“Stem Cells: They aren’t just for
leukemia transplantation anymore”.
Richard T. Maziarz, MD
Professor of Medicine
Oregon Health & Science University
September 12, 2013
Stem cell Transplantation:
Current Indications
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Hematologic Malignancies
Solid Tumor Malignancy
Hereditary Disorders
Immune Deficiency Syndromes
Genetic Disorders
Indications for Hematopoietic Stem Cell Transplants in the
United States, 2009
5,500
Allogeneic (Total N=7,012)
5,000
Autologous (Total N=9,778)
Number of Transplants
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Multiple
Myeloma
NHL
AML
HD
ALL
MDS/MPD Aplastic
Anemia
CML
Other
Leuk
NonOther
Malig Cancer
Disease
Slide 8
SUM-WW11_8.ppt
Stem cell Transplantation:
Future Indications?
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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
Stem Cells
What is a Stem Cell?
•Self renewing
•Capable of producing multiple different cell types
Adapted from: http://stemcells.nih.gov/info/scireport/chapter4.asp
Bone Marrow
Hematopoietic Stem Cells
Stem Cells: Embryonic and Adult
totipotent
Loose definition
Strict definition
pluripotent
What is a hematopoietic stem
cell?
1.
2.
3.
4.
5.
6.
Adult stem cell
Self regeneration
Downstream target cell production
High (unlimited) potential for cell division
Transplantable product
Phenotype: CD34 marker; full
characterization unknown
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
http://onlinelibrary.wiley.com/doi/10.1634/stemcells.2005-0116/full#fig1
.
Nadin B M et al. Blood 2003;102:2436-2443
©2003 by American Society of Hematology
.
Nadin B M et al. Blood 2003;102:2436-2443
©2003 by American Society of Hematology
Where are stem cells found?
Bone marrow
Blood
Blood vessels?
All organs?
Heterologous applications of HSC?,
Goodell, 2000
Stem Cell Plasticity: Transdifferentiation
Early studies
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
Stem Cell Tx Futures:
Liver disease?
NOT everything is transdifferentiation
Cell fusion is the principal source of bone-marrow-derived hepatocytes
Wang et al, Nature 2003
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
Mesengenesis
Osteoblast
BONE
Chondrocyte
CARTILAGE
Mesenchymal
Stem Cell (MSC)
Myoblast
Fusion
Stromal
Fibroblast
Regenerative Tissue Therapy
MUSCLE
STROMA
Tenoblas
t
TENDON
Preadipocyte
ADIPOSE
Osteogenesis imperfecta- an osteoblast
disorder; product of the MSC??
Transplantion of Osteogenesis
imperfecta pts, Horwitz, 1999
Peri-HSCT Growth rates
Total Body Mineral Content
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
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
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
Prophylaxis of aGVHD in a haploidentical
rat model with MAPC
Kovacsovics, 2008
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!!!!!!!!!!!!!!!
MSC clinical trialsNon- Heme disease applications
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MI
Cardiomyopathy
Inflammatory bowel disease
Diabetes mellitis
Multiple sclerosis
Vascular disease: CVA, PVD
Spinal cord injury
ALS
Stem Cells for Heart disease
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
Stem Cell Tx Futures:
Cardiac disease?
Schema:
– Mouse model--> LCA infarct
– Injection of 2-10 x 104 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
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
Physiologic “Homing” to Myocardial Infarction
10 days
2 weeks REP
45’ OCCL
4 x 106 allo MSC
via tail vein
X-Gal Stained
Moseley, pers comm, 2000
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
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?
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
Stem cells:
Future Role in Vascular Surgery?
Potential application of endothelial progenitor cells
Generation of small diameter neovessels
Improved survival after implantation in sheep; marked decrease thrombosis
Kaushal, Nat Med, 2001
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
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
Stem cell therapies for vascular disease
Aranguren, J Mol Med, 2009
Engineered vascular grafts
Engineered vascular grafts
Human use- 23 grafts, f/u 6 yrs, Breuer,
2008
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)
Medical Tourism: adipose derived
adult stromal stem cells
Lung disease
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Pulmonary hypertension
ALI
COPD
Bronchiolitis
The Problem:
Acute Lung Injury
ALI is a significant contributor to illness and death
Induced by: Trauma
Blast Injury
Inhalation noxious substances
Exposure biologic agents- sepsis
Exposure radioactive substances
Lung-biopsy obtained
from pt 2 Da after ALI 2o
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
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.
Oregon Medical Laser Center
Oregon Center for Regenerative Medicine
Sepsis "the systemic inflammatory
response syndrome that occurs
during infection”
•Incidence of Sepsis still increasing
nd
•2 leading cause of death in ICU
•10th leading cause of death in USA
MSC Therapy Reduces LPS-Induced Lung Injury in Mice
Challenge with intratracheal instillation of
800μg LPS (E. coli 055:B5)
30 min
C57Bl/6J
Female Mice
Slowly infuse either saline or 2.5 x 105
MSCs via a jugular venous canula
3 days
Euthanize the mice to collect tissue for
analysis
Shirley H. J. Mei, et. al. 2007 PLOS Medicine 4(9):1525-1537
Oregon Medical Laser Center
Oregon Center for Regenerative Medicine
MSC therapy
• 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
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 SolutionTM
• 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
Representative H&E
LLL
(MAPC)
RLL
(Vehcile)
BAL analysis
Organ Transplantation
MSC as immune suppressive agent
Heterotopic Heart Transplant
AMS50
Graft >d50 after spleen
cell application from
“tolerant“ animal- MSC
exposure
Allogeneic heart is
grafted to adominal
artery and venous
circulation – keeps on
beating
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
Tracheal Replacement,
Macchiarini , Lancet 2012
Novel Therapeutic Interventions
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Organ regeneration
Decellularized organs
Recellularized liver with in vivo function
after heterotopic implantation,
Uygun, Nature Med, 2010
The future of cell therapy
Transplantation:
Rules of the game
• Change is coming……and arriving far too
quickly for most to nimbly maneuver
What are the options?
• Language of stem cells
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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?
Cell Therapy Development Trends
HSC Transplant
Engineered T Cells
Transplant Product Paradigm
Patient Designated
Heterologous HSC
Engineered Tissue
Approval for Cartilage, Skin Products
Autologous and Allogeneic
Universal Donor Product
Biologics/Drug Paradigm
HSC Transplant
Mesenchymal SC
Personalized Medicine
ES, iPS Technology
Tissue Regeneration
Anticipating Product Approvals
COURTESY OF GREG BONFIGLIO – PROTEUS VENTURES
Demographics Impacting Healthcare Costs
Courtesy of Gil van Bokkelen
Demographics Impacting Healthcare Costs
Courtesy of Gil van Bokkelen
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
Acknowledgements:
OHSU HSCT & Regenerative Medicine Teams
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