And Now For Something
Completely Different
Lee Landeen, Ph.D.
Associate Director, Research
Advanced BioHealing
Advanced BioHealing
• Regenerative medicine company
– Not wound care company
• Celaderm
– Keratinocyte-based, tissue-engineered product
• Purchased rights to Advanced Tissue Sciences / Smith
& Nephew dermal products
– May 2006
– Dermagraft and TransCyte
• Acquired by Shire
– June 2011 ($750M)
The History
• 1986: Marrow-Tech incorporates; tissue-engineering platform technology
• 1990: Markets skin2 for cytotoxicity testing (pre-cursor to Dermagraft)
• 1991: Marrow-Tech renamed Advanced Tissue Sciences; began
development of Dermagraft (burns)
• 1993: Began development of TransCyte (burns)
• 1996: ATS / Smith & Nephew form joint venture
• 1996: Dermagraft clinical trials for ulcers initiated
• 1997: TransCyte approved for partial and full-thickness burns
• 1998: ATS / S&N joint venture expanded to include TransCyte
• 2001:Dermagraft approved for diabetic foot ulcers
• 2002: ATS files Chapter 11; S&N acquires the JV
• Dec 2005: S&N decided to exit the business, put assets related to
Dermagraft and TransCyte up for sale
• May 2006: ABH purchased assets
• Feb 2007: ABH revalidated Manufacturing facility and shipped first
Dermagraft to customers
Why Has ABH Succeeded
(When Others Have Failed)?
• To date, ABH has generated > $400MM in sales revenue on Dermagraft
• Principles of Jim Collins’ “Good to Great”
– Narrow focus, culture of discipline, hire the right people, flywheel concept
• Selling price doubled
– Dermagraft was off market for >6 mo
• Positioned as the “Standard of Care”
– Close the wound vs. manage the wound
– Non-healing wounds after 4 weeks need an advanced therapy
• Commercially focused Sales team
– Multiple disciplines including pharma, biologics and device
– Single product portfolio
• Dedicated reimbursement staff and expertise
– Heal2Gether program to work with patient compliance issues
– Health economics of using vs. not using Dermagraft
– Physicians get reimbursed
Case Studies
Before
Case 1
(plantar surface)
(ulcer > 2 yr)
(healed at 8 wk)
Case 2
(heel)
(healed at 11 wk)
Case 3
(toe)
(ulcer 3 mo)
(healed at 7 wk)
After
Tissue Engineering
Biochemistry
Cell Biology
Polymer
Science
SEM of Fibroblasts
on Nylon
Bioengineering
Transplantation
SEM of Vicryl
SEM of Dermagraft
Dermagraft
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Human neonatal dermal fibroblasts (MCB, WCB)
Resorbable knitted mesh scaffold (poly[glycolide-co-L-lactide])
Class III medical device (CDRH, 2001) (biologic, cell therapy)
Treatment of diabetic foot ulcers (1 x 8 wks)
Cryopreserved dermal replacement (-75oC ± 10oC)
Past/present evaluation in venous leg ulcers, epidermolysis bullosa,
gingival resectioning, epicardial revascularization, rotator cuff repair
Dermagraft Manufacturing
Cell Expansion
Dermagraft Bioreactor Manifold
8-cavity bag
Manifold
(up to 12 per lot)
(up to 1,152 units)
Product
Normal Wound Healing
HEMOSTASIS
PLATELET AGGREGATION
NEUTROPHIL IMMIGRATION
MONOCYTE IMMIGRATION
GRANULATION TISSUE
RE-EPITHELIALIZATION
WOUND CLOSURE
SCAR FORMATION
REMODELING
SECOND
MINUTE
DAY
WEEK
MONTH
YEAR
Ulcers
HEMOSTASIS
PLATELET AGGREGATION
NEUTROPHIL IMMIGRATION
MONOCYTE IMMIGRATION
GRANULATION TISSUE
RE-EPITHELIALIZATION
WOUND CLOSURE
SCAR FORMATION
REMODELING
SECOND
MINUTE
DAY
WEEK
MONTH
YEAR
Proposed Mechanisms of Action of
Dermagraft®
• Delivery of normal, non-senescent fibroblasts
• Delivery of growth factors
– Extracellular matrix-bound
– Secreted
• Substrate for re-epithelialization
– Extracellular matrix molecules
• Influence on inflammatory processes
– Neutrophils
Proposed Mechanisms of Action of
Dermagraft®
• Delivery of normal, non-senescent fibroblasts
• Delivery of growth factors
– Extracellular matrix-bound
– Secreted
• Substrate for re-epithelialization
– Extracellular matrix molecules
• Influence on inflammatory processes
– Neutrophils
Normal Fibroblast Replicative Senescence
• Hayflick’s proposed 50 cell doublings
Reactive Oxygen Species
Pressure Ulcers
Chronic ischemia/reperfusion injury
Diabetic Ulcers
High mitochondrial potential
Chronic neutrophil activation
Chronic inflammation
Venous Stasis Ulcers
Iron from extravasated red cells
Chronic neutrophil activation
Chronic Inflammation
ROS
Protein
DNA
Lipid
Senescence-like
Phenotype
Role of Senescence
• Fibroblasts with a stress-induced premature
senescent phenotype fail to respond
appropriately to injury
• Neutrophil activation fails
• Bacterial colonization occurs
• Keratinocyte closure of the wound is delayed
Proposed Mechanisms of Action of
Dermagraft®
• Delivery of normal, non-senescent fibroblasts
• Delivery of growth factors
– Extracellular matrix-bound
– Secreted
• Substrate for re-epithelialization
– Extracellular matrix molecules
• Influence on inflammatory processes
– Neutrophils
Growth Factor Expression in Dermagraft
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IGF-II
IGFBP-4
IGF-BP-5
IGFBP-6
IL-la
IL-1 RA
Pro-IL-1b
IL-6
IL-8
IL-11
TNF-a
MCP-1
MCP-3
SDF-1
Interferon-b
Gro-a
Gro-b
Gro-g
CSF-1
G-CSF
GM-CSF
MAC25
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PDGF A chain
KGF
TGF-b1
TGF-b1 BP
TGF-b-related
TGF-b latency protein
CTGF
Wnt 4
Wnt 6
Wnt 11
WISP-2
VEGF
VEGF-B
HGF
PLGF
bFGF
Cyr61
FGF-1BP
FGF-5
HSFGF
AAMP
Angiopoietin-1
ECM-bound Growth Factors
Immunohisto for bFGF
ELISA for bFGF
VEGF in medium, ng/mL
Secretion of VEGF by Dermagraft®
After Thawing
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
0
1
2
3
4
Time in culture, days
5
6
Chick Chorioallantoic Membrane Assay
for Angiogenesis
Control, Scaffold
Dermagraft®
Chick Chorioallantoic Membrane Assay
for Angiogenesis
branch points/5 mm disc
25
20
15
10
5
0
Scaffold
Control
3-D culture + anti-VEGF + anti-HGF + anti-VEGF
+ anti-HGF
Laser-Doppler Showing Blood Supply
in a Treated Diabetic Ulcer
Pre-treatment
2 weeks
5 weeks
Proposed Mechanisms of Action of
Dermagraft®
• Delivery of normal, non-senescent fibroblasts
• Delivery of growth factors
– Extracellular matrix-bound
– Secreted
• Substrate for re-epithelialization
– Extracellular matrix molecules
• Influence on inflammatory processes
– Neutrophils
Extracellular Matrix Composition
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Biglycan
Collagen I
Collagen III
Collagen V
Collagen VI
Collagen VII
Decorin
Elastin
Fibronectin
Glycosaminoglycans (HSPG)
Lumican
SPARC
Tenascin
Thrombospondin II
Keratinocyte Migration
On Wound bed
Krejci-Pappa, et al. 1999
On Dermagraft
Proposed Mechanisms of Action of
Dermagraft®
• Delivery of normal, non-senescent fibroblasts
• Delivery of growth factors
– Extracellular matrix-bound
– Secreted
• Substrate for re-epithelialization
– Extracellular matrix molecules
• Influence on inflammatory processes
– Neutrophils
Factors Induced in DERMAGRAFT®
Moerge of normalized DG and ML data
Normalized
50.0 Intensity
48.0
46.0
44.0
42.0
40.0
IL-8
38.0
36.0
34.0
32.0
30.0
28.0
26.0
24.0
22.0
20.0
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Merge of prenormalized data Prenormalized data
Dermagraft®
Monolayer
IL-8 secretion by Dermagraft
6
IL-8, ng/10 cells
70
60
50
40
30
20
10
0
0
2
4
Time after thawing, days
6
Chemokine Message in Dermagraft
Chemokines
Macrophage
attractants
25000
Neutrophil
attractants
Stem cell
attractants
Dendritic cell
attractants
Monolayer fibroblasts
3D fibroblasts
Keratinocytes
15000
10000
5000
L1
XC 2
L
C 12
XC
L
C 14
XC
L1
6
C
XC
IL
8
C
CL
C 7
CL
1
C 3
CL
2
C 0
XC
L
C 1
XC
L
C 2
XC
L
C 3
XC
L
C 5
XC
L6
C
CL
2
0
C
Signal
20000
CXCL-1, 5, 6, 8
(Gro-a, ENA-78, GCP-2, IL-8)
• Secreted by fibroblasts, neutrophils,
keratinocytes, and other cells
• Chemoattractants and activators for neutrophils
• Primes neutrophil respiratory burst
• Antibacterial/antimicrobial activity
• Heparan sulphate-binding
• Activated by MMP-9
Overall Hypothesis
Ulcer Fibroblasts
(Senescence-like Phenotype)
Inappropriate
Response to
Injury
Bacterial
Colonization
No Closure
Chronic
Wound
Proposed Dermagraft MOA
HSPs, necrotic cells,
scaffold
HEMOSTASIS
PLATELET AGGREGATION
NEUTROPHIL IMMIGRATION
MONOCYTE IMMIGRATION
Dermagraft®
Cells
G-CSF IL-8
GRANULATION TISSUE
MCP-1
TGFb1
Gro-a
ENA-78 MCP-3 IL-6
RE-EPITHELIALIZATION
ECM Substrate
GCP-2 MCP-4 IL-11
VEGF
WOUND CLOSURE
HGF
bFGF
SCAR FORMATION
KGF
Dermagraft®
REMODELING
SECOND
MINUTE
DAY
WEEK
MONTH
YEAR
“Doctor, my brain hurts”