Boundaries of Stem Cells, approved cellular therapy technologies

Transcription

1 Boundaries of Stem Cells, approved cellular therapy technologies Professor Minghao Zheng, MD, PhD, FRCPath, FRCPA Medical School Associate Dean, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, 6009

2 Declaration of Interest I declare that in the past three years I have: held shares in Orthocell Ltd; received institutional support from NHMRC, ARC Signed: minghao zheng

3 What are the controversies surrounding stem cell therapies? How do we define the boundaries of practice? Is there a place for stem cell therapy in Orthopaedics

4 Life starts with blastocyte stem cells Inner cluster mass (ICM) of blastocytes

5 Stem cell therapy is not new First cellular therapy in 1959 Dr Georges Mathé Conducted first bone marrow cell therapy on five Yugoslavian nuclear workers whose own marrow had been damaged by irradiation

6 Stem cells the public perception

7 Stem cells are required more research, We don t want to see Lack of sufficient pre-clinical evaluation; Lack of regulatory control; Exploitation of regulatory loopholes; Overpromise;

8 Shapiro et al, A Prospective, Single-Blind, Placebo- Controlled Trial of Bone Marrow Aspirate Concentrate for Knee Osteoarthritis. Am J Sports Med Aug 26 Patients experienced a similar relief of pain in both BMAC- and saline-treated arthritic knees!

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10 Common adverse events of stem cells therapies Same day procedure is relatively safe (SD); Fat oil from adipose tissue cause pain (AD); Cultured MSCs promote disease progression (CE).

11 Recommendations Clinicians to establish a boundary of clinical practice; Improve community engagement and awareness of stem cell research and therapy; Improve patient access to clinical trials; Facilitate cross disciplinary collaboration

12 Liposuction stem cell therapy Stem cell clinics

13 What are the controversies surrounding stem cell therapies? How do we define the boundaries of practice? Is there a place for stem cell therapy in Orthopaedics

14 MACI - Autologous chondrocyte implantation for cartilage injuries; ATI - Autologous tendon cell injection for tendinopathy and tear.

15 Cartilage injury 30,000 to 40,000 cases of cartilage injury in Australia, cost over 30M each year Debridement, mirofracture, osteochondral graft, cell implantation years to develop OA

16 Am J Sport Med :1259

17 GMP Lab Matrix induced ACI (MACI) Cell-scaffold construct 30 minutes surgery; small incision or arthroscope

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19 Cells Safety Viability Purity Identity Potency Human tissue product application MACI pre-clinical development Cell seeding Scaffold Dose effect. Cell-scaffold interaction Final MACI product Safety, viability, potency, Cell Fate Scaffold Raw Material Selection Design Dossier Biocapability Scaffold Fabrication Medical device application -Collagen Human tissue product application Clinical use

20 Purity - Phenotypic Characterisation A Day 1: Post-digestion P2 C P1 P3 B Immunohistochemical analysis reveals preservation of chondrocytic phenotype at Passage 1, 2 and 3 with positive staining for Collagen II and S-100 protein markers. This is confirmed on RT-PCR.

21 Purity - Immunohistochemical characterisation Zheng et al In J Mol. Med. 2004

22 expression/mean expression/mean expression/mean expression/mean expression/mean expression/mean expression/mean Matrix proteins gene expression Aggrecan * * Aggrecan P2 P4 P Type II Collagen *** * * Type II Collagen P2 P4 P6 Type I Collagen Type X Collagen Type I Collagen P2 P4 P Type X Collagen P2 P4 P Fibromo- dulin *** ** Fibromo- dulin P2 P4 P Fibronectin * Fibronectin P2 P4 P Link Protein * Link Protein P2 P4 P6 Zhen & Zheng et al. J Orth. Res. 2008

23 Integration of chondrocytes with collagen membrane - MACI A B C D Zheng et al Tissue Engineering 2005

24 High density of cells on membranes A Low magnification High magnification B C D

25 Formation of neocartilage on collagen membrane before implant

26 Cell fate: PKH26 Labelled Chondrocyte Localisation Integration DAY 3 post MACI in rabbit A D E F B G H C Chondrocyte seeded membrane (Pre-implantation) Confocal imaging superimposed on H&E Histology Image revealing location of labeled chondrocytes

27 MACI (low, moderate and high density)

28 Graft infill 67% - 89% Pain relieve - 98% Ability to perform daily tasks - 86% Ability to participate sport - 73%

29 Graft infill 83% Graft integration -82% Subchondral bone edema - 47%

30 Arthroscopic Matrix-Induced Autologous Chondrocyte Implantation: 2-Year Outcomes Jay R. Ebert; Michael Fallon,Timothy R. Ackland, David J. Wood, Gregory C. Janes Graft infill 90% MRI composition score -70%

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32 SUMMIT Trial

33 MACI just repairs the cartilage, not the joint!

34 MACI - Autologous chondrocyte implantation for cartilage injuries; ATI - Autologous tendon cell injection for tendinopathy and tear.

35 Tendon is a mechanical sensitive tissue uniaxial Tension Compression Khan, K.M. and A. Scott. Br J Sports Med, Smith & Zheng et al WIREs Syst Biol Med 2013; Wang & Zheng et al Biotechnol. Bioeng. 2013; Bi et al, Nature Medicine, 2007

36 Cellular response in tendinopathy Wu et al. Arch Orthop Trauma Surg 2011 Chen et al, J Shou. Elb. Surg, 2009 Wave collagen Angiofroblastic hyperplasia Fatty infiltration Collagen/ECM breakdown

37 Cook & Purdam, Br J Sports Med 2008 & 2016; Chen et al, J Shou. Elb. Surg, 2009 Wu et al. Arch Orthop Trauma Surg 2011

38 Research Evidence of ATI Substitution of tendon cell by injection to central tear site improve tendon healing in tendinopathy. Chen et al 2007; 2011; Wu et al 2011; Zheng et al Science (supplementary) 2012

39 Aggrecan relative expression Log COL2A1 relative expression Log BMP2 relative expression Log OPN relative expression Log CEB/P relative expression Log PPAR relative expression Log Tendon Derived Stem Cell Characterization A C Control Alizarin Red Oil Red O B 100/plate 1,000/plate 10,000/plate 10 * ** 1000 ** * D 0.1 Control Osteo Alcian Blue 0.1 Control Osteo Control ** Adipo 0.1 Control 100 * Adipo Control Induction 0.1 Control Chondro 0.1 Control Chondro

40 Tendon organoid in bioreactor system A B C Cell sheet formation 6 Days Culture 15mm D Dynamic Loading

41 Characterisation of Tendon organoind

42 Feridex cell tracking within the tendon J Chen, M.B.Ph.D.et al TISSUE ENGINEERING: Part A 17:15, 2011 Cover page

43 Biopsy Starting tissue GMP cell culture injection

44 Clinical Evidence: level III/IV AJSM2013 AJSM 2014 BMJ 2013

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46 MRI Changes Pre-ATI 12mo post-ati Pre-ATI advanced common extensor tendinopathy partial thickness tearing of the deep (ECRB) portion 12mo post-ati reduction in tendinopathy severity low grade partial thickness tearing remains, though significantly diminished

47 Greater Trochanteric Pain Syndrome (GTPS) ATI Pilot Trial - Clinical Results - - Gluteal tendinopathy Oxford Hip Score (0-48) p< Pre-treatment 3 months 6 months 12 months 24 months Pre- and Post-injection Timeline Mean improvement of 14.9 points (95%CI: , p<0.001) 7/12 demonstrated a clinically important change of 11 or more points

48 ATI Pilot Trial Gluteal tendinopathy 30 second single limb stance test & gait Pre-injection (Pain 6/10) 12mo (Pain 0/10)

49 ATI for treatment of degenerative tendinopathy All of 320 patients treated were patients with recalcitrant tendinopathies with failure of other conservative treatment; Epicondylitis 1,2 with mean symptoms of month; Rotator cuff tendon tear 3 with 1 year; Gluteal tendinopathy 4 with mean symptoms of 33 month. 1 Wang et al, 2013 Am J Sports Med 41(12): Wang et al, 2015 Am J Sports Med 43(7): Wang et al, 2013 BMJ Case Rep 4 Bucher et al, 2017 Orthop J Sports Med 5(2): 8

50 Summary Patients can tolerate the biopsy & injection; Continued clinical & MRI improvement to 12 mths, maintained at 4.5yrs Indications of efficacy - significant positive changes from baseline data, almost comparable to those who had surgery Limitations: small cohort, lack of comparative cohort

51 Level II Clinical evidence Comparison of ATI with surgery in patients with chronic resistant lateral epicondylitis (ACTRN p),

52 Treatment principle and algorithm of tendinopathy Bhabra et al JOSM 2016 Pathogenesis Treatment principle Overuse Avoid re-injury Rest Angiofibroblastic hyperplasia Mechanical induction of intrinsic repair Physiotherapy Degenerative change of tendon cell & matrix Matrix breakdown & Fatigue healing Structural changes with mechanical failure Control of pain Substitution of tendon progenitor cells for tendon repair Correction of biomechanics & decompression Injection Cell Surgery

53 Take home messages - Clinicians need to define their boundary of practice for stem cell therapy; - Any stem cells injection into joint have shown not working; - Autologous chondrocyte implantation works for localised cartilage injury and is an FDA approval cellular product; - Autologous Tenocyte Injection is working but need higher level of clinical evidence (level II and above).

54 Experiences of my journey

55 Acknowledgement Professors Allan Wang, David wood, Greg Janes, Bill Breidahl; Drs Gangyi Li, Jim Chen, Tao Wang, Katherine Mackie, Bing Wu Mr Paul Anderosn

56 MACI development time table 1985 Lars Peterson s rabbit ACI 1994 Mat Brittberg first generation of ACI by cell injection; 1998 Verigen Collagen cover ACI (CACI); 2000 Rabbit MACI by Willers & Zheng first cell-scaffold implant; 25 publications; 3 patents; Human MACI by Wood & Zheng & first GMP lab for MACI PhD in Australia and ; TGA two licensed MSc Sheep MACI by Johns & Zheng; 2005 Verigen MACI sold to Genzyme in USD50M; 2007 Arthroscopic MACI by Greg Jane; 2011 Genzyme sold to Sanofi Aventis; 2012 MACI removed from MASAC; 2015 MACI sold to Vericell; 2016 MACI approved by FDA