Steroid-refractory cGVHD Research Articles

Decreased pro‐inflammatory cytokines and increased CCR7 expression on T‐lymphocyte subsets are predictive of response to extracorporeal photopheresis in patients with GvHD

Decreased pro‐inflammatory cytokines and increased CCR7 expression on T‐lymphocyte subsets are predictive of response to extracorporeal photopheresis in patients with GvHD

Rituximab Treatment in Chronic GVHD: Clinical Efficacy Associates With Restoring a Physiological B-Cell Balance

Rituximab Treatment in Chronic GVHD: Clinical Efficacy Associates With Restoring a Physiological B-Cell Balance

Tirosin Kinase Inhibitors in Chronic Graft versus Host Disease: From Bench to Bedside

Chronic Graft Versus Host Disease (cGVHD) is a major complication of allogeneic stem-cell transplantation (SCT). In many inflammatory fibrotic diseases, such as Systemic Scleroderma (SSc) and cGVHD with fibrotic features, an abnormal activation of transforming growth factor (TGFβ) and platelet-derived growth factor receptor (PDGF-R) pathways have been observed. Tyrosin Kinase Inhibitors (TKIs), which are currently used for treatment of patients with Chronic Myeloid Leukemia (CML), share potent antifibrotic and antiinflammatory properties, being powerful dual inhibitors of both PDGF-R and TGFβ pathways. Moreover accumulating in vitro data confirm that TKIs, interacting with the TCR and other signalling molecules, carry potent immunomodulatory effects, being involved in both T-cell and B-cell response. Translation to the clinical setting revealed that treatment with Imatinib can achieve encouraging responses in patients with autoimmune diseases and steroid-refractory cGVHD, showing a favourable toxicity profile. While the exact mechanisms leading to such efficacy are still under investigation, use of TKIs in the context of clinical trials should be promoted, aiming to evaluate the biological changes induced in vivo by TKIs and to assess the long term outcome of these patients. Second-generation TKIs, with more favourable toxicity profile are under evaluation in the same setting.

Effects of Daily Low Dose IL-2 Therapy on Homeostatic Regulation of CD4+Foxp3+ Regulatory T Cells In Patients with Chronic Graft-Versus-Host Disease

AbstractAbstract 895CD4+FoxP3+ regulatory T cells (Treg) play a central role in the maintenance of tolerance after allogeneic hematopoietic stem cell transplantation (HSCT) and recent studies have demonstrated that Treg deficiency leads to the development of chronic GHVD (cGVHD). Interleukin-2 (IL-2) is known to promote thymic generation and maintenance of peripheral Treg and IL-2 deficiency results in a profound deficiency of Treg in vivo. Based on these findings we initiated a clinical trial to evaluate the safety, clinical efficacy and immunologic effects of low dose recombinant IL-2 in patients with steroid-refractory cGVHD. We recently reported the clinical outcomes of this trial demonstrating that IL-2 administration preferentially increased Treg in patients with active cGVHD and resulted in clinical improvement with only minor toxicities (Koreth et al, ASBMT 2010). However, the mechanisms responsible for Treg expansion in patients during IL-2 administration have not been characterized. To elucidate these mechanisms, we examined phenotypic and functional characteristics of Treg in 14 patients who received daily subcutaneous IL-2 (3×105-3×106IU/m2/day) for 8 weeks. Peripheral blood samples were obtained before and at 1, 2, 4, 6, 8, 10 and 12 weeks after starting IL-2. Treg were compared to conventional CD4+FoxP3- T cells (Tcon) within individual patient samples and examined for expression of Ki-67, PD-1 and BCL-2. In some experiments, Treg and Tcon were further divided into subpopulations by the expression of CD45RA and CD31. Absolute numbers of functionally suppressive Treg increased 5-fold in the first 4 weeks of therapy. Treg numbers then slowly decreased despite continued IL-2 therapy, but remained 2-fold higher than baseline at 8 weeks. Absolute numbers of Tcon increased 2-fold in the first 4 weeks and then returned to baseline levels at 8 weeks. This resulted in a sustained increase of Treg/Tcon ratio for the entire duration of therapy, which persisted for at least 4 weeks after treatment was completed. Plasma IL-2 levels peaked at 1 week and gradually declined despite continued treatment at the same dose. Nevertheless, IL-2 levels remained significantly higher than baseline throughout treatment (median 1.4pg/ml at baseline and 18.1pg/ml at 8 weeks, p<0.05). The proliferative response to IL-2 was examined by measuring expression of Ki-67 in each subset. Initially, Ki-67 expression in Treg rapidly increased in an IL-2 dose-dependent manner. Ki-67 also increased in Tcon but at a significantly lower level (median 20.0% Treg vs 6.7% Tcon, p=0.0001). Increased Ki-67 was seen in both CD45RA+CD31+ recent thymic emigrant Treg (RTE-Treg) and CD45RA- activated/memory Treg (MEM-Treg) at similar levels (median 20.1% and 18.5%, respectively, p=0.54). Treg proliferation peaked in the first week of IL-2, and rapidly returned to baseline levels in weeks 2–3. Despite changes in proliferation, the absolute number of RTE-Treg remained significantly elevated (median 1.05/ul at baseline, 9.43/ul at 4 weeks, p=0.001). In contrast, the absolute number of RTE-Tcon did not change. Phenotypic analysis of Treg showed that expression of both PD-1 and BCL-2 increased during IL-2 therapy (%PD-1+ Treg; median 15.7% at baseline and 38.3% at 8 weeks, p=0.02: relative BCL-2 MFI; median 1.00 at baseline and 1.59 at 8 weeks, p=0.04). To determine the functional effects of these changes on susceptibility to apoptosis, Treg and Tcon were purified and cultured with or without agonistic FAS antibody, and apoptosis was measured using Annexin-V staining. Remarkably, Treg obtained during IL-2 therapy were relatively resistant to apoptosis compared to baseline. In summary, these results indicate that the selective expansion of Treg during prolonged IL-2 administration is characterized by a series of homeostatic changes. Initial high levels of IL-2 lead to selective and rapid Treg proliferation. Treg proliferation is not maintained as numbers of Treg increase and IL-2 levels decrease. Subsequent maintenance of increased Treg appears to be mediated primarily by increased resistance to apoptosis and prolonged survival. Increased thymic output of Treg also appears to support this peripheral homeostatic process. These findings demonstrate the complex effects of IL-2 on Treg homeostasis and provide important information for developing strategies to promote immune tolerance. Disclosures:No relevant conflicts of interest to declare.

Imatinib Is Safe and Effective In Patients with Refractory Chronic Graft Versus Host Disease: Analysis of Two Consecutive Prospective GITMO* Studies.*Gruppo Italiano Trapianto Midollo Osseo

AbstractAbstract 246 Introduction.Chronic graft versus host disease (cGvHD) remains a serious and potentially lethal complication following allogeneic hemopoietic stem cell transplants (HSCT). Imatinib may be a treatment option, because of its inhibitory activity on platelet derived growth factor (PDGF)(Svegliati Blood 2007; 110:237). Last year we reported a first feasibility study in 19 patients, receiving Imatinib as compassionate use for refractory cGVHD, with encouraging results (Blood 2009;114:709). We have treated an additional 25 patients (with Imatinib supplied by Agenzia Italiana del Farmaco-AIFA) using similar inclusion/exclusion criteria, and are now reporting response rates on 44 patients, with a median follow up of 31 months. Patients and methods.Overall 44 patients with cGVHD, refractory to two or more lines of therapy, including steroids, have been consecutively enrolled: 29 were male and 15 female, with median age 38 years (range 10–67). Median duration of cGVHD was 35 (range 6–148) months and all patients received ≥2 lines of therapy, (22 previously treated with ECP and/or Rituximab). The main cGVH targets were represented by lung in 19 patients (Bronchiolitis Obliterans Pneumonia/fibrosis), skin in 38 (generalized scleroderma in 17 and localized in 21); 17 patients had Sicca Syndrome, 9 other visceral manifestations and one severe eosinophilic fasciitis. Imatinib administration was planned for a minimum of 6 months and all patients received the same schedule of Imatinib: in absence of severe toxicity the initial dose of 100 mg/day was increased to 200 mg/day and if no response occurred the dose was increased up to 400 mg/day. The median duration of treatment was 24 months (6-40) and 23 patients are still on Imatinib. Results:the treatment was well tolerated (41 patients were able to complete the treatment for at least 6 months) and we did not observe toxic deaths; the haematological toxicity was mild, only one patient developing a grade 3 anemia, while the main grade 3–4 extrahematological adverse events were infections (3 pneumonia and 1 John Cunningham Virus infection) or fluid retention (2 cases). The response rate (excluding minor responses), evaluated according to the NIH criteria, was 59%, both at 6 months and at 12 months after the start of treatment. In 5 patients we observed the relapse of the underlying disease, while two developed a second tumor (1 diffuse large cell lymphoma and 1 spinocellular carcinoma). With a median follow-up of 31 months (8-40) 33 patients are alive (OS=75 %) and 11 patients died: causes of death were the underlying disease (n=5), second tumour (n=2), and cGVHD (n=4) (2 due to GVHD progression and 2 due to infections). Twenty patients of the original 44 (45%) are still maintaining a response to Imatinib, without requiring additional treatment; 13/44 (29%) are recorded as responders, but, after further treatment. Purified immunoglobulins from 8 patients have now been evaluated for their ability to induce Reactive oxygen species (ROS) output in PDGF-R+ve murine fibroblasts, before and during Imatinib treatment, by using the same methodology previously published)(Svegliati Blood 2007;110:237); at baseline we confirmed the high ROS output in all evaluable patients; interestingly the IgG samples from 4 patients responding to Imatinib, showed a significantly reduced ability to increase ROS output; on the contrary 3 out of the 4 IgG samples from patients refractory to Imatinib, showed a persistence of the ability to trigger the ROS output during treatment with Imatinib. ConclusionsIn conclusion we can confirm safety and efficacy of Imatinib in this larger series of patients with steroid-refractory cGVHD, with promising OS. Whether this benefit is mainly due to the anti-fibrotic effect or to an immunomodulatory effect (or both) induced by Imatinib, remains to be determined. This work has been partly supported by AIFA. Disclosures:Leoni:Celgene: Honoraria.

Positive Effect of Extracorporeal Photopheresis In Reducing Immunosuppression in Patients with Chronic Graft Versus Host Disease.

AbstractAbstract 3452Extracorporeal photopheresis (ECP) has become a recognised treatment for steroid refractory chronic Graft versus Host Disease (cGvHD) but the optimal frequency and duration of treatment has yet to be established. We report on a large cohort of 75 patients who commenced ECP treatment for cGvHD from 01/01/2005 to 31/12/2009 at St Thomas' Hospital, London. Patients were initially treated with a bimonthly regimen of 2 ECP treatments on consecutive days (one cycle) which was subsequently tapered to a monthly regimen depending on response. Patients were reviewed pre-treatment and at 3 monthly intervals. Immunosuppression was tapered at the discretion of the referring transplant centre. Data were collected from the unit's GvHD database which had ethical approval. The median age of patients at time of commencing ECP was 43 years (16-67 years). 30 were female and 45 were male. Patients had undergone allogeneic transplant (22 – unrelated donor, 53 – sibling/related donor) at 13 referral centres. Underlying diagnoses were acute leukaemia (31), lymphoma (16), chronic leukaemias (16), myeloma (6) and other (6). The median time from transplant to commencing ECP was 2 years (6 months to 10 years). 16 patients had developed GvHD following donor lymphocyte infusion. 27 had denovo cGvHD and 18 had progressive disease. 72 patients had cutaneous disease. 38 had sclerodermoid disease and 32 had lichenoid disease (1 - both types, 1 - unknown). 37 patients had oral disease. Other organs involved included liver (17), eyes (12), gut (4), tongue (1), joint (1), genitalia (1). 29 had one organ involved, 26 had two, 17 had three and 3 had four organs involved. At the start of ECP, 64 patients were on immunosuppressive drugs (prednisolone – 56, cyclosporine – 36, mycophenolate mofetil – 26 and other (tacrolimus, rituximab, azathioprine, pentostatin, methotrexate) – 18). 10 patients were on a single agent, 38 were on 2, 14 were on 3 and 2 were on 4 agents. The median dose of prednisolone was 25mg (5mg-135mg). 52 patients had completed ECP at time of analysis. 23 were receiving ongoing treatment but had received at least 6 months of ECP. The median duration of treatment in those that had completed ECP was 330 days (42-987). The median number of ECP cycles received was 15 (1.5-32 cycles). 46 patients had reduced the frequency of ECP to monthly. The median time to reduction in treatment was 206 days (74-571 days). Reduction of immunosuppression at 6 months was used as a global measure of response to ECP as many patients had multiorgan involvement and response in organs may vary. Assessment of cGVHD symptoms and signs was also documented in 62/75 patients. 51 patients had a partial improvement, 8 patients had a complete improvement and 3 patients had no improvement. 49/64 patients on immunosuppression were reassessed and 37/49 (76%) had a dose reduction. 37/45 (82%) had decreased their steroid dose (10 stopped completely and 18 had ≥ 50% reduction). 3 patients' doses were stable and 5 had increased. The median dose was 10mg (3-30mg). 4 patients on other immunosuppressive drugs remained on a stable dose. The remaining patients had died (5), completed < 6 months treatment (6) or dosage data were missing (4). Of the 11 patients not on immunosuppression at start of ECP, 3 had recommenced steroids and 8 remained on no systemic immunosuppression. All patients were included in the survival analysis including those who had completed < 6 months of treatment. Overall survival at 2.5 years from the start of ECP was 73%. This study reports the largest series of patients receiving bimonthly ECP treatment for cGvHD. We confirm that ECP is highly effective in steroid refractory chronic cGvHD with 76% of patients successfully reducing immunosuppression within 6 months. Further randomised studies are required to assess the optimal ECP treatment schedule and to rationalise the reduction in immunosuppression. Disclosures:Dignan:Therakos (Johnson and Johnson): Honoraria, Research Funding. Off Label Use: The extracorporeal administration of UVADEX (methoxsalen) sterile solution was used with the THERAKOS UVARXTS system in this study for the treatment of patients with chronic graft versus host disease. Scarisbrick:Therakos (Johnson and Johnson): Honoraria, Speakers Bureau.

Nilotinib as Salvage Therapy In Patients with Chronic Graft Versus Host Disease

AbstractAbstract 2329The mainstay of treatment for Chronic Graft Versus Host Disease (cGVHD) is steroids, but there are limited treatment options for steroid refractory cGVHD particularly in its sclerotic and fibrotic form (ScGVHD). We initially reported the efficacy and safety of imatinib mesylate (IM), a first generation tyrosine kinas' inhibitor, as a salvage therapy for ScGVHD patients (Magro L, et al. Blood, 2009). However, about 50% of the patients (Pts) became refractory or intolerant to IM. Nilotinib, a second generation tyrosine kinas' inhibitor, is labelled for IM resistant and advanced Chronic Myeloid leukemia and could be an attractive alternative to IM especially in refractory and intolerant patients.We studied the clinical outcomes of 7 Pts who developed extensive ScGVHD at our institution. Among them, 5 had received prior IM. Patients' characteristics and transplantation modalities are summarised in table 1. Acute and cGVHD was scored according to standard criteria. All pts but one failed at least 3 lines of prior systemic immunosuppressive therapy.CGVHD features, responses to nilotinib and patients' outcomes are described in table 2.To our knowledge, this is the first report relating the impact of nilotinib on cGVHD setting. Although, tolerance to nilotinib has not been as good as we could expect, this drug appeared to be effective with manageable side-effects in some patients. One of the limitations of this study, is that nilotinib was used in patients with advanced cGVHD. Prospective studies are, therefore, warranted to investigate the efficacy and the tolerance of nilotinib in patients with less advanced disease. Disclosures:No relevant conflicts of interest to declare.

B- Cell Depletion as Therapy for Steroid Refractory Chronic Gvhd Is Most Effective for Sclerosis of the Skin.

Abstract 2232Poster Board II-209 IntroductionChronic graft-versus-host disease (cGVHD) is the major long term complication of allogeneic stem cell transplantation and shares similarities with auto-immune diseases, like systemic sclerosis (SSc).Although the contribution of donor T cells in the development of both acute and chronic GVHD is beyond doubt; the role of B cells is less defined. However, two observations suggest that B cells do contribute to chronic GVHD. First, autoantibodies can be detected in 15-90% of chronic GVHD patients. Furthermore, several small-scale retrospective clinical studies demonstrated that in vivo depletion of B cells with the CD20-specific Ab rituximab results in amelioration of chronic GVHD symptoms in heavily pretreated steroid-refractory patients. ObjectiveIn order to prospectively investigate B cell depletion as therapy for cGVHD, we have studied the efficacy of the CD20-specific antibody rituximab in patients with steroid-refractory extensive cGVHD. MethodsIn an ongoing prospective phase I/II study 15 patients with steroid-refractory extensive cGVHD were treated with rituximab (375 mg/m2 per week for 4 consecutive weeks). Clinical responses were monitored monthly for 1 year according to the NIH criteria (EudraCT 2008-004125-42). ResultsA total of 60 rituximab infusions were administered to 15 patients with steroid-refractory cGvHD. Toxicity was limited to one infectious event and one allergic reaction. Clinical responses were so far analyzed in 12 patients. Median follow-up was 6.5 months (range 1-13). Eight patients showed a partial response (67%) of which 5 patients (42%) had an ongoing response up to 1 year of follow-up and 3 patients (25%) relapsed. Two relapsed patients were retreated with rituximab 8 months after cessation of the initial rituximab treatment and showed again a partial response. In patients with deep sclerosis (n=10), sclerotic features disappeared completely or partially in 8 patients (80%). In patients with involvement of eyes (n=10), mucosa (n=4) and gastro-intestinal tract (n=4) response was observed in 50%, 25% and 25% of patients, respectively. Consequently, prednisone dosage could be reduced in 7 patients (58%). In 4 patients (33%) prednisone treatment was stopped completely. ConclusionRituximab treatment is a feasible and effective treatment in patients with steroid refractory cGVHD. In addition, also patients with relapse of cGVHD after cessation of rituximab treatment can be successfully treated. Thereby, sclerotic lesions of the skin improved in the majority of patients whereas eye, mucosal and gastro-intestinal tract involvement was less reversible. We speculate that the lack of improvement of eye and mucosal involvement is a consequence of an early and irreversible destruction of lacrimal and salivary glands and this argues for an upfront application of rituximab in patients with cGVHD. Disclosures:Off Label Use: Rituximab, a monoclonal anti-CD20 antibody, is used to deplete B-cells in the treatment of chronic GVHD.

A Prospective Multicenter Phase II Trial of Pentostatin in Adult Patients with Steroid-Refractory Chronic Graft-Versus-Host Disease (cGvHD): A Cancer and Leukemia Group B/Eastern Cooperative Oncology Group Study.

Abstract 2238Poster Board II-215Chronic graft-versus-host disease is the most common late complication occurring following allogeneic transplantation, and is the principal cause of late morbidity and non-relapse mortality. Corticosteroids remain the cornerstone of primary treatment for cGvHD with about half of patients responding. Patients who fail to respond to initial corticosteroid therapy, however, have a poor outcome with no standard approach uniformly accepted. Pentostatin is a purine nucleoside analogue that irreversibly inhibits adenosine deaminase, with accumulation of dATP, causing apoptosis of lymphocytes, and holds promise for the management of acute and cGvHD. We conducted a multi-institutional, prospective phase II trial to evaluate the response rate (RR) of pentostatin in patients with steroid-refractory cGvHD. In a two-stage design with both types I and II errors set at 0.1, we hypothesized that pentostatin would produce a response rate (complete response + partial response) of 40% or more, with less than 20% being unaccpetable. Patients were eligible if they were >18 years old, had a Karnofsky performance status (KPS) of >30%, histologically-proven extensive stage cGvHD that was refractory to corticosteroids defined as progression of disease despite at least 2 weeks of treatment with 1 mg/kg/day of prednisone or equivalent, no response or minor response to at least 4 weeks of 1 mg/kg/day prednisone (or equivalent), or who achieved only a partial response after 8 weeks of corticosteroid therapy. Response was assessed using the Hopkins scoring system as previously reported (Jacobsohn et al. J Clin Oncol, 25:4255-61, 2007). Pentostatin was administered at a dose of 4 mg/m2 IV every 2 weeks for a maximum of 12 doses. From March 2004 to March 2007, 38 patients with median age 46.5 (27-66) years and median KPS 70% (40%-90%) were treated with pentostatin. cGvHD followed transplantation from matched related donors in 29 and unrelated donors in 9 patients. Thirty-three patients had progressive onset cGvHD, while onset was quiescent in 2, and de novo in 3 patients. The median time from onset of cGvHD to start of study treatment was 416 (26-2,813) days, and the median number of prior lines of therapy for cGvHD was 3 (range, 1-6). cGvHD involved skin (n=35) with scleroderma present in 21 patients, oral mucosa (n=24), liver (n=9), gut (n=4), and lung (n=2). Thirty-five patients were evaluable for response; 2 patients died after 6 and 7 days of treatment, respectively, due to sepsis, and data was incomplete in 1 patient who committed suicide after 3 cycles. Of 35 patients evaluable for response, there were 2 complete responses (CR), 5 partial responses (PR) for a total response rate of 20%. If minor responses (in 7 patients) are also considered, then 14 of 35 (40%) had an objective improvement in cGvHD. Six patients had stable disease, 1 a mixed response, and 14 patients progressed on therapy. Of 34 patients evaluable for toxicity, grade 3-4 hematological toxicity included neutropenia (n=4), thrombocytopenia (n=3), and anemia (n=1). Grade 3-4 clinically significant non-hematological toxicity that was at least possibly related to pentostatin included fatigue (n=3), renal failure (n=3), anorexia (n=2), infection (n=9), CNS hemorrhage (n=1), and rash (n=1). Thirteen patients died on study; causes of death were infection (n=6), cGvHD progression (n=3), and unrelated causes (n=3). The 1-year and 2-year progression-free survival (for GvHD) for all patients treated on study were 32% (95% CI: 18%-46%) and 24% (95% CI: 12%-38%), respectively. The 1-year and 2-year overall survival was 53% (95% CI: 38%-60%) and 50% (95% CI: 33%-65%), respectively. We conclude that pentostatin is an active agent in patients with steroid-refractory chronic GvHD but should be investigated further in cGvHD patients in an earlier course of their disease where a greater impact on long-term outcome may be observed. Disclosures:No relevant conflicts of interest to declare.

Extracorporeal photopheresis: what is it and when should it be used?

Extracorporeal photopheresis (ECP) is a technique that was developed > 20 years ago to treat erythrodermic cutaneous T-cell lymphoma (CTCL). The technique involves removal of peripheral blood, separation of the buffy coat, and photoactivation with a photosensitizer and ultraviolet A irradiation before re-infusion of cells. More than 1000 patients with CTCL have been treated with ECP, with response rates of 31-100%. ECP has been used in a number of other conditions, most widely in the treatment of chronic graft-versus-host disease (cGvHD) with response rates of 29-100%. ECP has also been used in several other autoimmune diseases including acute GVHD, solid organ transplant rejection and Crohn's disease, with some success. ECP is a relatively safe procedure, and side-effects are typically mild and transient. Severe reactions including vasovagal syncope or infections are uncommon. This is very valuable in conditions for which alternative treatments are highly toxic. The mechanism of action of ECP remains elusive. ECP produces a number of immunological changes and in some patients produces immune homeostasis with resultant clinical improvement. ECP is available in seven centres in the UK. Experts from all these centres formed an Expert Photopheresis Group and published the UK consensus statement for ECP in 2008. All centres consider patients with erythrodermic CTCL and steroid-refractory cGvHD for treatment. The National Institute for Health and Clinical Excellence endorsed the use of ECP for CTCL and suggested a need for expansion while recommending its use in specialist centres. ECP is safe, effective, and improves quality of life in erythrodermic CTCL and cGvHD, and should be more widely available for these patients.

Clinical Utility of Rituximab in Chronic Graft-Versus-Host Disease

To evaluate the use of rituximab in the clinical management of steroid-refractory chronic graft-versus-host disease (GVHD). Literature was accessed through MEDLINE and International Pharmaceutical Abstracts (1990-September 2008), both indexed and nonindexed citations, using the terms rituximab, graft-versus-host disease, monoclonal antibodies, and CD20. In addition, reference citations from the publications identified were reviewed. All articles discussing rituximab as a therapeutic option in the treatment of GVHD that were published in English and enrolled human study participants were evaluated. Rituximab is a genetically engineered chimeric murine monoclonal antibody that binds to the CD20 differentiation antigen found on B-lymphocytes. GVHD is the leading cause of procedural-related morbidity and mortality following allogeneic hematopoietic stem cell transplantation (HSCT). Chronic GVHD (cGVHD) occurs in up to 70% of individuals undergoing HSCT, and approximately 40% of those patients are refractory to conventional T-lymphocyte-directed therapies. Limited treatments are available for individuals with steroid-refractory cGVHD. Rituximab therapy in individuals with extensive cGVHD has demonstrated clinical efficacy with manageable toxicities in retrospective and prospective studies. Available data suggest that rituximab is a treatment option for patients with extensive steroid-refractory cGVHD. Rituximab may be particularly effective for individuals with steroid-refractory cGVHD manifesting as thrombocytopenia or with sclerodermatous, cutaneous, and rheumatologic involvement.

Treatment of Chronic Steroid-Refractory Graft-Versus-Host Disease With Low-Dose Rituximab

Rituximab, an anti-CD20 chimeric monoclonal antibody, is widely used in hematologic malignancies and has been introduced as a therapeutic option in autoimmune disorders. In recent studies, rituximab has shown promising activity in steroid-refractory chronic graft-versus-host disease (cGvHD) at a weekly dose of 375 mg/m2. We now report on 13 subjects after peripheral blood stem-cell transplantation receiving low-dose rituximab (50 mg/m2) for steroid-refractory cGvHD and autoimmune disorders (membranous glomerulonephritis and immune thrombocytopenic purpura). The overall response rate was 69%, including two patients with complete responses. In accordance, we observed clearance of peripheral blood B cells even after the first dose of rituximab in four patients. We conclude that low-dose rituximab seems to be active and safe in intensively pretreated patients with steroid-refractory cGvHD.

201: Extracorporeal Photopheresis (ECP) is an Effective Therapy for the Treatment of Children with Steroid Refractory (SR) Chronic Graft vs Host Disease (cGVHD)

ECP is an immune modulatory therapy that works by causing donor lymphocyte apoptosis and tolerance. We hypothesize that ECP is an effective therapy in treating SR cGVHD and allows for reduction in corticosteroids. We performed a retrospective study at Children's Memorial Hospital to evaluate the effectiveness of ECP in SR cGVHD in children.

Ocular Manifestations of Chronic Graft-Versus-Host Disease in Patients Treated with Extracorporeal Photochemotherapy

Eye involvement has long been appreciated in patients with chronic graft versus host disease (cGVHD). In particular, ocular complications are frequent and can be potentially severe in patients with steroid-refractory cGVHD, and therefore necessitate close monitoring. This prospective study was designed to describe eye manifestations of cGVHD in a large series of patients monitoring them before and after 1 year of extracorporeal photochemotherapy (ECP). ECP is a relatively new therapeutic approach based on the biological effects of psoralen 8-methoxypsoralen (8-MOP) and ultraviolet A light (UVA) on mononuclear cells collected by apheresis, and reinfused into the patient. Only patients with steroid-refractory cGVHD under treatment with ECP, who developed cGVHD-related eye symptoms, were selected for the study. Ophthalmologic examination was repeated every 3 months. Only patients with complete recovery of the ocular manifestations and symptoms were considered responsive. In our study we observed eye alterations in 24 out of 140 patients (17%) with cGVHD. After 12 months of ECP, 10 out of 21 patients (48%) completely responded to the therapy. In all these cases the contribution of ECP was also essential in all the other organs subject to cGVHD. Further studies are necessary to clarify the role of ECP in patients with cGVHD, especially in associated eye manifestations. Although our experience is limited, it suggests that ECP could be a safe and effective therapy for steroid-refractory eye manifestations of cGVHD.

Unique Abnormalities of CD4 + and CD8 + Central Memory Cells Associated with Chronic Graft-versus-Host Disease Improve after Extracorporeal Photopheresis

Chronic graft-versus-host disease (cGVHD) remains a problematic complication of allogeneic hematopoietic stem cell transplantation. Laboratory parameters correlated with cGVHD have not been fully defined, although changes in CD4/CD8 ratios occur and a decrease in CD4 + central memory T cells has been noted. Extracorporeal photopheresis (ECP) is an effective therapy for steroid-refractory cGVHD. We have noted changes in lymphocyte subsets after ECP. CD4 + and CD8 + T-cell central and effector memory populations were enumerated by flow cytometry in a cohort of 37 patients postallogeneic transplantation with symptomatic cGVHD. Of the patients with symptomatic cGVHD, 7 were treated with ECP over 6 months and prospectively assessed for changes in lymphocyte subsets. There was a highly significant correlation of an increase in CD8 + central memory cells and a concomitant decrease in CD4 + central memory cells in patients with symptomatic cGVHD. These changes were not detected in patients without cGVHD posttransplantation. In all, 7 patients with cGVHD followed up prospectively during ECP treatment showed a statistically significant normalization of the pattern of CD4 + and a trend toward normalization of CD8 + central memory T cells coincident with improvement of cGVHD. These data indicate a high correlation between disturbances in the balance of central and effector memory populations and cGVHD suggesting use in following up responses to therapy. The normalization of central and effector memory populations in response to ECP coincident with clinical improvement of cGVHD support a correlation between these laboratory parameters and cGVHD. Further studies are needed to demonstrate whether laboratory measurements of the magnitude of changes in central and effector memory populations are useful prognostically or can be used to guide response to therapy. The contrasting change in central memory cells (CD8 + increased versus CD4 + decreased) in cGVHD provide support for recent reports suggesting unique differences in the differentiation pathways for CD8 + versus CD4 + T cells.

Role of extracorporeal photochemotherapy in patients with refractory chronic graft‐versus‐host disease

Recent studies suggest that extracorporeal photochemotherapy (ECP) may be beneficial in patients with steroid-refractory chronic graft-versus-host disease (cGvHD). However, it is not yet clear whether certain conditions, such as age, mode of onset of cGvHD etc., influence clinical response and whether certain affected organs are more sensitive to ECP than others. We analysed the main clinical and laboratory parameters related to evolution of the disease in 32 steroid-refractory cGvHD patients, to identify any useful response predictors to ECP. ECP affected the course of the disease positively in 78% (25/32) of our cases.

Sirolimus in combination with tacrolimus for the treatment of resistant chronic graft-versus-host disease

6657 Introduction: Chronic graft versus host disease (cGVHD) remains a major complication in hematopoietic transplant recipients. We conducted a phase II trial of sirolimus in combination with tacrolimus for patients with steroid-refractory cGVHD. Patients and Methods: The median age of the 35 patients was 45 years (19–69). The median number of prior treatments for chronic GVHD was 3 (range 2–6). Chronic GVHD was defined as GVHD present beyond day 100 post-transplantation. The patients were divided into two groups. One group had continuous or recurrent manifestations of acute GVHD (late acute GVHD group). The remaining 23 patients had clinical manifestations of chronic GVHD (true chronic GVHD group). Results: Six patients had a complete remission and 16 had a partial remission for an overall response rate (ORR) of 63%. Skin was the organ most often involved (n= 29) and had an ORR of 65%. Eight patients with sclerodermatous skin involvement responded to therapy (73%). Responses were also seen in patients with GVHD of the lower GI tract (67%), liver (33%), eye (64%), and oral mucosa (75%). Major adverse events related to sirolimus were hyperlipidemia and cytopenias. Median survival was 15 months, and estimated actuarial survival at 2 years was 41% (95% CI 20–61). A significantly worse non-relapse mortality was noted in patients who had a platelet count of less than 100,000/mm3 (p < 0.0001) or late acute GVHD features (p = 0.001). Actuarial survival at 1 year was 25% in the late acute GVHD group, and 76% in the true chronic group (p = 0.0003). Corresponding estimates at 2 years were 12% (95% CI 1–40) and 62% (95% CI 34–80) (p = 0.0005). Non-relapse mortality at 2 years post initiation of therapy was significantly higher in patients with late acute GVHD (75%, 95% CI 49–99%) than in those with true chronic GVHD (35%, 95% CI 17–64%, p = 0.003). Conclusions: The addition of sirolimus to tacrolimus and methylprednisolone was effective for the treatment of resistant chronic GVHD with an ORR of 63%. It was most effective in patients with true chronic features and sclerodermatous skin involvement. Differentiating between late acute GVHD and true chronic GVHD may result in better interpretation of studies intended to target chronic GVHD. No significant financial relationships to disclose.

Rituxan for steroid-refractory chronic GVHD

Donor-derived T cells are thought to be the primary effectors of chronic graft-versus-host disease (cGVHD); however, additionalmechanisms of tissue injury may exist. Antibodies against minor histocompatibility antigens develop in association with cGVHD, suggesting a role for B cells. We therefore began a clinical trial of specific anti-B-cell therapy with rituxan for steroid-refractory cGVHD. Methods: Subjects had steroid-refractory (> 0.5 mg/kg prednisone each day for 4 weeks), clinically extensive cGVHD on stable doses of immunosuppressants.

Serum Level of Interleukin-10 Correlates Well with the Activity of Chronic Graft-Versus-Host Disease and the Responsiveness to Corticosteroid Treatment.

Current evidence suggest the interaction between subset of T cells, the T help1 (Th1) and T help2 (Th2), plays an important role in the pathogenesis of GVHD. Cytokines, either produced by Th1/Th2 or other cells, are important regulators in the whole process and will define the polarization of Th1 or Th2 from naïve T cell. In this study, we used ELISA (R&D, Minneapolis, MN, US) to monitor the serum level of Interleukin-4 (IL-4), IL-10, IL-12, and interferon-γ (INF-γ) in patients receiving allogeneic transplant weekly from day 0 to at least day 200. From Jan. 2003, consecutive 20 patients were enrolled. The GVHD prophylaxis consisted of Cyclosporine-A and short course Methotrexate. Of the 20 patients, 2 had grade 3/4 acute GVHD (aGVHD) and 7 had extensive chronic GVHD (cGVHD). The serum levels of IL-4 and IL-12 were below the detectable level (0.13pg/ml and 0.5pg/ml respectively) in most occasions, even during the period of GVHD. Nevertheless, the serum level of IL-10 correlated well with the activity of cGVHD and we used data gathered from 5 patients to demonstrate this good correlation in figure 1 and 2. Patient 1 (open square, figure 1) had no GVHD and the IL-10 levels were below 5pg/ml during the whole period of follow-up. Patient 2 (solid triangle, figure 1) and 3 (open triangle, figure 2) had de novo cGVHD. The IL-10 level increased gradually when cGVHD developed, however, both clinical manifestations of cGVHD and serum IL-10 level decreased rapidly after the administration of Prednisolone (black bar on figure 1 and 2, with the thickness indicating the relative dosage of Prednisolone). Patient 4 (open circle, figure 2) had grade 2 aGVHD that resolved quickly after Prednisolone treatment. However, IL-10 level increased gradually after discontinuing Prednisolone and cGVHD developed subsequently. After adding Prednisolone again, cGVHD improved and IL-10 decreased to undetectable level rapidly. Patient 5 (solid square, figure 2) had steroid-refractory cGVHD. The IL-10 level kept above 5pg/ml for more than 1 month despite Prednisolone 1mg/kg/day giving at the same time and the patient eventually needed further salvage treatment (thalidomide). The serum INF-γ were undetectable in most occasions. It became detectable during period of cGVHD in patients 3, 4 and 5 but not patient 2. In conclusion, post-transplant serum IL-10 level correlates well with the clinical activity of cGVHD as well as the responsiveness to corticosteroid treatment. This novel finding will allow the functional evaluation of individuals' immune system after allogeneic transplant and should give insight for the adjustment of immunosuppression necessary for cGVHD control. [Display omitted] [Display omitted]

Extracorporeal photoimmunotherapy for the treatment of steroid refractory progressive chronic graft-versus-host disease

Background: Chronic graft-versus-host disease (cGVHD) can arise frequently as a late complication after allogeneic hematopoietic cell transplantation. Patients with extensive disease to date require intensive and long-term immuno-suppression. We aimed to share our single center experience using extracorporeal photoimmunotherapy (ECP) in our steroid refractory extensive cGVHD patients. Patients and Methods: Eight patients with a median age 42 (range, 17–43) and M/F: 2/6 were treated with ECP (UVAR XTS) on 2 consecutive days every 2–4 weeks until resolution of GVHD over a period of 6–15 months concomitantly with immunosuppressive agents. Beyond extensive steroid refractory cutaneous cGVHD, three patients had also bronchiolitis obliterans (BO). Skin scores were assessed by an experienced dermatologist. Clinical, laboratory and radiological findings after 4 months of ECP were accepted as response criteria. The patients received in this almost fully automated system mean 261.4 ml buffy-coat was processed within 193 min using UVADEX sterile solution. Results: After a median of 12 cycles of treatment, 6 patients showed a favorable response. ECP was tolerated well only one patient developed Gr4 thrombocytopenia and another patient had a massive GIS bleeding due to an esophageal tear. Reduction in cholestatic parameters was observed in patients with liver cGVHD, improvement in respiratory functions and CT evaluations in two, and reduction in immunosuppressive requirement in all patients. The most impressive result was the reduced need for hospitalization of these patients and improvement of skin lesions. All but one of the skin biopsy scores was also better after ECP. Conclusion: As extensive cGVHD is a life devastating disorder, every attempt to improve the quality of life should be evaluated carefully. Our findings suggest that ECP is a safe and effective adjunctive therapy for steroid refractory extensive cGVHD of the skin. ECP will find a place both for the treatment and may be for the prevention of GVHD as well.