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Asensi Cantó P, Sanz Caballer J, Solves Alcaína P, de la Rubia Comos J, Gómez Seguí I. Extracorporeal Photopheresis in Graft-versus-Host Disease. Transplant Cell Ther 2023; 29:556-566. [PMID: 37419324 DOI: 10.1016/j.jtct.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/09/2023]
Abstract
Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity following allogeneic hematopoietic stem cell transplantation. Extracorporeal photopheresis (ECP), which exposes mononuclear cells to ultraviolet A irradiation in the presence of a photosensitizing agent, has shown efficacy in the treatment of GVHD. Recent observations in molecular and cell biology have revealed the mechanisms by which ECP can reverse GVHD, including lymphocyte apoptosis, differentiation of dendritic cells from circulating monocytes, and modification of the cytokine profile and T cell subpopulations. Technical innovations have made ECP accessible to a broader range of patients; however, logistical constraints may limit its use. In this review, we scrutinize the development of ECP from its origins to recent insights into the biology underlying ECP efficacy. We also review practical aspects that may complicate successful ECP treatment. Finally, we analyze how these theoretical concepts translate into clinical practice, summarizing the published experiences of leading research groups worldwide.
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Affiliation(s)
- Pedro Asensi Cantó
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - Jaime Sanz Caballer
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Solves Alcaína
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Javier de la Rubia Comos
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
| | - Inés Gómez Seguí
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
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2
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Asensi Cantó P, Sanz Caballer J, Fuentes Socorro C, Solves Alcaína P, Lloret Madrid P, Solís Ruíz J, Torres Guerola B, de la Rubia Comos J, Fernández Navarro JM, Gómez-Seguí I. Role of extracorporeal photopheresis in the management of children with graft-vs-host disease. J Clin Apher 2022; 37:573-583. [PMID: 36134700 DOI: 10.1002/jca.22012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/24/2022] [Accepted: 08/19/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Graft-vs-host disease (GVHD) is a frequent cause of morbidity and mortality in allogeneic stem cell transplants. Extracorporeal photopheresis (ECP) is one of the most accepted second-line treatments, but technical issues of ECP in children might be prohibitive. MATERIALS AND METHODS Patients under 18 y of age with corticodependant or corticorefractory GVHD receiving ECP at our hospital were included in this retrospective study. ECP was performed with an in-line system (CellExTherakos) in 2013-2014 and with an off-line system (Spectra Optia) from 2015 onwards. Cumulative incidence curves were obtained to compare ECP efficacy among patients grouped by different baseline, apheresis, and disease characteristics. Significant variables on univariate analysis (Gray's test) were pooled into a multivariate analysis (Fine-Gray proportional hazard regression for competing events). RESULTS A total of 701 ECP sessions were performed on 33 patients between October 2013 and December 2021. In total, 97% of the sessions could be executed. In 8% of the sessions an incident was detected, most of them mild and related to catheter dysfunction. With a median follow-up for alive patients of 33.6 mo (range, 8-95), the composite partial and complete response cumulative incidence was 70% (95% confidence interval, 51%-82%) and the median time to maximal response was 2.8 mo (range, 0.25-9.8). Significantly lower response ratios were found in patients with hepatic, gastrointestinal, acute, or severe GVHD. The only variable that influenced response on multivariate analysis was GVHD severity. DISCUSSION ECP is feasible, safe, and effective for pediatric patients with corticorefractory or corticodependant GVHD, offering a less toxic and nonimmunosuppressive treatment option.
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Affiliation(s)
- Pedro Asensi Cantó
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jaime Sanz Caballer
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Pilar Solves Alcaína
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pilar Lloret Madrid
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jürgen Solís Ruíz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Javier de la Rubia Comos
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
| | | | - Ines Gómez-Seguí
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
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3
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Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
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Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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4
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Knobler R, Arenberger P, Arun A, Assaf C, Bagot M, Berlin G, Bohbot A, Calzavara-Pinton P, Child F, Cho A, French LE, Gennery AR, Gniadecki R, Gollnick HPM, Guenova E, Jaksch P, Jantschitsch C, Klemke C, Ludvigsson J, Papadavid E, Scarisbrick J, Schwarz T, Stadler R, Wolf P, Zic J, Zouboulis C, Zuckermann A, Greinix H. European dermatology forum - updated guidelines on the use of extracorporeal photopheresis 2020 - part 1. J Eur Acad Dermatol Venereol 2020; 34:2693-2716. [PMID: 33025659 PMCID: PMC7820969 DOI: 10.1111/jdv.16890] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/06/2020] [Indexed: 01/01/2023]
Abstract
Background Following the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T‐cell lymphoma published in 1983, this technology has received continued use and further recognition for additional earlier as well as refractory forms. After the publication of the first guidelines for this technology in the JEADV in 2014, this technology has maintained additional promise in the treatment of other severe and refractory conditions in a multi‐disciplinary setting. It has confirmed recognition in well‐known documented conditions such as graft‐versus‐host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection including lung, heart and liver and to a lesser extent inflammatory bowel disease. Materials and methods In order to further provide recognized expert practical guidelines for the use of this technology for all indications, the European Dermatology Forum (EDF) again proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. All authors had the opportunity to review each contribution as it was added. Results and conclusion These updated 2020 guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion. The guidelines are divided in two parts: PART I covers cutaneous T‐cell lymphoma, chronic graft‐versus‐host disease and acute graft‐versus‐host disease while PART II will cover scleroderma, solid organ transplantation, Crohn's disease, use of ECP in paediatrics practice, atopic dermatitis, type 1 diabetes, pemphigus, epidermolysis bullosa acquisita and erosive oral lichen planus.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Arenberger
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Arun
- FRCPath, The Rotherham NHA Foundation Trust, Rotherham, UK
| | - C Assaf
- Department of Dermatology and Venerology, Helios Klinikum Krefeld, Krefeld, Germany
| | - M Bagot
- Hospital Saint Louis, Université de Paris, Paris, France
| | - G Berlin
- Department of Clinical Immunology and Transfusion Medicine, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A Bohbot
- Onco-Hematology Department, Hautepierre Hospital, Strasbourg, France
| | | | - F Child
- FRCP, St John's Institution of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Cho
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - L E French
- Department of Dermatology, University Hospital, München, Germany
| | - A R Gennery
- Translational and Clinical Research Institute, Newcastle University Great North Children's Hospital Newcastle upon Tyne, Newcastle University, Newcastle upon Tyne, UK
| | - R Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - H P M Gollnick
- Dept. Dermatology & Venereology, Otto-von-Guericke University, Magdeburg, Germany
| | - E Guenova
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Dermatology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - P Jaksch
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - C Jantschitsch
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Klemke
- Hautklinik Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - J Ludvigsson
- Crown Princess Victoria Children's Hospital and Division of Pediatrics, Department of Biomedical and Clinical Sciences, University Hospital, Linköping University, Linköping, Sweden
| | - E Papadavid
- National and Kapodistrian University of Athens, Athens, Greece
| | | | - T Schwarz
- Department of Dermatology, University Clinics Schleswig-Holstein, Kiel, Germany
| | - R Stadler
- University Clinic for Dermatology Johannes Wesling Medical Centre, UKRUB, University of Bochum, Minden, Germany
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - J Zic
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - A Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - H Greinix
- Division of Haematology, LKH-Univ. Klinikum Graz, Medical University of Graz, Graz, Austria
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5
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Nygaard M, Wichert S, Berlin G, Toss F. Extracorporeal photopheresis for graft‐vs‐host disease: A literature review and treatment guidelines proposed by the Nordic ECP Quality Group. Eur J Haematol 2020; 104:361-375. [DOI: 10.1111/ejh.13381] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/30/2019] [Accepted: 01/01/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Marietta Nygaard
- Department of Haematology Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Stina Wichert
- Department of Haematology Skåne University Hospital in Lund Lund Sweden
| | - Gösta Berlin
- Department of Clinical Immunology and Transfusion Medicine Department of Clinical and Experimental Medicine Faculty of Medicine and Health Sciences Linköping University Linköping Sweden
| | - Fredrik Toss
- Division of Clinical Immunology Department of Clinical Microbiology Umeå University Umeå Sweden
- Department of Integrative Medical Biology Umeå University Umeå Sweden
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6
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Winther-Jørgensen S, Nygaard M, Heilmann C, Ifversen M, Sørensen K, Müller K, Masmas T. Feasibility of extracorporeal photopheresis in pediatric patients with graft-versus-host disease after hematopoietic stem cell transplantation. Pediatr Transplant 2019; 23:e13416. [PMID: 30973668 DOI: 10.1111/petr.13416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
Abstract
Graft-versus-host disease (GVHD) is a main cause of morbidity and mortality following hematopoietic stem cell transplantation. The cumulative incidence of acute and chronic GVHD (aGVHD, cGVHD) reaches 30%-50% and 20% in pediatric populations, respectively. Prednisolone and/or calcineurin inhibitors (CNI) are first-line treatments, but no superior second-line treatment has yet been established. Several treatments have been suggested, among others extracorporeal photopheresis (ECP). Technical advances have made treatment of pediatric patients possible; however, only few reports on the feasibility of ECP in children have been published. We retrospectively studied the feasibility, safety, and efficacy of ECP in 15 children with steroid-dependent/refractory acute or chronic GVHD, who initiated ECP treatment between April 2014 and January 2018. Only few and mild side effects directly related to the ECP procedure were registered, even in patients with low body weight. The most frequent cause of shortened or canceled ECP treatment was difficulties with vascular accesses, which were more rarely seen using central venous catheters with larger lumens and made of stiffer material. Nine patients had grade II-III aGVHD. Six of these experienced a response to ECP at day 28, while eight of nine had responded at the last ECP treatment. Six patients had cGVHD when ECP was initiated, and of these, four had a partial response at last ECP treatment. We found ECP to be a feasible and safe treatment, and particularly, children with aGVHD appeared to respond well to ECP.
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Affiliation(s)
- Signe Winther-Jørgensen
- The Child and Adolescent Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marietta Nygaard
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Carsten Heilmann
- The Child and Adolescent Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Ifversen
- The Child and Adolescent Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kaspar Sørensen
- The Child and Adolescent Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Müller
- The Child and Adolescent Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Rheumatology and Spine Disease, Institute for Inflammation Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Tania Masmas
- The Child and Adolescent Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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7
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Verdú-Amorós J, Woessmann W, Maecker-Kolhoff B, Schulz A, Strauss G, Bein G, Hackstein H. Mini photopheresis for refractory chronic graft-versus-host disease in children and adolescents. Transfusion 2018; 58:2495-2500. [PMID: 30291766 DOI: 10.1111/trf.14880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 04/24/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) has been established to treat graft-versus-host disease. Our mini ECP technique (mini-ECP) allows for treatment of patients with GVHD and contraindications for classical ECP or low body weight. The safety and efficacy of applying ECP for the long-term treatment of chronic GVHD (cGVHD) have not been described. STUDY DESIGN AND METHODS A retrospective analysis of mini-ECP treatments for children and adolescents with cGVHD was performed. Mini-ECP with 100 to 200 mL of whole blood was used to treat 14 patients. The median age at the start of treatment was 7 years (range, 1-17 years), and median body weight was 20 kg (range, 8-53 kg). A total of 703 mini-ECP treatments was performed. The median number of treatments per patient was 35 (range, 8-129), and median treatment duration was 11 months (range, 1.4-28.5 months). RESULTS Mini-ECP was well tolerated. Four adverse events occurred in three patients, and two of them were related to the ECP procedure. Complete or partial responses were observed in 10 patients. Steroids were discontinued in seven patients and tapered in three others. Responses were seen in the skin, mouth, gastrointestinal tract, and eyes. CONCLUSION Mini-ECP represents a less invasive ECP alternative for low-body-weight patients with cGVHD and contraindications for apheresis.
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Affiliation(s)
- Jaime Verdú-Amorós
- Department of Pediatric Hematology and Oncology, Justus-Liebig-University, Giessen, Germany
| | - Wilhelm Woessmann
- Department of Pediatric Hematology and Oncology, Justus-Liebig-University, Giessen, Germany
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Gabriele Strauss
- Department of Pediatric Hematology and Oncology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany
| | - Holger Hackstein
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University, Giessen, Germany
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8
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Flinn AM, Gennery AR. Treatment of Pediatric Acute Graft-versus-Host Disease-Lessons from Primary Immunodeficiency? Front Immunol 2017; 8:328. [PMID: 28377772 PMCID: PMC5359217 DOI: 10.3389/fimmu.2017.00328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/07/2017] [Indexed: 11/13/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant (HSCT) is used to treat increasing numbers of malignant and non-malignant disorders. Despite significant advances in improved human leukocyte antigens-typing techniques, less toxic conditioning regimens and better supportive care, resulting in improved clinical outcomes, acute graft-versus-host disease (aGvHD) continues to be a major obstacle and, although it principally involves the skin, gastrointestinal tract, and liver, the thymus is also a primary target. An important aim following HSCT is to achieve complete and durable immunoreconstitution with a diverse T-cell receptor (TCR) repertoire to recognize a broad range of pathogens providing adequate long-term adaptive T-lymphocyte immunity, essential to reduce the risk of infection, disease relapse, and secondary malignancies. Reconstitution of adaptive T-lymphocyte immunity is a lengthy and complex process which requires a functioning and structurally intact thymus responsible for the production of new naïve T-lymphocytes with a broad TCR repertoire. Damage to the thymic microenvironment, secondary to aGvHD and the effect of corticosteroid treatment, disturbs normal signaling required for thymocyte development, resulting in impaired T-lymphopoiesis and reduced thymic export. Primary immunodeficiencies, in which failure of central or peripheral tolerance is a major feature, because of intrinsic defects in hematopoietic stem cells leading to abnormal T-lymphocyte development, or defects in thymic stroma, can give insights into critical processes important for recovery from aGvHD. Extracorporeal photopheresis is a potential alternative therapy for aGvHD, which acts in an immunomodulatory fashion, through the generation of regulatory T-lymphocytes (Tregs), alteration of cytokine patterns and modulation of dendritic cells. Promoting normal central and peripheral immune tolerance, with selective downregulation of immune stimulation, could reduce aGvHD, and enable a reduction in other immunosuppression, facilitating thymic recovery, restoration of normal T-lymphocyte ontogeny, and complete immunoreconstitution with improved clinical outcome as the ability to fight infections improves and risk of secondary malignancy or relapse diminishes.
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Affiliation(s)
- Aisling M Flinn
- Medical School, Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Andrew R Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
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9
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DeSimone RA, Schwartz J, Schneiderman J. Extracorporeal photopheresis in pediatric patients: Practical and technical considerations. J Clin Apher 2017; 32:543-552. [DOI: 10.1002/jca.21534] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/06/2017] [Accepted: 02/27/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Robert A. DeSimone
- Department of Pathology and Laboratory Medicine; New York-Presbyterian Hospital-Weill Cornell Medicine; New York New York
| | - Joseph Schwartz
- Department of Pathology and Cell Biology; New York-Presbyterian Hospital-Columbia University Medical Center; New York New York
| | - Jennifer Schneiderman
- Department of Pediatrics; Division of Hematology/Oncology/Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University; Chicago Illinois
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10
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Alfred A, Taylor PC, Dignan F, El-Ghariani K, Griffin J, Gennery AR, Bonney D, Das-Gupta E, Lawson S, Malladi RK, Douglas KW, Maher T, Guest J, Hartlett L, Fisher AJ, Child F, Scarisbrick JJ. The role of extracorporeal photopheresis in the management of cutaneous T-cell lymphoma, graft-versus-host disease and organ transplant rejection: a consensus statement update from the UK Photopheresis Society. Br J Haematol 2017; 177:287-310. [PMID: 28220931 PMCID: PMC5412836 DOI: 10.1111/bjh.14537] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/23/2016] [Indexed: 12/17/2022]
Abstract
Extracorporeal photopheresis (ECP) has been used for over 35 years in the treatment of erythrodermic cutaneous T‐cell lymphoma (CTCL) and over 20 years for chronic and acute graft‐versus‐host disease (GvHD) and solid organ transplant rejection. ECP for CTCL and GvHD is available at specialised centres across the UK. The lack of prospective randomised trials in ECP led to the development of UK Consensus Statements for patient selection, treatment schedules, monitoring protocols and patient assessment criteria for ECP. The recent literature has been reviewed and considered when writing this update. Most notably, the national transition from the UVAR XTS® machine to the new CELLEX machine for ECP with dual access and a shorter treatment time has led to relevant changes in these schedules. This consensus statement updates the previous statement from 2007 on the treatment of CTCL and GvHD with ECP using evidence based medicine and best medical practise and includes guidelines for both children and adults.
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Affiliation(s)
- Arun Alfred
- Rotherham Foundation NHS Trust, Rotherham, UK
| | | | - Fiona Dignan
- Central Manchester NHS Foundation Trust, Manchester, UK
| | - Khaled El-Ghariani
- Therapeutics and Tissue Services, NHS Blood and Transplant, Sheffield, UK
| | - James Griffin
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University and Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - Denise Bonney
- Royal Manchester Children's Hospital, Manchester, UK
| | - Emma Das-Gupta
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ram K Malladi
- University Hospitals Birmingham NHS Trust, Birmingham, UK
| | | | | | - Julie Guest
- Institute of Cellular Medicine, Newcastle University and Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | | | - Andrew J Fisher
- Institute of Transplantation, Newcastle University and Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Fiona Child
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London, UK
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11
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Flinn AM, Gennery AR. Extracoporeal photopheresis treatment of acute graft-versus-host disease following allogeneic haematopoietic stem cell transplantation. F1000Res 2016; 5. [PMID: 27408705 PMCID: PMC4926758 DOI: 10.12688/f1000research.8118.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 01/03/2023] Open
Abstract
Acute graft-versus-host disease (aGvHD) continues to be a major obstacle to allogeneic haematopoietic stem cell transplantation. Thymic damage secondary to aGvHD along with corticosteroids and other non-selective T lymphocyte-suppressive agents used in the treatment of aGvHD concurrently impair thymopoiesis and negatively impact on immunoreconstitution of the adaptive immune compartment and ultimately adversely affect clinical outcome. Extracorporeal photopheresis (ECP) is an alternative therapeutic strategy that appears to act in an immunomodulatory fashion, potentially involving regulatory T lymphocytes and dendritic cells. By promoting immune tolerance and simultaneously avoiding systemic immunosuppression, ECP could reduce aGvHD and enable a reduction in other immunosuppression, allowing thymic recovery, restoration of normal T lymphopoiesis, and complete immunoreconstitution with improved clinical outcome. Although the safety and efficacy of ECP has been demonstrated, further randomised controlled studies are needed as well as elucidation of the underlying mechanisms responsible and the effect of ECP on thymic recovery.
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Affiliation(s)
- Aisling M Flinn
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; Paediatric Haematopoietic Stem Cell Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
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Kitko CL, Braun T, Couriel DR, Choi SW, Connelly J, Hoffmann S, Goldstein S, Magenau J, Pawarode A, Reddy P, Schuler C, Yanik GA, Ferrara JL, Levine JE. Combination Therapy for Graft-versus-Host Disease Prophylaxis with Etanercept and Extracorporeal Photopheresis: Results of a Phase II Clinical Trial. Biol Blood Marrow Transplant 2015; 22:862-8. [PMID: 26551636 DOI: 10.1016/j.bbmt.2015.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/02/2015] [Indexed: 02/08/2023]
Abstract
Reduced-intensity conditioning (RIC) regimens minimize early toxicity after allogeneic hematopoietic cell transplantation (HCT) by placing greater reliance on establishing a graft-versus-leukemia effect (GVL). Because graft-versus-host disease (GVHD) and GVL are tightly linked, inhibition of T cell populations that cause GVHD may lead to an unintended increased risk of relapse in the RIC setting. Although not completely understood, etanercept and extracorporeal photopheresis (ECP) are thought to ameliorate GVHD without direct T cell inhibition. We hypothesized that adding these 2 agents to a standard GVHD prophylaxis regimen of tacrolimus and mycophenolate mofetil (MMF) would improve survival by reducing GVHD-related mortality without increasing relapse rates. Therefore, we conducted a prospective phase II clinical trial that incorporated tacrolimus, MMF, etanercept, and ECP as GVHD prophylaxis in 48 patients undergoing RIC unrelated donor transplantation. The preferred RIC was fludarabine 160 mg/m(2) + busulfan 6.4 mg/kg to 12.8 mg/kg ± total body irradiation 200 cGy. Etanercept .4 mg/kg (maximum dose, 25 mg) was given subcutaneously twice weekly for 8 weeks after HCT and ECP was given for 12 treatments, starting weekly on day 28 weekly and tapering off by day 180. The median age of the study patients was 60 (range, 18 to 71) years. Donors were 7/8 (n = 14, 29%) or 8/8 (n = 34, 71%) HLA matched. All patients engrafted neutrophils at a median of 12 days. The cumulative incidence of grades II to IV acute GVHD at day 100 was 46%, but it was typically sensitive to initial steroid treatment (84% day 56 complete response/partial response rate). Overall survival at 1 year in this older, frequently mismatched unrelated donor setting was excellent (73%) because of low rates of nonrelapse mortality (21%) and relapse (19%). However, this strategy was not effective at preventing a high incidence of chronic GVHD and late deaths led to a drop in 2-year survival, declining to 56%, reflecting a high incidence of chronic GVHD.
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Affiliation(s)
- Carrie L Kitko
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan; Pediatric Stem Cell Transplant Program, Vanderbilt University, Nashville, Tennessee.
| | - Thomas Braun
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Daniel R Couriel
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Sung W Choi
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - James Connelly
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan; Pediatric Stem Cell Transplant Program, Vanderbilt University, Nashville, Tennessee
| | - Sandra Hoffmann
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Steven Goldstein
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - John Magenau
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Attaphol Pawarode
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Pavan Reddy
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Charles Schuler
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Yanik
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - James L Ferrara
- Blood and Marrow Transplant Program, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John E Levine
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan; Blood and Marrow Transplant Program, Icahn School of Medicine at Mount Sinai, New York, New York
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Im A, Pavletic SZ. Deciphering the Mystery: Extracorporeal Photopheresis in Graft-versus-Host Disease. Biol Blood Marrow Transplant 2015; 21:1861-2. [PMID: 26386319 DOI: 10.1016/j.bbmt.2015.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/10/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Annie Im
- Division of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steven Z Pavletic
- National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland.
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Calore E, Marson P, Pillon M, Tumino M, Tison T, Mainardi C, De Silvestro G, Rossin S, Franceschetto G, Carraro E, Pescarin M, Varotto S, Destro R, Gazzola MV, Basso G, Messina C. Treatment of Acute Graft-versus-Host Disease in Childhood with Extracorporeal Photochemotherapy/Photopheresis: The Padova Experience. Biol Blood Marrow Transplant 2015; 21:1963-72. [PMID: 26183078 PMCID: PMC7110492 DOI: 10.1016/j.bbmt.2015.07.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 07/07/2015] [Indexed: 11/08/2022]
Abstract
Acute graft-versus-host disease (aGVHD) is the major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Systemic steroid treatment represents the first-line therapy for aGVHD and is associated with a response rate of 30% to 60%. Steroid-resistant patients have a poor prognosis with high transplantation-related mortality (TRM). Several second-line therapies have been proposed for the management of unresponsive aGVHD, without proven beneficial effects on patients' outcome or overall long-term survival. For these reasons, extracorporeal photochemotherapy/photopheresis (ECP), a cell-based approach to control GVHD that spares generalized immunosuppression, seems to be promising. In this study, we report the outcome of 72 consecutive pediatric patients treated with ECP between 1997 and 2013 for aGVHD. Among them, 21 patients had steroid-resistant aGVHD, 42 had steroid-dependent aGVHD, and 9 did not receive steroid as first-line therapy because of clinical contraindications. A complete response was obtained in 72% of patients, a partial response was observed in 11%, and there was no response in 17% of patients. At day +180, TRM was 4% in the whole cohort; TRM was 3% and 20% among responders and nonresponders to ECP, respectively (P < .0001). The 5-year overall survival was 71%, showing a difference between responders and nonresponders of 78% and 30%, respectively (P = .0004). The 5-year time to progression of primary disease was 81%, without any significant difference between the 2 groups. Moreover, the 5-year progression-free survival of primary disease was 72%, with a significant difference (P = .0007) between responders (79%) and nonresponders (30%) to ECP. In conclusion, this study demonstrates that ECP is highly effective in aGVHD without a negative impact on primary disease. We conducted a retrospective study of 72 consecutive pediatric patients treated with extracorporeal photochemotherapy/photopheresis for acute graft-versus-host disease. Twenty-one steroid-refractory, 21 steroid-dependent, and 30 patients with infectious complications were included. The infectious complications group included 9 with no steroids before extracorporeal photochemotherapy/photopheresis and 21 with steroids. Outcomes at the end of extracorporeal photochemotherapy/photopheresis were complete remission, 72%; transplantation-related mortality day +180, 4%; 5-year overall survival, 71%; time to progression, 81%; and progression-free survival, 72%. Extracorporeal photochemotherapy/photopheresis was highly effective in acute graft-versus-host disease without negative impact on primary disease.
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Affiliation(s)
- Elisabetta Calore
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy.
| | - Piero Marson
- Department of Transfusion Medicine, Therapeutic Apheresis Unit, University Hospital of Padova, Italy
| | - Marta Pillon
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Manuela Tumino
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Tiziana Tison
- Department of Transfusion Medicine, Therapeutic Apheresis Unit, University Hospital of Padova, Italy
| | - Chiara Mainardi
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Giustina De Silvestro
- Department of Transfusion Medicine, Therapeutic Apheresis Unit, University Hospital of Padova, Italy
| | - Sara Rossin
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Genny Franceschetto
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Elisa Carraro
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Matilde Pescarin
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Stefania Varotto
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Roberta Destro
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Maria Vittoria Gazzola
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Giuseppe Basso
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
| | - Chiara Messina
- Clinic of Pediatric Hemato-Oncology, Department of Women's and Children's Health, University Hospital of Padova, Italy
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15
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Berger M, Albiani R, Sini B, Fagioli F. Extracorporeal photopheresis for graft-versus-host disease: the role of patient, transplant, and classification criteria and hematologic values on outcome-results from a large single-center study. Transfusion 2015; 55:736-47. [PMID: 25355659 PMCID: PMC4403977 DOI: 10.1111/trf.12900] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/27/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) has been shown as active therapy for graft-versus-host disease (GVHD). STUDY DESIGN AND METHODS The aim was to ascertain the role of ECP in 71 patients with steroid-refractory or -dependent acute and chronic GVHD (aGVHD and cGVHD) with special focus on hematologic variables and GVHD staging classification. A total of 34 patients were treated for aGVHD and 37 for cGVHD. RESULTS The overall response rate (ORR) for aGVHD was 65% and the complete aGVHD-free survival was 50% (95% confidence interval [CI], 36%-70%). The ORR for cGVHD response was 81% while the complete cGVHD-free survival was 50% (95% CI, 34%-73%). The aGVHD-free survival was associated with aGVHD grading (Grade II 81%, Grade III 33%, and Grade IV 0%, p ≤ 0.00) and the absence of visceral involvement (77% vs. 33%, p = 0.03). The cGVHD-free survival was associated with the female sex (67% vs. 25%, p = 0.01) and with the limited form according to the Seattle classification (67% vs. 20%, p = 0.003). No role for hematologic values or apheresis cell count was found, except for the cGVHD ORR (p = 0.037). Transplant-related mortality and overall survival were associated with ECP response 0% versus 54% (p = 0.0001) and 77% versus 45% (p = 0.03) for aGVHD patients and 7% versus 14% (p = 0.02) and 73% versus 20% (p = 0.0003) for cGVHD patients, respectively. CONCLUSIONS While confirming a higher probability of GVHD responses for early GVHD, our study shows no role of hematologic values or apheresis cell count on GVHD response.
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Affiliation(s)
- Massimo Berger
- Pediatric Onco-Hematology and Stem Cell Transplant Division, Regina Margherita Children's HospitalTurin, Italy
| | - Roberto Albiani
- Immunohematology and Transfusion Medicine, Regina Margherita Children's HospitalTurin, Italy
| | - Bruno Sini
- Immunohematology and Transfusion Medicine, Regina Margherita Children's HospitalTurin, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology and Stem Cell Transplant Division, Regina Margherita Children's HospitalTurin, Italy
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Abstract
Acute graft versus host disease (GVHD), a common complication after allogeneic hematopoietic cell transplantation (HCT), occurs in as many as 70% of recipients of this life saving treatment. Front line therapy for GVHD with corticosteroids will fail in up to 40% of patients, which leads to high morbidity and mortality. Traditional prevention and treatment strategies have focused on reducing alloreactivity, typically with therapy to reduce cytotoxic T-cell function. Emerging evidence exists that promotion of regularly T-cell function, through treatments such as extracorporeal photopheresis, is effective for GVHD treatment and has potential for prevention as well. This review will focus on literature reporting the success of ECP for steroid refractory acute GVHD and the potential for delivery of ECP in the early pre and post-transplant periods that shows promise as a less immunosuppressive strategy to reduce rates of acute GVHD.
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Affiliation(s)
- Carrie L Kitko
- Blood and Marrow Transplant Program, Division of Pediatric Hematology/Oncology, University of Michigan, 1500 E. Medical Center Dr. MPB 4202, Ann Arbor, MI 48109-5718.
| | - John E Levine
- Blood and Marrow Transplant Program, Division of Pediatric Hematology/Oncology, University of Michigan, 1500 E. Medical Center Dr. MPB 4202, Ann Arbor, MI 48109-5718
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17
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Connelly-Smith LS, Linenberger ML. Therapeutic Apheresis for Patients with Cancer. Cancer Control 2015; 22:60-78. [DOI: 10.1177/107327481502200109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Laura S. Connelly-Smith
- Seattle Cancer Care Alliance, School of Medicine, University of Washington, Seattle, Washington
- Division of Hematology, School of Medicine, University of Washington, Seattle, Washington
| | - Michael L. Linenberger
- Seattle Cancer Care Alliance, School of Medicine, University of Washington, Seattle, Washington
- Division of Hematology, School of Medicine, University of Washington, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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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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Knobler R, Berlin G, Calzavara-Pinton P, Greinix H, Jaksch P, Laroche L, Ludvigsson J, Quaglino P, Reinisch W, Scarisbrick J, Schwarz T, Wolf P, Arenberger P, Assaf C, Bagot M, Barr M, Bohbot A, Bruckner-Tuderman L, Dreno B, Enk A, French L, Gniadecki R, Gollnick H, Hertl M, Jantschitsch C, Jung A, Just U, Klemke CD, Lippert U, Luger T, Papadavid E, Pehamberger H, Ranki A, Stadler R, Sterry W, Wolf IH, Worm M, Zic J, Zouboulis CC, Hillen U. Guidelines on the use of extracorporeal photopheresis. J Eur Acad Dermatol Venereol 2014; 28 Suppl 1:1-37. [PMID: 24354653 PMCID: PMC4291097 DOI: 10.1111/jdv.12311] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND After the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma was published in 1983 with its subsequent recognition by the FDA for its refractory forms, the technology has shown significant promise in the treatment of other severe and refractory conditions in a multi-disciplinary setting. Among the major studied conditions are graft versus host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection and inflammatory bowel disease. MATERIALS AND METHODS In order to provide recognized expert practical guidelines for the use of this technology for all indications the European Dermatology Forum (EDF) proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. RESULTS AND CONCLUSION These guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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20
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Bruserud Ø, Tvedt THA, Paulsen PQ, Ahmed AB, Gedde-Dahl T, Tjønnfjord GE, Slåstad H, Heldal D, Reikvam H. Extracorporeal photopheresis (photochemotherapy) in the treatment of acute and chronic graft versus host disease: immunological mechanisms and the results from clinical studies. Cancer Immunol Immunother 2014; 63:757-77. [PMID: 24997173 PMCID: PMC11029168 DOI: 10.1007/s00262-014-1578-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 06/23/2014] [Indexed: 10/25/2022]
Abstract
Extracorporeal photopheresis (ECP) is an immunomodulatory alternative for treatment of graft versus host disease (GVHD). The blood is then separated into its various components through apheresis; buffy coat cells are thereafter treated with 8-methoxypsoralen before exposure to ultraviolet light and finally reinfused into the patient. There is a general agreement that this treatment has an anti-GVHD effect, but the mechanisms of action behind this effect are only partly understood. However, altered maturation of dendritic cells (DC) and thereby indirect modulation of T-cell reactivity seems to be one important mechanism together with DC-presentation of antigens derived from apoptotic donor T cells and induction of regulatory T cells. The treatment has been best studied in patients with chronic GVHD (both pediatric and adult patients), but most studies are not randomized and it is difficult to know whether the treatment is more effective than the alternatives. The clinical studies of ECP in adults with acute GVHD are few and not randomized; it is not possible to judge whether this treatment should be a preferred second- or third-line treatment. There is no evidence for increased risk of leukemia relapse or suppression of specific graft versus leukemia reactivity by this treatment, so specific antileukemic immunotherapy may still be possible. Thus, even though the treatment seems effective in patients with GVHD, further clinical (especially randomized) as well as biological studies with careful standardization of the treatment are needed before it is possible to conclude how ECP should be used in acute and chronic GVHD.
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Affiliation(s)
- Øystein Bruserud
- Section for Hematology, Institute of Clinical Science, University of Bergen, Bergen, Norway,
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21
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Malik MI, Litzow M, Hogan W, Patnaik M, Murad MH, Prokop LJ, Winters JL, Hashmi S. Extracorporeal photopheresis for chronic graft-versus-host disease: a systematic review and meta-analysis. Blood Res 2014; 49:100-6. [PMID: 25025011 PMCID: PMC4090330 DOI: 10.5045/br.2014.49.2.100] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 04/07/2014] [Accepted: 05/15/2014] [Indexed: 01/18/2023] Open
Abstract
Background The safety of extracorporeal photopheresis (ECP) in steroid-refractory chronic graft-versus-host disease (SR-cGVHD) has been explored in multiple studies but reported response rates (RR) vary significantly across studies. Methods We conducted a meta-analysis to assess the efficacy of ECP for SR-cGVHD. A search of electronic databases for studies published between 1984 and 2012 was conducted. End points included RR: complete response (CR), overall response rates (ORR), and organ-specific RR. The initial search generated 312 studies, of which 18 met the selection criteria (N=595). A random effects model was used for pooled rates. Results Pooled CR rates and ORR were 29% (confidence interval [CI], 19-42%) and 64% (CI, 65-82%), respectively. One-year overall survival was available for 4 studies only and was 49% (CI, 29-70%). The pooled RR for skin, liver, ocular, oral, lung, gastrointestinal and musculoskeletal SR-cGVHD was 74%, 68%, 60%, 72%, 48%, 53%, and 64%, respectively. There was a significant heterogeneity among studies due to differences in ECP schedules and duration. No significant differences in responses to ECP for pediatric and adult populations were found. Sensitivity analysis could not be undertaken due to a limited number of prospective studies. Conclusion ECP is an effective therapy for oral, skin, and liver SR-cGVHD, with modest activity in lung and gastrointestinal SR-cGVHD.
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Affiliation(s)
- Mohsin Ilyas Malik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, USA
| | - Mark Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, USA
| | - William Hogan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, USA
| | - Mrinal Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, USA
| | - Mohammad Hassan Murad
- Division of Preventive, Occupation and Aerospace Medicine, Mayo Clinic, Rochester, USA
| | - Larry J Prokop
- Library and Public Services, Mayo Clinic, Rochester, USA
| | - Jeffrey L Winters
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, USA
| | - Shahrukh Hashmi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, USA
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22
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Das-Gupta E, Dignan F, Shaw B, Raj K, Malladi R, Gennery A, Bonney D, Taylor P, Scarisbrick J. Extracorporeal photopheresis for treatment of adults and children with acute GVHD: UK consensus statement and review of published literature. Bone Marrow Transplant 2014; 49:1251-8. [PMID: 24887389 DOI: 10.1038/bmt.2014.106] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 03/15/2014] [Accepted: 03/25/2014] [Indexed: 12/18/2022]
Abstract
Extracorporeal photopheresis (ECP) has been used for over 20 years to treat acute GVHD (aGVHD) and chronic GVHD. Evidence on the efficacy of response in aGVHD has continued to accrue and data suggest that there is a good response and prolonged survival in both children and adults with grade II-IV aGVHD. Unlike chronic GVHD where treatment schedules are typically one or two times monthly for 12-18 months, patients with aGVHD respond rapidly to an intense weekly treatment schedule for 8 weeks, typically allowing steroids to be discontinued without flare-ups of aGVHD. Maintenance ECP therapy is generally not required. Many centres across Europe and United States treat aGVHD with ECP as second-line therapy and responses are excellent in a subset of patients. Unlike other second-line therapies, ECP is not immunosuppressive and has no reported drug interactions. Importantly, ECP does not have a negative impact on the graft-versus-malignancy effect of the transplant. This statement aims to select those patients most likely to respond to treatment and summarises treatment and monitoring schedules for the management of aGVHD in adult and paediatric patients to ensure the correct patients are treated with the optimal protocol for efficacy.
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Affiliation(s)
- E Das-Gupta
- Centre for Clinical Haematology, Nottingham University Hospitals NSH Trust, Nottingham, UK
| | - F Dignan
- Central Manchester University Hospitals, Manchester, UK
| | - B Shaw
- Royal Marsden Hospital, London, UK
| | - K Raj
- King's College Hospital, London, UK
| | - R Malladi
- University Hospital Birmingham NHS Trust, Birmingham, UK
| | - A Gennery
- Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - D Bonney
- Royal Manchester Children's Hospital, Manchester, UK
| | - P Taylor
- Rotherham Foundation NHS Trust, Rotherham, South Yorkshire, UK
| | - J Scarisbrick
- University Hospital Birmingham NHS Trust, Birmingham, UK
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Rutella S, Valentini CG, Ceccarelli S, Romano MT, Brescia LP, Milano GM, Locatelli F. Extracorporeal photopheresis for paediatric patients experiencing graft-versus-host disease (GVHD). Transfus Apher Sci 2014; 50:340-8. [DOI: 10.1016/j.transci.2014.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bredeson C, Rumble RB, Varela NP, Kuruvilla J, Kouroukis CT. Extracorporeal photopheresis in the management of graft-versus-host disease. ACTA ACUST UNITED AC 2014; 21:e310-25. [PMID: 24764713 DOI: 10.3747/co.21.1882] [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] [Indexed: 12/20/2022]
Abstract
QUESTION Is there a benefit associated with the use of extracorporeal photopheresis (ecp) compared with other treatment options for patients who have received allogeneic stem-cell transplantation (sct) and are experiencing graft-versus-host disease (gvhd), if response rate, survival, or improvement in symptoms are the outcomes of interest? PERSPECTIVES After allogeneic sct, gvhd is a common complication historically categorized as either acute (agvhd: onset ≤100 days post-transplantation) or chronic (cgvhd: >100 days post-transplantation). Graft-versus-host disease occurs when the donor's immune cells recognize the host patient's tissues and organs as foreign and attack them, causing a multitude of problems, often in liver, gastrointestinal system, and skin. Photopheresis is one therapy that has emerged since the early 2000s for the management of steroid-refractory gvhd because of its steroid-sparing ability, low associated toxicity, and efficacy in some clinical settings. The present recommendation report summarizes the available data about photopheresis for the treatment of gvhd and provides recommendations on its use. METHODOLOGY The medline (Ovid) database was systematically searched for January 1995 to August 2013, and the best available evidence was used to draft recommendations relevant to adult and pediatric patients in Ontario who have received allogeneic sct and are experiencing gvhd. Draft recommendations were first reviewed by clinical and methodology experts before undergoing internal review. Final approval of this practice guideline report was obtained from both the Stem Cell Transplant Steering Committee and the Report Approval Panel of the Program in Evidence-Based Care. RECOMMENDATIONS These recommendations apply to adult and pediatric patients who have received an allogeneic sct and are experiencing gvhd: ecp is an acceptable therapy for the treatment of steroid-dependent or refractory agvhd in adult and pediatric patients.ecp is an effective therapy for the treatment of steroid-dependent or refractory cgvhd in adult and pediatric patients. QUALIFYING STATEMENT In Ontario, ecp is currently a covered therapy for patients with steroid-refractory gvhd who meet certain eligibility criteria.
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Affiliation(s)
- C Bredeson
- The Ottawa Hospital Research Institute, and Department of Medicine, University of Ottawa, Ottawa, ON
| | - R B Rumble
- American Society of Clinical Oncology, Alexandria, VA, U.S.A. (The opinions expressed in this article are those of the authors and do not necessarily represent the views of the American Society of Clinical Oncology.)
| | - N P Varela
- Cancer Care Ontario, Program in Evidence-Based Care, McMaster University, Hamilton, ON
| | - J Kuruvilla
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON
| | - C T Kouroukis
- Division of Malignant Hematology, Juravinski Cancer Centre, McMaster University, Department of Oncology, Hamilton, ON
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Ussowicz M, Musiał J, Mielcarek M, Tomaszewska A, Nasiłowska-Adamska B, Kałwak K, Gorczyńska E, Mariańska B, Chybicka A. Steroid-Sparing Effect of Extracorporeal Photopheresis in the Therapy of Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Proc 2013; 45:3375-80. [DOI: 10.1016/j.transproceed.2013.07.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 07/05/2013] [Accepted: 07/24/2013] [Indexed: 12/12/2022]
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Rangarajan HG, Punzalan RC, Camitta BM, Talano JAM. The use of novel Therakos™ Cellex® for extracorporeal photopheresis in treatment of graft-versus-host disease in paediatric patients. Br J Haematol 2013; 163:357-64. [PMID: 23961954 DOI: 10.1111/bjh.12535] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 07/19/2013] [Indexed: 11/29/2022]
Abstract
Extracorporeal photopheresis (ECP) is an established second line treatment option for graft-versus-host disease (GVHD) post-haematopoietic progenitor cell transplant. At our centre, the Therakos™ Cellex(®) has replaced the Therakos™ UVAR-XTS™ machine for ECP since 2009. We reviewed the records of 385 procedures using the Therakos™ Cellex(®) for safety and tolerability. Nine patients underwent ECP for GVHD. The median age was 13·5 years (range 3·7-24) and weight was 49·2 kg (range 18·5-86·3). The mean duration per procedure was 106 min (range 60-205). Fifteen (3·9%) procedures were cancelled and 10 (2·6%) were delayed, with central venous line (CVL) issues being the most frequent problem. With the use of prophylactic tissue plasminogen activator, fewer CVL-related occlusions were observed (4·7% vs. 2·3%). There was one episode of a CVL-associated thrombosis and one episode of delayed bleeding. There were four episodes of viral reactivation, four CVL-associated infections (1142 catheter days) and one episode of systemic inflammatory response syndrome. No patient experienced symptomatic hypotension. This is the first report outlining the safety and tolerability of the Therakos™ Cellex(®) device for ECP in children and young adults.
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Affiliation(s)
- Hemalatha G Rangarajan
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
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Affiliation(s)
- Inken Hilgendorf
- University Medicine of Rostock, Department of Hematology, Oncology and Palliative Care, Ernst-Heydemann-Strasse 6, Rostock, D-18055, Germany
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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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Martin PJ, Inamoto Y, Flowers MED, Carpenter PA. Secondary treatment of acute graft-versus-host disease: a critical review. Biol Blood Marrow Transplant 2012; 18:982-8. [PMID: 22510383 DOI: 10.1016/j.bbmt.2012.04.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
Abstract
Management of steroid-resistant or steroid-refractory acute graft-versus-host disease (aGVHD) poses one of the most vexing and difficult problems faced by transplantation physicians. In the current study, we used 10 criteria to evaluate 67 reports describing secondary treatment of patients with aGVHD. The goal of this exercise was not only to provide a critical summary of the literature but also to offer suggestions that could improve future studies. Areas especially in need of improvement include the use of a consistent treatment regimen, the assessment of response at a consistent prespecified time point, consideration of concomitant treatment in assessing response, documentation that selection bias was minimized, and the use of methods that test a formal statistical hypothesis based on a contemporaneous or historical benchmark. Our results suggest that previous published reports collectively offer little guidance in discerning the most effective treatments for patients with steroid-resistant or steroid-refractory aGVHD. Adherence to the proposed criteria in future reports would enable meaningful comparisons across studies and thereby accelerate progress in evaluating new treatments for patients with aGVHD.
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Affiliation(s)
- Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA.
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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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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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Long-term extracorporeal photochemotherapy in a pediatric patient with refractory sclerodermatous chronic graft-versus-host disease. Transfus Apher Sci 2011; 45:187-90. [DOI: 10.1016/j.transci.2011.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Martin PJ, Inamoto Y, Carpenter PA, Lee SJ, Flowers MED. Treatment of chronic graft-versus-host disease: Past, present and future. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:153-63. [PMID: 22065969 PMCID: PMC3208197 DOI: 10.5045/kjh.2011.46.3.153] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 08/19/2011] [Indexed: 11/17/2022]
Abstract
Chronic GVHD was recognized as a complication of allogeneic hematopoietic cell transplantation more than 30 years ago, but progress has been slowed by the limited insight into the pathogenesis of the disease and the mechanisms that lead to development of immunological tolerance. Only 6 randomized phase III treatment studies have been reported. Results of retrospective studies and prospective phase II clinical trials suggested overall benefit from treatment with mycophenolate mofetil or thalidomide, but these results were not substantiated by phase III studies of initial systemic treatment for chronic GVHD. A comprehensive review of published reports showed numerous deficiencies in studies of secondary treatment for chronic GVHD. Fewer than 10% of reports documented an effort to minimize patient selection bias, used a consistent treatment regimen, or tested a formal statistical hypothesis that was based on a contemporaneous or historical benchmark. In order to enable valid comparison of the results from different studies, eligibility criteria, definitions of individual organ and overall response, and time of assessment should be standardized. Improved treatments are more likely to emerge if reviewers and journal editors hold authors to higher standards in evaluating manuscripts for publication.
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Affiliation(s)
- Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Müller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant 2011; 47:1020-9. [PMID: 21874057 DOI: 10.1038/bmt.2011.161] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Bronchiolitis obliterans (BO) following allogeneic haematopoietic SCT (HSCT) is a serious complication affecting 1.7-26% of the patients, with a reported mortality rate of 21-100%. It is considered a manifestation of chronic graft-versus-host disease, but our knowledge of aetiology and pathogenesis is still limited. Diagnostic criteria are being developed, and will allow more uniform and comparable research activities between centres. At present, no randomised controlled trials have been completed that could demonstrate an effective treatment. Steroids in combination with other immunosuppressive drugs still constitute the backbone of the treatment strategy, and results from our and other centres suggest that monthly infusions of high-dose pulse i.v. methylprednisolone (HDPM) might stabilise the disease and hinder progression. This article provides an overview of the current evidence regarding treatment options for BO and presents the treatment results with HDPM in a paediatric national HSCT-cohort.
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Affiliation(s)
- H H Uhlving
- Paediatric Clinic, National University Hospital Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark.
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[Rationale for the use of extracorporeal photochemotherapy in children]. Arch Pediatr 2010; 17:1327-37. [PMID: 20709512 DOI: 10.1016/j.arcped.2010.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 05/14/2010] [Accepted: 06/27/2010] [Indexed: 11/22/2022]
Abstract
The management of immune diseases in children remains challenging, although significant advances have been made. In addition to pharmacological approaches, extracorporeal photochemotherapy (ECP) is distinctive in its ability to provide immunomodulation without immune suppression or toxicity. However, in practice, this therapy is not widely used because of logistical issues and the lack of robust clinical pediatric studies. Here, we discuss the potential clinical applications of ECP in children and emphasize the need for a rigorous and specifically pediatric clinical evaluation of ECP.
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Choi SW, Levine JE, Ferrara JLM. Pathogenesis and management of graft-versus-host disease. Immunol Allergy Clin North Am 2010; 30:75-101. [PMID: 20113888 DOI: 10.1016/j.iac.2009.10.001] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is an important therapeutic option for various malignant and nonmalignant conditions. As allogeneic HCT continues to increase, greater attention is given to improvements in supportive care, infectious prophylaxis, immunosuppressive medications, and DNA-based tissue typing. However, graft versus host disease (GVHD) remains the most frequent and serious complication following allogeneic HCT and limits the broader application of this important therapy. Recent advances in the understanding of the pathogenesis of GVHD have led to new approaches to its management, including using it to preserve the graft versus leukemia effect following allogeneic transplant. This article reviews the important elements in the complex immunologic interactions involving cytokine networks, chemokine gradients, and the direct mediators of cellular cytotoxicity that cause clinical GVHD, and discusses the risk factors and strategies for management of GVHD.
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Affiliation(s)
- Sung W Choi
- Department of Pediatrics, Blood and Marrow Transplant Program, University of Michigan Medical School, 1500 E. Medical Center Drive, 6303 Comprehensive Cancer Center, Ann Arbor, MI 48109-5942, USA.
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Schneiderman J, Jacobsohn DA, Collins J, Thormann K, Kletzel M. The use of fluid boluses to safely perform extracorporeal photopheresis (ECP) in low-weight children: a novel procedure. J Clin Apher 2010; 25:63-9. [PMID: 20301140 DOI: 10.1002/jca.20231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Apheresis procedures in small children are technically challenging and require special planning with attention to extracorporeal volume. Discontinuous procedures such as extracorporeal photopheresis (ECP) require additional consideration. Alternative methods to perform ECP have been utilized in small children that require manipulation of mononuclear cells outside the standard closed-loop system. We present a safe and feasible alternative to the procedure for children who weigh less than 40 Kg, while maintaining a closed loop, sterile system utilizing the UVAR XTS device. A retrospective chart review was performed analyzing the use of fluid boluses (normal saline in those between 20 and 40 Kg, 5% albumin in those under 20 Kg) before ECP. Eleven patients underwent 334 ECP procedures for acute and chronic graft-versus-host disease (n = 9), and for prevention of graft-versus-host disease (n = 2). Volumes of fluid boluses were calculated based on the expected extracorporeal volume during the first draw cycle. Treatments consisted of at least three draw cycles using the 125 mL bowl. The median weight was 28.5 Kg (range 19 to 39); nine of 11 required red cell transfusions to maintain adequate hematocrit. Complications attributed to ECP included tachycardia, dizziness, nausea, and hypotension; these occurred either in combination or isolation in 31% of the procedures and resolved following additional fluid boluses. Only three (0.8%) required early photoactivation due to these complications. The median time to completion of treatment was 2 h and 58 min (range 1:30 to 5:03). ECP is well tolerated in low-weight pediatric patients if hematocrit and hydration are carefully maintained.
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Affiliation(s)
- Jennifer Schneiderman
- Division of Hematology/Oncology/Stem Cell Transplantation, The Children's Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60614, USA.
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Abstract
Chronic graft-versus-host disease (GVHD) is a major complication after allogeneic haematopoietic stem cell transplantation (HSCT). Not only is it the major cause of late mortality in HSCT patients, but it also accounts for significant morbidity. Much of the literature on chronic GVHD has focused on adults. Chronic GVHD is of major importance in children, especially since they have years to live following the complications of chronic GVHD and its therapy. The goal is to review incidence, manifestations, and therapies, especially when applicable to the paediatric population.
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Perotti C, Del Fante C, Tinelli C, Viarengo G, Scudeller L, Zecca M, Locatelli F, Salvaneschi L. Extracorporeal photochemotherapy in graft-versus-host disease: a longitudinal study on factors influencing the response and survival in pediatric patients. Transfusion 2010; 50:1359-69. [DOI: 10.1111/j.1537-2995.2009.02577.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
PURPOSE OF REVIEW Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT), despite improvements in our understanding of its pathophysiology as well as the generation of new monoclonal antibodies, immunomodulatory chemotherapy, cellular therapeutics and supportive care. Herein, we review therapies that have proven effective as well as newer agents that have recently improved GVHD response rates and survival following HCT. RECENT FINDINGS Novel approaches to prevent or treat GVHD are often based on evidence from experimental models. Our understanding of the pathophysiology of GVHD may lead to the development of innovative strategies that target both soluble and cellular effectors. Among such agents are sirolimus, anti-tumor necrosis factor antibodies, anti-LFA-3-IgG fusion protein, extracorporeal photopheresis, mesenchymal stem cells and regulatory T cells. SUMMARY Obstacles to the improvement of HCT include the tight linkage between GVHD toxicity and the beneficial graft-versus-leukemia (GVL) effect, as well as the impairment of immune reconstitution by immunomodulatory drugs leading to life-threatening infections. The design of newer phase I/II clinical trials are underway. Future therapies are likely to include modulation of cell types that play key roles in the GVH process, including regulatory T cells, dendritic cells, natural killer T cells and B cells.
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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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Extracorporeal photopheresis: From solid organs to face transplantation. Transpl Immunol 2009; 21:117-28. [DOI: 10.1016/j.trim.2009.04.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 04/19/2009] [Accepted: 04/24/2009] [Indexed: 12/21/2022]
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Innovative approaches to treat steroid-resistant or steroid refractory GVHD. Bone Marrow Transplant 2009; 42 Suppl 2:S101-5. [PMID: 18978736 DOI: 10.1038/bmt.2008.294] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
First-line treatment of GVHD is based on steroids and produces sustained responses in 50-80% of patients with acute GVHD (aGVHD) and 40-50% of patients with chronic GVHD (cGVHD) depending on the initial disease severity. Non-responding children are offered second-line therapy with combinations of various agents, but currently available agents have not improved survival in these high-risk populations. In this minireview, we will focus on new agents to treat GVHD in paediatric patients.
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