Extracorporeal photochemotherapy as an effective treatment modality in chronic graft-versus-host disease

Extracorporeal Photopheresis in Graft-versus-Host Disease

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.

Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

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.

Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

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.

Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

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.

Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

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. 

Evidence-based practice of photopheresis 1987-2001: a report of a workshop of the British Photodermatology Group and the U.K. Skin Lymphoma Group

Photopheresis or extracorporeal photochemotherapy (ECP) is a novel immunomodulatory therapy which involves separation of the patient's leucocyte-rich plasma, followed by ex vivo administration of a photosensitizer and ultraviolet A radiation, before reinfusion. ECP has been used successfully for the treatment of cutaneous T-cell lymphoma (CTCL: Sézary syndrome), graft-versus-host disease (GVHD) and cardiac transplant rejection. ECP has a dose-sparing effect on concurrent immunosuppressive therapy. The procedure induces apoptosis of the irradiated lymphocytes, but the exact mechanism by which ECP exerts its therapeutic effect in these different conditions is uncertain. The treatment has very few adverse effects and in particular is not associated with an increased incidence of opportunistic infections. The evidence for the efficacy of ECP has been appraised by a combined British Photodermatology Group and U.K. Skin Lymphoma Group workshop on the basis of evidence published up to the end of 2001 and on the consensus of best practice. There is fair evidence for the use of ECP in erythrodermic CTCL and steroid-refractory GVHD, but randomized controlled studies are needed. There is good evidence supporting the use of ECP in preventing cardiac rejection following transplantation. Randomized controlled trials have also shown a therapeutic benefit in type 1 diabetes mellitus, but the inconvenience associated with the procedure outweighed the clinical benefit. There is fair evidence not to use ECP for the treatment of systemic sclerosis and multiple sclerosis, and good evidence not to use ECP for other forms of CTCL.

Update on extracorporeal photochemotherapy for graft-versus-host disease treatment

Pediatric experience with extracorporeal photochemotherapy (ECP) for graft-versus-host disease (GvHD) has mainly been reported by Italian and French groups. Data concerning 41 children with acute GvHD and 63 children affected by chronic GvHD are available. In 73 and 63% of them, respectively, improvement was observed, with addition of ECP to their immunosuppressive regimen. Treatment with ECP was associated with minimal side effects, even in the smallest of patients. In all responded pediatric patients, both with acute and chronic GvHD, ECP allowed progressive reduction or discontinuation of the concomitant pharmacological immunosuppressive therapy without an increase in GvHD activity. These data show that ECP is a useful therapy for children affected by GvHD resistant to conventional treatment and can be safely used.

[Cell therapy for cancer treatment in children]

The cure rate for cancer in children is currently almost 75%. This rate has remained fairly constant over the past few years, which suggests that the limits of today's curative treatment potential have been reached. The development of cell therapy techniques opens up new therapeutic possibilities in paediatric oncology. Here, we deal both with a number of cell therapy techniques, which have already proved their efficacy in children, and other more innovative approaches, which require validation. Examples of the use of autologous and allogeneic cells are described. Clinical studies and their results, while often preliminary, are reported. The importance of well run clinical research, a clear and progressive legal framework and the necessary substantial economic support for the development of cell therapy are underlined.

Extracorporeal photochemotherapy for graft versus host disease in pediatric patients

Although worldwide experience with extracorporeal photochemotherapy (ECP) for GvHD treatment has grown enormously over the past decade, only a few pediatric centers have experience with ECP. Studies reporting clinical outcome in children with GvHD treated by ECP comprises a very limited number of patients with only few information described. This review article remain focused on the efficacy and the safety aspect of ECP in pediatric patients to provide information about the steps that should be taken to overcome the difficulties with ECP use in children with GvHD. Data concerning 19 children with acute GvHD and 54 children with chronic GvHD treated with ECP and reported so far have been considered. The principal reasons for the restriction in the use of ECP in children such as: (1) technical difficulties of leukapheresis procedures (venous access, hemodynamic, metabolic and hematological tolerance); and (2) the necessity of a specially adapted pediatric patient approach to improve the psychological tolerance of this treatment are discussed. The data of this retrospective review demonstrate that ECP is beneficial and well tolerated in children with GvHD. It can be safely used even in young children with low body weight and a poor performance status when it was performed by a qualified pediatric team. The observations concerning the response rate and onset suggest that in children with acute GvHD, ECP should be started early in the course of disease and employed over a relatively short period of time. As far as chronic GvHD is concerned, despite the fact that it is preferable to begin ECP early as second line therapy, it may also be beneficial in patients with late-stage disease.

Extracorporeal photopheresis: a review

Extracorporeal phototherapy (ECP) is a therapeutic approach based on the biological effect of psoralen 8-methoxypsoralen (8-MOP) and ultraviolet light A (UVA) on mononuclear cells collected by apheresis, and reinfused into the patient. Photopheresis is widely used for the treatment of patients with advanced cutaneous T-cell lymphoma (CTLC). Evidence suggests that it prolongs life, and also induces 50-75% response rates. In addition, more and more reports indicate that photopheresis is a potent agent in the therapy of acute allograft rejection among cardiac, lung and renal transplant recipients. There are increasing amounts of data showing that patients with chronic graft versus host disease benefit from this therapy. Likewise, there are indications that there may be a potential role for ECP in the therapy of certain autoimmune diseases resistant to conventional therapy. The mechanism of this treatment is likely due to the induction of anticlonotypic immunity directed against pathogenic clones of T lymphocytes. Treatment induces apoptotic death of pathogenic T-cells, and it is postulated that activation of antigen-presenting cells has important effects in this process.

Extracorporeal photochemotherapy in the treatment of severe graft-versus-host disease

Advances in posttransplant immunosuppression have to the present not been able to prevent the development of graft-versus-host disease (GVHD) in patients given related or unrelated stem cell grafts for cure of hematologic diseases. Patients with GVHD not responding to first line therapy with corticosteroids remain at high risk of death due to severe infections or organ failure. Extracorporeal exposure of peripheral blood mononuclear cells to the photosensitizing agent 8-methoxypsoralen and ultraviolet A radiation has been shown to be effective in treatment of selected T-cell mediated diseases, including cutaneous T-cell lymphoma and rejection after organ transplantation. Extracorporeal photochemotherapy (ECP) is also a safe and efficacious adjunct therapy for both acute and chronic extensive GVHD with skin and visceral involvement and resistance to conventional immunosuppressive therapy. A multicenter randomized study should help define the impact of ECP in the treatment of GVHD and overall survival of these patients.

Long-term application of extracorporeal photochemotherapy in severe atopic dermatitis

BACKGROUND

Extracorporeal photochemotherapy (ECP) using UVA irradiation of enriched leukocytes in the presence of methoxsalen as a photoactivatable substrate has been employed for the treatment of several immunologically mediated disorders.

OBJECTIVE

Our purpose was to determine the efficacy and safety of long-term ECP in the treatment of severe atopic dermatitis.

METHODS

Fourteen patients with severe recalcitrant atopic dermatitis were treated with ECP in an open clinical trial at 2-week intervals. Disease activity was scored before each ECP cycle by means of a standardized protocol.

RESULTS

A complete clinical remission was achieved in 4 patients (29%). Five patients (36%) experienced a substantial response with reduction of skin inflammation by at least 75%, whereas in one patient (7%) disease activity was reduced by more than 50%. Four patients were withdrawn from the study for unresponsiveness. No clinical signs of immunosuppression or other severe adverse events became evident.

CONCLUSION

Long-term ECP may have significant beneficial effects on the course of atopic dermatitis and should therefore be considered as a treatment modality for patients suffering from severe and otherwise refractory atopic skin disease.