1. A single centre study of the efficacy of extracorporeal photopheresis in Acute Graft Versus Host Disease Lynne Watson Nottingham University Hospital NHS Trust

2. Acute Graft-Versus-Host Disease Major complication of allogeneic HSCT. Triggered by immunocompetent donor cells. Incidence 30-50% in sibling and up to 80% in MUD transplants

3. GVHD Syndrome After Allotransplant Day 050100180 1 y2 y 3 y 5 y Acute GVHD: rash, GI, liverChronic GVHD: skin, eyes, mouth, GI liver, musculoskeletal, lungs, GU - Classic acute - Late acute- Classic chronic - Chronic overlap Activity Damage (inflammation) i n j u r y r e p a i r (fibrosis) Alloreactivity Autoimmunity Immunodeficiency

4. Treatment of severe acute GvHD High dose steroids (2mg/kg/day) is standard approach for the treatment of grade II-IV acute GvHD treatment ~ 40-50% of patients with grade II-IV disease are steroid responsive Higher response rates in grade II compared to grade III/IV disease and in patients with one organ involved compared to 2 or 3. Responses are worse in patients receiving MUD transplants. Overall CR is only seen in 25-40% of patients

5. Options for second line therapy for GVHD Second Line Therapy For AGVHD ATGRituximab CD5 Immunotoxins Etanercept Anti-TNF Mycophenolate MofetilSirolimus Extracorporeal photopheresis

6. Extracorporeal Photopheresis (ECP) ECP is based upon the re-infusion of apoptotic autologous blood mononuclear cells which have been treated extracorporeally with the DNA intercalating agent 8 – methoxypsoralen and then irradiated with PUVA ECP has demonstrated efficacy in selected T cell diseases including chronic GvHD and cutaneous T cell lymphoma The experience of ECP in Acute GVHD is much less than that with chronic. Greinix et al (2006) reported a phase II study of 59 patients treated with ECP for steroid refractory acute GvHD using an intensive schedule of a cycle of therapy ( 2 consecutive daily treatments) weekly for 8 weeks

7. ECP Schedule for acute GVHD We established an ECP programme for acute and chronic GVHD in Nottingham in 2006 using the Therakos XTS system Previously we had used ATG in this setting but with a poor response and a high incidence of infectious complications 18 consecutive patients with steroid-refractory acute GVHD have been treated with twice weekly ECP at weekly intervals for a planned 8 week course (Greinix schedule) In 2009 we started using the new Cellex system for suitable patients

8. ECP for Acute GVHD 18 consecutive patients with steroid-refractory acute GVHD post BMT (n=11) or DLI therapy (n=7) GVHD was grade II in 2, grade III in 6 and grade IV in 10 patients. 66% of patients had 2 or 3 organ involvement 66% of patients had 2 or 3 organ involvement Patients had been on steroids (2mg/kg) for a median of 14 days (7-88 days) before starting ECP. The aim was to achieve a rapid steroid taper in responding patients

11. Results – Response at 8 weeks Primary end point of the analysis was the response after 8 weeks of ECP therapy. CR was arbitrarily defined as resolution of features of acute GvHD with a reduction of prednisolone dose to 10mg/day or less 12/18 patients have completed 8 weeks of ECP 6 died of progressive GvHD prior to completing their 8 weeks of allocated ECP therapy. 6 died of progressive GvHD prior to completing their 8 weeks of allocated ECP therapy.

13. Overall Response to ECP All of the 12 /18 (66%) patients who completed 8 weeks of therapy have responded. In the 12 patients who have completed the 8 weeks of therapy CR was achieved in 8. 4 patients achieved a partial response but remained on higher dose of steroids than 10mg/day at 8 weeks. Response was dependent upon severity and extent of GvHD.

14. Example of Bilirubin Response Rates to ECP Wk 1 494 Wk 2 396 Wk 3 313 Wk 4 283 Wk 5 426 Wk 6 252 Wk 7 187 Wk 8 142 Wk 1 235 Wk 2 103 Wk 3 88 Wk 4 69 Wk 5 44 Wk 6 24 Wk 7 21 Wk 8 15

15. Updated Outcome on Responding Patients Median follow-up is now 2 years. 8 patients have developed chronic GvHD and remain on some immunosuppression. This includes 2 patients with major relapse of liver GVHD 4-6 months after stopping ECP. Both patients responded to re-starting ECP therapy. 3 patients have no GvHD and are off all immunosuppression. 1 patient who had a PR to ECP died of HHV 6 encephalitis. Only 1 patient has had relapsed of their disease.

16. Summary 12/18 patients with grade II - IV steroid-refractory acute GvHD completed their scheduled 8 weeks course of intensive ECP All patients responded with 8 achieving CR and 4 PR Excellent and rapid responses were seen in patients with isolated skin or liver GvHD. The response rate was lower in patients with 3 organ involvement 5/7 patients who developed GVHD post DLI responded 8 patients survive >12 months post completion of ECP and 3 patients are off all immunosuppression 2 patients have had significant relapse of liver GVHD and both responded again to re-introduction of ECP 8 patients survive >12 months post completion of ECP