2005 Volume 8Pages 9–13

Regulation of neutrophilia bygranulocyte colony-stimulating factor:

a new cancer therapy that reversed acase of terminal hepatocellular

carcinoma

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Journal of Clinical Research 2005; 8: 9–13 JME LOGO

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This work reports the possible cure of a56-year-old patient with advancedhepatocarcinoma. Intense peritumoralneutrophilia was achieved byadministering granulocyte colony-stimulating factor (G-CSF), an experimentaltreatment based on the theory of universaltumour dynamics. After the first 8-weekcycle of treatment, the patient’s

α-fetoprotein (AFP) levels were reduced tonormal and his general condition improvedsufficiently to allow him to return to work.Following a second cycle of treatment,administered because of doubt regardingthe tumoral or inflammatory nature of thenow smaller liver mass, the patient’s AFPlevels remained normal and he continuedto enjoy good general health.

Regulation of neutrophilia by granulocytecolony-stimulating factor: a new cancertherapy that reversed a case of terminalhepatocellular carcinoma

Antonio Brú1, Sonia Albertos2, Fernando García-Hoz3, Isabel Brú4

Summary

Key words: hepatocellular carcinoma, liver, granulocyte colony-stimulating factor (G-CSF),α-fetoprotein, tumour dynamics, peritumoral neutrophilia

Accepted for publication: 10th May 2005

1Departamento de Matemática Aplicada, Universidad Complutense de Madrid, Spain

2Servicio de Aparato Digestivo, Hospital Clínico San Carlos, Madrid, Spain

3Servicio de Aparato Digestivo, Hospital Ramón y Cajal, Madrid, Spain

4Centro La Estación, Talavera de la Reina, Toledo, Spain

Address for correspondence: Dr Antonio Brú, Departamento de Matemática Aplicada, Facultad de Ciencias Matemáticas, UniversidadComplutense de Madrid, Avenida Complutense s/n, 28040 Madrid, Spain. Tel: +34 91 294 4725, fax: +34 91 3946413, e-mail:antonio.bru@mat.ucm.es

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Introduction

Hepatocellular carcinoma (HCC) is a majorcause of death worldwide. Onlyapproximately 30% of cases are treatable,and then only by surgery or livertransplant. Most patients are notcandidates for this treatment because theyare usually diagnosed when the disease isadvanced, or because of liver failure due tounderlying cirrhosis. Even after surgicalresection, the tumour recurs inapproximately 70% of patients within3 years1–3. New therapies are thereforeurgently required.

This paper reports the treatment of apatient with HCC via generation of intenseneutrophilia. According to recentpublications, all solid tumours grow by thesame mechanism, namely ‘diffusion’ oftumour cells at the tumour border4,5.Via this mechanism, new tumour cells aidtheir future proliferation by relocatingthemselves in cavities at the tumoursurface. Even though these cavities providethem less oxygen and nutrients and arealtogether more acidic environments5, theevidence suggests that space is the majorlimiting factor of tumour growth, and it isin these cavities at the tumour/host tissueinterface where space is most available5.Here, these new tumour cells can continueto divide and to degrade the extracellularmatrix.

It has been shown in mice that neutrophilscome into intimate contact with thetumour/host interface, and that when theirnumbers are large enough they can

generate sufficient pressure to prevent thishost growth mechanism6. In fibroehrlichttumours, 80–90% regression was seen in8 out of 10 rats after only 8 weeksfollowing the induction of intenseneutrophilia. The tumours of the remainingtwo animals completely disappeared. Thispaper reports similar results in a humanpatient with terminal hepatocarcinoma.

The patient was a 56-year-old man whohad been diagnosed with hepatitis non-Anon-B (designated hepatitis C 10 years ago)some 25 years earlier. He consumedapproximately 80 g ethanol per day. Thepatient had undergone no surgery and hadnot received any transfusions, and hadalways been asymptomatic with respect tohepatitis C virus (HCV) infection. Indeed,he had received no treatment in thisrespect. He was admitted to hospital forthe first time in February 2004 because ofmoderate ascites. A physical examinationrevealed signs of chronic hepatitis (palmarerythema, vascular spiders on the chest).Cardiopulmonary auscultation wasnormal. The abdomen showed moderateascites without peritoneal irritation.

The results of blood analysis were: platelets98,000 cells/µl; creatinine 1.6 mg/dl; totalbilirubin 2 mg/dl; aspartateaminotransferase (AST) 162 U/l; alanineaminotransferase (ALT) 136 U/l; gammaglutamyltransferase 468 U/l; alkalinephosphatase 213 U/l; lactatedehydrogenase 574 U/l; prothrombinactivity 68%; albumin 3.3 g/dl; andα-fetoprotein (AFP) 216 ng/ml. Cytology ofthe ascitic fluid revealed no malignant cells.

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At the time of diagnosis of HCC inFebruary 2004, a CT scan of thepelvic–abdominal area revealed aheterogeneous liver, especially noticeablein the right lobe. Ascites was present.Non-specific alteration of the mesenteric fatwas also observed, along with an effusionof the left pleura and cholelitiasis. Nuclearmagnetic resonance (NMR) revealedfindings compatible with a diffusehepatocarcinoma of the right hepatic lobeapproximately 95 mm in diameter (in abackground of liver cirrhosis),accompanied by thrombosis of thecommon portal vein and its two mainbranches. Ascites was confirmed.A non-specific nodule was found in thespleen. Cholelitiasis was again observed.Fine needle aspiration under radiologicalcontrol revealed a poorly differentiatedhepatocarcinoma.

In June 2004, no conventional treatmentwas indicated given the stage of thecarcinoma (lesion larger than 6 cm with

portal thrombosis). The patient wastherefore treated compassionately withgranulocyte colony-stimulating factor(G-CSF) (Neupogen, 10 µg/kg/day for 8weeks; Amgen Labs, Thousand Oaks, CA),modifying the dose to maintain a leukocytecount of no greater than 60,000 cells/ml.Blood analysis showed: haemoglobin11.2 g/dl; leukocytes 4,760 cells/µl;platelets 115,000 cells/µl; creatinine 1.33mg/dl; AST 86 U/l; ALT 124 U/l; and AFP453 ng/ml.

During treatment, which was very welltolerated, the patient showed only sporadicepisodes of mild fever. The leukocyte countwas successfully maintained below 60,000cells/ml at all times. On only one occasiondid it reach 58,900 cells/µl, on day 17 oftreatment, which required an adjustment tohalf the normal dosage (5 µg/kg/day) for 1day. The following day the initial dose wasrestored since the increase in the number ofleukocytes in the blood had beencontrolled. Haemoglobin, platelet

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Figure 2. Nuclear magnetic resonance images (a) at the time of diagnosis, and (b) at the endof treatment

a) b)

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and creatinine levels underwent nosignificant changes.A significant reduction was seen in theAFP level, from 453 ng/ml to 8.2 ng/mlover the 8 weeks of treatment. Two weeksafter the end of treatment it had fallen to4.74 ng/ml (normal values <10 ng/ml)(Figure 1a). In addition, the leukocytecount normalised. No other significantchanges were observed.

After finishing this first cycle of treatment,NMR continued to show a mass smallerthan on the initial images (Figure 2).Despite the fall in AFP levels and thepatient’s general state of good health, itwas unclear whether this mass wastumoral or inflammatory in nature. Givenits inaccessibility to biopsy (owing to thereduction in size of the lesion) and owingto the good tolerance shown to the G-CSFtreatment, a second cycle of treatment wasbegun in September 2004 (same dose andduration). This second cycle was equallywell tolerated and the patient remained ingood general condition. At the end of thiscycle, no differences were noticed withrespect to the previous NMR images(Figure 2). Ascites was still present(although less than when treatment wasbegun), possibly attributable to thecirrhosis suffered by the patient.

Four months after the second cycle oftreatment, the patient underwent fineneedle aspiration again. The cytologicalresults were compatible with small celldysplasia, but not malignancy. In addition,

radiological images were unchanged andAFP levels remained normal.The patient remained asymptomatic andcontinued to work; the hepatocarcinomamay therefore have been cured.

This is the first report of maintainedG-CSF-induced neutrophilia leading to alikely cure of multicentric hepatocarcinomaaccompanied by portal hypertension. Theuse of G-CSF in the treatment of HCCshould be studied further.

References

1. Lin TY, Lee CS, Chen KM et al. Role ofsurgery in the treatment of primarycarcinoma of the liver: a 31-yearexperience. British Journal of Surgery 1987;74: 839–842.

2. Chen MF, Hwang TL, Jeng LB et al.Postoperative recurrence of hepatocellularcarcinoma. Two hundred five consecutivepatients who underwent hepatic resectionin 15 years. Archives of Surgery 1994; 129:738–742.

3. Nagasue N, Uchida M, Makino Y et al.Incidence and factors associated withintrahepatic recurrence followingresection of hepatocellular carcinoma.Gastroenterology 1993; 105: 488–494.

4. Brú A, Pastor JM, Fernaud I et al. Super-rough dynamics of tumor growth. PhysicalReview Letters 1998; 81: 4008–4011.

5. Brú A, Albertos S, Subiza JL et al. Theuniversal dynamics of tumor growth.Biophysical Journal 2003; 85: 2948–2961.

6. Brú A, Albertos S, López García-Asenjo JAet al. Pinning of tumoral growth byenhancement of immunological response.Physical Review Letters 2004; 92: 238101.

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