A comparison of four ultraviolet sources to alter graft-versus-host responses

Peritransplant use of ultraviolet-B irradiation (UV-B) therapy is detrimental to allogeneic stem cell transplantation outcome

Whole-body UV-B phototherapy has been used for the treatment of graft-versus-host disease (GVHD) of the skin and has systemic immunosuppressive and tolerogenic effects. We hypothesized that whole-body UV-B therapy would improve donor engraftment and decrease the incidence and severity of GVHD that is associated with decreased intensity allogeneic hematopoietic stem cell transplantation. This study tested the feasibility of using UV-B phototherapy that was initiated before grafting and continued until engraftment to determine its effect on transplantation outcome. Eight patients (median age, 55.5 years; range, 32-65 years) with hematologic malignancies were included. Allogeneic peripheral blood stem cells were obtained from matched related (n=5) or matched unrelated (n=3) donors. Conditioning regimen was fludarabine 30 mg/m2 intravenously for 5 days, cyclophosphamide 1 g/m2/d intravenously for 2 days, and equine antithymocyte globulin 30 mg/kg/d for 2 days. GVHD prophylaxis included cyclosporine, methylprednisolone, and escalating doses of narrowband UV-B (311 nm) according to skin tolerance, 3 days a week, from 10 days before to 28 days after transplantation. The conditioning regimen and the UV-B therapy were well tolerated. Two patients received all 14 prescribed UV-B treatments (cumulative doses of 2000 and 3260 mJ/cm2, respectively) and 6 patients received 8 to 13 treatments with a cumulative dose range of 528-3465 mJ/cm2. There was a rapid decrease in epidermal CD1a+ cells by day of transplantation. Myeloid engraftment was rapid. One patient had secondary engraftment failure at 3 months and another had mixed chimerism at day 100. Seven of 8 patients developed severe acute GVHD (grade III, n=5; grade IV, n=2). Six had skin involvement, 5 had gastrointestinal involvement, and 1 had liver involvement. Four patients died (2 from sepsis, 1 from acute GVHD, and 1 from chronic GVHD). Four patients are alive (130-287 days), 3 with extensive chronic GVHD. We conclude that extended peritransplant UV-B therapy at the standard minimally erythemogenic dose is detrimental to the outcome of allogeneic stem cell transplantation. It is unclear how UV-B at this immunsuppressive dose might have altered skin and systemic cytokine and immune cell compositions in the host and increased GVHD- and treatment-related mortalities. Different UV-B dose and schedules should be further explored. However, although other phototherapeutic modalities may be effective against GVHD, extended UV-B therapy should not be used during early phases of decreased conditioning allogeneic transplantation.

In vitro demonstration of a fundamental difference in the proliferation of murine and human bone marrow and lymphocytes following ultraviolet irradiation: relevance to bone marrow transplantation

Exposure of rodent allogeneic donor marrow and splenocyte grafts to ultraviolet radiation (UVR) has been shown to permit durable engraftment at doses that abolish graft-versus-host disease (GVHD) and graft rejection. We have compared both murine and human alloreactive and mitogen-induced lymphoid responses and bone marrow proliferation in mixed lymphocyte culture (MLC), phytohemagglutinin (PHA)-induced proliferation and colony-forming unit-granulocyte/macrophage (CFU-GM) assays using germicidal UVC (200-290 nm), broadband and narrowband UVB (290-320 nm) and UVA (320-400 nm) sources. Our data show a wavelength and dose-dependent reduction in lymphoid proliferation in the mouse with CFU-GM survival of 50-75% of control at doses required to abolish allogeneic lymphocyte responses for all lamps. In contrast, human lymphocyte responses are more resistant to UVC with CFU-GM proliferation reduced to zero when allostimulation is abolished. Mitogen-induced lymphoid responses show a similar wavelength-dependent sensitivity. Abolition of response in MLC using UV-irradiated stimulator cells was less sensitive than proliferation with UV-irradiated responder cells at all wavelengths in both species. With all sources, murine CFU-GM proliferation is less susceptible to UVR than human marrow at doses required to abolish lymphoid responses.