Assessing the potential role of photopheresis in hematopoietic stem cell transplant.

The First International Symposium on Photopheresis in Hematopoietic Stem Cell Transplantation was held in Vienna, Austria with an educational grant from Therakos Inc. from 25 May to 27 May 2005. Three general issues were addressed: (1) pathophysiology of graft-versus-host disease (GvHD), (2) induction of immune tolerance and the immunology of phototherapy and (3) current standard treatment and prevention strategies of acute and chronic GvHD and the use of extracorporeal photopheresis (ECP). The objectives of the meeting were to open a dialogue among leading researchers in photobiology, immunology, and hematopoietic stem cell transplantation; foster discussions and suggestions for future studies of the mechanism of action of ECP in acute and chronic GvHD; and promote collaboration between basic scientists and clinicians. As can be seen from the summaries of the individual presentations, important advances have been made in our understanding of GvHD, including the use of photoimmunology interventions and the development of robust model systems. It is our expectation that data from photoimmunology studies can be used to generate hypotheses in animal models that can further define the mechanism of action of ECP and help translate the findings to clinical trials of ECP for the prophylaxis and treatment of both chronic and acute GvHD.

Regional anticoagulation with acid citrate dextrose-A for extracorporeal photoimmunochemotherapy.

BACKGROUND AND OBJECTIVES: During photopheresis, intravenous heparin is used to prevent clotting in the extracorporeal circuit. Regional citrate anticoagulation could lower the risks associated with heparin treatment. MATERIALS AND METHODS: Four-hundred and six photophereses procedures that were anticoagulated by acid citrate dextrose-A (ACD-A) (of which 343 were performed in patients at risk for haemorrhage) were analysed together with 278 heparin-anticoagulated treatments. RESULTS: Four-hundred and four of 406 citrate treatments were completed. Seven transient paresthesias (1.73%), five of which occurred in the first 50 treatments, were observed. Bleeding complications were noted during heparin anticoagulation (1.07%), but not during citrate anticoagulation. During photopheresis, haemoglobin values and platelet counts decreased by 11.4% and 14.6%, respectively (P < 0.0001). Twenty-four hours after treatment, haemoglobin values, and platelet and leucocyte counts were still lower than at baseline (P < 0.0001). The changes of haemoglobin, platelet and leucocyte values did not differ for citrate and heparin. CONCLUSIONS: In patients with contraindications against heparin use, ACD-A citrate anticoagulation during photopheresis is a safe and efficient alternative. Photopheresis induces profound changes of the blood count, irrespective of the anticoagulation method.

Extracorporeal photochemotherapy in the treatment of severe steroid-refractory acute graft-versus-host disease: a pilot study.

Extracorporeal exposure of peripheral blood mononuclear cells to the photosensitizing agent 8-methoxypsoralen and UV-A radiation has been shown to be effective in the treatment of selected diseases mediated by T cells, rejection after solid organ transplantation, and chronic graft-versus-host disease (GVHD). We present 21 patients with a median age of 38 years who developed steroid-refractory acute GVHD grades II to IV after stem cell grafting from sibling or unrelated donors and were referred to extracorporeal photochemotherapy (ECP). Three months after initiation of ECP 60% of patients achieved a complete resolution of GVHD manifestations. Complete responses were obtained in 100% of patients with grade II, 67% of patients with grade III, and 12% of patients with grade IV acute GVHD. Three months after start of ECP complete responses were achieved in 60% of patients with cutaneous, 67% with liver, and none with gut involvement. Adverse events observed during ECP included a decrease in peripheral blood cell counts in the early phase after stem cell transplantation (SCT). Currently, 57% of patients are alive at a median observation time of 25 months after SCT. Probability of survival at 4 years after SCT is 91% in patients with complete response to ECP compared to 11% in patients not responding completely. Our findings suggest that ECP is an effective adjunct therapy for acute steroid-refractory GVHD with cutaneous and liver involvement. However, in patients with acute GVHD grade IV or gut involvement other therapeutic options are warranted.

Extracorporeal photochemotherapy in the treatment of severe graft-versus-host disease.

Advances in posttransplant immunosuppression have to the present not been able to prevent the development of graft-versus-host disease (GVHD) in patients given related or unrelated stem cell grafts for cure of hematologic diseases. Patients with GVHD not responding to first line therapy with corticosteroids remain at high risk of death due to severe infections or organ failure. Extracorporeal exposure of peripheral blood mononuclear cells to the photosensitizing agent 8-methoxypsoralen and ultraviolet A radiation has been shown to be effective in treatment of selected T-cell mediated diseases, including cutaneous T-cell lymphoma and rejection after organ transplantation. Extracorporeal photochemotherapy (ECP) is also a safe and efficacious adjunct therapy for both acute and chronic extensive GVHD with skin and visceral involvement and resistance to conventional immunosuppressive therapy. A multicenter randomized study should help define the impact of ECP in the treatment of GVHD and overall survival of these patients.

Expression of the 72-kD heat shock protein is induced by ultraviolet A radiation in a human fibrosarcoma cell line.

The 72-kD heat shock protein (hsp72) belongs to a family of stress inducible proteins (heat shock proteins, hsp) and its expression is associated with increased survival of cells in culture following exposure to ultraviolet radiation (UV). Hsp72 can be induced by a number of stresses, including heat, cold, and toxic chemicals. The purpose of this study was to evaluate whether UV is able to activate transcription of hsp72. The human fibrosarcoma cell line HT1080 was used for these experiments because hsp72 is not detectable in these cells under normal culture conditions. Cells were exposed to UVA and UVB using a solar simulating source and hsp72 was determined in whole cell extracts by immunoblotting. For inhibition of mRNA and protein synthesis cordycepin (20 microg/ml) and cycloheximide (10 microg/ml) were added to the cultures, respectively. UVA-induced lipid peroxidation was inhibited by alpha-tocopherol and butylated hydroxytoluene (BHT). UVA but not UVB induced hsp72 with maximal expression at 40 J/cm2, 8-12 h after exposure. Induction was blocked by cordycepin as well as by cycloheximide indicating that both, mRNA and protein synthesis, are required for UVA-induction of hsp72. Inhibition of cell lipid peroxidation with alpha-tocopherol and BHT had no effect on hsp72 expression. These results suggest that induction of hsp72 is part of an adaptive response mechanism in human cells to UV-related stress.

Successful use of extracorporeal photochemotherapy in the treatment of severe acute and chronic graft-versus-host disease.

Extracorporeal exposure of peripheral blood mononuclear cells to the photosensitizing compound 8-methoxypsoralen and ultraviolet A radiation has been shown to be effective in the treatment of several T-cell-mediated diseases, including cutaneous T-cell lymphoma and rejection after organ transplantation. We present 21 patients (10 men and 11 women) with hematological malignancies with a median age of 36 years (range, 25 to 55 years) who had received marrow grafts from sibling (n = 12) or unrelated (n = 9) donors. Six patients had acute graft-versus-host disease (GVHD) grade II to III not responding to cyclosporine A (CSA) and prednisolone when referred to extracorporeal photochemotherapy (ECP). In 15 patients, 2 to 24 months after bone marrow transplantation (BMT), extensive chronic GVHD with involvement of skin (n = 15), liver (n = 10), oral mucosa (n = 11), ocular glands (n = 6), and thrombocytopenia (n = 3) developed and was unresponsive to conventional therapy, including steroids. All patients were treated with ECP on 2 consecutive days every 2 weeks for the first 3 months and thereafter every 4 weeks until resolution of GVHD. ECP was tolerated excellently without any significant side effects. After a median of 14 cycles of ECP, acute GVHD resolved completely in 4 of 6 patients (67%) and partially in another 2 patients. Cutaneous chronic GVHD completely resolved in 12 of 15 (80%) patients. Contractures of knees and elbows due to scleroderma resolved partially. Oral mucosal ulcerations resolved in all patients. Seven of 10 patients (70%) with liver involvement had complete responses after ECP. After discontinuation of ECP, no severe infections were observed. Our findings suggest that ECP is a safe and effective adjunct therapy for both acute and extensive chronic GVHD with skin and visceral involvement and resistance to conventional therapy.

Overexpression of the small heat shock protein, hsp27, confers resistance to hyperthermia, but not to oxidative stress and UV-induced cell death, in a stably transfected squamous cell carcinoma cell line.

The 27 kD heat shock protein (hsp27) is expressed in human keratinocytes in association with differentiation in vitro and in situ. This study was conducted to investigate whether the expression of hsp27 in keratinocytes is associated with increased resistance to the deleterious effects of heat and UV radiation. A transfection vector carrying the human gene for hsp27, under the control of hsp27 as well as the SV40 promoter (pSG2711, M. Jäättelä et al., EMBO J. 11 (1992) 3507-3512), was introduced together with a neomycin-resistance gene into the squamous cell carcinoma cell line A431. Cells were exposed to either UVA, UVB, head (45 degrees C, 4 h) or hydrogen peroxide (0.025-0.5 mM) and the percentage of surviving cells was determined. Overexpression of hsp27 induced increased resistance to hyperthermia, but not to hydrogen peroxide-mediated oxidative injury. When cells were exposed to increasing amounts of UVA (5-80 J cm-2) and UVB (4-64 mJ cm-2), the percentage of surviving cells was identical for clones overexpressing hsp27 and control clones. From these data, we conclude that hsp27 is a mediator of thermotolerance, but does not protect keratinocytes from UV-induced cell death.

Stress proteins in the cellular response to ultraviolet radiation.

Virtually all cells-from prokaryotes to highly differentiated mammalian tissues-respond to a sudden increase in temperature with increased production of a limited set of proteins, called heat shock proteins or stress proteins (hsp). Other stress factors such as alcohol, heavy metals, oxidants and agents leading to protein denaturation are equally able to induce a similar response. Induction of hsp is followed by a transient state of increased resistance to further stress. Many hsp function as "molecular chaperones" by binding to partially folded or misfolded proteins thus preventing their irreversible denaturation during stress exposure. The high evolutionary conservation of this reaction suggests its importance for the survival of cells and tissues under hostile environment conditions. Ultraviolet radiation (UV) exerts many potentially harmful effects on prokaryotic and eukaryotic cells and hsp may help the cell to cope with UV-induced damage. This review will focus on the role of hsp in the cellular response of mammalian skin to UV. Hsp have been detected in resting as well as stress exposed epidermal and dermal cells and experimental evidence points to the fact that these proteins mediate protection from UV induced cell death in vitro and in vivo. Experimental studies further indicate that UV itself might be able to induce the expression of specific hsp. Thus, hsp might provide an adaptive cellular response to increasing exposure to UV. Furthermore, UV-activation of hsp synthesis may provide a valuable model for investigation of the transcription regulation of UV-induced gene expression.

Expression of the 27-kDa heat shock protein in human epidermis and in epidermal neoplasms: an immunohistological study.

The 27-kDa heat shock protein (HSP27) is a member of the small heat shock protein (HSP) family. In addition to its putative function in thermotolerance, this protein may play a part in the regulation of cell growth and differentiation. This study was conducted to assess the significance of the expression of HSP27 in human epidermis and in cutaneous neoplasms. Sixty-two biopsy samples from normal human skin and from inflammatory and neoplastic skin diseases were investigated by immunohistochemistry on formalin-fixed paraffin-embedded tissue sections, using a monoclonal antibody specific for HSP27. In normal human epidermis, HSP27 is expressed in the upper epidermal layers with a cytoplasmic staining pattern. The basal cell layer does not express detectable amounts of HSP27. In hair follicles, staining is mainly confined to the outer root sheath and to the infundibular epithelium. Melanocytes, dermal fibroblasts and endothelial cells do not express detectable amounts of HSP27. HSP27 could not be detected in fetal skin until the 20th week of gestation. Tumour cells in basal and squamous cell carcinomas do not express significant amounts of HSP27. In solar keratoses, seborrhoeic keratoses, human papillomavirus (HPV)-induced hyperproliferative lesions and inflammatory skin conditions, HSP27 expression largely resembles the pattern observed in normal human skin. HSP27 is expressed in a differentiation-related pattern in normal human epidermis and hyperproliferative disorders of the epidermis. We conclude that HSP27 may be regarded as a marker of differentiation in epidermal keratinocytes. Absence of HSP27 in the upper epidermal layers may be a marker for epidermal malignancy.

72-kD heat shock protein is a mediator of resistance to ultraviolet B light.

We have shown previously that human epidermal keratinocytes in situ and in vitro constitutively express high levels of the 72-kD heat shock protein (hsp72) and that hsp72 expression in these cells can be further induced with heat treatment. In the present study, we continue our investigation of the ultraviolet (UV) B protective effect of hyperthermic treatment and ask whether hsp72 is a mediator of heat-shock-induced UVB resistance. The results of our experiments demonstrate that heat treatment (42 degrees C for 4 h) before UVB exposure is able to increase significantly the UVB resistance of the epidermal carcinoma cell line A431. Heat-induced UVB resistance was most pronounced if the cells were exposed to UVB immediately after heat treatment. The protective effect was not detectable beyond a recovery period of 12 h. To investigate the role of hsp72 in hyperthermia-induced UVB resistance, we inhibited the expression of this protein using either a specific antisense oligodeoxynucleotide or quercetin, a flavonoid that has been shown to down-regulate hsp expression. Treatment with the oligomer as well as with quercetin significantly increased the susceptibility of A431 to UVB-induced damage and nullified the protective effect of heat preconditioning. A noncomplementary control oligodeoxynucleotide had no significant effect. These results indicate that heat treatment is able to induce a state of increased resistance to the deleterious effects of UVB in human keratinocytes in vitro. hsp72 is a molecular mediator of this protective effect, and its constitutive expression in human epidermal keratinocytes may be an important mechanism for the protection of human epidermis from UVB-induced damage.

Defective TCR surface expression associated with impaired TCR beta-chain assembly in a patient with cutaneous T-cell lymphoma.

We report on a patient with cutaneous T-cell lymphoma (CTCL) of long-standing duration. Phenotypic analysis of his peripheral blood mononuclear cells revealed an increased CD4+ T-helper subset and a decreased CD8+ cytotoxic T-cell population. Eighty-three to ninety-three percent of the patient's CD4+ T cells in the peripheral blood and 70% of the CD4+ T cells in the lesional skin lacked surface expression of the TCR/CD3 complex and showed a clonal rearrangement pattern of the TCR gamma-chain gene (V11-J1/J2). The lack in TCR surface expression correlated with defective assembly of the TCR beta-chain. Although mRNA for the TCR constant region beta 1 was found in the patient's purified CD4+ TCR-CD3- T cells, no intracytoplasmic TCR beta protein was detectable. In contrast, the patient's purified CD4+ TCR-CD3- T cells not only expressed mRNA specific for the TCR alpha-chain and for all CD3 chains, but intracytoplasmic TCR alpha and CD3 epsilon proteins could also be found. The lack of TCR beta protein clearly explains the defective surface expression of the TCR/CD3 complex in the patient's malignant T cells.

UVA- and UVB-induced changes in hairless mouse skin collagen.

UVA- and UVB-induced alterations in dermal collagen were investigated in a murine animal model. Groups of hairless mice were exposed to UVA and UVB for 28 weeks at a dose of 60 J/cm2 three times weekly and 0.06 J/cm2 three times weekly, respectively. Untreated animals were used as controls. Every 4 weeks dorsal skin was examined for quantitative and qualitative changes in dermal collagen. Neither UVA nor UVB caused a significant alteration in total skin collagen content. However, after UVA treatment the ability of skin collagen to be digested by pepsin decreased dramatically (up to 65% of skin collagen remained insoluble after 4 months), whereas exposure to UVB had no significant effect. Furthermore a shift in the ratio of alpha 1(I,III) chains to alpha 2(I) chains was detected after UVA exposure. The amount of type V collagen in mouse skin, as determined by a sensitive ELISA method, was markedly decreased after UVA treatment, but not after UVB treatment.

Parenteral administration of 8-methoxypsoralen in photopheresis.

BACKGROUND: Extracorporeal photochemotherapy (EP) is used for the treatment of cutaneous T-cell lymphoma (CTCL), progressive systemic sclerosis (PSS), pemphigus vulgaris, and rheumatoid arthritis. During this procedure, the oral administration of the photoactive drug 8-methoxypsoralen (8-MOP) results in an unpredictable range of serum levels and in side effects limiting its efficacy. OBJECTIVE: To circumvent this limitation, extracorporeally administrable 8-MOP (EX-8-MOP) was developed. It is administered directly to the leukocyte/plasma concentrate in the treatment bag of the EP apparatus before irradiation with UVA light. METHODS: Efficacy, tolerance, and side effects of EX-8-MOP were evaluated in 108 consecutive treatments of 16 patients who had previously been treated with oral 8-MOP (91 treatments). RESULTS: With EX-8-MOP constant drug levels for UV light exposure were obtained; for equivalent levels only a small fraction of the oral dose (1/250 to 1/500) was required with none of the side effects associated with oral 8-MOP. Effective and reproducible inhibition of lymphocyte proliferation and cell viability was attained. No difference in clinical efficacy could be observed. CONCLUSION: EX-8-MOP eliminates the need for premedication and drug level monitoring of 8-MOP and should improve the effectiveness of EP.

Human papillomavirus in cervix carcinoma and condylomata acuminata--identification of HPV-DNA by improved dot-blot-hybridization.

Using the benzoylated naphthoylated DEAE cellulose method (BND-method) we have designed a more efficient approach for the detection of human papillomavirus-DNA (HPV-DNA) via dot-blot and hybridization. Biopsy material from anogenital warts (40 patients), invasive carcinoma uteri (12 patients) and normal controls (20 patients) were studied for the presence of HPV-DNA. Phenol extracted DNA from representative lesions was loaded onto a pretreated nitrocellulose filter, was incubated under stringent conditions with 32-P-dCTP labelled HPV-DNA and exposed to a Kodak X-OMAT film. DNA of HPV types 11, 16, 18 were cloned into plasmid vectors. The common, time-consuming caesium-chloride density-gradient centrifugation used for purification of plasmid DNA (20-36 h), was substituted by the BND-method (15 min). Complete HPV genomes were excised using the restriction endonucleases Eco RI and Bam HI. The HPV-DNA fragments obtained were then electroeluted using the 'Bio-Trap' method and subsequently labelled with 32P-dCTP by nick translation. Without resorting to more complex and sensitive technology, such as the polymerase chain reaction, efficiency of specific analysis of large numbers of cervical samples and condylomata was achieved without loss of accuracy or increased costs. The time required for HPV identification from biopsy or sample receipt was shortened considerably (approximately 50%).