Trasplante Hematopoyético y

Terapia Celular: Medicina Reparadora

Aguilas 11-15 Julio 2011

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Terapia Celular en Cirugía. Enseñanzas de los ensayos clínicos

Tendencias.

Garcia Olmo 2011

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1982 . La ciclosporina A

La cirugía y sus revoluciones: 1846-1952

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La revolución pendiente, EL CONTROL DE LA CICATRIZACIÓN

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La cicatrización es un proceso “celular” Nuestra hipótesis

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Células pluripotenciales

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Clinical trials process

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•  Perianal discharge •  Pain •  Swelling •  Bleeding •  Diarrhoea •  Skin excoriation •  External opening

Looking for a Testing Bench Fistula in Crohn’s Disease: a real problem of wound healing

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Looking for the best cells source Stem Cells from Adipose Tissue

Adipose derived mesenchymal stem cells: Higher yield (between 100 and 1000 times higher yield than bone marrow) BM stimulation is not required (G-CSF)

Expendable and accessible: Simple liposuction

Biosafety: No chromosomal alterations/ tumorigenic behavior after long term ex vivo cultures

Wide range of potential applications

2003 heart

2001 Grasa

1999 brain

1993 Muscle

Hematopoetic (bone marrow) 1986

1990 Intestine

1992 Liver

1993 Skin

1999 Mesenchymal cells (bone marrow)

2001 MAPC (bone marrow)

2003 Pancreas

Adipose tissue

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III 207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III

207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic

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Clinical Proof of Concept Successful cell treatment of a young woman with a recurrent

recto-vaginal Crohn’s fistula unresponsive to medical treatment

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III

207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic

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Phase I clinical trial

TRIAL SUMMARY

Trial Location La Paz Hospital, Madrid

Start April 2002

Enrollment 5 patients (total of 8 fistulas)

Design Open Label; Feasibility / Safety Study

Administration Intralesional use

Duration First evaluation of endpoint: 8 weeks

Controlled No

Endpoint Complete closure/healing of the fistula clinically assessed

Results 75% success

Fistula closure

Phase I Patients Treatments Rejection Complete Partial

n 5 8 0 6 2

NO SEVERE ADVERSE EVENTS NO TUMOROGENIC EVENTS Garcia Olmo 2011

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III

207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic

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Injection of ADSC cell suspension

Cell suspension is injected in the internal opening (the syringe enters through the anus) and through the fistula tract walls (the syringe enters

trough the external opening of the fistula)

Needle

Needle

ADSC

(*) 50% of total cell dose placed in the intersphincteric tracts and adjacent to the internal opening; 50% in the tract walls in

the direction of the external opening. Superficial injection (< 2mm)

Garcia Olmo 2011

Safety Acute phase

•  Primary evaluation (eight weeks after last treatment) revealed 17 adverse

events with Cx401 and 11 with fibrin glue •  Only 2 serious adverse events (SAEs) were observed with fibrin glue and 2

with Cx401 •  Not a single SAEs was related to Cx401

Group Crohn´s disease Description Severity Results Causality

Fibrin glue Yes Crohn´s crisis and intrabdominal abscess

Yes In recovery Not related

Cx401 No Perianal abscess Yes Recovered Not related

Cx401 No Cholecystitis and cholelithiasis. Choledocholothiasis after cholecystomy

Yes In recovery Not related

Fibrin glue Yes Perianal abscess Yes Recovered Related 16

Administration of Adipose Derived Stem Cells was effective in inducing healing in patients with complex

fistula-in-ano including Crohn’s disease, and this procedure can be considered safe

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III 207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic

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Phase III (Autologuous ASCs):

Crohn: FATT I TRIAL DESIGN

Condition Fistula in non-Crohn´s patients

Study design ●  Randomised ●  Double blind ●  Parallel Assignment

Recruitment: Completed: 200 patients Dosed: 135 patients

Controlled Yes (fibrin and placebo)

# of centres 23 centres in Spain

Primary endpoint

Complete healing assessed clinically and through MRI

Secondary endpoint

Long term healing, Quality of Life parameters, surgeries avoided, etc

Results Release anticipated 1 Q 2010

Non-Crohn:

Garcia Olmo 2011

Safety

Treatment received group ASCs (N=64)

ASCs+Fibrin tissue adhesive

(N=59) Fibrin tissue

adhesive (N=60)

Total (N=183)

N

% N

% N

% N

% p-value, general

association

p-value ASCs vs Fibrin tissue

adhesive

p-value ASCs and Fibrin tissue

adhesive vs Fibrin tissue adhesive

p-value ASCs vs ASCs

and Fibrin tissue adhesive

Related to study treatment

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6.3 4

6.8 6

10.00 14

7.7 0.7026

0.4473 0.5291

0.9053

Related to study procedures

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43.8 24

40.7 25

41.7 77

42.1 0.9397

0.8147 0.9128

0.7305

Adverse events related to either study procedures or treatment*

Overall, there were no significant differences among the three treatment groups in the proportion and nature of both non-serious and serious adverse events. In

addition, all treatments were safe as they had a low proportion adverse events either related to study treatment or related to study procedures, and a few severe/life-

threatening adverse events. In conclusion, the results of this trial indicate that the use of ASCs alone or with fibrin tissue adhesive does not increase the risk for the

patients at least during the period covered in this phase III clinical trial.

Garcia Olmo 2011

FATT1 Non-Crohn Population

Efficacy 24 weeks COMMITTEE All cases

0

10

20

30

40

50

A  (Cells  Alone) B  (Cells+FibrinGlue) C  (FibrinGlue)

No statistical significance

Garcia Olmo 2011

Looking for subgroups

•  Male/Female •  Age •  Physical evaluation (Drainage, pain, excoriation,

swelling, bleeding, Num. external openings, •  Previous surgery for fistulous disease •  Previously diagnosed perianal abcesses •  Incontinence (Wexner score) •  Complexity score •  Etc…

No statistical significance

Garcia Olmo 2011

Efficacy by centre

-0,6

-11,5

0,38

N % N % N % N %

CenterYesSubTotal 3 100.00 5 100.00 3 100.00 11 6.01

Yes 1 100.00 . . . . 1 100.00

SubTotal 1 100.00 . . . . 1 0.55

Yes

1 33.33 1 25.00 . . 2 20.00

SubTotal 3 100.00 4 100.00 3 100.00 10 5.46

Yes

. . . . 1 33.33 1 20.00

SubTotal . . 2 100.00 3 100.00 5 2.73

Yes 4 50.00 4 57.14 3 50.00 11 52.38

SubTotal 8 100.00 7 100.00 6 100.00 21 11.48

Yes 3 42.86 1 16.67 2 40.00 6 33.33

SubTotal 7 100.00 6 100.00 5 100.00 18 9.84

Yes 1 50.00 1 50.00 1 50.00 3 50.00

SubTotal 2 100.00 2 100.00 2 100.00 6 3.28

Yes 2 66.67 2 50.00 3 100.00 7 70.00

SubTotal 3 100.00 4 100.00 3 100.00 10 5.46

No data 1 11.11 . . . . 1 3.85

Yes 1 11.11 2 25.00 3 33.33 6 23.08

SubTotal 9 100.00 8 100.00 9 100.00 26 14.21

Yes 3 42.86 2 33.33 . . 5 26.32

SubTotal 7 100.00 6 100.00 6 100.00 19 10.38

Yes . . . . 1 100.00 1 100.00

SubTotal . . . . 1 100.00 1 0.55

Yes . . . . 1 50.00 1 25.00

SubTotal 2 100.00 . . 2 100.00 4 2.19

No1 100.00 1 100.00 2 100.00 4 100.00

SubTotal 1 100.00 1 100.00 2 100.00 4 2.19

Yes 6 54.55 10 83.33 2 18.18 18 52.94

SubTotal 11 100.00 12 100.00 11 100.00 34 18.58

Yes 1 100.00 . . 1 100.00 2 100.00

SubTotal 1 100.00 . . 1 100.00 2 1.09

Yes 1 25.00 . . 1 100.00 2 33.33

SubTotal 4 100.00 1 100.00 1 100.00 6 3.28

No 1 100.00 . . . . 1 100.00

SubTotal 1 100.00 . . . . 1 0.55

Yes . . . . 1 100.00 1 25.00

SubTotal 1 100.00 2 100.00 1 100.00 4 2.19

Hosp. Virgen del Camino

Hosp. de Fuenlabrada

Hosp. Univ. Girona Josep Trueta (ICO Girona)

Hosp. Univ. La Paz

Hosp. Univ. Tarragona Joan XXIII

Hosp. Univ. de Salamanca

Hosp. Gregorio Marañón

Hosp. Mutua de Terrassa

Hosp. Ntra. Sra. de Valme

Hosp. Sagunto

Hosp. Clínico San Carlos

Hosp. Doce de Octubre

Hosp. Donostia

Hosp. Gral Univ. de Valencia

Clínica U. de Navarra

Corporación Sanitaria Parc Taulí

Hosp. Clinic i Provincial de Barcelona

Hosp. Clinico Univ. Lozano Blesa

2 66.67 6 54.551 33.33 3 60.00

Fistula closed? Investigator criteria- V4

Treatment

TotalA B C

Garcia Olmo 2011

Efficacy 24 weeks COMITTEE

0102030405060708090

A  (Cells  Alone) B  (Cells+FibrinGlue) C  (FibrinGlue)

All  CasesLa  PazOthers

Why? P<0.0001

Garcia Olmo 2011

Looking for diferences

•  Male/Female •  Age •  Physical evaluation (Drainage, pain, excoriation,

swelling, bleeding, Num. external openings, •  Previous surgery for fistulous disease •  Previously diagnosed perianal abcesses •  Incontinence (Wexner score) •  Complexity score •  Etc…

Garcia Olmo 2011

Patient distribution by “Complexity Score” and center (Median)

4

5

6

7

8

9

La  Paz Others

P<0.001

Garcia Olmo 2011

Efficacy 24 weeks COMITTEE

0102030405060708090

A  (Cells  Alone) B  (Cells+FibrinGlue) C  (FibrinGlue)

Toda  La  SerieLa  PazOtros

Why?

Garcia Olmo 2011

Technical survey

We detect a large numbers of mistakes during the surgical procedure in “others hospitals”: use of

hydrogen peroxide (H2O2), cell shake, cells spilling..

Garcia Olmo 2011

What have we learned?

Clinical Trials Peculiarities in Cell Therapy

•  Surgical procedure for Cell delivering : •  Enviroment •  Aggressiveness •  Scrub •  Needle •  …

Garcia Olmo 2011

•  This is a “Living medicament” and hence a careful management is a key point.

What have we learned?

Clinical Trials Peculiarities in Cell Therapy

Garcia Olmo 2011

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III 207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic X

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2002 2003 2004 2005 2006 2007 2008 2009 2010

1 case 1 center

8 cases 1 center

ASC Clinical Development in fistula

50 cases 3 centers

Preclinical

Proof of Concept

Phase I

Phase II

Phase III 207 cases

10 centers FATT1

210 cases

22 centers FATT2

24 cases

3 centers CX601

10 cases

1 center FIS NC

Ongoing Completed

Autologous Allogenic X

Next step: Alogenic ASCs

•  2 PHASE I/IIb Allogenic • Crohn recto-vaginal fistula • Crohn perianal fistula

Starting: December 2009 Results: December 2011

CX601

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CURVA DE GARNET

How does it work? • An inmunomodulator effect of adipose derived stem cells has been recently described. • These immunosuppressive properties are the same as MSCs (mesenchymal stem cells derived from bone marrow)

Inflammation

Infiltration oflymphocytes (PBLs)in wound areaSecretion of pro-inflammatorycytokinesSensation of pain

A B CDelivery of eASCs

Activation of eASC by a cytokine called IFN-γExpression of an enzyme called IDO by eASCsSuppression of the proliferation of activatedPBLsSuppression of production of inflammatorysignals

Healing

Elimination of activatedPBLsAbrogation of pro-inflammatory cytokinesCessation of painRepair of tissue

Garcia Olmo 2011

Mechanism of Action of ASCs

●  ASCs are activated in an inflamed environment

●  Activated ASCs suppress the proliferation of lymphocytes and suppress the inflammation

●  Local treatment of inflammatory diseases with tissue damage/ wounds: ASCs act at the source of the inflammation and establish an environment that will permit a healing

●  Systemic treatment of diseases with acute inflammatory component: ASCs migrate to the inflammatory environment and suppress inflammation, avoiding tissue damage

36 Garcia Olmo 2011

Indoleamine 2,3 dioxygenase activity: a Trp catabolizing enzyme

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% o

f PB

MC

inhi

bitio

n

eASC

-em

pty

eASC

-IDO

si

1:25 (hASC: PBMC)

0

25

50

75

100

*

IDO enzyme is involved in the antiproliferative property of eASCs

IDO synthesis

IFN-γ eASC

cytoplasm

Trp IDO

Kyn

Trp

Kyn

eASC

cytoplasm

HAA

( DelaRosa, Lombardo, Tissue Engineering 2009)

How many time are ADSCs alive?

•  Durability •  Long-term adverse events…

Where do we go?

•  Safety Profile Excellent

§ DOSE INCREASE

•  Cell Mortality

§ IMPROVING METHODS FOR DELIVERING

•  Soft effects

§ CELL INGENIERING

§ CELL IMPROVING WITH STIMULATING FACTORS (BMPs,…)

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Matrices, andamiajes,…

§  Hidrogeles de polifosfoester (Quiang Li. Biomaterials. 2006).

§ Microesferas (Sang-Soo Kim, et. al. Apli Biomaterials. 2005)

§  Coágulos de fibrina y trombina (Steve Cox, et. al. Tissue Engineering. 2004).

§  Silastic, condroitin 6 sulfato, colageno (piel

artificial) (M. Kremer, E, et. al. B J Plastic Surg 2000)

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¡Gracias por la atención!