Chokri Ben Lamine: Extracorporeal Photopheresis for aGVHD cGVHD Post-SCT – 50 Pearls

Chokri Ben Lamine, Adult Hematology and SCT Assistant Consultant at Oncology Center of Excellence at King Faisal Specialist Hospital and Research Center, shared a post on X:

“Extracorporeal Photopheresis (ECP) for aGVHD cGVHD Post-SCT – 50 Pearls

Fundamentals and Mechanism

1.ECP is an immunomodulatory therapy, not an immunosuppressive treatment.

2.It involves leukapheresis, photoactivation with 8-methoxypsoralen (8-MOP), and UVA exposure.

3.UVA exposure induces apoptosis of pathogenic T cells.

4.Promotes immune tolerance through regulatory T-cell (Treg) expansion.

5.Modulates dendritic cell function toward a tolerogenic phenotype.

6.Reduces inflammatory cytokines such as TNF-α and IL-2.

7.Restores immune homeostasis without increasing infection risk significantly.

8.Preserves graft-versus-leukemia (GVL) effect.

9.Ideal steroid-sparing therapy.

10.Minimizes long-term toxicity compared with systemic immunosuppression.

Indications

11.Second-line therapy for steroid-refractory acute GVHD (aGVHD).

12.Standard second-line treatment for chronic GVHD (cGVHD).

13.Particularly effective in steroid-dependent GVHD.

14.Highly beneficial in cutaneous GVHD.

15.Effective in pulmonary GVHD, including bronchiolitis obliterans.

16.Useful in oral and mucosal cGVHD.

17.Effective in sclerodermatous cGVHD.

18.Beneficial in ocular GVHD.

19.Can be used in gastrointestinal GVHD.

20.Suitable for both adult and pediatric SCT recipients.

Technique and Protocol

21.Peripheral or central venous access is required.

22.Standard schedule: two consecutive treatments per cycle.

23.aGVHD: typically administered 2–3 times weekly.

24.cGVHD: administered every 1–2 weeks initially.

25.Gradual tapering based on clinical response.

26.Mononuclear cells are collected via leukapheresis.

27.Cells are incubated with 8-MOP before UVA exposure.

28.Photoactivated cells are reinfused into the patient.

29.Each session lasts approximately 2–3 hours.

30.Typically performed as an outpatient procedure.

Outcomes and Efficacy

31.Overall response rates in cGVHD: 60–80%.

32.Best responses seen in skin and oral cGVHD.

33.aGVHD response rates range from 50–70%.

34.Significant steroid-sparing effect.

35.Improves quality of life and functional status.

36.Stabilizes or improves lung function in BOS.

37.Reduces skin fibrosis and sclerosis.

38.Associated with improved overall survival in responders.

39.Enables tapering of calcineurin inhibitors.

40.Does not compromise immune reconstitution significantly.

Precautions and Safety

41.Advise sun protection for 24 hours after treatment.

42.Patients must wear UVA-protective sunglasses.

43.Monitor for hypotension due to extracorporeal volume shifts.

44.Watch for anemia and thrombocytopenia.

45.Low risk of opportunistic infections compared with other therapies.

46.Strict aseptic technique to prevent line-related infections.

47.Dose adjustments may be needed in low body weight patients.

48.Use cautiously in pregnancy due to psoralen exposure.

49.Avoid in patients with photosensitivity disorders.

50Requires multidisciplinary coordination among hematology, transfusion medicine, and apheresis teams.

References

• American Society of Hematology. GVHD Guidelines.
• European Society for Blood and Marrow Transplantation. GVHD Management Handbook.
• National Comprehensive Cancer Network. NCCN Guidelines for Hematopoietic Cell Transplantation.
• Malik MI, et al. Extracorporeal photopheresis in GVHD. Transfusion and Apheresis Science.
• Knobler R, et al. ECP Guidelines. Journal of the European Academy of Dermatology and Venereology.”

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