The role of the extracorporeal photopheresis in the management of the graft-versus-host disease

Transfusion and Apheresis Science 46 (2012) 211–219

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Transfusion and Apheresis Science journal homepage: www.elsevier.com/locate/transci

Review

The role of the extracorporeal photopheresis in the management of the graft-versus-host disease Panayotis Kaloyannidis ⇑, Despina Mallouri 1 Department of Haematology, BMT-Unit, George Papanicolaou Hospital, 57010 Exokhi, Thessaloniki, Greece

a r t i c l e

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Article history: Received 5 September 2011 Accepted 13 October 2011

Keywords: Refractory GvHD Extracorporeal photopheresis Acute GvHD Chronic GvHD

a b s t r a c t Over the last decades significant advances have been made in the field of donor selection, alternative transplant sources, immunosuppressive treatment and supportive care, as well as in the better understanding of the immunobiology of allogeneic hematopoietic stem cell transplantation (alloTx). Nevertheless, several factors still affect unfavorably the outcome of the procedure. Graft-versus-host disease (GvHD) remains the leading cause of morbidity, non-relapse mortality and treatment failure post alloTx. So far, steroids are the widely used 1st line treatment for GvHD achieving considerable response rate however, patients who fail to respond to the initial therapy have a dismal prognosis and no standard treatment is well established for them to date. In recent years, extracorporeal photopheresis (ECP) has been proposed as an efficacious and safe treatment for steroid refractory GvHD. Overall responses of 75% have been reported in the cutaneous and mucosal involvement and 45– 65% in other organ manifestations (lung, liver and intestinal), allowing reduction and even discontinuation of steroids, thus contributing towards a significant reduction of morbidity. Although the mechanism of action of ECP is not fully understood, it seems that it has an immunomodulatory rather than an immunosuppression effect and induces immunotolerance, preserving the beneficial graft-versus-tumor effect. Given these very promising results in steroid-refractory or steroid-depended GvHD, currently, extracorporeal photopheresis is being investigated as both first-line and prevention therapy also. Ó 2011 Elsevier Ltd. All rights reserved.

Contents 1. 2. 3. 4.

5. 6.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute GvHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic GvHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mechanism of action of ECP in GvHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Cell apoptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Circulating monocytes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3. Dendritic cells and ECP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Lymphocyte subpopulations and ECP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results of aGvHD management by ECP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. ECP as prevention of aGvHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results of cGvHD management by ECP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

⇑ Corresponding author. Tel.: +30 2313 307 533; fax: +30 2313 307 521. E-mail addresses: [email protected] (P. Kaloyannidis), [email protected] (D. Mallouri). 1 Tel.: +30 2313 307 533; fax: +30 2313 307 521. 1473-0502/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.transci.2011.10.018

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Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

1. Introduction Graft-versus-host disease (GvHD) still remains a major barrier for a successful outcome of allogeneic stem cell transplantation (alloTx) [1]. Despite the improvements in HLA-typing, supportive care, conditioning regimens and post transplant immunosuppression the problems of serious morbidity and mortality due to GvHD have not been overcome yet [2,3]. Moreover, in the last years the incidence of GvHD seems to be increased as more patients in older ages undergo alloTx and the field of the HLA-mismatched transplants has been widened by the usage of haploidentical or with P2 HLA-mismatched donors as well as by the usage of double cord blood units as graft source [4–7]. Traditionally, GvHD is separated in two different forms: acute GvHD (aGvHD) which appears within the first 100 days post alloTx and chronic GvHD (cGvHD) which develops from 3 months post alloTx onwards[8]. According to clinical and histological features, aGvHD represents an inflammatory process which finally leads to the target organ being damaged [9]. The major clinical manifestations of cGvHD resemble autoimmune disease and may involve almost any recipient’s organ and several mechanisms for its pathophysiology have been proposed [10–15]. Although the 1st line of therapy for the GvHD is well established including steroids with or without calcineurin inhibitors (CNIs) administration, the optimal treatment for steroid refractory GvHD has not been clarified yet [16–20]. Over the last 15 years, extracorporeal photopheresis (ECP) has emerged as a safe and efficacious approach for the management of the resistant to the 1st line treatment GvHD (acute or chronic) [21–23]. ECP is a technique where lymphocytes are collected by a leukapheresis process and exposed ex-vivo to psoralen and UVA (PUVA) treatment. Finally the treated lymphocytes are re-infused into the patient [24]. This review will focus on the possible mechanisms of action and the results of the clinical application of ECP in patients with steroid refractory acute or chronic GvHD. 2. Acute GvHD Clinically significant (grade II–IV) acute GvHD occurs in a median incidence of 40% (range 10–80%). The incidence and severity is directly related to a number of risk factors (type and sex of donor, age of the recipient, conditioning regimen) [16]. HLA matching in alloTx is of major importance and well established, but despite the HLA-identity between a patient and a donor, a significant proportion of patients develops systemic aGvHD requiring treatment with high doses of steroids. This is due to genetic differences encoded by regions outside the major histocompatibility complex (MHC) and that encode proteins such as

minor histocompatibility antigens. Genetic polymorphisms in both recipients and donors of cytokines and proteins connected with innate immunity have also been associated with this disorder [25,26]. The complex pathophysiology of aGvHD is a consequence of interactions between the donor host innate and adaptive immune responses and has been summarized in three phases (phase I: effect of conditioning, phase II: Tcell activation, phase III: cellular and inflammatory effector phase), as first proposed by Ferrara and colleagues [9,27]. Multiple inflammatory molecules and cell types are implicated in the development of GvHD: (1) triggers that initiate GvHD by therapy-induced tissue damage and also by the antigen disparities between host and graft tissues; (2) sensors that detect the triggers, process and present alloantigens: antigen presenting cells (APCs) sense allodisparity through MHC and peptide complexes. Dendritic cells (DCs) are the most potent APCs and the primary sensors of allodisparity. Recipient DCs that have been primed by the conditioning regimen, and later on donor DCs, will process and present MHC and peptide complexes to donor T cells; (3) mediators such as T-cell subsets: naïve, memory, regulatory, Th17 and natural killer T cells and (4) the effectors and amplifiers that cause damage of the target organs [28]. With myeloablative conditioning regimens and in vivo GvHD prophylaxis, aGvHD becomes clinically apparent early (within 100 days) post transplantation. With the introduction of reduced intensity conditioning and donor lymphocyte infusions, the onset of aGvHD may be delayed beyond day 100. Therefore, the National Institutes of Health (NIH) Consensus Conference recently distinguished classic acute GvHD occurring within the first 100 days of hematopoietic cell transplantation with acute GvHD features from persistent, recurrent or late-onset aGvHD (>day 100). In both, chronic GvHD features are absent [29]. It clinically affects the skin, gastrointestinal and liver and it is graded in four grades (I–IV) according to the extent and severity as well as the number of organs involved. Severe aGvHD (grade III–IV) has a poor prognosis reaching a 5-year survival at 25% and 5% for grade III and grade IV, respectively. In recent years a remarkable progress in the understanding of the pathophysiology of aGvHD has been made and more targeted immunosuppressive therapies have been developed such as monoclonal antibodies directed against T cells, cytokines and cytokine receptors. Nonetheless, corticosteroids remain the standard first-line treatment for patients with clinically significant aGvHD producing sustained responses in 50–80% of patients mainly dependent on the initial severity of aGvHD. Patients with steroid-refractory aGvHD are treated with a second-line therapy consisting of a combination of immunosuppressive agents, but these patients have a dismal prognosis due to high risk of overwhelming infections

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and organ failure as well as relapse of the primary disease, with reported 1-year survival of 30% in most large trials. Most therapeutic approaches for steroid-refractory aGvHD consist of high dose steroids, addition of anti-thymocyte globulin (ATG), IL2 receptor monoclonal antibodies, TNF antibodies and other agents such as mycophenolate mofetil (MMF), but failed to show any survival advantage over standard steroid treatment mostly due to a higher infection rate. Cellular therapies are also used including mesenchymal stem cells, suicide gene transduced T cells and extracorporeal photopheresis directed against APCs [17,18,30,31]. Regarding the efficacy of ECP in steroid resistant aGvHD, few studies have been reported (retrospective, small prospective phase II studies) showing a response rate of 50–93% for skin involvement, up to 65% for liver and 40– 100% for gut involvement. In most studies ECP was well tolerated, indicated a significant steroid-sparing effect and durable responses without flare-ups of GvHD activity being obtained. Its mechanisms of action are rather immunomodulatory than immunosuppressive, since neither increased rates of infections nor recurrence of the malignant disease have been reported. Based on the results of various studies, ECP seems to be an effective therapy for acute steroid-refractory and steroid-dependent aGvHD [17,18,21,23]. Moreover, since both first- and second-line treatments for aGvHD remain unsatisfactory, the use of ECP with its immunomodulatory effects as preemptive therapy could maybe reduce the incidence of aGvHD while preserving the graft-versus-tumor effect [23].

3. Chronic GvHD Chronic GvHD as well as its treatment by immunosuppressive agents represent major causes of late morbidity and mortality and poor quality of life post alloTx [3]. The pathophysiology of cGvHD is generally poorly understood and in part this is due to the lack of appropriate animal models that mimic human’s GvHD. It has been suggested that immune tolerance is broken during cGvHD appearance, resulting in the immune manifestations of the syndrome. The T-cell abnormal selection in host’s thymus, dis-regulation of Th1 and Th2 responses, elimination of T-regulatory cells and dysfunction of B-cells producing auto antibodies have been proposed as possible pathogenetic mechanisms [10–15]. Steroids with or without CNIs are considered as the cornerstone for the management of cGvHD representing the most widely used 1st line of therapy. However, patients who fail to respond to the initial therapy have a poor outcome and several immunosuppressive agents have been used as 2nd line treatment but no standard approach has uniformly been accepted so far [20,22]. MMF has been used as salvage treatment for refractory cGvHD achieving responses in 45–75% of patients [32]. Thalidomide and azathioprime have also been studied in controlled trials as 2nd line treatment but both factors have been associated with high rates of unacceptable toxicity while additionally, azathioprime with increased inci-

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dence of non-relapse mortality [19,20,32,33]. Other agents, such as monoclonal antibodies (mabThera, infliximab, daclizumab), rapamycin, ATG, cladribine, hydroxychloroquine, clofazimine have also been used as salvage treatment for refractory cGvHD, all of them in non-control trials and therefore, it is difficult to evaluate their safety or efficacy [20–22]. ECP is an innovative approach in the treatment of refractory cGvHD. The clinical application of ECP was firstly introduced by Edelson to treat Sézary syndrome and then, was also proven efficacious in the treatment of several autoimmune diseases [22]. The fact that cGvHD has several clinical or histopathological similarities to autoimmune diseases, induced certain researchers to investigate the role of ECP in the treatment of steroid refractory cGvHD [34,35]. Although most results come from retrospective studies and only few randomized studies are available so far, it seems that ECP represents a reliable procedure for the management of refractory cGvHD, achieving overall responses of 75% in the cutaneous lesions and 45–65% in other organ manifestations (lung, liver or oral mucosa) [23]. However, the exact mechanism of its action still remains obscure [36,37]. 4. Mechanism of action of ECP in GvHD 4.1. Cell apoptosis It is well known that ECP treatment induces apoptosis in the activated lymphocytes. The ability of phototherapy to provoke DNA damage and subsequently cell death in lymphocytes was reported 20 years ago in cultured cells exposed to ECP conditions in vitro [38]. In agreement to this evidence Yoo et al. demonstrated that T cells from healthy donors as well as T-cells from patients with Sézary syndrome showed morphological signs of apoptosis 24 h after ECP treatment, while Bladon et al. using Annexin-V as an apoptosis marker demonstrated apoptotic cells early after the initiation of ECP [39,40]. The programmed cell death process is regulated by several intra- and extra-cellular signals named inducers, enhancers, effectors and inhibitors. In a complex procedure as ECP the apoptosis might be considered as the result of a balance between promoter and/or mediator stimuli and pro- and anti-apoptotic cell functions though this aspect has not been sufficiently investigated in ECP treatment. In a published study by Di Renzo et al. cultured lymphocytes from patients with cGvHD treated with ECP showed a down-regulation of the apoptosis inhibitor Bcl-2 and up-regulation of the enhancer molecule Box and the Fas molecule as well [41]. However, taking into account that less than 10% of activated lymphocytes are exposed to PUVA during ECP treatment, it is unlikely that T-cell apoptosis represents the unique mechanism responsible for its efficacy. 4.2. Circulating monocytes In contrast to other types of leukocytes, under the same conditions monocytes demonstrate resistance to the ECP-

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induced apoptosis. Nevertheless, ECP procedure induces several immunological effects in monocytes. Following ECP an enhanced synthesis of the well-known immunosuppressive and anti-inflammatory cytokines IL-10 and IL-1 receptor antagonist (IL-1Ra) has been observed as well as an increased production of IL-6 and IL-1b cytokines and tumor necrosis factor-a (TNF-a) [42–44]. The later induces T-cell and DCs apoptosis as well as a number of antitumor responses although TNF-a did not have a powerful statistical significance in certain studies [43,45]. Moreover, photoactivation of monocytes and macrophages induces their differentiation into immature plasmacytoid DCs capable for phagocytosis of apoptotic T-cells. Consequently, these DCs, present tumor antigens and stimulate antitumor responses through the production and proliferation of effector cells (e.g., cytotoxic T cells and natural killer cells) [43]. Therefore, it seems that activated monocytes have also a pivotal role in ECP actions. 4.3. Dendritic cells and ECP Dendritic cells are the professional APCs and their precursors are divided into two distinct types: myeloid or DC1 and plasmacytoid or DC2. The DC1 stimulate T-cells in Th1 actions while DC2 induce T-cells in Th2 actions. Experimental and clinical data suggest that ECP directly affects the activities of DCs in patients with GVHD. Previous reports have demonstrated that ECP results in a significant decrease of circulating DC1 together with an increase of DC2. This effect was associated with a simultaneous shift from Th1 to Th2 cytokine profile responses [46,47]. Di Renzo and colleagues created in an in vitro model that mimics the potential in vivo effects of the re-infused ECP-treated cells by co-culturing ECP-treated peripheral blood mononuclear cells with monocyte derived DCs from the same patient. They found that the co-culture of ECP-treated cells with DCs resulted in down-regulation of the co-stimulatory molecules on DCs inducing non-fully mature DCs with low signal 2. More interestingly, following ECP the monocyte-derived CD83+ CD36+ DC2 cells under specific conditions, such as presence of TNF-a and/or co-stimulatory molecules B7.1 and B7.2 became capable of presenting tumor antigens from phagocyted tumor cells and hence initiating anti-tumor cytotoxic immune responses [44]. These observations suggest that ECP crucially affects the action and the maturation of DCs; however, more studies are needed to further evaluate the exact effect of ECP on DCs. 4.4. Lymphocyte subpopulations and ECP It is well known that GvHD alters the number as well as the skills of lymphocytes. Alcindor et al. in a small series of patients reported normalization of T4/T8 ratio due to CD8+ cells elimination following ECP treatment. They also found an increase in the absolute number of NK-lymphocytes [48]. Seaton et al. published similar results with an upward CD4/CD8 ratio 6 months after ECP treatment due to an increase of CD4+ and decrease of CD8+ counts, but these differences were not significant [49]. Blandon and Taylor studied the alteration of T-cell subpopulations in a series

of eight refractory cGvHD patients and they demonstrated that absolute numbers of CD4+ and CD8+ cells had increased following ECP compared to pre-ECP levels, although CD4+ cells never reached the normal counts [40]. Recently, the interest has focused on the role of T-regulatory cells (T-regs: Foxp3+CD4+CD25+) to induce immune tolerance between the recipient and the donor’s-derived cells. Deficiency of T-regs has been observed in GvHD and restoration of their counts to normal has been associated with clinical improvement although there is conflicting data concerning the number of T-regs during GvHD development [50–52]. Data from preclinical studies as well as clinical trials has demonstrated that ECP exerts its beneficial effect in GvHD by increasing T-regs numbers [40,53–55]. However, the mechanism by which T-regs ameliorate the clinical process of GvHD remains obscure. It seems that this effect is mediated through increasing the levels of immunosuppressive molecules such as transforming growth factor-b (TGF-b) and IL-10 or through contact with DC2 cells [55].

5. Results of aGvHD management by ECP The published data concerning the use of ECP in aGvHD is limited. Smith et al. reported the results of ECP treatment in 24 patients with drug-resistant GvHD including 6 patients with acute grade IV liver GvHD, between 1991 and 1996 [56]. All patients had failed to respond to conventional treatment with cyclosporine and prednisone. The six patients with aGvHD had also received antithymocyte globulin. In this pilot study some efficacy of ECP was shown in cGvHD patients, but none of the patients with liver aGvHD responded and all of them had progressive liver failure with short survival despite frequent ECP. Salvaneschi et al. reported the results of a phase I–II study with ECP in children with GVHD. Nine patients with steroidresistant, grade II–IV aGVHD and 14 with cGVHD, refractory to at least one line of treatment, were analyzed. Overall 7 out of 9 patients with acute GVHD responded to EPC, whereas the disease progressed in the remaining two (both with skin, gastrointestinal, and liver GVHD), and they died of grade IV acute GVHD. Among the seven children who responded to ECP, the immunosuppressive treatment was completely discontinued in three [57]. The beneficial role of ECP in steroid refractory aGvHD was also reported in a series of 15 pediatric patients after unrelated hematopoietic cell transplantation, by Calore et al. The ECP-treated patients had steroid refractory (7), dependent (4) aGvHD, or viral reactivations (4) and were comparatively analyzed with 16 patients with steroid-sensitive aGvHD. The ECP group was treated on 2 consecutive days per week during the first month, followed by every 2 weeks for the next 2 months and subsequently monthly for at least 3 months. Complete resolution of aGvHD was achieved in 73% of ECP-treated children and partial remission in 27% whereas for the group with good response to steroids the complete and partial response rates were 56% and 44%, respectively. Interestingly, 3 out of 5 patients treated with ECP for grade IV aGvHD achieved a complete response. Immunosuppression was discontinued in 10/15

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(67%) of patients by the end of ECP. The side effects were mild (hypotension and abdominal pain). The non-relapse mortality rate was 6% in the steroid-responding group and 0% in the ECP group (D 100 and 180). Relapse of primary disease occurred in 3 of the ECP-group and in 5 of the steroid-responding group. The 2-year overall survival and progression free survival rates were 85% and 87% for the ECP-group versus 57% and 67%, respectively, for the steroid-responding group, but the differences were not of statistical significance [58]. The clinical experience in aGvHD treatment with ECP was reviewed by Dall’ Amico and Messina. They considered 11 series for a total of 76 patients with aGvHD treated with ECP after the failure of a first line treatment. Fifty-nine patients had skin, 47 had liver and 28 had gastrointestinal involvement. The duration of ECP treatment ranged from 1 to 24 months. The response rate according to the organ involvement was 83% for skin (67% complete remission), and complete remission of liver and gastrointestinal manifestations in 38% and 54% of the patients, respectively. Maximal response was observed after 6–8 weeks (2–5 cycles of ECP) of therapy. Overall survival rate was 53%. Among the responders 5 patients experienced aGvHD relapse. The immunosuppression was discontinued in 28% and reduced in 46% of patients. Only one patient was reported with relapse of the primary disease [59]. In a pilot study by Garban et al. 27 patients were treated with ECP, 12 of them for steroid refractory aGvHD grade II– IV. The schedule was short-term and intensive, consisting of six courses given during the first 3 weeks and then in case of complete response ECP was stopped. A maintenance therapy with one course per week was given in case of partial response until complete resolution or stabilization. Nine out of the 12 patients responded to the treatment and did not require additional immunosuppressive treatment. Corticosteroids were discontinued in all responding patients between 1 and 2 months after ECP initiation. Of the evaluable patients, three developed cGvHD. According to the authors, ECP appears to be more effective if performed early after the diagnosis of aGvHD and particularly in skin involvement or minimal gut injury, whereas it failed to alleviate the requirement for other immunosuppressive treatments in liver disease [60]. The largest series of patients was reported by the Vienna group [21]. Based on the promising results of their previous pilot study reported in 2000 [59], in a prospective phase II study 59 patients (21 of whom were previously reported) with aGvHD, either steroid refractory or steroid dependent, were given ECP [61]. Initially the patients were treated on two consecutive days (one cycle) at 1- to 2week intervals until improvement and then every 2– 4 weeks until maximal response. The treatment was then tapered off individually. Since no flare-ups of GvHD were observed in the pilot study and durable responses were noted, in the phase II study ECP was given on two consecutive days on a weekly basis and was stopped immediately after maximum response. Complete resolution of GvHD was achieved in 82% of patients with cutaneous, 61% with liver and 61% with gut involvement. Response rates in grade IV and gut involvement were significantly improved compared to the pilot study. Lower grade of GvHD at the

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beginning of ECP treatment and later onset of steroid after transplantation, were significant favorable factors for ECP complete response. Treatment related mortality at 4 years was overall 36%, 14% in ECP-responders and 73% in patients not achieving a complete resolution of GvHD during ECP (p < 0.0001). The probability of survival at 4 years was 47% for all patients, and significantly improved for those achieving a complete resolution (59% versus 11% for not CR, p < 0.0001). The cumulative incidence of relapse for both studies at 4 years was 28%. On univariate analysis, among other factors, a lower steroid dose 4 and 8 weeks after the initiation of ECP treatment was associated with significantly less treatment related mortality and improved survival, whereas failure to achieve complete resolution by 3 months after the start of ECP was associated with worse survival. In the phase II study more patients with grade II GvHD were included in comparison with the pilot study (68% versus 48%). Thus, prompt initiation of second line treatment in addition to the intensified schedule may have let to improved response rates in the phase II study. Best responses were observed after a median of 4 (range 1–13) cycles equaling to a median of 1.4 (0.5–6) months of therapy. Median time of discontinuation of steroids after the start of ECP was 51 days. Thus, besides the impressive steroid sparing effect and durable responses to ECP, without flare-ups of GvHD activity after discontinuation of steroids, short ECP treatment duration seems to be another advantage [21]. More recently, Perfetti et al. reported a retrospective study concerning the treatment of steroid refractory mostly and steroid dependent aGvHD in 23 patients. The ECP schedule was: a cycle (each cycle consisted of treatments on 2 consecutive days) every week for the first month, a cycle every 2 weeks for the following 2 months and a cycle every month until complete resolution or stabilization of GvHD. The overall response rate was 52% (12/23). Complete responses were achieved in 70%, 42% and 0% of patients with grade II, III and IV aGvHD, respectively, and were higher in skin (66%) rather than in liver (27%) or gut (40%). Although higher response rates were observed in patients treated earlier after the onset of aGvHD (83% versus 47%) this difference was not statistically significant. However, when compared with a statistical matched control group, there was a trend for significantly improved survival in the ECP group only for aGvHD grades III–IV (38% versus 14%, p = 0.08) [62]. In line to the above studies, Fritsch et al. reported a retrospective study in 30 patients offered ECP as a second-line therapy for steroid-resistant aGvHD (including 10 patients with grade IV disease), with a median duration of ECPtreatment of 54 days. The schedule consisted of two ECPcycles per week until response, followed by 1 cycle every other week. Complete response was achieved in 36.7%, partial response in 30% and minor response in 13.3% of the patients. The 1-year non-relapse mortality was 44% (2/30) and in only one patient the primary disease relapsed while on the ECP treatment. With a median follow up of 304 (45– 994) days the overall survival was 53.3% [63]. In most studies ECP was well tolerated with very few and mild side-effects such as hypotension, dizziness, or chills. In some patients with severe aGvHD a fall in the

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peripheral blood cells counts was noted after the first cycles of ECP. ECP is unlikely to induce a generalized immunosuppression since neither increased rates of infections nor recurrence of malignant disease have been reported during ECP [18,58,62,64]. 5.1. ECP as prevention of aGvHD Miller et al. incorporated ECP in a reduced intensity conditioning in an attempt to reduce treatment related mortality and GvHD in a clinical study including 55 patients. The preparative regimen consisted of ECP treatment on days 7 and 6, followed by a 48 h pentostatin infusion and then by total body irradiation delivered in three 200 cGy fractions. All patients received GvHD prophylaxis with cyclosporine and two doses of methotrexate, followed by a switch to MMF later on up to one year. The 100-day and 1-year non-relapse mortality rate were 11% and 23%, respectively, while the 2-years overall and event free survival reached at 58% and 47%, respectively. Greater than grade II aGVHD developed in 9% and chronic cGVHD in 43% (extensive in 12%). However, the authors were not able to attribute the beneficial effect of the low incidence of aGvHD solely to the ECP treatment, as pentostatin and prolonged course of immunosuppression had also been used [65]. The role of ECP in prevention of GvHD in patients undergoing standard myeloablative allogeneic hematopoietic cell transplantation has been reported recently in preliminary data of a comparative to a historical control study. In this multicenter phase II study 62 patients were treated with ECP on 2 consecutive days within 4 days before the beginning of the preparative regimen. GvHD prophylaxis was cyclosporine plus short term methotrexate. Acute GvHD grade II–IV developed in 9/30 (30%) of HLA-matched related transplants and 13/32 (41%) of matched unrelated or mismatched related donor transplants. Patients from the database of IBMTR were used as historical control. In multivariate analysis a lower risk of aGvHD grade II–IV was indicated in patients receiving ECP (p = 0.04), but this was attributed by the authors to a substantial delay in the onset of aGvHD in the group of ECP-treated patients rather than a decrease in the incidence of aGvHD. One-year overall survival was significantly improved in the study group (83% versus 67%, p = 0.007). Interestingly, while regimenrelated toxicities were similar among the two groups, a significantly lower rate of opportunistic infections was identified in the ECP group and ECP did not appear to increase the risk of relapse rates that have been observed in other attempts to prevent GvHD. A randomized phase II study is currently underway with or without ECP (NCT00402714; http://www.clinicaltrials.gov) [66]. 6. Results of cGvHD management by ECP No standard treatment schedule for ECP exists so far. The weekly versus the fortnight or even the twice per week procedures have not revealed a statistically significant superiority in terms of response rates. As a variety of ECP schedules have been used, the appropriate number of

ECP cycles per month and the appropriate duration of treatment are difficult to be assessed accurately [22]. Since the first report of a successful treatment of cGvHD by Owisanowski et al. several retrospective studies with a variety in the number of patients involved and two prospective trials have assessed the efficacy of ECP in steroid refractory GvHD [19,22,23,67]. Despite the heterogeneity of patient populations that had been included in those studies, very encouraging response rates have been reported by ECP in steroid refractory cGvHD with skin, visceral and oral mucosa involvement. In a pilot study of 15 patients with extensive cGvHD, Greinix et al. used ECP every 2–4 weeks until maximal response. The reported rates of complete remission of GvHD manifestations were 80% for skin, 70% for liver and 100% for oral mucosa involvement. Fourteen out of 15 patients survived with >90% Karnofsky score. Moreover dose-reduction of steroids was feasible in all responsive patients minimizing the risk of infection development [68]. The same center conducted a larger study to evaluate the role of ECP in 47 patients with quiescent (30), progressive (11) and de novo (4) onset of cGvHD with a median time of appearance of 8 months post alloTx. The complete response rates were 68% for skin, 81% for mouth, 68% for liver, 28% for ocular and 11% for joint manifestations [23]. Couriel et al. evaluated 71 patients with steroid refractory GvHD and observed an overall response rate of 60%. In patients with scleroderma form of cGvHD the response rate was 67% (14/21 patients). Responses were also seen in liver (71%), oral mucosa (77%) and interestingly in bronchiolitis obliterans (54%). Patients with thrombocytopenia or any other than a de novo form of cGvHD had an inferior outcome [69]. In a retrospective study Jagasia et al. reported the outcome of ECP treatment in a series of 43 patients with classic (31) or overlapping (12) steroid refractory cGvHD. The overall response was similar for each type, 67% for overlapping and 65% for classic cGvHD. The overall survival was significantly superior (p < 0.0001) for patients with classic cGvHD (median survival, not reached) compared to overlapping (median survival, 395 days). The authors reported also that the ECP usage led to a significant decrease in steroid doses (mean dose pre-ECP: 0.52 mg/kg versus 0.37 mg/kg post-ECP, p = 0.009) [70]. In 2002, Dall’ Amico and Messina reviewed 20 studies with a total of 204 patients treated with ECP for cGvHD 1–110 months from alloTx. One hundred and twenty-eight of them presented with skin, 84 with liver, 31 with lung and 59 with oral involvement. Regression of clinical manifestations was observed in 76% of patients with skin (38% achieved CR), 48% with liver, 39% with lung and 63% with oral mucosal involvement. The overall survival was 79% [59]. Another study evaluated 28 patients with initiation of ECP treatment approximately 2 years post cGvHD development. The authors observed 48% improvement in skin manifestations after 6 months of therapy. In 8 out of 25 patients with liver abnormal function the ECP treatment ameliorated the levels of liver enzymes by 25%, 3 months after treatment initiation. Patients with lung involvement had relatively disappointing results as in only one patient

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the vital capacity was increased, while in four it remained stable for 5–14 months after starting ECP. Six out of 14 patients with mucosal lesions presented severe ulcers and three of them improved during ECP. No patient with oral GvHD deteriorated during ECP treatment. Although skin responses were comparable with other published studies, the results on visceral GvHD were quite unsatisfactory [41]. This fact could be attributed to the delayed application of ECP, as the highest response rates were reported in series with an earlier initiation of GvHD. However, the above findings have not been confirmed by other studies [71–74]. In a multicenter prospective phase II study 95 patients with steroid intolerant, steroid-depended or refractory cGvHD, were randomly subjected either to standard treatment (prednisone plus CNIs, n = 47) or standard treatment plus ECP (n = 48). The median improvement in the total scin score (TSS) at week 12 post treatment was similar in both groups (14.5% for ECP versus 8.5% for control group, p = 0.48). However, after a 12-week treatment the proportion of patients who achieved at least a 25% improvement in TSS simultaneously with at least a 50% reduction in the steroids dosage was 8.3% in ECP arm versus 0% in control arm (p = 0.04). What is more, the overall responses for the extracutaneous involved organs were superior for the ECP-group as well, although not significant for all the organs. Improvement in ocular GvHD was noticed in 30% of the patients in the ECP group compared to 7% in the control arm (p = 0.04). Responses in oral mucosal were achieved in 53% and 27% of the patients in ECP and control group, respectively (p = 0.06) and joint symptoms ameliorated at 22% in the ECP-treated patients versus 12% in the control group (p = 0.66) [75]. Following this prospective study the same researchers conducted another open-label crossover study in 29 eligible participants randomized initially to the standard nonECP (control) arm. Eligible for the crossover to the ECP arm were patients from the non-ECP arm who had progression or less than 15% improvement of cutaneous cGvHD or had less than 25% reduction in steroids dosage at week 12 in the initial study. Thirty-one percent of patients achieved complete or partial response at week 24 and in 33% of them a P50% reduction of steroid dosage was feasible. Regarding the extracutaneous organs involvement, the highest response was observed in oral mucosal (70% at week 24). These results suggest that prolonged treatment with ECP is needed in order to reach a beneficial effect in steroid refractory GvHD [76]. Interestingly, very low rates of malignant disease recurrence have been reported following ECP treatment compared to historical controls of patients who had been treated with other 2nd line immunosuppressive regimens [63,75–77]. In part, this may reflect the powerful antitumor effect of the long lasting and resistant to steroids graft-versus-host alloreactivity. An additional possible explanation could be that ECP may preserve the beneficial graft-versus-malignancy activity as the effect of phototherapy relies on immunoregulating actions rather than generalized immunosuppression through heavy inactivation or elimination of T-lymphocytes. Moreover, as it has previously been pointed out, ECP enhances the capacity of DCs

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to present tumor antigens and thus may reinforce the Tcell alloreactivity against malignancy.

7. Conclusions Several studies have shown that ECP exerts an objective positive activity in steroid refractory acute or chronic GvHD. Besides the obvious clinical improvement in GvHD manifestations, it seems that treatment with ECP allows for a considerable reduction or even discontinuation of steroids administration resulting in less infections and lower relapse rates of malignant diseases. Having such features, ECP has currently emerged as a very promising approach as 2nd line treatment for refractory GvHD. However, ECP represents a quite expensive approach and therefore a better understanding of its mechanisms of action as well as a further evaluation of its efficacy in well designed prospective randomized studies is required towards a rational use of ECP. Acknowledgement The authors thank Natasa Aslanidou for her professional assistance on the editing of this review. References [1] Klingebiel T, Schlegel PG. GvHD: overview on pathophysiology, incidence, clinical and biological features. Bone Marrow Transplant 1998;21:45–9. [2] Bacigalupo A, Palandri F. Management of acute graft versus host disease. Hematol J 2004;5:189–96. [3] Socie G, Stone JV, Wingard JR, Weisdorf D, Henslee-Downey PJ, Bredeson C, et al. Long-term survival and late deaths after allogeneic bone marrow transplantation. Late Effects Working Committee of the International Bone Marrow Transplant Registry. New Engl J Med 1999;341:14–21. [4] Horowitz MM, Rowlings PA. An update from the International Bone Marrow Transplant Registry and the Autologous Blood and Marrow Transplant Registry on current activity in hematopoietic stem cell transplantation. Curr Opin Hematol 1997;4:395–400. [5] Kernan NA, Bartsch G, Ash RC, et al. Analysis of 462 transplantations from unrelated donors facilitated by the National Marrow Donor Program. N Engl J Med 1993;328:593–602. [6] Henslee-Downey PJ, Abhyankar SH, Parrish RS, et al. Use of partially mismatched related donors extends access to allogeneic marrow transplant. Blood 1997;89:3864–72. [7] Gluckman E, Rocha V, Boyer-Chammard A, et al. Outcome of cord blood transplantation from related and unrelated donors. N Engl J Med 1997;337:373–81. [8] Sullivan K, Agura E, Anasetti C. Chronic graft versus host disease in other late complications of bone marrow transplantation. Semin Hematol 1991;28:250–9. [9] Ferrara JLM, Cooke KR, Teshima T. The pathophysiology of acute graft-versus-host disease. Int J Hematol 2003;78:181–7. [10] Baird K, Pavletic SZ. Chronic graft versus host disease. Curr Opin Hematol 2006;13:426–35. [11] Soiffer RJ. Immune modulation and chronic graft-versus-host disease. Bone Marrow Transplant 2008;42(Suppl. 1):S66–9. [12] Perreault C, Decary F, Brochu DA, Gyger M, Bélanger R, Roy D. Minor histocompatibility antigens. Blood 1990;76:1269–80. [13] Ferrara JL, Krenger W. Graft-versus-host disease: the influence of type 1 and type 2 T cell cytokines. Transfus Med Rev 1998;12:1–17. [14] Krenger W, Ferrara JL. Graft-versus-host disease and the Th1/Th2 paradigm. Immunol Res 1996;15:50–73. [15] Patriarca F, Skert C, Sperotto A, Zaja F, Falleti E, Mestroni R, et al. The development of autoantibodies after allogeneic stem cell transplantation is related with chronic graft-vs-host disease and immune recovery. Exp Hematol 2006;34:389–96.

218

P. Kaloyannidis, D. Mallouri / Transfusion and Apheresis Science 46 (2012) 211–219

[16] Devergie A. Graft versus host disease. Haematopoietic stem cell transplantation. The EBMT handbook, 2008 revised edition. p. 218– 34 [Chapter 11]. [17] Bacigalupo A. Management of acute graft-versus-host-disease. Br J Haematol 2007;137:87–98. [18] Greinix HT. Graft-versus-host-disease. Uni-Med Science; 2008 (3.4 Treatment of acute GVHD. p. 50–6). [19] Arora M. Therapy of chronic graft-versus-host disease. Best Pract Res Clin Haematol 2008;21(2):271–9. [20] Wolff D, Gerbitz A, Ayuk F, Kiani A, Hildebrandt GC, Vogelsang GB, et al. Consensus conference on clinical practice in chronic graftversus-host disease (GVHD): first-line and topical treatment of chronic GVHD. Biol Blood Marrow Transplant 2010;16(12):1611–28. [21] Greinix HT, Knobler RM, Worel N, Schneider B, Schneeberger A, Hoecker P, et al. The effect of intensified extracorporeal photochemotherapy on long-term survival in patients with severe acute graft-versus-host disease. Haematologica 2006;91:405–8. [22] Wolff D, Schleuning M, von Harsdorf S, Bacher U, Gerbitz A, Stadler M, et al. Consensus conference on clinical practice in chronic GVHD: second-line treatment of chronic graft-versus-host disease. Biol Blood Marrow Transplant 2011;17:1–17. [23] Greinix HY, Socie G, Bacigalupo A, Holler E, Edinger MG, Apperley JF, et al. Assessing the potential role of photopheresis in hematopoietic stem cell transplant. Bone Marrow Transplant 2006;38:265–73. [24] Edelson R, Berger C, Gasparro F, Jegasothy B, Heald P, Wintroub B, et al. Treatment of cutaneous T-cell lymphoma by extracorporeal photochemotherapy. Preliminary results. N Engl J Med 1987;316(6):297–303. [25] Dickinson AM, Harrold JL, Cullup H. Haematopoietic stem cell transplantation: can our genes predict clinical outcome? Expert Rev Mol Med 2007;9:1–19. [26] Ferrara JLM, Levine JF, Reddy P, Holler E. Graft versus host disease. Lancet 2009;373:1550–61. [27] Reddy P, Ferrara JLM. Immunobiology of acute graft-versus-hostdisease. Blood Rev 2003;17:187–94. [28] Paczesny S, Hanauer D, Sun Y, Reddy P. New perspectives on the biology of acute GVHD. Bone Marrow Transplant 2010;45:1–11. [29] Filipovich AH, Weisdorf D, Pavletic S, Socie G, Wingard JR, Lee SJ, et al. National institutes of health consensus development project on criteria for clinical trials in chronic graft-versus-host-disease. I: Diagnosis and staging working group report.. Biol Blood Marrow Transplant 2005;11:945–56. [30] Le Blanc K, Frassoni F, Ball L, Locatelli F, Roelofs H, Lewis I, et al. Mesenchymal stem cells for treatment of steroid-resistant, severe, acute graft-versus-host disease: a phase II study. Lancet 2008;371(9624):1579–86. [31] Ciceri F, Bonini C, Stanghellini MT, Bondanza A, Traversari C, Salomoni M, et al. Infusion of suicide-gene-engineered donor lymphocytes after family haploidentical haemopoietic stem-cell transplantation for leukaemia (the TK007 trial): a non-randomised phase I–II study. Lancet Oncol 2009;10(5):489–500. [32] Lopez F, Parker P, Nademanee A, Rodriguez R, Al-Kadhimi Z, Bhatia R, et al. Efficacy of mycophenolate mofetil in the treatment of chronic graft-versus-host disease. Biol Blood Marrow Transplant 2005;11:307–13. [33] Sullivan KM, Witherspoon RP, Storb R, Weiden P, Flournoy N, Dahlberg S, et al. Prednisone and azathioprine compared with prednisone and placebo for treatment of chronic graft-v-host disease: prognostic influence of prolonged thrombocytopenia after allogeneic marrow transplantation. Blood 1988;72:546–54. [34] Ullrich SE. Photoinactivation of T-cell function with psoralen and UVA radiation suppresses the induction of experimental murine graft-versus-host disease across major histocompatibility barriers. J Invest Dermatol 1991;96:303–8. [35] Dippel E, Goerdt S, Orfanos CE. Long-term extracorporeal photoimmunotherapy for treatment of chronic cutaneous graftversus-host disease: observations in four patients. Dermatology 1999;198:370–4. [36] Fimiani M, Di Renzo M, Rubengi P. Mechanism of action of extracorporeal photochemotherapy in chronic graft-versus-host disease. Br J Dermatol 2004;150(6):1055–60. [37] Gorgun G, Miller KB, Foss FM. Immunologic mechanisms of extracorporeal photochemotherapy in chronic graft-versus-host disease. Blood 2002;100(3):941–7. [38] Marks DI, Fox RM. Mechanisms of photochemotherapy-induced apoptotic cell death in lymphoid cells. Biochem Cell Biol 1991;69:754–60. [39] Yoo EK, Rook AH, Elenitsas R, et al. Apoptosis induction of ultraviolet light A and photochemotherapy in cutaneous T-cell lymphoma:

[40]

[41]

[42]

[43]

[44]

[45]

[46]

[47]

[48]

[49]

[50]

[51]

[52]

[53]

[54]

[55]

[56]

[57]

[58]

[59]

[60]

relevance to mechanism of therapeutic action. J Invest Dermatol 1996;107:235–42. Bladon J, Taylor P. Extracorporeal photopheresis normalizes some lymphocyte subsets (including T regulatory cells) in chronic graftversus-host disease. Ther Apher Dial 2008;12(4):311–8. Di Renzo M, Rubegni P, Sbano P, Cuccia A, Castagnini C, Pompella G, et al. ECP-treated lymphocytes of chronic graft-versus-host disease patients undergo apoptosis which involves both the Fas/FasL system and the BCL-2 protein family. Arch Dermatol Res 2003;295:175–82. Berger CL, Hanlon D, Kanada D, Girardi M, Edelson RL. Transimmunization, a novel approach for tumor immunotherapy. Transfus Apher Sci 2002;26:205–16. Craciun LI, Stordeur P, Schandene L, Duvillier H, Bron D, Lambermont M, et al. Increased production of interleukin-10 and interleukin-1 receptor antagonist after extracorporeal photochemotherapy in chronic graft-versus-host disease. Transplantation 2002;74:995–1000. Di Renzo M, Sbano P, De Aloe G, Pasqui AL, Rubegni P, Ghezzi A. Extracorporeal photopheresis affects co-stimulatory molecule expression and interleukin-10 production by dendritic cells in graft-versus-host disease patients. Clin Exp Immunol 2008;151(3):407–13. Vowels BR, Cassin M, Boufal MH, Walsh LJ, Rook AH. Extracorporeal photochemotherapy induces the production of tumor necrosis factor-alpha by monocytes: implications for the treatment of cutaneous T-cell lymphoma and systemic sclerosis. J Invest Dermatol 1992;98:686–92. Gorgun G, Miller KB, Foss FM. Immunologic mechanisms of extracorporeal photochemotherapy in chronic graft-versus-host disease. Blood 2002;100:941–7. Foss FM, Gorgun G, Miller KB. Extracorporeal photopheresis in chronic graft-versus-host disease. Bone Marrow Transplant 2002;29:719–25. Alcindor T, Gorgun G, Miller KB, et al. Immunomodulatory effects of extracorporeal photochemotherapy in patients with extensive chronic graft-versus-host disease. Blood 2001;98:1622–5. Seaton ED, Szydlo RM, Kanfer E, Apperley JF, Russell-Jones R. Influence of extracorporeal photopheresis on clinical and laboratory parameters in chronic graft-versus-host disease and analysis of predictors of response. Blood 2003;102:1217–23. Rieger K, Loddenkemper C, Maul J, Fietz T, Wolff D, Terpe H, et al. Mucosal FOXP3+ regulatory T cells are numerically deficient in acute and chronic GvHD. Blood 2006;107:1717–23. Zorn E, Kim HT, Lee SJ, et al. Reduced frequency of FOXP3+CD4+CD25+ regulatory T cells in patients with chronic graft-versus-host disease. Blood 2005;106:2903–11. Clark FJ, Gregg R, Piper K, Dunnion D, Freeman L, Griffiths M, et al. Chronic graft-versus-host disease is associated with increased numbers of peripheral blood CD4+CD25 high regulatory T cells. Blood 2004;103(6):2410–6. Gatza E, Rogers CE, Clouthier SG, Lowler KP, Tawara I, Liu C, et al. Extracorporeal photopheresis reverses experimental graft-versushost disease through regulatory T cells. Blood 2008;112:1515–21. Biagi E, Di Biaso I, Leoni V, Gaipa G, Rossi V, Bugarin C, et al. Extracorporeal photochemotherapy is accompanied by increasing levels of circulating CD4+CD25+GITR+Foxp3+CD62L+ functional regulatory T-cells in patients with graft-versus-host disease. Transplantation 2007;84(1):31–9. Sharma MD, Baban B, Chandler P, Hou DY, Singh N, Yagita H, et al. Plasmacytoid dendritic cells from mouse tumor-draining lymph nodes directly activate mature Tregs via indoleamine 2,3dioxygenase. J Clin Invest 2007;117(9):2570–82. Smith EP, Sniecinski I, Dagis AC, Parker PM, Snyder DS, Stein AS, et al. Extracorporeal photochemotherapy for treatment of drug-resistant graft-vs-host-disease. Biol Blood Marrow Transplant 1998;4(1):27–37. Salvaneschi L, Perotti C, Zecca M, Bernucci S, Viarengo G, Giorgiani G, et al. Extracorporeal photochemotherapy for treatment of acute and chronic GVHD in childhood. Transfusion 2001;41(10):1299–305. Calore E, Calò A, Tridello G, Cesaro S, Pillon M, Varotto S, et al. Extracorporeal photochemotherapy may improve outcome in children with acute GVHD. Bone Marrow Transplant 2008;42:421–5. Dall’Amico R, Messina C. Extracorporeal photochemotherapy for the treatment of graft-versus-host-disease. Ther Apheresis 2002;6(4):296–304. Garban F, Drillat P, Makowski C, Jacob MC, Richard MJ, Favrot M, et al. Extracorporeal chemophototherapy for the treatment or graftversus-host-disease: hematologic consequences of short-term, intensive courses. Haematologica 2005;90(8):1096–101.

P. Kaloyannidis, D. Mallouri / Transfusion and Apheresis Science 46 (2012) 211–219 [61] Greinix HT, Volc-Platzer B, Kalhs P, Fischer G, Rosenmayr A, Keil F, et al. Extracorporeal photochemotherapy in the treatment of severe steroid-refractory acute graft-versus-host-disease: a pilot study. Blood 2000;96:2426–31. [62] Perfetti P, Carlier P, Strada P, Gualandi F, Occhini D, Van Lint MT, et al. Extracorporeal photopheresis for the treatment of steroid refractory acute GVHD. Bone Marrow Transplant 2008;42:609–17. [63] Fritsch S, Tischer J, Ledderose G, Maier B, Reibke R, Rank A. Extracorporeal photopheresis for the treatment of steroid-resistant acute graft-versus-host disease. Bone Marrow Transplant 2009;43(Suppl. 1):S130. [64] Marshall SR. Technology insight: ECP for the treatment of GvHD-can we offer selective immune control without generalized immunosuppression? Nat Clin Pract Oncol 2006;3(6):302–14. [65] Miller KB, Roberts TF, Chan G, Schenkein DP, Lawrence D, Sprague K, et al. A novel reduced intensity regimen for allogeneic hematopoietic stem cell transplantation associated with a reduced incidence of graft-versus-host disease. Bone Marrow Transplant 2004;33:881–9. [66] Shaughnessy PJ, Bolwell BJ, Van Besien K, Mistrik M, Griggs A, Dodds A, et al. Extracorporeal photopheresis for the prevention of acute GVHD in patients undergoing standard myeloablative conditioning and allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2010;45:1068–76. [67] Owsianowski M, Gollnick H, Siegert W, Schwerdtfeger R, Orfanos CE. Successful treatment of chronic graft-versus-host disease with extracorporeal photopheresis. Bone Marrow Transplant 1994;14(5):845–8. [68] Greinix HT, Volc-Platzer B, Rabitsch W, Gmeinhart B, GuevaraPineda C, Kalhs P, et al. Successful use of extracorporeal photochemotherapy in the treatment of severe acute and chronic graft-versus-host disease. Blood 1998;92:3098–104. [69] Couriel DR, Hosing C, Saliba R, Shpall EJ, Anderlini P, Rhodes B, et al. Extracorporeal photochemotherapy for the treatment of steroidresistant chronic GVHD. Blood 2006;107:3074–80. [70] Jagasia MH, Savani BN, Stricklin G, Engelhardt B, Kassim A, Dixon S, et al. Classic and overlap chronic graft-versus-host disease (cGVHD)

[71]

[72]

[73]

[74]

[75]

[76]

[77]

219

is associated extracorporeal photopheresis (ECP). Biol Blood Marrow Transplant 2009;15(10):1288–95. Apisarnthanarax N, Donato M, Korbling M, Couriel D, Gajewski J, Giralt S, et al. Extracorporeal photopheresis therapy in the management of steroid-refractory or steroid-dependent cutaneous chronic graft-versus-host disease after allogeneic stem cell transplantation: feasibility and results. Bone Marrow Transplant 2003;31:459–65. Child FJ, Ratnavel R, Watkins P, Samson D, Apperley J, Ball J, et al. Extracorporeal photopheresis (ECP) in the treatment of chronic graft-versus-host disease (GVHD). Bone Marrow Transplant 1999;23:881–7. Foss FM, DiVenuti GM, Chin K, Sprague K, Grodman H, Klein A, et al. Prospective study of extracorporeal photopheresis in steroidrefractory or steroid resistant extensive chronic graft-versus-host disease: analysis of response and survival incorporating prognostic factors. Bone Marrow Transplant 2005;35:1187–93. Messina C, Locatelli F, Lanino E, Uderzo C, Zacchello G, Cesaro S, et al. Extracorporeal photochemotherapy for paediatric patients with graft-versus-host disease after haematopoietic stem cell transplantation. Br J Haematol 2003;122:118–27. Flowers ME, Apperley JF, van Besien K, Elmaagacli A, Grigg A, Reddy V, et al. A multicenter prospective phase 2 randomized study of extracorporeal photopheresis for treatment of chronic graft-versushost disease. Blood 2008;112:2667–74. Greinix HT, Van Besien K, Elmaagacli AH, Hillen U, Grigg A, Knobler R, et al. Progressive improvement in cutaneous and extracutaneous chronic graft-versus-host disease after a 24-week course of extracorporeal photopheresis—results of a crossover randomized study. Biol Blood Marrow Transplant 2011 [Epub ahead of print]. Kaloyannidis P, Papalexandri A, Sakellari I, Yannaki E, Batsis I, Mallouri D, et al. Extracorporeal photopheresis in the management of steroid-refractory chronic graft-versus-host disease after stem cell transplantation. Bone Marrow Transplant 2009;43(Suppl. 1):S130.