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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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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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Sebastián E, Andrés Esteban EM, González‐Vicent M, González de Pablo J, Zubicaray J, Gálvez E, Guillén M, Ruiz Pato J, Molina B, Albi G, Ramírez M, Castillo A, Pérez Maroto F, Madero L, Díaz MÁ, Sevilla J. Extracorporeal photopheresis in paediatric patients: A retrospective comparison between different ‘off‐line’ protocols. Vox Sang 2022; 117:1220-1229. [DOI: 10.1111/vox.13346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Elena Sebastián
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
- Fundación Investigación Biomédica Hospital Infantil Niño Jesús (FIBHINJ) Madrid Spain
| | - Eva María Andrés Esteban
- Fundación Investigación Biomédica Hospital Infantil Niño Jesús (FIBHINJ) Madrid Spain
- Applied Economics Department Universidad Rey Juan Carlos Madrid Spain
| | | | | | - Josune Zubicaray
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
- Fundación Investigación Biomédica Hospital Infantil Niño Jesús (FIBHINJ) Madrid Spain
| | - Eva Gálvez
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - María Guillén
- Hematology Department Hospital Universitario Miguel Servet Zaragoza Spain
| | - Julia Ruiz Pato
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Blanca Molina
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Gustavo Albi
- Radiology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Manuel Ramírez
- Hematology and Oncology Laboratory Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Ana Castillo
- Hematology and Oncology Laboratory Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Florencio Pérez Maroto
- Hematology and Oncology Laboratory Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Luis Madero
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Miguel Ángel Díaz
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
| | - Julián Sevilla
- Onco‐Hematology Department Hospital Infantil Universitario Niño Jesús Madrid Spain
- Fundación Investigación Biomédica Hospital Infantil Niño Jesús (FIBHINJ) Madrid Spain
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Kitko CL, Abdel-Azim H, Carpenter PA, Dalle JH, Diaz-de-Heredia C, Gaspari S, Gennery AR, Handgretinger R, Lawitschka A. A Prospective, Multicenter Study of Closed System Extracorporeal Photopheresis for Children With Steroid-Refractory Acute Graft-Versus-Host Disease. Transplant Cell Ther 2022; 28:261.e1-261.e7. [PMID: 35124293 DOI: 10.1016/j.jtct.2022.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Steroid-refractory (SR) acute graft-versus-host disease (aGvHD) therapy involves intensive immunosuppression, which is associated with significant infectious risk. Extracorporeal photopheresis (ECP) is used to treat SR-aGvHD and is considered to be more immunomodulatory than immunosuppressive. However, pediatric data are mostly retrospective and often involve multi-step ECP that includes apheresis followed by separate photosensitizing/reinfusion on another device. OBJECTIVE To prospectively evaluate the efficacy and safety of a single-device ECP system in children with SR-aGvHD. STUDY DESIGN Open-label, multicenter, phase 3 study of the THERAKOS® CELLEX® Photopheresis System in children/young adults aged 1 to 21 years with SR-aGvHD. Patients were treated 3 times per week for 4 weeks, then twice weekly through week 12 while maintaining standard aGvHD prophylaxis. The primary efficacy endpoint was the proportion of patients achieving overall response (OR) at day 28 without the addition of next-line systemic treatment. Secondary endpoints included the proportion of patients achieving OR at weeks 8 and 12; the mean weekly steroid dose at weeks 4, 8, and 12; and treatment-emergent adverse events (TEAEs). RESULTS Twenty-nine children (median age, 8 years) were enrolled. OR was 55% by day 28, 74% by week 8, and 79% by week 12. Progressive improvements were observed in the skin and the gastrointestinal tract. Mean steroid dose decreased from 1.54 mg/kg/day at baseline to 0.90 mg/kg/day at week 4; 35% of patients achieved >50% steroid dose reduction at week 4 and 75% achieved >50% steroid dose reduction at week 12. Of 168 TEAEs reported among 25 patients (86%), 28 (17%) events were infections and 14 (8%) events were considered to be probably treatment related (all nonserious). Of 627 ECP treatments administered in children/young adults, 68% required blood priming. Treatment-related AEs, including hypotension, hypocalcemia, central line infection, and catheter-site bruising, were rare (1 event each). Three deaths occurred and were deemed unrelated to ECP by the investigators. CONCLUSION Use of the THERAKOS® CELLEX® Photopheresis System was effective in children with SR-aGvHD, with more than half experiencing improvement by day 28 and further responses observed over 12 weeks. Very few TEAEs were attributable to ECP, and no new safety signals were observed.
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Affiliation(s)
- Carrie L Kitko
- Pediatric Hematology/Oncology Division, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jean-Hugues Dalle
- Hôpital Robert Debré, GH AP-HP. Nord Université de Paris, Paris, France
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Stefania Gaspari
- Department of Pediatric Hematology and Oncology, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Great North Children's Hospital, Newcastle, United Kingdom
| | - Rupert Handgretinger
- Department of Hematology/Oncology, Children's University Hospital, Tübingen, Germany
| | - Anita Lawitschka
- SCT Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria; St. Anna Children's Cancer Research Institute, Vienna, Austria
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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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Extracorporeal photopheresis in the treatment for acute and chronic graft-versus-host disease: a position statement from The Turkish Society of Apheresis (TSA). Transfus Apher Sci 2022; 61:103373. [DOI: 10.1016/j.transci.2022.103373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Cueto Sarmiento KY, Baquero Rey JA, Andrade Miranda A, Bruey SA, Makiya ML, Mazzuoccolo LD, Enz PA. Extracorporeal Photopheresis in Pediatric Graft-vs-Host Disease. ACTAS DERMO-SIFILIOGRAFICAS 2021:S1578-2190(21)00177-3. [PMID: 34078587 DOI: 10.1016/j.adengl.2021.05.017] [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: 10/21/2020] [Accepted: 02/10/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is an immunomodulatory therapy used to treat graft-vs-host disease (GVHD) in adults and children. Few studies have examined its use in children. OBJECTIVE To describe demographic characteristics, clinical response, adverse effects, and outcomes in a series of pediatric patients with acute or chronic GVHD treated with ECP. MATERIAL AND METHODS We included all pediatric patients with acute or chronic GVHD treated with ECP by the dermatology department of Hospital Italiano de Buenos Aires between January 2012 and December 2018. We used the UVAR-XTS™ system (2 patients) and the CELLEX system (7 patients). Patients with acute GVHD received 2 sessions a week and were reassessed at 1 month, while those with chronic GVHD received 2 sessions every 2 weeks and were reassessed at 3 months. Treatment duration in both scenarios varied according to response. RESULTS We evaluated 9 pediatric patients with corticosteroid-refractory, -dependent, and/or -resistant GVHD treated with ECP. Seven responded to treatment and 2 did not. Response was complete in 1 of the 9 patients with skin involvement and partial in 7. Complete response rates for the other sites of involvement were 60% (3/5) for the liver, 50% (1/2) for the gastrointestinal system, and 80% (4/5) for mucous membranes. Two patients died during the study period. CONCLUSION ECP is a good treatment option for pediatric patients with acute or chronic GVHD.
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Affiliation(s)
- K Y Cueto Sarmiento
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J A Baquero Rey
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Andrade Miranda
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S A Bruey
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M L Makiya
- Equipo de Trasplante de Médula Ósea Pediátrico, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - L D Mazzuoccolo
- Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - P A Enz
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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8
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Cueto Sarmiento KY, Baquero Rey JA, Andrade Miranda A, Bruey SA, Makiya ML, Mazzuoccolo LD, Enz PA. Extracorporeal Photopheresis in Pediatric Graft-vs-Host Disease. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00088-0. [PMID: 33621559 DOI: 10.1016/j.ad.2021.02.003] [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: 10/21/2020] [Revised: 01/24/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is an immunomodulatory therapy used to treat graft-vs-host disease (GVHD) in adults and children. Few studies have examined its use in children. OBJECTIVE To describe demographic characteristics, clinical response, adverse effects, and outcomes in a series of pediatric patients with acute or chronic GVHD treated with ECP. MATERIAL AND METHODS We included all pediatric patients with acute or chronic GVHD treated with ECP by the Dermatology Department of Hospital Italiano de Buenos Aires between January 2012 and December 2018. We used the UVAR-XTS™ system (2 patients) and the CELLEX system (7 patients). Patients with acute GVHD received 2 sessions a week and were reassessed at 1 month, while those with chronic GVHD received 2 sessions every 2 weeks and were reassessed at 3 months. Treatment duration in both scenarios varied according to response. RESULTS We evaluated 9 pediatric patients with corticosteroid-refractory, -dependent, and/or -resistant GVHD treated with ECP. Seven responded to treatment and 2 did not. Response was complete in 1 of the 9 patients with skin involvement and partial in 7. Complete response rates for the other sites of involvement were 60% (3/5) for the liver, 50% (1/2) for the gastrointestinal system, and 80% (4/5) for mucous membranes. Two patients died during the study period. CONCLUSION ECP is a good treatment option for pediatric patients with acute or chronic GVHD.
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Affiliation(s)
- K Y Cueto Sarmiento
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J A Baquero Rey
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A Andrade Miranda
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S A Bruey
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M L Makiya
- Equipo de Trasplante de Médula Ósea Pediátrico, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - L D Mazzuoccolo
- Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - P A Enz
- Sección de Fotoféresis, Fototerapia y Linfomas Cutáneos, Servicio de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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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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Drexler B, Buser A, Infanti L, Stehle G, Halter J, Holbro A. Extracorporeal Photopheresis in Graft-versus-Host Disease. Transfus Med Hemother 2020; 47:214-225. [PMID: 32595426 DOI: 10.1159/000508169] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background and Summary Extracorporeal photopheresis (ECP) is a leukapheresis-based procedure used in the therapy of acute and chronic graft-versus-host disease (aGvHD, cGvHD) and other diseases. Based on the substantial efficacy and the excellent safety profile in the absence of immunosuppression ECP has established itself as a major treatment form for steroid-refractory GvHD. Here we review the current literature on ECP as a treatment option for patients with aGvHD as well as cGvHD. Key Messages ECP is a well-established second-line therapy for cGvHD. Its role in the treatment of aGvHD is less clear but also points towards an effective second-line therapy option. In the future ECP could play a role in the prevention of GvHD. More experimental and randomized controlled trials are needed to define the best patient selection criteria, settings, and therapy regimens for GvHD.
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Affiliation(s)
- Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Andreas Buser
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Laura Infanti
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Gregor Stehle
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
| | - Joerg Halter
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Andreas Holbro
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Blood Transfusion Center, Swiss Red Cross, Basel, Switzerland
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11
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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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12
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 760] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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13
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Wolff D, Hilgendorf I, Wagner-Drouet E, Jedlickova Z, Ayuk F, Zeiser R, Schäfer-Eckart K, Gerbitz A, Stadler M, Klein S, Middeke JM, Lawitschka A, Winkler J, Halter J, Holler E, Kobbe G, Stelljes M, Ditschkowski M, Greinix H. Changes in Immunosuppressive Treatment of Chronic Graft-versus-Host Disease: Comparison of 2 Surveys within Allogeneic Hematopoietic Stem Cell Transplant Centers in Germany, Austria, and Switzerland. Biol Blood Marrow Transplant 2019; 25:1450-1455. [PMID: 30876928 DOI: 10.1016/j.bbmt.2019.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/04/2019] [Indexed: 12/27/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) remains the leading cause of late morbidity and mortality. Despite the growing number of treatment options in cGVHD, evidence remains sparse. The German-Austrian-Swiss GVHD Consortium performed a survey on clinical practice in treatment of cGVHD among transplant centers in Germany, Austria, and Switzerland in 2009 and 2018 and compared the results. The survey performed in 2009 contained 20 questions on first-line treatment and related issues and 4 questions on second-line scenarios followed by a survey on all systemic and topic treatment options known and applied, with 31 of 36 transplant centers (86%) responding. The survey in 2018 repeated 7 questions on first-line treatment and 3 questions on second-line scenarios followed by an updated survey on all current systemic treatment options known and applied, with 29 of 66 centers (43%) responding. In summary, the results show a large overlap of first-line treatment practice between centers and the 2 surveys because of a lack of new data that changes practice, except significant heterogeneity of treatment of cGVHD progressive onset type, which can be explained by the lack of trials focusing on this high-risk entity. In contrast, treatment options applied to second-line therapy vary considerably, with new agents like ibrutinib and ruxolitinib entering clinical practice. Moreover, treatment of bronchiolitis obliterans syndrome demonstrates heterogeneity in applied therapeutic options and sequence because of a lack of controlled data and different conclusions from already existing evidence. In summary, the survey results demonstrate an increasing number of treatment options applied to cGVHD accompanied by a significant heterogeneity in second-line treatment and underline the urgent need for clinical trials and registry analyses on rare entities with high mortality like progressive onset type and lung involvement of cGVHD.
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Affiliation(s)
- Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.
| | - Inken Hilgendorf
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Eva Wagner-Drouet
- 3rd Medical Department, Hematology, Oncology and Pneumology, University Medical Center, Mainz, Germany
| | - Zuzana Jedlickova
- Medizinische Klinik 2, Universitätsklinikum Frankfurt, Frankfurt/Main, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, University of Freiburg, Freiburg, Germany
| | | | - Armin Gerbitz
- Department of Hematology, Oncology and Tumorimmunology, Campus Virchow Klinikum, Charite, Berlin, Germany
| | - Michael Stadler
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Stefan Klein
- III. Medizinische Klinik Hämatologie und Onkologie, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Jan-Moritz Middeke
- Department of Internal Medicine I, University Hospital Dresden, Dresden, Germany
| | - Anita Lawitschka
- St. Anna Children's Hospital, Medical University Vienna, Austria
| | - Julia Winkler
- Department of Hematology, University Hospital Erlangen, Erlangen, Germany
| | - Jörg Halter
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Ernst Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Matthias Stelljes
- Department of Hematology, University Hospital Muenster, Muenster, Germany
| | - Markus Ditschkowski
- Department for Bone Marrow Transplantation, University of Essen, Essen, Germany
| | - Hildegard Greinix
- Division of Hematology, Department of Internal Medicine I, Medical University of Graz, Graz, Austria
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14
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Matic T, Bojanic I, Mazic S, Golubic Cepulic B, Bilic E. An automated mini buffy coat preparation method for use in mini extracorporeal photopheresis treatment of graft-vs-host-disease in a low body weight pediatric patient. J Clin Apher 2019; 34:468-473. [PMID: 30829417 DOI: 10.1002/jca.21700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 07/30/2018] [Accepted: 02/18/2019] [Indexed: 11/11/2022]
Abstract
A mini extracorporeal photopheresis (mini-ECP) "off line" technique has been developed for use in the treatment of small children and patients with apheresis contraindications. Until now various methods have been used for buffy coat separation from whole blood. In this report we describe a protocol for mini buffy coat preparation using the automated Sepax laboratory separator for "off line" ECP treatment in a low body weight child with graft-vs-host-disease. According to our results this alternative method has been proven feasible and tolerable.
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Affiliation(s)
- Toni Matic
- Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ines Bojanic
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Sanja Mazic
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Branka Golubic Cepulic
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Ernest Bilic
- Department of Pediatrics, University Hospital Center Zagreb, Zagreb, Croatia
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15
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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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16
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Abstract
PURPOSE OF REVIEW The pediatric transplant patient population is growing as the number of solid organ transplants and indications for hematopoietic stem cell transplant increase. Understanding cutaneous sequelae of pediatric transplant and treatment strategies to manage these outcomes is vital to the care of these patients. RECENT FINDINGS Important work in the past year enhances our understanding of the cutaneous implications of pediatric transplantation, including further work in areas of malignancy, infection, and graft versus host disease as well as newly reported risks. SUMMARY This review highlights recent developments in the recognition and management of dermatological complications of pediatric transplant that will be useful for the practicing pediatrician or dermatologist.
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17
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Longitudinal follow-up of response status and concomitant immunosuppression in patients treated with extracorporeal photopheresis for chronic graft versus host disease. Bone Marrow Transplant 2018; 54:35-43. [PMID: 29740177 DOI: 10.1038/s41409-018-0206-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/16/2018] [Accepted: 04/09/2018] [Indexed: 12/22/2022]
Abstract
Improvement in chronic graft vs. host disease (cGvHD) following treatment with extracorporeal photopheresis (ECP) has been shown previously. However, the effect is often measured at only one point in time or as best response. Chronic GvHD activity fluctuates over time, so we retrospectively evaluated cGvHD responses in 54 patients with primarily moderate or severe cGvHD throughout the ECP treatment course and after stopping ECP. The dominant response was partial remission (PR) in 33 patients, no change (NC) in 10 patients, progressive disease (PD) in 10 patients and complete remission (CR) in one patient. Response rates and reduction in glucocorticoid dose reached a plateau after nine months. The main reason for stopping ECP was the absence of further improvement. Flares in cGvHD activity were seen in 36 patients. Additional treatment during ECP was administered to 29 patients. Failure free survival with response was achieved for 52% of patients at 6 months and 43% at 1 year. Our study confirms that ECP is a safe option for cGvHD therapy. The majority of the patients experience improvement and reduction in glucocorticoid dose but flares in cGvHD activity and the need for additional immunosuppression are seen frequently.
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18
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Allogeneic Hematopoietic Stem Cell Transplantation in the Treatment of Human C1q Deficiency: The Karolinska Experience. Transplantation 2017; 100:1356-62. [PMID: 26516671 DOI: 10.1097/tp.0000000000000975] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Human C1q deficiency is associated with systemic lupus erythematosus (SLE) and increased susceptibility to severe bacterial infections. These patients require extensive medical therapy and some develop treatment-resistant disease. Because C1q is produced by monocytes, it has been speculated that allogeneic hematopoietic stem cell transplantation (allo-HSCT) may cure this disorder. METHODS We have so far treated 5 patients with C1q deficiency. In 3 cases, SLE symptoms remained relatively mild after the start of medical therapy, but 2 patients developed treatment-resistant SLE, and we decided to pursue treatment with allo-HSCT. For this purpose, we chose a conditioning regimen composed of treosulfan (14 g/m) and fludarabine (30 mg/m) started on day -6 and given for 3 and 5 consecutive days, respectively. Thymoglobulin was given at a cumulative dose of 8 mg/kg, and graft-versus-host disease prophylaxis was composed of cyclosporine and methotrexate. RESULTS A 9-year-old boy and a 12-year-old girl with refractory SLE restored C1q production after allo-HSCT. This resulted in normal functional properties of the classical complement pathway followed by reduced severity of SLE symptoms. The boy developed posttransplant lymphoproliferative disease, which resolved after treatment with rituximab and donor lymphocyte infusion. Unfortunately, donor lymphocyte infusion induced severe cortisone-resistant gastrointestinal graft-versus-host disease, and the patient died from multiple organ failure 4 months after transplantation. The girl is doing well 33 months after transplantation, and clinically, all signs of SLE have resolved. CONCLUSIONS Allo-HSCT can cure SLE in human C1q deficiency and should be considered early in subjects resistant to medical therapy.
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19
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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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20
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Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher 2017; 31:149-62. [PMID: 27322218 DOI: 10.1002/jca.21470] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joseph Schwartz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anand Padmanabhan
- Blood Center of Wisconsin, Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance and University of Washington, Seattle, Washington
| | - Meghan Delaney
- Bloodworks Northwest, Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks Northwest, Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Beth H Shaz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.,New York Blood Center, Department of Pathology.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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21
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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: 93] [Impact Index Per Article: 13.3] [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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22
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Mohammadi S, Malek Mohammadi A, Norooznezhad AH, Heshmati F, Alimoghaddam K, Ghavamzadeh A. Extra corporeal photochemotherapy in steroid refractory graft versus host disease: A review of guidelines and recommendations. Transfus Apher Sci 2017; 56:376-384. [PMID: 28359604 DOI: 10.1016/j.transci.2017.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/04/2016] [Accepted: 01/29/2017] [Indexed: 12/18/2022]
Abstract
Regardless of remarkable progresses in prevention and treatment approaches, graft versus host disease (GVHD) remains a major impediment for successful allogeneic hematopoietic stem cells transplantation (HSCT) and leads to morbidity and mortality in transplanted patients. Corticosteroids are the standard therapy for GVHD; however, a great number of patients will not respond sufficiently and others will be significantly affected by adverse effects of steroids. Extracorporeal photochemotherapy (ECP), as one of the numerous second line therapies, through modulation of immune cells may improves GVHD affected organ function in steroid-refractory forms. Considering to widespread utilization of ECP as a therapeutic strategy, we performed review on current literature of ECP, regarding the treatment strategies, monitoring protocols and technical aspects in chronic and acute GVHD.
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Affiliation(s)
- Saeed Mohammadi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashraf Malek Mohammadi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Norooznezhad
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Kamran Alimoghaddam
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
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23
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Acute Disseminated Encephalomyelitis. J Clin Apher 2016; 31:163-202. [PMID: 27322219 DOI: 10.1002/jca.21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Weitz M, Strahm B, Meerpohl JJ, Schmidt M, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2015; 2015:CD009898. [PMID: 26666581 PMCID: PMC7093760 DOI: 10.1002/14651858.cd009898.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE and EMBASE databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings on 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS No additional studies were identified in this 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs cannot be evaluated since the original version of this review and the first review update found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, patients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Brigitte Strahm
- University Medical School FreiburgPediatric Hematology and Oncology Centre for Pediatrics and Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Maria Schmidt
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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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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Kapadia E, Wong E, Perez-Albuerne E, Jacobsohn D. Extracorporeal photopheresis performed on the CELLEX® compared with the UVAR-XTS® instrument is more efficient and better tolerated in children with steroid-refractory graft-versus-host disease. Pediatr Blood Cancer 2015; 62:1485-8. [PMID: 25881179 DOI: 10.1002/pbc.25487] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/02/2015] [Indexed: 11/09/2022]
Abstract
Extracorporeal photopheresis (ECP) is an effective therapy in children with refractory graft-versus-host disease (GVHD). The two most frequently used instruments are UVAR-XTS® and CELLEX®. We performed a retrospective chart review of ten patients who underwent ECP with both UVAR-XTS® and CELLEX® instruments for steroid-refractory acute or chronic GVHD to compare instrument run times, percentages of cells treated, and complication rates. We found that compared to the UVAR-XTS® instrument, use of the CELLEX® instrument resulted in shorter run times, increased percentage of mononuclear cells treated, reduced incidence of line occlusions requiring TPA treatment, and decreased incidence of patient-related complications.
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Affiliation(s)
- Ekta Kapadia
- Department of Hematology/Oncology/BMT, Children's National Health System, Washington DC
| | - Edward Wong
- Department of Transfusion Medicine, Children's National Health System, Washington DC
| | - Evelio Perez-Albuerne
- Department of Hematology/Oncology/BMT, Children's National Health System, Washington DC
| | - David Jacobsohn
- Department of Hematology/Oncology/BMT, Children's National Health System, Washington DC
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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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de Waure C, Capri S, Veneziano MA, Specchia ML, Cadeddu C, Di Nardo F, Ferriero AM, Gennari F, Hamilton C, Mancuso A, Quaranta G, Raponi M, Valerio L, Gensini G, Ricciardi W. Extracorporeal Photopheresis for Second-Line Treatment of Chronic Graft-versus-Host Diseases: Results from a Health Technology Assessment in Italy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:457-466. [PMID: 26091600 DOI: 10.1016/j.jval.2015.01.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 12/09/2014] [Accepted: 01/09/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To develop a comparative, cost-effectiveness, and budget impact analysis of Therakos online extracorporeal photopheresis (ECP) compared with the main alternatives used for the treatment of steroid-refractory/resistant chronic graft-versus-host disease (cGvHD) in Italy. METHODS The current therapeutic pathway was identified by searching medical databases and from the results of a survey of practice in Italian clinical reference centers. A systematic review was performed to evaluate the efficacy and safety of second-line alternatives. Budget impact and cost-effectiveness analyses were performed from the Italian National Health Service perspective over a 7-year time horizon through the adaption of a Markov model. The following health states were considered: complete and partial response, stable disease, and progression. A discount rate of 3% was applied to costs and outcomes. RESULTS The most common alternatives used in Italy for the management of steroid-refractory/resistant cGvHD were ECP, mycophenolate, pentostatin, and imatinib. The literature review highlighted that complete and partial responses are higher with ECP than with the alternatives while serious adverse events are less common. The economic analysis showed that Therakos online ECP represents the dominating alternative, in that it delivers greater benefit at a lower cost. In fact, according to the alternatives considered, cost saving ranged from €3237.09 to €19,903.51 per patient with 0.04 to 0.21 quality-adjusted life-year gained. CONCLUSIONS Therakos online ECP should be considered an effective, safe, and cost-effective alternative in steroid-refractory/resistant cGvHD. There is inequality in access, and a dedicated reimbursement tariff, however, should be introduced to overcome these barriers.
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Affiliation(s)
- Chiara de Waure
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy.
| | - Stefano Capri
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy; School of Economics and Management, LIUC University, Castellanza (VA), Italy
| | - Maria Assunta Veneziano
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Lucia Specchia
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Chiara Cadeddu
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Di Nardo
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Anna Maria Ferriero
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Agostino Mancuso
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Gianluigi Quaranta
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Matteo Raponi
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Luca Valerio
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Gianfranco Gensini
- Faculty of Medicine, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Walter Ricciardi
- Section of Hygiene, Institute of Public Health, Catholic University of the Sacred Heart, Rome, Italy
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A concise review on extracorporeal photochemotherapy: Where we began and where we are now and where are we going! Transfus Apher Sci 2015; 52:360-8. [PMID: 25910538 DOI: 10.1016/j.transci.2015.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Currently, more than 1080 peer-reviewed papers are displayed on PubMed when initiating a search for therapeutic indications and mechanisms of action of extracorporeal photochemotherapy (ECP). This concise review focuses mainly on some prevalent and traditional treatment-resistant disorders with an emphasis on immunologic complications emerging from stem cell and solid organ transplantation.
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30
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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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Zhang H, Chen R, Cheng J, Jin N, Chen B. Systematic review and meta-analysis of prospective studies for ECP treatment in patients with steroid-refractory acute GVHD. Patient Prefer Adherence 2015; 9:105-11. [PMID: 25653504 PMCID: PMC4303403 DOI: 10.2147/ppa.s76563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this systematic review was to evaluate the efficacy and safety of extracorporeal photopheresis (ECP) treatment in patients with steroid-refractory acute graft-versus-host disease (SR-aGVHD). METHODS An electronic search was carried out on the MEDLINE, EMBASE, Science Citation Index (SCI), and Cochrane Library databases. We included prospective clinical trials in SR-aGVHD treated by ECP. The main endpoints consisted of mortality, exacerbation, or response. RESULTS Only seven studies involving 121 patients met the inclusion criteria for further review. Our analysis showed positive results of ECP for aGVHD. The overall response rate (ORR) was 0.71 and the complete response rate (CRR) was 0.71. The efficacy of ECP for skin aGVHD, liver aGVHD, and gut aGVHD were 0.86, 0.60, and 0.68, respectively. However, no sufficient evidence verifies the exact benefit in this review, because the number of patients enrolled in trials is limited and publish bias exists. CONCLUSION ECP is an effective therapy for skin, liver, and gut aGVHD, and large double-blind clinical trials are required to prove the outcome of this meta-analysis.
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Affiliation(s)
- Hongming Zhang
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Runzhe Chen
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Jian Cheng
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Nan Jin
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Baoan Chen
- Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
- Correspondence: Baoan Chen, Department of Hematology and Oncology (Key Department of Jiangsu Medicine), Zhongda Hospital, Medical School, Southeast University, Dingjiaqiao 87, Gulou District, Nanjing, Jiangsu Province, People’s Republic of China, Tel +86 25 8327 2006, Fax +86 25 8327 2011, Email
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Abstract
We describe 16 leukapheresis (LK) procedures performed in 7 children with different types of leukemia and hyperleukocytosis. We also provide an analysis of previously published experiences of pediatric LK. Median age and body weight of patients were 12.3 years (range, 0.2 to 16.7 y) and 49 kg (range, 5 to 61 kg). Immediate pre-first-LK median white blood cell count was 478×10/L (108×10/L to 988×10/L). All cytoreduction were performed on Cobe Spectra cell separator. Sixty-eight percent of procedures were performed with peripheral veins. Extracorporeal line had been primed with red blood cell for 31% of LK. The median decrease in white blood cell count after each LK was 33% (0% to 69%), and overall decrease after completion of LK procedures was 62% (11% to 94%). Only minor clinical adverse events and no metabolic complication were attributable to LK. No more clinical symptom of hyperleukocytosis was observed after completion of LK procedures. Our findings are consistent with reported results in other pediatric series: LK is a well-tolerated procedure that can be safely performed with an experienced pediatric team even on the smallest children.
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Abu-Dalle I, Reljic T, Nishihori T, Antar A, Bazarbachi A, Djulbegovic B, Kumar A, Kharfan-Dabaja MA. Extracorporeal Photopheresis in Steroid-Refractory Acute or Chronic Graft-versus-Host Disease: Results of a Systematic Review of Prospective Studies. Biol Blood Marrow Transplant 2014; 20:1677-86. [DOI: 10.1016/j.bbmt.2014.05.017] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 05/19/2014] [Indexed: 01/19/2023]
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National Institutes of Health State of the Science Symposium in Therapeutic Apheresis: scientific opportunities in extracorporeal photopheresis. Transfus Med Rev 2014; 29:62-70. [PMID: 25459074 DOI: 10.1016/j.tmrv.2014.09.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 09/28/2014] [Accepted: 09/30/2014] [Indexed: 12/20/2022]
Abstract
The clinical use of extracorporeal photopheresis (ECP) for accepted indications such as graft-versus-host disease, transplant rejection, and cutaneous T-cell lymphoma continues to increase. Expanded applications for ECP, such as the treatment of select autoimmune diseases, are being explored. Extracorporeal photopheresis's capacity to both immunotolerize in the autoreactive setting, while immunizing against a lymphoma is unusual and suggestive of a unique mechanism. It is likely that ECP's induction of dendritic cells is key to its efficacy in both of these settings, but exactly how ECP impacts other immune components and their interactions is not fully understood. Further basic science research is necessary to elucidate how these dissimilar cellular activities are functionally integrated. On the clinical side, collaborative multicenter trials designed to recognize the principal variables controlling therapeutic responses and improve prognostic indicators may enable tailoring devices, treatment schedules, and doses to the needs of the individual patients or diseases. This review describes our current understanding of how ECP influences the immune system, reviews the existing clinical applications of ECP, and explores areas for future basic science and clinical research as presented at the National Institutes of Health State of the Science Symposium in Therapeutic Apheresis in November 2012.
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Taverna F, Coluccia P, Arienti F, Birolini A, Terranova L, Mazzocchi A, Rini F, Mariani L, Melani C, Ravagnani F. Biological quality control for extracorporeal photochemotherapy: Assessing mononuclear cell apoptosis levels in ECP bags of chronic GvHD patients. J Clin Apher 2014; 30:162-70. [PMID: 25220858 DOI: 10.1002/jca.21357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 07/13/2014] [Accepted: 08/26/2014] [Indexed: 12/18/2022]
Abstract
Extracorporeal photochemotherapy (ECP) is a treatment approved by the FDA for cutaneous T-cell lymphoma, and it is currently used off-label for graft-versus-host disease (GvHD) and other conditions. In agreement with good practices for the therapeutic use of human cells, quality control has to be performed to validate the ECP procedure with the off-line technique. Since no gold-standard biological test is available, we assessed the apoptosis generated in the ECP bag using a flow cytometric analysis. Thirty-one ECP procedures performed on 13 patients with chronic GvHD were studied by monitoring the induction of mononuclear cell (MNC) apoptosis using annexin V/propidium iodide double staining; residual lymphocyte proliferation to standard mitogens was also measured in 17 of the procedures. The kinetics of apoptosis was analyzed at different times in MNCs untreated or treated with 8-methoxy-psoralen plus ultraviolet A; the variation (ΔAPOPTOSIS ) after 24 h revealed the efficacy of the treatment. In 88.6% of the 31 ECP procedures, ΔAPOPTOSIS was >15% (the "alerting" threshold for ΔAPOPTOSIS was set at 15% on the basis of our data); in the remainder (19.4%), the increment in apoptosis was lower. In four procedures, the proliferation assay was useful for assessing the effect of ECP on the apheretic bag. In conclusion, both flow cytometric assays enabled a biologically significant result to be obtained. In our opinion, the apoptosis test-being faster and easier than the proliferation test-could be a reliable way to validate ECP procedures.
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Affiliation(s)
- Francesca Taverna
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Paola Coluccia
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Flavio Arienti
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Annalisa Birolini
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Terranova
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Arabella Mazzocchi
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Rini
- Human Tumor Immunotherapy Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Mariani
- Clinical Epidemiology and Trial Organization Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Cecilia Melani
- Scientific Directorate, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Fernando Ravagnani
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
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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: 141] [Impact Index Per Article: 14.1] [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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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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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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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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Greinix HT, Worel N, Just U, Knobler R. Extracorporeal photopheresis in acute and chronic graft-versus-host disease. Transfus Apher Sci 2014; 50:349-57. [DOI: 10.1016/j.transci.2014.04.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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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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Hackstein H, Amoros JJV, Bein G, Woessmann W. Successful use of miniphotopheresis for the treatment of graft-versus-host disease. Transfusion 2014; 54:2022-7. [DOI: 10.1111/trf.12596] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/29/2013] [Accepted: 12/26/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Holger Hackstein
- Institute for Clinical Immunology and Transfusion Medicine; Justus-Liebig-University Giessen; Giessen Germany
| | - Jose Jaime Verdu Amoros
- Department of Pediatric Hematology and Oncology; Justus-Liebig-University Giessen; Giessen Germany
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine; Justus-Liebig-University Giessen; Giessen Germany
| | - Wilhelm Woessmann
- Department of Pediatric Hematology and Oncology; Justus-Liebig-University Giessen; Giessen Germany
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Weitz M, Strahm B, Meerpohl JJ, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2014:CD009898. [PMID: 24569961 DOI: 10.1002/14651858.cd009898.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options in these people include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE and EMBASE databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings. We also contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs can currently not be evaluated since we have found no such studies. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical grounds in favour of ECP are made, people should be carefully monitored for beneficial and harmful effects and efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- Department of Pediatrics, University of Tuebingen, Hoppe-Seyler-Strasse 1, Tübingen, Germany, 72076
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Cherqaoui B, Rouel N, Auvrignon A, Defachelles AS, Deméocq F, Kanold J, Merlin E. Peripheral blood stem cell collection in low-weight children: retrospective comparison of two apheresis devices. Transfusion 2013; 54:1371-8. [PMID: 24117598 DOI: 10.1111/trf.12448] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/20/2013] [Accepted: 08/27/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Apheresis is a major challenge in peripheral stem cell collection from low-weight children with cancer. Comparisons between the new apheresis device Optia (TerumoBCT) and the earlier COBE Spectra (CaridianBCT) have been performed in adults but not in low-weight children. The objective was to compare the performance of these two devices in small children. STUDY DESIGN AND METHODS In this retrospective study, all patients were reviewed weighing less than 15 kg undergoing stem cell collection using the Optia device between April 2011 and April 2012. They were paired on weight in a 3:1 ratio with patients whose cells had been collected with the COBE Spectra since 2006. RESULTS Six patients were treated with the Optia and were matched with 18 patients treated with the Spectra. No side effects occurred. Collection efficiency (CE) was similar between the two groups (50% vs. 47%), but CD34 cell blood clearance was lower with the Optia (0.4 mL/min/kg vs. 0.6 mL/min/kg, p < 0.01). Platelet (PLT) loss and hemoglobin (Hb) loss were significantly reduced with the Optia (respectively, 32% vs. 54%, p < 0.01; and 1.4 g/dL vs. 2.9 g/dL, p < 0.01). Apheresis duration was increased with the Optia (159 min vs. 134 min, p < 0.05). The cell product harvested with the Optia had a lower volume and lower hematocrit, but similar white blood cell and PLT content. CONCLUSION Compared with the Spectra, the Optia allows similar CE with a reduced PLT and Hb loss but with a longer duration.
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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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Cheerva A, Dillard R, Bertolone S. Extracorporeal photopheresis for the treatment of severe, refractory steroid dependent pediatric Crohn's Disease. J Clin Apher 2013; 28:381-6. [PMID: 23720057 DOI: 10.1002/jca.21275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 01/06/2013] [Accepted: 02/08/2013] [Indexed: 01/26/2023]
Abstract
Crohn's disease is a chronic, inflammatory disease of the gastrointestinal tract, affecting both children and adults. Extracorporeal photopheresis (ECP) has been used in steroid dependent adults with moderate to severely active Crohn's disease, with response rates up to 50%, with up to 25% complete responses. A 12-year-old male patient had severe unremitting Crohn's disease for one year, despite treatment with anti-inflammatory, immunosuppressive, and biologic agents. He failed elemental enteral nutrition and required total parenteral nutrition (TPN). A diverting colostomy for perforation was required. He required frequent hospitalizations and required homebound schooling. Endoscopy revealed severe inflammation and ulcerations of the entire colon. ECP was begun twice weekly for 4 weeks, then twice per week every 14 days for a total of 28 weeks. ECP was well tolerated and prednisone was gradually discontinued. He continued daily azathioprine and infliximab at 6 week intervals. TPN was weaned as enteral intake improved. Disease abatement allowed a return to school and normal activities. Endoscopy at completion of ECP course revealed normal upper tract, normal ano-rectum, and decreased, although significant, colonic disease. This response has continued for at least 16 months since completion of ECP. We conclude that ECP is useful for pediatric patients with steroid dependent Crohn's disease and prospective evaluation is warranted.
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Affiliation(s)
- Alexandra Cheerva
- Division of Hematology/Oncology, Department of Pediatrics, University of Louisville School of Medicine and Kosair Children's Hospital, Louisville, Kentucky
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Current practice in diagnosis and treatment of acute graft-versus-host disease: results from a survey among German-Austrian-Swiss hematopoietic stem cell transplant centers. Biol Blood Marrow Transplant 2013; 19:767-76. [PMID: 23376495 DOI: 10.1016/j.bbmt.2013.01.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/23/2013] [Indexed: 12/19/2022]
Abstract
To assess current clinical practice in diagnosis and treatment of acute graft-versus-host disease (aGVHD), we performed a survey among German, Austrian, and Swiss allogeneic hematopoietic stem cell transplantation (allo-HSCT) centers. Thirty-four of 72 contacted centers (47%) completed both the diagnostic and therapeutic sections of the survey, representing 65% of allo-HSCT activity within the participating countries in 2011. Three pediatric centers answered as requested only the diagnostic part of the survey. In the presence of diarrhea and decreased oral intake after engraftment, only 4 centers (12%) do not perform any endoscopy before the start of immunosuppressive treatment. In case of a skin rash with the differential diagnosis of drug reaction, only 12 centers (35%) perform a skin biopsy up front, whereas 19 do so after failure of systemic steroids. In the presence of rapidly increasing cholestasis occurring without any other signs of aGVHD, 11 centers (32%) perform a liver biopsy up front and 14 only after failure of steroid treatment, whereas 9 centers do not perform a liver biopsy at all. Twenty centers (59%) use a percutaneous approach, 12 a transvenous approach, and 1 mini-laparoscopy for liver biopsies. First-line treatment of cutaneous aGVHD stage 1 consists of topical treatment alone in 17 of 31 responding centers (61%), whereas isolated cutaneous aGVHD stage III is treated with systemic steroids (prednisolone below 0.5 mg/kg/day n = 2, 0.5 to 1.0 mg/kg/day n = 10, above 1.0 to 2.5 mg/kg/day n = 19) without or with topical agents (steroids n = 10; calcineurin inhibitors n = 3). In gastrointestinal manifestations of aGVHD, 9 centers (29%) add topical to systemic steroids, and 3 consider topical steroids as the only treatment for mild gastrointestinal and cutaneous aGVHD. The choice of agent for second-line treatment as well as the sequence of administration are extremely heterogeneous, most likely due to a lack of convincing data published. Most frequently used are mycophenolate mofetil (n = 14) and extracorporeal photopheresis (n = 10). Our survey also demonstrates that clinicians chose salvage therapies for steroid-refractory aGVHD based on their centers' own clinical experience.
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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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Extracorporeal photopheresis in 62 patients with acute and chronic GVHD: results of treatment with the COBE Spectra System. Bone Marrow Transplant 2012; 48:439-45. [PMID: 22922407 DOI: 10.1038/bmt.2012.156] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In this retrospective analysis, 30 patients with acute GVHD (aGVHD) and 32 patients with chronic GVHD (cGVHD) treated with extracorporeal photopheresis (ECP) performed by the COBE Spectra System were evaluated. After 3 months of ECP treatment, a CR and PR were observed in 9 (30%) and 6 (20%) patients with aGVHD and in 2 (6%) and 12 (38%) patients with cGVHD. In 16 (53%) patients with aGVHD and 9 (28%) with cGVHD ECP treatment was already stopped after 3 months. One (3%) patient with aGVHD and 7 (22%) patients with cGVHD received new additional immunosuppressive therapy started during the first 3 months of ECP treatment and were classified as 'nonresponder' with regard to ECP. Of these patients a PR was achieved in one patient with aGVHD and in three patients with cGVHD. Steroids could be tapered by 50 in 83% of patients with aGVHD and in 29% of patients with cGVHD after 3 months of ECP treatment. Patients with aGVHD achieving a CR or PR showed a significant improved OS after allo-SCT (P=0.019). ECP is associated with significant response rates and successful reduction of steroids in patients with GVHD.
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