Treatment of Radiation-Induced Injuries with Mesenchymal Stem Cells: the French Experience

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Gourmelon, Director of Radiation Protection and Human Health, In Charge of International Partnerships and

1 Treatment of Radiation-Induced Injuries with Mesenchymal Stem Cells: the French Experience Jean-René Jourdain, Pharm.D., Ph.D. Representative of P. Gourmelon, Director of Radiation Protection and Human Health, In Charge of International Partnerships and Cross-Departmental Activities IRSN French Institute for Radiological Protection and Nuclear Safety GHSI Public Health Emergency Medical Countermeasures Workshop November 4-5, Washington, DC United States of America

2 The French Experience in Radiation Accident Management Radiation Source Accidents with Severe Radiation Burns GEORGIA Lilo ( ) PERU (1999) GEORGIA Lia (2002) CHILE (2005) SENEGAL (2006) TUNISIA (2008) ECUADOR (2009) Radiation Source Accidents with Acute Radiation Syndrome (ARS) BELGIUM (2006) SENEGAL (2006) Radiation Therapy Accidents POLAND (2001) External Radiotherapy/Breast Cancer/Radiation Burn FRANCE Epinal ( ) Conformal External Radiotherapy/Prostate Cancer FRANCE Toulouse ( ) Stereotactic Radiosurgery/Central Nervous System 2

3 Specificities of the Radiological vs Thermal Burn The radiological burn is a dynamic process The lesions may appear a long time after the irradiation The spatial temporal progression of lesions is unpredictable Successive waves of recurrences after surgery The healing is a fragile, uncertain and long-term process Irrepressible pains +++ opiates resistant The Radiological Burn IS NOT a Thermal Burn 3

4 Thermal Burn Clinical Progression of Thermal vs Radiological Burn (Mini Pig) D0 D1 D3 D8 Radiological Burn (100ºC, 30 seconds, 5 x 5 cm) D0 D1 D2 D33 D104 D175 D8 D197 (Gamma Irradiation 40 Gy, 10 x 10 cm) 4

5 Radiological Cutaneous Syndrome Progression Acute Phases Subacute Phase Chronic Phase Advanced Phase 4 24 h 48 h 1 week 1 month 1 year 10 year 5

6 Spatial Temporal Progression of the Burn Gammagraphy Accident in Peru D18 PI D4 PI 6

7 Failure of the Conventional Burn Treatment D6 PI D98 PI Leg Amputation D176 PI 7

8 The Treatment of the Severe Radiation Burns The conventional surgical treatment ( The 1 st Approach ): Large excision of radio-damaged tissues combined to the conventional techniques of plastic reconstructive surgery (Muscle rotation flap or omentum flap) In case of deep and large necrosis, the lesion should be excised and the wound bed should be covered with a good quality, full-thickness skin graft, like performed in the thermal burn treatment BUT The surgical excisions are rarely efficient because the limits between safe and injured tissues are not well defined, in contrast with thermal burns Every surgical operation seems to stimulate the inflammatory waves and boosts ischemic and fibrosis processes These phenomena lead to a spread of the radionecrosis that can escape to the surgical treatment New Therapeutic Approaches 8

9 History of New Therapeutic Approaches Artificial Skin Graft (Integra ) GEORGIA Lilo ( ) GEORGIA Lia (2002) CHILE (2005) SENEGAL (2006) Dosimetry-Guided Surgery CHILE (2005) ECUADOR (2009) Cell Therapy with Mesenchymal Stem Cells CHILE (2005) SENEGAL (2006) TUNISIA (2008) ECUADOR (2009) 9

10 History of New Therapeutic Approaches Artificial Skin Graft (Integra ) GEORGIA Lilo ( ) GEORGIA Lia (2002) CHILE (2005) SENEGAL (2006) Dosimetry-Guided Surgery CHILE (2005) ECUADOR (2009) Cell Therapy with Mesenchymal Stem Cells CHILE (2005) SENEGAL (2006) TUNISIA (2008) ECUADOR (2009) 10

11 The Chilean Accident On December 15th, 2005, an 192 Ir source ( Bq) was found by a worker, and put in the back pocket of his trousers This source was used for quality control of welding The alert was given within one hour by another worker wearing an active dosimeter Duration of exposure: 40 min, including 10 min in the back pocket Hospitalization the day of the accident, and early follow-up of the lesions Localized irradiation to the hands (particularly the left one), the buttock, the head and the chest The IAEA was requested by Chilean authorities Transfer in France on December 26 th, 2005, in the burn treatment centre of the Percy hospital 11

12 The Chilean Accident Day 1 Day 4 Day 8 Initial dosimetric evaluation based upon 192 Ir source activity and exposure duration Evidence for a very severe lesion Needs for New therapeutic Approaches 12

13 2 nd Approach : Dosimetry-Guided Surgery CT SCAN FIRST EXERESIS (day 21) 1900 Gy 25 Gy 20 Gy 10 Gy 5 Gy 1 Gy Source PHANTOM VOXELISATION DOSIMETRIC MAP 2000 Gy: skin surface 20 Gy 5 cm deepth 13

3 rd Approach: Cell Therapy with Mesenchymal Stem Cells Mesenchymal stem cells Bone Cartilage Muscle Stroma Tendon Adipocyte High proliferating ability Multipotential, especially for structural

14 3 rd Approach: Cell Therapy with Mesenchymal Stem Cells Mesenchymal stem cells Bone Cartilage Muscle Stroma Tendon Adipocyte High proliferating ability Multipotential, especially for structural tissues Production of cytokines and soluble factors Induction of immunotolerance Easy to harvest from BM puncture, adipocyte tissue and other sources High potential for therapeutic use in tissue reconstruction Pre-clinical studies in animal model for the treatment of radiation burns 14

15 The Radiological Burn in NOD/SCID Mouse Model Mesenchymal Stem Cell Transplant 30 Gy 6 weeks 8 weeks 30 Gy Mensenchymal Stem Cell Better Repair of the Wound in MSC-Treated Mice 15

16 MSC Production for Clinical Use MSC Amplification MSC Freezing Illiac Crest Aspiration Partnership: French FDA Approved Process Closed Culture Device: Cellstack MSC harvesting (10 days culture) Quality Controls: Sterility, Phenotype: CD45 - CD73 + CD90 + CD105 +, CFU-F: 225/10 6 MNC, Numeration Telomerase activity MSC Injection 16

17 Treatment with Mesenchymal Stem Cells (MSC) Excision Day 21 Recurrence Radiolesion Day 71 MSC 168 x 10 6 Day 90 MSC 226 x 10 6 Day 98 Day 109 Day

18 Left Hand Treatment at Day 42 PI Exudative Dermatitis Covering with Integra Artificial Derma Skin Autograft 76x10 6 Autologous MSC 18

19 Left Hand Evolution 1 month post treatment (70 days PI) 3 months post treatment Post treatment evaluation of radiation dose by ESR dosimetry using a sample of bone : 28.3 ± 2.9 Gy, more than 30 Gy to the skin surface This radiation dose usually induces a necrosis leading to amputation 19

20 History of New Therapeutic Approaches Artificial Skin Graft (Integra ) GEORGIA Lilo ( ) GEORGIA Lia (2002) CHILE (2005) SENEGAL (2006) Dosimetry-Guided Surgery CHILE (2005) ECUADOR (2009) Cell Therapy with Mesenchymal Stem Cells CHILE (2005) SENEGAL (2006) TUNISIA (2008) ECUADOR (2009) 20

Hospitalized at Percy at D29 post-irradiation Acute

21 Accidental Irradiation in Dakar (2006) Gammagraphy Accident: Iridium 192 Patient: 32 years old man Hospitalized at Percy at D29 post-irradiation Acute Radiation Syndrome Severe Radiation Burns Initial Lesions at Left Axilla (D20 PI) 21

22 Progression of the Initial Lesion D43 PI D63 PI 22

23 1 st EXCISION DERMAL SUBSTITUTE Integra 1 st SKIN AUTOGRAFT Treatment with Conventional Approach IRRADIATION D 0 D 100 D 121 Excision and Integra Covering (D100 PI) Mashed Thickness Skin Autograft (D121 PI) Necrosis of the Graft (D170 PI) 23

2 nd MSC LOCAL ADMINISTRATION MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) D 0 D 100 D 121 D 175 D 191 D 200

24 New Therapeutic Approach: Conservative Surgery + Local MSC Therapy 1 st EXCISION DERMAL SUBSTITUTE Integra IRRADIATION 1 st SKIN AUTOGRAFT 1 st BONE MARROW HARVESTING 2 nd EXCISION LATISSIMUS DORSI MUSCLE FLAP + 1 st MSC LOCAL ADMINISTRATION 2 nd MSC LOCAL ADMINISTRATION MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) D 0 D 100 D 121 D 175 D 191 D MSC for 2 nd Amplification MSC for Quality Controls TBMC were seeded MSC for Injection 24

Integra IRRADIATION 1 st SKIN AUTOGRAFT 1 st BONE

MUSCLE FLAP + 1 st MSC LOCAL ADMINISTRATION 2 nd

passage) MSC EXPANSION (2 nd passage) D 0 D 100 D

Multiple Injections of MSC within the Wound Bed

25 New Therapeutic Approach: Conservative Surgery + Local MSC Therapy 1 st EXCISION DERMAL SUBSTITUTE Integra IRRADIATION 1 st SKIN AUTOGRAFT 1 st BONE MARROW HARVESTING 2 nd EXCISION LATISSIMUS DORSI MUSCLE FLAP + 1 st MSC LOCAL ADMINISTRATION 2 nd MSC LOCAL ADMINISTRATION MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) D 0 D 100 D 121 D 175 D 191 D 200 Excision of Necrotic Tissues Multiple Injections of MSC within the Wound Bed ( MSC) Latissimus dorsi Muscle Flap and Skin Autograft 25

26 Evolution after Latissimus dorsi Muscle Flap and MSC Injection New Approach Associating Surgery and Local Stem Cell Therapy Septic Necrosis of the Third Distal Part of the Flap 26

«Chinese Flap» Associated to MSC Injection 1 st EXCISION DERMAL SUBSTITUTE Integra 1 st SKIN AUTOGRAFT 2 nd EXCISION LATISSIMUS DORSI MUSCLE FLAP +

3 rd MSC LOCAL ADMINISTRATION MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) D 0

27 «Chinese Flap» Associated to MSC Injection 1 st EXCISION DERMAL SUBSTITUTE Integra 1 st SKIN AUTOGRAFT 2 nd EXCISION LATISSIMUS DORSI MUSCLE FLAP + FOREARM RADIAL FLAP + IRRADIATION 1 st BONE MARROW HARVESTING 1 st MSC LOCAL ADMINISTRATION 2 nd MSC LOCAL ADMINISTRATION 2 nd BONE MARROW HARVESTING 3 rd MSC LOCAL ADMINISTRATION MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) D 0 D 100 D 121 D 175 D 191 D 200 D 205 D 226 Mesenchymal Stem Cells MSC Amplification MSC Quality Controls MSC Local Injection 27

28 Evolution after the «Chinese Flap» and MSC Injection No New Necrotic Process Incomplete Healing Skin Dose: around 70 Gy Amputation Probability: Extremely High Stop of Invasive Surgical Operations Intensification of Mesenchymal Stem Cell Therapy 28

Intensified MSC Administration 1 st EXCISION DERMAL SUBSTITUTE Integra 1 st SKIN AUTOGRAFT 2 nd EXCISION

HARVESTING 1 st MSC LOCAL ADMINISTRATION 2 nd MSC LOCAL ADMINISTRATION 2 nd BONE MARROW HARVESTING 3 rd MSC

MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd

29 Intensified MSC Administration 1 st EXCISION DERMAL SUBSTITUTE Integra 1 st SKIN AUTOGRAFT 2 nd EXCISION LATISSIMUS DORSI MUSCLE FLAP + FOREARM RADIAL FLAP + 2nd SKIN AUTOGRAFT + IRRADIATION 1 st BONE MARROW HARVESTING 1 st MSC LOCAL ADMINISTRATION 2 nd MSC LOCAL ADMINISTRATION 2 nd BONE MARROW HARVESTING 3 rd MSC LOCAL ADMINISTRATION 4 th MSC LOCAL ADMINISTRATION 3 rd BONE MARROW HARVESTING 5 th MSC LOCAL ADMINISTRATION MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) MSC EXPANSION (1 st passage) MSC EXPANSION (2 nd passage) MSC EXPANSION (1 st passage) D 0 D 100 D 121 D 175 D 191 D 200 D 205 D 226 D 239 D 253 D 268 D239 D249 D268 29

30 Evolution 1-Year after the Accident (May 2008) Necrosis Process Stopped - Complete Healing No Pain However, the radial nerve damage has led to a partial paralysis 30

ESR Dosimetry of the Left Arm Bone Sample taken at D171 and D220 p.i. D171: Biopsy 1 D220: Biopsy 2 53.5 Gy ± 3.7 Gy 44.4 Gy ± 4.

An osteonecrosis can also be observed from 40 Gy The result indicates that the mesenchymal stem cells have a high potential in

31 ESR Dosimetry of the Left Arm Bone Sample taken at D171 and D220 p.i. D171: Biopsy 1 D220: Biopsy Gy ± 3.7 Gy 44.4 Gy ± 4.9 Gy The results of ESR analysis showed that the dose received is well above the limit of the appearance of skin necrosis (25 Gy) An osteonecrosis can also be observed from 40 Gy The result indicates that the mesenchymal stem cells have a high potential in treating radiation burns The coupling of surgery and administration of mesenchymal stem cells seems to important key to healing the patient 31

32 The Radiation Burn: Conclusion Patients suffering from a cutaneous radiation reaction after accidental radiation exposure are not burn patients If possible, a numerical dose reconstruction allows a better definition of irradiated tissus with a risk of necrotic evolution This numerical reconstitution may guide the surgical excision The excision of potential necrotic areas as soon as possible is of outstanding importance in order to preserve healthy surrounding tissues Autologous MSC local administration as a new tool to treat radiationinduced burns: Strongly reduces pain Promotes wound healing of the skin and underlying tissues Impressive efficiency in 3 accidental cases when combined with surgery, but Mechanisms completely unknown: bystander effect, in situ implantation and proliferation, differentiation, immunodepression, in situ cytokines? A breakthrough in the treatment of radiation burns? 32

Percy Hospital Multidisciplinary Team SURGERY E.BEY, MD P.DUHAMEL, MD M.

LATAILLADE, MD, PhD M.PRAT-LEPESANT, PhD C.AIT-MANSOUR L.BOUTIN S.CREA M.

BARGUE, MD HEMATOLOGY T. de REVEL, MD T. FAGOT, MD B. SOULEAU, MD JV.

33 Percy Hospital Multidisciplinary Team SURGERY E.BEY, MD P.DUHAMEL, MD M.BRACHET, MD JP.PRADIER, MD A.LAKEL, MD CELL THERAPY M.JOUSSEMET, MD JJ.LATAILLADE, MD, PhD M.PRAT-LEPESANT, PhD C.AIT-MANSOUR L.BOUTIN S.CREA M.GOURVEN F.TISSEDRE BURN CENTER H.CARSIN, MD T.LECLERC, MD L.BARGUE, MD HEMATOLOGY T. de REVEL, MD T. FAGOT, MD B. SOULEAU, MD JV. MALFUSON, MD P. GOURMELON, MD, PhD Physical Dosimetry: J-F BOTTOLLIER, PhD, F.TROMPIER Biological Dosimetry: L.ROY, PhD E.GREGOIRE 33

34 Treatment of Radiation-Induced Injuries with Mesenchymal Stem Cells: the French Experience Jean-René Jourdain, Pharm.D., Ph.D. Representative of P. Gourmelon, Director of Radiation Protection and Human Health, In Charge of International Partnerships and Cross-Departmental Activities IRSN French Institute for Radiological Protection and Nuclear Safety GHSI Public Health Emergency Medical Countermeasures Workshop November 4-5, Washington, DC United States of America

J.F. Bottollier-Depois - M. Benderiter - P. Gourmelon. Contribution of IRSN in the medical management of radiological accidents

J.F. Bottollier-Depois - M. Benderiter - P. Gourmelon Contribution of IRSN in the medical management of radiological accidents Radiological accidents More than 600 incidents/accidents are known since 1945