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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: 45] [Impact Index Per Article: 11.3] [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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Ni X, Austin M, Langridge T, Bojaxhi P, Bijani P, Wang X, Duvic M. CD209 + monocyte-derived myeloid dendritic cells were increased in patients with leukemic cutaneous T-cell lymphoma undergoing extracorporeal photopheresis via the CELLEX TM system. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2020; 36:290-298. [PMID: 32187738 DOI: 10.1111/phpp.12552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/21/2020] [Accepted: 03/13/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND/PURPOSE We previously reported that myeloid dendritic cells (mDC) were increased in patients with leukemic cutaneous T-cell lymphoma (L-CTCL) following extracorporeal photopheresis (ECP) using the Therakos UVAR XTS™ system. We now assessed monocyte-derived mDCs (Mo-DCs) in L-CTCL patients treated with the CELLEXTM photopheresis system. CD209, a transmembrane receptor, was used to define Mo-DCs. METHODS Peripheral blood samples from baseline pre-ECP and at Day 2, 1 month, 3 months, and 6 months post-ECP were analyzed by flow cytometry for Lin- HLA-DR+ CD123+ plasmacytoid dendritic cells (pDCs), Lin- HLA-DR+ CD11c+ mDCs, and CD209+ mDCs. The expression of CD209 mRNA was assessed by real-time PCR. RESULTS At baseline, 7 of 19 patients had lower than normal mDCs, and all patients had lower than normal CD209+ mDCs in peripheral blood mononuclear cells (0.005% in patients, n = 19, vs 0.50% in healthy donors, n = 7, P < .0001). The CD209+ mDC numbers only accounted for 3.28% out of total mDCs in patients compared with 66.51% in healthy donors. After treatment, the CD209+ mDC numbers showed increasing trends in patients. The average absolute numbers of CD209+ mDCs went up by 4.8-fold at 3 months (n = 10, P = .103) and by 6.4-fold at 6 months (n = 9, P = .100). CD209 mRNA expression went up in two patients responsive to therapy, parallel to CD209+ mDC numbers. L-CTCL patients achieved 70% overall clinical response rate (7/10) following ECP therapy with the CELLEXTM system. CONCLUSIONS Our results suggest that the CELLEXTM photopheresis system is effective for treating L-CTCL patients like the UVAR XTS™ system, and in vivo-generated Mo-DCs increase following ECP.
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Affiliation(s)
- Xiao Ni
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Austin
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy Langridge
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pierr Bojaxhi
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedram Bijani
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaohong Wang
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Madeleine Duvic
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Ying Z, Shiue L, Park K, Kollet J, Bijani P, Goswami M, Duvic M, Ni X. Blood transcriptional profiling reveals IL-1 and integrin signaling pathways associated with clinical response to extracorporeal photopheresis in patients with leukemic cutaneous T-cell lymphoma. Oncotarget 2019; 10:3183-3197. [PMID: 31139332 PMCID: PMC6516711 DOI: 10.18632/oncotarget.26900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/14/2019] [Indexed: 01/07/2023] Open
Abstract
Extracorporeal photopheresis (ECP) is a frontline therapy for patients with leukemic cutaneous T-cell lymphoma (L-CTCL), but its mechanisms of action are not fully understood. This study was to explore the molecular mechanisms underlying clinical response versus non-response in patients with L-CTCL. We performed blood transcriptional profiling of ten L-CTCL patients at Day 2 and 1 month post- ECP compared to pre-ECP baseline using Agilent Whole Human Genome Microarray technology. Differentially expressed genes (DEGs) between five clinically-responsive patients and five clinically-resistant patients were cross-compared. Higher numbers of genes were modulated in responders than non-responders after ECP at both Day 2 and 1 month, with two thirds of DEGs down-regulated. The down-regulated DEGs at 1 month post-ECP were related to inflammatory, immune and/or stress responses, platelet functions, and chromatin remodeling. Upregulated DEGs were mainly related to functions of the nucleolus. Pathway analysis revealed that integrin and IL-1 signaling pathways were the top pathways affected in responders, which were minimally affected in non-responders. The top upstream transcription regulators affected were IL1B, EGR1, FAS, and TGFB1. Our results suggest that the modulation of cell adhesion and suppression of IL-1β induced inflammation may underlie the efficacy of ECP in L-CTCL.
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Affiliation(s)
- Zuolin Ying
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lisa Shiue
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Katherine Park
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jutta Kollet
- Bioinformatics, Miltenyi Biotec GmbH, Beigisch Gladbach, 51429, Germany
| | - Pedram Bijani
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Meghali Goswami
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Madeleine Duvic
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xiao Ni
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Geskin L, Malone DC. An exploratory cost-effectiveness analysis of systemic treatments for cutaneous T-cell lymphoma. J DERMATOL TREAT 2017; 29:522-530. [DOI: 10.1080/09546634.2017.1412064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Larisa Geskin
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA
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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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6
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Shiue LH, Couturier J, Lewis DE, Wei C, Ni X, Duvic M. The effect of extracorporeal photopheresis alone or in combination therapy on circulating CD4(+) Foxp3(+) CD25(-) T cells in patients with leukemic cutaneous T-cell lymphoma. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2015; 31:184-94. [PMID: 25772268 DOI: 10.1111/phpp.12175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE Extracorporeal photopheresis (ECP) alone or in combination therapy is effective for treatment of leukemic cutaneous T-cell lymphoma (L-CTCL), but its mechanism(s) of action remain unclear. This study was designed to investigate the effect of ECP on regulatory T cells and CD8(+) T cells in L-CTCL patients. EXPERIMENTAL DESIGN Peripheral blood from 18 L-CTCL patients at baseline, Day 2, 1 month, 3 month, and 6 month post-ECP therapy was analyzed by flow cytometry for CD4(+) CD25(+/high) , CD4(+) Foxp3(+) CD25(+/-) , CD3(+) CD8(+) , CD3(+) CD8(+) CD69(+) , and CD3(+) CD8(+) IFN-γ(+) T cells. Clinical responses were assessed and correlated with changes in these T-cell subsets. RESULTS Twelve of 18 patients achieved clinical responses. The average baseline number of CD4(+) CD25(+/high) T cells of PBMCs in L-CTCL patients was normal (2.2%), but increased at 6-month post-therapy (4.3%, P < 0.01). The average baseline number of CD4(+) Foxp3(+) T cells out of CD4(+) T cells in nine evaluable patients was high (66.8 ± 13.7%), mostly CD25 negative. The levels of CD4(+) Foxp3(+) T cells in responders were higher (n = 6, 93.1 ± 5.7%) than nonresponders (n = 3, 14.2 ± 16.0%, P < 0.01), and they declined in parallel with malignant T cells. The numbers of CD3(+) CD8(+) CD69(+) and CD3(+) CD8(+) IFN-γ(+) T cells increased at 3-month post-therapy in five of six patients studied. CONCLUSIONS Extracorporeal photopheresis alone or in combination therapy might be effective in L-CTCL patients whose malignant T cells have a CD4(+) Foxp3(+) CD25(-) phenotype.
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Affiliation(s)
- Lisa H Shiue
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate Program in Immunology, Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jacob Couturier
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA.,Graduate Program in Virology, Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dorothy E Lewis
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA.,Graduate Program in Virology, Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Caimiao Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiao Ni
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate Program in Immunology, Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Madeleine Duvic
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Graduate Program in Immunology, Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
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Duvic M. Choosing a systemic treatment for advanced stage cutaneous T-cell lymphoma: mycosis fungoides and Sézary syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:529-544. [PMID: 26637769 DOI: 10.1182/asheducation-2015.1.529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Madeleine Duvic
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX
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8
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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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9
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Quaglino P, Knobler R, Fierro MT, Savoia P, Marra E, Fava P, Bernengo MG. Extracorporeal photopheresis for the treatment of erythrodermic cutaneous T-cell lymphoma: a single center clinical experience with long-term follow-up data and a brief overview of the literature. Int J Dermatol 2013; 52:1308-18. [PMID: 23786842 DOI: 10.1111/ijd.12121] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Extracorporeal photopheresis (ECP) is a therapeutic procedure in which leukapheresed peripheral blood mononuclear cells are exposed to ultraviolet A in the presence of the photosensitizer 8-methoxypsoralen and then reinfused. Several guidelines recommend ECP as a treatment of choice in erythrodermic primary cutaneous T-cell lymphomas (E-CTCL). However, the level of evidence is low due to the rarity of this disease and the lack of randomized controlled trials. We performed a review of the English literature, restricting our analysis to studies including erythrodermic patients and more than 10 cases. Based on these criteria, we identified 28 studies, with a total of 407 patients. The median response rate in erythrodermic patients was 63% (range 31-86%), with a complete response rate ranging between 0 and 62% (median 20%). In our experience, we treated 51 patients with E-CTCL since 1992. A clinical response was obtained in 32 of 51 patients (63%), with a 16% complete response rate. The median time for response induction was eight months (range: 1-23). The median response duration was 22.4 months (range six months to 11 years). The treatment was generally well tolerated without systemic toxicities grade III-IV. The pretreatment parameters significantly associated with a higher likelihood to obtain a clinical response were the B-score in the peripheral blood, CD4/CD8 ratio, and amount of circulating CD3+CD8+ cells. Literature data together with our personal experience clearly support the clinical activity and tolerability of ECP in patients with E-CTCL. Prospective controlled clinical trials are strongly recommended to better document the evidence.
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Affiliation(s)
- Pietro Quaglino
- Department of Medical Sciences and Human Oncology, Section of Dermato-Oncology, University of Turin, Turin, Italy
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11
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The role of extracorporeal photopheresis in the treatment of cutaneous T-cell lymphomas. Transfus Apher Sci 2011; 46:195-202. [PMID: 22067605 DOI: 10.1016/j.transci.2011.10.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/13/2011] [Indexed: 11/20/2022]
Abstract
Extracorporeal photochemotherapy (ECP) is an effective treatment modality for patients with erythrodermic myocosis fungoides (MF) and Sezary syndrome (SS). During ECP, a fraction of peripheral blood mononuclear cells is collected, incubated ex-vivo with methoxypsoralen, UVA irradiated, and finally reinfused to the patient. Although the mechanism of action of ECP is not well established, clinical and laboratory observations support the hypothesis of a vaccination-like effect. ECP induces apoptosis of normal and neoplastic lymphocytes, while enhancing differentiation of monocytes towards immature dendritic cells (imDCs), followed by engulfment of apoptotic bodies. After reinfusion, imDCs undergo maturation and antigenic peptides from the neoplastic cells are expressed on the surface of DCs. Mature DCs travel to lymph nodes and activate cytotoxic T-cell clones with specificity against tumor antigens. Disease control is mediated through cytotoxic T-lymphocytes with tumor specificity. The efficacy and excellent safety profile of ECP has been shown in a large number of retrospective trials. Previous studies showed that monotherapy with ECP produces an overall response rate of approximately 60%, while clinical data support that ECP is much more effective when combined with other immune modulating agents such as interferons or retinoids, or when used as consolidation treatment after total skin electron beam irradiation. However, only a proportion of patients actually respond to ECP and parameters predictive of response need to be discovered. A patient with a high probability of response to ECP must fulfill all of the following criteria: (1) SS or erythrodermic MF, (2) presence of neoplastic cells in peripheral blood, and (3) early disease onset. Despite the fact that ECP has been established as a standard treatment modality, no prospective randomized study has been conducted so far, to the authors' knowledge. Considering the high cost of the procedure, the role of ECP in the treatment of SS/MF needs to be clarified via well designed multicenter prospective randomized trials.
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12
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Sézary syndrome: Immunopathogenesis, literature review of therapeutic options, and recommendations for therapy by the United States Cutaneous Lymphoma Consortium (USCLC). J Am Acad Dermatol 2011; 64:352-404. [DOI: 10.1016/j.jaad.2010.08.037] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 08/10/2010] [Accepted: 08/30/2010] [Indexed: 11/19/2022]
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Prince HM, Duvic M, Martin A, Sterry W, Assaf C, Sun Y, Straus D, Acosta M, Negro-Vilar A. Phase III Placebo-Controlled Trial of Denileukin Diftitox for Patients With Cutaneous T-Cell Lymphoma. J Clin Oncol 2010; 28:1870-7. [DOI: 10.1200/jco.2009.26.2386] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This phase III, placebo-controlled, randomized trial was designed to investigate efficacy and safety of two doses of denileukin diftitox (DD; DAB389–interleukin-2 [IL-2]), a recombinant fusion protein targeting IL-2 receptor–expressing malignant T lymphocytes, in patients with stage IA to III, CD25 assay–positive cutaneous T-cell lymphoma (CTCL), including the mycosis fungoides and Sézary syndrome forms of the disease, who had received up to three prior therapies. The primary end point was overall response rate (ORR). Patients and Methods Patients (N = 144) with biopsy-confirmed, CD25 assay–positive CTCL were randomly assigned to DD 9 μg/kg/d (n = 45), DD 18 μg/kg/d (n = 55), or placebo infusions (n = 44), administered for 5 consecutive days every 3 weeks for up to eight cycles. Patients were monitored for drug efficacy, clinical benefit, and safety of DD. Results ORR was 44% for all participants treated with DD (n = 100; 10% complete response [CR] and 34% partial response [PR]) compared with 15.9% for placebo-treated patients (2% CR and 13.6% PR). ORR was higher in the 18 μg/kg/d group versus the 9 μg/kg/d group (49.1% v 37.8%, respectively), and both doses were significantly superior to placebo. Progression-free survival (PFS) was significantly longer (median, > 2 years) for both DD doses compared with placebo (median, 124 days; P < .001). Rates of moderately severe and severe adverse events (AEs) were slightly higher in the DD groups, whereas moderate and mild AEs were similar to placebo. No statistical differences were observed for drug-related serious AEs. Conclusion DD had a significant and durable effect on ORR and PFS with an acceptable safety profile in patients with early- and late-stage CTCL.
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Affiliation(s)
- H. Miles Prince
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Madeleine Duvic
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Ann Martin
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Wolfram Sterry
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Chalid Assaf
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Yijun Sun
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - David Straus
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Mark Acosta
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
| | - Andres Negro-Vilar
- From the Peter MacCallum Cancer Centre; University of Melbourne, Melbourne, Victoria, Australia; Skin Cancer Center Charité, Universitätsmedizin, Berlin; Department of Dermatology, HELIOS Klinikum Krefeld, Krefeld, Germany; The University of Texas M.D. Anderson Cancer Center, Houston, TX; Washington University School of Medicine, St Louis, MO; Eisai, Woodcliff Lake, NJ; Memorial Sloan-Kettering Cancer Center, New York, NY; and TransMed Institute, Washington, DC
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14
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Booken N, Weiss C, Utikal J, Felcht M, Goerdt S, Klemke CD. Combination therapy with extracorporeal photopheresis, interferon-alpha, PUVA and topical corticosteroids in the management of Sézary syndrome. J Dtsch Dermatol Ges 2010; 8:428-38. [PMID: 20180887 DOI: 10.1111/j.1610-0387.2010.07319.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is recommended for the treatment of Sézary syndrome (SS), the leukemic variant of cutaneous T-cell lymphoma (CTCL). Several combination therapies are used to increase response rates to ECP. PATIENTS AND METHODS We report our experience with the combination therapy of ECP, interferon-alpha, PUVA and topical corticosteroids in SS. RESULTS The treatment outcome in 12 SS patients was retrospectively analyzed and showed an overall response rate to this combination treatment of 42 % with 4/12 patients achieving a partial remission and 1/12 patients a stable disease. The median overall survival time was 42 months. We investigated several clinical and laboratory parameters as an indicator for a response to treatment in our patient cohort. A combined analysis of the erythroderma assessment scale, WBC, LDH, CD4/CD8 ratio and the number of Sézary cells revealed that a reduction of several parameters significantly correlated with response to treatment. The parameters which correlated best with response were number of Sézary cells, CD4/CD8 ratio and WBC. CONCLUSIONS The investigated combination therapy was effective and well-tolerated in a subgroup of SS patients but needs to be evaluated in a larger patient population.
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Affiliation(s)
- Nina Booken
- Department of Dermatology, Venereology and Allergology, University Medical Centre Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany.
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15
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16
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Berger CL, Edelson RL. Current Concepts of the Immunobiology and Immunotherapy of Cutaneous T Cell Lymphoma: Insights Gained through Cross-talk between the Clinic and the Bench. Leuk Lymphoma 2009; 44:1697-703. [PMID: 14692521 DOI: 10.1080/1042819031000104033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
An understanding of the immunologic features of cutaneous T cell lymphoma (CTCL) has led to insights into the life cycle of the malignancy. The identification of the T cell lineage of the neoplastic CTCL cells has allowed unification of diverse clinical presentations under a single entity. The CD4 inducer T cell phenotype of the malignant cells has provided an understanding of the patient's ability to resist infection with certain bacteria. The clonality of the tumor cells, beyond its diagnostic implications, has made them a valuable resource for studying both normal and neoplastic T cell biology. The recently identified immunosuppressive features of the malignant T cells and their dependency for survival on an interaction with immature dendritic cells have explained previously cryptic clinical observations and identified new targets for immunotherapy. Future insights gained both from the bedside and the bench will provide not only an understanding of the immunobiology of the malignancy but also open new avenues for therapeutic intervention.
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Affiliation(s)
- Carole L Berger
- Department of Dermatology, School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510-8059, USA.
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17
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Extracorporeal Photopheresis in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70102-7] [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] Open
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18
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Ni X, Richmond HM, Liao XM, Decker WK, Shiue LH, Shpall EJ, Duvic M. Induction of T-cell responses against cutaneous T-cell lymphomas ex vivo by autologous dendritic cells transfected with amplified tumor mRNA. J Invest Dermatol 2008; 128:2631-2639. [PMID: 18480841 DOI: 10.1038/jid.2008.125] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Sézary syndrome (SzS), the leukemic variant of cutaneous T-cell lymphomas, is incurable. Dendritic cells (DCs) transfected with tumor mRNA can stimulate antitumor immunity in certain cancer patients. In this study, we determined whether mRNAs from Sézary cells could be used for loading DCs and stimulating antitumor immunity. Autologous DCs were generated from monocytes of the peripheral blood from 10 patients with SzS. Total RNA was extracted from Sézary cells and amplified by T7 in vitro transcription. The induction of antitumor IFN-gamma and granzyme B (GrB)-producing cytotoxic T lymphocytes (CTL) by RNA-transfected DCs was determined by ELISPOT assays. We found that IFN-gamma was required for IL-12p70 production by monocyte-derived DCs from SzS. The oncogenic transcription factor Twist and the tyrosine kinase receptor EphA4 were expressed in total RNA from Sézary cells and the paired amplified mRNAs. RNA-transfected DCs induced antitumor IFN-gamma-producing CTLs in 7 of 10 subjects and GrB-producing CTLs in 6 of 9 subjects. Both CD3+CD8+ T cells and CD4+CD25+ T cells were expanded without induction of regulatory T cells. These data support the concept of using tumor mRNA for a vaccine strategy that requires small amounts of tumor cells without need for specific antigens in patients with SzS.
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Affiliation(s)
- Xiao Ni
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Heather M Richmond
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Xingsheng M Liao
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA; Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - William K Decker
- Department of Stem Cell Transplantation and Cell Therapy, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Lisa H Shiue
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cell Therapy, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Madeleine Duvic
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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19
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Scarisbrick J, Taylor P, Holtick U, Makar Y, Douglas K, Berlin G, Juvonen E, Marshall S. U.K. consensus statement on the use of extracorporeal photopheresis for treatment of cutaneous T-cell lymphoma and chronic graft-versus-host disease. Br J Dermatol 2008; 158:659-78. [DOI: 10.1111/j.1365-2133.2007.08415.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Perseghin P. Extracorporeal Photochemotherapy as a Challenging Treatment for Cutaneous T-Cell Lymphoma, Acute and Chronic Graft-versus-Host Disease, Organ Rejection and T-Lymphocyte-Mediated Autoimmune Diseases. Transfus Med Hemother 2007; 35:8-17. [PMID: 21547105 DOI: 10.1159/000111755] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 10/09/2007] [Indexed: 11/19/2022] Open
Abstract
SUMMARY: 20 years ago, in 1987, Edelson and co-workers published their first report on the effectiveness of a new procedure, called extracorporeal photochemotherapy (ECP), in patients with advanced stage cutaneous T-cell lymphoma (CTCL). The positive response (>70% overall) achieved in those patients encouraged several groups to try out this new technology in other T-lymphocyte-mediated autoimmune diseases and a number of dermatological diseases, which sometimes gave conflicting results. In the following years, ECP obtained FDA approval as first line treatment in CTCL. In the 1990s ECP was applied to acute and chronic graft-versus-host disease (GvHD) refractory to conventional immunosuppressive therapy and proved to be effective in >60% of cases of this larger patient population. Today, although the effectiveness of ECP in GvHD is generally acknowledged, this is mainly based on retrospective or observational studies, as data from large, randomized multicenter trials, has yet to be published. Moreover, ECP's real mechanism of action and optimal treatment schedule are still under investigation. The aim of this review is to summarize knowledge acquired to date about ECP.
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Affiliation(s)
- Paolo Perseghin
- U.O.S. Aferesi e nuove tecnologie trasfusionali-Laboratorio di criobiologia, Dipartimento di Patologia Clinica-Servizio di immunoematologia e Trasfusionale, Ospedale San Gerardo de' Tintori, Monza, Italy
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21
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Abstract
A large body of evidence establishing the existence of an underlying T-cell disorder in a subset of patients fulfilling hypereosinophilic syndrome (HES) diagnostic criteria has accumulated over the past decade, resulting in the definition of a novel HES variant termed "lymphocytic" HES. Although end-organ complications of hypereosinophilia are generally benign, with predominant cutaneous manifestations, long-term prognosis is overshadowed by an increased risk of developing T-cell lymphoma, as a result of malignant transformation of aberrant T cells years after HES diagnosis. Therapeutic strategies should target pathogenic T cells in addition to eosinophils, but the practical implications remain largely unexplored.
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Affiliation(s)
- Florence Roufosse
- Department of Internal Medicine, Erasme Hospital, Université Libre de Bruxelles, 808 Route de Lennik, B-1070 Brussels, Belgium.
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22
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McKenna KE, Whittaker S, Rhodes LE, Taylor P, Lloyd J, Ibbotson S, Russell-Jones R. Evidence-based practice of photopheresis 1987-2001: a report of a workshop of the British Photodermatology Group and the U.K. Skin Lymphoma Group. Br J Dermatol 2005; 154:7-20. [PMID: 16403088 DOI: 10.1111/j.1365-2133.2005.06857.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Photopheresis or extracorporeal photochemotherapy (ECP) is a novel immunomodulatory therapy which involves separation of the patient's leucocyte-rich plasma, followed by ex vivo administration of a photosensitizer and ultraviolet A radiation, before reinfusion. ECP has been used successfully for the treatment of cutaneous T-cell lymphoma (CTCL: Sézary syndrome), graft-versus-host disease (GVHD) and cardiac transplant rejection. ECP has a dose-sparing effect on concurrent immunosuppressive therapy. The procedure induces apoptosis of the irradiated lymphocytes, but the exact mechanism by which ECP exerts its therapeutic effect in these different conditions is uncertain. The treatment has very few adverse effects and in particular is not associated with an increased incidence of opportunistic infections. The evidence for the efficacy of ECP has been appraised by a combined British Photodermatology Group and U.K. Skin Lymphoma Group workshop on the basis of evidence published up to the end of 2001 and on the consensus of best practice. There is fair evidence for the use of ECP in erythrodermic CTCL and steroid-refractory GVHD, but randomized controlled studies are needed. There is good evidence supporting the use of ECP in preventing cardiac rejection following transplantation. Randomized controlled trials have also shown a therapeutic benefit in type 1 diabetes mellitus, but the inconvenience associated with the procedure outweighed the clinical benefit. There is fair evidence not to use ECP for the treatment of systemic sclerosis and multiple sclerosis, and good evidence not to use ECP for other forms of CTCL.
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Affiliation(s)
- K E McKenna
- Department of Dermatology, Belfast City Hospital, Belfast, UK.
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Umeh OC, Kubak BM, Pegues DA, Leibowitz MR, Froch L. Corynebacterium jeikeium sepsis after 8-methoxypsolaren photopheresis for cutaneous T-cell lymphoma. Diagn Microbiol Infect Dis 2004; 50:71-2. [PMID: 15380280 DOI: 10.1016/j.diagmicrobio.2004.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Accepted: 05/10/2004] [Indexed: 10/26/2022]
Abstract
We describe a patient with cutaneous T-cell lymphoma who developed Corynebacterium jeikeium sepsis after experimental treatment with 8-methoxypsolaren. The epidemiology and clinical features of C. jeikeium infection are discussed. The patient was successfully treated with intravenous vancomycin without recurrence.
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Girardi M, Knobler R, Edelson R. Selective immmunotherapy through extracorporeal photochemotherapy: yesterday, today, and tomorrow. Hematol Oncol Clin North Am 2003; 17:1391-403. [PMID: 14710891 DOI: 10.1016/s0889-8588(03)00106-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
ECP's extensive clinical record, as well as a considerable improvement in the understanding of the mechanism that underlies its efficacy, opens potential novel strategies for the treatment of cancer, GVHD, transplant rejection, and autoimmunity. The low side effect profile of this therapy has made it a more attractive treatment consideration than current conventional chemotherapeutic and immunosuppressive medications. As the mechanism of action of ECP is more fully elucidated and clinical studies are completed, the role of ECP in modern therapeutics of CTCL and other malignancies, as well as in the treatment of other T-cell mediated diseases, will be become clearer.
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Affiliation(s)
- Michael Girardi
- Department of Dermatology, Yale University, School of Medicine, Post Office Box 208059, New Haven, CT 06520-8059, USA.
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25
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Abstract
Extracorporeal photochemotherapy was originally conceived for the treatment of cutaneous T-cell lymphoma (CTCL) and as well as other T-cell mediated diseases. Evidence collected in the past 17 years has demonstrated that this treatment modality can have a very significant effect on the course of a subset of CTCL patients. The evidence available is positive but for a variety of reasons has been controversial within the medical community. A number of very well-designed multi-center trials which have been lacking since the first publication by Edelson et al. are being carried out so that hopefully a number of open questions will be resolved with greater clarity in the coming years. The fact remains that this innovative approach for the treatment of CTCL and T-cell mediated diseases has certainly opened new avenues of therapy and thought in photoimmunology and photomedicine. Clearly the very low side effect profile of this therapy has made it more attractive than the chemotherapeutic and immunosuppressive substances that are presently available or in experimental protocols. If and when the mechanisms of action are fully understood and appropriate studies investigating different treatment schedules and different combination therapies and modifications of its present form are performed the place of photopheresis in the therapeutics of CTCL as well as other T-cell mediated diseases and oncology will be better placed.
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Affiliation(s)
- R Knobler
- Division of Special and Environmental Dermatology, Department of Dermatology, Vienna Medical School, University of Vienna, Währinger Gürtel 18-20, Vienna A 1090, Austria.
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Abstract
Extracorporeal photochemotherapy (ECP), or photopheresis, is a widely used treatment for cutaneous T cell lymphoma (CTCL) and other T cell-mediated disorders, having been administered in more than 150 centers worldwide more than 200,000 times. Consistent with the theme of this conference--that is, highlighting the potentially most productive investigative avenues for unraveling the mysteries of CTCL in the next decade--ECP has been futuristic since its inception in the early 1980s. In 1988, the treatment was the first FDA-approved selective immunotherapy for any type of cancer. Yet, the mechanism by which it could suppress a clone of CTCL cells or inactivate multiple autoreactive T cell clones in graft-versus-host disease (GVHD) or allograft rejection remained obscure until quite recently. In fact, the scientific principles necessary to begin to comprehend the basis of ECP's efficacy were not available when the treatment was first introduced in 1982. In the intervening years, necessary detailed knowledge of the structure and function of the clonotypic T cell receptors, of class I major histocompatibility complex (MHC) presentation of tumor antigens, of CTCL tumor-specific antigens, of dendritic antigen presenting cell (DC) biology, and of 8-methoxypsoralen immunopharmacology has been attained. Although much remains to be learned, we now appreciate that ECP simultaneously and efficiently induces both apoptosis of disease-causing T cells and conversion of monocytes to functional DCs. By processing and presenting the unique antigenic determinants of pathogenic T cell clones, the DCs can either initiate a clinically relevant anti-CTCL cytotoxic response or suppress the activity of autoreactive T cell clones. This paper will review clinical trials of ECP in CTCL and evolving scientific understanding of ECP's mechanism in the context of exciting future directions.
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Affiliation(s)
- R Knobler
- Department of Dermatology, University of Vienna Medical School, University of Vienna, Austria.
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