Mechanisms of photochemotherapy-induced apoptotic cell death in lymphoid cells

Extracorporeal Photopheresis for Bronchiolitis Obliterans Syndrome After Lung Transplantation

BACKGROUND

Lung transplantation is a therapeutic option for select patients with end-stage lung disease. However, successful lung transplantation is hampered by chronic lung allograft dysfunction, in particular bronchiolitis obliterans syndrome (BOS). Although there is no approved or standard treatment for BOS, which may have several distinct phenotypes, extracorporeal photopheresis (ECP) has shown promising results in patients who develop BOS refractory to azithromycin treatment.

METHODS

We reviewed all relevant clinical data indexed on PubMed from 1987 to 2017 to evaluate the role of ECP in patients with BOS.

RESULTS

Seven small studies investigated the immunomodulatory effects of ECP in patients after solid organ transplant, and 12 studies reported clinical data specific to ECP therapy for BOS. Studies indicate that ECP triggers an apoptotic cellular cascade that exerts various immunomodulatory effects mediated via increases in anti-inflammatory cytokines, a decrease in proinflammatory cytokines, and an increase in tolerogenic regulatory T cells. Clinical evidence derived from relatively small single-center studies suggests that ECP therapy is associated with improvement or stabilization in lung function and sustainable, statistically significant, decreases in the rate of lung function decline in patients with BOS. Additionally, when adverse event data were reported, ECP was generally well tolerated. None of the comparative studies were randomized.

CONCLUSIONS

Immunomodulation mediated via ECP is a rational therapeutic option that may improve clinical outcomes in patients with BOS, particularly in the context of in-depth patient phenotyping as part of a stratified approach to treatment; good quality randomized controlled trials are needed to confirm observational findings.

Management of atopic dermatitis: safety and efficacy of phototherapy

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that can affect all age groups. It is characterized by a relapsing course and a dramatic impact on quality of life for patients. Environmental interventions together with topical devices represent the mainstay of treatment for AD, in particular emollients, corticosteroids, and calcineurin inhibitors. Systemic treatments are reserved for severe cases. Phototherapy represents a valid second-line intervention in those cases where non-pharmacological and topical measures have failed. Different forms of light therapy are available, and have showed varying degrees of beneficial effect against AD: natural sunlight, narrowband (NB)-UVB, broadband (BB)-UVB, UVA, UVA1, cold-light UVA1, UVA and UVB (UVAB), full-spectrum light (including UVA, infrared and visible light), saltwater bath plus UVB (balneophototherapy), Goeckerman therapy (coal tar plus UVB radiation), psoralen plus UVA (PUVA), and other forms of phototherapy. In particular, UVA1 and NB-UVB have gained importance in recent years. This review illustrates the main trials comparing the efficacy and safety of the different forms of phototherapy. No sufficiently large randomized controlled studies have been performed as yet, and no light modality has been defined as superior to all. Parameters and dosing protocols may vary, although clinicians mainly refer to the indications included in the American Academy of Dermatology psoriasis guidelines devised by Menter et al in 2010. The efficacy of phototherapy (considering all forms) in AD has been established in adults and children, as well as for acute (UVA1) and chronic (NB-UVB) cases. Its use is suggested with strength of recommendation B and level of evidence II. Home phototherapy can also be performed; this technique is recommended with strength C and level of evidence III. Phototherapy is generally considered to be safe and well tolerated, with a low but established percentage of short-term and long-term adverse effects, with the most common being photodamage, xerosis, erythema, actinic keratosis, sunburn, and tenderness. A carcinogenic risk related to UV radiation has not been excluded. Phototherapy also has some limitations related to costs, availability, and patient compliance. In conclusion, phototherapy is an optimal second-line treatment for AD. It can be used as monotherapy or in combination with systemic drugs, in particular corticosteroids. It must be performed conscientiously, especially in children, and must take into account the patient's features and overall condition.

A review of the use of tanning beds as a dermatological treatment

Introduction

In-office phototherapy is an effective treatment for many dermatologic conditions, however, many patients are unable to adhere to the rigorous travel and time commitments sometimes needed. Tanning bed facilities are nearly ubiquitous in modern society and could represent a more convenient means to obtain ultraviolet (UV) exposure when office phototherapy is not feasible. The purpose of this study was to review available evidence on the use of tanning facilities as a treatment for dermatologic conditions.

Methods

PubMed was searched on February 2015 for “tanning beds” and “phototherapy”, and with some dermatologic conditions sensitive to UV light, including “psoriasis”, “mycosis fungoides”, “acne”, “atopic dermatitis” and “eczema”. From there, further articles were found using the reference sections of the initial papers. A similar methodology was used with the Google Scholar search engine. Only articles in English and prospective studies were included in this review.

Results

We found studies validating the use of tanning facilities for psoriasis treatment. Use as a treatment option for atopic dermatitis, mycosis fungoides, acne, scleroderma, vitiligo, and pruritus, as well as other UV sensitive dermatoses, may also be beneficial. This study is limited by the lack of double-blind, placebo-controlled trials, long-term follow-up studies, and meta-analyses for tanning facility use in dermatologic phototherapy, and by the lack of standardization of both tanning facilities and exposure dosing.

Conclusion

Unsupervised sun exposure is a standard recommendation for some patients to obtain phototherapy. Selected use of commercial tanning beds in the treatment of dermatologic conditions may be another useful and effective treatment for those patients with an inability to access office-based or home-based phototherapy.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-015-0071-8) contains supplementary material, which is available to authorized users.

Modern aspects of phototherapy for atopic dermatitis

Phototherapy has still great importance in the treatment of atopic dermatitis, though costs, compliance, and long-term risks narrow its relevance. In spite of its long history, up to now, the therapeutic regimes are mostly empirical. Narrowband UVB und UVA1 are the most frequently applied regimens in atopic dermatitis with proven efficacy. However, even for these modalities randomized prospective and controlled studies are still pending. Advances in photoimmunology and molecular biology had demonstrated that phototherapy targets inflammatory cells, alters cytokine production, and has a significant antimicrobial effect within atopic skin. This paper summarizes the current literature on the different regimes of phototherapy and also discusses therapeutic modalities like photochemotherapy and extracorporeal photopheresis. These more complex regimes should be restricted to severe cases of atopic dermatitis, which are refractory to topical treatment.

Breast cancer cell survival signal is affected by bergapten combined with an ultraviolet irradiation

In this study we have reported that bergapten (B) and bergapten plus UV (PUVA) are able to significantly affect MCF-7, ZR-75 and SKBR-3 breast cancer cell proliferations. B induced a lowering of PI3K/AKT survival signal in MCF-7 cells even in presence of IGF-I stimulation. Furthermore, B and in a higher extent, PUVA up-regulated the p53 mRNA and the protein content. An increased co-association between p21 WAF and proliferating cell nuclear antigen (PCNA) has been observed in PUVA-treated MCF-7 cells, thus inhibiting DNA replication. These results highlight how B, and its photoactivated compound, exert antiproliferative effects and induce apoptotic responses in breast cancer cells.

Intracellular free calcium mediates glioma cell detachment and cytotoxicity after photodynamic therapy

Photofrin photodynamic therapy (PDT) caused a dose-dependent decrease of enzymatic cell detachment by trypsin/ethylenediamine tetra-acetic acid (EDTA) in human glioma U251n and U87 cells. This happened coincidently with the increase of intracellular free calcium ([Ca(2+)](i)). Thapsigargin, which increased [Ca(2+)](i), induced further decrease in enzymatic cell detachment and increased cytotoxicity. Opposite effects were observed when 1,2-bis(2-aminophenoxy) ethane-N,N,N',N'-tetra-acetic acid tetrakis, an intracellular Ca(2+) chelator, was used. PDT-induced changes in [Ca(2+)](i) and cell detachment were not blocked by calcium channel antagonists nickel (Ni(2+)) or nimodipine, nor were they altered when cells were irradiated in a buffer free from Ca(2+) and magnesium (Mg(2+)), suggesting that [Ca(2+)](i) is derived from the internal calcium stores. Decreased cell migration was observed after PDT, as assessed by chemotactic and wound-healing assays. Our findings indicated that internal calcium store-derived [Ca(2+)](i) plays an important role in PDT-induced enzymatic cell detachment decrease and cytotoxicity. Cell migration may be affected by these changes.

Extracorporeal photopheresis: A focus on apoptosis and cytokines

Induction of apoptosis and changes to cytokine secretion patterns have been implicated in the mechanism of action of extracorporeal photopheresis (ECP). Lymphocyte apoptosis is initially detected in significant numbers prior to re-infusion and by 48 h post-ECP the majority of treated lymphocytes are apoptotic. The early apoptosis involves changes to mitochondrial function, reversal of the Bcl-2/Bax ratio and externalisation of phosphatidylserine. Apoptotic lymphocytes, observed from 20 h post-ECP, are associated with enhanced levels of CD95 and Fas-ligand. For cutaneous T cell lymphoma (CTCL), processing of the apoptotic lymphocytes, by suitable antigen presenting cells (APCs), is suggested to induce a clonal cytotoxic response which targets the malignant T cell population. Increased levels of TNFalpha and IFNgamma, observed post-ECP in monocytes and lymphocytes, respectively, are thought to further contribute to the proposed anti-tumour reaction seen in CTCL. However, down-regulation of pro-inflammatory cytokines and enhanced anti-inflammatory responses have been reported following ECP treatment. These immune responses may contribute to the tempering of the inflammatory conditions, such as graft versus host disease, which respond to ECP. Furthermore, untreated monocytes exposed to ECP-treated lymphocytes have also demonstrated a shift in monocyte cytokine-secretory pattern, toward one associated with immune tolerance. Recently, a mechanism of ECP-induced immune tolerance has been linked to the stimulation of the anti-inflammatory cytokines IL10 and TGFbeta by T regulatory cells, following the infusion of ECP-treated CD11c(+) APCs. Ultimately, the multifaceted responses, induced by ECP, may explain the diversity of clinical conditions that benefit.

Maturation state of dendritic cells during the extracorporeal photopheresis and its relevance for the treatment of chronic graft-versus-host disease

BACKGROUND

Chronic graft-versus-host disease (cGVHD) represents a major cause of morbidity and mortality after allogeneic bone marrow transplantation (BMT). Extracorporeal photochemotherapy (ECP), a technique used in the treatment of cutaneous T-cell lymphoma, has also shown clinical efficacy in the treatment of refractory cGVHD.

STUDY DESIGN AND METHODS

In this study, the dynamics of dendritic cell (DC) activation were investigated during the process of photopheresis in patients treated for refractory cGVHD.

RESULTS

It is reported that myeloid DCs can be isolated from the photopheretic products before retransfusion to the patient. It is shown that DCs in ECP product are in the immature state with respect to the phenotypic and functional characteristics. In contrast to the in vitro-generated monocyte-derived DCs and DCs not treated by 8-methoxypsoralen and UVA, they produce significant amounts of interleukin-10 (IL-10). They efficiently capture apoptotic lymphocytes and do not induce proliferation of T lymphocytes. They preserve the capacity to be activated by polyriboinosinic polyribocytidylic acid and lipopolysaccharide, however. ECP also induces rapid and massive apoptosis of alloreactive lymphocytes. A model of the potential implication of IL-10-producing DCs in the down regulation of harmful alloreactive immune reaction is presented.

CONCLUSION

It is believed that this study provides a novel insight into the mechanisms of action of ECP in the control of cGVHD.

Mechanism of action of 4-hydroxymethyl-1,6,8-trimethylfuro[2,3-h]quinolin-2(1H)-one, a very active angular furocoumarin-like sensitizer

The molecular structure of 1,4,6,8-tetramethylfuro[2,3-h]quinolin-2(1H)-one (FQ), a recent furocoumarin-like photosensitizer, has been modified with the aim of reducing its strong genotoxicity, by replacing the methyl group at 4 position with a hydroxymethyl one, and so obtaining 4-hydroxymethyl-1,6,8-trimethylfuro[2,3-h]quinolin-2(1H)-one (HOFQ). This modification gave rise to a strong reduction of lipophilicity and dark interaction with DNA. The formation of monoadducts (MA) was deeply affected, whereas the induction of bifunctional adducts between DNA and proteins (DPC(L>0)) was replaced by an efficient production of DNA-protein cross-links at zero length (DPC(L=0)), probably via guanine damage. Because of its angular molecular structure, HOFQ does not form interstrand cross-links (ISC): therefore, DPC(L=0) and MA represent the main lesions induced by HOFQ in DNA. In comparison with FQ (which induces MA and DPC(L>0)) and 8-methoxypsoralen (8-MOP) (MA, ISC, DPC(L>0)), HOFQ seems to be a more selective agent. In fact, contrary to FQ and 8-MOP, HOFQ, together with a noticeable antiproliferative activity, shows low levels of point mutations in bacteria and of clastogenic effects in mammalian cells. HOFQ is also an efficient apoptosis inducer, especially in comparison with 8-MOP, when tested at equitoxic experimental conditions; this property might be correlated with the complete HOFQ inability of inducing skin erythemas, a well-known side effect of classic furocoumarin photosensitization.

Intracellular signaling mechanisms in photodynamic therapy

In photodynamic therapy (PDT) a sensitizer, light and oxygen are used to induce death of tumor cells and in the treatment of certain noncancerous conditions. Cell death in PDT may occur by apoptosis or by necrosis, depending on the sensitizer, on the PDT dose and on the cell genotype. Some sensitizers that have been used in PDT are accumulated in the mitochondria, and this may explain their efficiency in inducing apoptotic cell death, both in vitro and in vivo. In this review we will focus on the events that characterize apoptotic death in PDT and on the intracellular signaling events that are set in motion in photosensitized cells. Activation of phospholipases, changes in ceramide metabolism, a rise in the cytosolic free Ca2+ concentration, stimulation of nitric oxide synthase (NOS), changes in protein phosphorylation and alterations in the activity of transcription factors and on gene expression have all been observed in PDT-treated cells. Although many of these metabolic reactions contribute to the demise process, some of them may antagonize cell death. Understanding the signaling mechanisms in PDT may provide means to modulate the PDT effects at the molecular level and potentiate its antitumor effectiveness.

Mechanism of action of extracorporeal photochemotherapy in chronic graft-versus-host disease

Chronic graft-versus-host disease (GvHD) affects 50% of long-term bone marrow transplant survivors and remains a cause of major long-term morbidity in these patients despite aggressive therapy. Extracorporeal photochemotherapy (ECP), considered as an effective treatment for patients with erythrodermic cutaneous T-cell lymphoma (CTCL), has recently been used successfully in the treatment of GvHD. One of the most intriguing aspects of ECP is its ability to induce two apparently opposite effects: activation of the immune system against neoplastic cells (as in CTCL) and downregulation of the activity of T-cell clones in autoimmune diseases (as in systemic sclerosis, systemic lupus erythematosus and pemphigus vulgaris) and autoallogeneic immune responses (as in GvHD and allograft rejection). Only a better and more complete understanding of the various mechanisms involved will enable this interesting new therapy to be made more effective and selective.

Treatment of cutaneous T cell lymphoma with extracorporeal photopheresis induces Fas-ligand expression on treated T cells, but does not suppress the expression of co-stimulatory molecules on monocytes

Following extracorporeal photopheresis (ECP), lymphocytes become apoptotic and upregulate class I MHC antigenic peptides. Conversely, ECP treated monocytes demonstrate activation markers and have an increased avidity for the phagocytosis of apoptotic T cells. Processing of apoptotic T cells by monocytes, following ECP, is thought to induce an immunomodulatory response, which targets untreated, but clonal T cells. Recently we detected apoptotic lymphocytes immediately post ECP. Although enhanced CD95 (Fas) expression has been observed 24 h post ECP, CD95 and Fas-ligand (Fas-L) expression have not been determined at this very early apoptotic stage. Exposure of monocytes to UV has previously suppressed expression of the co-stimulatory molecules required for the presentation of processed antigens to T cells. Our data demonstrate no increase in CD95 or Fas-L expression on T cells tested immediately following ECP. However, the number of T cells expressing Fas-L significantly increased 24 h post ECP (P<0.005). The expression of the co-stimulatory molecules, CD54, CD80 and CD86, remained unaltered on monocytes treated by ECP. Although the mechanism responsible for early induction of lymphocyte apoptosis remains unclear, the later apoptosis involves Fas-L expression. The maintenance of co-stimulatory molecules, on treated monocytes, indicates that they retain the ability to induce an immunomodulatory response.

PUVA apoptotic response in activated and resting human lymphocytes

In extracorporeal photopheresis (ECP) collected cells are treated by 8 methoxypsoralen and UVA (PUVA) which induced apoptosis. The mechanism of action of reinfused cell is unclear. A vaccination model postulates an efficient presentation of apoptotic alloreactive cells to the patient immune system. The efficiency may depend upon a predominance of apoptotic alloreactive cells after PUVA. Such selectivity could result from their activation. We studied apoptosis in resting and PHA-activated lymphocytes. Both were equally susceptible. Changes in early apoptosis were possibly missed. We evaluated the effect of preincubation before PUVA. During preincubation monocyte could affect lymphocytes susceptibility to apoptosis as an increase of number of apoptotic cells was observed after 72 hours in stimulated and resting cells. Our findings do not preclude a selectivity of other PUVA effects since expression of membrane marker also targets to PUVA is modified by activation.

Apoptosis in leukocytes induced by UVA in the presence of 8-methoxypsoralen, chlorpromazine or 4,6,4'-trimethylangelicin

Although 8-methoxypsoralen (8-MOP) has been successfully used in extracorporeal photochemotherapy (ECP) of several T cell-mediated diseases, the exact mechanism of the drug therapeutic action has not been established. We have studied in vitro apoptotic activity of 8-MOP, and for comparison of 4,6,4'-trimethylangelicin (TMA) and chlorpromazine (CPZ) as alternative photosensitizers for potential use in photopheresis. However, while 8-MOP and CPZ are known for their immune suppressive activity, TMA does not exhibit such an activity in an animal model for ECP. Apoptosis and necrosis were measured in both Jurkat cells and primary rat leukocytes under conditions comparable to those used in the animal model to suppress contact hypersensitivity (CHS). Cells were irradiated with UVA (200 kJ/m(2)) after treatment with 8-MOP, CPZ or TMA (300 ng/ml). Flow cytometric analysis (annexin-V-FLUOS/propidium iodide) and fluorescence microscopy examinations, using acridine orange/propidium iodide, indicated that the number of cells undergoing apoptosis or necrosis increased significantly after 24 h following treatment. Similar results were observed irrespective of the cell type and photosensitizer used. The results of the present study, combined with previous observations with the animal model for ECP, suggest that apoptosis is not likely to be a critical step in the cascade of events leading to immunosuppression.

Role of immunomodulation in diseases responsive to phototherapy

Within the last two decades phototherapy has turned out to be a major therapeutic strategy in dermatology and thus has significantly influenced the treatment of many dermatoses. The goals of therapeutic photomedicine are the suppression of ongoing disease processes and, more importantly, the prevention, modulation, or abrogation of pathogenic mechanisms causing the disease. Therapeutic photomedicine has been largely empirical and most of it is still empirical today. However, parts of it are already based on the advances in photoimmunology and molecular biology. Although, we are far from a detailed understanding of the mechanisms underlying phototherapy, there is increasing evidence that phototherapy acts via modulation of the immune system. Most of the effects of both ambient and therapeutic ultraviolet radiation are immunosuppressive in nature.

Extracorporeal photopheresis induces apoptosis in the lymphocytes of cutaneous T-cell lymphoma and graft-versus-host disease patients

Extracorporeal photopheresis (ECP) is used in the treatment of T-cell-mediated disorders. However, the mechanism by which ECP achieves its effect remains illusive. Over recent years the ability of ECP to induce apoptosis has been demonstrated by cell culture experiments and retrospective histological analysis. We investigated if apoptosis could be determined in samples tested ex vivo from the UVAR:ECP system. Lymphocytes from 11 patients (six with cutaneous T-cell lymphoma, four with graft-versus-host disease, and one with scleredema) were isolated at three stages of the ECP process: immediately before ECP treatment, from the first buffy coat collected, and post UV irradiation, prior to re-infusion. Using flow cytometry each stage was tested for the early apoptotic markers; Annexin V, ApoptestTM and Carboxy-SNARF-1-AM. Comparisons of the pre-ECP and pre-infusion samples demonstrated a significant increase in apoptotic lymphocytes for all three flow cytometric techniques (P < 0.01). Increases between the pre-ECP and first buffy coat, used as a measure of the extracorporeal manipulation, were much lower. These results demonstrate that ECP directly induces significant levels of apoptosis in lymphocytes of CTCL, GvHD and scleredema patients. The apoptosis of these lymphocytes may contribute to the ECP effect.

Potentials and limitations of the natural antioxidants RRR-alpha-tocopherol, L-ascorbic acid and beta-carotene in cutaneous photoprotection

Sun exposure has been linked to several types of skin damage including sun burn, photoimmunosuppression, photoaging and photocarcinogenesis. In view of the increasing awareness of the potentially detrimental long term side effects of chronic solar irradiation there is a general need for safe and effective photoprotectants. One likely hypothesis for the genesis of skin pathologies due to solar radiation is the increased formation of reactive oxidants and impairment of the cutaneous antioxidant system. Consequently, oral antioxidants that scavenge reactive oxidants and modulate the cellular redox status may be useful; systemic photoprotection overcomes some of the problems associated with the topical use of sunscreens. Preclinical studies amply illustrate the photoprotective properties of supplemented antioxidants, particularly RRR-alpha-tocopherol, L-ascorbate and beta-carotene. However, clinical evidence that these antioxidants prevent, retard or slow down solar skin damage is not yet convincing. The purpose of this review is to provide the reader with current information on cutaneous pathophysiology of photoxidative stress, to review the literature on antioxidant photoprotection and to discuss the caveats of the photo-oxidative stress hypothesis.

PUVA inhibits DNA replication, but not gene transcription at nonlethal dosages

The combination of psoralens and UVA radiation (PUVA photochemotherapy) is an established treatment for many skin disorders. UVA-induced psoralen-DNA interactions are assumed to contribute to the cutaneous anti-inflammatory and anti-proliferative effects of PUVA. PUVA-induced DNA modifications might interfere not only with DNA replication, but also with gene transcription of proinflammatory genes. We therefore studied the effect of PUVA on cell proliferation and on the transcription of the c-jun and intercellular adhesion molecule-1 genes in a promyelocytic (HL60) and a keratinocyte (HaCaT) cell line. PUVA inhibited cell proliferation increasingly with increasing 8-methoxypsoralen concentrations or UVA doses. The inhibition was observed at conditions not affecting cell viability up to 48 h after PUVA. In contrast, PUVA did not inhibit gene transcription at anti-proliferative, yet nonlethal conditions. Baseline and phorbol-ester induced c-jun mRNA expression was not inhibited, nor was baseline and IFN-gamma or phorbol-ester induced intercellular adhesion molecule-1 mRNA expression. In order to assess possible transcriptional effects of PUVA-generated reactive oxygen intermediates, the reactive oxygen intermediates-sensitive transcription factor nuclear factor kappaB was assayed in mobility shift experiments. Nuclear factor kappaB-specific binding activity was not induced 1-24 h after PUVA in extracts from PUVA-treated cells when compared with controls, whereas the pro-oxidant cytokine TNF-alpha caused a marked increase in nuclear factor kappaB binding. The presented data suggest that PUVA inhibits cell proliferation, but not transcription, at nonlethal PUVA conditions. Furthermore, the data do not support a major role for PUVA-generated reactive oxygen intermediates in the regulation of gene transcription.

Therapeutic photoimmunology: photoimmunological mechanisms in photo(chemo)therapy

Ultraviolet radiation, either alone or in combination with photosensitizing agents, is widely used for the treatment of skin diseases. The efficacy of photo- and photochemotherapeutic modalities is thought to result, at least in part, from the induction of immunomodulatory effects. In particular, UV radiation has been shown to affect (i) the production of soluble mediators, (ii) the expression of cell-surface receptors and (iii) to induce apoptosis in pathogenetically relevant cells. UVB radiation-induced immunomodulatory effects are limited to the epidermis, whereas UVA radiation affects both epidermal and dermal cell populations. UVB and UVA radiation can exert essentially identical immunomodulatory effects, which result, however, from different photobiological mechanisms.

Different DNA repair time courses in human lymphoid cells after UVA, UVA1, UVB and PUVA in vitro

The time course of DNA repair was investigated using the nucleoid sedimentation technique. Human lymphoid cells were irradiated with membrane related equitoxic doses of UVB, UVA/B, UVA and UVA1. Additionally, PUVA treatment of cells using two different light sources was performed. It was found that in the case of UVB and UVA/B irradiation of the cells, DNA repair activity arose lasting not longer than 4 h. However, in the case of UVA and UVA1 no repair activity was detectable with the used method but an increasing nucleoid density believed to indicate apoptosis. This could be shown with the same irradiation protocol. When the irradiation dose of UVA and UVA1 was lowered to one fifth of the equitoxic dose neither repair activity nor apoptosis was detected. There was no difference between UVA and UVA1 with respect to the nucleoid density time course. Hence, the initial absorbing chromophore is probably located in the UVA1 region. In the case of PUVA, we found DNA repair that was complete after 12 h. The UVB part in the irradiation spectrum of a PUVA system had an accelerating effect on the repair kinetics. The time course of DNA density appears to be related to subsequent cell behaviour: apoptosis or incomplete DNA repair including the risk of mutation.

Clinical and mechanistic aspects of photopheresis

Photopheresis is an extracorporeal form of photochemotherapy with 8-methoxypsoralen (8-MOP) and ultraviolet A (UVA) radiation. Photopheresis is used for the management of T-cell-mediated diseases, and such treatment leads to the induction of antigen-specific immune suppression directed to the pathogenic clone of T cells. Photopheresis is used to treat a wide variety of diseases--such as cutaneous T-cell lymphoma, systemic sclerosis; rheumatoid arthritis, lupus erythematosus--and is also successfully applied in the suppression of graft rejection. In addition to the clinical achievements, attention will be paid to results from animal studies. An important outcome of these studies is that photopheresis can be used to treat airway hyperreactivity. Furthermore, it was shown that the therapeutic strategy can be changed drastically: the presence of plasma during irradiation should be avoided and the amount of blood that must be treated to obtain the desired antigen-specific immunosuppression can be greatly decreased. Also, results from cellular experiments are discussed. An example of this is the increase in the major histocompatibility complex expression on the surface of cells found after treatment. The mechanism that underlies photopheresis has not yet been elucidated, but progress has been made. The following related points will be reviewed: models for investigation; and mechanistic aspects, with the emphasis on cellular biomacromolecules and on photosensitizers (drugs) other than 8-MOP.

Singlet oxygen producing photosensitizers in photophoresis

In this study, the immunosuppressive properties of two photosensitizers (benzoporphyrin derivative monoacid ring A (BPD) and Photofrin (HPD)), used for the photodynamic therapy of cancer, were investigated. The investigations were performed in our rat model for photophoresis. The validity of this model has been amply demonstrated. It enables a distinction to be made between antigen-specific and antigen non-specific immune suppression. With this model, the immune response which can be specifically suppressed is the contact hypersensitivity (CHS). CHS is induced by 2,4-dinitrofluorobenzene (DNFB). Both BPD and HPD are able to suppress CHS induced by DNFB. Furthermore, this generated suppression is transferable by the spleen cells of treated animals and is antigen non-specific.

Extracorporeal photochemotherapy (photopheresis) induces apoptosis in lymphocytes: a possible mechanism of action of PUVA therapy

The mechanism of action of psoralen plus UVA (PUVA) and photopheresis is not entirely understood. These therapies are assumed to be immunomodulating partly by gradually decreasing leukocyte viability. We investigated whether this delayed form of cell death was due to apoptosis. Untreated and treated (PUVA exposed) leukocytes obtained from six patients with systemic sclerosis and (untreated) leukocytes from healthy control individuals were studied. Qualitative gel electrophoresis and quantitative in situ nick translation analysis of DNA fragmentation was performed. Apoptosis of the treated cells did occur (gel electrophoresis) after 24 h. At t = 0 h, immediately after exposure to PUVA, there was no evidence of DNA fragmentation in the treated cells. The percentage of treated cells undergoing apoptosis was 20-55% at t = 24 h (in situ nick translation). The untreated leukocytes of the patients and the healthy individuals showed no distinctive rise in apoptotic cells. Apoptosis of the leukocytes after PUVA or photopheresis treatment might be a mechanism of action and might explain the therapeutic response.

Apoptosis induction of ultraviolet light A and photochemotherapy in cutaneous T-cell Lymphoma: relevance to mechanism of therapeutic action

The anti-tumor action of many chemotherapeutic agents has recently been attributed to the induction of apoptosis in the malignant cell population. In this study, we investigated the ability of extracorporeal photopheresis (ExP) and in vitro PUVA (8-methoxy-psoralen + ultraviolet A) therapy to induce apoptosis in peripheral blood mononuclear cells from Sezary syndrome patients and normal controls. Flow cytometric analysis of ExP- or PUVA-treated peripheral blood lymphocytes demonstrated two distinct cell populations within 24 h of treatment. One population was similar to untreated controls with the other exhibiting characteristics of apoptotic cell death, i.e., a loss of cell volume and an accompanying increase in cell density. This latter population was comprised of cells with DNA strand breaks as determined by the Tdt-mediated deoxyuridine triphosphate-biotin nick end labeling assay. Apoptosis was also confirmed morphologically by fluorescent and electron microscopy as well as by demonstration of characteristic DNA strand breaks (laddering) using gel electrophoresis. Apoptosis was not observed with 8-methoxypsoralen (< or = 300 ng per ml) alone; however, ultraviolet A alone at doses > or = 2 J per cm2 induced apoptosis in lymphocytes. Peripheral blood T-cell subpopulations of Sezary syndrome patients, including the malignant clone, were equally susceptible to apoptosis subsequent to either photopheresis or PUVA treatment. In contrast, monocytes (CD14+/CD45+) appear to be resistant to apoptosis induction by ExP or PUVA treatment. Moreover, ExP-treated and untreated monocytes phagocytized apoptotic, but not untreated, peripheral blood mononuclear cells. ExP and PUVA have been shown to be efficacious and well-tolerated therapies in the treatment of dermatologic diseases and transplant rejection. These data suggest that induction of apoptosis may be an important event for therapeutic efficacy.

Kinetic analysis of apoptosis induction in human cell lines by UVA and 8-MOP

Whereas previous studies have indicated that DNA damage as a result of 8-methoxypsoralen (8-MOP) and UVA treatment leads to cell death, this study establishes the minimum concentrations of 8-MOP and UVA necessary to induce apoptosis in human T-lymphocytic and monocytic cell lines. In order to asses apoptosis, we used fluorescent microscopy to examine changes in light scattering as well as internucleosomal DNA fragmentation. Generation of a dose response curve showed that the minimum combination of UVA and 8-MOP that was necessary to induce greater than background levels of apoptosis within 24 h of treatment was 0.5 J/cm2 UVA and 12.5 ng/mL of 8-MOP. A striking observation was that UVA alone at doses > or = 1.0 J/cm2, but not 8-MOP alone (0-300 ng/mL), induced significant apoptosis in the Sup-T1 cells induced by UVA alone was not as great as that of 8-MOP and UVA in combination, a highly significant correlation between the product of the concentration of 8-MOP (ng/mL) times the dose of UVA (J/cm2) and the percentage of apoptotic cells was observed. This correlation provides an important tool for studying the relationship of UVA-induced DNA damage to apoptosis induction. moreover, it will provide a means by which early events in the apoptotic pathway can be dissected.