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In the context of the promising results seen in the article by Greer et al (page 911), and with the failure of most conventional immunosuppressive agents to have any impact on the clinical course of bronchiolitis obliterans syndrome or chronic lung allograft dysfunction, the author discusses the need for prospective randomized trials to assess the effi cacy of extracorporeal photopheresis as an early stage interventional or prophylactic immunomodulatory strategy and associated cellular mechanisms and biomarkers.