2012 The UK Photopheresis Society

1. 2012The UK PhotopheresisSociety Friday 28th September The Copthorne Tara Hotel Kensington, London

2. Dr Peter Taylor Introduction & Welcome

5. Dr Julia Scarisbrick Secretary’s report

6. UKPS 2012 • Pharma Mix as secretariat • Website with online registrations for meetings • 2 meetings successfully run with excellent feedback from delegates • Meeting attendance in January = 54 • Meeting attendance in September = 52 • Delegate communication before, during and after the event • Database established of haematologists, dermatologists, pharmacists, nurses who may have an interest in photopheresis for meeting information

7. UKPS 2012 • Feedback from January was to have nurse led workshop which we have in September • Selected slides will be available from the website

8. UKPS 2013 • 2 Meetings • Further development of website • Filming of photopheresiscentres for inclusion in the gallery • Promoting the group to more industry partners to encourage funding

9. Society Updates Debbie Lancaster UK Registry

10. Society Updates Dr Peter Taylor UK Quality Assurance / JACIE

11. The Rotherham NHS Foundation Trust Photopheresis Quality Assurance To begin the debate UKPS 28 September 2012 Peter Taylor

12. The Rotherham NHS Foundation Trust Quality assurance The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled • Fit for Purpose • Right First Time

13. The Rotherham NHS Foundation Trust JACIE DRAFT STANDARDS B7.2 There shall be a policy addressing safe administration of extracorporeal photopheresis (ECP). B7.2.1 There shall be a consultation with the facility that performs ECP prior to initiation of therapy. B7.2.2 Before ECP is undertaken, there shall be a written order from a physician specifying, at a minimum, the patient’s diagnosis, proposed regimen, timing of the procedure, and any other factors that may affect the safe administration of ECP. B7.2.3 A final report of the details of ECP administered, including an assessment of the response, shall be documented in the patient’s medical record. B7.2.4 The ECP procedure shall be performed according to written standard operating procedures of the facility performing the procedure appropriate for the clinical condition of the patient. B7.2.5 Outcomes, including adverse events, related to the administration of ECP to patients within the Clinical Program shall be analyzed annually.

14. The Rotherham NHS Foundation Trust Standards • Quality Management System • Personnel • Premises • Equipment, Information systems & materials • Treatment Process • Evaluation

15. The Rotherham NHS Foundation Trust Quality Management • Define organisation and management • Service objective setting • Management/Service review process • User agreements / requirements (sharing arrangements) • Documentation

16. The Rotherham NHS Foundation Trust Personnel • Head of service with JD • Staffing • Numbers, training, job descriptions, induction, staff records and review • Regular meetings - ToR

17. The Rotherham NHS Foundation Trust Premises • Definition of working environment • Facilities for staff & patients & storage • Health & Safety

18. The Rotherham NHS Foundation Trust Equipment, Information systems • Management of equipment • Management of data and information • Management of materials

19. The Rotherham NHS Foundation Trust Treatment Process • Patient selection, information and review • Treatment process – definitions & review • Documentation • Monitoring outcomes/evaluation • Feedback on service

20. The Rotherham NHS Foundation Trust Evaluation • Staff feedback • Patient feedback • Clinical evaluation of service • Complaints • Incident reporting processes and feedback

21. The Rotherham NHS Foundation Trust Way forward.... • 1 Agree in principle • 2 Circulate draft document • 3 Develop assessors guidance • 4 Commence date??

22. Monica Minguzzi Therakos – Current Developments

24. Dr Peter Taylor ECP – Mechanism of Action

25. Photopheresis Mechanism of Action Towards an understanding...... UKPS 28 September 2012 Peter Taylor

26. Objectives What is known about the pathogenesis of chronic graft vs host disease ? What is known about the effects of photopheresis ?

27. Pathogenesis of chronic GvHD The pathogenesis of chronic GvHD is not well understood Much of our current knowledge is based upon animal studies, with no single animal model reflecting all aspects of cGvHD

28. Chronic GvHD – Heterogeneous Disease • Variable clinical presentation involving: • Skin, mouth, eyes, liver, gut, upper respiratory tract, oesophagus, genitalia and fascia • Variable pathology: • Inflammatory infiltrate leading dermal/epidermal junction destruction and then fibrosis and sclerosis • Tuboalveolar gland destruction

29. Experimental Studies & cGvHD • Basic theories: • Thymic damage and defective negative selection of T cells • Fibrosis and aberrant production of TGFβ • Altered B cell homeostasis • Immune tolerance / T regulatory cells

30. Failure of negative thymic selection T cells with receptors for high affinity peptide-MHC self antigens are deleted by DC’s and thymicmedullary epithelial cells Depletion of DC’s allowed cCD4 with a cGvHD enhancing effect that was abrogated by KGF. Zhang J Immunol 2007 179, 3305 Anti KGF has not been found to be effective in human studies Failure of T cell deletion can lead to acute GVHD in the presence of recipient epithelial antigens or cGvHD when they recognise antigens on marrow derived cells but not epithelial tissues (mouse) Jones J Clin Invest 2003 112, 1880

31. Immune tolerance to Self Antigens and T regs • Acute GvHD impairs negative selection of T cells and the development of T regsMorohashiImmunobiology 2000 202, 268 • cGvHD can develop in the absence of acute GvHD • Conflicting data - T reg numbers in cGvHDReiger Blood 2006 107, 1717 vs Clark Blood 2004 103,2410 • T reg suppression of cGvHD mediated via cytokines TGFβ, IL-10, or by contact with DC’s via Indoleamine 2,3 dioxygenase • J Clin Invest 2007 117, 2570 • Absence of T reg control of Th1 and Th17 cells is responsible for the autoimmune mediated pathology in cGvHD • Chen Blood 2007 110,3804 • Photodepletion of T cells but sparing T regs can raise T reg numbersBastien Blood 2010 116,4859

32. Role of B cells • Presence of autoantibodies • Clinical presentation of cGvHD with autoimmune manifestations • Improvement in cGvHD induced by anti-CD20 therapy • Enhanced CD 86 expression after stimulation of B cells • Raised BAFF levels • High BAFF levels at 6 months in asymptomatic patients • predicts onset of cGvHD • Antibdies to mHA encoded on the Y chromosome in male recipients receiving female transplants have increased cGvHD incidence

33. Photopheresis Photo-irradiates a methoxypsoralen primed buffy coat preparation which is returned to the donor. UVA + Psoralen is used as a damaging agent to prompt apoptosis of the buffy coat cells First described in the treatment of Cutaneous T cell Lymphoma, where the primed cells were assumed to be malignant

34. Photopheresis - Evidence • Cellular Vaccination • Apoptosis of ECP treated Lymphocytes • Tumour peptides • ECP modulation of Monocytes • Distal Effects on untreated Lymphocytes • T regulatory cells • B cell Homeostasis

35. ‘Vaccination against autoimmunity’ Edelson Scientific American August 1988 referencing work of Cohen Transferable anti-clonatypic response generated by infusion of pathogenic T cells Processing of engulfed apoptotic cells yields T cell epitopes and preferential recognition of TCRhypervariable region by anti-idiotypicclonal T cells induced by T cell vaccination

36. Apoptosis of ECP treated Lymphocytes Both immediate and early apoptosis is induced Majority of lymphocytes apoptose in 48 hours Externalisation of phosphotidyl serine, with Annexin V as a hallmark of early apoptosis which is expressed almost immediately on 75% of lymphocytes A second, later wave of apoptosis accounts for final cell death via caspase activation Note - only 1% of the total lymphoid mass is treated, and cells localised to site of disease are not treated

37. Apoptosis

38. Text Reduction in Bcl/Bax ratio in ECP treated cells Bladon Dermatology 2002 204, 104

39. Tumour peptides Edelson 1988 Tumour specific peptides are exposed which generate an idiotype-specific effector CD 8 response

40. ECP modulation Monocytes Kinetics of monocyte apoptosis remain controversial 25% up to 6 days functional vs 80% apoptosed at 48 hours Early apoptosis could lead to early removal and and ‘apoptotic cell load’ Later apoptosis may leave an opportunity for monocytes to contribute directly Initial mouse studies showed rapid clearance of ECP treated cells to RES Cell trafficking studies in ECP treated cells have demonstrated differential uptake between PMBC’s and neutrophils, with 80% uptake in liver & spleen at 24 hours Just Exp Dermatol. 2012 21, 443 Differential cell dose studies have demonstrated no correlation with monocyte dose

41. Monocytes and Dendritic cells post ECP Ingestion by Antigen Presenting Cells (APCs) has a profound effect on immune regulation ECP Inhibits pro-inflammatory cytokine production Bladon Transplantation Intl 2006 19, 319

42. Monocytes and Dendritic cells post ECP • Modulation of circulating DCs in ECP treated patients with reduced CD80+, CD123+, mature DC phenotypeAlcindor Blood 2001 98, 1622 • Immature DC are prevalent in ECP treated cell populations with retained: • ability for activation • phagocytosis • increased anti-inflammatory cytokinesSpisek Transfusion 2006 46, 55 • DC’s from post ECP samples and demonstrated reduced IL1, TNFα, IL-12, and signature chemokine receptor expression of CCR4 and CCR10Holtick Transplantation 2008 85, 757

43. Distal Effects on untreated Lymphocytes - Th2 in CTCL Normalisation of CD4/CD8 ratios - not universal Th2 to TH1 in CTCL - (malignant clone Th2) Di Renzo Immunology 1997 92, 99

44. Distal Effects on untreated Lymphocytes - Th1 in GvHD In patients with symptomatic cGVHD there is an increase in CD8(+) central memory cells and a concomitant decrease in CD4(+) central memory cells Statistically significant normalisation of the pattern of CD4(+) and a trend toward normalization of CD8(+) central memory T cells coincident with improvement of cGVHD. Yamashita Biol Blood Marrow Transplant. 2006 12, 22 Immune surveillance by T helper type 1 cells is not only critical for the host response to tumours and infection, but also contributes to autoimmunity and GVHD BUT.... Hypothesis that pulmonary GVHD can occur independent of Th1 cells using T-bet-deficient donors GawdyAm J Respir Cell Mol Biol. 2012 46, 249

45. T regulatory cells and the emergence of ‘tolerance’ T reg numbers improve following ECP ? normalisation Bladon & Taylor TherApher Dial. 2008 Aug;12(4):311-8 Syngeneic apoptotic cells (ECP) induced antigen specific T regs, loss of which was associated with loss of tolerance (mouse) Maeda 2005 J Immunol 174 Apoptotic cell infusions generate T regulatory cells (mouse) Mahnke Blood 2003 ECP treated splenocytes indirectly modulate T cell mediated alloreactivity via IL-10 producing DC’s not in the ECPinnocula resulting in expansion of T reg (mouse) CapactiniBiol Blood Marrow Transplant 2011 17,790 ECP reverses experimental GVHD, mediated via T regs (mouse) Gatza Blood 2008, 112, 1515 T reg function augmented by ECP Scmitt 2009 Transplantation 87,1422

47. Future directions? Immune surveillance by T helper type 1 cells is not only critical for the host response to tumours and infection, but also contributes to autoimmunity and GVHD The PDL1-PD1 axis converts human Th1 cells into regulatory T cells AmarnathSciTransl Med. 2011 3, 120.

48. B cell Homeostasis • Dysregulation of the B cell compartment is a hallmark of cGvHDSocie Blood 2011 117, 2086 • Clinical features of autoimmune disease • B cell Activating Factor (BAFF) is elevated in GVHD and is related to production of autoimmunitySarantopoulos Clin Cancer Res 2007 13,6107

49. Immature CD21- immature transitional B cells and deficiency of CD 27+ memory cells is associated with cGvHD Greinix Biol Blood Marrow Transplant 2008 14, 208 Reduced CD21+ cells is marker of response to GvHD Kuzmina Blood 2009 114, 744

50. Persisting levels of BAFF at 4 weeks is predictive of response of cGvHD to ECP, independent of reduction in immunosuppression Whittle 2011 Blood 118, 6446 Persisting high BAFF levels are associated with an increased risk of GVHD failure or of need to re-escalate steroids Whittle Bone Marrow Transplantation 2012 47