Extracorporeal photopheresis in children with graft-versus-host disease

Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia

Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.

Photopheresis of a less than 10-kg child with acute graft versus host disease accompanied with hyperbilirubinemia: A case report

Hematopoietic stem cell transplantation is a curative treatment for many hematologic malignancies with its most important side effect being graft-versus-host disease (GVHD). Herein, we present a 3.5 year-old male with weight of 9.8 kg with acute GVHD (grade IV gastrointestinal and cutaneous) who did not respond to the first line therapies (corticosteroids). Thus, the patient was a candidate for extracorporeal photochemotherapy (ECP). Due to the hyperbilirubinemia, two sessions of ECP every week as well as one session of plasmapheresis 24 h before each ECP session were performed (Spectra^™Optia^® apheresis system). The procedures were performed successfully without any side effects and the GVHD manifestations of skin and GI responded perfectly to the treatment after 12 and 14 sessions of ECP, respectively. According to the results, it seems that ECP could be successfully performed in even less than 10-kg patients.

Analysis of clinical outcome and survival in pediatric patients undergoing extracorporeal photopheresis for the treatment of steroid-refractory GVHD

Extracorporeal photopheresis (ECP) has been used for treatment of steroid-refractory graft-versus-host disease (GVHD) with encouraging results. However, only a few pediatric centers have experienced with ECP, mainly by technical difficulties of leukapheresis in children. We retrospectively analyzed 27 patients treated during 5 years with ECP for steroid-refractory acute and chronic GVHD. We performed an "off-line" approach using a continuous flow cell separator (Cobe Spectra) and a Ultraviolet A irradiator (UVAMATIC). Among acute GVHD patients, 11 of 21 obtained a complete remission (CR) and another 8 reached partial remission. In the chronic GVHD group, 3 patients obtained CR and another 2 were in partial remission. Disease-free survival probability was 43±9% in the whole group. The only variable that impacts on disease-free survival on multivariate analysis was achieving CR with ECP. We also found a better CD4/CD8 ratio after ECP. In detail, among CD4 lymphocyte population, an increase in the effector memory and T-regulatory population was found. We may conclude that ECP is a safe and effective steroid-refractory GVHD treatment using the ex-vivo collection method, even in small children. Clinical response favorably impacts on long-term survival and seems to be associated with peripheral blood lymphocyte subset changes generating peripheral tolerance.

Technical report: effects of PUVA treatment on the optical properties of blood/tissue storage bags during extracorporeal photochemotherapy

Extracorporeal photochemotherapy (photopheresis, ECP) is a novel therapeutic method for patients who do not respond to immunosuppressive medications, and gaining interest in the treatment of Graft-vs-Host Disease. This paper is focused on the optical transmission properties of plastic bags which can be used in an independent (off-line) method of ECP, and reports the results of spectral measurements on various bags of different chemical compositions, with and without PUVA treatment. Regarding their higher and more uniform UVA transmission values, FEP based bags perform superior to the others. Considering its UVB absorption and UVA transmission properties, the EVA bag is a good choice, while Polyimide Kapton-FEP plastic film should not be considered for use in ECP. PUVA treatment of blood bags may affect their optical behaviour, and causes reduction of transmission of the material in UV range of the spectrum.