Autologous Stem Cell Transplantation: Sequential Production of Hematopoietic Cytokines Underlying Granulocyte Recovery1

We investigated the serum concentrations of a variety of cytokines [granulocyte-macrophage-colony-stimulating factor (GM-CSF), granulocyte colony stimulating factor (G-CSF), interleukin (IL) la, IL-3, IL-6, II .-X, erythropoietin, tumor necrosis factor a, -y-interferon in 10 patients with advanced ovarian cancer undergoing autologous peripheral blood stem cell (PBSC) harvesting followed by treatment with high-dose cisplatin, etoposide, and carboplatin and PBSC transplantation (chemother apy was administered on days 1 through 3, PBSCT on day 6). Preliminary observations on cytokine serum levels were performed for 4 patients; on this basis, the kinetics of cytokines was then investigated in greater detail at closely sequential times in 6 further patients. We observed a consistent pattern of sequential GM-CSF, G-CSF, and II -X release after chemotherapy/PBSCT in all 10 cases, including the 6 patients monitored in detail: (a} at days 5-10 a GM-CSF peak; (ft) at days 12-14 a pronounced release of both G-CSF and II -fi, which always pre ceded granulocyte recovery by ~7 days. At days 17-23, a second GM-CSF peak was monitored in 5 of the 6 patients analyzed in detail, as well as in the other 4 cases. Particularly relevant are the observations that: (a) the peak of G-CSF serum concentration and neutrophil number in the recov ery phase are strikingly and directly correlated, thus indicating a key role for G-CSF in granulocyte rescue; (b) the time courses of G-CSF and II -S levels are strictly parallel, thereby suggesting a coordinate stimulus for production of granulocytes, mediated by G-CSF, and their activation/ migration capacity, mediated by IL-8. Results were essentially negative for IL-3, tumor necrosis factor a, and •¿ y-interferon concentrations (except in one case for each cytokine). An early peak of IL-la was observed in all 3 analyzed patients, while an IL-6 peak was monitored at days 13-15 in all 4 patients analyzed in detail. The present results indicate a sequential coordinate pattern of cytokine release after ablative therapy and PBSCT and shed light on the mecha nisms mediating the recovery of granulocytes, and more generally of hematopoiesis, after stem cell transplantation. Furthermore, these studies may contribute to the design of improved protocols for cytokine admin istration following myelosuppressive anticancer therapy, as well as to the prediction of granulocytic response. INTRODUCTION Autologous hematopoietic SCT1 is widely used to facilitate BM recovery following marrow ablative therapy. In this regard, PB SCT has been indicated for treatment of hematological malignancies as well as for solid tumors (\-4). Following marrow-ablative chemotherapy, the recovery of hemato poiesis is dependent on stem cell self-renewal and differentiation to Received 9/3/92; accepted 1/11/93. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. 1This work was supported by the "Terepia dei Tumori" Program, Istituto Superiore di s.uni.i. Rouse and "Progetto Finalizzato Applicazioni Cliniche della Ricerca Oncologica" (Grants §2.02344.PF 3g and g2. 02363. PF3g to C. P. and U. T, respectively). 2 To whom requests for reprints should be addressed. ' The abbreviations used are: SCT, stem cell transplantation; BM. bone marrow; PB. peripheral blood; BMT. bone marrow transplantation; HGF. hematopoietic growth factor; G-CSF, granulocyte colony-stimulating factor; GM-CSF, granulocyte-macrophage colony-stimulating factor; IL. interleukin; Ep. erythropoietin; IFN-y. y-interferon; TNF-o. tumor necrosis factor a; CFU, colony-forming unit. lineage-committed progenitors, which undergo further differentiation and then maturation to morphologically recognizable precursors and terminal cells circulating in PB (5). Both autologous BMT and PBSCT following intensive chemother apy or chemoradiation are associated with absolute leukopenia before hematopoietic recovery (6-9). Several attempts have been made to alleviate the period of leukopenia by treatment with recombinant HGFs, e.g., G-CSF and GM-CSF; the results indicate a faster engraftment of the transplanted autologous stem cells and a reduction of the period and severity of neutropenia (10-12). Little is known about the in vivo secretion of endogenous HGFs following high-dose chemotherapy and autologous SCT. Although the kinetics of GM-CSF and G-CSF levels has been investigated after chemotherapy and/or BMT (13-15), a systematic and detailed evalu ation of HGFs released following SCT has not been performed thus far. Cairo et al. (16) have recently reported that after allogeneic or autologous BMT a rise of endogenous circulating G-CSF levels pre cedes and correlates with the myeloid engraftment. In September 1989, we started a phase II study with high-dose combination chemotherapy and PBSCT in advanced ovarian cancer (17). One of the objectives of this study was to evaluate the kinetics of a variety of HGFs/cytokines (GM-CSF, G-CSF, IL-la, IL-3, IL-6, IL-8, Ep, TNF-a, IFN-y) in response to the myelosuppressive regi men. Results indicate a coordinate cascade of early GM-CSF produc tion followed by peak G-CSF and IL-8 release after high-dose chemotherapy and PBSCT. MATERIALS AND METHODS Patients. Patients between 28 and 51 years of age, with stage III-IV un treated ovarian cancer (according to the International Federation of Gynecol ogists and Obstetricians) eligible for chemotherapy were included in the study. Patients with heart, lung, liver, or kidney impairment (creatinin clearance, <60 ml/min) and/or a <80 Karnofsky performance status were excluded. Patients entering this study had histological proof of stage III or IV ovarian carcinoma of grades 1-3 after diagnostic and staging laparotomy and a residual tumor of >0.5 cm after cytoreductive surgery. Written informed consent was provided by each patient, and the study has been approved by the Hospital Human Subjects Investigational Review Board (Catholic University, Rome. Italy). Patients were treated in private rooms and placed on a low bacterial and fungal diet. Chemotherapy. The chemotherapy regimen and methods for harvesting PBSC have been described elsewhere (17). Briefly, after surgery patients underwent two courses of induction chemotherapy consisting of cisplatin, 40 mg/nr/day i.v. from days 1 to 5, and cyclophosphamide. 1500 mg/m2 i.v. given over 2 h on day 5. After 2-3 weeks from the start of each cycle, when the recovery from transient myelosuppression was observed (platelets >50 X 10'Vliter, leukocytes >1 x lO'Vliter). patients underwent PBSC harvesting by repeated leukaphereses. All cases responsive to induction chemotherapy were eligible for high-dose chemotherapy on days 1-3. Patients were given cisplatin ( 1(X)mg/m2 i.v.) on day 1. etoposide (600 mg/m2 i.v.) on day 2 and carboplatin ( 1800 mg/m2 i.v.) as continuous infusion over 24 h on day 3. Thawed autologous PBSC were given in 3-4 infusions on day 6.