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Original Research: Diffuse Lung Disease |

Duration of Benefit in Patients With Autoimmune Pulmonary Alveolar Proteinosis After Inhaled Granulocyte-Macrophage Colony-Stimulating Factor TherapyVital Capacity and Pulmonary Alveolar Proteinosis FREE TO VIEW

Ryushi Tazawa, MD; Yoshikazu Inoue, MD; Toru Arai, MD; Toshinori Takada, MD; Yasunori Kasahara; Masayuki Hojo, MD; Shinya Ohkouchi, MD; Yoshiko Tsuchihashi, MD; Masanori Yokoba, MD; Ryosuke Eda, MD; Hideaki Nakayama, MD; Haruyuki Ishii, MD; Takahito Nei, MD; Konosuke Morimoto, MD; Yasuyuki Nasuhara, MD, FCCP; Masahito Ebina, MD; Masanori Akira, MD; Toshio Ichiwata, MD; Koichiro Tatsumi, MD, FCCP; Etsuro Yamaguchi, MD; Koh Nakata, MD
Author and Funding Information

From the Niigata University Medical and Dental Hospital (Drs Tazawa and Nakata), Niigata; the National Hospital Organization (NHO) Kinki-Chuo Chest Medical Center (Drs Inoue, Arai, and Akira), Osaka; the Niigata University Graduate School of Medical and Dental Sciences (Drs Takada and Nakayama), Niigata; the Department of Respirology (Drs Kasahara and Tatsumi), Graduate School of Medicine, Chiba University, Chiba; the Division of Respiratory Medicine (Dr Hojo), National Center for Global Health and Medicine, Tokyo; the Department of Respiratory Medicine (Drs Ohkouchi and Ebina), Tohoku University Medical School, Sendai; the Juzenkai Hospital (Dr Tsuchihashi), Nagasaki; the Institute of Tropical Medicine (Drs Tsuchihashi and Morimoto), Nagasaki University, Nagasaki; the Kitasato University School of Allied Health Sciences (Dr Yokoba), Kanagawa; the NHO Yamaguchi-Ube Medical Center (Dr Eda), Ube; the Kurashiki Municipal Kojima Hospital (Dr Eda), Kurashiki; the Department of Respiratory Medicine (Dr Nakayama), Tokyo Medical University, Tokyo; the Department of Respiratory Medicine (Dr Ishii), Kyorin University School of Medicine, Tokyo; the Department of Respiratory Medicine (Dr Nei), Nippon Medical University School of Medicine, Tokyo; the First Department of Medicine (Dr Nasuhara), Hokkaido University School of Medicine, Sapporo; the Department of Respiratory Medicine (Dr Ichiwata), Tokyo Medical University Hachioji Medical Center, Tokyo; and the Division of Respiratory Medicine and Allergology (Dr Yamaguchi), Department of Medicine, Aichi Medical University School of Medicine, Aichi, Japan.

Correspondence to: Koh Nakata, MD, Niigata University Medical & Dental Hospital, Bioscience Medical Research Center, 1-754 Asahimachi-dori, Chuo-ku Niigata, Niigata, Japan 951-8520; e-mail: radical@med.niigata-u.ac.jp


Funding/Support: This work was supported in part by grants from the Japanese Ministry of Education and Science, Ministry of Health, Labour, and Welfare of Japan [Grant H14-trans-014 to Dr Nakata, H21-Nanchi-Ippan-161 to Dr Inoue, and H24-Rinkensui-Ippan-003 to Dr Tazawa], Grant-in-Aid for Scientific Research [Category B 18406031 to Dr Inoue and Category C 22590852 to Dr Tazawa], and National Hospital Organization of Japan [Category Network to Dr Inoue].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(4):729-737. doi:10.1378/chest.13-0603
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Background:  Treatment of autoimmune pulmonary alveolar proteinosis (aPAP) by subcutaneous injection or inhaled therapy of granulocyte-macrophage colony-stimulating factor (GM-CSF) has been demonstrated to be safe and efficacious in several reports. However, some reports of subcutaneous injection described transient benefit in most instances. The durability of response to inhaled GM-CSF therapy is not well characterized.

Methods:  To elucidate the risk factors for recurrence of aPAP after GM-CSF inhalation, 35 patients were followed up, monitoring for the use of any additional PAP therapies and disease severity score every 6 months. Physiologic, serologic, and radiologic features of the patients were analyzed for the findings of 30-month observation after the end of inhalation therapy.

Results:  During the observation, 23 patients remained free from additional treatments, and twelve patients required additional treatments. There were no significant differences in age, sex, symptoms, oxygenation indexes, or anti-GM-CSF antibody levels at the beginning of treatment between the two groups. Baseline vital capacity (% predicted, %VC) were higher among those who required additional treatment (P < .01). Those patients not requiring additional treatment maintained the improved disease severity score initially achieved. A significant difference in the time to additional treatment between the high %VC group (%VC ≥ 80.5) and the low %VC group was seen by a Kaplan-Meier analysis and a log-rank test (P < .0005).

Conclusions:  These results demonstrate that inhaled GM-CSF therapy sustained remission of aPAP in more than one-half of cases, and baseline %VC might be a prognostic factor for disease recurrence.

Trial registry:  ISRCTN Register and JMACCT Clinical Trial Registry; No.: ISRCTN18931678 and JMAIIA00013; URL: http://www.isrctn.org and http://www.jmacct.med.or.jp

Figures in this Article

Autoimmune pulmonary alveolar proteinosis (aPAP) is a rare lung disease characterized by the accumulation of surfactant protein (SP), which causes progressive respiratory insufficiency.13 The pathogenesis has been attributed to the excessive production of a neutralizing autoantibody against granulocyte-macrophage colony-stimulating factor (GM-CSF) that impairs GM-CSF-dependent surfactant clearance mediated by alveolar macrophages.48 On pulmonary function testing, the most common pattern seen is that of a restrictive defect, with a disproportionate reduction in diffusing capacity of the lung for carbon monoxide (Dlco) relative to a modest impairment of vital capacity (VC).2 The disease is usually treated by whole-lung lavage (WLL), which remains the standard therapy to date.

The first patient successfully treated with subcutaneously administered GM-CSF was reported in 1996.9 In an international multicenter phase 2 trial study, 14 patients were treated with GM-CSF by subcutaneous injection in escalating doses over a 3-month period, with an overall response rate of 43%.10,11 A subsequent single-center study of 21 patients with aPAP treated with GM-CSF by subcutaneous administration in escalating doses for 6 to 12 months reported an overall response rate of 48%.12 Several single cases of subcutaneous GM-CSF therapy have reported similar outcomes.13,14 However, local reaction at sites of injection and other minor toxicities occurred in 85% of patients receiving subcutaneous GM-CSF.2

GM-CSF inhalation is a promising alternative therapy for aPAP that has been demonstrated to lead to functional, biologic, and radiologic improvement.1518 Our national, multicenter phase 2 study revealed that the therapy reduced alveolar-arterial oxygen difference (A-aDO2) by 12.3 mm Hg in 35 patients who completed the therapy, resulting in 24 responders. No treatment-related side effects were noted. Of importance, our previous phase 2 study showed that there was no significant difference in serologic, physiologic, and CT scan testing, except for serum Krebs von den Lungen-6 (KL-6) levels, between the responders and the nonresponders.18

There is limited information regarding the duration of benefit after various treatments of aPAP. In the literature analysis of 55 cases with a therapeutic response to WLL, the median duration of clinical benefit from lavage was 15 months.2 A phase 2 study of subcutaneous GM-CSF administration demonstrated that 45% of patients required WLL during follow-up observation of 39 ± 17.3 months.12 In a retrospective analysis of inhaled GM-CSF therapy (250 μg bid), five of 12 patients manifest progressive disease during observation.17 As the disease progresses very slowly and can fluctuate in some cases, it is necessary to evaluate the prognosis by monitoring prospectively at the same time points after the treatment and by disease severity score as well as the need for additional treatment. The aim of this study was to define the duration of benefit among patients who underwent GM-CSF inhalation therapy.

Patients and Protocols

The present study prospectively observed patients who participated in a multicenter phase 2 trial (35 patients, registered as ISRCTN18931678 and JMAIIA00013) of GM-CSF inhalation therapy described previously. In brief, patients who had lung biopsy or cytologic findings diagnostic for pulmonary alveolar proteinosis (PAP), including elevated serum anti-GM-CSF antibody (Ab) levels and no improvement during a 12-week observation period, entered the treatment phase. Recombinant human GM-CSF dissolved in 2 mL of sterile saline was inhaled using an LC-PLUS nebulizer (PARI International). The treatment consisted of high-dose GM-CSF administration (125 μg bid on days 1-8, none on days 9-14; sargramostim) for six repetitions of 2-week cycles, then low-dose administration (125 μg once daily on days 1-4, none on days 5-14) for six repetitions of 2-week cycles (for a total dose of 15 mg). The clinical information including physiologic, serologic, and radiologic features obtained18 was compared with the results of the following 30-month observation.

Patients were regularly evaluated by their physicians at the network hospitals after the GM-CSF inhalation therapy. The worsening dyspnea was evaluated with pulse oximetry, arterial blood gas analysis, or both in outpatient settings. Disease severity in patients was evaluated using PAP disease severity score (DSS) described previously.19 Patients underwent additional treatments based on either of the following criteria: (1) DSS is 3 or 4 and symptoms are worsening or (2) DSS 5, as shown in Figure 1. The consortium office of Niigata University contacted the network hospitals every 6 months with a questionnaire regarding additional treatment and disease severity score of the patient. The follow-up clinical information obtained at each network hospital was entered into a database to be compared with the results of the baseline clinical evaluation of each patient. The data were collected from nine clinical research centers in Japan (Hokkaido University, Tohoku University, Chiba University, Kitasato University, Niigata University, Aichi Medical University, National Hospital Organization Kinki-Chuo Chest Medical Center, National Hospital Organization Yamaguchi-Ube Medical Center, and Nagasaki University Institute of Tropical Medicine).

Figure Jump LinkFigure 1. Profile of the study cohort. AT = additional treatment; DSS = disease severity score; FR = free from additional treatment.Grahic Jump Location

The study was approved by institutional review board of Niigata University (approval No. NH17-006) and the institutional review boards at all participating centers. Informed consent was obtained from all control subjects. The clinical information obtained by the clinical studies was entered into a database to be compared with the results of the 30-month observation. The study was designed and monitored for data quality and safety by a steering committee composed of the principal investigator at each participating site. The steering committee held a conference twice a year, where the findings of the observation were monitored.

BAL Procedures and GM-CSF Autoantibodies

The steering committee edited a standard operational procedure for BAL, which was followed by all participating institutes and described previously.18,20 The concentration of GM-CSF autoantibodies in BAL fluid (BALF) or in serum were measured using a sandwich enzyme-linked immunosorbent assay as described previously.4,21

Statistical Analysis

Numerical results are presented as the mean ± SE or the median and interquartile range (IQR). The χ2 test was used to evaluate proportions for variables between high and low responders. The paired t test was used for comparisons between normally distributed data and the treatment periods. Comparisons of nonparametric data were made using the Wilcoxon signed-rank test. For group comparisons, unpaired t tests and Wilcoxon rank-sum tests were used. All P values were reported as two-sided. Analysis was performed using JMP software, version 8.0.2 (SAS Institute Inc).

Patient Characteristics and Requirements for Additional Treatments as an Indicator of Recurrence

Demographic data of patients are shown in Table 1. During the 30 months of observation after the end of GM-CSF inhalation, the need for treatments was monitored as an indicator of disease recurrence in each patient. Twenty-three patients were free from additional treatments during 30 months of observation and were designated as FR (free from additional treatment). Twelve patients who required additional treatments, including six patients with recurrence described in our previous study,18 were designated as AT (additional treatment). Of those, two patients maintained most severe disease (DSS 5) even after the GM-CSF treatment and underwent subsequent WLL. One patient who had dyspnea, cough, and sputum production did not respond to the GM-CSF treatment and underwent subsequent WLL. One patient with cough and dyspnea showed worsening in Pao2 and cough and had WLL 12 months after the GM-CSF inhalation. The other eight patients with dyspnea showed worsening in Pao2/oxygen saturation by pulse oximetry (two patients worsened to DSS 5) and underwent additional therapy (e-Fig 1); five underwent additional GM-CSF inhalation treatments, two had WLL, and one patient, a nonresponder, declined WLL and underwent acetylcysteine inhalation, showing much improvement in hypoxia. Median time to additional treatment of the 12 patients was 50.5 weeks, with a range of 8.5 to 117.5 weeks. There was no significant difference in age, sex, symptoms, smoking status, history of dust exposure, arterial blood gas analysis, numbers of responders to GM-CSF inhalation, history of previous lung lavage, and anti-GM-CSF-Ab titer between the FR and AT groups (Table 1). There was no significant difference in disease markers, including baseline levels of Pao2, A-aDO2, %VC, %Dlco, CT scan scores, lactate dehydrogenase (LDH), and KL-6 between the patients who underwent WLL (n = 6, AT-WLL group) and those treated with GM-CSF inhalation (n = 5, AT-GM group) (e-Table 1). However, changes in A-aDO2 during the GM-CSF treatment were significantly higher in the AT-GM group,

Table Graphic Jump Location
Table 1 —Baseline Clinical Characteristics of Patients Free From Additional Treatment and Those Who Required Additional Treatment After GM-CSF Inhalation

Thirty-five patients completed both the high-dose and low-dose period of GM-CSF inhalation therapy. A-aDO2 = alveolar-arterial oxygen difference; AT = additional treatment; FR = free from additional treatment; GM-CSF = granulocyte-macrophage colony-stimulating factor; IQR = interquartile range (range from the 25th to the 75th percentiles of the distribution).

a 

Calculated using the Wilcoxon rank sum test.

b 

Calculated using the χ2 test.

c 

Measured with patient in a supine position and breathing room air.

d 

Calculated using Student t test.

e 

Calculated using the following equation: A-aDO2 = (PB − Ph2o) × Fio2 − Paco2/R + {Paco2 × Fio2 × (1 − R)/R} − Pao2, where PB = barometric pressure measured by local observatories; Ph2o = partial pressure of water vapor in inspired air (assumed to be 47 mm Hg); Fio2 = fractional concentration of oxygen in dry gas (assumed to be 0.21); and R = respiratory quotient (assumed to be 0.8).

Association of Clinical Parameters With Requirement for Additional Treatment

There was no significant difference in baseline findings in terms of Pao2, Paco2, FEV1, and Dlco between AT and FR groups. Both %VC (% predicted value) and %FVC were higher in the FR group (P < .01) (Fig 2A, Table 2, e-Fig 2). There was no correlation between baseline %VC and age (P = .97), sex (P = .41), baseline Pao2 (P = .18), or baseline %Dlco (P = .34). There was no significant difference in high-resolution CT scan scores and serum markers, including LDH, KL-6, carcinoembryonic antigen (CEA), SP-A, and SP-D (Table 2). As for differential blood cell counts, no significant difference was observed between FR and AT groups, except for numbers of basophils and platelets. The cell density of macrophages in BALF was lower in the FR group than those in the AT group (P < .05), whereas lymphocytes were lower in the AT group as compared with the FR group.

Figure Jump LinkFigure 2. The association between VC (% predicted, %VC) and additional treatments during the 30-mo observation period (**P < .01). A, Baseline levels of %VC in FR and AT patient groups. B, Receiver operating curve of %VC. C, Kaplan-Meier plot showing patients of the high %VC group (%VC ≥ 80.5) and those of the low %VC group (%VC < 80.5). AUC = area under the receiver operating curve; VC = vital capacity. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location
Table Graphic Jump Location
Table 2 —Baseline Pulmonary Function, Radiologic Appearance, Serum Biomarkers, Hematologic Indexes, and BALF Cell Findings in Patients With PAP in FR and AT Groups Before GM-CSF Inhalation Treatment

BALF = BAL fluid; CEA = carcinoembryonic antigen; Dlco = diffusing capacity of the lung for carbon monoxide; HRCT = high-resolution CT; KL-6 = Krebs von den Lungen-6; LDH = lactate dehydrogenase; PAP = pulmonary alveolar proteinosis; SP = surfactant protein; VC = vital capacity. See Table 1 legend for expansion of other abbreviations.

a 

Calculated using Student t test.

b 

Described previously,18 left lung.

c 

Calculated using the Wilcoxon rank sum test.

Next, clinical parameters at the end of treatment were evaluated. The %Dlco was lower in the AT group than that in the FR group, and serum markers (eg, LDH, KL-6, CEA, SP-D, SP-A) and CT scan scores were higher in the AT group than those in the FR group at the end of treatment (P < .05). However, there was no significant difference in A-aDO2, blood cell counts, and cell differentials in BALF (Table 3). The patients free from additional treatment maintained the improved disease severity score initially achieved (e-Fig 3).

Table Graphic Jump Location
Table 3 —Pulmonary Function, Radiologic Appearance, Serum Biomarkers, Hematologic Indexes, and BALF Cell Findings in Patients With PAP in FR and AT Groups at the End of GM-CSF Inhalation Treatment and Before the 30-Mo Observation

See Table 1 and 2 legends for expansion of abbreviations.

a 

Calculated using Student t test.

b 

Described previously,18 left lung.

c 

Calculated using the Wilcoxon’s rank sum test.

Predictive Value of VC for Prognosis After GM-CSF Inhalation

Because only %VC and %FVC differed between FR and AT groups among treatment-related pretreatment factors, the predictive value of parameters for recurrence after GM-CSF inhalation was evaluated using receiver operating characteristics curve (ROC) analysis and Kaplan-Meier analysis of time to additional treatment.

For ROC analysis, the area under the ROC curve was calculated nonparametrically, as proposed by Hanley and McNeil.22 An additional therapy was defined as a positive indicator for disease recurrence. When the cutoff level of 80.5% was set for %VC, the baseline %VC predicted the additional therapy with a sensitivity of 92% and a specificity of 74% (Fig 2B).

For Kaplan-Meier analysis of time to additional treatment, we divided the patients into two groups, namely the high %VC group (%VC ≥ 80.5) and the low %VC group (%VC < 80.5). A significant difference in the time to additional treatment between the two groups was seen when the whole period of follow-up was compared (P = .0001) (Fig 2C). In the univariate Cox proportional analysis of baseline markers, %VC < 80.5% (hazard ratio, 18.42; 95% CI, 3.55-337.68; P < .0001) was associated with additional treatment, whereas no correlations were found between additional treatment and age, sex, baseline Pao2, changes in A-aDO2, and baseline levels of LDH, KL-6, SP-A, CEA, and anti-GM-CSF-Ab.

Subgroup Analysis:

To test whether VC is an independent predictive factor for the time to additional therapy, we did subgroup analyses because of the small number of the AT patients. The patients were divided into two groups of an upper one-half and a lower one-half regarding age; sex; baseline Pao2; change in A-aDO2; baseline levels of LDH, KL-6, SP-A, CEA; and anti-GM-CSF-Ab. In these subgroups, a significant difference in the time to additional treatment between the high %VC group (%VC ≥ 80.5) and the low %VC group (%VC < 80.5) was still evident, suggesting that VC might be an independent factor predicting the time to additional therapy (e-Fig 4).

Time Course of Autoantibody Levels:

In our previous reports, serum levels of anti-GM-CSF-Ab levels did not change during treatment.16 To study longitudinal changes of serum levels of anti-GM-CSF-Ab after the inhaled GM-CSF therapy, serum samples were collected for anti-GM-CSF-Ab testing as an optional evaluation after the 30-month observation period. The serum levels were unchanged during the observation period except for three cases (e-Fig 5). In two cases, the serum levels increased by > 100 μg/mL, and one case required an additional treatment, whereas the others did not. In the third case, the serum levels decreased to 0.47 μg/mL, and additional treatments were not required.

In the present study we have prospectively analyzed, for the time to our knowledge, the requirements of additional therapy and disease severity scores in 35 patients who completed GM-CSF inhalation therapy. The results demonstrate that 23 patients were free from administration of additional treatment during the 30-month observation period, indicating the enduring nature of the therapy. VC could be a useful predictive parameter for the recurrence of disease after GM-CSF therapy. This study contributes to the promotion of GM-CSF inhalation for initial therapy of aPAP.

WLL remains the standard of care today. A retrospective analysis of 231 cases found clinically significant improvement in Pao2, FEV1, VC, and Dlco and reported that the median duration of clinical benefit from lavage was 15 months.2 In a report of 21 patients with PAP who underwent WLL in an experienced center, > 70% of patients remained free from recurrent PAP during 7-year observation.23 In our study, the median time to application of additional therapy was 30 months after GM-CSF therapy, suggesting the effects of GM-CSF inhalation may be comparable to those of WLL. Notably, the difference in changes in A-aDO2 during the GM-CSF treatment between the AT-WLL group patients and the AT-GM group patients suggests that nonresponders to the first GM-CSF treatment might be likely to undergo WLL when disease recurred.

In a single-center, phase 2 study for subcutaneous administration of GM-CSF for PAP, Venkateshiah et al12 reported that nine of 21 patients (43%) required WLL. In a retrospective study of 12 patients who underwent aerosolized GM-CSF therapy, Wylam et al17 reported that five of 11 responders had recurrence of disease. In four of five patients, the mean time to relapse was 6.3 months and ranged from 5.5 to 12 months.15 It is notable that the dose of GM-CSF used in their study was twice that used in our study, although the prognosis of our cases was comparable to that of their study.

PAP is often described as a lung disorder with restrictive physiology. In the present study, 18 of 35 patients were in the normal range (≤ 80) in %FVC, whereas the other 17 patients were mildly to moderately restricted, which was comparable to previous studies.24 Seymour et al25 investigated 14 patients who underwent subcutaneous GM-CSF administration and suggested that higher VC before treatment was one marker to define responsiveness to GM-CSF therapy. In the present study, VC did not correlate with responsiveness to GM-CSF therapy, but it showed significant association with the requirement for additional treatment. Although limited by the small number of cases, the subgroup analyses suggested that VC is an independent factor from age, sex, baseline Pao2, change in A-aDO2, and baseline levels of serum markers, including anti-GM-CSF-Ab. However, there is a possibility that some clinical variables might be intrinsically related to VC. The physicians’ decision for retreatment might be influenced by such clinical markers. Notably, a recent study of a series of patients with PAP followed in a reference center reported that the need for lavage was significantly associated with FVC.26

Reduction of VC might be due to two different factors: accumulation of surfactant-derived materials in the alveolar space and fibrotic changes of lung tissue. In a study of a quantitative CT scan analysis of patients with PAP who underwent WLL and showed improvements in %Dlco and %FVC, Perez et al27 demonstrated that there was a reduction in lung weight following lavage, which correlated with the dry weight of the lavage effluent. The study demonstrated a shift in the regional lung inflation toward more inflated lung with a corresponding increase in the mean lung inflation. Surfactant accumulation might be associated with an elevated ventilation-perfusion mismatch and disproportionately impaired Dlco in patients with aPAP.2 Seymour et al25 demonstrated serum levels of SP-A correlated with VC in 14 patients at baseline. The present study also showed that serum levels of SP-A correlated with VC at baseline as well as after treatment. However, requirement of additional therapy was not significantly associated with SP-A at baseline. Surfactant materials might be easily redistributed in alveolar spaces and may not be related to the impairment of lung tissue that might lead to additional treatment.

The other factor, fibrotic changes of lung tissue, might be maintained even after GM-CSF therapy or WLL. Pulmonary fibrosis has been reported to be associated with PAP, and exposure to oxygen or repeated WLL have been suggested as potential contributors to fibrosis. Although irreversible scarring of the lung is rarely associated with PAP, a small fraction of patients with PAP demonstrated substantially impaired %VC and rather poor prognosis. To investigate this possibility, two radiologists reevaluated baseline CT scans of 32 of the 35 participants for findings other than PAP without knowing the study results regarding responsiveness and prognosis of the GM-CSF inhalation. They only pointed out traction bronchiectasis in one patient (responder, FR), bronchiectasis in one patient (responder, FR), and multiple bullae in one patient (responder, AT). Thus, we failed to find any significant association between fibrotic change in CT scan and requirement of additional treatments. In the present study, the mean %VC levels of patients in the FR group improved from 85.9% to 93.4%, whereas those of patients in the AT group changed from 71.6% to 74.2%. The difference in improvement between the groups might be associated with the balance of surfactant accumulation and lung fibrosis in the lungs of patients.

For future studies, it would be useful to explore novel treatment regimens for patients with moderately impaired VC. As shown in this study, inhaled GM-CSF therapy did not change serum levels of anti-GM-CSF-Ab. However, the BALF titers of anti-GM-CSF-Ab were reduced in responders, which was likely due to the improved clearance in alveolar spaces. The future treatments might include a combination of GM-CSF inhalation with WLL to improve the environment of airway/alveolar spaces or with administration of rituximab to reduce the systemic production of anti-GM-CSF-Ab.

In conclusion, this study demonstrated that VC might be clinically useful in predicting the need for additional therapy in patients with aPAP who were treated with inhaled GM-CSF therapy. We believe this study contributes to improving the quality of life and treatments for patients with aPAP.

Author contributions: Drs Tazawa and Nakata are guarantors of the manuscript and take responsibility for the integrity of the data and accuracy of the data analysis.

Dr Tazawa: contributed to study conception and design, collection and analysis of data, and writing of the manuscript.

Dr Inoue: contributed to study design and assistance with the writing of the manuscript.

Dr Arai: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Takada: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Kasahara: contributed to manuscript preparation, critical patient samples and data, and revision of the manuscript.

Dr Hojo: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Ohkouchi: contributed to data collection and analysis, manuscript preparation, and revision of the manuscript.

Dr Tsuchihashi: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Yokoba: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Eda: contributed to study design, data collection, manuscript preparation, and revision of the manuscript.

Dr Nakayama: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Ishii: contributed to study design, data collection, manuscript preparation, and revision of the manuscript.

Dr Nei: contributed to manuscript preparation, performance of research assays, and revision of the manuscript.

Dr Morimoto: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Nasuhara: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Ebina: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Akira: contributed to evaluation of CT scan, data collection, manuscript preparation, and revision of the manuscript.

Dr Ichiwata: contributed to data collection, clinical information on lung lavage, manuscript preparation, and revision of the manuscript.

Dr Tatsumi: contributed to data collection, manuscript preparation, and revision of the manuscript.

Dr Yamaguchi: contributed to manuscript preparation, critical patient samples and data, and revision of the manuscript.

Dr Nakata: contributed to study design, data analysis performance, assistance with the writing of the manuscript, and revision of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Other contributions: We thank the investigators and patients who participated in this study; John F. Seymour, MBBS, PhD, for critical reading of this manuscript; Bruce C. Trapnell, MD, Nobutaka Kitamura, DDS, PhD, and Kohei Akazawa, PhD, for helpful suggestions; Gen Tazaki, MD, and Hiroyuki Kamiya, MD, for valuable clinical information; Yuko Ito, BS, for measurement of GM-CSF autoantibody levels; and Marie Mori, BA, for help with preparation of data for the manuscript.

Additional information: The e-Figures and e-Table can be found in the “Supplemental Materials” area of the online article.

A-aDO2

alveolar-arterial oxygen difference

Ab

antibody

aPAP

autoimmune pulmonary alveolar proteinosis

AT

additional treatment

BALF

BAL fluid

CEA

carcinoembryonic antigen

Dlco

diffusing capacity of the lung for carbon monoxide

DSS

disease severity score

FR

free from additional treatment

GM-CSF

granulocyte-macrophage colony-stimulating factor

IQR

interquartile range

KL-6

Krebs von den Lungen-6

LDH

lactate dehydrogenase

PAP

pulmonary alveolar proteinosis

ROC

receiver operating characteristics curve

SP

surfactant protein

VC

vital capacity

WLL

whole-lung lavage

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Kavuru MS, Sullivan EJ, Piccin R, Thomassen MJ, Stoller JK. Exogenous granulocyte-macrophage colony-stimulating factor administration for pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2000;161(4 pt 1):1143-1148. [CrossRef]
 
Venkateshiah SB, Yan TD, Bonfield TL, et al. An open-label trial of granulocyte macrophage colony stimulating factor therapy for moderate symptomatic pulmonary alveolar proteinosis. Chest. 2006;130(1):227-237. [CrossRef]
 
Price A, Manson D, Cutz E, Dell S. Pulmonary alveolar proteinosis associated with anti-GM-CSF antibodies in a child: successful treatment with inhaled GM-CSF. Pediatr Pulmonol. 2006;41(4):367-370. [CrossRef]
 
Schoch OD, Schanz U, Koller M, et al. BAL findings in a patient with pulmonary alveolar proteinosis successfully treated with GM-CSF. Thorax. 2002;57(3):277-280. [CrossRef]
 
Anderson PM, Markovic SN, Sloan JA, et al. Aerosol granulocyte macrophage-colony stimulating factor: a low toxicity, lung-specific biological therapy in patients with lung metastases. Clin Cancer Res. 1999;5(9):2316-2323.
 
Tazawa R, Hamano E, Arai T, et al. Granulocyte-macrophage colony-stimulating factor and lung immunity in pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2005;171(10):1142-1149. [CrossRef]
 
Wylam ME, Ten R, Prakash UB, Nadrous HF, Clawson ML, Anderson PM. Aerosol granulocyte-macrophage colony-stimulating factor for pulmonary alveolar proteinosis. Eur Respir J. 2006;27(3):585-593. [CrossRef]
 
Tazawa R, Trapnell BC, Inoue Y, et al. Inhaled granulocyte/macrophage-colony stimulating factor as therapy for pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2010;181(12):1345-1354. [CrossRef]
 
Inoue Y, Trapnell BC, Tazawa R, et al. Characteristics of a large cohort of autoimmune pulmonary alveolar proteinosis in Japan. Am J Respir Crit Care Med. 2008;177(7):752-762. [CrossRef]
 
Ohashi K, Sato A, Takada T, et al. Direct evidence that GM-CSF inhalation improves lung clearance in pulmonary alveolar proteinosis. Respir Med. 2012;106(2):284-293. [CrossRef]
 
Uchida K, Beck DC, Yamamoto T, et al. GM-CSF autoantibodies and neutrophil dysfunction in pulmonary alveolar proteinosis. N Engl J Med. 2007;356(6):567-579. [CrossRef]
 
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29-36.
 
Beccaria M, Luisetti M, Rodi G, et al. Long-term durable benefit after whole lung lavage in pulmonary alveolar proteinosis. Eur Respir J. 2004;23(4):526-531. [CrossRef]
 
Bonella F, Bauer PC, Griese M, Ohshimo S, Guzman J, Costabel U. Pulmonary alveolar proteinosis: new insights from a single-center cohort of 70 patients. Respir Med. 2011;105(12):1908-1916. [CrossRef]
 
Seymour JF, Doyle IR, Nakata K, et al. Relationship of anti-GM-CSF antibody concentration, surfactant protein A and B levels, and serum LDH to pulmonary parameters and response to GM-CSF therapy in patients with idiopathic alveolar proteinosis. Thorax. 2003;58(3):252-257. [CrossRef]
 
Campo I, Mariani F, Rodi G, et al. Assessment and management of pulmonary alveolar proteinosis in a reference center. Orphanet J Rare Dis. 2013;8:40. [CrossRef]
 
Perez A IV, Coxson HO, Hogg JC, Gibson K, Thompson PF, Rogers RM. Use of CT morphometry to detect changes in lung weight and gas volume. Chest. 2005;128(4):2471-2477. [CrossRef]
 

Figures

Figure Jump LinkFigure 1. Profile of the study cohort. AT = additional treatment; DSS = disease severity score; FR = free from additional treatment.Grahic Jump Location
Figure Jump LinkFigure 2. The association between VC (% predicted, %VC) and additional treatments during the 30-mo observation period (**P < .01). A, Baseline levels of %VC in FR and AT patient groups. B, Receiver operating curve of %VC. C, Kaplan-Meier plot showing patients of the high %VC group (%VC ≥ 80.5) and those of the low %VC group (%VC < 80.5). AUC = area under the receiver operating curve; VC = vital capacity. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Baseline Clinical Characteristics of Patients Free From Additional Treatment and Those Who Required Additional Treatment After GM-CSF Inhalation

Thirty-five patients completed both the high-dose and low-dose period of GM-CSF inhalation therapy. A-aDO2 = alveolar-arterial oxygen difference; AT = additional treatment; FR = free from additional treatment; GM-CSF = granulocyte-macrophage colony-stimulating factor; IQR = interquartile range (range from the 25th to the 75th percentiles of the distribution).

a 

Calculated using the Wilcoxon rank sum test.

b 

Calculated using the χ2 test.

c 

Measured with patient in a supine position and breathing room air.

d 

Calculated using Student t test.

e 

Calculated using the following equation: A-aDO2 = (PB − Ph2o) × Fio2 − Paco2/R + {Paco2 × Fio2 × (1 − R)/R} − Pao2, where PB = barometric pressure measured by local observatories; Ph2o = partial pressure of water vapor in inspired air (assumed to be 47 mm Hg); Fio2 = fractional concentration of oxygen in dry gas (assumed to be 0.21); and R = respiratory quotient (assumed to be 0.8).

Table Graphic Jump Location
Table 2 —Baseline Pulmonary Function, Radiologic Appearance, Serum Biomarkers, Hematologic Indexes, and BALF Cell Findings in Patients With PAP in FR and AT Groups Before GM-CSF Inhalation Treatment

BALF = BAL fluid; CEA = carcinoembryonic antigen; Dlco = diffusing capacity of the lung for carbon monoxide; HRCT = high-resolution CT; KL-6 = Krebs von den Lungen-6; LDH = lactate dehydrogenase; PAP = pulmonary alveolar proteinosis; SP = surfactant protein; VC = vital capacity. See Table 1 legend for expansion of other abbreviations.

a 

Calculated using Student t test.

b 

Described previously,18 left lung.

c 

Calculated using the Wilcoxon rank sum test.

Table Graphic Jump Location
Table 3 —Pulmonary Function, Radiologic Appearance, Serum Biomarkers, Hematologic Indexes, and BALF Cell Findings in Patients With PAP in FR and AT Groups at the End of GM-CSF Inhalation Treatment and Before the 30-Mo Observation

See Table 1 and 2 legends for expansion of abbreviations.

a 

Calculated using Student t test.

b 

Described previously,18 left lung.

c 

Calculated using the Wilcoxon’s rank sum test.

References

Rosen SH, Castleman B, Liebow AA. Pulmonary alveolar proteinosis. N Engl J Med. 1958;258(23):1123-1142. [CrossRef]
 
Seymour JF, Presneill JJ. Pulmonary alveolar proteinosis: progress in the first 44 years. Am J Respir Crit Care Med. 2002;166(2):215-235. [CrossRef]
 
Trapnell BC, Whitsett JA, Nakata K. Pulmonary alveolar proteinosis. N Engl J Med. 2003;349(26):2527-2539. [CrossRef]
 
Kitamura T, Tanaka N, Watanabe J, et al. Idiopathic pulmonary alveolar proteinosis as an autoimmune disease with neutralizing antibody against granulocyte/macrophage colony-stimulating factor. J Exp Med. 1999;190(6):875-880. [CrossRef]
 
Uchida K, Nakata K, Trapnell BC, et al. High-affinity autoantibodies specifically eliminate granulocyte-macrophage colony-stimulating factor activity in the lungs of patients with idiopathic pulmonary alveolar proteinosis. Blood. 2004;103(3):1089-1098. [CrossRef]
 
Dranoff G, Crawford AD, Sadelain M, et al. Involvement of granulocyte-macrophage colony-stimulating factor in pulmonary homeostasis. Science. 1994;264(5159):713-716. [CrossRef]
 
Stanley E, Lieschke GJ, Grail D, et al. Granulocyte/macrophage colony-stimulating factor-deficient mice show no major perturbation of hematopoiesis but develop a characteristic pulmonary pathology. Proc Natl Acad Sci U S A. 1994;91(12):5592-5596. [CrossRef]
 
Sakagami T, Beck D, Uchida K, et al. Patient-derived granulocyte/macrophage colony-stimulating factor autoantibodies reproduce pulmonary alveolar proteinosis in nonhuman primates. Am J Respir Crit Care Med. 2010;182(1):49-61. [CrossRef]
 
Seymour JF, Dunn AR, Vincent JM, Presneill JJ, Pain MC. Efficacy of granulocyte-macrophage colony-stimulating factor in acquired alveolar proteinosis. N Engl J Med. 1996;335(25):1924-1925. [CrossRef]
 
Seymour JF, Presneill JJ, Schoch OD, et al. Therapeutic efficacy of granulocyte-macrophage colony-stimulating factor in patients with idiopathic acquired alveolar proteinosis. Am J Respir Crit Care Med. 2001;163(2):524-531. [CrossRef]
 
Kavuru MS, Sullivan EJ, Piccin R, Thomassen MJ, Stoller JK. Exogenous granulocyte-macrophage colony-stimulating factor administration for pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2000;161(4 pt 1):1143-1148. [CrossRef]
 
Venkateshiah SB, Yan TD, Bonfield TL, et al. An open-label trial of granulocyte macrophage colony stimulating factor therapy for moderate symptomatic pulmonary alveolar proteinosis. Chest. 2006;130(1):227-237. [CrossRef]
 
Price A, Manson D, Cutz E, Dell S. Pulmonary alveolar proteinosis associated with anti-GM-CSF antibodies in a child: successful treatment with inhaled GM-CSF. Pediatr Pulmonol. 2006;41(4):367-370. [CrossRef]
 
Schoch OD, Schanz U, Koller M, et al. BAL findings in a patient with pulmonary alveolar proteinosis successfully treated with GM-CSF. Thorax. 2002;57(3):277-280. [CrossRef]
 
Anderson PM, Markovic SN, Sloan JA, et al. Aerosol granulocyte macrophage-colony stimulating factor: a low toxicity, lung-specific biological therapy in patients with lung metastases. Clin Cancer Res. 1999;5(9):2316-2323.
 
Tazawa R, Hamano E, Arai T, et al. Granulocyte-macrophage colony-stimulating factor and lung immunity in pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2005;171(10):1142-1149. [CrossRef]
 
Wylam ME, Ten R, Prakash UB, Nadrous HF, Clawson ML, Anderson PM. Aerosol granulocyte-macrophage colony-stimulating factor for pulmonary alveolar proteinosis. Eur Respir J. 2006;27(3):585-593. [CrossRef]
 
Tazawa R, Trapnell BC, Inoue Y, et al. Inhaled granulocyte/macrophage-colony stimulating factor as therapy for pulmonary alveolar proteinosis. Am J Respir Crit Care Med. 2010;181(12):1345-1354. [CrossRef]
 
Inoue Y, Trapnell BC, Tazawa R, et al. Characteristics of a large cohort of autoimmune pulmonary alveolar proteinosis in Japan. Am J Respir Crit Care Med. 2008;177(7):752-762. [CrossRef]
 
Ohashi K, Sato A, Takada T, et al. Direct evidence that GM-CSF inhalation improves lung clearance in pulmonary alveolar proteinosis. Respir Med. 2012;106(2):284-293. [CrossRef]
 
Uchida K, Beck DC, Yamamoto T, et al. GM-CSF autoantibodies and neutrophil dysfunction in pulmonary alveolar proteinosis. N Engl J Med. 2007;356(6):567-579. [CrossRef]
 
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29-36.
 
Beccaria M, Luisetti M, Rodi G, et al. Long-term durable benefit after whole lung lavage in pulmonary alveolar proteinosis. Eur Respir J. 2004;23(4):526-531. [CrossRef]
 
Bonella F, Bauer PC, Griese M, Ohshimo S, Guzman J, Costabel U. Pulmonary alveolar proteinosis: new insights from a single-center cohort of 70 patients. Respir Med. 2011;105(12):1908-1916. [CrossRef]
 
Seymour JF, Doyle IR, Nakata K, et al. Relationship of anti-GM-CSF antibody concentration, surfactant protein A and B levels, and serum LDH to pulmonary parameters and response to GM-CSF therapy in patients with idiopathic alveolar proteinosis. Thorax. 2003;58(3):252-257. [CrossRef]
 
Campo I, Mariani F, Rodi G, et al. Assessment and management of pulmonary alveolar proteinosis in a reference center. Orphanet J Rare Dis. 2013;8:40. [CrossRef]
 
Perez A IV, Coxson HO, Hogg JC, Gibson K, Thompson PF, Rogers RM. Use of CT morphometry to detect changes in lung weight and gas volume. Chest. 2005;128(4):2471-2477. [CrossRef]
 
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