Extracorporeal photopheresis (ECP) in the treatment of chronic graft-versus-host disease (GVHD)

Abstract

Summary:The aim of our study was to assess the efficacy of extracorporeal photopheresis (ECP) in chronic graft-versushost disease (GVHD). Eleven patients with chronic cutaneous GVHD were studied. Four had mucosal involvement and five had pulmonary involvement. All had failed to improve on first-and second-line therapy. Three patients received ECP alone; the remainder continued to receive steroids and/or immunosuppressive therapy. Patients received ECP twice monthly for 4 months and then once monthly for 3 months. They were evaluated by serial skin scores, mucosal and skin photography, pulmonary function tests, biochemical and haematological parameters. Nine patients showed objective evidence of cutaneous improvement with a mean reduction in skin score of 48% overall. In the 10th patient, skin scores and oral involvement improved on twice monthly ECP but deteriorated when reduced to once monthly. The final patient died from renal failure secondary to cyclosporin toxicity. Two out of five patients with lung involvement showed a mild improvement in pulmonary function tests. Liver function tests were abnormal in five patients; they improved in one and deteriorated in three. All patients receiving concomitant immunosuppressive/steroid therapy were able to reduce drug dosages by trial completion. Our results indicate that ECP can benefit patients with cutaneous and mucosal chronic GVHD who have failed on firstand second-line therapies. The effect on the systemic manifestations of GVHD is less consistent.

Extracorporeal photopheresis in chronic graft-versus-host disease

“…43 Two recent studies reported results of ECP in 11 and 15 patients, respectively. 44,45 All patients had failed first-and second-line therapies, including corticosteroids and CsA. In one study ECP therapy was initiated late after the onset of cGVHD (median 510 days), while in the other it was initiated earlier (median 178 days).…”

Impact of extracorporeal photopheresis on skin scores and quality of life in patients with steroid-refractory chronic GVHD

“…Our group and others have previously reported the efficacy of ECP in the management of cGVHD in retrospective studies. [2][3][4][5] To date, there are only a few prospective studies of ECP for this condition [6][7][8][9] and one randomised prospective trial. 10 In addition, there are few data on the effect of ECP on quality of life (QoL) in patients with cGVHD.…”

What we know and mostly do not know about bronchiolitis obliterans syndrome

“…Three publications were cited as specific support in considering ECP for first-line treatment of chronic GVHD. [12][13][14] In our view, the evidence from these publications does not support this endorsement. One of the three studies was a single-arm prospective clinical trial evaluating the safety and efficacy of ECP for treatment of chronic GVHD and was not limited to patients with pulmonary involvement.…”

“…The single study cited by Conference report as support for considering the use of azithromycin in first-line treatment of pulmonary GVHD 15 differs strikingly from the three studies cited as support for considering the use of ECP for the same indication. [12][13][14] The high-quality evidence from the azithromycin study far outweighs the ostensible numerical advantage of the much less persuasive ECP studies. In evaluating the literature, the strength of the evidence is not necessarily related to the number of publications recommending any given treatment.…”

“…The other two studies were retrospective reviews. In one study, 13 responses were observed in six of 11 patients with chronic GVHD involving the lung, but criteria for definition of pulmonary involvement and response were not provided. In addition, the report did not describe time to response or duration of response and did not account for possible effects of any changes in concomitant treatment with other agents.…”