes, N. Tidow, K. Welte, B. Lo¨wenberg, and I. P. Touw. C. Rudolph, M. Reiser, D. K. Hossfeld, H. Eimermacher, et al; German High- 1995. Mutations in the gene for the granulocyte colony-stimulating-factor receptor Grade Non-Hodgkin’s Lymphoma Study Group. 2004. Two-weekly or 3-weekly in patients with acute myeloid leukemia preceded by severe congenital neu- CHOP chemotherapy with or without etoposide for the treatment of elderly tropenia. N. Engl. J. Med. 333: 487–493. patients with aggressive lymphomas: results of the NHL-B2 trial of the DSHNHL. 84. Dong, F., D. C. Dale, M. A. Bonilla, M. Freedman, A. Fasth, H. J. Neijens, Blood 104: 634–641. J. Palmblad, G. L. Briars, G. Carlsson, A. J. Veerman, et al. 1997. Mutations in the € 64. Pfreundschuh, M., L. Trumper, M. Kloess, R. Schmits, A. C. Feller, C. Rudolph, granulocyte colony-stimulating factor receptor gene in patients with severe con- M. Reiser, D. K. Hossfeld, B. Metzner, D. Hasenclever, et al; German High-Grade genital neutropenia. Leukemia 11: 120–125. Non-Hodgkin’s Lymphoma Study Group. 2004. Two-weekly or 3-weekly CHOP 85. Dong, F., L. H. Hoefsloot, A. M. Schelen, C. A. Broeders, Y. Meijer, chemotherapy with or without etoposide for the treatment of young patients with A. J. Veerman, I. P. Touw, and B. Lo¨wenberg. 1994. Identification of a nonsense good-prognosis (normal LDH) aggressive lymphomas: results of the NHL-B1 trial mutation in the granulocyte-colony-stimulating factor receptor in severe congenital of the DSHNHL. Blood 104: 626–633. neutropenia. Proc. Natl. Acad. Sci. USA 91: 4480–4484. 65. Vogel, C. L., M. Z. Wojtukiewicz, R. R. Carroll, S. A. Tjulandin, L. J. Barajas- 86. Dong, F., M. van Paassen, C. van Buitenen, L. H. Hoefsloot, B. Lo¨wenberg, and Figueroa, B. L. Wiens, T. A. Neumann, and L. S. Schwartzberg. 2005. First and I. P. Touw. 1995. A point mutation in the granulocyte colony-stimulating factor subsequent cycle use of pegfilgrastim prevents febrile neutropenia in patients with receptor (G-CSF-R) gene in a case of acute myeloid leukemia results in the breast cancer: a multicenter, double-blind, placebo-controlled phase III study. J. overexpression of a novel G-CSF-R isoform. Blood 85: 902–911. Clin. Oncol. 23: 1178–1184. 87. Hunter, M. G., and B. R. Avalos. 1999. Deletion of a critical internalization 66. Timmer-Bonte, J. N., T. M. de Boo, H. J. Smit, B. Biesma, F. A. Wilschut, domain in the G-CSFR in acute myelogenous leukemia preceded by severe con- S. A. Cheragwandi, A. Termeer, C. A. Hensing, J. Akkermans, E. M. Adang, et al. genital neutropenia. Blood 93: 440–446. 2005. Prevention of chemotherapy-induced febrile neutropenia by prophylactic 88. Ward, A. C., Y. M. van Aesch, A. M. Schelen, and I. P. Touw. 1999. Defective antibiotics plus or minus granulocyte colony-stimulating factor in small-cell lung internalization and sustained activation of truncated granulocyte colony-stimulating cancer: a Dutch Randomized Phase III Study. J. Clin. Oncol. 23: 7974–7984. factor receptor found in severe congenital neutropenia/acute myeloid leukemia. Blood 67. Yang, B. B., P. K. Lum, M. M. Hayashi, and L. K. Roskos. 2004. Polyethylene 93: 447–458. glycol modification of filgrastim results in decreased renal clearance of the protein 89. Hermans, M. H., C. Antonissen, A. C. Ward, A. E. Mayen, R. E. Ploemacher, and in rats. J. Pharm. Sci. 93: 1367–1373. I. P. Touw. 1999. Sustained receptor activation and hyperproliferation in response The Journal of Immunology 1349

to granulocyte colony-stimulating factor (G-CSF) in mice with a severe congenital 102. Brissette, W. H., D. A. Baker, E. J. Stam, J. P. Umland, and R. J. Griffiths. 1995. neutropenia/acute myeloid leukemia-derived mutation in the G-CSF receptor GM-CSF rapidly primes mice for enhanced cytokine production in response to gene. J. Exp. Med. 189: 683–692. LPS and TNF. Cytokine 7: 291–295. 90. Jeha, S., K. W. Chan, A. G. Aprikyan, W. K. Hoots, S. Culbert, H. Zietz, 103. Da¨britz, J., E. Bonkowski, C. Chalk, B. C. Trapnell, J. Langhorst, L. A. Denson, D. C. Dale, and M. Albitar. 2000. Spontaneous remission of granulocyte colony- and D. Foell. 2013. Granulocyte macrophage colony-stimulating factor auto- stimulating factor-associated leukemia in a child with severe congenital neu- antibodies and disease relapse in inflammatory bowel disease. Am. J. Gastro- tropenia. Blood 96: 3647–3649. enterol. 108: 1901–1910. 91. Maxson, J. E., J. Gotlib, D. A. Pollyea, A. G. Fleischman, A. Agarwal, C. A. Eide, 104. Egea, L., C. S. McAllister, O. Lakhdari, I. Minev, S. Shenouda, and D. Bottomly, B. Wilmot, S. K. McWeeney, C. E. Tognon, et al. 2013. Oncogenic M. F. Kagnoff. 2013. GM-CSF produced by nonhematopoietic cells is required CSF3R mutations in chronic neutrophilic leukemia and atypical CML. N. Engl. J. for early epithelial cell proliferation and repair of injured colonic mucosa. J. Med. 368: 1781–1790. Immunol. 190: 1702–1713. 92. Pardanani, A., T. L. Lasho, R. R. Laborde, M. Elliott, C. A. Hanson, 105. Roth, L., J. K. MacDonald, J. W. McDonald, and N. Chande. 2012. Sar- R. A. Knudson, R. P. Ketterling, J. E. Maxson, J. W. Tyner, and A. Tefferi. 2013. CSF3R T618I is a highly prevalent and specific mutation in chronic neutrophilc gramostim (GM-CSF) for induction of remission in Crohn’s disease: a Cochrane leukemia. Leukemia. 27: 1870–1830. inflammatory bowel disease and functional bowel disorders systematic review of 93. Mehta, H. M., T. Glaubach, A. Long, H. Lu, B. Przychodzen, H. Makishima, randomized trials. Inflamm. Bowel Dis. 18: 1333–1339. M. A. McDevitt, N. C. Cross, J. Maciejewski, and S. J. Corey. 2013. Granulocyte 106. Bonneau, J., C. Dumestre-Perard, M. Rinaudo-Gaujous, C. Genin, M. Sparrow, colony-stimulating factor receptor T595I (T618I) mutation confers ligand inde- X. Roblin, and S. Paul. 2015. Systematic review: new serological markers (anti- pendence and enhanced signaling. Leukemia 27: 2407–2410. glycan, anti-GP2, anti-GM-CSF Ab) in the prediction of IBD patient outcomes. 94. Weise, M., M. C. Bielsky, K. De Smet, F. Ehmann, N. Ekman, T. J. Giezen, Autoimmun. Rev. 14: 231–245. I. Gravanis, H. K. Heim, E. Heinonen, K. Ho, et al. 2012. Biosimilars: what 107. Rosen, S. H., B. Castleman, and A. A. Liebow. 1958. Pulmonary alveolar pro- clinicians should know. Blood 120: 5111–5117. teinosis. N. Engl. J. Med. 258: 1123–1142. 95. Mellstedt, H., D. Niederwieser, and H. Ludwig. 2008. The challenge of bio- 108. Suzuki, T., T. Sakagami, L. R. Young, B. C. Carey, R. E. Wood, M. Luisetti, similars. Ann. Oncol. 19: 411–419. S. E. Wert, B. K. Rubin, K. Kevill, C. Chalk, et al. 2010. Hereditary pulmonary 96. Sun, D., T. M. Andayani, A. Altyar, K. MacDonald, and I. Abraham. 2015. alveolar proteinosis: pathogenesis, presentation, diagnosis, and therapy. Am. J. Potential cost savings from chemotherapy-induced febrile neutropenia with bio- Respir. Crit. Care Med. 182: 1292–1304. Downloaded from similar filgrastim and expanded access to targeted antineoplastic treatment across 109. Trapnell, B. C., J. A. Whitsett, and K. Nakata. 2003. Pulmonary alveolar pro- the European Union G5 countries: a simulation study. Clin. Ther. 37: 842–857. teinosis. N. Engl. J. Med. 349: 2527–2539. 97. Lo¨wenberg, B., W. van Putten, M. Theobald, J. Gmur,€ L. Verdonck, 110. Jouneau, S., M. Kerjouan, E. Briens, J. P. Lenormand, C. Meunier, J. Letheulle, P. Sonneveld, M. Fey, H. Schouten, G. de Greef, A. Ferrant, et al; Dutch-Belgian D. Chiforeanu, C. Laine´-Caroff, B. Desrues, and P. Delaval. 2014. [Pulmonary Hemato-Oncology Cooperative Group; Swiss Group for Clinical Cancer Research. alveolar proteinosis]. Rev. Mal. Respir. 31: 975–991. 2003. Effect of priming with granulocyte colony-stimulating factor on the out- 111. Suzuki, T., P. Arumugam, T. Sakagami, N. Lachmann, C. Chalk, A. Sallese, come of chemotherapy for acute myeloid leukemia. N. Engl. J. Med. 349: 743– S. Abe, C. Trapnell, B. Carey, T. Moritz, et al. 2014. Pulmonary macrophage

752. http://www.jimmunol.org/ transplantation therapy. Nature 514: 450–454. 98. Carulli, G. 1997. Effects of recombinant human granulocyte colony-stimulating 112. Garber, B., J. Albores, T. Wang, and T. H. Neville. 2015. A plasmapheresis factor administration on neutrophil phenotype and functions. Haematologica 82: protocol for refractory pulmonary alveolar proteinosis. Lung 193: 209–211. 606–616. 113. Tazawa, R., B. C. Trapnell, Y. Inoue, T. Arai, T. Takada, Y. Nasuhara, N. Hizawa, 99. Kim, S. O., H. I. Sheikh, S. D. Ha, A. Martins, and G. Reid. 2006. G-CSF- mediated inhibition of JNK is a key mechanism for Lactobacillus rhamnosus-in- Y. Kasahara, K. Tatsumi, M. Hojo, et al. 2010. Inhaled granulocyte/macrophage- duced suppression of TNF production in macrophages. Cell. Microbiol. 8: 1958– colony stimulating factor as therapy for pulmonary alveolar proteinosis. Am. J. 1971. Respir. Crit. Care Med. 181: 1345–1354. 100. D’Aveni, M., J. Rossignol, T. Coman, S. Sivakumaran, S. Henderson, T. Manzo, 114. Reed, J. A., M. Ikegami, E. R. Cianciolo, W. Lu, P. S. Cho, W. Hull, A. H. Jobe, P. Santos e Sousa, J. Bruneau, G. Fouquet, F. Zavala, et al. 2015. G-CSF mobilizes and J. A. Whitsett. 1999. Aerosolized GM-CSF ameliorates pulmonary alveolar CD341 regulatory monocytes that inhibit graft-versus-host disease. Sci. Transl. proteinosis in GM-CSF-deficient mice. Am. J. Physiol. 276: L556–L563. Med. 7: 281ra42. 115. Tazawa, R., E. Hamano, T. Arai, H. Ohta, O. Ishimoto, K. Uchida,

101. Martins, A., J. Han, and S. O. Kim. 2010. The multifaceted effects of granulocyte M. Watanabe, J. Saito, M. Takeshita, Y. Hirabayashi, et al. 2005. Granulocyte- by guest on September 27, 2021 colony-stimulating factor in immunomodulation and potential roles in intestinal macrophage colony-stimulating factor and lung immunity in pulmonary alveolar immune homeostasis. IUBMB Life 62: 611–617. proteinosis. Am. J. Respir. Crit. Care Med. 171: 1142–1149.