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Background Proper stem cell mobilization is one of the most important steps in hematopoietic stem cell transplantation (HSCT). The aim of this paper is to share our 6 years’ experience and provide practical clinical approaches particularly for stem cell mobilization and collection within the series of more than 200 successive allogeneic HSCT at our transplant center. Subjects & Methods Two hundred and seven consecutive patients who underwent allogeneic peripheral blood stem cell transplantation were included in this study. Age, sex, weight, complete blood counts, CD34 + cell counts, total collected amount of CD34 + cells, CD34 + cells per 10 l processed, mobilization failure and adverse events were reviewed. Results Median age was 40.2 ± 12.9 (21–68) years and 46.4 ± 13.4 (17–67) years for donors and patients, respectively. The number of donors who had undergone adequate CD34 + cell harvesting and completed the procedure on the fourth day was 67 (32.8% of all patients). Only 12 patients required cell apheresis both on day 5 and 6. Apheresis was completed on day 4 and/or day 5 in 94.2% of all our donors. There was no significant association between CD34 + stem cell volume and age, gender and weight values of donors. Mobilization failure was not seen in our series. Conclusions G-CSF is highly effective in 1/3 of the donors on the 4th day in order to collect enough number of stem cells. We propose that peripheral stem cell collection might start on day 4th of G-CSF treatment for avoiding G-CSF related side effects and complications. [ABSTRACT FROM AUTHOR]

Autologous hematopoietic cell transplantation (AHCT) is a routinely used procedure in the treatment of adult patients presenting with multiple myeloma (MM), Hodgkin lymphoma (HL) and various subtypes of non-Hodgkin lymphoma (NHL) in upfront and relapsed/refractory settings. Successful hematopoietic progenitor cell mobilization (HPCM) and collection are the rate limiting first steps for application of AHCT. In 2015, almost 1700 AHCT procedures have been performed for MM, HL and NHL in Turkey. Although there are recently published consensus guidelines addressing critical issues regarding autologous HPCM, there is a tremendous heterogeneity in terms of mobilization strategies of transplant centers across the world. In order to pave the way to a more standardized HPCM approach in Turkey, Turkish Society of Apheresis (TSA) assembled a working group consisting of experts in the field. Here we report the position statement of TSA regarding autologous HPCM mobilization strategies in adult patients presenting with MM and lymphoma. [ABSTRACT FROM AUTHOR]

Allogeneic (allo) hematopoietic stem cell transplantation (HSCT) is the only curative option for many malignant and benign hematological disorders. It seems hopeless for patients who relapse after this strategy. In the era of developing breakthrough therapies, we can hope for better, but for patients relapsed after the first allo HSCT probably the best therapy option for long term survival is still another allo HSCT. Interval between first allo HSCT and relapse of primary disease and achievement of complete response after the relapse are the most prominent factors for long time survival for patient after second all HSCT. [ABSTRACT FROM AUTHOR]

Background: The number of therapeutic procedures is increasing steadily year by year with growing collaboration of departments other than Hematology. In the aim to demonstrate our single center activity we analyzed our data since four years.Methods: Between years 1998 and 2001, 658 therapeutic plasma exchange (TPE) procedures were performed on 158 patients. Median age and male/female ratio were 37 (range, 15–87) and 80/78, respectively. Main indications were myastenia gravis (n=55, 34%), TTP (n=13, 8.5%), post ABO mismatched allogeneic hematopoietic cell transplantation aregeneratoric anemia (n=6, 7.5%), progressive systemic sclerosis (n=10, 6.5%), multiple myeloma (n=10, 6.5%), Gullian Barre Syndrome (n=9, 5.9%), multiple sclerosis (n=7, 4.6%), Waldenström Macroglobulinemia (n=5, 3.4%), polymyositis (n=4, 2.7%), sepsis and disseminated intravascular coagulation (n=4, 2.7%). Departments who referred the majority of the patients for TPE were neurology (n=199), hematology (n=153), immunology (n=78), intensive care unit (n=78) and thorax surgery (n=51).Results: The median TPE procedure per patient was 4 (range, 1–50). All the procedures were performed on continuous flow cell separators and median plasma volume processed per cycle was 2471 ml (range 436–5000). The replacement fluids used were 3% hydroxyethylstarch (HES) (24%), 5% albumin (35%), fresh frozen plasma (25%), and HES and albumin (16%). HES was tolerated well even as a sole replacement fluid with acceptable minor side effects. In three patients with progressing hypoalbuminemia HES was replaced or combined with 5% albumin. Close monitoring of serum albumin and fibrinogen levels after repeated procedures is mandatory.Conclusion: In our four years of TPE experience we have increased our collaboration with other departments. 3% HES ± 5% Albumin is a feasible, well tolerated and cost effective replacement fluid combination especially for short-term plasma exchange therapy. [Copyright &y& Elsevier]

Background and objectives: Donor lymphocyte infusions (DLI) have become widely used for prevention or treatment of relapse after allogeneic hematopoietic stem cell transplantation. Increasing use of reduced intensity conditioning regimens (RICR) and subsequent application of DLI forced the hemapheresis centers to collect donor lymphocytes in certain quantity and quality. The place of growth factors especially granulocyte colony stimulating factor (rhG-CSF, filgrastim) in allogeneic hemapoietic stem cell (HSC) collection is established, but there is no consensus about the role of rhG-CSF. We aimed to clarify the dose effect of rhG-CSF on lymphocyte subpopulations (CD3+, CD3+4+, CD3+8+, CD19+, CD3−16+56+) cells and CD34+ HSC.Donors and methods: Major indications for DLI (mean volume: 180 ± 52 ml) were for relapse or transplants using RICR mainly in patients with acute leukemia (n=20) or chronic myeloid leukemia (n=15). In four years we performed 40 lymphocyte apheresis (LA) on 30 healthy (med. age 28, M/F 21/9) donors using continuous flow cell separators by processing 2–2.5 times of their total blood volume (TBV). The apheresis data is divided into three groups according to rhG-CSF dose used for priming. Donors in Group I (n=18), Group II (n=9) and Group III (n=13) received no rhG-CSF (steady state), rhG-CSF 5 μg/kg/d sc × 5 days and rhG-CSF 10 μg/kg/d sc × 5 days, respectively. There was no difference within groups concerning TBV processed and recipient body weight.Results: A total of 11,565 ml (±3700) of blood was processed in 216 min (±36.5) at an inlet of 56.8 ml/min (±10.6) using 999 ml (±307) ACD. The CD34+ HSC increased with increasing rhG-CSF dose as expected. Median CD3+ lymphocyte yield per recipient body weight in Group I, II and III were 0.9 × 10e8/kg (range: 0.1–2.1), 2.9 × 10e8/kg (range: 1.6–4.3) and 2.1 × 10e8/kg (range: 0.6–6.9), respectively. The primed donors T lymphocyte yield was 2–3-fold more in comparison to Group I. This gain was most significant between Group I and III in terms of mean CD3+ (1.09 × 10e8/kg vs 2.41 × 10e8/kg, p=0.02), CD3+4+ (0.64 × 10e8/kg vs 1.44 × 10e8/kg, p=0.02) and CD3+8+ (0.42 × 10e8/kg vs 0.89 × 10e8/kg, p=0.03) cells, respectively.Conclusion: Though the yield of lymphocyte subsets in G-CSF primed donors exceeds the non-primed donors, the target range of 1 × 10e7–1 × 10e8/kg CD3+ lymphocytes could be achieved in the majority of the apheresis procedures without rhG-CSF priming. The yield of T and B lymphocyte subsets are increased by G-CSF stimulation but not on a logarithmic scale, which did not correlate into a clinical relevance. [Copyright &y& Elsevier]

Abstract: Data collection in the field of medicine is extremely important for patient safety. It is viewed as a quality issue in several countries around the world. In order to achieve this goal, nationwide apheresis registries were planned. In 2003, World Apheresis Association (WAA) decided to establish a world-wide apheresis registry. Although some of the apheresis centers in our country sent data to this registry, we believe that we need our own Turkish Registry. For this purpose, we launched new web based apheresis software for donor and therapeutic apheresis procedures. This paper summarizes the characteristics of this new software. [Copyright &y& Elsevier]

Background: The rate of utilizing peripheral blood stem cells (PBSC) as a source for allogeneic stem cells is growing rapidly. We aimed to demonstrate our 4 years experience as the largest apheresis center in Turkey and analyzed the content of the apheresis material.Patients and Methods: From 1998 to the end of April 2002, 151 leukopheresis procedures were performed on 116 healthy donors (M/F:66/50) with a median age of 30 years (14–53). The HLA identical sibling donors received rhG-CSF 10 μg/kg/day sc. for 4 days and at the 5th day leukopheresis was started until collecting >4 × 10e6/kg CD34+ cells. Two times the donors'' total blood volume was processed in 195 min (178–245) on continuous flow cell separators using peripheral venous access.Results: Preapheresis WBC was 51.5 × 10e9/L (range, 13.11–91.3). Mono nuclear cell, CD34 and CD3 quantity of the harvest material were 5.35 × 10e8/kg (range, 0.45–23.46), 6.4 × 10e6/kg (range, 2.49–33.27) and 2.79 × 10e8/kg (range, 0.46–30.95), respectively. We were able to reach the target CD34 count after 1st cycle in 39% and 2nd cycle 61% of the procedures. In all donors with a peripheral blood CD34 count >80/mcl we succeeded to collect enough stem cells with only one leukopheresis.Conclusion: Collection of peripheral blood stem cells with continuous flow cell separators is well tolerated, with no mobilization failures or poor mobilizers. We collected high values of CD34+ cells (med. 6.4 × 10e6/kg) at the expense of high CD3 + lymphocytes (med. 2.79 × 10e8/kg), which may increase the risk of acute and chronic GVHD after allogeneic hemapoietic cell transplantation. [Copyright &y& Elsevier]

Background: Chronic graft-versus-host disease (cGVHD) can arise frequently as a late complication after allogeneic hematopoietic cell transplantation. Patients with extensive disease to date require intensive and long-term immuno-suppression. We aimed to share our single center experience using extracorporeal photoimmunotherapy (ECP) in our steroid refractory extensive cGVHD patients.Patients and Methods: Eight patients with a median age 42 (range, 17–43) and M/F: 2/6 were treated with ECP (UVAR XTS) on 2 consecutive days every 2–4 weeks until resolution of GVHD over a period of 6–15 months concomitantly with immunosuppressive agents. Beyond extensive steroid refractory cutaneous cGVHD, three patients had also bronchiolitis obliterans (BO). Skin scores were assessed by an experienced dermatologist. Clinical, laboratory and radiological findings after 4 months of ECP were accepted as response criteria. The patients received in this almost fully automated system mean 261.4 ml buffy-coat was processed within 193 min using UVADEX sterile solution.Results: After a median of 12 cycles of treatment, 6 patients showed a favorable response. ECP was tolerated well only one patient developed Gr4 thrombocytopenia and another patient had a massive GIS bleeding due to an esophageal tear. Reduction in cholestatic parameters was observed in patients with liver cGVHD, improvement in respiratory functions and CT evaluations in two, and reduction in immunosuppressive requirement in all patients. The most impressive result was the reduced need for hospitalization of these patients and improvement of skin lesions. All but one of the skin biopsy scores was also better after ECP.Conclusion: As extensive cGVHD is a life devastating disorder, every attempt to improve the quality of life should be evaluated carefully. Our findings suggest that ECP is a safe and effective adjunctive therapy for steroid refractory extensive cGVHD of the skin. ECP will find a place both for the treatment and may be for the prevention of GVHD as well. [Copyright &y& Elsevier]

Abstract: Therapeutic plasma exchange (TPE) has been used for the treatment of neurologic diseases in which autoimmunity plays a major role. We reviewed the medical records of our patients who had consecutively been treated by TPE between January 1998 and June 2000. Neurological indications included myasthenia gravis (30 patients), multiple sclerosis attack (6 patients with remitting-relapsing course and 3 patients with secondary progressive course), Guillain-Barrè syndrome (6 patients), paraproteinemic neuropathy (2 patients), and chronic inflammatory demyelinating neuropathy (CIDP), transverse myelitis due to systemic lupus erythematosus, acute disseminated encephalomyelitis in one patient each. Continuous flow cell separators were used for TPE. TPE was generally given every other day for all of the patients and one plasma volume was exchanged for each cycle. Although the patients with secondary progressive multiple sclerosis (3 patients) and paraproteinemic neuropathy (2 patients) did not show any improvement after TPE, other patients’ targeted neurological deficits were improved by TPE. During the TPE procedures, no patient had any morbidity or mortality, and the complications were mild and manageable such as hypotension, hypocalcemia and mild anemia; three patients had septicemia due to the venous catheter used for TPE. TPE is an effective treatment in neurologic diseases in which autoimmunity plays an important role in pathogenesis, and it is safe when performed in experienced centers. [Copyright &y& Elsevier]

Abstract: One of the important clinical variables determining the success of hematopoietic stem cell transplantation is the number of viable CD34+ stem cells transfused to the patient. G-CSF mobilized peripheral blood stem cells from 17 healthy donors were collected by continuous flow apheresis. The median (range) proportions of early apoptotic (Annexin V-FITCpos/7-AADneg) and viable (Annexin V-FITCneg/7-AADneg) CD45dimCD34+ stem cells were 1.5 (0.9–3.7)% and 97.7 (82.8–100)% in the peripheral blood before apheresis and 2.6 (0.8–7.9)% and 97.3 (91.9–99)% in the apheresis products, respectively. Despite an increase in the number of apoptotic cells among all cell compartments, this was statistically significant only in CD34+ cells and granulocytes. The majority of the cells still retained their viability. [Copyright &y& Elsevier]

Introduction: Apheresis is a procedure in which one of the components of blood is removed. The aim of therapeutic plasma exchange (TPE) is to remove a large fraction of the patient’s plasma from the body, and to exchange this with replacement solutions using automatic devices. With this procedure circulating pathogens and toxins are reduced. Before each TPE results of a baseline basal complete blood count, serum protein electrophoresis, coagulation tests and serum electrolytes must be known. The efficacy of this therapy is assessed only by these values. The proteins responsible for disease may be monoclonal proteins, cryoglobulins, lipoproteins, auto or allo antibodies or toxins. In this study, we aimed to compare the effects of several replacement fluids on plasma viscosity and oncotic pressure. At the same time, we evaluated the correlation between plasma viscosity and oncotic pressure.Material and Methods: 111 TPE were performed on 42 patients. Before TPE, the patients whose veins were not suitable were catheterised either by using a subclavian or jugular 11F dialysis catheter. At each session, approximately 1–1.5L of plasma was exchanged. The procedure was performed with albumin in patients whose albumin was under 3gr/dl. Over this value, the exchange fluids were randomised.Results: When the overall results were analysed, there was no statistically significant difference between groups 1 (HES+albumin) and group 3 (albumin). The statistical difference between group 2 and 3 was significant, but no difference was observed between group 1 and 2. According to the decreasing plasma viscosity, there was a significant difference between group 2 and group 3, but there was no difference between group 1 and group 2.Conclusions: The replacement solutions used for plasmapheresis are similar when compared for hemorheologic effects, but we have chosen fresh frozen plasma because of fewer side effects. [Copyright &y& Elsevier]

Therapeutic apheresis is a widely used treatment alternative for several diseases. In 29 patients with different diseases, we have monitored the PT, aPTT, thrombin time (TT), fibrinogen, D-dimer, factor VIII, IX, X, XI, XII, VWF, Protein C, S, Active Protein C Resistance (APCR) and Antithrombin-III during TPE. Patients were divided into four groups based on the replacement fluids used: 3% VARIHES or ISOHES+4% albumin (1:1) (group 1), fresh frozen plasma (FFP) (group 2), 3% VARIHES or ISOHES (group 3) and 4% albumin (group 4). In our study, the fibrinogen level decreased to 83% of the base line level after the end of 48 h therapy. The APTT, PT, and TT increased during TPE. However no statistical difference was observed between the groups. We found a significant change in factor levels with time, only the difference in factors IX and XI between the groups was significant. In addition, factor levels measured at 48 h were close to the levels measured before aphereses. In our study, time the related change in AT-3 values was significant. Time-related changes of the Protein S and APCR were not statistical significant significant but on the other hand, we found a significant difference in AT-III and Protein C values between groups. The side effects of HES on coagulation factors and tests were comparable to those of other replacement fluids. Its low cost makes it favourable. [Copyright &y& Elsevier]

Background: Central venous catheters (CVC) are frequently used for stem cell collection and recurrent therapeutic hemapheresis procedures for patients with poor peripheral venous access. There is a tendency to prefer a right sided approach for insertion of a CVC via the subclavian route. We designed a sequential randomized study to examine the issue of catheter insertion side and analyzed all the technical data on surgical skill and observed complications.Method: Seventy-five patients who are candidates for stem cell collection and high dose chemotherapy underwent placement of Hickman catheters via the percutaneous subclavian vein (SCV) route. One experienced surgeon inserted 12F, double lumen, tunnelled, silicon based catheters in the operation room via fluoroscopic control. All of the procedure related complications, morbidity and mortality were analyzed on the basis of the side of catheter insertion.Results: The total rate of malpositioning in this series was 14.66%. The Jugular vein was the most common malpositioning site (66.6%). We observed a statistically significant difference in malpositioning between left versus right sided attempts, at 5.55% versus 20.51%, respectively (p=0.032). The routes of malpositioning encountered for left sided attempts were the right SCV and the left internal jugular vein, the right internal jugular vein (n=5), the left SCV vein (n=2), and one left internal jugular vein. There was no significant difference between the right and left sided attempts for mechanical complications other than malpositioning (p<0.05).Conclusion: In this study the rate of malpositioning was greater in the right sided approach (p=0.032) and the other mechanical complication rates did not differ for the two methods. Our results indicate that there is no need for hesitancy in using left sided attempts at CVC insertion. [Copyright &y& Elsevier]

Therapeutic plasma exchange (TPE) is used to treat more than 60 diseases worldwide and has drawn growing interest. Little is known about the current situation of TPE activity in Turkey, so we developed a survey to obtain information about this timely topic. We collected data on TPE from 28 apheresis units throughout Turkey. We performed a total of 24,912 TPE procedures with 3203 patients over the past decade. Twenty years ago, the majority of procedures were performed for neurological and hematological disorders, and today, most TPE procedures are done for the same reasons. The only historical change has been an increase in TPE procedures in renal conditions. Currently, renal conditions were more frequently an indication for TPE than rheumatic conditions. Fresh frozen plasma was the most frequently used replacement fluid, followed by 5% albumin, used in 57.9% and 34.6% of procedures, respectively. The most frequently used anticoagulants in TPE were ACD-A and heparin/ACD-A, used with 1671 (52.2%) and 1164 (36.4%) patients, respectively. The frequency of adverse events (AEs) was 12.6%. The most common AEs were hypocalcemia-related symptoms, hypotension, and urticaria. We encountered no severe AEs that led to severe morbidity and mortality. Overall, more than two thirds of the patients showed improvement in the underlying disease. Here, we report on a nationwide survey on TPE activity in Turkey. We conclude that there has been a great increase in apheresis science, and the number of TPE procedures conducted in Turkey has increased steadily over time. Finally, we would like to point out that our past experiences and published international guidelines were the most important tools in gaining expertise regarding TPE. [ABSTRACT FROM AUTHOR]

Autologous hematopoietic cell transplantation (AHCT) is an established treatment option for adult patients presenting with multiple myeloma (MM), Hodgkin lymphoma (HL) and various subtypes of non-Hodgkin lymphoma (NHL) in upfront and/or relapsed/refractory disease settings. Although there are recently published consensus guidelines addressing critical issues regarding autologous hematopoietic progenitor cell mobilization (HPCM), mobilization strategies of transplant centers show high variability in terms of routine practice. In order to understand the current institutional policies regarding HPCM in Turkey and to obtain the required basic data for preparation of a national positional statement on this issue, Turkish Hematology Research and Education Group (ThREG) conducted a web-based HPCM survey. The survey was designed to include multiple-choice questions regarding institutional practice of HPCM in adults presenting MM, HL, and NHL. The representatives of 27 adult HCT centers participated to the study. Here we report the results of this survey shedding light on the real-world experience in Turkey in terms of autologous HPCM mobilization strategies in patients presenting with MM and lymphoma. [ABSTRACT FROM AUTHOR]

Hematopoietic cell transplantation is an established treatment option with curative potential for a variety of clinical conditions. The last decade especially witnessed a remarkable increase in HCT activity in Turkey. In 2014, 696 pediatric and 2631 adult (total 3327) HCT were performed in Turkey. Corresponding transplant rates per 10 million inhabitants for autologous-HCT and allogeneic-HCT were 226 and 202, respectively. Total HCT procedures in Turkey increased 177% in the last 5 years and 791% in the last 14 years. This report focuses mainly on HCT activity of Turkey in 2014 based on the national HCT registry and presents a general picture of national HCT activity. [ABSTRACT FROM AUTHOR]

Abstract: Depletion of bone marrow (BM) from erythrocytes is used to prevent early hemolysis in major ABO incompatible allogeneic hematopoietic cell transplantation (Allo-HCT). This method was also strongly recommended before storing of autologous and even allo-BM for volume reduction in order to prevent early hemolysis and DMSO toxicity after infusion. In our center, erythrocyte depletion of BM harvests has been performed on a continuous flow cell separator, which used a closed system with a high mononuclear cell (MNC) yield and low rate of erythrocyte contamination. According to the protocol of a cellular therapy approach in a cardiovascular collaborative study we have to adopt the process to lower volumes. We aimed to compare our results with standard volume (SV) (historical control) to low volume ED procedures. Patients and method: Data has been collected from the last five years. We analyzed 28 cases in the SV group (BM volume >750ml) and 39 cases in the low volume (LV) group. Nineteen of these cases were allogeneic, and 48 were autologous procedures. We used the software COBE PBSC coll vers 5.1 and a standard disposable set (Gambro BCT, Lakewood, USA) for the procedure, and simultaneously, a double bag system with intermediate connectors were used to overcome re-circulation (COBE Spectra Bone Marrow Processing Set, Lakewood USA). Results: The mean volume reduction was 88% (range, 84.4–93.5%) for SV and 90.8% (range, 87.2–91.3%) for the LV group. We did not find any significant difference for MNC yield, volume reduction rate and CD34+ cell recovery between the SV and LV group. There were no complications experienced with regards to device or technical difficulties during procedures. Acute massive intravascular hemolysis was not observed in allogeneic recipients. Conclusion: ED and volume reduction with COBE spectra produced successful results in standard and low harvest volumes. This process can be successfully applied to lower volumes and comparable results to the SV harvest can be achieved for the ED rate, reduction of volume and recovery of MNCs and CD34+ cells. [Copyright &y& Elsevier]

Abstract: Transplant physicians are generally using the recipient’s actual body weight (ABW) for the calculation of the content of CD34+ cells in the harvest material in hematopoietic stem cell transplantation (HSCT). As a reference center performing both the stem cell collection and HSCTs, we aimed to evaluate whether there were any differences for neutrophil recovery by calculating the CD34+ cell content in the graft according to actual, ideal (IBW) or adjusted IBW (AIBW) of the recipients in both autologous (n =148) and allogeneic stem cell collection setting (n =234). We observed a negative correlation between the neutrophil recovery and the cell doses infused as to each of these BWs in the allo-HSCT group, but not in the auto-HSCT group. This negative correlation was stronger for IBW and AIBW rather than for ABW in allo-HSCT group. In addition, calculations for both IBW and AIBW in autologous and allogeneic transplants revealed a significant difference in comparison to ABW for different cut-off values of infused CD34+ cells. Consequently, we suggested that both IBW and AIBW based calculations of CD34+ cells infused are better predictors of neutrophil recovery in comparison to ABW in allo-HSCT. We were not able to show this impact in autologous transplants. [Copyright &y& Elsevier]

Abstract: P-selectin is an useful marker to determine platelet activation and nitric oxide inhibits platelet activation, secretion, adhesion and aggregation. The aim of this study was to investigate the relationship between nitric oxide and P-selectin values in both single donor apheresis and random donor platelet concentrates. According to the results of this study, we found that the best platelet concentrate is freshly prepared single donor apheresis concentrate and it is important to prevent activation at the beginning of the donation. Nitric oxide, which is synthesized from platelets during the storage period, is not sufficient to prevent platelet activation. [Copyright &y& Elsevier]

Abstract: Graft versus host disease (GvHD) is the most prominent cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (Allo-HCT). Extracorporeal photoimmunotherapy (ECP) is an alternative therapeutic modality in steroid and/or cyclosporin-A refractory GvHD developing after Allo-HCT. The aim of this study was to evaluate whether there was any relation between serum TNF-a levels and the response to ECP in patients with steroid refractory of extensive chronic GvHD. Between March 2001 and August 2003, seven patients (male: 1, female: 6) had ECP for treatment of steroid refractory extensive chronic GvHD. Five age and gender matched healthy volunteers were included in this study as the control group. The age of the patients ranged from 18 to 49 years. All patients were allografted from HLA-idenditical sibling donors. The median number of ECP sessions was 10 (8–36), consisting of two sequential cycles monthly. For measurement of serum TNF-a levels, blood samples were obtained both prior to ECP (basal) and after the first and second in all patients and in five patients after the 10th session. Serum TNF-a levels (Quantakine HS, R&D system, UK) were measured in peripheral venous blood samples by an ELISA method. ECP was given at a median of 5.8 months (1–14 months) after allo-HCT. No complications were seen during or after the ECP procedures. The median time of an ECP session was 183 minutes. The median volume of Uvadex used per session was 4.40ml (3.61–5.61). The basal mean level of TNF-a was higher in patients than in the control group (2.47±0.83pg/ml vs. 1.75±0.06, p =0.05). The mean TNF-a levels decreased from 2.47±0.83pg/ml to 1.77±0.93pg/ml after the initial session (p =0.045) and from 2.32±0.92pg/ml to 1.69±0.93pg/ml after the second day (p =0.015). After completion of the ECP sessions, extensive chronic GvHD recovered in only three patients. In three clinically responsive patients, the TNF-a levels were significantly reduced after both the second and tenth sessions. In contrast, in two patients not responding to ECP therapy, TNF-a levels were increased. In order to report whether these changes in TNF levels is an early predictor for evaluation of the efficacy of ECP in extensive chronic GvHD, TNF-a levels should be studied in a larger series. [Copyright &y& Elsevier]