GM-CSF

12 Pages·2000·0.257 MB·English

by  Nicola N.

GM-CSF
Nicos A. Nicola
*
The Walter and Eliza Hall Institute of Medical Research and the Cooperative Research Centre for
Cellular Growth Factors, PO Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia
*corresponding author tel: [phone], fax: [phone], e-mail: [email protected]
DOI: 10.1006/rwcy.2000.09004.
SUMMARY cell-conditioned media and that mouse lung-condi-
tioned media contained a particularly potent, low
molecular weight (23,000) form that was called
Granulocyte–macrophage colony-stimulating factor
granulocyte–macrophage colony-stimulating factor
(GM-CSF) was originally described as a potent
(GM-CSF) because it stimulated the formation of
stimulus of the growth and differentiation of granu-
colonies containing granulocytes, macrophages or
locyteandmacrophageprecursorcellsinvitro.Itisan
both (Sheridan and Metcalf, 1973). Mouse GM-CSF
approximately 23kDa glycoprotein with a four (cid:11)
waspurifiedfrommouselung-conditionedmediumin
helical bundle structure that binds to a heterodimeric
1977 (Burgess et al., 1977) and it was shown subse-
receptorcomposedofsubunitsbelongingtothetype1
quently that this form was produced by multiple
cytokinereceptorfamily.Subsequentstudiesrevealed
tissues(Nicolaetal.,1979a).Itwasfirstdemonstrated
that it also stimulated the mature end cells, as well as
in 1979 (Nicola et al., 1979b) that human CSFs from
antigen-presenting dendritic cells, to increase their
placental-conditioned medium could be separated by
functionalcapacityincombatinginfections.Somewhat
hydrophobic interaction chromatography into forms
surprisingly, genetic ablation experiments in mice
called CSF(cid:11) and CSF(cid:12). CSF(cid:11) was subsequently
indicated that GM-CSF was not absolutely required
found to be equivalent to GM-CSF and CSF(cid:12) to be
for steady state hematopoiesis, but was essential for
equivalent to G-CSF (Nicola et al., 1985).
maintaining the functional activity of some macro-
phage populations such as those involved in clearing
surfactant in the lung and in responding to certain Alternative names
kinds of infection or immune responses. GM-CSF is
in current clinical use for enhancing hematopoietic
GM-CSF has also been called CSF-2 (Pimentel,
recovery following cancer chemotherapy with or
1990), macrophage and granulocyte inducer-1GM
without bone marrow or peripheral blood stem cell
(MGI-1GM) (Lotem and Sachs, 1986) and, in the
transplants.
human,CSF(cid:11)(Nicolaet al.,1979b)or pluripoietin-(cid:11)
(Gabrilove et al., 1986).
BACKGROUND
Structure
Discovery
Mouse and human GM-CSF are 141 or 144 amino
Thegenerictermcolony-stimulatingfactor(CSF)was acid proteins, respectively, that contain a 17 amino
coined in the late 1960s to represent substances in acid leader sequence, two intramolecular disulfide
media(conditionedbycells)thatcouldinducecolony bonds and two potential sites of N-glycosylation as
formation from single cell suspensions of mouse well as sites of O-glycosylation. The apparent molec-
hematopoietic tissues like bone marrow in semi-solid ular weight of the mature glycosylated proteins is
agar cultures (Bradley and Metcalf, 1966; Ichikawa 14,000–33,000. The three-dimensional structure of
et al., 1966). It soon became apparent that different nonglycosylated human GM-CSF has been solved by
molecular forms of CSFs existed in different X-ray crystallography and shown to take up the
900 Nicos A. Nicola
conformation of a four (cid:11) helical bundle that char- Regulatory sites and corresponding
acterizes a large number of cytokines.
transcription factors
Main activities and
The mouse and human gene promoters extend to
pathophysiological roles
about 110bp upstream of the transcription initiation
site with a TATA box at position (cid:255)28. Two highly
While GM-CSF has potent stimulatory activities conserved sequence elements called CLE1 and CLE2
in vitro on progenitor cells for neutrophils, eosino- in the mouse and CK1 or CK2 in human occur from
phils, macrophages, and to a lesser extent erythroid (cid:255)100 to (cid:255)180. The CK1 element is found in many
andmegakaryocyticcells,resultsobtainedinvivowith cytokinegenepromoters(IL-2,IL-3,IL-4,IL-5,IL-6,
gene knockout mice suggest that the major physio- and G-CSF), while the CK2 element is also found in
logical role of GM-CSF is to maintain or stimulate the IL-3 gene promoter. The CK1 element was ori-
the functional activity of mature macrophages and ginally shown to bind to a transcription factor NF-
granulocytes. In addition, more recent results suggest GMa and more recent work suggests that this may
that GM-CSF may have important roles in stimulat- comprise p65(RelA), c-Rel, and HMGI(Y). This site
ing the action of dendritic cells in antigen presenta- confers transcriptional responsiveness to TNF in
tion. In pathology, overexpression of GM-CSF may fibroblasts and endothelial cells, to the HTLV1 Tax
lead to inflammatory reactions, toxic shock, and transactivator and the CD28 costimulator in T cells.
autoimmunity,whileunderexpressionmaybeinvolved The CK2 element bound a transcription factor called
in some cases of alveolar proteinosis. NF-GMbandthissiteoverlapswithaNF(cid:20)B-binding
site and is adjacent to an SP-1-binding site. This
GENE AND GENE REGULATION region binds p50 homodimers or p50/p65 hetero-
dimers ofNF(cid:20)B/Rel andSP-1 andis requiredforthe
Accession numbers phorbol ester/calcium ionophore induction of tran-
scription in T cells.
Both genes also contain two CATT(AT) repeats
GenBank:
within a conserved region called CLE0 that coopera-
Human cDNA: M10663, M11220, M11734
tively binds the AP-1 (probably c-Fos and JunB) and
Human gene: M13207, X03021
Ets (probably Ets-1) transcription factors. It also
Mouse cDNA: X03221, X05906, X03019
binds to NFATp, but phorbol ester/calcium sensitiv-
Mouse gene: X03020
ity of transcription at this site is probably mediated
Rat cDNA: U00620
through activation of AP-1 factors. Just upstream of
Pig cDNA: U61139, U67318, U67175, D21074
the CLE0 element is a core-binding factor (CBF) site
Bovine cDNA: U22385
which also increases gene expression in response to
Sheep cDNA: X53561
phorbol ester/calcium activation (Nimer and Uchida,
Dog cDNA: S49738
1995; Shannon et al., 1997; Tsuruta et al., 1998).
Guinea pig cDNA: U46779
In addition to regulation by the promoter region,
Red deer cDNA: U14392
human GM-CSF expression in T cells is regulated by
Cat cDNA: AF053007
astrongenhancerthatliesbetweentheGM-CSFand
IL-3 genes (about 3kb upstream of the GM-CSF
Chromosome location
promoter). This DNase1 hypersensitivity site was
induced by phorbol ester/calcium and inhibited by
The human gene maps to chromosome 5q31.1 cyclosporin A and acted as a powerful enhancer. The
(OMIM accession 138960, GDB accession 119812). enhancercontainedat leastthree cooperativeNFAT/
The mouse gene maps to chromosome 11 at 29.5cM AP-1 binding sites with the consensus sequence
(MGI accession 88531). The bovine gene maps to GGAN TCA that were functional as strong enhan-
9
chromosome 7 (ArkDB accession BOVMAP:CSF2). cers in a reporter system and additional potential
GATA, Ets, SP-1, E2A, and CBF-binding sites of
Relevant linkages
unknown function (Cockerill et al., 1993, 1995;
Shannon et al., 1997).
For both mouse and human GM-CSF genes there NegativeregulationofGM-CSFtranscriptionisless
is very tight linkage to the IL-3 gene (<10kb). There wellunderstood,buttheidentificationofNF-GMbas
is also a cluster of cytokine (M-CSF, IL-4, IL-5) and a cold shock domain-containing protein that binds
receptor (c-fms) genes in this general area. selectivelytosingle-strandedDNAhassuggestedthat
GM-CSF 901
this complex binds to repressor elements not only cleaved during secretion. It includes two intramolec-
within the CK1 and CK2 regions but also further ular disulfide bonds (Cys51–93, Cys85–118) and two
upstream ((cid:255)230 to (cid:255)320). NF-GMb may act by potential sites of N-glycosylation (Asn66 and 75) as
directly binding to double-stranded DNA and well as sites of O-glycosylation (Ernst et al., 1992).
unwinding it or by direct interaction with positive The apparent molecular weight of the mature glyco-
transcription factors to suppress NF(cid:20)B-dependent sylated protein is 14,000–33,000 and it is very resis-
transcription (Coles et al., 1996). A second nuclear tant to denaturing and proteolytic conditions.
factor,YY-1,isazincfingerproteinthatbindswithin Human GM-CSF is a 144 amino acid protein that
the CLE0 region and inhibits AP-1/CBF-mediated contains a similar length leader sequence, homo-
transcription (Ye et al., 1996). logous disulfide bonds (Cys54–96, Cys88–121) and
Finally,expressionofGM-CSFisalsoregulatedat two N-glycosylation sites (Asn27 and 37), as well as
the level of message stability. AU-rich sequences in O-glycosylationsitesatSer9andThr10.Bothproteins
the 30 untranslated region of GM-CSF mRNA were exist primarily as monomers. The nonglycosylated
shown to result in inherent instability in this and proteinsarefullyactivebiologicallyandinfactareup
other mRNAs and to mediate increased stability to 10 times more potent than the fully glycosylated
under inductive conditions (Shaw and Kamen, 1986). molecules (Moonen et al., 1987; Cebon et al., 1990).
Destabilizationinvolvesenzymaticdeadenylationand
stabilization probably occurs by the induction of
Discussion of crystal structure
proteins that bind to AU elements (Nakamaki et al.,
1995; Xu et al., 1997).
The three-dimensional structure of nonglycosylated
human GM-CSF has been solved by X-ray crystal-
Cells and tissues that express
lographyandshowntotakeuptheconformationofa
the gene
four(cid:11)helicalbundlethatcharacterizesalargenumber
of cytokines. Within this class of cytokines, the short
See Cellular sources and tissue expression. chainlengthofthehelicesandthelargeskewangleof
the antiparallel helical pairs place GM-CSF in the
short chain subclass. The topology of the four main
PROTEIN
helices is up-up-down-down for helix A (amino acids
13–28),B(55–64),C(68–87),andD(103–116),witha
Accession numbers small helix in the A–B loop and two antiparallel (cid:12)
strands contributed by the A–B and C–D loops
SwissProt: (Diederichs et al., 1991; Walter et al., 1992). The two
Human: P04141 disulfide bonds covalently link the ends of the C and
Mouse: P01587 D helices and the N-terminal end of the B helix with
the C–D loop. The region of GM-CSF thought to
Rat: P48750
interact with the (cid:11) chain of the receptor (site I) con-
Pig: Q29046
sists of residues in the D helix (especially Asp102 and
Bovine: P11052
Lys108 in the mouse and Asp108 and Glu112 in
Sheep: P28773
human) (Kaushansky et al., 1989; Hercus et al.,
Dog: P48749
Guinea pig: Q60481 1994b;Altmannetal.,1995)andtheAhelix(Goodall
Red deer: P51748 et al., 1993). The major contacts with the (cid:12) chain
PDB structure accession numbers for human GM- appear to be through residues on the A helix with a
criticalroleforGlu21.Indeed,chargereversalmutants
CSF are 1CSG and 2GMF.
such as E21R in human GM-CSF result in the pro-
duction of GM-CSF antagonists (Lopez et al., 1992;
Sequence Hercus et al., 1994a; Altmann and Kastelein, 1995).
See Figure 1.
Important homologies
Description of protein
None known. GM-CSF has weak homology to IL-4
andisstructurallyhomologoustoothershort-chain(cid:11)
Mouse GM-CSF is a 141 amino acid protein helicalcytokines(M-CSF,IL-2toIL-13,IFN(cid:13),SCF,
containing a 17 amino acid leader sequence that is and FLK-2L).
9
0
2
N
ic
o
s
A
.
N
ic
o
Figure 1 Protein sequence of GM-CSF in various species. la
GM-CSF 903
Posttranslational modifications Antiinflammatory agents are inhibitory stimuli for
GM-CSF production from T cells and macrophages.
Glucocorticoids inhibit T cell production of GM-
The signal peptide sequence is removed and carbo-
CSF, while IL-4, IL-13, and especially IL-10, inhibit
hydrateattachedatsitesofN-andO-glycosylationas
GM-CSFproductionbymacrophages(Lenhoffetal.,
described above.
1998).
CELLULAR SOURCES AND
RECEPTOR UTILIZATION
TISSUE EXPRESSION
GM-CSF utilizes a receptor complex consisting of
Cellular sources that produce
the GM-CSF receptor (cid:11) chain and the common (cid:12)
chain.GM-CSFbindstothe(cid:11)chainwithlowaffinity
GM-CSF is a product of activated T lymphocytes, but high specificity and this interaction is converted
fibroblasts, endothelial cells, macrophages, and to one of high affinity by engagement of the (cid:12) chain.
stromal cells. Isolated reports also suggest that B The(cid:12) chainservesasimilarroleinreceptorsforIL-3
lymphocytes, mast cells, eosinophils, blast cells, and and IL-5.
osteoblasts may also produce GM-CSF.
IN VITRO ACTIVITIES
Eliciting and inhibitory stimuli,
including exogenous and
In vitro findings
endogenous modulators
GM-CSF stimulates the survival (prevents apoptosis)
For T lymphocytes, the major inductive stimulus is of hematopoietic colony-forming cells of the neutro-
engagement of the T cell receptor (TCR) by antigen phil, eosinophil, macrophage, megakaryocytic, and
and this can be mimicked by the combined action of erythroid cell lineages, as well as extending the sur-
calcium ionophores and phorbol esters or by lectins. vival time of mature neutrophils and eosinophils. It
This induction results in the activation of protein alsomaintainsthesurvivaloffactor-dependenthema-
kinase C (PKC) and the release of calcium from topoietic cell lines such as FDC-P1 (Metcalf and
intracellular stores. PKC activates AP-1 (Fos/Jun) Nicola, 1995).
transcription factors while calcium activates the GM-CSF stimulates the proliferation and differ-
calcineurin phosphatase that in turn dephosphory- entiationofhematopoieticcolony-formingcellsofthe
lates and activates NFATp transcription factors. The neutrophil, macrophage, and eosinophil lineages, as
importanceofthesefactorsforcytokinetranscription well as megakaryocytic and some early erythroid
is underscored by the powerful immunosuppressive progenitors (BFU-E). It also stimulates, in synergy
effects of cyclosporin A, which inhibits calcineurin with TNF(cid:11), the proliferation and differentiation of
activity. In addition, the cytokines IL-1 and IL-2 and myeloid(butnotlymphoid)dendriticcellsinvolvedin
infection with the human T cell lymphotropic virus antigen presentation to lymphoid cells (Metcalf and
(HTLV) each induce increased GM-CSF production Nicola, 1995).
in T cells. For B lymphocytes, antigen receptor acti- GM-CSFstimulatesthefunctionalactivitiesofneu-
vation (e.g. by Staphylococcus aureus) and bacterial trophils, eosinophils, and monocyte-macrophages.
lipopolysaccharide (LPS) or phorbol esters induce These include enhancement of chemotactic activity
GM-CSF synthesis. For mast cells, degranulating (both to GM-CSF itself and to other chemoattrac-
agents like IgE and calcium ionophores induce GM- tants such as fMLP), increased expression of cel-
CSF synthesis and, for osteoblasts, LPS and para- lular adhesion molecules and increased adhesion to
thyroid hormone are effective (Metcalf and Nicola, surfaces, and increased phagocytic activity. GM-CSF
1995; Shannon et al., 1997). also stimulates the capacity of these cells to medi-
Formacrophages,fibroblasts,andendothelialcells, ate antibody-dependent cell cytotoxicity and to kill
themajorinducersofGM-CSFsynthesisareLPSand microorganisms intracellularly (bacteria in neutro-
theproinflammatorycytokinesIL-1andTNF,aswell phils, schistosomes in eosinophils, and mycobacteria,
as phorbol esters. These appear to act primarily Leishmania and Candida spp. in macrophages). GM-
through the NF(cid:20)B transcription complex (Metcalf CSF also has a ’priming’ effect on these cells to
and Nicola, 1995; Shannon et al., 1997). enhance their response to subsequent stimuli for the
904 Nicos A. Nicola
oxidative burst (superoxide anion production), de- probably by acting directly on alveolar macrophages
granulation and release of antimicrobial agents, and andtypeIIpneumocytes(seebelow).Italsoappearsto
chemotaxis. Finally, GM-CSF stimulates the release have a role in antigen presentation and the develop-
ofsecondarycytokinesandmediatorsfromthesecells ment of autoimmunity as well as a role in pro-
includingIL-1,G-CSF,M-CSF,andleukotrienesfrom inflammatory reactions.
neutrophils, and IL-1, TNF, IL-6, G-CSF, M-CSF,
and prostaglandins from macrophages (Grant and Species differences
Heel, 1992; Metcalf and Nicola, 1995).
GM-CSF stimulates antigen presentation to the
Human and mouse GM-CSF do not show any cross-
immune system. It does this by its direct effects on
reactivityacross species, butwithinspecies theyshow
dendritic cell and macrophage production, but also
broadly similar actions. In mouse and man loss of
by increasing expression of the class II major
functional GM-CSF expression leads to the disease
histocompatibility complex and Fc receptors on
pulmonary alveolar proteinosis.
macrophages and dendritic cells (Witmer-Pack et al.,
1987; Jonuleit et al., 1996).
Knockout mouse phenotypes
Regulatory molecules: Inhibitors GM-CSFknockoutmicearebornattheexpectedrate,
initially have normal growth rates, and show relat-
and enhancers
ively little perturbation in steady state hematopoietic
parameters with normal white blood cell counts and
The stimulators and inhibitors of GM-CSF produc-
normal cellularity in the bone marrow, spleen, and
tion are discussed in other sections of this entry.
peritoneal cavity. However, they surprisingly exhibit
Enhancers of GM-CSF action include TNF(cid:11) in the
majorlungabnormalitiessimilartothehumandisease
actions on dendritic cells, M-CSF in the action on a
pulmonary alveolar proteinosis (Dranoff et al., 1994;
subset of granulocyte/macrophage progenitors, EPO Stanley et al., 1994). This results in an accumulation
in the action on early erythroid progenitors and ofsurfactantinthealveolarspaces,dueprimarilytoa
complex cytokine cocktails in the action on hemato-
reduced rate of catabolism or clearance of surfactant
poietic stem cells (Metcalf and Nicola, 1995). Soluble
protein A, and an increased susceptibility to sub-
forms of the GM-CSF receptor (cid:11) chain have been
clinical lung infections associated with focal accumu-
described as alternative transcripts from the receptor
lations of lymphocytes. This appears to be due to
gene and these may serve as natural antagonists of
local action of GM-CSF, since the defect in GM-
GM-CSF action.
CSF-null mice can be cured either by bone marrow
transplantation (Nishinakamura et al., 1996) or by
creating transgenic mice that express GM-CSF from
Bioassays used
the surfactant protein C promoter (specific to the
respiratory epithelium) (Huffman et al., 1996). These
In vitro colony formation assays of bone marrow,
data suggest that locally produced GM-CSF acting
spleen,fetalliverorperipheralbloodcellsinsemisolid
either on alveolar macrophages or type II pneumo-
agar or methylcellulose cultures; chemotaxis; adher-
cytes is essential for physiological clearance of lung
ence; phagocytosis; antibody-dependent cell cytotoxi-
surfactant from the alveolar spaces.
city (ADCC); cytokine production; flow cytometry;
GM-CSF knockout mice have been shown to be
superoxide and reactive oxygen ion generation; and
relatively resistant to endotoxic shock (Basu et al.,
intracellular bacteriocidal activity.
1997) and to the development of some autoimmune
diseasessuchascollagen-inducedarthritisanddiabetes
(Campbell et al., 1998). This may be related to the
IN VIVO BIOLOGICAL action of GM-CSF in stimulating the synthesis and
release from macrophages of proinflammatory cyto-
ACTIVITIES OF LIGANDS IN
kines such as IL-1 and TNF(cid:11) and in generating
ANIMAL MODELS
myeloid-type dendritic cells.
Normal physiological roles Transgenic overexpression
GM-CSF plays an essential role in the physiological The consequences of sustained overexpression of
clearance of lung surfactant from alveolar spaces, GM-CSF have been studied in mice expressing a
GM-CSF 905
transgene off a constitutive viral promoter (Lang Interactions with cytokine network
etal.,1987)orinmicerepopulatedwithbonemarrow
cells infected with a retrovirus expressing GM-CSF
TGF(cid:12) has been reported to both stimulate (Keller
(Johnson et al., 1989).
et al., 1991) and inhibit (Ohta et al., 1987) GM-CSF-
GM-CSF transgenic mice are fertile, have normal
stimulated colony formation. The combination of
litter sizes and develop normally to early adulthood.
GM-CSFandM-CSFcaninhibitsometypesofmacro-
Most hematological parameters are normal (white
phage colony formation (Metcalf and Nicola, 1995).
blood cell counts, spleen, and bone marrow cellu-
In primary colony formation in vitro, addition of
larity), but the mice are distinguished by a 100-fold
otherCSFstoGM-CSFdoesnotincreasethenumber
increaseinthecellularityoftheperitonealandpleural
ofcolonies,buttheaveragecolonysizeissignificantly
cavities due primarily to elevated numbers of macro-
increased (2- to 3-fold), especially with M-CSF and
phages and dendritic cells. The macrophages arise
IL-3. For the formation of blast cell colonies or
through local proliferation at these sites during the
coloniesfrompurifiedstemcells,GM-CSFwasavery
first 2 months of life and thereafter show an increas-
inefficientstimulus,butincombinationwithstemcell
ing tendency to fuse and form multinucleate cells.
factor, IL-11 or IL-12 it was able to stimulate such
Alltransgenicmicecanbeidentifiedbyabnormally
coloniestoamuchgreaterextentthaneitherstimulus
small eyes with opaque corneas. This results from
alone (Metcalf and Nicola, 1995).
earlyinfiltrationoftheeyechambersbymacrophages
followed by destruction of the photoreceptor layer of
PATHOPHYSIOLOGICAL ROLES
the retina and cataract-like lesions of the lens. In
addition, transgenic mice showed chronic inflamma- IN NORMAL HUMANS AND
tory lesions and tissue damage in the skeletal muscles
DISEASE STATES AND
and other organs, the severity and type depending on
DIAGNOSTIC UTILITY
the particular transgenic line studied.Consistent with
these pathological changes, the different transgenic
lines showed variably premature death rates. How- Normal levels and effects
ever,despitethesustainedhyperproliferationofhema-
topoietic populations (especially macrophages and
Mouse and human GM-CSF are half-maximally
neutrophil and eosinophil precursors) seen in these
active in vitro at concentrations of about 0.5ng/mL
mice, transplantation studies failed to reveal the
for granulocyte/macrophage colony formation and
development of leukemic populations.
at higher concentrations for eosinophil (4ng/mL),
erythroid(30ng/mL),andmegakaryocyte(100ng/mL)
colony formation. GM-CSF administered to humans
Pharmacological effects
by i.v. or s.c. routes has discernible biological
effects within the range of 1–60mg/kg per day (20–
The pharmacological effects of injected GM-CSF are 1000mg/m2 per day).
broadly consistent with results seen in GM-CSF
InmostnormalmouseandhumanseraGM-CSFis
transgenic mice. In mouse and the human there is a
undetectable (detection limit 20pg/mL) or barely
biphasic response to injected GM-CSF consisting of
detectable (20–100pg/mL). These levels are too low
aninitial rapidandprofounddecreaseinwhiteblood
for normal circulating levels of GM-CSF to have
cellcounts(withinthefirsthour)duetosequestration
significant biological effects. Even after infection or
within the lungs followed by restoration of normal
injection with bacterial endotoxin, when other CSFs
numbers by 2–4 hours and thereafter a progressive
(G-CSFandM-CSF)risetosupramaximalbiological
riseincirculatingneutrophils,eosinophils,andmono-
doses, the elevation of serum GM-CSF is modest
cytes. While these rises are significant (2- to 4-fold),
(about 0.5ng/mL) (Metcalf and Nicola, 1995). This
theyaresignificantlylessthanthoseseenwithinjected
suggeststhatlocalproductionandactionofGM-CSF
G-CSF. Similarly, injected GM-CSF results in an
willprobablybemoreimportantphysiologicallythan
increase in circulating progenitor cells for all lineages
serum-derived GM-CSF.
(colony-forming cells), but again these rises (5- to 10-
fold)aresignificantlylessthanthoseseenwithG-CSF Role in experiments of nature and
(>100-fold). In contrast, the effects of GM-CSF in
disease states
elevatingperitonealcellnumbers(particularlymacro-
phages and eosinophils) are more profound (>10-
fold) than those seen with G-CSF (Metcalf and Pulmonary alveolar proteinosis (PAP) is a hetero-
Nicola, 1995). geneousdisorder,butsomepatientshavebeenshown
906 Nicos A. Nicola
to benefit from GM-CSF treatment. Some patients Toxicity
havealsobeenshowntohaveeitherdefectiveproduc-
tion or release of GM-CSF or a defective expression
GM-CSF is generally well tolerated at clinically
of the common (cid:12) chain receptor component of the
effective doses, but serious adverse events may
GM-CSFreceptor(Dirksenetal.,1997;Tchou-Wong
increase at doses of 16mg/kg per day. The most
et al., 1997). In several cases, the hematopoietic
common adverse effects are mild flu-like symptoms
response to GM-CSF is impaired in PAP patients
(includingmyalgia,chills,bonepain,diarrhea,nausea,
(Seymour et al., 1998).
fatigue, and headache) which are reversible and can
usually be controlled by the use of aspirin or para-
cetamol. With s.c. administration, transient erythe-
IN THERAPY
matous eruptions may occur at the injection site.
Respiratorydistress,probablyduetohypotensionand
Preclinical – How does it affect
hypoxia, is occasionally seen after the first dose of
disease models in animals? GM-CSF. Capillary leak syndrome with fluid reten-
tion and flare up of pre-existing autoimmune
conditions have also been noted occasionally (Grant
Injection of GM-CSF into mice infected with a lethal
and Heel, 1992).
dose of Pseudomonas aeruginosa, Staphylococcus
aureus, Salmonella typhimurium, or Candida albicans
increased survival times and rates and decreased
Clinical results
bacterial loads. Prophylactic use of GM-CSF also
improved survival rates of thermally injured rats.
The major current uses of GM-CSF relate to its
GM-CSF significantly enhanced the rate of recovery
ability to enhance the rate of recovery of hemato-
ofwhitebloodcellandplateletcountsfollowingacute
poietic cells after myeloablative therapies and to
radiation injury in mice and monkeys. Recombinant
reduce infections by its actions on white blood cells.
viruses encoding mouse GM-CSF have been used to
infect poorly immunogenic tumor cells (e.g. MC-38
colon adenocarcinoma). The growth of such tumor Cancer Patients Receiving Chemotherapy
cells was shown to be highly suppressed in syngeneic
One of the major limitations in the use of chemo-
hosts in a T cell-dependent manner, suggesting that
therapyorradiotherapyinthetreatmentofcancersis
GM-CSF induced an antigen-specific antitumor
the associated myelotoxicity. The fall of circulating
response(Dranoffetal.,1993;McLaughlinetal.,1997).
neutrophil levels below 500–100 per mL is associated
withincreasedriskofinfectionsandthefallinplatelet
Effects of therapy: Cytokine, levels is associated with increased risk of bleeding.
GM-CSF administration in this setting (before che-
antibody to cytokine inhibitors, etc.
motherapy) has a minor effect in reducing the degree
ofthenadirinneutrophillevelsfollowingchemother-
These can be predicted from the effects of gene apy,buthasaclearlysignificanteffectinreducingthe
knockout studies in mice (see Knockout mouse durationoftheneutropeniapriortorecoverybyupto
phenotypes), but no studies have been reported in 50%. This has reduced the incidence and severity of
humans yet. mucositis and stomatitis and the need for antibiotic
treatments.Theeffectsonplateletrecoveryhavebeen
inconsistent, but generally weak or nonexistent.
Pharmacokinetics
However, the effects on neutrophil recovery have
allowed more effective chemotherapy regimens either
The pharmacokinetics of both glycosylated (sargra- by allowing all planned cycles to be achieved or by
mostim) and nonglycosylated (molgramostim) forms allowing dose escalation.
of recombinant human GM-CSF administered either
by the i.v. bolus or s.c. routes into healthy adults or
Bone Marrow Transplantation
adults and children with malignancies have been
studied. For sargramostim the terminal elimination Autologous bone marrow transplantation (ABMT)
half-life (t (cid:12)) varied from 60 to 120 minutes for i.v. and peripheral blood progenitor cell transplantation
1/2
and 2–3 hours for s.c. routes of administration. The (PBCT) are procedures where the patient’s hemato-
corresponding figures for molgramostim were 30–90 poietic stem cells are removed before the use of high-
minutes and 2–3 hours (Armitage, 1998). dose myeloablative therapies for the treatment of
GM-CSF 907
malignancies and then reinfused after the treatment these settings. In most congenital or cyclic neutrope-
to reconstitute the hematopoietic system. GM-CSF nias GM-CSF had little effect on neutrophil counts
administration within 24 hours of marrow reinfusion while elevating eosinophil counts. Beneficial effects
in ABMT reduced the period of neutropenia wereusuallyinferiortothoseseenwithG-CSF(Welte
(Nemunaitis et al., 1991a, 1991b). et al., 1990).
Inallogeneicbonemarrowtransplantationmatched
foreign bone marrow is used to reconstitute the
hematopoietic system of patients who have received Priming in Leukemia
myeloablativetherapyandgraft-versus-hostdiseaseor
Because most cases of chronic myeloid leukemia and
graft rejection can be significant problems. In this
acute myeloid leukemia express GM-CSF receptors
setting GM-CSF again reduced the period of neutro-
and respond to GM-CSF, attempts have been made
penia and, despite its potential immunostimulatory
to use GM-CSF to force chemotherapy-resistant leu-
action,didnotaltertheincidenceorseverityofgraft-
kemic cells into cycle so that they become more sen-
versus-host disease.
sitive to antileukemic agents. In some cases increased
Inpatientswhofailedtoengraftafterconventional
rates of remission and survival have been reported,
autologous or allogeneic bone marrow transplanta-
although more data need to be accumulated.
tion subsequent GM-CSF treatment resulted in an
increased rate of engraftment and long-term survival
(Nemunaitis et al., 1990). Use as a Vaccine Adjuvant or in
GM-CSF has also been used to mobilize hemato- Tumor Immunotherapy
pietic stem cells into the peripheral blood for subse-
Based on animal studies a few human studies have
quent autologous transplantation. Such stem cells
beguntoappearevaluatingtheuseofGM-CSFasan
result in a more rapid recovery of both neutrophils
antiviral vaccine adjuvant for immunization against
andplateletsthanisachievedbyABMT(Giannietal.,
hepatitis B and influenza with encouraging but pre-
1989), but the greater mobilizing efficiency of G-CSF
liminary results (Taglietti, 1995; Hess et al., 1996;
has seen a decline in the use of GM-CSF for this
Tarr et al., 1996). Trials have also been initiated in
purpose.
which GM-CSF is administered after surgical resec-
tion of melanoma tumors or with passive (antimela-
AIDS
noma or antineuroblastoma antibodies) or active
AIDS patients have reduced numbers of monocytes (autologousmelanomacellswithBCG)immunization
and neutrophils (as well as the well-documented against tumor cells (Armitage, 1998). Again some of
reduction in T lymphocyte numbers) and the most these initial results are promising and deserve further
common treatment (AZT) is myelotoxic. One of the follow-up.
earliest clinical trials with GM-CSF was in neutro-
penic AIDS patients (Groopman et al., 1987), where
it successfully elevated neutrophil, monocyte, and
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