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“Stem Cells: They aren’t just for leukemia transplantation anymore”. Richard T. Maziarz, MD Professor of Medicine Oregon Health & Science University September.

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Presentation on theme: "“Stem Cells: They aren’t just for leukemia transplantation anymore”. Richard T. Maziarz, MD Professor of Medicine Oregon Health & Science University September."— Presentation transcript:

1 “Stem Cells: They aren’t just for leukemia transplantation anymore”. Richard T. Maziarz, MD Professor of Medicine Oregon Health & Science University September 12, 2013

2 Stem cell Transplantation: Current Indications Hematologic Malignancies Solid Tumor Malignancy Hereditary Disorders Immune Deficiency Syndromes Genetic Disorders

3 Indications for Hematopoietic Stem Cell Transplants in the United States, 2009 SUM-WW11_8.ppt Slide 8 Number of Transplants

4 Stem cell Transplantation: Future Indications? Myocardial infarction / CHF CVA Critical limb ischemia/ claudication Endstage Liver Disease Diabetes mellitis Neurologic degenerative disorders Bone disorders Acute lung injury Brain and spinal cord injury Other

5 Stem Cells

6 What is a Stem Cell? Adapted from: Self renewing Capable of producing multiple different cell types

7 Bone Marrow Hematopoietic Stem Cells

8 Stem Cells: Embryonic and Adult Loose definition Strict definition pluripotent totipotent

9 What is a hematopoietic stem cell? 1.Adult stem cell 2.Self regeneration 3.Downstream target cell production 4.High (unlimited) potential for cell division 5.Transplantable product 6. Phenotype: CD34 marker; full characterization unknown

10 Goodell, J Exp Med 1996; Nat Med 1997 Stem Cells: The SP Phenotype STEM CELLS Volume 24, Issue 1, pages 3-12, 1 JAN 2006 DOI: 10.1634/stemcells.2005-0116 Volume 24, Issue 1,

11 . Nadin B M et al. Blood 2003;102:2436-2443 ©2003 by American Society of Hematology

12 . Nadin B M et al. Blood 2003;102:2436-2443 ©2003 by American Society of Hematology

13 Where are stem cells found? Bone marrow Blood Blood vessels? All organs?

14 Heterologous applications of HSC?, Goodell, 2000

15 Stem Cell Plasticity: Transdifferentiation

16 Early studies

17 Stem Cell Tx Futures: Liver disease? Lethal liver failure mouse model, (hereditary tyrosinemia) Tx with total bone marrow or highly purified HSC (50, 100, 1000) Survival achieved 4 of 9 BM; 100% animals with > 50 HSC HSC NOT HEPATOCYTES!!!!! – Lagasse et al, Nature Medicine, 2000

18 Stem Cell Tx Futures: Liver disease?

19 NOT everything is transdifferentiation Cell fusion is the principal source of bone-marrow-derived hepatocytes NOT everything is transdifferentiation Cell fusion is the principal source of bone-marrow-derived hepatocytes Wang et al, Nature 2003

20 Multipotential mesenchymal stromal cells Friedenstein, 1968, 1974 - marrow stroma supports hematopoiesis; identified CFU-F Caplan, 1991 - proposed that MSC met criteria of stem cell with multilineage differentiation capacity, self renewal and transplantable product

21 Regenerative Tissue Therapy Mesenchymal Stem Cell (MSC) Chondrocyte Myoblast Fusion Stromal Fibroblast Tenoblas t Preadipocyte Osteoblast Mesengenesis BONESTROMATENDONCARTILAGEMUSCLEADIPOSE


23 Osteogenesis imperfecta- an osteoblast disorder; product of the MSC??

24 Transplantion of Osteogenesis imperfecta pts, Horwitz, 1999 Peri-HSCT Growth rates Total Body Mineral Content

25 Bone Marrow Stroma in HCST Allo tx in osteogenesis imperfecta: increase bone mineral content, decrease fracture, and enhance growth. Horwitz, Nat Med, 1999. – (presence of selective pressure?) – benefit identified with 1.5-2% donor osteoblast

26 Current Opinion: MSC in HCST 2000 and beyond- change of paradigm MSC may best be utilized not for long term engraftment with goal of complete, sustained chimerism but for delivery of package of soluble mediators – Constitutive secretion: SDF-1, IL6, IL7, IL8, IL11, IL12, IL14, IL15, MCSF, FLT3L, SCF, LIF – Induced secretion: LIF, CCL2, CCL4, CCL5, CCL20 – soluble mediators of angiogenesis and immune suppression Engraftment evolves  immunomodulatory functions

27 BMSCs inhibit T-lymphocyte proliferation induced by allogeneic PBLs, DCs, or PHA. (+) MSC (black bars) (-) (white bars) MSCs Di Nicola M et al. Blood 2002;99:3838-3843 ©2002 by American Society of Hematology

28 Prophylaxis of aGVHD in a haploidentical rat model with MAPC Kovacsovics, 2008

29 Adult Stem Cell Therapy: Supportive Care Treatment for HSCT Historical data- (multiple studies): – MSC have immune sanctuary and are immune modulatory – In vitro/ preclinical data to support use in GVHD – Phase II data for treatment encouraging EBMT-30/55 complete response, 9 partial (Lancet,2008) Osiris- 23/31 complete, 6/31 partial – Phase III data Osiris- did not reach endpoints but hepatic and GI responses noted MSC in HSCT take a back seat!!!!!!!!!!!!!!!

30 MSC clinical trials- Non- Heme disease applications MI Cardiomyopathy Inflammatory bowel disease Diabetes mellitis Multiple sclerosis Vascular disease: CVA, PVD Spinal cord injury ALS

31 Stem Cells for Heart disease

32 Stem Cell Tx Futures: Cardiac Disease? Transplanted hematopoietic stem cells (HSC) repair myocardial infarcts, Orlic et al., Nature, 2001 Rationale: – HSC are used in tx for heme malignancies to rescue bone marrow failure – HSC have been shown to generate skeletal muscle, osteocytes, glia

33 Stem Cell Tx Futures: Cardiac disease? Schema: – Mouse model--> LCA infarct – Injection of 2-10 x 10 4 Lin -, kit + bone marrow stem/ progenitor cells into adj myocardium, 3-5 hrs post-infarct – BM cells obtained from GFP transgenic – Necropsy at 6 -12 days

34 Stem Cell Tx Futures: Cardiac disease? Results: – 40% with GFP + myocytes within damage site – Histochemistry + : cardiac myosin, α sarcomere actin – BRDU assay: ~ 30% cells in cycle!!! – Conclusions: HSC can differentiate into myocardial cells after infarct

35 Physiologic “Homing” to Myocardial Infarction 4 x 10 6 allo MSC via tail vein 2 weeks REP 10 days 45’ OCCL X-Gal Stained Moseley, pers comm, 2000

36 Human studies: 1997: 1.1 million MIs; 800,000 revascularization procedures 2001- first cell therapy intervention for CHF 2003- intracardiac skeletal myoblast injections, Smits, J Am Coll Cardio 2004- auto BMC cath delivered  coronary artery infusion with improved LVEF (n=60), Wollert, Lancet 2007- Zenovich reported 5 yrs of collective experience> 1000 pts  generally safe but some concerns exist; mixed results in clinical studies, Exp Pharm 2009- randomized trials emerge with mixed endpoints

37 Meta-analysis of intramyocardial BMSCT during CAPG, Donnderf et al, 2011 6 randomized controlled trials & cohort studies BMSCT  significant improvement of LVEF and LVEDV No increase in adverse cardiovascular events from controls – ventricular arrhythmia – other cardiovascular events Are these viable clinical endpoints? OS? CHF?

38 Possible Explanations for Improved Cardiac Function after Administration of Bone Marrow– Derived Cells, Keating, 2007 Neovascularization Paracrine effect: cytokine/chemokine release Extracellular matrix remodeling Recruitment of endogenous stem cells Engraftment/differentiation/cell fusion of administered cells

39 Stem cells: Future Role in Vascular Surgery?

40 Potential application of endothelial progenitor cells Generation of small diameter neovessels Improved survival after implantation in sheep; marked decrease thrombosis Kaushal, Nat Med, 2001

41 TEN yrs later Derivation and characterization of human induced pluripotent stem cells-endothelial cells (hiPSC-ECs). Rufaihah A J et al. Arterioscler Thromb Vasc Biol 2011;31:e72-e79 Copyright © American Heart Association

42 Improvement in blood perfusion in the ischemic hindlimb after human induced pluripotent stem cells-endothelial cells (hiPSC-EC) transplantation. Rufaihah A J et al. Arterioscler Thromb Vasc Biol 2011;31:e72-e79 Copyright © American Heart Association

43 Stem cell therapies for vascular disease Aranguren, J Mol Med, 2009

44 Engineered vascular grafts

45 Engineered vascular grafts Human use- 23 grafts, f/u 6 yrs, Breuer, 2008

46 PVD/ Critical Limb Ischemia Human: multiple case series; small randomized trials--> BM MNC concentrate injection with potential benefit In progress- large, randomized control studies but data not yet available Today’s difference between PVD and MI/ CAD/ CHF  – Beginning 7/11  designated CPT category III codes (#0263T; 0264T; 0265T)

47 Medical Tourism: adipose derived adult stromal stem cells

48 Lung disease Pulmonary hypertension ALI COPD Bronchiolitis

49 Oregon Medical Laser Center Oregon Center for Regenerative Medicine ALI is a significant contributor to illness and death Induced by:Trauma Blast Injury Inhalation noxious substances Exposure biologic agents- sepsis Exposure radioactive substances ALI is associated with a 39% death rate with >190,000 cases/yr leading to 74,500 deaths and 3.6 million hospital days. Therapeutic strategies and treatment options for ALI are limited Acute respiratory distress syndrome that results from ALI is an important contributor to prolonged mechanical ventilation in the ICU, with mortality remaining high (30-50%) despite optimal supportive care. The Problem: Acute Lung Injury Lung-biopsy obtained from pt 2 Da after ALI 2 o aspiration. Hyaline membranes are evident (arrow), with associated intraalveolar red cells and neutrophils, findings that are consistent with the pathological diagnosis of diffuse alveolar damage NEJM 2000 342:1334

50 Sepsis "the systemic inflammatory response syndrome that occurs during infection” Incidence of Sepsis still increasing 2 nd leading cause of death in ICU 10 th leading cause of death in USA

51 Oregon Medical Laser Center Oregon Center for Regenerative Medicine MSC Therapy Reduces LPS-Induced Lung Injury in Mice Shirley H. J. Mei, et. al. 2007 PLOS Medicine 4(9):1525-1537 Challenge with intratracheal instillation of 800μg LPS (E. coli 055:B5) Slowly infuse either saline or 2.5 x 10 5 MSCs via a jugular venous canula C57Bl/6J Female Mice 30 min 3 days Euthanize the mice to collect tissue for analysis

52 Improved survival Reduced systemic and pulmonary cytokines Prevented ALI and organ dysfunction Down-regulation of inflammation and inflammation-related genes (IL-10, IL-6) Up-regulation of genes involved in phagocytosis Improved bacterial clearance by enhanced phagocytic activity In multiple clinical trials currently MSC therapy

53 Ex‐vivo Lung Perfusion Donated lungs not viable for transplant (PaO2 <300) On ice for 12 hrs 10M MultiStem delivered into left lower lobe (LLL) Vehicle in right lower lobe (RLL) 4 hrs on Ex‐vivo system with Steen Solution TM Collect BAL and tissue for analysis The STEEN Solution™ is a buffered extracellular solution that includes human albumin to provide an optimal colloid osmotic pressure and dextran 40 to coat and protect the endothelium from excessive leucocyte interaction

54 Representative H&E LLL (MAPC) RLL (Vehcile)

55 BAL analysis

56 Organ Transplantation

57 AMS50 Graft >d50 after spleen cell application from “tolerant“ animal- MSC exposure MSC as immune suppressive agent Heterotopic Heart Transplant Allogeneic heart is grafted to adominal artery and venous circulation – keeps on beating

58 Tracheal Replacement, Macchiarini, Lancet 2011 Autologous BM derived MSC expanded in bioreactor and cocultured with scaffold; 3D imaging to reconstruct model of trachea; implanted in 33 yo s/p resection of tracheal cancer

59 Tracheal Replacement, Macchiarini, Lancet 2012

60 Novel Therapeutic Interventions 60

61 Organ regeneration

62 Decellularized organs

63 Recellularized liver with in vivo function after heterotopic implantation, Uygun, Nature Med, 2010

64 The future of cell therapy

65 Transplantation: Rules of the game Change is coming……and arriving far too quickly for most to nimbly maneuver

66 What are the options? Language of stem cells – Autologous vs allogeneic – Universal donor or donor directed – IPS – MSC : bone marrow vs adipose vs placenta – HSC : cord vs bone marrow vs PBSC – Selected? – Activated? – Manipulated? – Fresh vs cryopreserved?

67 Cell Therapy Development Trends HSC Transplant Engineered T Cells Engineered Tissue Mesenchymal SC HSC Transplant Personalized Medicine Approval for Cartilage, Skin Products Autologous and Allogeneic Transplant Product Paradigm Patient Designated Universal Donor Product Biologics/Drug Paradigm ES, iPS Technology Tissue Regeneration Heterologous HSC


69 Demographics Impacting Healthcare Costs Courtesy of Gil van Bokkelen

70 Demographics Impacting Healthcare Costs Courtesy of Gil van Bokkelen

71 Reflections: What have we learned? Maximal tolerated dose (MTD) has not identified in most if not all studies Maximal deliverable dose (MDD) may be more relevant endpoint !!!!! No understanding of clearance of cells or biodistribution No potency determination Personalized product  genetic variants But stem cell products are being used with intentions of being a drug………….or is it an embedded scaffold or a device………or something new

72 72 Acknowledgements: OHSU HSCT & Regenerative Medicine Teams





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