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Oza K, Kang J, Patil D, Owen KL, Cui W, Khan K, Kaufman SS, Kroemer A. Current Advances in Graft-versus-host Disease After Intestinal Transplantation. Transplantation 2024; 108:399-408. [PMID: 37309025 DOI: 10.1097/tp.0000000000004703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Graft-versus-host disease (GvHD) remains a potentially fatal complication following intestinal transplant (ITx). Over the past decade, advances in the understanding of the pathophysiology of this complex immunological phenomenon have led to the reassessment of the host systemic immune response and have created a gateway for novel preventive and therapeutic strategies. Although sufficient evidence dictates the use of corticosteroids as a first-line option, the treatment for refractory disease remains contentious and lacks a standardized therapeutic approach. Timely diagnosis remains crucial, and the advent of chimerism detection and immunological biomarkers have transformed the identification, prognostication, and potential for survival after GvHD in ITx. The objectives of the following review aim to discuss the clinical and diagnostic features, pathophysiology, advances in immune biomarkers, as well as therapeutic opportunities in the prevention and treatment of GvHD in ITx.
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Affiliation(s)
- Kesha Oza
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Digvijay Patil
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Kathryn L Owen
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Wanxing Cui
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Stuart S Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
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2
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Vitiello P, Sagnelli C, Ronchi A, Franco R, Caccavale S, Mottola M, Pastore F, Argenziano G, Creta M, Calogero A, Fiorelli A, Casale B, Sica A. Multidisciplinary Approach to the Diagnosis and Therapy of Mycosis Fungoides. Healthcare (Basel) 2023; 11:healthcare11040614. [PMID: 36833148 PMCID: PMC9957453 DOI: 10.3390/healthcare11040614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Mycosis fungoides is the most common primary cutaneous T-cell lymphoma, characterized by skin-homing CD4+ T cells derivation, indolent course, and low-grade of malignancy. Mycosis fungoides's classic type typically onsets with cutaneous erythematous patches, plaque, and tumor. In WHO-EORTC classification, folliculotropic mycosis fungoides, pagetoid reticulosis, and granulomatous slack skin are recognized as distinct variants of mycosis fungoides, because of their clinical and histological features, behavior, and /or prognosis. Mycosis fungoides often shows diagnostic difficulties, due to its absence of specific features and lesional polymorphism. A patient's treatment requires staging. In about 10% of cases, mycosis fungoides can progress to lymph nodes and internal organs. Prognosis is poor at advanced stage and management needs a multidisciplinary team approach. Advanced stage disease including tumors, erythroderma, and nodal, visceral, or blood involvement needs skin directed therapy associated with systemic drugs. Skin directed therapy includes steroids, nitrogen mustard, bexarotene gel, phototherapy UVB, and photochemiotherapy, i.e., total skin electron radiotherapy. Systemic therapies include retinoids, bexarotene, interferon, histone deacetylase inhibitors, photopheresis, targeted immunotherapy, and cytotoxic chemotherapy. Complexity of mycosis fungoides associated with long-term chronic evolution and multiple therapy based on disease stage need a multidisciplinary team approach to be treated.
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Affiliation(s)
- Paola Vitiello
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-39-3810-7860
| | - Andrea Ronchi
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Renato Franco
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Stefano Caccavale
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Maria Mottola
- Department of Heart Surgery and Transplantations, AORN Dei Colli-V Monaldi, 80131 Naples, Italy
| | | | - Giuseppe Argenziano
- Dermatology Unit, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Massimiliano Creta
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, 80131 Naples, Italy
| | - Armando Calogero
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
| | - Beniamino Casale
- Department of Pneumology and Tisiology, AO Dei Colli-V. Monaldi, 80131 Naples, Italy
| | - Antonello Sica
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80131 Naples, Italy
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Buder K, Zirngibl M, Bapistella S, Meerpohl JJ, Strahm B, Bassler D, Weitz M. Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in children and adolescents. Cochrane Database Syst Rev 2022; 9:CD009759. [PMID: 36166494 PMCID: PMC9514720 DOI: 10.1002/14651858.cd009759.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute graft-versus-host disease (aGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT), occurring in 8% to 85% of paediatric recipients. Currently, the therapeutic mainstay for aGvHD is treatment with corticosteroids. However, there is no established standard treatment for steroid-refractory aGvHD. Extracorporeal photopheresis (ECP) is a type of immunomodulatory method amongst different therapeutic options that involves ex vivo collection of peripheral mononuclear cells, exposure to the photoactive agent 8-methoxypsoralen and ultraviolet-A radiation, and reinfusion of these treated blood cells to the patient. The mechanisms of action of ECP are not completely understood. This is the second update of a Cochrane Review first published in 2014 and updated in 2015. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of aGvHD in children and adolescents after HSCT. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (PubMed) and Embase (Ovid) databases from their inception to 25 January 2021. We searched the reference lists of potentially relevant studies without any language restrictions. We searched five conference proceedings and nine clinical trial registries on 9 November 2020 and 12 November 2020, respectively. SELECTION CRITERIA We sought to include randomised controlled trials (RCTs) comparing ECP with or without standard treatment versus standard treatment alone in children and adolescents with aGvHD after HSCT. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreement in the selection of trials by consultation with a third review author. MAIN RESULTS We identified no additional studies in the 2021 review update, so there are still no studies that meet the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of aGvHD in children and adolescents after HSCT is unknown, and its use should be restricted to within the context of RCTs. Such studies should address a comparison of ECP alone or in combination with standard treatment versus standard treatment alone. The 2021 review update brought about no additions to these conclusions.
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Affiliation(s)
- Kathrin Buder
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Matthias Zirngibl
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Sascha Bapistella
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Joerg J Meerpohl
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Brigitte Strahm
- Pediatric Hematology and Oncology Centre for Pediatrics and Adolescent Medicine, University Medical School Freiburg, Freiburg, Germany
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zürich, Zürich, Switzerland
| | - Marcus Weitz
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
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Buder K, Zirngibl M, Bapistella S, Meerpohl JJ, Strahm B, Bassler D, Weitz M. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in children and adolescents. Cochrane Database Syst Rev 2022; 6:CD009898. [PMID: 35679154 PMCID: PMC9181448 DOI: 10.1002/14651858.cd009898.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation, occurring in 6% to 65% of the paediatric recipients. Currently, the therapeutic mainstay for cGvHD is treatment with corticosteroids, frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory cGvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is the second update of a Cochrane Review first published in 2014 and first updated in 2015. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of cGvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (2021), MEDLINE (PubMed) and Embase databases from their inception to 25 January 2021. We searched the reference lists of potentially relevant studies without any language restrictions. We searched five conference proceedings and nine clinical trial registries on 9 November 2020 and 12 November 2020, respectively. SELECTION CRITERIA We aimed to include randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in children and adolescents with cGvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this 2021 review update. AUTHORS' CONCLUSIONS We could not evaluate the efficacy of ECP in the treatment of cGvHD in children and adolescents after haematopoietic stem cell transplantation since the second review update again found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this population will be challenging due to the limited number of eligible participants, variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, recipients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for children and adolescents treated with ECP.
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Affiliation(s)
- Kathrin Buder
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Matthias Zirngibl
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Sascha Bapistella
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Joerg J Meerpohl
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Brigitte Strahm
- Pediatric Hematology and Oncology Centre for Pediatrics and Adolescent Medicine, University Medical School Freiburg, Freiburg, Germany
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zürich, Zürich, Switzerland
| | - Marcus Weitz
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
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Assessment of extracorporeal photopheresis related cell damage. Transfus Apher Sci 2022; 61:103472. [DOI: 10.1016/j.transci.2022.103472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022]
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Kozlov A, Estrina M, Paina O, Bykova T, Osipova A, Kozhokar P, Rakhmanova Z, Solodova I, Morozova E, Alyansky A, Kulagina I, Gevorgian A, Dotsenko A, Moiseev I, Chukhlovin A, Kulagin A, Bondarenko S, Semenova E, Zubarovskaya L. Extracorporeal Photopheresis in Children with Chronic Graft-Versus-Host Disease. Pharmaceuticals (Basel) 2021; 14:808. [PMID: 34451905 PMCID: PMC8398239 DOI: 10.3390/ph14080808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/06/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022] Open
Abstract
Chronic graft versus host disease (cGVHD) remains a major complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). It significantly decreases survival and quality of life. The present study demonstrates retrospective data on extracorporeal photopheresis (ECP) in children with cGVHD. A total of 42 children with steroid-refractory cGVHD were enrolled in the study. The majority of patients had acute leukemia (n = 32, 76%). All patients received ECP as second (n = 18, 43%) or third (n = 24, 57%) line of therapy. Initial ECP schedule consisted of bimonthly regimen for two consecutive days with possibility of further tapering according to response. Any concurrent treatment administered before ECP could be continued if considered necessary. Complete response to ECP was registered in seven (17%) patients and partial response in 24 (57%). Overall response according to organ involvement was as follows: skin (n = 24, 75%), mucous membranes (n = 16, 73%), liver (n = 8, 80%), gut (n = 4, 80%), lungs (n = 2, 22%) and joints (n = 2, 67%). Five-year overall, progression-free and failure-free survival was 57%, 56% and 30%, respectively. Non-relapse mortality at 5 years was 14%. We didn't observe any clinically significant complications in children that could be attributed to the procedure. ECP remains important and safe treatment option in children with cGVHD.
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Affiliation(s)
- Andrey Kozlov
- RM Gorbacheva Research Institute, Pavlov University, 197022 St. Petersburg, Russia; (M.E.); (O.P.); (T.B.); (A.O.); (P.K.); (Z.R.); (I.S.); (E.M.); (A.A.); (I.K.); (A.G.); (A.D.); (I.M.); (A.C.); (A.K.); (S.B.); (E.S.); (L.Z.)
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7
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Protective immune response against P32 oncogenic peptide-pulsed PBMCs in mouse models of breast cancer. Int Immunopharmacol 2021; 93:107414. [PMID: 33578183 DOI: 10.1016/j.intimp.2021.107414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/23/2020] [Accepted: 01/17/2021] [Indexed: 12/22/2022]
Abstract
High expression of p32 in certain tumors makes it a potential target for immunotherapy. In the present study, the first goal was to design multi-epitope peptides from the P32 protein and the second goal was to compare the prophylactic effects of DCs- and PBMCs- based vaccines by pulsing them with designed peptides. For these purposes, 160 BALB/c mice were vaccinated in 5 different subgroups of each 4 peptides using PBS (F1-4a), F peptides alone (F1-4b), F peptides with CpG-ODN (F1-4c), F peptides with CpGODN and DCs (F1-4d), and F peptides with CpG-ODN and PBMCs (F1-4e). We found a significantly higher interferon-γ (IFN-γ) and granzyme B levels in T cells of F4d and F4e subgroups compared to control (p ≤ 0.05). The result of challenging spleen PBMCs of vaccinated mice with 4T1 cells showed significant up- and down- regulation of Fas ligand (FasL) and forkhead box P3 (Foxp3) gene expression between F4d and F4e subgroups with control, respectively. In addition, a significant change was seen in Caspase3 gene expression of F4d subgroup compared to control (p ≤ 0.05). Supernatant levels of IFN-γ and perforin were significantly increased in F4d and F4e subgroups compared to control. Consequently, significantly lower tumor sizes and prolonged survival time were detected in F4d and F4e subgroups compared to control after challenging mice with 4T1 cells. Accordingly, these results demonstrated that PBMCs pulsed F4 peptide-based vaccine could induce a protective immune response while it is a simple and less expensive vaccine.
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Du AX, Osman M, Gniadecki R. Use of Extracorporeal Photopheresis in Scleroderma: A Review. Dermatology 2019; 236:105-110. [PMID: 31362294 DOI: 10.1159/000501591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/13/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Scleroderma is a heterogeneous group of diseases that can be localized or systemic. Localized scleroderma is a fibrosis of the skin characterized by inflammation and thickening due to excessive collagen deposition, and systemic sclerosis (SSc) is characterized by vasculopathy, immune dysregulation and skin fibrosis. In general, the prognosis of scleroderma highly depends on the degree of visceral involvement and relates to the degree of skin fibrosis. Despite the numerous therapies used for patients with scleroderma, the disease-related morbidity and mortality are high. Studies have explored the effects of extracorporeal photopheresis (ECP) in scleroderma treatment. Originally used in the treatment of cutaneous T-cell lymphoma, ECP is an immunomodulatory procedure in which a patient's white blood cells are treated with 8-methoxypsoralen and exposed to UVA radiation to inhibit cell proliferation and induce immunosuppression. SUMMARY Multiple lines of evidence suggest that ECP may be a safe and possibly effective therapy for patients with scleroderma, specifically demonstrating improvement in patients with cutaneous manifestations of the disease. However, future studies assessing its role in managing visceral involvement are needed. Our review aims to examine and consolidate the results of clinical studies and propose a possible role for ECP in the management of scleroderma. KEY POINTS ECP may be an effective and safe procedure for the treatment of SSc.
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Affiliation(s)
- Amy X Du
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamed Osman
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Gniadecki
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada, .,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, .,Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada,
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Extracorporeal photopheresis for the treatment of graft rejection in 33 adult kidney transplant recipients. Transfus Apher Sci 2019; 58:515-524. [PMID: 31383541 DOI: 10.1016/j.transci.2019.06.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/06/2019] [Accepted: 06/03/2019] [Indexed: 01/02/2023]
Abstract
Background - Extracorporeal photopheresis (ECP) has shown encouraging results in the prevention of allograft rejection in heart transplantation. However, the role of ECP in kidney transplant (KT) rejection needs to be determined. Methods - This multicentre retrospective study included 33 KT recipients who were treated with ECP for allograft rejection (23 acute antibody-mediated rejections (AMRs), 2 chronic AMRs and 8 acute cellular rejections (ACRs)). The ECP indications were KT rejection in patients who were resistant to standard therapies (n = 18) or in patients for whom standard therapies were contraindicated because of concomitant infections or cancers (n = 15). Results - At 12 months (M12) post-ECP, 11 patients (33%) had a stabilization of kidney function with a graft survival rate of 61%. The Banff AMR score (g + ptc + v) was a risk factor for graft loss at M12 (HR 1.44 [1.01-2.05], p < 0.05). The factorial mixed data analysis identified 2 clusters. Patients with a functional graft at M12 tended to have cellular and/or chronic rejections. Patients with graft loss at M12 tended to have acute rejections and/or AMR; higher serum creatinine levels; DSA levels and histologic scores of AMR; and a longer delay between the rejection and ECP start than those of patients with functional grafts. Conclusions - ECP may be helpful to control ACR or moderate AMR in KT recipients presenting concomitant opportunistic infections or malignancies when it is initiated early.
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Rushton C, Bacon E, Jennings E, Marchetti P, Alfred A. Adrenal insufficiency of patients with graft versus host disease treated with extracorporeal photopheresis. ACTA ACUST UNITED AC 2019; 28:698-701. [PMID: 31188658 DOI: 10.12968/bjon.2019.28.11.698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Graft versus host disease (GvHD) is a serious and common complication of allogenic haematopoietic stem cell transplant. Corticosteroids are considered the standard care for initial treatment of GvHD but a significant proportion of patients will need long-term steroid treatment for control of GvHD. Extracorporeal photopheresis (ECP) is a cell-based immunomodulatory therapy that is an accepted second line treatment in patients with steroid refractory, dependent or intolerant GvHD and has shown efficacy in allowing steroid dose reduction and discontinuation in this cohort of patients. Adrenal cortical insufficiency is defined by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids leading to a severe and potentially life-threatening condition. The most common cause of drug-induced adrenal insufficiency is the suppression of the hypothalamic-pituitary-adrenal axis by exogenous glucocorticoid doses ≥5 mg prednisolone equivalent for more than 4 weeks. The aim of the study was to ascertain the number of patients with GvHD receiving ECP that are affected by adrenocortical insufficiency.
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Affiliation(s)
- Cherie Rushton
- Specialist Nurse Photopheresis, The Rotherham NHS Foundation Trust, Rotherham
| | - Elizabeth Bacon
- Specialist Nurse Photopheresis, The Rotherham NHS Foundation Trust, Rotherham
| | - Emma Jennings
- Research Assistant, The Rotherham NHS Foundation Trust, Rotherham
| | - Paula Marchetti
- Consultant Clinical Scientist, The Rotherham NHS Foundation Trust, Rotherham
| | - Arun Alfred
- Consultant Haematologist, The Rotherham NHS Foundation Trust, Rotherham
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11
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Laulhé M, Lefebvre S, Le Broc-Ryckewaert D, Pierre M, Ferry A, Delorme B. A standardized methodical approach to characterize the influence of key parameters on the in vitro efficacy of extracorporeal photopheresis. PLoS One 2019; 14:e0212835. [PMID: 30822323 PMCID: PMC6396964 DOI: 10.1371/journal.pone.0212835] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
Extracorporeal photopheresis (ECP) is an autologous immunomodulatory cell therapy that consists of the ex vivo collection of mononuclear cells (MNCs), which are irradiated with UVA in the presence of the photosensitizing agent 8-methoxypsoralen (8-MOP) to induce cell apoptosis. This photoactivated cell preparation is then reinfused into the patient. While the clinical benefits of ECP are well-demonstrated, no study has yet characterized the influence of variations in the composition of the cell preparation on the efficacy of ECP in vitro. Here, we describe a standardized methodology for the in vitro assessment of ECP that uses the human lymphoma T-cell line and mimics the clinical procedure. By quantifying cell apoptosis, inhibition of cell proliferation, and 8-MOP consumption, we used this approach to characterize the specific influence of key variables on the cellular response to ECP. We found that (i) increases in hematocrit and plasma concentrations attenuated the cellular response to ECP; (ii) plasma concentration was the only variable tested that influenced 8-MOP consumption; and (iii) the loss of efficacy due to variations in the concentration of certain blood components could be counteracted by modulating the UVA dose. This methodology may enable evaluation of other leukapheresis preparation protocols and better determination of the optimal working parameters for ECP.
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Affiliation(s)
- Marie Laulhé
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | - Sylvie Lefebvre
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | | | - Maxime Pierre
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | - Aurélie Ferry
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
| | - Bruno Delorme
- MacoPharma, Biotherapy Division, Rue Lorthiois, Mouvaux, France
- * E-mail:
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12
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In vitro effects of different 8-methoxypsoralen treatment protocols for extracorporeal photopheresis on mononuclear cells. Cent Eur J Immunol 2017; 42:1-9. [PMID: 28680325 PMCID: PMC5470608 DOI: 10.5114/ceji.2017.67312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 05/20/2016] [Indexed: 12/19/2022] Open
Abstract
Extracorporeal photopheresis (ECP) is an important second-line therapy for graft-versus-host disease. A central therapeutic mechanism is the induction of immune tolerance through apoptosis in patient’s leukocytes, caused by ex vivo incubation with 8-methoxypsoralen (8-MOP) and subsequent UVA irradiation. We hypothesized that different 8-MOP incubation times and an additional 8-MOP removal step could influence the apoptosis kinetics of leukocytes in general and in particular could lead to different apoptotic levels in the leukocyte subpopulations. After 8-MOP/UVA treatment of human leukocytes, cells were cultured and the percentage of annexin V positive cells from several leukocyte subpopulations was determined. Only regulatory T cells (Tregs) were relatively resistant to 8-MOP/UVA induced apoptosis. When cells were incubated for 30 minutes with 8-MOP prior to UVA exposure, higher percentages of annexin V positive cells were detected on day 1 and day 2 after treatment. Removal of 8-MOP after UVA exposure caused no significant changes in the apoptosis kinetics during the 72 h culture period compared with unwashed cells. The results of our in vitro study indicate that it could be possible to adjust the apoptosis kinetics via modulation of the 8-MOP incubation time. In further in vivo studies it should be elucidated to which extent different apoptosis kinetics influence the therapeutic effect of ECP since steady-state apoptosis levels are probably important for establishing a long lasting immune tolerance. Furthermore we found that Tregs, according to their well-known tolerogenic function, are more resistant to apoptosis after 8-MOP/UVA treatment compared to GvHD inducing T cell populations.
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Abstract
Extracorporeal photochemotherapy (ECP) is considered as an immune modulating therapy majorly targeting the T cells of the Immune system. ECP induces an anti-inflammatory condition with tolerogenic responses without inducing a global immunosuppression state which is a typical feature of other therapeutic options such as steroids. Clinical indication of ECP has grown over time since its initial applications. Our review discusses the technical aspects of the concept of photopheresis with the available methods for its clinical applications.
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Affiliation(s)
- Satyam Arora
- Department of Transfusion Medicine and Hematology, BLK Super Speciality Hospital, New Delhi, India
| | - Rasika Setia
- Department of Transfusion Medicine and Hematology, BLK Super Speciality Hospital, New Delhi, India
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Becherucci V, Allegro E, Brugnolo F, Piccini L, Gori V, Bisin S, Bindi B, Ceccantini R, Pavan P, Cunial V, Gentile F, Ermini S, Bambi F. Extracorporeal photopheresis as an immunomodulatory agent: Haematocrit-dependent effects on natural killer cells. J Clin Apher 2016; 32:257-265. [PMID: 27476149 DOI: 10.1002/jca.21490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 06/18/2016] [Accepted: 07/10/2016] [Indexed: 12/22/2022]
Abstract
The GvHD is a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Extracorporeal photopheresis (ECP) represents an alternative therapeutic strategy to immunosuppressive therapy. Although ECP is used since 1990s, the mechanism of action has not yet been completely clarified. We analyzed cells collected from 20 ECP procedures of 4 patients affected by chronic GvHD and, for comparison, Peripheral Blood Mononuclear Cells (PBMCs) of 10 healthy donors undergoing from same type of photochemiotherapy, evaluating by flow cytometry, the effects before and after photoactivation with 8-MOP. The analysis showed a significant increase in cell death after ECP in particular in CD4 T lymphocytes as described in literature correlated with haematocrit value. Most interesting data emerge from the analysis of cytotoxic activity of NK cells, using flow cytometry analysis of surface expression of CD107a in the presence of target cells (K562). In all analyzed samples it was possible to document a statistically significant reduction of the cytotoxic activity of NK cells after photoactivation. The decrease of the cytotoxic activity was related to hematocrit value of leukoapheresis: in fact, lower HCT values were associated with a more marked reduction of cytotoxic activity. The study confirms literature data about the increase of cellular mortality induce by ECP. Furthermore, for the first time it is demonstrated that the ECP exerts a marked and significant inhibitory effect on the cytotoxic activity of NK cells. Our study suggests that lower values of hematocrit are associated with better treatment outcome.
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Affiliation(s)
- V Becherucci
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - E Allegro
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - F Brugnolo
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - L Piccini
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - V Gori
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - S Bisin
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - B Bindi
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - R Ceccantini
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - P Pavan
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - V Cunial
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - F Gentile
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - S Ermini
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
| | - F Bambi
- Department of Oncohematology, Cell Therapy Laboratory, Azienda Ospedaliero Universitaria Meyer, AOU Meyer, Florence, Italy
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Weitz M, Strahm B, Meerpohl JJ, Schmidt M, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2015; 2015:CD009898. [PMID: 26666581 PMCID: PMC7093760 DOI: 10.1002/14651858.cd009898.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE and EMBASE databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings on 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS No additional studies were identified in this 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs cannot be evaluated since the original version of this review and the first review update found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, patients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Brigitte Strahm
- University Medical School FreiburgPediatric Hematology and Oncology Centre for Pediatrics and Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Maria Schmidt
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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16
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Weitz M, Strahm B, Meerpohl JJ, Schmidt M, Bassler D. Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2015; 2015:CD009759. [PMID: 26666580 PMCID: PMC7093896 DOI: 10.1002/14651858.cd009759.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acute graft-versus-host disease (aGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT) occurring in 8% to 59% of the recipients. Currently, the therapeutic mainstay for aGvHD is corticosteroids. However, there is no established standard treatment for steroid-refractory aGvHD. Extracorporeal photopheresis (ECP) is a type of immunomodulatory method amongst different therapeutic options that involves ex vivo collection of peripheral mononuclear cells, exposure to the photoactive agent 8-methoxypsoralen and ultraviolet-A radiation, and re-infusion of these treated blood cells to the patient. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of aGvHD in children and adolescents after HSCT. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE (PubMed) and EMBASE (Ovid) databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restrictions. We searched eight trial registers and four conference proceedings on 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without standard treatment versus standard treatment alone in paediatric patients with aGvHD after HSCT. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreement in the selection of trials by consultation with a third review author. MAIN RESULTS We identified no additional studies in the 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of aGvHD in paediatric patients after HSCT is unknown and its use should be restricted within the context of RCTs. Such studies should address a comparison of ECP alone or in combination with standard treatment versus standard treatment alone. The 2015 review update brought about no additions to these conclusions.
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Affiliation(s)
- Marcus Weitz
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Brigitte Strahm
- University Medical School FreiburgPediatric Hematology and Oncology Centre for Pediatrics and Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Maria Schmidt
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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17
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Zhang H, Chen R, Cheng J, Jin N, Chen B. Systematic review and meta-analysis of prospective studies for ECP treatment in patients with steroid-refractory acute GVHD. Patient Prefer Adherence 2015; 9:105-11. [PMID: 25653504 PMCID: PMC4303403 DOI: 10.2147/ppa.s76563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this systematic review was to evaluate the efficacy and safety of extracorporeal photopheresis (ECP) treatment in patients with steroid-refractory acute graft-versus-host disease (SR-aGVHD). METHODS An electronic search was carried out on the MEDLINE, EMBASE, Science Citation Index (SCI), and Cochrane Library databases. We included prospective clinical trials in SR-aGVHD treated by ECP. The main endpoints consisted of mortality, exacerbation, or response. RESULTS Only seven studies involving 121 patients met the inclusion criteria for further review. Our analysis showed positive results of ECP for aGVHD. The overall response rate (ORR) was 0.71 and the complete response rate (CRR) was 0.71. The efficacy of ECP for skin aGVHD, liver aGVHD, and gut aGVHD were 0.86, 0.60, and 0.68, respectively. However, no sufficient evidence verifies the exact benefit in this review, because the number of patients enrolled in trials is limited and publish bias exists. CONCLUSION ECP is an effective therapy for skin, liver, and gut aGVHD, and large double-blind clinical trials are required to prove the outcome of this meta-analysis.
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Affiliation(s)
- Hongming Zhang
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Runzhe Chen
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Jian Cheng
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Nan Jin
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Baoan Chen
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
- Correspondence: Baoan Chen, Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Dingjiaqiao 87, Gulou District, Nanjing, Jiangsu Province, People’s Republic of China, Tel +86 25 8327 2006, Fax +86 25 8327 2011, Email
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18
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Capuano M, Sommese L, Pignalosa O, Parente D, Fabbricini R, Nicoletti GF, De Pascale MR, Schiano C, Napoli C. Current Clinical Applications of Extracorporeal Photochemotherapy. Ther Apher Dial 2014; 19:103-10. [DOI: 10.1111/1744-9987.12245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Maria Capuano
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
| | - Linda Sommese
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
| | - Orlando Pignalosa
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
| | - Delia Parente
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
| | - Rossella Fabbricini
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
| | - Giovanni Francesco Nicoletti
- Dipartimento Multidisciplinare di Specialità Medico-Chirurgiche e Odontoiatriche; Second University of Naples; Naples Italy
| | - Maria Rosaria De Pascale
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
| | - Concetta Schiano
- Institute of Diagnostic and Nuclear Development (SDN); IRCCS; Naples Italy
| | - Claudio Napoli
- U.O.C. Immunohematology, Transfusion Medicine and Transplant Immunology (SIMT); Azienda Ospedaliera Universitaria (AOU); Second University of Naples; Naples Italy
- Institute of Diagnostic and Nuclear Development (SDN); IRCCS; Naples Italy
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19
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Taverna F, Coluccia P, Arienti F, Birolini A, Terranova L, Mazzocchi A, Rini F, Mariani L, Melani C, Ravagnani F. Biological quality control for extracorporeal photochemotherapy: Assessing mononuclear cell apoptosis levels in ECP bags of chronic GvHD patients. J Clin Apher 2014; 30:162-70. [PMID: 25220858 DOI: 10.1002/jca.21357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 07/13/2014] [Accepted: 08/26/2014] [Indexed: 12/18/2022]
Abstract
Extracorporeal photochemotherapy (ECP) is a treatment approved by the FDA for cutaneous T-cell lymphoma, and it is currently used off-label for graft-versus-host disease (GvHD) and other conditions. In agreement with good practices for the therapeutic use of human cells, quality control has to be performed to validate the ECP procedure with the off-line technique. Since no gold-standard biological test is available, we assessed the apoptosis generated in the ECP bag using a flow cytometric analysis. Thirty-one ECP procedures performed on 13 patients with chronic GvHD were studied by monitoring the induction of mononuclear cell (MNC) apoptosis using annexin V/propidium iodide double staining; residual lymphocyte proliferation to standard mitogens was also measured in 17 of the procedures. The kinetics of apoptosis was analyzed at different times in MNCs untreated or treated with 8-methoxy-psoralen plus ultraviolet A; the variation (ΔAPOPTOSIS ) after 24 h revealed the efficacy of the treatment. In 88.6% of the 31 ECP procedures, ΔAPOPTOSIS was >15% (the "alerting" threshold for ΔAPOPTOSIS was set at 15% on the basis of our data); in the remainder (19.4%), the increment in apoptosis was lower. In four procedures, the proliferation assay was useful for assessing the effect of ECP on the apheretic bag. In conclusion, both flow cytometric assays enabled a biologically significant result to be obtained. In our opinion, the apoptosis test-being faster and easier than the proliferation test-could be a reliable way to validate ECP procedures.
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Affiliation(s)
- Francesca Taverna
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Paola Coluccia
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Flavio Arienti
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Annalisa Birolini
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Terranova
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Arabella Mazzocchi
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Rini
- Human Tumor Immunotherapy Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Mariani
- Clinical Epidemiology and Trial Organization Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Cecilia Melani
- Scientific Directorate, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Fernando Ravagnani
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
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20
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Budde H, Kolb S, Salinas Tejedor L, Wulf G, Reichardt HM, Riggert J, Legler TJ. Modified extracorporeal photopheresis with cells from a healthy donor for acute graft-versus-host disease in a mouse model. PLoS One 2014; 9:e105896. [PMID: 25148404 PMCID: PMC4141828 DOI: 10.1371/journal.pone.0105896] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 07/25/2014] [Indexed: 01/08/2023] Open
Abstract
Background Graft-versus-host disease (GvHD) is a major challenge after hematopoietic stem cell transplantation but treatment options for patients are still limited. In many cases first-line treatment with glucocorticoids is not successful. Among second-line therapies the extracorporeal photopheresis (ECP) is frequently performed, due to induction of selective tolerance instead of general immunosuppression. However, for some patients with severe acute GvHD the leukapheresis step of the ECP procedure is physically exhausting and limits the number of ECP cycles. Methods We hypothesized that leukocytes from healthy cell donors could be used as a replacement for ECP leukocytes gained from the GvHD patient. For this purpose we used a well established mouse model of acute GvHD. The ECP therapy was based on cells with the genetic background of the initial donor of the stem cell transplantation. As a precondition we developed a protocol representing conventional ECP in mice equivalent to clinical used ECP setup. Results We could demonstrate that conventional, clinically derived ECP setup is able to alleviate acute GvHD. By using leukocytes obtained from healthy mice with the bone marrow donor’s genetic background we could not observe a statistically significant therapeutic effect. Conclusions Conventional human ECP setup is effective in the mouse model of severe acute GvHD. In addition we could not prove that ECP cells from healthy mice with bone marrow donor’s genetic background are as effective as ECP cells derived from GvHD mice. Based on our findings, new questions arise for further studies, in which the cellular characteristics for ECP mediated immune tolerance are a matter of investigation.
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Affiliation(s)
- Holger Budde
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
- * E-mail:
| | - Susanne Kolb
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Laura Salinas Tejedor
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Gerald Wulf
- Department of Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Holger M. Reichardt
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, Göttingen, Germany
| | - Joachim Riggert
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Tobias J. Legler
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
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21
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Marques MB, Adamski J. Extracorporeal photopheresis: technique, established and novel indications. J Clin Apher 2014; 29:228-34. [PMID: 24828404 DOI: 10.1002/jca.21333] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/01/2014] [Indexed: 01/06/2023]
Abstract
Extracorporeal photopheresis (ECP) has had a major impact in the treatment of various conditions in the past 25 years. Although it was initially developed for the treatment of patients with resistant cutaneous T cell lymphoma (CTCL), this therapy was later used to treat recipients of solid organs and stem cell transplants with rejection or graft-versus-host disease (GVHD), respectively. A significant number of patients with CTCL can achieve long term remission with ECP therapy. Those patients with heart or lung transplants may experience fewer or shorter rejection episodes following ECP. Furthermore, patients that respond to ECP can generally reduce the dose of immunosuppression medication, thus minimizing the morbidity caused by drugs such as corticosteroids and calcineurin inhibitors. While the exact mechanism of action of ECP is not well-understood, evidence suggests that reinfusion of the patient's apoptotic white blood cells, the ultimate product of ECP, promotes immunomodulatory events that are beneficial in patients with CTCL, transplant rejection, GVHD, and possibly other inflammatory conditions.
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Affiliation(s)
- Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
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22
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Dieterlen MT, Bittner HB, Pierzchalski A, Dhein S, Mohr FW, Barten MJ. Immunological monitoring of extracorporeal photopheresis after heart transplantation. Clin Exp Immunol 2014; 176:120-8. [PMID: 24329680 DOI: 10.1111/cei.12254] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2013] [Indexed: 01/07/2023] Open
Abstract
Extracorporeal photopheresis (ECP) has been used as a prophylactic and therapeutic option to avoid and treat rejection after heart transplantation (HTx). Tolerance-inducing effects of ECP such as up-regulation of regulatory T cells (T(regs)) are known, but specific effects of ECP on regulatory T cell (T(reg)) subsets and dendritic cells (DCs) are lacking. We analysed different subsets of T(regs) and DCs as well as the immune balance status during ECP treatment after HTx. Blood samples were collected from HTx patients treated with ECP for prophylaxis (n = 9) or from patients with histologically proven acute cellular rejection (ACR) of grade ≥ 1B (n = 9), as well as from control HTx patients without ECP (HTxC; n = 7). Subsets of T(regs) and DCs as well as different cytokine levels were analysed. Almost 80% of the HTx patients showed an effect to ECP treatment with an increase of T(regs) and plasmacytoid DCs (pDCs). The percentage of pDCs before ECP treatment was significantly higher in patients with no ECP effect (26·3% ± 5·6%) compared to patients who showed an effect to ECP (9·8% ± 10·2%; P = 0·011). Analysis of functional subsets of CD4⁺CD25(high)CD127(low) T(regs) showed that CD62L-, CD120b- and CD147-positive T(regs) did not differ between the groups. CD39-positive T(regs) increased during ECP treatment compared to HTxC. ECP-treated patients showed higher levels for T helper type 1 (Th1), Th2 and Th17 cytokines. Cytokine levels were higher in HTx patients with rejection before ECP treatment compared to patients with prophylactic ECP treatment. We recommend a monitoring strategy that includes the quantification and analysis of T(regs), pDCs and the immune balance status before and up to 12 months after starting ECP.
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Affiliation(s)
- M-T Dieterlen
- Department of Cardiac Surgery, Heart Center, University Hospital Leipzig, Leipzig, Germany
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23
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Weitz M, Strahm B, Meerpohl JJ, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2014:CD009898. [PMID: 24569961 DOI: 10.1002/14651858.cd009898.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options in these people include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE and EMBASE databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings. We also contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs can currently not be evaluated since we have found no such studies. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical grounds in favour of ECP are made, people should be carefully monitored for beneficial and harmful effects and efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- Department of Pediatrics, University of Tuebingen, Hoppe-Seyler-Strasse 1, Tübingen, Germany, 72076
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Weitz M, Strahm B, Meerpohl JJ, Bassler D. Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2014:CD009759. [PMID: 24569960 DOI: 10.1002/14651858.cd009759.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acute graft-versus host disease (aGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT) occurring in 8% to 59% of the recipients. Currently, the therapeutic mainstay for aGvHD is corticosteroids. However, there is no established standard treatment for steroid-refractory aGvHD. Extracorporeal photopheresis (ECP) is a type of immunomodulatory method amongst different therapeutic options that involves ex vivo collection of peripheral mononuclear cells, exposure to the photoactive agent 8-methoxypsoralen and ultraviolet-A radiation, and re-infusion of these treated blood cells to the patient. The mechanisms of action of ECP are not completely understood OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of aGvHD in children and adolescents after HSCT. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE/PubMed and EMBASE (Ovid) databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and four conference proceedings. We also contacted an expert in the field to request information on unpublished study that involves ECP in aGvHD after HSCT. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without standard treatment versus standard treatment alone in paediatric patients with aGvHD after HSCT. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreement in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of aGvHD in paediatric patients after HSCT is unknown and its use should be restricted within the context of RCTs. Such studies should address a comparison of ECP alone or in combination with standard treatment versus standard treatment alone.
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Affiliation(s)
- Marcus Weitz
- Pediatric Nephrology, University Children's Hospital, Steinwiesstrasse 75, Zurich, Switzerland, 8032
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Pierelli L, Perseghin P, Marchetti M, Messina C, Perotti C, Mazzoni A, Bacigalupo A, Locatelli F, Carlier P, Bosi A. Extracorporeal photopheresis for the treatment of acute and chronic graft-versus-host disease in adults and children: best practice recommendations from an Italian Society of Hemapheresis and Cell Manipulation (SIdEM) and Italian Group for Bone Marrow Tra. Transfusion 2013; 53:2340-52. [DOI: 10.1111/trf.12059] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 10/24/2012] [Accepted: 11/05/2012] [Indexed: 01/01/2023]
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Martino M, Fedele R, Cornelio G, Moscato T, Imbalzano L, Ressa G, Massara E, Bresolin G. Extracorporeal photopheresis, a therapeutic option for cutaneous T-cell lymphoma and immunological diseases: state of the art. Expert Opin Biol Ther 2012; 12:1017-30. [PMID: 22587646 DOI: 10.1517/14712598.2012.688025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Extracorporeal photopheresis (ECP) has been extensively used for the treatment of immune-mediated diseases for over 20 years and has a consistent and predictable safety profile with long-term use. Documenting the efficacy of ECP as therapeutic treatment has long been a matter of importance for physicians. AREAS COVERED The authors reviewed publications in this field with the goal of providing an overview of this therapeutic approach. EXPERT OPINION ECP is efficacious in a high percentage of those cutaneous T-cell lymphoma patients who have circulating malignant T cells in the context of a still-near-normal immune competence. From the side of graft-versus-host disease (GVHD), the use of ECP showed a clinical benefit in patients with steroid-refractory acute GVHD (aGVHD) and it is believed that ECP deserves to be evaluated as part of a combination strategy in first-line therapy of aGVHD. In chronic GHVD, the published data show that ECP can be effective in extensive and long-standing disease even when treatment is initiated at an advanced stage after conventional immunosuppressive and corticosteroid therapy has failed. ECP should be considered most beneficial for patients with predominantly mucocutaneous chronic GVHD. The fields of application of the procedure could be vast, and could also include autoimmune and metabolic diseases. The most important methodological issues which affect ECP evaluation is that the large majority of data about ECP result from single-arm observational series and the significant efficacy is mainly based on small and retrospective studies. ECP has never been proved to offer any survival advantage in a context of a randomized trial and the above-mentioned limitation also affects the accuracy of many biological modifications observed during ECP. Starting from these considerations, the need of a prospective randomized study becomes increasingly urgent.
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Affiliation(s)
- Massimo Martino
- Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Bianchi-Melacrino-Morelli, 89100 Reggio Calabria, Italy.
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Extracorporeal photopheresis in the treatment of chronic graft-versus-host disease. The Hellenic experience: A study by the Hellenic association of hematology. Transfus Apher Sci 2012; 46:173-80. [DOI: 10.1016/j.transci.2011.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 08/12/2011] [Accepted: 09/23/2011] [Indexed: 01/29/2023]
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Siakantaris MP, Tsirigotis P, Stavroyianni N, Argyropoulos KV, Girkas K, Pappa V, Chondropoulos S, Papadavid E, Sakellari I, Anagnostopoulos A, Antoniou C, Dervenoulas J. Management of cutaneous T-Cell lymphoma patients with extracorporeal photopheresis. The hellenic experience. Transfus Apher Sci 2012; 46:189-93. [DOI: 10.1016/j.transci.2011.10.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/13/2011] [Indexed: 11/24/2022]
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Tsirigotis P, Kapsimalli V, Baltadakis I, Kaloyannidis P, Karakasis D, Papalexandri A, Psarra E, Nosi E, Konsta E, Vikentiou M, Papageorgiou S, Sakellari I, Pappa V, Harhalakis N, Anagnostopoulos A, Dervenoulas J. Extracorporeal photopheresis in refractory chronic graft-versus-host disease: The influence on peripheral blood T cell subpopulations. A study by the Hellenic Association of Hematology. Transfus Apher Sci 2012; 46:181-8. [DOI: 10.1016/j.transci.2011.10.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 10/13/2011] [Indexed: 12/01/2022]
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Update on the mechanism of action and on clinical efficacy of extracorporeal photopheresis in the treatment of acute and chronic graft versus host disease in children. Transfus Apher Sci 2011; 46:203-9. [PMID: 22079263 DOI: 10.1016/j.transci.2011.10.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/13/2011] [Indexed: 11/21/2022]
Abstract
Extracorporeal photopheresis (ECP) has been used for treatment of steroid-refractory graft versus host disease (GVHD) with encouraging results. Although its exact mechanism of action is not fully understood, photoapheresed cells seem to induce a selective immune response directed against alloreactive T cell populations without causing generalized immunosuppression. Current pediatric experience with ECP for GVHD is available in the form of a few retrospective small studies concerning children with steroid refractory GVHD. Reviewing these data we conclude that ECP is a safe procedure, well tolerated even in low-weight pediatric patients, which warrants further evaluation in well-designed, prospective, controlled studies.
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The role of extracorporeal photopheresis in the treatment of cutaneous T-cell lymphomas. Transfus Apher Sci 2011; 46:195-202. [PMID: 22067605 DOI: 10.1016/j.transci.2011.10.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/13/2011] [Indexed: 11/20/2022]
Abstract
Extracorporeal photochemotherapy (ECP) is an effective treatment modality for patients with erythrodermic myocosis fungoides (MF) and Sezary syndrome (SS). During ECP, a fraction of peripheral blood mononuclear cells is collected, incubated ex-vivo with methoxypsoralen, UVA irradiated, and finally reinfused to the patient. Although the mechanism of action of ECP is not well established, clinical and laboratory observations support the hypothesis of a vaccination-like effect. ECP induces apoptosis of normal and neoplastic lymphocytes, while enhancing differentiation of monocytes towards immature dendritic cells (imDCs), followed by engulfment of apoptotic bodies. After reinfusion, imDCs undergo maturation and antigenic peptides from the neoplastic cells are expressed on the surface of DCs. Mature DCs travel to lymph nodes and activate cytotoxic T-cell clones with specificity against tumor antigens. Disease control is mediated through cytotoxic T-lymphocytes with tumor specificity. The efficacy and excellent safety profile of ECP has been shown in a large number of retrospective trials. Previous studies showed that monotherapy with ECP produces an overall response rate of approximately 60%, while clinical data support that ECP is much more effective when combined with other immune modulating agents such as interferons or retinoids, or when used as consolidation treatment after total skin electron beam irradiation. However, only a proportion of patients actually respond to ECP and parameters predictive of response need to be discovered. A patient with a high probability of response to ECP must fulfill all of the following criteria: (1) SS or erythrodermic MF, (2) presence of neoplastic cells in peripheral blood, and (3) early disease onset. Despite the fact that ECP has been established as a standard treatment modality, no prospective randomized study has been conducted so far, to the authors' knowledge. Considering the high cost of the procedure, the role of ECP in the treatment of SS/MF needs to be clarified via well designed multicenter prospective randomized trials.
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Koreth J, Antin JH. Current and future approaches for control of graft-versus-host disease. Expert Rev Hematol 2011; 1:111. [PMID: 20151032 DOI: 10.1586/17474086.1.1.111] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Graft-versus-host disease (GVHD), both acute and chronic, remains one of the major barriers to improving outcomes after allogeneic stem cell transplantation. The pathophysiology of GVHD is complex and incompletely understood. GVHD is believed to arise from the interaction of: tissue damage and proinflammatory cytokines causing activation of antigen-presenting cells (APCs, donor T-cell activation by APCs and cytokines and host tissue injury by effector T lymphocytes and proinflammatory cytokines. There is also a role for additional lymphocyte subtypes (naive and memory T cells, regulatory T cells, natural killer T cells and B cells) in GVHD pathogenesis. Strategies to improve donor-recipient HLA match, and to minimize conditioning toxicity, cytokine release and APC and effector T-lymphocyte activation, will likely improve prophylaxis of acute (and possibly chronic) GVHD. Therapy of established acute and chronic GVHD is still heavily dependent on corticosteroids, despite their limited efficacy and considerable toxicity. Novel agents (and/or combinations of agents) comprising pharmacologic, biologic and cellular therapies targeting specific steps or subsets involved in immune activation will likely comprise future advances in GVHD control. This article reviews the current state of knowledge regarding the prevention and treatment of acute and chronic GVHD. Novel approaches currently undergoing evaluation are also highlighted.
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Affiliation(s)
- John Koreth
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA
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McGirt LY, Thoburn C, Hess A, Vonderheid EC. Predictors of response to extracorporeal photopheresis in advanced mycosis fungoides and Sézary syndrome. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2010; 26:182-91. [PMID: 20626820 DOI: 10.1111/j.1600-0781.2010.00514.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) has been utilized for more than 20 years to treat cutaneous T-cell lymphoma (CTCL), but a clinical response can take up to 9 months to manifest. This study was undertaken to determine whether clinical features, laboratory values, cytokine levels, or gene expression levels of tumor markers are useful to predict the subsequent response to ECP in CTCL patients with blood involvement. METHODS Twenty-one patients with CTCL treated with ECP as monotherapy for at least 6 months were retrospectively identified. Laboratory and clinical data and blood obtained at baseline, 3, and 6 months of treatment were used for analysis. RESULTS In pretreatment blood specimens, a lower percentage of Sézary cells and a higher absolute eosinophil count were associated with a favorable clinical response. Clinical evidence of an early response after 3 months of ECP did not reliably predict a favorable response at 6 months or beyond. Comparison of cytokines, gene transcripts, and other laboratory measures of disease did not correlate with the subsequent clinical response, although lactate dehydrogenase levels tended to decrease progressively in ECP-responsive cases and increase progressively in ECP-non-responsive cases. Additionally, serum levels of TNF-alpha significantly increased from baseline to 6 months of ECP, but was not found to correlate with the clinical response. CONCLUSIONS Although we found that increased eosinophils and decreased percentage of Sézary cells were associated with a favorable clinical response to ECP, we were not able to identify the predictors of ECP response within the first 3 months of treatment.
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Affiliation(s)
- Laura Y McGirt
- Dermatology, Johns Hopkins Medical Institutes, Baltimore, MD, USA.
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Perseghin P, Incontri A. Mononuclear cell collection in patients treated with extracorporeal photochemotherapy by using the off-line method: A comparison between COBE Spectra AutoPbsc version 6.1 and Amicus cell separators. J Clin Apher 2010; 25:310-4. [DOI: 10.1002/jca.20261] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 07/15/2010] [Indexed: 11/06/2022]
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CFSE flow cytometric quantification of lymphocytic proliferation in extracorporeal photopheresis: use for quality control. Transfus Apher Sci 2010; 42:11-9. [PMID: 19931489 DOI: 10.1016/j.transci.2009.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 09/18/2009] [Indexed: 11/22/2022]
Abstract
Quality control is essential to validate extracorporeal photopheresis (ECP) processes. There is just one protocol based on PHA-induced proliferation. Since it involves the use of radioactive thymidine, we developed another technique using CFSE labeling. We compared the two tests in a paired series including 18 procedures. The thymidine test was valid. Once proliferation was obtained (10 patients out of 13), the CFSE test was in close agreement with it. In particular, two cases of residual proliferation after ECP were simultaneously detected by both techniques. Only the CFSE test allows targeted analysis of lymphocytes, thus identifying a surviving lymphocytic sub-population.
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Zheng DH, Dou LP, Wei YX, Du GS, Zou YP, Song JY, Zhu ZD, Cai M, Qian YY, Shi BY. Uptake of donor lymphocytes treated with 8-methoxypsoralen and ultraviolet A light by recipient dendritic cells induces CD4+CD25+Foxp3+ regulatory T cells and down-regulates cardiac allograft rejection. Biochem Biophys Res Commun 2010; 395:540-6. [DOI: 10.1016/j.bbrc.2010.04.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 04/09/2010] [Indexed: 11/28/2022]
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Experimental extracorporeal photopheresis therapy significantly delays the development of diabetes in non-obese diabetic mice. Clin Immunol 2010; 135:374-83. [PMID: 20223712 DOI: 10.1016/j.clim.2010.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 01/27/2010] [Accepted: 01/29/2010] [Indexed: 12/14/2022]
Abstract
In our previous studies, we demonstrated that infusion of apoptotic cells significantly prevented type 1 diabetes (T1D) in non-obese diabetic (NOD) mice. Extracorporeal photopheresis (ECP) is an apoptotic cell-based therapy used clinically for immune-mediated disorders. In this study, we examined the effect that intravenous delivery of apoptotic cells (ECP-treated) has in the prevention of T1D in NOD mice. We discovered that five weekly injections of ECP-treated NOD spleen cells, beginning at 8 weeks of age, significantly delayed diabetes onset. Furthermore, cell dose studies demonstrated that low dose ECP-treated spleen cells (2x10(5) cells/injection/mouse) had similar protective effects as compared to high dose (5x10(6) cells/injection). In contrast to ECP-treated cells alone, ECP-treated cells combined with beta cell antigens appeared to improve the protective effect as shown by the marked reduction in insulitis in the islets. Delivery of ECP-treated spleen cells or ECP-treated spleen cells plus beta cell antigen increased Foxp3(+) Tregs, and beta cell antigen-specific T cell proliferation was significantly suppressed in vivo in these two groups. In addition, we found that ECP-treated cells did not induce global immunosuppression or autoimmunity against nuclear antigens. In conclusion, ECP-treated cells provide a safe and effective approach in T1D prevention, suggesting that clinical ECP has great potential for managing human T1D.
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Viguier M, Pouthier F, Tiberghien P, Aubin F. La photochimiothérapie extracorporelle. Transfus Clin Biol 2010; 17:28-33. [DOI: 10.1016/j.tracli.2009.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 10/23/2009] [Indexed: 11/15/2022]
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Trannoy L, Roelen D, Koekkoek K, Brand A. Impact of Photodynamic Treatment with Meso-substituted Porphyrin on the Immunomodulatory Capacity of White Blood Cell-containing Red Blood Cell Products. Photochem Photobiol 2010; 86:223-30. [DOI: 10.1111/j.1751-1097.2009.00624.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Remund K, Rechsteiner T, Guo Z, Hofer M, Boehler A. Extracorporeal photopheresis in a rat model of pulmonary fibrosis. Exp Lung Res 2009; 35:359-70. [PMID: 19842838 DOI: 10.1080/01902140902718205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Extracorporeal photopheresis has anti-inflammatory properties. The development of pulmonary fibrosis includes inflammatory episodes. This study evaluates effects of extracorporeal photopheresis in experimental pulmonary fibrosis. The bleomycin model of pulmonary fibrosis was used. Two groups of 4 rats received intratracheal bleomycin to induce fibrosis. The treatment group received infusions of photochemically treated leukocytes harvested from syngeneic animals. All animals were sacrificed at day 21 after fibrosis induction and analyzed with respect to lung histology and hydroxyproline content, cellular composition of bronchoalveolar lavages, serum and lavage concentrations of transforming growth factor-beta, interferon-gamma, and interleukin-10, and expression of selected genes in the lung. Interleukin-10 and transforming growth factor-beta protein concentrations increased in the plasma of treated animals, whereas the interferon-gamma protein concentration was higher in bronchoalveolar lavages. Interferon-gamma gene expression was up-regulated in the lung tissue of treated animals. No significant differences between treated and untreated animals were found with respect to hydroxyproline, histology, and lavage cell count. To conclude, extracorporeal photopheresis has positive molecular effects but does not attenuate experimental lung fibrosis with respect to histology, hydroxyproline, and lavage cell count in the applied treatment regimen. Further investigations of extracorporeal photopheresis in experimental pulmonary fibrosis are justified.
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Affiliation(s)
- Kaspar Remund
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
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Jardine MJ, Bhandari S, Wyburn KR, Misra AK, McKenzie PR, Eris JM. Photopheresis therapy for problematic renal allograft rejection. J Clin Apher 2009; 24:161-9. [PMID: 19536814 DOI: 10.1002/jca.20199] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Photopheresis is an immunomodulatory therapy for the treatment of T cell-mediated disorders. It has been used for rejection prophylaxis in cardiac transplantation, adjuvant treatment of bronchiolitis obliterans in lung transplantation, treatment of graft verse host disease, and in a small number of cases, for treatment of acute rejection in renal transplantation. Little is known of long-term outcomes following the use of photopheresis in solid organ transplantation. METHODS We report prospective follow-up of our consecutive experience of the use of photopheresis as adjuvant/salvage therapy for problematic rejection in patients undergoing renal transplantation. Transplant graft survival, infective and malignant outcomes were reported. RESULTS A cohort of 10 renal transplants recipients received photopheresis therapy for therapy-resistant rejection. Conventional therapy included an average of 6.2 g pulse methyl-prednisolone and 17.1 days antilymphocyte therapy. The cohort received additional photopheresis therapy when the unresponsive nature of their rejections raised concerns of graft loss. Median follow-up censored for patient loss was 66.7 months following photopheresis commencement. Rejection resolved in association with photopheresis use in all 10 patients. Six patients continued to have stable graft function (median serum creatinine: 191.5 micromol/L) at a median follow-up of 71.0 months. There has been one patient death from sepsis and two from malignancy with functioning grafts while one graft has been lost to disease recurrence. CONCLUSION Photopheresis may have a role as an adjuvant or salvage antirejection therapy in solid organ transplantation. Furthermore, evaluation in randomized controlled clinical trials is required to evaluate its potential.
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Affiliation(s)
- Meg J Jardine
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
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Baird K, Wayne AS. Extracorporeal photo-apheresis for the treatment of steroid-resistant graft versus host disease. Transfus Apher Sci 2009; 41:209-16. [PMID: 19819186 DOI: 10.1016/j.transci.2009.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acute and chronic graft versus host disease are frequent and potentially severe complications of allogeneic hematopoietic stem cell transplantation and are among the leading causes of non-relapse transplant-related mortality. For patients with steroid refractory disease, prognosis is particularly poor and although a variety of treatment options are available, responses are commonly transient and the side effects often intolerable. Since it was first introduced for the treatment of cutaneous T-cell lymphoma, extracorporeal photo-apheresis has been utilized as an immunomodulatory therapy for certain autoimmune diseases and solid organ transplant rejection. Recently, extracorporeal photo-apheresis has become a promising alternative for patients with graft versus host disease with disabling or potentially lethal complications. Here we review the experience of extracorporeal photo-apheresis for the treatment of steroid refractory acute and chronic graft versus host disease based on the current literature.
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Affiliation(s)
- Kristin Baird
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD, USA.
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Photopheresis with UV-A light and 8-methoxypsoralen leads to cell death and to release of blebs with anti-inflammatory phenotype in activated and non-activated lymphocytes. Biochem Biophys Res Commun 2009; 386:71-6. [DOI: 10.1016/j.bbrc.2009.05.130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 05/29/2009] [Indexed: 11/30/2022]
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Regulatory T cells and extracorporeal photochemotherapy: correlation with clinical response and decreased frequency of proinflammatory T cells. Transplantation 2009; 87:1422-5. [PMID: 19424046 DOI: 10.1097/tp.0b013e3181a27a5d] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Immune mechanisms of extracorporeal photochemotherapy (ECP) in refractory/resistant graft-versus-host disease (GvHD) are complex. We have previously analyzed the role of CD4CD25Foxp3 regulatory T cells (T-regs). METHODS In the current study, we have enlarged the size of the population (n=27; chronic GvHD=18, acute GvHD=9) for a median follow-up of 24 months. T-regs were monitored for CD4, CD25, glucocorticoid-induced tumor necrosis factor receptor (GITR), CD62L, CCR7, Foxp3, and STAT-5. Immune analysis by interleukin (IL)-17 Elispot was carried out on circulating T-helper CD4 cells secreting IL-17, a subset of T cells considered relevant in the pathogenesis of GvHD. RESULTS We confirm that ECP is accompanied by a significant increase of CD4CD25Foxp3GITRCD62LCCR7 T-regs. Sorted T-regs show augmented phosphorylation of STAT-5. Only ECP-responding patients demonstrate a raise of circulating T-regs, being mostly affected by chronic GvHD. Moreover, this phenomenon corresponds to a diminished secretion of IL-17. DISCUSSION In conclusion, our study shows that T-regs represent important immune mediators of the clinical benefits of ECP in patients affected by GvHD.
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Jonson CO, Pihl M, Nyholm C, Cilio CM, Ludvigsson J, Faresjö M. Regulatory T cell-associated activity in photopheresis-induced immune tolerance in recent onset type 1 diabetes children. Clin Exp Immunol 2008; 153:174-81. [PMID: 18549445 DOI: 10.1111/j.1365-2249.2008.03625.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Extracorporeal photochemotherapy (ECP) has demonstrated immunological effects. The proposed cytotoxic lymphocyte antigen 4 (CTLA-4) involvement, together with forkhead box P3 (FoxP3) and transforming growth factor (TGF)-beta are associated with regulatory T cell activity. The aim of the study was to evaluate the regulatory T cell-associated effect of ECP in recent onset type 1 diabetic (T1D) children. Children (n = 20) with T1D received photopheresis 8-methoxypsoralen + ECP or placebo + shampheresis. Peripheral blood mononuclear cells (PBMC) collected pretreatment (day 1) and post-treatment (day 90) were stimulated with phytohaemagglutinin (PHA) and T1D-associated glutamic acid decarboxylase 65 (GAD(65)) peptide a.a. 247-279. CTLA-4, sCTLA-4, FoxP3 and TGF-beta mRNA transcription was quantified. Photopheresis-treated individuals' relative mRNA expression was generally maintained during the course of the study. Placebo individuals increased in spontaneous CTLA-4 mRNA (P < 0.05) but decreased in expression after stimulation with GAD(65)-peptide (P < 0.05) and PHA (P < 0.05). Spontaneous TGF-beta (P < 0.05) increased whereas PHA- (P < 0.01) and GAD(65)-peptide (P < 0.01)-induced TGF-beta expression decreased in the placebo group, whereas it was maintained in the treated group. Without intervention, expression of CTLA-4 and TGF-beta, stimulated with PHA and GAD(65) peptide, decreased with time, with a parallel reduction of GAD(65)-peptide and PHA-stimulated TGF-beta expression. These parameters were counteracted by ECP. In conclusion, our results indicate that ECP maintains regulatory T cell-associated activity in recent-onset T1D.
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Affiliation(s)
- C-O Jonson
- Division of Pediatrics and Diabetes Research Centre, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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Marchesseau-Merlin AS, Perea R, Kanold J, Demeocq F, Souteyrand P, D'Incan M. [Photopheresis: an alternative therapeutic approach in corticoresistant erosive oral lichen planus]. Ann Dermatol Venereol 2008; 135:209-12. [PMID: 18374853 DOI: 10.1016/j.annder.2007.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Accepted: 06/15/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND The immunomodulatory effect of extracorporeal photochemotherapy (photopheresis) coupled with its efficacy in lymphocytic skin diseases provides a rationale for its use for erosive lichen planus. We report two cases of chronic oral erosive and corticoresistant lichen planus successfully treated with photopheresis. PATIENTS AND METHODS Case 1. A 61-years-old man had erosive oral lichen planus for four years. Oral steroids were contra-indicated due to iatrogenic pancreatitis. After nine photopheresis sessions, subjective improvement occurred and the oral lesions were stabilized. Case 2. A 17-years-old woman presented corticodependent oral and genital erosive lichen planus and cutaneous lesions. After seven sessions of photopheresis, the patient was able to eat again and the pain decreased. After 20 sessions, the cutaneous lichen planus disappeared and complete remission of the mucous lesions was obtained without corticotherapy. DISCUSSION These two cases, together with 23 other cases reported elsewhere, strongly suggested the value of photopheresis in the treatment of erosive lichen planus. However, relapses after treatment withdrawal appear extremely frequent.
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Affiliation(s)
- A-S Marchesseau-Merlin
- Service de Dermatologie, Hôtel-Dieu, CHU Clermont-Ferrand, 63058 Clermont-Ferrand cedex 1, France
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Perseghin P. Extracorporeal Photochemotherapy as a Challenging Treatment for Cutaneous T-Cell Lymphoma, Acute and Chronic Graft-versus-Host Disease, Organ Rejection and T-Lymphocyte-Mediated Autoimmune Diseases. Transfus Med Hemother 2007; 35:8-17. [PMID: 21547105 DOI: 10.1159/000111755] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 10/09/2007] [Indexed: 11/19/2022] Open
Abstract
SUMMARY: 20 years ago, in 1987, Edelson and co-workers published their first report on the effectiveness of a new procedure, called extracorporeal photochemotherapy (ECP), in patients with advanced stage cutaneous T-cell lymphoma (CTCL). The positive response (>70% overall) achieved in those patients encouraged several groups to try out this new technology in other T-lymphocyte-mediated autoimmune diseases and a number of dermatological diseases, which sometimes gave conflicting results. In the following years, ECP obtained FDA approval as first line treatment in CTCL. In the 1990s ECP was applied to acute and chronic graft-versus-host disease (GvHD) refractory to conventional immunosuppressive therapy and proved to be effective in >60% of cases of this larger patient population. Today, although the effectiveness of ECP in GvHD is generally acknowledged, this is mainly based on retrospective or observational studies, as data from large, randomized multicenter trials, has yet to be published. Moreover, ECP's real mechanism of action and optimal treatment schedule are still under investigation. The aim of this review is to summarize knowledge acquired to date about ECP.
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Affiliation(s)
- Paolo Perseghin
- U.O.S. Aferesi e nuove tecnologie trasfusionali-Laboratorio di criobiologia, Dipartimento di Patologia Clinica-Servizio di immunoematologia e Trasfusionale, Ospedale San Gerardo de' Tintori, Monza, Italy
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Lee CH, Mamelak AJ, Vonderheid EC. Erythrodermic cutaneous T cell lymphoma with hypereosinophilic syndrome: Treatment with interferon alfa and extracorporeal photopheresis. Int J Dermatol 2007; 46:1198-204. [DOI: 10.1111/j.1365-4632.2007.03190.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Bisaccia E, Palangio M, Gonzalez J. Extracorporeal photochemotherapy for the treatment of refractory Crohn’s disease. Transfus Apher Sci 2007; 37:171-4. [DOI: 10.1016/j.transci.2007.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 08/13/2007] [Indexed: 11/25/2022]
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Miller JD, Kirkland EB, Domingo DS, Scull H, Jekutis B, Dallas M, Cooper KD, Baron ED. Review of extracorporeal photopheresis in early-stage (IA, IB, and IIA) cutaneous T-cell lymphoma. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2007; 23:163-71. [PMID: 17803594 DOI: 10.1111/j.1600-0781.2007.00300.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) has been used for nearly 20 years for the treatment of cutaneous T-cell lymphoma (CTCL). A substantial body of literature reports that this form of photoimmunotherapy improves or stabilizes the course of disease in a subset of patients across all stages. However, current clinical approach usually reserves ECP for patients who do not respond to other treatments or for patients with late-stage disease or Sézary syndrome (SS). METHODS A comprehensive Pubmed/Medline literature search was performed to identify studies reporting the use and efficacy of ECP in early stage (IA, IB, and IIA) CTCL. Information regarding prognostic factors and survival of early-stage patients treated with ECP was also obtained and summarized. RESULTS The heterogenous nature of the reports and lack of any prospective randomized trials made evaluation of response to treatment difficult. However, the current literature contains at least 124 early-stage patients treated with ECP or ECP plus adjuvant therapy from 1987-2007 in 16 different reports. Response rates of treatment for this patient population with ECP and ECP plus adjuvant therapy varied from 33-88%. CONCLUSIONS Given the very low side effect profile of ECP compared with other therapies and its demonstrated efficacy, this treatment modality is possibly beneficial for patients with earlier stages of CTCL. Randomized prospective studies are needed to establish the role of ECP in this disease subset.
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Affiliation(s)
- Janine D Miller
- Department of Dermatology, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH 44106, USA.
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