Intravascular cell delivery RESSTORE trial

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1 Intravascular cell delivery RESSTORE trial Dr Olivier DETANTE Stroke Unit, CHU Grenoble Alpes Grenoble Institute of Neurosciences - GIN U th Kuopio Stroke Symposium, Finland 2016 Grant agreement GA/ Dr Olivier DETANTE (Grenoble, France) Pr Exuperio DIEZ-TEJEDOR (Madrid, Spain) Pr Jukka JOLKKONEN (Kuopio, Finland) 1

2 Ischemic stroke - Treatments Management in Stroke Unit / Rehabilitation Recanalization: IV thrombolysis / Thrombectomy < 6h Aspirin < 48h Decompressive craniectomy for large infarction Elgendy, JACC 2015 Wahlgren, Lancet 2008 Hacke, NEJM 2008 Vahedi, Lancet Neurol 2007 Post-stroke recovery Functions of survivor tissue Reorganization of damaged neural networks, fibers growth Cell processes for brain plasticity: Genesis of neural cells: neurons, astrocytes, microglia and oligodendrocytes Synaptogenesis and activation of inactive connections Angiogenesis/ vasculogenesis: vessels Favre, Stroke 2014 Glio-vascular niche for neurogenesis Vessel MOUSE at D7 Ohab, J Neurosc 2006 BrdU DCX = neuroblasts Neurons Dcx+ HUMAN at 1 month Jin, PNAS

3 Stroke damages Ca 2+ Glutamate / K + Excitotoxicity Free radicals Inflammation Necrosis Depol. Apoptosis Minutes Hours Days Weeks Months / Years Endogenous protection Collaterals Reperfusion GABA K + ATP HSP, BCL protein, IL10 Free radical scavengers BDNF, VEGF, EPO NOS, GABA A receptors IL1-R antagonist GluR2 Structural plasticity: Neurogenesis Synaptogenesis Angiogenesis Oligodendrogenesis Astrogliosis scar modulation Brain Protection Brain Repair Therapeutic strategies General and Stroke Unit care: BP, glycemia, nursing (mobilization, infection prevention ) IV thrombolysis Thrombectomy Craniectomy GF / Cell therapy: - GCSF, EPO - Cell therapy (MSC, MNC, HSC, EP ) Rehabilitation Neural graft: - Precursors - Neural SC - Neurons Modified from: Gutiérrez M, et al. Cerebrovasc Dis 2009 and Detante O, Rev Neurol 2014 Neuroprotective drug failures: too target-specific? Relevance of regenerative medicine by cell-based therapy O Collins, Ann Neurol 2006 Hermann, Lancet Neurol 2012 Detante, Rev Neurol

4 Mesenchymal Stromal/Stem Cells - MSC Adult multipotent cells Asymmetric division Auto-renewal Differentiation 1/10 5 to 1/10 6 in bone marrow (or adipose tissue) > Delay for autologous culture Vats, Lancet 2005 Chamberlain, Stem Cells 2007 Cell therapy in stroke Translational project Preclinical assessment of human MSC therapy: IV injection at subacute phase of stroke Regional trial of safety: ISIS-HERMES (phase 2 / NCT ) European trial of efficacy: RESSTORE (phase 2b / H2020-PHC15) 1. Biodistribution of IV-injected hmsc (at D8) 2. IV injection of hmsc: preclinical study 3. Mechanisms of action? - Microvascular effects of hmsc (IC graft and IV injection at D8) - Brain inflammation effects (IV injection at D4) 8 4

5 Biodistribution by nuclear imaging: hmsc labeled with 99m Tc-HMPAO 3 million of hmsc IV injection at D8 post-stroke (subacute phase) Transient lung trapping Low sensitivity for brain location Detante, Cell Transplant 2009 Isolated brain counts ( counter) 20 h after IV injection 0,008 0,007 0,006 0,005 MCAo Contralateral * Control MCAo Lesion * %DI/g 0,004 0,003 0,002 0,001 0 L HEMISPHERE Cerveau G Right (damaged) hemisphere activity higher than control Left (undamaged) of MCAo group > control R HEMISPHERE Cerveau D (Lesion) hmsc are attracted to lesion and contralateral hemisphere but 1 per 10,000 injected hmsc! Detante, Cell Transplant

6 IV injection of MSC Mechanisms for stroke? Chopp, Lancet Neurol 2002 «The Vascular Brain» Microvascular architecture = stimulation / guidance for neurogenesis Neural stem cells Reina de la Torre, Anat Record 1998 Shen, Science

7 Preclinical study hmsc IV injection 78 Sprague-Dawley adult rats: transient MCAo Day 8 / Subacute phase: randomization MRI Diffusion D0 D8 post-stroke IV injection of 3 million of human MSC IV injection of PBS-glutamine (control) Behavior (sensory-motor and cognitive) follow-up: 7 weeks MRI follow-up: 25 days - Blood brain barrier permeability (T 1 Gadolinium) - Cerebral Blood Volume (CBV) - Vessel density = R 2 / ( R 2* ) 2/3 - Vessel Size Index (VSI): perfused vessel caliber (MGESE before and after IV iron-contrast agent, USPIO P904 Guerbet) 8-arm radial maze Histology / RT-qPCR Moisan, Cell Transplant 2016 NSS Neurological Severity Score Functional recovery MCAo + hmsc MCAo + PBS ART Adhesive removal test Injection Injection Maze: predelay Maze: postdelay Injection 8-arm radial maze MCAo + hmsc (n=13) vs MCAo + PBS (n=12) No adverse effect of cell therapy Sensory-motor and cognitive (spatial memory) benefit from 4 to 6 weeks after hmsc IV injection (at D8) 7

8 STROKE LESION at W6 Rare direct differentiations Human Nuclei Neuron NF200 Rare differentiations to neurons, glial cells and endothelial cells Human Nuclei Astrocyte GFAP Human cells in spleen, liver, lungs (not muscles) Human Nuclei Endothelial cell vwf (VIII) * D3 D25 Microvascular MRI + PBS + hmsc Injection Preservation of CBV and BBB integrity (after 2 weeks) Earlier decrease of vessel caliber: VSI = 7.9 +/- 1.4 m, 1 week after hmsc injection Enhance microvessel density, 1 and 2 weeks after hmsc injection (158 +/- 20 /mm 2 vs sham 190 +/- 44.6) Systemic injection of hmsc increases post-stroke angiogenesis 8

9 Sham surgery MCAo + PBS MCAo + hmsc Injection RT-qPCR Overexpression of angiogenic factors (rats): One day after hmsc injection: Ang-1 (Tie-1 decrease? Maintenance of VEGFR-1?) One week after hmsc injection: Ang-1, Ang-2 and TGF 1 (Tie-2? SDF-1?) Mechanisms of action of MSC? Host neurogenesis (Bao, Brain Res 2010), Immunomodulation (Yanez, Stem Cells 2006) Angiogenesis (Onda, JCBFM 2008 ; Toyama, Exp Neurol 2009 ; Zacharek, Stroke 2010) Events chronology after hmsc IV-injection at the subacute stage: 1. Angiogenic factors (Ang-1, Ang-2, TGF 1) from 1 day to 1 week after injection 2. Increase of microvessel density (MRI) from 1 to 2 weeks 3. Delayed functional benefit from 4 to 6 weeks Moisan and Favre, CVD

10 To Bedside Intravenous Stem cell therapy for Ischemic Stroke ISIS-HERMES trial 3 parallel groups, controlled, randomized, opened Blind for clinical assessments Autologous MSC (from bone marrow) Objective: Feasibility and safety of IV MSC after stroke Inclusion: 18 to 70 yo (mean = 52 yo) / Ischemic stroke < 14 days (NIHSS 7) (mean = 18; n=21 left stroke) 31 patients in 3 groups (already recruited): million of MSC (n=10) million of MSC (n=10) 3. Controls (n=11) ISIS: safety preliminary data No cell-related adverse event Feasability (80%, n = 16 /20) / autologous therapy: 1 st patient: 60% of required dose (too short culture) 4 patients untreated (/ 20 in «treated» groups): - Caryotype «abnormalities» at P0: 2 trisomies 8 on 50 mitosis (normal at P1 and P3) - Cell deaths (at P1) - Poor quality of bone marrow sample: poor growth and caryotype abnormalities at P0, infection 10

11 Grant agreement GA/ Dr Olivier DETANTE (Grenoble, France) Pr Exuperio DIEZ-TEJEDOR (Madrid, Spain) Pr Jukka JOLKKONEN (Kuopio, Finland) RESSTORE European trial Horizon H2020 / Regenerative Medicine PHC (ID: ) : 6.4 million Euros for 5 years Coordination: Grenoble Alpes University (France) Sponsor: CHU Grenoble Alpes PI: - Dr Olivier DETANTE (Grenoble, France): CoPI - coordinator - Pr Exuperio DIEZ TEJEDOR (Madrid, Spain): CoPI - Pr Jukka JOLKKONEN (Kuopio, Finland): scientific coordinator 5 countries : Czech Republic, Finland, France, Spain, United Kingdom 24 academic partners + 5 private partners 23 stroke centers for enrolment and follow-up 4 experimental labs: Madrid, Paris, Grenoble, Kuopio 11

12 RESSTORE Methodology 2 parallel groups, randomized, double-blind 400 patients + 45 healthy controls for MRI Ischemic stroke (NIHSS > 7) Controlled (placebo = vehicle used for cell suspension) Allogenic Adipose Derived Stem Cells (ADSC) from 5 donors (5 Master Banks) IV delivery of ADSC vs placebo < 2-weeks post-stroke Primary objective: Efficacy of intravenous ADSC to improve recovery after ischemic stroke Primary endpoint: 6 months / deficit scale (NIHSS including hand testing) Secondary endpoints: handicap, physiotherapist / multimodal MRI, blood biomarkers, health economics ISCHEMIC STROKE NIHSS > 7 V1: Inclusion < 4 days post-stroke Initial imaging to be collected Randomization Pretreatment 3T-MRI V2: < 2 weeks - Clinical scores + physiotherapist (optional: speech therapist) - Serum biomarkers IV PLACEBO V2: < 2 weeks - Clinical scores + physiotherapist (optional: speech therapist) - Serum biomarkers IV Allo ADSC 1 M/kg V3: 3 weeks post stroke - Clinical scores - Serum biomarkers (Biobank, Barcelona) V4: 3 months - Clinical scores V5: 6 months (primary endpoint) Clinical scores Physiotherapist: Fugl-Meyer, PASS, Ashworth scale Optional: Speech therapist + Cognitive assessment) Multimodal 3T-MRI Serum biomarkers (Biobank, Barcelona) V6: 1 year Clinical scores Physiotherapist: Fugl-Meyer, PASS, Ashworth scale Optional: Speech therapist + Cognitive assessment Standard blood tests Optional multimodal MRI V7: 2 years - Clinical scores - Standard blood tests 12

13 RESSTORE Data Analysis Clinical database: CRO / ecrf (Finland) BioBank: Barcelona (Spain) MRI database: ShaNoir (France) Health economics / Virtual population Experimental studies: - Effect of intensive rehabilitation and co-morbidities - Explore neurobiological mechanisms - Safety of IV infusion of human ADSC in mice Ancillary studies (clinical, experimental ) Scale changes Clinical assessment Biomarkers Recovery Translational Networks!!!!!!! LEADERS PARTICIPANTS WP1 Cell Production WP2 Clinical Trial WP3 Biomarkers WP4 Data Management WP5 Statistics WP6 MRI development WP7 Translational development WP8 Valorisation WP9 Coordination Management A. Moisan S. Miettinen, L. Leyva, E. Gonzalez (HISTOCELL) E. Diez-Tejedor O. Detante J. Montaner A. Jaillard (MRI) CRO (Medfiles) M. Hommel B. Fuentes, F. Moniche, K. Muir, H. Numminen, R. Mikulik, monitoring (CRO) Consortium (exploitation), ESSEC buisness school (health economics), NOVADISCOVERY (virtual population) A. Jaillard M. Dojat, L. Lamalle J. Jolkkonen J. Montaner, M. Guiterrez-Fernandez, N. Kubis, E. Barbier FINOVATIS O. Detante E. Diez-Tejedor J. Jolkkonen Consortium Consortium, FINOVATIS 13