Efficacy and immunologic effects of extracorporeal photopheresis plus interleukin-2 in chronic graft-versus-host disease

Chronic graft-versus-host disease (cGVHD) affects >50% of hematopoietic stem cell transplant patients. Extracorporeal photopheresis (ECP), an immunomodulatory therapy, provides clinical benefit in steroid-refractory (SR) cGVHD, possibly via regulatory T (T reg) and natural killer (NK) cell expansion. We demonstrated that low-dose interleukin-2 (IL2) led to clinical improvement in SR-cGVHD and stimulated preferential T reg and NK-cell expansion with minimal effect on conventional T (T con) cells. We evaluated the effect of ECP (weeks 1-16) plus IL2 (1 × 10 6 IU/m 2, weeks 9-16) in 25 adult patients with SR-cGVHD in a prospective phase 2 trial. Objective responses occurred in 29% and 62% of evaluable patients at weeks 8 (ECP alone) and 16 (ECP plus IL2), respectively. Eight weeks of ECP alone was associated with a marked decline in CD4 + T con ( P = .03) and CD8 + T cells ( P = .0002), with minimal change in T reg cells, T reg:T con cell ratio, or NK cells. Adding IL2 induced an increase in T reg cells ( P < .05 at weeks 9-16 vs week 8), T reg:T con cell ratio ( P < .0001 at weeks 9-16 vs week 8), and NK cells ( P < .05 at weeks 9-16 vs week 8). Patients responding to ECP alone had significantly fewer CD4 + T con and CD8 + T cells at baseline compared with patients who responded after IL2 addition and patients who did not respond; neither T reg nor NK cells were associated with response to ECP alone. Altogether, ECP plus IL2 is safe and effective in patients with SR-cGVHD. ECP and IL2 have distinct immunologic effects, suggesting different therapeutic mechanisms of action. This trial was registered at www.clinicaltrials.gov as #NCT02340676.