Small-scale extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma: a report of 3 cases.

Extracorporeal photopheresis is an accepted method for the treatment of cutaneous T-cell lymphoma and much progress has recently been achieved in therapy and understanding of its mechanism. In general large numbers of white blood cells are collected by a cell separator and irradiated in the presence of 8-MOP. In contrast to this practice, data from an animal model showed that as few as 0.2% of the body's blood volume irradiated are sufficient to achieve an immune response after photopheresis. Based on these data we developed a small-scale photopheresis procedure and applied the method in 3 end-stage T-cell lymphoma patients who were not eligible for apheresis. The mononuclear cells from 50 ml of blood were separated by density gradient centrifugation, irradiated with UV-light in the presence of 8-Methoxy-Psoralen (MOP) with 2J/cm(2) and reinjected. 2-3 treatments per week were conducted. The three patients-2 male and 1 female, age 63-86, Sezary syndrome (1x) and mycosis fungoides in tumour stage (2x)-showed no side effects on cell injection. The two patients with mycosis fungoides showed a prompt regression and softening of the tumours. The patient with Sezary syndrome developed numerous necrotic spots on the skin after 6 weeks of therapy that turned normal within a few days. Patient 1 died of pneumonia 4 weeks after the start of therapy and patient 3 died of heart failure 8 weeks after start of therapy, both during regression of the tumours. Patient 2 was treated over a period of 11 months, with an initial regression in the first weeks followed by a slow progression of the tumours after she rejected any form of further treatment. The small-scale extracorporeal photopheresis therapy presented is effective in cutaneous T-cell lymphoma. But questions regarding the optimal number of cells irradiated per treatment, the conditions of cell incubation after irradiation and the number of treatment cycles are still open. Therefore further studies are required to establish a method that is effective and circumvents the use of apheresis technology.

The role of rheology in hemapheresis.

Rheological therapy attempts to favorably influence the blood flow mechanics for the treatment of diseases, mainly of the microcirculation but also of the macrocirculation. Hemapheresis, originally used only for the elimination of an excess of cellular or plasmatic components, was shown to also influence the hemorheology favorably. As extracorporeal therapy affects the rheology much more than conventional hemorheotherapy, not only cellular or plasmatic hyperviscosity syndromes but also many more diseases associated with organ perfusion problems due to diseases of the micro- and macrocirculation, especially in the elderly, were and are increasingly considered to be indicated. Technical progress led away from plasma exchange as an unspecific and unselective procedure to plasma differential separation using precipitation. adsorption, and filtration. With our recent development, we demonstrated that rheohemapheresis is the most advanced technical procedure. The mechanism of action can well be related to a synergetic consideration of rheology. However. one has to keep in mind that the elimination of blood components such as lipids, immunoglobulins, and endothelial factors may well contribute to the explanation and understanding of the positive clinical effects observed. These speculative aspects need further investigation.

[Granulocyte transfusion as a part of compensation for a biological defect]. / Die Granulozytentransfusion als Teil des biologischen Defektausgleichs.

As compared to the widespread application of erythrocyte- and platelet transfusion, granulocyte substitution is still not without difficulties. In spite of the introduction of automated separation systems, the procurement of adequate numbers of granulocytes is not easy, mainly for numerical-technical reasons. Also, the need for an effective organizational background and a close functional connection of transfusion medicine and oncology are not appropriately observed. Whereas the results of studies investigating the prophylactic value of granulocyte transfusions remained negative, mainly due to an inadequate granulocyte dosage, the importance of earlier trials, demonstrating the therapeutic efficacy remains without objection, as subsequent studies also suffer from the transfusion of cells too low for clinical requirements. Granulocyte substitution is only one aspect of the biological defect compensation in the immunocompromised host. In spite of a reduced frequency of applications and the introduction of newer therapeutic developments, granulocyte transfusion, if sufficient cell numbers are applied, may well play a valuable role within the concept of biological defect compensation for the control of septicemia.

Predictive value of lymphocytotoxic test and platelet aggregometry for the effect of transfused platelet concentrates.

Sera of patients with thrombocytopenic diathesis before platelet transfusion were evaluated using donor's platelets in the aggregometry test the donor's lymphocytes in the lymphocytotoxicity test. In most cases the results of both tests were in agreement, although sometimes, despite strongly positive results of LCTT, the Agr was negative. Both tests showed a similar value for the prediction of the effectiveness of platelet concentrates: Agr in 80% and LCTT in 71% of cases.

Plasmapheresis as a supplementary treatment in pemphigus.

Four cases with pemphigus 3 p. vulgaris and one p. foliaceus were treated with plasmapheresis. The volume of plasma exchange was 500-800 ml once a week for 6 weeks. In one patient the procedure was repeated four times, within 8 months. All patients were treated with prednisone and azathioprine or cyclophosphamide at the same time, but in lower dosages. The results were satisfactory and the remission after the treatment lasted for 11 months to 2 years.

Plasmapheresis in the treatment of systemic lupus erythematosus.

Plasmapheresis has been used as a supplementary method for the treatment of 11 cases of SLE (7 with lupus nephritis and 4 without renal changes). In 7 cases there was a marked improvement during the plasma exchanges which lasted from 2 months to 3 years of follow up. In one case the direct result was satisfactory but after 3 months there was a severe relapse and the patient died. In 3 cases (two without lupus nephritis) plasmapheresis was without any effect. We believe that plasmapheresis is chiefly indicated in severe cases with high levels of ds-DNA antibody titers.

Infusion of physiological saline supplemented with adenine, pyruvate and phosphate.

After controlled bleeding 20 ml/kg enriched infusion fluid containing 0.005 mol/1 adenine, 0.1 mol/1 pyruvate, 0.1 mol/1dibasic sodium phosphate and 0.15 mol/1 sodium chloride was given to 14 dogs. Three dogs received after bleeding the same infusion fluid without adenine. One dog received only dextran after blood withdrawal and served as control Before and after bleeding and 1, 4, 24, 48 and 72 hours after infusion the levels of 2,3-DPG, ATP and P50 index were determined. After infusion of enriched fluid with and without adenine the level of 2,3-DPG and the value of P50 index increased. No rise in the ATP level was observed.