Mononuclear cell recruitment during extracorporeal photopheresis: Partial results of a phase 1/2 randomized clinical trial in multiple sclerosis

BACKGROUND

Despite the routine clinical use of extracorporeal photopheresis (ECP) for the last decades, there has been no sufficient investigation on the intra-apheresis dynamics of mononuclear cells (MNCs).

OBJECTIVE

This research aims to verify the "intra-apheresis recruitment" (IAR) of MNCs, which may be particularly useful in cases with low preapheresis MNC counts.

METHODS

Prospective data of ECP procedures for patients with multiple sclerosis (MS) in the context of the PHOMS study (NCT05168384) were analyzed. ECPs were performed with the use of the Therakos® CellEx® Photopheresis System, and the recruitment factor (RF), collection efficiency 1 (CE1), and fold enrichment (FE) for MNCs, lymphocytes, monocytes, and neutrophils were calculated at various intervals per the approved protocol.

RESULTS

A total of 252 ECP procedures were performed on nine patients with MS, and data from 45 ECPs were analyzed for this study. IAR (RF ≥ 1) of MNCs, lymphocytes, and monocytes was observed in the 93.3 %, 95.5 %, and 88.8 % of the ECP procedures, respectively. CE1 exceeded 100 % for these populations in 13.3 %, 11.1 %, and 24.4 % of ECPs, while FE ≥ 1 for MNCs and lymphocytes was found in all ECPs, and in 97.8 % of ECPs for monocytes. Additionally, RF correlated positively with CE1 for MNCs (r = 0.40, p = 0.006) and lymphocytes (r = 0.43, p = 0.003), as well as with FE for monocytes (r = 0.39, p = 0.01) and lymphocytes (r = 0.48, p = 0.001), further improving collection quality.

CONCLUSIONS

Administering photopheresis with suboptimal MNC counts was plausible and did not worsen the anticipated cytopenias. Moreover, our findings revealed sustained IAR of MNCs in patients with MS who underwent ECP.

A paired study comparing mononuclear cell collection using a new in-line system with an off-line extracorporeal photopheresis apheresis system

BACKGROUND

Extracorporeal photopheresis (ECP) product characteristics are not well established. The aim of this study was to compare mononuclear cells (MNCs) collection using the new Amicus blue (AB) In-line ECP system to our standard Off-line ECP system using the Optia apheresis device and the MacoGenic G2 inactivation system (OM).

STUDY DESIGN AND METHODS

We assessed the ECP products and procedure parameters, patient characteristics, and adverse events for both AB and OM systems in paired patients. Comparisons were made with t-test for paired samples.

RESULTS

Thirteen patients underwent 15 double, paired procedures using both ECP protocols and processing the same blood volume of 4000 mL. Total MNC collected in the product were 51.6 × 108 (95% CI 30.0-73.1) and 42.2 × 108 (95% CI 22.4-62.0) for the AB and OM, respectively (not significant). Both products were also similar regarding volume, MNC concentration, purity, and hematocrit. However, total platelet count (×1011) was significantly lower in the AB products: 0.25 (95% CI 0.15-0.36) versus 1.2 (95% CI 0.9-1.5). The new AB system reduced significantly also the time invested and anticoagulant used per procedure compared with OM, albeit with similar collection efficiency and percentage of MNC captured per procedure. Hypocalcemia was the commonest adverse event with both systems, but it was not severe.

CONCLUSIONS

The new AB system collected MNC products comparable to our current experience with OM, although in a significantly shorter time, with a reduced use of anticoagulant and lower contamination with platelets, which are all valuable advantages of the new system.

Comparison of two inline photopheresis systems: A paired crossover trial

BACKGROUND

Extracorporeal photopheresis (ECP) has been demonstrated as an effective treatment for graft-versus-host disease (GvHD). The inline system was developed by Therakos in 1987. Recently, Fresenius Kabi implemented an integration of cell separator Amicus and a UVA photoactivation device (Phelix), realizing an inline photopheresis system.

STUDY DESIGN AND METHODS

In 2022 we designed a prospective paired crossover trial (NCT05718674) comparing two integrated ECP protocols: Therakos CELLEX and Amicus ECP system. Twenty patients affected by corticosteroid resistant GvHD were submitted to 80 ECP, 40 paired procedures.

RESULTS

All procedures were well tolerated, with no significant differences in procedure duration. CELLEX cell product showed higher granulocytes and platelet content, while Amicus cell product exhibited higher enrichment of lymphocytes, resulting in significantly higher MNC purity (92.9% vs. 84%). A significantly higher granulocytes and platelets absolute content was observed in CELLEX cell products, while Amicus cell products showed a significantly higher number of TNCs and MNCs. Differences in granulocyte and platelet content remained significant even after normalization of the data according to blood volume processed. These findings are confirmed by a statistically significant higher CE2% for CELLEX for granulocytes and platelets along with the lack of significant difference observed for TNCs and MNCs.

DISCUSSION

Our analysis shows differences in the characteristics of the procedure and the cell product. Anyway, both devices are effective for performing ECP procedure, as they collect a cell product suitable for photopheresis. At present, our results represent the first data set comparing two available inline ECP devices.

Evaluating a New Photopheresis System: A Comparison with Two Established Systems on Cell Yield and Collection Efficiency

Background/Objectives: Extracorporeal photopheresis (ECP) is a well-established and efficacious cell therapy for a range of diseases. The objective of this retrospective study was to compare the new Amicus Blue inline system with the Therakos Cellex inline system and the Spectra Optia offline system in terms of collection efficiency, mononuclear cell (MNC) yield of mononuclear cell products (MCPs), processing time and correlation between MCP cell count and peripheral blood count of patients.

METHODS

This retrospective study compared 127 procedures utilizing the Spectra Optia offline system, 93 procedures employing the Amicus Blue inline system, and 81 procedures applying the Therakos Cellex inline system. The MNCs were subjected to flow cytometry analysis for CD45 and CD14 expression in order to ascertain the precise composition of the collected lymphocyte and monocyte fractions.

RESULTS

The Therakos inline system demonstrated the highest MNC collection efficiency (Therakos: 74.42 ± 1.82; Optia: 65.79 ± 1.48; Amicus: 56.32 ± 2.80; p < 0.01). Regarding the content of collected MNCs (×10⁶/kg body weight), the Spectra Optia offline system was superior to the other systems (Optia: 42.69 ± 1.42; Therakos: 31.21 ± 1.66; Amicus: 27.56 ± 1.54; p < 0.01).

CONCLUSIONS

This study represents the first direct comparison of the new Amicus Blue inline system with the two most commonly used ECP systems in the same patient cohort of a single center. The data show that the Amicus Blue inline system collects sufficient MNCs to perform an ECP, but it has a significantly lower CE than the other systems and a significantly lower amount of collected MNCs than the Spectra Optia offline system.

Treatment of acute and chronic graft-versus-host disease with extracorporeal photopheresis: Update of best practice recommendations from Italian Society of Hemapheresis and Cell Manipulation (SIdEM) and the Italian Transplant Group for Bone Marrow Transplantation, Hematopoietic Stem Cells and Cell Therapy (GITMO)

These guidelines represent a GRADE-method revision of the recommendations produced by the Italian Society of Hemapheresis and Cell Manipulation (SIDEM) and the Italian Transplant Group for Bone Marrow Transplantation, Hematopoietic Stem Cells and Cell Therapy (GITMO) in 2013. Since 2013 several studies have been published that have strengthened the role of ECP in the management of GVHD. Thus, it was deemed appropriate to proceed with an update, with the aim to define uniform criteria for the application of ECP in adult and pediatric patients affected by GVHD throughout the national territory, in line with international guidelines, in maintaining of high standards of safety for patients and quality of the procedures provide. Post-HSCT GvHD therapies other than ECP and ECP therapy of other diseases, such as CTCL, are not covered by these guidelines.The development panel for this guideline includes professionals from various specialties who routinely interact in the management of the patient with GVHD, namely the transfusionist, the adult and pediatric hematologist, and the hospital pharmacist. A hematologist experienced in systematic reviews and GRADE guideline development ccordinated the development process, and an experienced transfusionist coordinated the assignment of tasks and reporting. External reviewers of the guideline included a patient representative.

The Role of Extracorporeal Photopheresis in the Management of Graft Versus Host Disease: Narrative Review

Hematopoietic stem cell donation is a method used to treat both blood-related and non-blood-related malignancies. Graft-versus-host disease is a potentially life-threatening complication that can occur following a stem cell transplant from a donor. This happens after the transplanted grafts attack the recipient's body as foreign cells, causing significant morbidity and mortality. Clinically, this condition can be classified as acute or chronic based on onset and pathophysiology. This review aims to provide an overview of recent studies on extracorporeal photopheresis as a treatment strategy option for graft-versus-host-diseased patients. It will explain how it treats graft-versus-host disease, summarize its promising effects, and provide future recommendations for its use in treating this illness. Extracorporeal photopheresis is used to treat graft-versus-host disease by collecting and separating white blood cells from the patient. This blood is fractionated into different parts, and white blood cells undergo treatment with 8-methoxy psoralen, a photoactivable drug, before exposure to ultraviolet light A. Lastly, the cells that have been treated are reinfused into the recipient's body. It prompts the programmed cell death of lymphocytes and the engulfment of cellular debris by host antigen-presenting, leading to a subsequent rise in T regulatory cells. However, more experimental and randomized controlled studies are required to identify the best patient selection requirements, environments, and treatment regimens for graft-versus-host disease.

Recent insights into extracorporeal photopheresis for graft-versus-host disease

INTRODUCTION

Extracorporeal Photopheresis (ECP) may be considered the unique large-scale cell therapy currently available. It is currently employed mainly as second-line treatment, especially in steroid-resistant or steroid-dependent Graft versus Host Disease (GvHD) with good results and very few limitations.

AREAS COVERED

Many points need to be clarified regarding the ECP mechanism of action, that conditions the lack of uniqueness among the different centers, essentially cycle frequency, treatment duration, and the number of cells to be treated to obtain a response, according to the organs involved. Moreover, reliable biomarkers for prediction of response are lacking, as well as the best pharmacological combination. We will focus on the recent advances concerning ECP for GvHD treatment. We performed a systematic literature research in Pubmed and Embase as of September 2023.

EXPERT OPINION

The recent studies on ECP mechanism of action along with the promising biomarkers of response, and the synergistic benefit of ECP in association with the new drugs render this therapy an important weapon for GvHD resistant to conventional treatment and can be proposed as a valid first-line therapy option with promising results. We believe that it should be used early in all categories of patients, considering its high safety profile.

Real-World Experience in Extracorporeal Photopheresis for Adults with Graft-versus-Host Disease

Extracorporeal photopheresis (ECP) has shown efficacy in treating graft-versus-host disease (GVHD). We aim to summarize eight years of real-world experience with off-line ECP in our institution, in order to validate this treatment schedule and analyze predictive factors. All consecutive adult patients with steroid-dependent or steroid-refractory GVHD undergoing off-line ECP were included in this single-center retrospective study. ECP was performed with a Spectra Optia device, processing 1 total blood volume, at a twice-weekly frequency for acute GVHD (aGVHD) and once weekly for chronic GVHD (cGVHD), and tapered individually according to clinical response. The cumulative incidence of response, including complete response (CR) and partial response (PR), were compared among patients grouped by different baseline, apheresis, and disease characteristics. Between January 2015 and May 2022, a total of 1382 ECP procedures were proposed for 82 patients. No incidents were reported in 97% of the ECP sessions. GVHD responded in 78% of patients (aGVHD: 57% CR and 4% PR; cGVHD, 39% CR and 48% PR). Overall survival was statistically greater for aGVHD patients who responded to ECP compared to those who did not respond (67.5% versus 26% at 1 year; P = 0.037). Severity was an independent predictor of response in aGVHD, whereas the absence of mouth involvement and lower lymphocyte counts in the apheresis product correlated with a higher response in cGVHD. Our findings support the effectiveness of this treatment schedule for GVHD. Further investigation is required to identify ECP-specific predictive factors, given that findings are not homogeneous across studies.

Extracorporeal Photopheresis in Graft-versus-Host Disease

Graft-versus-host disease (GVHD) is a major cause of mortality and morbidity following allogeneic hematopoietic stem cell transplantation. Extracorporeal photopheresis (ECP), which exposes mononuclear cells to ultraviolet A irradiation in the presence of a photosensitizing agent, has shown efficacy in the treatment of GVHD. Recent observations in molecular and cell biology have revealed the mechanisms by which ECP can reverse GVHD, including lymphocyte apoptosis, differentiation of dendritic cells from circulating monocytes, and modification of the cytokine profile and T cell subpopulations. Technical innovations have made ECP accessible to a broader range of patients; however, logistical constraints may limit its use. In this review, we scrutinize the development of ECP from its origins to recent insights into the biology underlying ECP efficacy. We also review practical aspects that may complicate successful ECP treatment. Finally, we analyze how these theoretical concepts translate into clinical practice, summarizing the published experiences of leading research groups worldwide.

Increasing the collection flow rate to 2 mL/min is effective and reduces the procedure time in off-line photopheresis

BACKGROUND

Extracorporeal photopheresis (ECP) treatment, mostly based on apheresis technology, is used for immunomodulation in various diseases such as cutaneous T-cell lymphoma, graft versus host disease and other (auto)immune disorders. The aim of this study was to collect high cell counts and purity in shorter procedure times using an ECP off-line system with an increased collection flow rate of 2 mL/min to a target volume of 200 mL buffy coat.

STUDY DESIGN AND METHODS

In this prospective study, data of routinely performed off-line photopheresis treatments were collected and analyzed at the Central Institute for Blood Transfusion & Department of Immunology (ZIB) of the Tirol Kliniken, to assess absolute cell counts and procedure times and to calculate collection efficiencies (CE2).

RESULTS

A total of 22 patients participated in this study. The processed blood volume was 4312 mL, the collection time 120 min, overall procedure time 157 min and the absolute cell counts of treated white blood cells (WBC) and mononuclear cells (MNC) were 5.0 and 4.3 × 109 respectively (median values). The calculated CE2 for WBC and MNC was 21.1% and 58.5%, the proportion of treated MNCs of the total number of MNCs present was 55.0%.

CONCLUSION

The data presented in this study show high therapeutically effective cell counts collected with a high MNC purity within a shorter overall collection/procedure time due to an increased collection flow rate.

Optimierung der extrakorporalen Photopherese

Die Extrakorporale Photopherese ist ein etabliertes Therapieverfahren für Patienten mit T-Zell vermittelten Erkrankungen. Dabei besteht das Verfahren aus der Gewinnung autologer mononukleärer Zellen, deren Behandlung mit 8-Methoxypsoralen und UVA-Licht und die Retransfusion der behandelten Zellen.

Die Wirkmechanismen der Photopherese sind zwar noch nicht vollständig geklärt, ein zentraler Mechanismus stellt jedoch die Apoptose mononukleärer Zellen dar. Das Ziel der Studie war eine Optimierung der Photopherese im Hinblick auf die Behandlung der Zellen mit 8-Methoxypsoralen/UVA und der daraus induzierten verstärkten Apoptose der Lymphozyten. Dabei sind einige Faktoren bekannt, welche die Effektivität der 8-Methoxypsoralen/UVA-Behandlung der Zellen beeinflussen können, wie z.B. der Hämatokrit oder die UVA-Dosis. Unser Fokus lag auf der Verfügbarkeit der photoaktiven Substanz und dem Einfluss der Zellsuspensionsmatrix auf die Apoptose der Lymphozyten.

Die Verfügbarkeit von 8-Methoxypsoralen für die Aufnahme in die Zellen reduzierte sich durch Absorption an Kunststoffe der Bestrahlungssysteme sowie durch Bindung an Proteine bei der Verwendung von autologem Plasma bei der Suspendierung der Zellen. Eine Steigerung der Zugabe von 8-Methoxypsoralen auf 340 ng/mL anstelle von 200 ng/mL führte zu einem Anstieg der T-Zell Apoptose, die sich unter Verwendung von physiologischer Kochsalzlösung als Zellsuspensionsmatrix weiter erhöhte. Eine Anpassung des Verfahrens mit NaCl anstelle von Plasma und die Verwendung einer höheren 8-Methoxypsoralen Konzentration führte zu einer gesteigerten Apoptoseinduktion der T-Zellen. Inwiefern sich eine Erhöhung der Apoptose auf die klinische Wirksamkeit auswirkt, bedarf hingegen noch weiterer klinischen Untersuchungen.

Extracorporeal photopheresis in acute and chronic steroid‑refractory graft-versus-host disease: an evolving treatment landscape

Patients with steroid-refractory graft-versus-host disease (GvHD) are known to have a poor prognosis and for decades no approved drug has been available to treat this serious condition. Although ruxolitinib, a selective Janus kinase (JAK)1/2 inhibitor demonstrated significantly higher response rates in randomized trials compared to the best available therapy, and thus, is of benefit in both acute as well as chronic GvHD, there is an urgent medical need to improve results, such as durability of responses, response in eye, liver and lung manifestations and reduction of infectious complications. In this "Review" article we would like to offer strategies for improving treatment results in patients with steroid-refractory GvHD by combining ruxolitinib with extracorporeal photopheresis (ECP), a leukapheresis-based immunomodulatory treatment frequently applied in T-cell mediated immune disease including GvHD. Our article explores key published evidence supporting the clinical efficacy of both ruxolitinib and ECP in the treatment of GvHD and highlights their potentially complementary mechanisms of action.

Extracorporeal photopheresis in the treatment of acute graft-versus-host disease: A multicenter experience

BACKGROUND AND OBJECTIVES

Extracorporeal photopheresis (ECP) is one of the second-line treatment strategies in steroid-refractory acute graft-versus-host disease (aGvHD). We aimed to share our multicenter experience using ECP in our steroid-refractory aGvHD patients.

MATERIALS AND METHODS

A retrospective observational series of 75 aGvHD patients from 4 transplant centers were analyzed. All ECP procedures were performed with the off-line system. All patients received ECP as second-line therapy.

RESULTS

74.7 % of aGvHD patients were grade 3 or 4. The overall response rate was 42.7 % (32/75) in aGvHD including 17 complete responses (22.7 %). Median follow-up was 6 months (range, 1-68). Median overall survival (OS) was 5 months for non-responders and 68 months for responders (p < 0.001). Twenty-seven (36 %) patients are alive, and 48 (64 %) patients have died.

CONCLUSIONS

Early initiated ECP could be an effective treatment alternative in patients with steroid-refractory aGvHD.

[Management of patients developing acute gastro-intestinal graft-versus-host-disease: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

Graft-versus-host disease (GVHD) is the most common complication after allogeneic hematopoietic cell transplantation (allo-HCT) with a frequency range of 30% to 50%. GVH is the leading cause of non-relapse-related deaths and a cause early mortality. Gastro-intestinal (GI) GVH results in digestive manifestations that involve the small intestine and the colon. The patient may then have diarrhea, intestinal bleeding, abdominal pain but also clinical signs such as nausea and vomiting may lead to anorexia. GI-GVHD promotes undernutrition as well as significant losses of vitamins and trace elements. In the case of post-transplant diarrhea, differential diagnosis can include GI-GVHD, infection and drug toxicity. Although, corticosteroids w/wo calcineurin inhibitors represent the standard of care in first line treatment, there is no consensus regarding salvage therapy in case of corticoresistant GI-GVH. In addition, assessment of early nutritional status would help combating undernutrition, which is an independent risk factor for mortality in patients with GI-GVHD. In this workshop of the Fancophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) we focused on the management of patients developing GI-GVHD following allo-HCT.

Current Prophylaxis and Treatment Approaches for Acute Graft-Versus-Host Disease in Haematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukaemia

Acute graft-versus-host disease (aGvHD) continues to be a leading cause of morbidity and mortality following allogeneic haematopoietic stem cell transplantation (HSCT). However, higher event-free survival (EFS) was observed in patients with acute lymphoblastic leukaemia (ALL) and grade II aGvHD vs. patients with no or grade I GvHD in the randomised, controlled, open-label, international, multicentre Phase III For Omitting Radiation Under Majority age (FORUM) trial. This finding suggests that moderate-severity aGvHD is associated with a graft-versus-leukaemia effect which protects against leukaemia recurrence. In order to optimise the benefits of HSCT for leukaemia patients, reduction of non-relapse mortality-which is predominantly caused by severe GvHD-is of utmost importance. Herein, we review contemporary prophylaxis and treatment options for aGvHD in children with ALL and the key challenges of aGvHD management, focusing on maintaining the graft-versus-leukaemia effect without increasing the severity of GvHD.

CD11c+ dendritic cells mediate antigen-specific suppression in extracorporeal photopheresis

Extracorporeal photopheresis (ECP) represents one of the most widespread and effective cell therapies for graft‐versus‐host disease and other T cell‐mediated disorders. However, the key factors affecting the therapeutic efficacy of ECP remain unclear. We hypothesized that therapeutic effects are mediated by ECP‐treated antigen‐presenting dendritic cells (DC). To test this hypothesis, we used the experimental model of contact hypersensitivity (CHS). The ECP’s therapeutic activity improved when the total cell dose of the ECP‐treated cells was increased. We used different haptens during sensitization to demonstrate that the anti‐inflammatory activity of ECP is antigen‐specific. This confirmed the hypothesis that professional antigen‐presenting cells are involved in the mode of action. Also, the ECP’s therapeutic activity was abrogated by the depletion of CD11c⁺ DC, which represents fewer than 1% of all the ECP‐exposed cells. Finally, we confirm the critical importance of CD11c⁺ DC for ECP activity by showing that only a few purified CD11c⁺ DC are sufficient to mediate its therapeutic effect. The finding that ECP‐treated, physiological antigen‐presenting DC alone mediate antigen‐specific modulation of a pathological immune response may result in better‐targeted interventions when treating patients.

Inline and offline extracorporeal photopheresis: Device performance, cell yields and clinical response

BACKGROUND

Extracorporeal photopheresis (ECP) is an effective treatment for graft-vs-host-disease (GvHD). Photopheresis can be performed in offline or inline method. The first uses a conventional cell separator for collection of mononuclear-cells that are photoactivated by a separate device and manually reinfused; the second one involves a dedicated device performing the entire procedure (collection, photoactivation and reinfusion).

STUDY DESIGN AND METHODS

The objective was to compare the two methods and cell product features to highlight key process, devices performance, and to evaluate ECP clinical response. Patients developing steroid-resistant GvHD underwent ECP as second-line treatment using either inline (Therakos CellEx) or offline system (Terumo BCT Spectra or Optia and UVA PIT system). Data about patients' features, pre-apheresis blood-count, cell product characteristics and clinical response were collected for analysis.

RESULTS

We evaluated 494 procedures performed on 28 patients from April 2018 to March 2019. The offline procedure allows to achieve greater cell yield, it is characterized by larger processed blood volume, longer runtime, and higher ACD consumption. The inline procedure shows shorter runtime, high mononuclear-cells percentage and low percentage of granulocytes in cell product. We observed a significant difference in cell yields between inline and offline system; furthermore we did not find a significant relationship between cell dose and clinical response.

CONCLUSION

Inline ECP is fast, highly automated and productive, making it particularly suitable for ECP treatments. Offline ECP collects high cell yields implying longer procedure and greater operator intervention. Our study did not find a significant relationship between cell dose and GVHD response.

Does Offline Beat Inline Treatment: Investigation into Extracorporeal Photopheresis

Background

Extracorporeal photopheresis is a therapy based on the induction of apoptosis to cells harvested from peripheral blood, followed by direct retransfusion. Currently, there are two approaches: inline procedures, where cell harvesting, 8-methoxypsoralen (8-MOP) incubation, and UV irradiation is performed with a single device, and offline procedures, with collection in one device, followed by 8-MOP incubation/UV irradiation using a second device.

Study Design and Methods

In a prospective crossover study, we compared an inline (Cellex, Therakos) with an established offline procedure (Optia, Terumo, and MacoGenic G2, Macopharma) in 6 patients, focusing on cell composition and apoptosis induction after 24 h. In total, 32 photopheresis treatments per device were performed.

Results

We observed an overall 2-fold higher number of apoptotic "target" cells for each patient with offline treatment. All yields were stratified per patient. Yields were compared as ratio offline/inline for CD3+ (2.5-fold), CD4+ (2-fold), CD8+ (2.8-fold), CD56+ (2.8-fold), CD19+ (1.8-fold), CD15+ (0.5-fold), and CD14+ (2.2-fold) cells. Apoptosis induction was measured after 24 h with Annexin V/7-AAD for early and late apoptosis rates of CD3+ (CD4+, CD8+) and CD56+ cells. CD3+ cells of the inline treatment had an average of 88% (26% early, 62% late) of apoptotic cells compared to 75% (34% early, 41% late) in the offline treatment. Procedure duration ranged from 80 to 100 min inline, with a maximum of 1,500 mL processed blood, and 125-140 min offline, with at least 3,000 mL processed blood, depending on blood flow. Average hematocrit levels of the products were 2.7% inline versus 1.7% offline.

Conclusions

The offline procedure, as established in our department, provides more apoptotic cells for treatment. The increased number of mononuclear cells collected outweighs a slightly reduced apoptosis rate after 24 h in comparison to the inline procedure. Besides this, the final decision for one or the other procedure has to take into account additional aspects, such as peripheral white blood cell count, hematocrit, and weight of the patient, required before apheresis, extracorporeal volume, and, last but not least, overall costs. The final criterion, however, has to be the reported clinical efficacy of the system applied.

Extracorporeal photopheresis as first-line strategy in the treatment of acute graft-versus-host disease after hematopoietic stem cell transplantation: A single-center experience

BACKGROUND AIMS

Corticosteroids are the standard first-line treatment for acute graft-versus-host disease (aGVHD), but they are associated with many complications, and less than half of patients have a sustained response.

METHODS

To improve outcomes, we performed a retrospective study to analyze the efficacy of the addition of extracorporeal photopheresis (ECP) to low-dose corticosteroids in 37 adult patients (median age, 57 years) with skin-predominant aGVHD (grade I, n = 17; grade II, n = 18; and grade III, n = 2). All patients received ECP in combination with 1 mg/kg prednisone (n = 26) or topical steroids (n = 11).

RESULTS

Overall response rate was 81% after a median of three ECP procedures (range, 2-8), including 22 complete responses (CR, 59%) and eight very good partial responses (VGPR, 22%). The 11 patients treated with topical corticosteroids achieved CR. Furthermore, 16 (62%) patients reached prednisone withdrawal at a median of 100 days (range, 42-174 days) after its initiation. Eighteen patients developed chronic GVHD (cGVHD); 11 of them (who were in CR of aGVHD) had a new-onset cGVHD, and seven experienced progressive cGVHD (five non-responding and two VGPR patients). A second-line immunosuppressive treatment was initiated in only five (14%) non-responding patients. With a median follow-up of 31 months (range, 6-57 months) 2-year overall survival and non-relapse mortality were 74% and 11%, respectively.

CONCLUSIONS

Overall, the combination of low-dose corticosteroids and ECP appear to be safe and effective for first-line treatment of skin predominant aGVHD.

How I treat steroid-refractory acute graft-versus-host disease

Steroid-resistant or steroid-refractory acute graft-versus-host disease (SR-aGVHD) poses one of the most vexing challenges faced by providers who care for patients after allogeneic hematopoietic cell transplantation. For the past 4 decades, research in the field has been driven by the premise that persistent graft-versus-host disease (GVHD) results from inadequate immunosuppression. Accordingly, most efforts to solve this problem have relied on retrospective or prospective studies testing agents that have direct or indirect immunosuppressive effects. Retrospective studies far outnumber prospective studies, and no controlled prospective trial has shown superior results for any agent over others. Truth be told, I do not know how to treat SR-aGVHD. Preclinical work during the past decade has provided fresh insights into the pathogenesis of acute GVHD, and translation of these insights toward development of more effective treatments for patients with SR-aGVHD has at last begun. Given the limited state of current knowledge, this "How I Treat" review highlights the overriding imperative to avoid harm in caring for patients with SR-aGVHD. Prospective trials that are widely available are urgently needed to advance the field.

Retrospective Multicenter Study of Extracorporeal Photopheresis in Steroid-Refractory Acute and Chronic Graft-versus-Host Disease

Extracorporeal photopheresis (ECP) is an established treatment strategy in steroid-refractory graft-versus-host disease (GVHD). This study's main objective was to analyze the clinical response and impact of ECP therapy in steroid dose reduction. A retrospective observational series of 113 patients from 7 transplantation centers was analyzed. Sixty-five patients (58%) had acute GVHD (aGVHD), and 48 (42%) had chronic GVHD (cGVHD). All ECP procedures were performed with the off-line system. The median number of procedures until achievement of initial response was 3 for both patients with aGVHD and those with cGVHD. ECP was the second-line therapy in 48% of the aGVHD cases and in 50% of the cGVHD cases. 71% of the cases of aGVHD were grade III-IV, and 69% of the cases of cGVHD were severe. The overall response rate on day 28 was 53% (complete response [CR] rate, 45%) in the patients with aGVHD and 67% (CR, 23%) in those with cGVHD. Skin was the most frequently involved organ, with a response rate of 58% (CR, 49%) in the patients with aGVHD and 69% (CR 29%) in those with cGVHD. At the end of ECP treatment, 60% of patients treated for aGVHD who responded were able to stop steroid therapy, with a median dose reduction of 100%. Significant differences in overall survival were observed for patients responding to ECP with aGVHD (hazard ratio [HR], 4.3; P < .001) and with cGVHD (HR, 4.8; P = .003). Our data indicate that ECP is a valid therapeutic alternative in patients with steroid-refractory aGVHD and cGVHD, permitting significant steroid dosage reductions.

Inline extracorporeal photopheresis: evaluation of cell collection efficiency

BACKGROUND

Extracorporeal photopheresis (ECP) therapy has proved to be an effective and safe treatment for graft-versus-host-disease (GvHD), an important complication after hematopoietic stem cell transplantation. In 2016, we acquired Therakos CellEx, a dedicated inline ECP device to accomplish a significant increase in ECP activity. In literature, we found few data reporting CellEx performance evaluated in terms of collection efficiency to qualify the device. Hence, we decided to collect and analyze our data in order to build a reference in terms of expected results of the procedure. Here we report our data of ECP performed using CellEx in a 12-month period focusing on collection efficiency assessment, as well as procedural and apheretic product characteristics.

STUDY DESIGN AND METHODS

We collected data of patients undergoing ECP from April 2018 to March 2019 using CellEx in order to evaluate collection efficiency.

RESULTS

Between April 2018 and March 2019 we treated 28 adult patients affected by GvHD performing 319 ECP using CellEx. CellEx mononuclear cell product was characterized by high mononuclear cell percentage and low percentage of granulocytes, resulting particularly suitable for ECP treatments. Median collection efficiency for total nucleated cells and for mononuclear cells was 31.2% and 62.3%, respectively.

CONCLUSION

Collection efficiency of CellEx was comparable to that usually obtained by cell separators designed for cell collection and was comparable to that of offline systems. Our results provide a detailed performance evaluation for inline ECP system users.

An automated mini buffy coat preparation method for use in mini extracorporeal photopheresis treatment of graft-vs-host-disease in a low body weight pediatric patient

A mini extracorporeal photopheresis (mini-ECP) "off line" technique has been developed for use in the treatment of small children and patients with apheresis contraindications. Until now various methods have been used for buffy coat separation from whole blood. In this report we describe a protocol for mini buffy coat preparation using the automated Sepax laboratory separator for "off line" ECP treatment in a low body weight child with graft-vs-host-disease. According to our results this alternative method has been proven feasible and tolerable.

A paired trial comparing mononuclear cell collection in two machines for further inactivation through an inline or offline extracorporeal photopheresis procedure

BACKGROUND

Extracorporeal photopheresis (ECP) is an effective treatment. However, protocols differ widely, and some questions, such as the number of cells to be collected or the number of ECP treatment days per treatment cycle, are still unsolved. The aim of this study was to compare a multistep (offline) (Spectra Optia and Macogenic G2) against an integrated (inline) ECP system (Therakos Cellex system) with respect to mononuclear cell (MNC) collection.

STUDY DESIGN AND METHODS

The number and quality parameters of the MNC products collected were evaluated together with some machine parameters, such as collection time. Comparisons were made through paired sample analysis with the t test.

RESULTS

Fourteen patients underwent 15 double-paired procedures using both ECP protocols. The average MNC collected in the multistep procedure was 77.4 × 10⁸ , four times more than in the integrated procedure (18.5 × 10⁸ ). MNC purity (84.4% vs. 63.8%) and enrichment (27.9 vs. 5.9) in the product collected were also higher in the multistep procedure. The whole ECP time was higher in the multistep than in the integrated procedure (272 vs. 106 min), but the calculated time to collect 25 × 10⁸ MNCs in the multistep was shorter compared with the one-step procedure (77.8 vs. 172 min). All these differences between the two protocols were statistically significant.

CONCLUSIONS

These two ECP protocols are different with respect to MNC collection and length of procedure. Some unresolved questions, such as the better MNC dose to inactivate or the number of consecutive days that ECP should be performed for optimal clinical efficacy, require further review.