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  • At a registry size of 10 million [bone marrow] donors, approximately 7 million additional donors are needed to increase the chance of matching by only 1% http://www3.interscience.wiley.com/journal/122614197/abstract The study showed that 50,000 donors would be required to provide at least one donor for 98% of the patients with at least a 4 out of 6 HLA match, to 80% with a 5 out of 6 match, and to 34% with a 6 out of 6 match http://www.haematologica.org/cgi/content/full/94/4/536
  • Allogeneic use of cord blood among children  can be predicted based on the actual  transplant rates. The cumulative probability is 1 in 5000 Autologous use of cord blood among children can be estimated based on the prevalence (ie: cumulative probability) of those indications for which clinical trials use autologous of CB We compare the autologous and allogeneic use of cord blood by plotting the cumulative number of cord blood treatments versus time, for the autologous data from PGCB and the allogeneic data from the WMDA. Looking at 2008, the number of autologous treatments is about 100 times lower than the number of allogeneic treatments. However, the rise in the cumulative number of allogeneic cord blood use is linear over the last few years, whereas that number for autologous use is rising faster than exponential. Medical societies or individual physicians who issue opinions on cord blood storage that ignore the fast growing autologous use of cord blood for mainly regenerative medicine are not making evidence-based recommendations.
  • (GVH and host-mediated immune clearance)
  • 598 CB transplants for non-hematopoietic use reported in Europe. None of them indicated CB as a source of stem cells (EBMT survey activity 2009)
  • After release, antigen-presenting dendritic cells migrate to lymphoid organs and activate specific anti-tumor clon of cytotoxic T-cells. Alginate scaffold with VEGF and endothelial progenitors. VEGF could attract endogenous endothelial cells or support scaffold-embed ones and stimulate local neovascularization.
  • It is therefore highly interesting to note a comment from Geoff MacKay, CEO and President of Organogenesis that, “In the USA, on average, once every 2 minutes Monday to Friday a patient is treated with Apligraf.”
  • CellTherapyTrends10

    1. 1. Current Trends in Cell Therapy Alexey Bersenev, MD, PhD Children’s Hospital of Philadelphia www.Hematopoiesis.info www.StemCellAssays.com twitter: @cells_nnm Moscow, Sep. 27, 2010 under the following license Creative Commons Atribution Non-Commercial
    2. 2. personal communication (Lab, conference) blog professional networking online discussion personal filters RSS PubMed journals blogs news reference managers collaborative filters groups on LinkedIn rooms on FriendFeed shared Google Waves faculty of 1000 shared references collaborative blogs … new real connections and collaboration shared posts (Twitter/ LinkedIn) networking with other bloggers Trending is information processing Bersenev A. Cellular Therapy and Transplantation. 2010;2(7). 10.3205/ctt-2010-en-000084.01
    3. 3. www.Hematopoiesis.info www.StemCellAssays.com Frequently discussed topics and outline of the talk: <ul><li>Link between stem cell self-renewal, expansion and cancer </li></ul><ul><li>Hematopoietic stem cell expansion for clinical use </li></ul><ul><li>Cord blood banking and use </li></ul><ul><li>Clinical trials and cell therapy activity </li></ul><ul><li>Paradigms shift in cell therapy </li></ul><ul><li>Cell therapy and Regenerative Medicine industry today </li></ul><ul><li>Cell products development </li></ul>
    4. 4. Cancer Cell proliferation Stem cell self-renewal HSC aging Arf Ink4a Bmi-1 Hmga2 Sean Morrison group 2005-2008 Link between stem cell renewal, cancer and aging
    5. 5. Stem cell renewal, expansion and cancer <ul><li>Link between stem cell self-renewal, cancer, aging, regeneration seem to be universal across adult tissues </li></ul><ul><li>All regulators of SC self-renewal are very good candidates for targeted expansion </li></ul><ul><li>We can not uncouple self-renewal and cancer activation pathways (Wnt, Notch, SHH…) </li></ul>
    6. 6. Playing with stem cell self-renewal is a dangerous game!
    7. 7. http://hematopoiesis.info/2010/07/07/do-we-really-need-hematopoietic-stem-cell-expansion-for-clinical-use/ Do we really need HSC expansion for clinical use? <ul><li>Unlike preclinical data we actually can not achieve expansion of engraftable long-term HSCs in clinic </li></ul><ul><li>In order to achieve significant clinical improvement we don’t need a lot of HSCs but we need a lot of progenitors </li></ul><ul><li>T-cells alone, without engraftable HSCs can induce graft-versus-tumor effect and eradicate neoplasm </li></ul><ul><li>Methods for HSCs engraftment improvement will be more clinically sufficient than chasing for increasing of HSCs number through expansion </li></ul><ul><li>Cost, scalability and commercialization issues </li></ul>
    8. 8. Two ongoing clinical trials for cord blood HSC expansion: 1. Fred Hutchinson Cancer Center (Irwing Bernstein group. Nat Med 2010; 16:232 ) Set up: CB isolated CD34+ cultured on immobilized engineered Notch ligand in SCF /Flt3L /TPO /IL-3 /IL-6 for 16 days 2. MD Anderson Cancer Center (Elizabeth Shpall group. Reported at ASH and other conferences 2008-2010)   Set up: CB isolated CD34+ or CD133+ in liquid culture in SCF /Flt3L /G-CSF /TPO for 2 weeks Co-culture with allogeneic related matched MSC or commercially available MSCs (Angioblast)
    9. 9. Expanded versus unmanipulated human cord blood samples neutrophils engraftment kinetics Adapted from Elizabeth Shpall report at 10th Anniversary of Netcord Conference16-19 October 2008 - Mandelieu, France (modified) time after transplant hematopoietic contribution one year
    10. 10. Lin- CD34+ CD38- CD90+ CD45RA- CD34+ CD38- CD90- CD45RA+ HSC MLP ETP B/NK CMP CD34+ CD38+ CD10+ CD45RA+ CD34+ CD38+ Flt3+ CD45RA- GMP MEP CD34+ CD38+ Flt3+ CD45RA+ CD34+ CD38+ Flt3- CD45RA- MDP MPP Lin- CD34+ CD38- CD90- CD45RA- Current map of human hematopoietic CD34+ population Irv Weissman group Cell Stem Cell 2007; 1: 635 John Dick group Nat Immunol 2010; 11: 585 stem cell (<10% of CD34+ in bone marrow and 0.5-1% of CD34+ in cord blood) progenitors (90-99% of CD34+) CD34+ ex vivo expansion possibility
    11. 11. Summary of HSC expansion in clinic: <ul><li>Expanded CB unit doesn’t sustain long-term repopulation and is always overtaken by unmanipulated unit, which dominates the engraftment (Irwing Bernstein, 2010, Elizabeth Shpall, 2008-2010) </li></ul><ul><li>Total CD34+ number is expanded and correlates with rapid engraftment and improved neutrophil and platelet recovery   </li></ul><ul><li>Stem cell expansion was not achieved </li></ul><ul><li>No engraftment failure observed and there was clear clinical benefit </li></ul><ul><li>We should continue to pursue expansion approaches, but focus on hematopoietic progenitors </li></ul>
    12. 12. Approaches used for improvement of HSC engraftment: approach examples phase increase yield of HSC by isolation procedure <ul><li>cord + placental blood HSC ( HemaCell Perfusion system ) </li></ul><ul><li>improving CB processing ( BioE PrepaCyte - CB ) </li></ul>preclinical - I co-transplantation with few HSC sources <ul><li>double unit CB transplant </li></ul><ul><li>CB+MB or CB+BM from 3 rd party </li></ul>II-III- wide clinical use split dosages CB transplant preclinical - I manipulation of HSC homing and migration <ul><li>Fucosyltransferase - ASC101 (Engraftin) </li></ul><ul><li>CD26 inhibition (Diprotin A) </li></ul>preclinical - I manipulation of bone marrow niche 1. Parathyroid Hormone (PHT) 2. new conditioning (anti-cKit or CD45 Ab) preclinical -I new route for transplant intra-bone BMT I-II co-transplantation with cells engraftment mesenchymal stromal progenitors ( Pluristem PLX-I ) I hematopoietic progenitors expansion ex vivo <ul><li>allo- myeloid progenitors ( Cellerant CLT-08 ) </li></ul><ul><li>mix of CD34+ progenitors ( StemEx Gamida Cell ) </li></ul>I HSCs expansion ex vivo Aryl Hydrocarbon Receptor Antagonists? experiment
    13. 13. Trends in cord blood banking <ul><li>Private, public and hybrid banks will and should co-exist, but number of private banks could shrink </li></ul><ul><li>CB inventory: How many samples is enough? ( For UK = 50,000 units ) </li></ul><ul><li>Quality versus quantity (nearly 2/3 of samples delivered to public bank could be rejected) </li></ul><ul><li>If private banks want to play “the regenerative medicine game”, quality of samples should be improved! </li></ul><ul><li>How to calculate probability of use? </li></ul><ul><li>Allogeneic CB for non-hematological diseases will enter the clinical trials = game changer </li></ul>
    14. 14. Current use of cord blood <ul><li>Currently much more inferior to other sources of HSCs: Allo BM >> Auto BM; if Auto: MPBSC >> BM; if Allo: MPBSC >> BM >> CB (2x) </li></ul><ul><li>Autologous CB procurement and transplantation is more expensive than MPBSC (Beguin Y, 2009) </li></ul><ul><li>Probability of suitable graft for adults (70kg) - 25% of inventory for Auto use, 5% - for Allo malignant disease; 0% - for Allo non-malignant disease (Beguin Y, 2009) </li></ul><ul><li>Number of CB transplants now more in adults than in children since 2006 (EuroCord, 2009)   </li></ul><ul><li>About 40% of CB transplants in adults is double-unit transplants (EuroCord, 2009) </li></ul>
    15. 15. Autologous use of CB in Regenerative Medicine <ul><li>Right now pediatrics only: 255 patients treated by April of 2010 (cerebral palsy = 166; brain injury = 35; type I diabetes = 24 and other indications) (Frances Verter, Parent's Guide to Cord Blood Foundation , ISCT’2010 report) </li></ul><ul><li>How to calculate the probability? cumulative number of allogeneic cord blood use is linear, whereas that number for autologous use is rising faster than exponential (Frances Verter, Parent's Guide to Cord Blood Foundation, ISCT’2010 report) </li></ul><ul><li>In adults: Regenerative Medicine will be most applicable in “aging boomers”. Would you store your sample for 60 or more years if there are other (cheaper and better) alternatives? </li></ul>
    16. 16. Allogeneic use of CB in Regenerative Medicine <ul><li>Allogeneic CB could be as suitable as autologous CB </li></ul><ul><li>Matched unrelated allo CB transplant - same results (leukemia-free survival) with matched in children and adults </li></ul><ul><li>Questions: </li></ul>Can we transplant HLA-mismatched CB cells into the patient with degenerative disease without fear of adverse immune reactions? Can we transplant allogeneic CB cells with a regenerative purpose without myeloablative or immunosuppressive conditioning? What therapeutic benefit would we expect after allogeneic CB cell therapy in immunocompetent (non-conditioned) patient?
    17. 17. Non-hematopoietic stem /progenitor cells in CB for regenerative medicine <ul><li>What is unique stem and non-stem cells properties CB can offer that is not available in BM? Pluripotent SC candidates: USSC, VSEL, MAPC – are not unique </li></ul><ul><li>MSC number is inferior to other sources (BM) </li></ul><ul><li>EPC - highly allo-immunogeneic </li></ul><ul><li>In case of autologous use: What cell viability and potential will be after 30-70 years of storage? Will standards in 50 years comparable with current collection and storage practice? </li></ul>
    18. 18. Cell therapy activity in numbers: <ul><li>The feasibility and safety of cell therapy has been established in over 3000 patients with heart diseases ( Behfar A, et al, 2010 ) </li></ul><ul><li>MSC: 101 trials total launched and available for analysis ( www.ClinicalTrials.gov ) ; 59 allo- , 42 auto-; 21 trials were completed in 2010; total number of patients treated - 5344 </li></ul><ul><li>HSC transplantation for autoimmune diseases in Europe: 1122 patients were treated in 30 countries. 85% 5-years overall survival and 43% 5-years progression-free survival (Saccardi R., EBMT 2010)  </li></ul><ul><li>Cellular therapy activity survey 2008 in Europe: 1040 patients treated - 376 (36%) with allo- and 664 (64%) with auto- cells. Non-hematopoietic use: 454 total. Indications: cardiovascular, neurological and tissue repair (EBMT activity survey 2008)   </li></ul>
    19. 19. Current view on transdifferentiation of adult SC (HSC or MSC) as rationale for regenerative cell therapies <ul><li>lack of assays, false positive results and artifacts; </li></ul><ul><li>fusion </li></ul><ul><li>genetic material transfer by microvesicles/ exosomes or phagocytosis of apoptotic bodies </li></ul><ul><li>even if phenomenon of transdifferentiation exist, it can not justify therapeutic potential of injected cells </li></ul>
    20. 20. Paradigm shift in understanding therapeutic efficiency of mesenchymal stem cells (MSC) <ul><li>long-term engraftment of transplanted MSC was not demonstrated in human </li></ul><ul><li>trophic function and immunomodulation as mechanisms (indirect or paracrine; growth factors; angiogenesis) </li></ul><ul><li>differentiation is not the mechanism of action </li></ul><ul><li>it becomes more like a drug therapy but not as cell replacement transplantation where mechanism is differentiation </li></ul>
    21. 21. Paradigm shift – manipulation of endogenous cells instead of cell injection – cell therapy without the cells <ul><li>Manipulation by homing/ migration </li></ul><ul><li>Differentiational mobilization </li></ul><ul><li>Stem cell niche manipulation </li></ul><ul><li>Cell therapy in citu </li></ul>
    22. 22. Controlled (differentiational) mobilization - experiment <ul><li>MSC: substance P , VEGF+AMD3100 </li></ul><ul><li>EPC: VEGF alone, VEGF+AMD3100, SDF-1,Ang-1, AMD3100 4 hours </li></ul><ul><li>HPC: AMD3100, G-CSF, S1P, Flt3L 5 days </li></ul><ul><li>HSC: Flt3L 10 days </li></ul>Pitchford S. et al. Cell Stem Cell 2009; 4:62
    23. 23. Cell therapy in citu <ul><li>PEGylated fibrinogen, bound with recombinant SDF-1 heart patch of Jianyi Zhang </li></ul><ul><li>In situ bioreactive devices (iBD) of David Mooney </li></ul>http://hematopoiesis.info/2009/06/04/future-of-implantable-cell-capturing-devices/ <ul><li>PLG matrix with mobilized GM-CSF and tumor antigen. G-CSF attracts dendritic cells, which start to expand and present tumor antigen. </li></ul>
    24. 24. The place of cell therapy in Regen industry cell bio scaffold gene protein Regen /Cell Tx Biotech healthcare industry Pharma biologic Small molecule tissue chemical RNAi Regenerative Medicine replaces or regenerate human cells, tissue or organs, to restore or establish normal function (Chris Mason, 2008) cell therapy tissue engineering scaffold /biomatrix gene therapy growth factors /proteins Medical Device polymerscaffold micro RNA
    25. 25. Where cell therapies will play a role? <ul><li>Offers cures, not just manage symptoms </li></ul><ul><li>Can actually replace and repair tissue </li></ul><ul><li>Persistent potential </li></ul>
    26. 26. Regenerative Medicine cell therapy industry today <ul><li>New sector of advanced healthcare </li></ul><ul><li>Regen is the profitable business! </li></ul><ul><li>Minimum baseline of 675,000 therapeutic units manufactured and 323,000 patients treated with FDA/EMA approved cell therapeutics </li></ul><ul><li>Regenerative medicine cell therapy - $100–200 million per year industry </li></ul>Chris Mason, Elisa Manzotti Regen Med 2010; 5:307
    27. 27. Regenerative Medicine business models: <ul><li>banking </li></ul><ul><li>cell & tissue acquisition </li></ul><ul><li>cells, kits and reagents for research </li></ul><ul><li>devices </li></ul><ul><li>logistics/ shipping </li></ul><ul><li>consulting </li></ul><ul><li>IP/ licensing/ patenting </li></ul><ul><li>contract manufacturing </li></ul><ul><li>cell lines for toxicology and drug screening </li></ul><ul><li>veterinary cell therapy </li></ul><ul><li>therapies </li></ul>
    28. 28. Cell therapy business models: Autologous and Allogeneic <ul><ul><ul><li>Autologous: </li></ul></ul></ul><ul><li>physiological limit - number, function and proliferative potential could decline with age </li></ul><ul><li>immunogenicity is zero but could be at some degree if product is manipulated extensively; potential tumorigeneicity </li></ul><ul><li>personalized cell product could be highly complex and business model is not always clear </li></ul><ul><ul><ul><li>Allogeneic: </li></ul></ul></ul><ul><li>“ of-the-shelf” with different level of manipulations ex vivo </li></ul><ul><li>manufactured by companies and available on the market </li></ul><ul><li>scale up manufacturing </li></ul><ul><li>“ cost of goods” could be brought down by outsourcing (contract manufacturing) </li></ul><ul><li>reasonable cost </li></ul><ul><li>immunogenicity at different degree, potential tumorigeneicity </li></ul><ul><li>clear business model </li></ul>
    29. 29. Features of autologous cell products: <ul><ul><ul><li>For acute disease: </li></ul></ul></ul><ul><li>minimally manipulated (cell processing, separation, washing) </li></ul><ul><li>can be embedded in healthcare (all steps could be done in the hospital) </li></ul><ul><li>cheap </li></ul><ul><ul><ul><li>For chronic disease: </li></ul></ul></ul><ul><li>usually extensively manipulated ex vivo (cell separation, expansion, differentiation, gene-modification) </li></ul><ul><li>manufacturing usually outsourced (contract manufacturing) </li></ul><ul><li>product manufacturing scaled out </li></ul><ul><li>expensive </li></ul>
    30. 30. http://celltherapyblog.blogspot.com/2009/02/how-many-cell-therapy-products-are-in.html Cell products in development and on the market: Number of cell products in different phases of development: 78 Pre-clinical 77 Phase I 89 Phase II 33 Phase III 67 Commercial Total number of companies - stakeholders in the cell therapy sector ~ 700. This includes ~250 therapeutic companies with ~340 cell-based therapeutic products (Lee Buckler, Cell Therapy Group, 2009) Cell product is defined as any cell-based product involving live cells ‘produced’ ex vivo intended for therapy
    31. 31. Cost/ profitability of approved cell products in US: Only about 2.2% of the overall cell therapy market is spent on manufacturing http://celltherapyblog.blogspot.com/2008/08/cell-therapy-manufacturing-market.html ~ 12% of cell therapy product manufacturing is currently outsourced to private, industry contract manufacturers product brand FDA approval donor profitability cost-effectiveness price, USD Carticel Genzyme 1997 autologous yes yes 17,000- 38,000 Apligraf Organogenesis 1998 allogeneic yes yes ~1,200 per use Provenge Dendreon 2010 autologous ? ? 93,000 (31,000 x3)
    32. 32. Allogeneic versus Autologous Manufacturing Summary Master Cell Bank Lot Tested Working Cell Banks Lot Tested Patient Doses Lot Tested Cell Expansion Cell Expansion or Purification Testing Patient or Donor Cell Ampoule or Dose Submitted for Testing Allogeneic / Universal Donor Autologous / Patient Specific courtesy of Jon Rowley , LO nza
    33. 33. The value of stem cells in cell therapy products <ul><li>We can not support and activate self-renewal and stem cell expansion without risk of carcinogenesis </li></ul><ul><li>Adult stem cells (MSC, HSC), expanded ex vivo , loosing stemness and ability to long-term engraftment </li></ul><ul><li>The mechanism of therapeutic action of injected stem cells (MSC, HSC) still unknown </li></ul><ul><li>We have very hard time in characterization and development of stem cell products - potency and safety assays </li></ul><ul><li>At  the most indications, all we need is well characterized progenitors and mature cell types </li></ul><ul><li>Overall, the value of stem cells as a product in cell therapy currently is low </li></ul>