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Extracorporeal photochemotherapy as second- or first-line therapy of acute GVHD?

Bone Marrow Transplantation volume 45, pages 963–965 (2010)Cite this article

Extracorporeal photochemotherapy (ECP) is a fascinating type of immunotherapy that is capable of providing immune tolerance without immunosuppression. A clinical benefit has first been suggested in patients with chronic GVHD, and several prospective or retrospective studies reported promising results in patients with steroid refractory acute GVHD (aGVHD).1, 2 The theoretical advantages of ECP are no increased risk of infection, no adverse events such as metabolic or organic impairment and potential preservation of the GVL effect.2 Moreover, as its immunomodulatory effects do not rely on the destruction or inactivation of cells but rather on the generation of active immune cells, these effects can be sustained and no severe flare-up of GVHD has been reported.1 In a recent retrospective study, Calore et al.3 have compared the outcome of children with aGVHD depending on whether they had been treated with ECP or not. In this study, the indications for ECP were steroid resistance or dependence, or viral reactivations. The authors reported a non-significant rise in the survival rate of children in the ECP group compared with children who did not meet the indications for ECP. In particular, in this group of 15 patients of whom 4 had grade IV aGVHD, none died from either aGVHD or chronic GVHD.

In our center, the indications for ECP are steroid refractory or steroid-dependent aGVHD, or grade ⩾2 aGVHD that responds to ‘conventional treatment’ (steroids+CYA as first-line therapy, mycophenolate or monoclonal antibodies as second-line therapy) but has intolerable treatment-related side effects. From January 2001 to June 2008, 42 children with hematological malignancy received myeloablative-conditioned allogeneic BM transplants. In total, 17 patients had grade I aGVHD or no GVHD (group NG=no GVHD). Overall, grades II–IV aGVHD occurred in 25 of 42 patients (59%) and 14 of those (34%) had either grade III or IV. All 25 patients received a combination of steroids (median 1.5 mg/kg/day, range 0.5–4) and CYA A as first-line therapy. In total, 13 responded to this treatment before 8-day steroid treatment (median 5 days) and suffered no severe side effects. Steroids were then gradually tapered and could be stopped on day 72 (range 31–143) (group SO=steroids only). Overall, 12 patients received ECP as second- or third-line therapy for refractory or steroid-dependent GVHD (n=10), or for intolerable adverse effects of the immunosuppressive therapy (n=2) (ECP group). In total, five patients received ECP in combination with another treatment because of life-threatening GVHD (two patients) or because the second-line therapy was not stopped immediately after initiation of ECP (three patients). No patients were treated with ECP because of previous viral reactivation in context with GVHD. ECP was performed using the off-line process, that is, a CMN harvest with Cobe Spectra (Caridian BCT, Bourg-la-Reine, France) followed by UVA exposure (2 J/cm2) by means of a UVAMATIC illuminator (Vilber-Lourmat, Marne-la-vallée, France) as previously described.4 Three sessions a week were performed for 3 weeks; after that the frequency was reduced. The characteristics of these three groups of patients (no aGVHD=NG, steroids only=SO group or requiring ECP=ECP group) are detailed in the Table 1.

Table 1 Characteristics of patients
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Figure 1

References

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Authors and Affiliations

  1. CHU Clermont-Ferrand, Centre régional de cancérologie et Thérapie Cellulaire Pédiatrique, Hôtel-Dieu, F-63058, Clermont-Ferrand, France

    E Merlin, C Paillard, E Rochette, A David, F Isfan, E Doré, F Deméocq & J Kanold

  2. INSERM CIC-501, F-63003, Clermont-Ferrand, France

    E Merlin, C Paillard, E Rochette, A David, F Isfan, E Doré, F Deméocq & J Kanold

  3. Université d'Auvergne, F-63001, Clermont-Ferrand, France

    E Merlin, F Deméocq & J Kanold

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  1. E Merlin
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Correspondence to E Merlin.

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Merlin, E., Paillard, C., Rochette, E. et al. Extracorporeal photochemotherapy as second- or first-line therapy of acute GVHD?. Bone Marrow Transplant 45, 963–965 (2010). https://doi.org/10.1038/bmt.2009.271

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