ECP in adult patients with GvHD: A real-world experience

Extracorporeal photopheresis (ECP) can be used to treat adult patients with steroid-refractory or steroid-dependent graft-versus-host disease (GvHD).¹ The optimal schedule for ECP treatment is not defined clearly, and it is thought that using an off-line treatment schedule, rather than the traditional in-line regime, may allow for fewer sessions as well as a reduced amount of disposal apheresis instrumentation.¹

Here, we summarize key findings regarding real-world experience in ECP for adults with GvHD, published by Canto et al.¹ in Transplantation and Cellular Therapy.

Study design¹

• Patients were eligible for inclusion if they had been diagnosed with acute GvHD (aGvHD) or chronic GvHD (cGvHD) and had previously undergone at least one off-line ECP session.
  • ECP was indicated for these patients after the failure of steroid therapy.
• In total, 82 adult patients ≥18 years were included for analysis, and 1,382 ECP procedures were performed.
• Off-line ECP procedure:
  • 28 patients with aGvHD received: 2 procedures per week for 2 weeks, followed by 1 procedure per week for 2 weeks, and then 1 procedure biweekly for 5 months;
  • 54 patients with cGvHD received: 1 procedure per week for 1 month, followed by 1 procedure biweekly for 5 months;
  • ECP was tapered for each patient based on the individual’s GvHD response and introduction or withdrawal of immunosuppressants.
• Steroids were tapered by 0.2 mg/kg prednisone-equivalent per day, every day for 5 days in aGvHD, and 20–30% every 2 weeks in cGvHD.
• Cumulative incidences of response, including complete response (CR) and partial response (PR), were compared among patients grouped by different baseline, apheresis, and disease characteristics.

Key findings¹

In the aGvHD cohort, patients who responded to ECP treatment had a 1-year overall survival (OS) of 67.5%, whereas patients who did not respond had an OS of 26.0% (p = 0.037). Patients in the cGvHD cohort who responded to ECP treatment had a 1-year OS of 85.0%, and those who did not respond had an OS of 85.7% (p = 0.57). Table 1 summarizes the response rates and median duration of response of patients who received ECP treatment.

Table 1. Efficacy outcomes following ECP treatment*

aGvHD, acute graft-versus-host disease; cGvHD, chronic graft-versus-host disease; CR, complete response; ECP, extracorporeal photopheresis; PR, partial response. *Adapted from Canto et al.1
	aGvHD cohort	cGvHD cohort
Patients who achieve CR	16 (57%)	21 (39%)
Patients who achieve PR	1 (4%)	26 (48%)
Median duration of treatment	3 months	7 months
Median duration of response	4.1 months	14.3 months
Median number of ECP procedures	11.5	17

Below, Figure 1 illustrates complete response rates in patients with aGvHD and cGvHD, focusing on skin, gut, and liver involvement.

aGvHD, acute graft-versus-host disease; cGvHD, chronic graft-versus-host disease; CR, complete response; ECP, extracorporeal photopheresis.
*Adapted from Canto, et al.¹

Incidences that prevented ECP procedures included issues with venous access, autologous mononuclear cell collection, apheresis instrumentation errors, and psychological intolerances (1.4%); the remainder of the ECP procedures (98.6%) were completed successfully.

Key learnings1

The use of the off-line ECP regimen is safe, feasible, and efficacious for the treatment of adult patients with aGvHD and cGvHD. Further research that can build on these results is warranted in order to fully enhance treatment strategies and improve patient outcomes.