Κατανοώντας τα περιεδρικά συρίγγια στη νόσο Crohn: παρελθόν και μέλλον. Ι. Γ. Παπακωνσταντίνου Αναπλ. Καθηγητής Χειρουργικής

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1 Κατανοώντας τα περιεδρικά συρίγγια στη νόσο Crohn: παρελθόν και μέλλον Ι. Γ. Παπακωνσταντίνου Αναπλ. Καθηγητής Χειρουργικής

2 Epidemiology, Burden of Disease and Pathophysiology

3 Epidemiology of Perianal Fistulas in CD Fistula is a debilitating manifestation of CD and may occur in 17% 50% of CD patients 1,2 Perianal fistula is the most common type, reported in 54% 65% of patients with fistula 1,3 Overall, perianal fistulas affect up to one third of CD patients 1-4 In 10% of patients, perianal fistulas are the initial manifestation of CD, which may precede the onset of luminal CD by several years Percentage of Fistulas by Type 1 Other* 7% 6% Enterocutaneous E X Recto-vaginal T 9% E 60% R N 54% Perianal A L 24% I N Entero-enteric T 40% E R N A *Enterovesical and entero-intra-abdominal fistulas. L 1. Schwartz DA, et al. Gastroenterology. 2002;122: Hellers G, et al. Gut. 1980;21: Bell SJ, et al. Aliment Pharmacol Ther. 2003;17: Buchmann P, et al. Am J Surg. 1980;140:

4 Risk Factors for the Development of Perianal Fistulas in CD Colonic and rectal involvement 1 Prevalence of perianal fistulas reported as 12% in patients with isolated ileal disease 15% with ileocolonic disease 41% with colonic disease and rectal sparing 92% with colonic disease involving the rectum* Early age at diagnosis 2 Smoking(?) 3 Male predominance(?) 1,4 *Although perianal fistula is common in CD patients with colonic disease involving the rectum, rectal involvement is not a typical CD phenotype (as opposed to ulcerative colitis, where rectal involvement is typical). 1. Hellers G, et al. Gut. 1980;21:525-7; 2. Ingle SB, Loftus EV Jr. Dig Liver Dis. 2007;39:963-9; 3. Devaraj B, et al. Dis Colon Rectum. 2011;54:681-5; 4. Tang LY, et al. Clin Gastroenterol Hepatol. 2006;4:

5 Quality of Life Impairment in Patients With Perianal CD Patients with perianal CD have significant negative impact on QoL across physical, functional, and psychosocial domains In one study, physical symptoms were rated more important and adverse than functional, psychosocial and body image factors (Table) Aspects Ranked by Importance Aspects Ranked by Aversion (Willing to Accept Stoma for Relief) HI, high importance. QoL, quality of life. WTA, willingness to accept. a Proportion indicating the aspect is of high importance. b Proportion willing to accept a stoma for relief of the aspect. Mahadev S, et al. Dis Colon Rectum. 2011;54:579-85; 5

6 Pathophysiology of Perianal Fistulas in CD 1. Ulcer in mucosal lining 2. Penetrating behavior The etiology of perianal fistulas in CD is still unclear: according to one theory, they result from deep penetrating ulcer of the rectum or anus 1,2 1. Marzo M, et al. World J Gastroenterol. 2015;21: Scharl M, et al. World J Gastrointest Pathophysiol. 2014;5:

7 Pathogenesis of Crohn s Disease-Associated Fistulae Scharl M, et al. World J Gastrointest Pathophysiol. 2014;5:

8 Classification and Scoring

9 Anatomic Classification of Perianal Fistulas in CD Classification of perianal fistulas is essential to determine 1 Optimal management strategy Prognosis Classification systems currently used include 2-4 Parks classification: based on the course of the fistula tract in relation to the normal muscular anatomy of the pelvic floor American Gastroenterological Association (AGA) classification of simple vs complex fistulas: includes physical inspection together with endoscopic evaluation ECCO 2016: Classification of Perianal Fistula 2 ECCO Statement 9C There is no consensus for classifying perianal fistulas in CD. In clinical practice, most experts use a classification of simple or complex [EL5] 1. Gecse KB, et al. Gut. 2014;63: ; 2. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /eccojcc/jjw169; 3. Parks AG, et al. Br J Surg. 1976;63:1-12; 4. American Gastroenterological Association. Gastroenterology. 2003;125:

10 AGA Classification of Perianal Fistulas Simple fistula 1 Low tract (superficial, low intersphincteric, low trans-sphicteric)* Single external opening No abscess, rectovaginal fistula, or stricture Complex fistula 1 High tract (high intersphincteric, high trans-sphincteric, extrasphincteric, suprasphincteric) May have multiple external openings May be associated with abscess, rectovaginal fistula, or stricture 72-78% of perianal fistulas are complex 2-4 *A low fistula tract runs through the lower one third of the external anal sphincter. 1. American Gastroenterological Association. Gastroenterology. 2003;125: Bell SJ, et al. Aliment Pharmacol Ther. 2003;17: Eglinton TW, et al. Dis Colon Rectum. 2012;55: Molendijk I, et al. Inflamm Bowel Dis. 2014;20:

11 Scoring of Perianal Fistula Activity in CD Assessment of fistula activity (scoring), a dynamic measure, is essential to evaluate 1 Disease severity Response to therapy Prognosis Clinical and radiologic (MRI) features are used to evaluate fistula activity 2-4 Perianal Disease Activity Index (PDAI): assesses quality of life and perianal disease severity rated on a 5-point Likert scale Fistula drainage assessment: utilizes gentle finger compression MRI based scoring system: combines anatomical fistula description and features reflecting active inflammation MRI, magnetic resonance imaging. 1. Gecse KB, et al. Gut. 2014;63: ; 2. Irvine EJ. J Clin Gastroenterol. 1995;20:27-32; 3. Present DH, et al. N Engl J Med. 1999;340: ; 4. Van Assche G, et al. Am J Gastroenterol. 2003;98:

12 Multidisciplinary Management From Diagnosis to Treatment

13 Teamwork RADIOLOGIST SURGEON GASTROENTEROLOGIST 13

14 Diagnosis

15 ECCO 2016 Consensus Recommendations for Diagnosing Perianal Fistulas in CD Initial Diagnostic Approach ECCO Statement 9A Contrast-enhanced pelvic magnetic resonance imaging is considered the initial procedure for the assessment of perianal fistulizing CD [EL2] If rectal stenosis is excluded, endoscopic anorectal ultrasound is a good alternative [EL2] The specificity and sensitivity of both imaging modalities is increased when combined with examination under anesthetic (EUA) [EL1] Fistulography is not recommended [EL3] If a perianal fistula is detected, EUA is considered the gold standard in the hands of an experienced surgeon [EL5] ECCO Statement 9B Since the presence of concomitant rectosignmoid inflammation has prognostic and therapeutic relevance, proctosigmoidoscopy should be used routinely in the initial evaluation [EL2] ECCO, European Crohn s and Colitis Organisation; EL, evidence level. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /ecco-jcc/jjw

16 Physical Examination and Endoscopic Examination for Perianal Fistula in CD Physical examination is conducted to assess 1-3 Presence of perianal lesions, particularly stenosis, fissure, ulcer Number of external openings Active drainage Physical exam: Perianal lesions 4 Endoscopic examination is essential to assess 1-3 Extent and severity of luminal inflammation Presence of internal openings and other complications such as strictures and cancer Endoscopy: Presence and extent of rectal disease 4 1. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /ecco-jcc/jjw169; 2. Gecse K, et al. United European Gastroenterol J. 2013;1:206-13; 3. Gecse KB, et al. Gut. 2014;63: ; 4. Scanu AM. Perianal fistulas in Crohn s disease (2008). Available at: Last accessed on Nov 10,

17 Imaging Modalities for Perianal Fistula in CD: Pelvic MRI Imaging yields information on anatomy of the fistula tract, relation to external sphincter, number of tracts (single or multiple), location of internal (high or low) and external openings, presence of abscesses 1,2 Pelvic MRI is the gold standard imaging technique: good resolution of high tracts, good identification of secondary tracts, preferred for complex fistulas 1,2 A) Axial T2-weighted turbo spinecho shows a trans-sphicteric, horsehoe-shaped fistula (white arrow), with an internal opening (black arrowhead) 2 B) Axial fat saturated T1-weighted turbo spin-echo after IV contrast medium administration. Note intense enhancement indicating extensive inflammation but no abscess 2 MRI, magnetic resonance imaging. 1. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /eccojcc/jjw169; 2. Gecse K, et al. United European Gastroenterol J. 2013;1:

18 Imaging Modalities for Perianal Fistula in CD: Anorectal Ultrasound Anorectal ultrasound is a useful alternative to MRI (if rectal stenosis is excluded); however, accuracy can be limited by its restricted view 1,2 Intersphincteric fistula (arrow) 3 Horse-shoe fistula 4 Transsphincteric track (arrow) and ischiorectal extension (arrowheads) 3 1. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /ecco-jcc/jjw169; 2. Gecse KB, et al. Gut. 2014;63: ; 3. Buchanan GN, et al. Radiology. 2004;233:674-81; 4. Scanu AM. Perianal fistulas in Crohn s disease (2008). Available at: Last accessed on Nov 10,

19 Examination Under Anesthesia for Perianal Fistula in CD Examination under anesthesia (EUA) 1-3 Consists of visual inspection, palpation, passage of probes into fistula tracks Allows immediate therapeutic intervention such as abscess drainage and/or seton placement EUA: fistula; draining abscesses; positioning seton 5 Assess perianal fistula in CD by Accuracy, % (95% CI) 4 Examination under anesthesia (EUA) 91% (75% - 98%) Endoscopic ultrasound (EUS) 91% (75% - 98%) Magnetic resonance imaging (MRI) 87% (69% - 96%) EUA and imaging combined 100% MRI, magnetic resonance imaging. 1. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /ecco-jcc/jjw169; 2. Gecse K, et al. United European Gastroenterol J. 2013;1:206-13; 3. Gecse KB, et al. Gut. 2014;63: ; 4. Schwartz DA, et al. Gastroenterology. 2001;121: ; 5. Scanu AM. Perianal fistulas in Crohn s disease (2008). Available at: Last accessed on Nov 10,

20 Treatment

21 Treatment Goals for Perianal Fistulas in CD Short-term goals 1 Abscess drainage Reduction of symptoms Long-term goals 1 Resolution of fistula discharge Improvement in quality of life Fistula healing Preservation of continence Avoidance of proctectomy with stoma Treatment should be multidisciplinary (medical/surgical) and individualized based on type of fistula (simple vs complex), degree of rectal inflammation, and severity of symptoms 2 1. Gecse KB, et al. Gut. 2014;63: ; 2. Katsanos KH, et al. Ann Gastroenterol. 2009;22:

22 Medical Treatment

23 Antibiotics and Immunosuppressants Antibiotics Metronidazole/ciprofloxacin 1-4 Mostly uncontrolled case series; a few small controlled trials Improve symptoms, but exacerbate after discontinuation Immunosuppressants Thiopurines (azathioprine/mercaptopurine) 5,6 No RCT with fistula closure as primary endpoint; evidence from uncontrolled case series and meta-analysis of RCTs with closure as secondary endpoint Moderate efficacy in fistula closure Tacrolimus 7 Single RCT with short-term follow-up Improved fistula drainage, but failed to induce fistula healing Use limited due to frequent toxicity Cyclosporine 8 Uncontrolled case series with low patient numbers Rapid response rates but high relapse rates upon drug discontinuation RCT, randomized, controlled trial. 1. Bernstein LH, et al. Gastroenterology. 1980;79:357-65; 2. Brandt LJ, et al. Gastroenterology. 1982;83:383-7; 3. Thia KT, et al. Inflamm Bowel Dis. 2009;15:17-24; 4. Jakobovits J, Schuster MM. Am J Gastroenterol. 1984;79:533-40; 5. Present DH, et al N Engl J Med. 1980;302:981-7; 6. Pearson DC, et al. Ann Intern Med. 1995;123:132-42; 7. Sandborn WJ, et al. Gastroenterology. 2003;125:380-8; 8. Sandborn WJ. Inflamm Bowel Dis. 1995;1:

24 Patients, % Infliximab Treatment of Fistulas in CD: Induction Trial (18 Weeks) Patients, % 50% in the No. of Draining Fistulas at 2 Consecutive Study Visits (primary endpoint) Complete Response* (secondary endpoint) P=0.02 P= /31 21/31 18/32 Placebo 5 mg/kg 10 mg/kg P=0.04 P= /31 17/31 12/32 Placebo 5 mg/kg 10 mg/kg Median length of time during which fistulas remained closed: 3 months Study included 94 adult CD patients who had draining abdominal or perianal fistulas of 3 months duration who were randomly assigned to receive placebo, infliximab 5 mg/kg, infliximab 10 mg/kg intravenously at 0, 2, and 6 weeks. *Absence of any draining fistulas at 2 consecutive study visits. Present DH, et al. N Engl J Med. 1999;340:

25 Patients With Response, % Patients With Complete Response, % Infliximab Maintenance Therapy for Fistulizing CD: ACCENT II Trial (54 Weeks) Time to Loss of Response * Percentage of Patients With Complete Response at Each Visit* Infliximab maintenance P=0.002 Infliximab maintenance P= % 20 0 P<0.001 Placebo maintenance Placebo maintenance % Week Week After randomization, the median time to loss of response was >40 weeks in the infliximabmaintenance group vs 14 weeks in the placebo-maintenance group Study included 306 adult CD patients with 1 draining abdominal or perianal fistulas of 3 months duration who received IV infliximab 5 mg/kg at weeks 0, 2, and 6; 195 patients who had a response at weeks 10 and 14, and 87 patients who had no response were randomly assigned to placebo or infliximab 5 mg/kg q8wk to week 54. *Among patients with a response at randomization; Defined by recrudescence of draining fistulas, need for change in CD medication or additional therapy for persistent or worsening luminal disease activity, need for surgical procedure for CD, or discontinuation of study medication due to perceived lack of efficacy; Defined by absence of draining fistulas. Sands BE, et al. N Engl J Med. 2004;350:

26 Fistula recurrence among the 108 patients who experienced fistula closure. 16.6% (1 y) 40.1% (5 ys) Bouguen G, et al. CGH 2013;11:

27 Outcomes of Perianal Fistulising Crohn s Disease Following Anti-TNFα Treatment Discontinuation Clémence Legué, MD Charlène Brochard, MD Grégoire Bessi, MDTimothée Wallenhorst, MD Marie Dewitte, MD Laurent Siproudhis, MD PhDGuillaume Bouguen, MD PhD Inflammatory Bowel Diseases, izy008, Published: 04 May 2018 Aim The aim of this study was to assess the rate and type of perianal and luminal relapses following anti-tnfα discontinuation. Methods All patients treated with anti-tnfα for perianal fistulising Crohn s disease with subsequent discontinuation of therapy were retrospectively reviewed from a prospective database ( ). Cumulative probabilities of relapse-free survival were estimated by actuarial analysis. Results After a median follow-up of 62 months, 24 of the 45 patients experienced perianal relapse. A new surgical drainage was needed in 19 (79%) patients. The cumulative probabilities of perianal relapse at 1 and 5 years were 24% and 55%, respectively. Ileal localization (L1) at diagnosis, persistence of an external fistula opening, second line anti-tnfα use, or prior dose optimization was associated with perianal relapse, whereas continuation of immunosuppressive agents decreased this risk (HR = 0.3). Luminal relapse occurred in 42% of patients at 5 years. The cumulative probability of global relapse at 5 years was 67%. Retreatment with anti-tnfα allowed further remission in 23 of 24 (96%) patients. Conclusion Half of patients with perianal fistulising Crohn s disease relapse within 5 years after anti-tnfα discontinuation. Immunosuppressant continuation may decrease this risk. The high risk of relapse (perianal and luminal) may suggest a benefit in pursuing biologics over a longer period in patients with perianal fistulas.

28 Adalimumab Maintenance Therapy for Fistulizing CD: Pre-specified Analysis of CHARM Trial Patients With Complete Closure*, % Placebo Adalimumab 40 mg weekly Adalimumab 40 mg EOW Both adalimumab groups 50 P=0.043 P= n= /47 10/30 11/40 21/70 6/47 10/30 11/40 21/70 Week 26 Week 26 and 56 Similar definition: Fistula closure = cessation of draining Patients received open-label induction therapy with adalimumab 80 mg (week 0) followed by 40 mg (week 2); at week 4, patients randomized to placebo, adalimumab 40 mg every other week, or adalimumab 40 mg weekly through week 56. *Defined as closure of all fistulas draining at baseline for 2 consecutive visits. EOW, every other week. Colombel J-F, et al. Gastroenterology. 2007;132:

29 Surgical Treatment

30 Surgical treatment Emergency treatment of sepsis Incision and drainage of abscess Damage limitation Seton drain bridging" Definitive treatment fistulotomy Mucosal advancement plasty Glues/Anal Fistula Plug Ligation Intersphincteric Fistula Tract (LIFT) VAAFT Stemcell injection Defunctioning stoma Proctectomy

31 Emergency Treatment of Sepsis and Damage Limitation Abscess drainage and seton placement are necessary for complex perianal fistula in CD Abscess drainage Surgical drainage (vs spontaneous drainage) minimizes risk of additional septic complications, which may be aggravated by concomitant immunosuppressive treatment 1 Seton drain Maintains patency of fistula tracts and limits recurrent abscess formation 2 Loose setons (vs cutting setons) preserve integrity of external anal sphincter 3,4 Disadvantage: fistula tract cannot close with seton in place 5,6 Optimal timing for seton removal not well established Placement of Multiple Setons in Severe Fistulizing Perianal CD 8 A diverting stoma is reserved for severe disease refractory to medical therapy 7 1. Gecse KB, et al. Gut. 2014;63: ; 2. Buchanan GN, et al. Br J Surg. 2004;91:476-80; 3. Parks AG, Stitz RW. Dis Colon Rectum. 1976;19:487-99; 4. Hamalainen KP, Sainio AP. Dis Colon Rectum. 1997;40:1443-6; 5. Sands BE, et al. N Engl J Med. 2004;350:876-85; 6. Tanaka S, et al. Hepatogastroenterology. 2010;57:3-7; 7. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /ecco-jcc/jjw169; 8. Fichera A, et al. Inflamm Bowel Dis. 2015;21:

32 Definitive Surgical Treatment of Perianal Fistulas in CD fistulotomy should only be performed for complex fistulas selectively, because of the risk of incontinence 2 Surgical Management Of Fistula-In-Ano Among Patients With Crohn s Disease: Analysis Of Outcomes After Fistulotomy Or Seton Placement Single-Center Experience I. Papaconstantinou1, E. Kontis1, V. Koutoulidis2, G. Mantzaris3, I. Vassiliou1. 32

33 Definitive Surgical Treatment of Perianal Fistulas in CD Less Invasive Strategies: Fistula Track Fillers Plug Plugs Retrospective cohorts and 1 open-label study show success rates of 24% 88% 1-4 Failure caused by dislodgment in 22% of patients 5 In a recent RCT, no more effective than seton removal alone 6 Fibrin glue Open-label multicenter RCT showed initial success with fibrin glue vs observation-only (38% vs 16%, respectively); however, only 20% of patients in clinical remission at long-term follow-up 7 A: Outside aspect of the fistula; B: Fistula with a probe within the fistula; C: Fistula Plug; D: Situs after excision of the external opening of the fistula and curettage of the fistula tract, pull-though of the plug. 8 RCT, randomized, controlled trial. 1. O Connor L, et al. Dis Colon Rectum. 2006;49: ; 2. Ellis CN, et al. Dis Colon Rectum. 2010;53; ; 3. Owen G, et al. ANZ J Surg. 2010;80:341-3; 4. Lawes DA, et al. World J Surg. 2008;32:1157-9; 5.Thekkinkattil DK, et al. Colorectal Dis. 2009;11:584-7; 6. Senéjoux A, et al. J Crohns Colitis. 2016;10:141-8; 7. Grimaud JC, et al. Gastroenterology. 2010;138: ; 8. Ommer A, et al. Ger Med Sci. 2012;10:Doc13. 33

34 Definitive Surgical Treatment of Perianal Fistulas in CD Mucosal advancement flap Based on a systematic literature review, 64% of patients achieved success; incontinence occurred in 9.4%; reintervention needed in almost 50% of patients 1 Ligation of the intersphincteric fistula tract (LIFT) Small case series and a pilot study show success rate of 94% 2,3 In a single center study, >1 year healing rate, 56%; all recurrences occurred within 2 months following surgery 4 Mucosal Advancement Flap 5 LIFT 6 1. Soltani A, Kaiser AM. Dis Colon Rectum. 2010;53:486-95; 2. Rojanasakul A, et al. J Med Assoc Thai. 2007;90:581-6; 3. Abcarian AM, et al. Dis Colon Rectum. 2012;55:778-82; 4. Realis Luc A, et al. Tech Coloprotoctol. 2012;16:82-3; 5. Soltani A, et al. Dis Colon Rectum. 2010;53: ; 6. Tomiyoshi SD, et al. Arq Bras Cir Dig. 2014;27:

35 Current surgical treatment options There have been few RCTs evaluating the efficacy of these techniques for the treatment of complex perianal fistulas. Success rates of surgical/endoscopic procedures: a systematic review *1 Treatment Success rate * Incontinen ce rate No. of patients Median follow up (months) Rectal advancement flap % 0 35% LIFT 51 94% Low Fistula plug % 0% Fibrin glue 0 86% Very low Differences in patient selection, duration of follow-up and heterogeneity of treatment protocols contribute to the diverse results in the literature Further prospective randomized controlled trials with homogeneity are needed to substantiate these findings *Success rate = healing rate, however defined by the original authors of each study. RCT: Randomized controlled trial; LIFT: ligation of the intersphincteric fistula tract 1. Kontovounisios C, et al. Colorectal Dis 2016;18:

36 Intestinal Resection for Treatment of Perianal Fistulas in CD Proximal resection: Removal of symptomatic proximal Crohn s disease may lead to improvement of perianal lesions 1 However, perianal disease alone should not be an indication for proximal resection Proctectomy or proctocolectomy is reserved for severe perianal disease refractory to medical therapy or local surgery 1,2 1. Singh B, et al. Br J Surg. 2004;91:801-14; 2. Gionchetti P, et al. J Crohns Colitis September 22 [Epub ahead of print]. doi: /ecco-jcc/jjw

37 Unmet Needs

38 Perianal Fistulas in CD: Treatment Remain Unsatisfactory Perianal fistulas affect up to one third of CD patients during the course of their disease, and are associated with considerable morbidity and negative impact on patient quality of life 1,2 Despite the significant disease burden, current treatment options remain unsatisfactory Patients often do not respond to conventional medical/surgical management, and recurrence rates are high 3 1. Buchmann P, et al. Am J Surg. 1980;140:642-4; 2. Mahadev S, et al. Dis Colon Rectum. 2011;54:579-85; 3. Gecse KB, et al. Gut. 2014;63:

39 Perianal Fistulas in CD: Effective Treatment and Well- Designed Trials Needed Effective and safe new treatments are needed for patients with fistulizing CD, especially those with complex perianal fistula However, little progress has been made over the past decade in improving treatment options Studies with validated endpoints are limited, and current knowledge is largely based on retrospective series, expert opinion, and subanalyses of RCTs Additionally, due to the complexity of the disease, patients often receive inappropriate treatment A comprehensive clinically useful classification system of perianal fistulas is needed to help determine optimal management strategies Well-designed and powered RCTs with endpoints specifically aimed at perianal fistulas are needed to help standardize diagnosis, treatment, and follow-up in patients with fistualizing CD RCT, randomized, controlled trials. Gecse KB, et al. J Crohns Colitis. 2016;

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41 Investigational: Stem Cell Therapy for Perianal Fistulas in CD Stem cell therapy (investigational) Adipose-derived mesenchymal stem cells (ASCs) have potent immunomodulatory and antiinflammatory actions that may support the fistula tract to heal 1,2 Stem cell therapy deck (GLO/EYV/ ) details rationale of using ASCs for the treatment of perianal fistula in CD and supporting evidence from pre-clinical and early clinical studies ADMIRE-CD study deck (GLO/EYV/ [1]) details results of the recently published phase 3, multicenter, RCT evaluating expanded allogeneic ASCs (Cx601) for the treatment of complex perianal fistula in CD RCT, randomized, controlled, trial. 1. de la Portilla F, et al. Int J Colorectal Dis. 2013;28:313-23; 2. Panés J, et al. Lancet. 2016;388:

42 What is A Stem Cell? What is a stem cell? replicate itself, or A single cell that can differentiate into many cell types US National Academies. Understanding Stem Cells. Available at: Last accessed on October 17,

43 Mesenchymal Stem Cells (MSCs)

44 Mesenchymal Stem Cells Mesenchymal stem cells (MSCs) 1 A type of tissue stem cells Hematopoietic stem cell Mesenchymal stem cell Can be isolated from bone marrow, muscle, fat, dermis, and umbilical cord 1 1. Singer NG, et al. Annu Rev Pathol 2011;6:

45 The Mesengenic Process MSCs may differentiate into bone, cartilage, and adipose tissue, etc, depending on the stimuli and culture conditions under which they are expanded Singer NG, et al. Annu Rev Pathol 2011;6:

46 MSCs and Their Immunomodulatory Role Singer NG, et al. Annu Rev Pathol. 2011;6:

47 Therapeutic Areas MSCs Are Being Studied The potent immune regulatory actions of MSCs make them attractive for use in settings such as tissue injury, transplantation, and autoimmunity MSCs have been shown in clinical trials and in practice to alleviate graft-versus-host disease following bone marrow transplantation, without any observed adverse effects MSCs are being evaluated in a wide range of autoimmune conditions, e.g.: Demyelinating neurological disease (multiple sclerosis) Systemic lupus erythematosus Crohn s disease Singer NG, et al. Annu Rev Pathol. 2011;6:

48 Adipose-derived Mesenchymal Stem Cells (ASCs)

49 Rationale for Use of ASCs in Complex Fistula The pathogenesis of perianal fistulas is largely unknown, but may arise from an epithelial defect caused by ongoing inflammation 1 The reduction of the inflammatory environment by ASCs is expected to support the fistula tract to heal Support for this MoA principle has been indirectly demonstrated in vivo in colitic mouse models 2,3 1. Scharl M, et al. World J Gastrointest Pathophysiol 2014; 5: González MA, et al. Gastroenterology. 2009;136: Gonzalez- Rey E, et al. Gut. 2009;58:

50 Human ASCs Modulate Inflammation in Experimental Colitis Mouse Model Human ASCs treatment reduces systemic and colonic inflammatory responses in colitis 1,2 The reduction of inflammatory cells in the damaged tissue is a clear indication of an active anti-inflammatory process in the tissue 1,2 A hasc treatment reduces inflammatory responses in colitic mice: (A) colon and (B) sera 1 B 1. González MA, et al. Gastroenterology. 2009;136: Gonzalez-Rey E, et al. Gut. 2009;58:

51 Autologous ASCs for Treatment of Complex Perianal Fistula: A Phase 2 Study Healing* of Complex Perianal Fistula 8 Weeks After Last Treatment All Patients (ITT) Subgroup Analysis ASC+fibrin glue Fibrin glue alone P<0.001 P= P=N.S. P=0.001 P=N.S /24 4/25 Complex perianal 12/17 3/18 Cryptoglandular origin 5/7 1/7 Crohn s disease 10/14 2/16 Suprasphincteric 3/4 0/4 Rectovaginal fistula fistula (non-crohn s) fistulous tract At 1 year follow-up, the recurrence rate in patients treated with ASCs was 17.6% *Healing was predefined as the absence of drainage through the external openings (whether occurring spontaneously or under externally applied pressure) and complete re-epithelialization of external openings. Intralesional treatment with fibrin glue or fibrin glue plus 20 million ASCs. If healing was not seen at eight weeks, a second dose of fibrin glue or fibrin glue plus 40 million ASCs was administered. N.S., not significant. Garcia-Olmo D, et al. Dis Colon Rectum. 2009;52:

52 Good Tolerability of ASCs and Feasibility of Allogeneic Cell Therapy In addition to the immunomodulatory properties, ASCs are considered immune privileged because of: 1-3 Low expression of HLA I and lack of expression of HLA II (constitutively) After priming, there is up-regulation of HLA1 and induced expression of HLA II, but without expression of classic costimulatory molecules Low expression of ligands for NK cell receptors (constitutively or after priming) Delay of the maturation of terminally differentiated effector T cells Low Levels of HLA I Expression 2 More Resistant to NK-mediated Lysis 2 ASC, Adipose-derived mesenchymal stem cells. BM, bone marrow. HLA, human leukocyte antigen. MSC, mesenchymal stem cells. NK cell, natural killer cell. 1. de la Portilla F, et al. Int J Colorectal Dis. 2013;28: DelaRosa O, et al. Stem Cells Dev. 2012;21: Ghannam S, et al. J Immunol. 2010;185:

53 Good Tolerability of ASCs and Feasibility of Allogeneic Cell Therapy In addition to the immunomodulatory properties, ASCs are considered immune privileged because of: 1-3 Low expression of HLA I and lack of expression of HLA II (constitutively) After priming, there is up-regulation of HLA1 and induced expression of HLA II, but without expression of classic costimulatory molecules Low expression of ligands for NK cell receptors (constitutively or after priming) Delay of the maturation of terminally differentiated effector T cells Anergy of T lymphocytes and immune tolerance Delayed or reduced activation of the innate and adaptive immune responses Feasibility of allogeneic treatments without suppression of host immunity Easily available cell therapy Economically affordable ASC, Adipose-derived mesenchymal stem cells. BM, bone marrow. HLA, human leukocyte antigen. MSC, mesenchymal stem cells. NK cell, natural killer cell. 1. de la Portilla F, et al. Int J Colorectal Dis. 2013;28: DelaRosa O, et al. Stem Cells Dev. 2012;21: Ghannam S, et al. J Immunol. 2010;185:

54 Expanded Allogeneic Adipose-derived Mesenchymal Stem Cells (eascs) (Cx601)

55 Expanded Allogeneic Adipose-derived Mesenchymal Stem Cells for Medical Use Cellular suspension of living adult stem cells of mesenchymal origin extracted from the subdermal adipose tissue of healthy donors 1 Homogeneous cell population that complies with the ISCT criteria 2 for MSC Consecutively passaged cell population, e(xpanded)asc Homogeneity and passaging confers easc following particularities: Stable expansion Reduced differentiation potential Homogeneous surface markers expression during passaging ISCT, International Society for Cellular Therapy. 1. de la Portilla F, et al. Int J Colorectal Dis. 2013;28: Dominicci M, et al. Cytotherapy. 2006;8:

56 Phase 1/2a Clinical Trial of eascs For the Treatment of Complex Perianal Fistula in Crohn s Disease Initial proof of concept was achieved in a phase 1/2a study An open-label, single-arm clinical trial conducted at 6 Spanish hospitals Treatment and follow-up 24 patients were administered intralesionally with 20 million eascs in one draining fistula tract A subsequent administration of 40 million eascs was performed if fistula closure was incomplete at week 12 Patients were followed until week 24 after the initial administration de la Portilla F, et al. Int J Colorectal Dis. 2013;28:

57 Phase 1/2a Trial of eascs For Complex Perianal Fistula in CD Efficacy: Fistula Closure 100 Full Analysis at 12 and 24 Weeks wks 12/20 24 wks 9/13 Reduction from screening in number of draining fistulas wks 8/21 24 wks 9/ wks 6/20 Closure of external openings Fistula closure Luminal relapse wks 6/20 12 wks 0/ wks 5/24 Fistula closure was strictly defined as: Absence of suppuration of the fistula through the external orifice, both spontaneously and upon application of pressure and Complete re-epithelization of the external orifice during clinical evaluation and MRI absence of collections >2 cm, in three axis, directly related to the fistula tract treated de la Portilla F, et al. Int J Colorectal Dis. 2013;28:

58 Phase 3 ADMIRE CD Study

59 Cx601: Isolation and Expansion Cx601 cells are isolated from the stromal vascular fraction of human lipoaspirates. The lipoaspirates were extracted by liposuction from healthy adult donors Cells are subsequently expanded according to classic cell culture practices with culture media containing 10% fetal bovine serum of certified origin and quality and kept cryopreserved until use Cells from a single donor are used in each Cx601 dose Homogeneity and passaging confers easc following particularities: Stable expansion Reduced differentiation potential Homogeneous surface markers expression during passaging de la Portilla F, et al. Int J Colorectal Dis. 2013;28:

60 Study Objective Evaluate the efficacy and safety of Cx601 added on to current medical treatment for complex perianal fistulas in patients with CD who failed conventional therapy including antibiotics, immunomodulators, or anti tumor necrosis factor (TNF) therapy Panés J, et al. Lancet. 2016;388:

61 Study Design Double-blind, placebo-controlled, randomized, parallel-arm, multicenter, phase 3 study (NCT ) 1,2 Single local injection of 120x10 6 easc or placebo Primary endpoint: 24 weeks Screening Preparation Primary Endpoint Follow-Up Treatment week W-5 W-3 D0 W6 W12 W18 W24 W36 W52 W104 Randomization Clinical Assessment Baseline MRI W24 MRI W52 MRI Double-blind: patient and investigator both blinded. easc, expanded allogeneic adipose-derived stem cells; MRI, magnetic resonance imaging. 1. Panés J, et al. Lancet. 2016;388: ; 2. ClinicalTrials.gov: NCT Accessed September 16,

62 Study Overview Status 1 Condition 1 Summary 24-week primary analysis results published; ongoing longterm (2 years) follow-up Complex perianal fistulas in patients with CD Study design 1 Phase 3, randomized, double-blind, placebo-controlled All fistula tracts treated; single intralesional injection a Enrollment 1 Number of sites patients recruited 49 hospitals; 7 European countries and Israel Primary endpoint 1 Combined remission at Week 24 Secondary endpoints at Week 24, 52 and 104 1,2 Clinical remission Response Relapse Time to combined remission / to clinical remission / to response / to relapse PDAI, CDAI, IBDQ, and van Assche score Safety a 120 million Cx601 cells. CDAI, Crohn s Disease Activity Index; IBDQ, Inflammatory Bowel Disease Questionnaire; MRI, magnetic resonance imaging; PDAI, Perianal Disease Activity Index. 1. Panés J, et al. Lancet. 2016;388: ClinicalTrials.gov: NCT Accessed September 16,

63 Key Inclusion Criteria Adults 18 years Nonactive/mildly active luminal CD disease for 6 months (CDAI 220) Presence of complex perianal fistulas defined as 1 of the following: High inter-sphincteric, high trans-sphincteric, extra-sphincteric, suprasphincteric origin 2 external openings Associated collections Fistulas had to have a maximum of 2 internal and 3 external openings, and draining for 6 weeks before inclusion Refractory to 1 of the following: Antibiotics ciprofloxacin or metronidazole (no response after 1 month) a Immunomodulators AZA, 6-MP, or MTX (no response after 3 months) Anti-TNFs (induction or maintenance) a Patients refractory only to antibiotics were to represent less than 25% of the total population. 6-MP, 6-mercaptopurine. AZA, azathioprine. CDAI, Crohn s Disease Activity Index. MTX, methotrexate. Panés J, et al. Lancet. 2016;388:

64 Randomization, Stratification, and Masking Patients randomly assigned (1:1) to Cx601 or placebo after fistula preparation visit at least 2 weeks before investigational product administration Patients stratified based on concomitant treatment at randomization: Anti-TNF Immunomodulator Both Neither Unmasked surgeon administered treatment a Masked gastroenterologist/radiologist assessed therapeutic effect a Masking of treatments not possible because cell suspension was clearly different to saline solution (ie, placebo). Panés J, et al. Lancet. 2016;388:

65 Procedures: Screening and Preparation visit Screening visit Pelvic MRI scan to guide surgical procedure and assess abscesses Fistula preparation visit Examination under anaesthesia, fistula curettage, seton placement as clinically indicated 2 weeks before investigational product administration Panés J, et al. Lancet. 2016;388:

66 Procedures: Treatment Administration Visit Conditioning of fistula Seton(s) removed if present Closure of internal opening(s) (IO) done using polyglactin absorbable 2/0 stitches and confirmed by pressured injection of 10 ml physiological saline solution through the external opening Cx601 administration (Figure) Re-suspend Cx601 vials Inject the contents of 2 vials (60x10 6 cells) into tissue surrounding IO(s) Inject the contents of the other 2 vials (60x10 6 cells) into the fistula walls along the length of the fistula tract(s) Placebo administration: 24 ml of saline solution Post-injection care Massage softly EO(s) area Patient discharged according to outpatient surgery Panés J, et al. Lancet. 2016;388:

67 Study Endpoints Primary endpoint Combined remission at Week 24: clinical assessment of closure of all treated external openings that were draining at BL, and the absence of collections >2 cm of the treated perianal fistulas in 2 of 3 dimensions, confirmed by masked central MRI Clinical assessment of closure: absence of draining despite gentle finger compression Key secondary endpoints Clinical remission: closure of all treated external openings that were draining at BL despite gentle finger compression, by Week 24 Response: closure of 50% of all treated external openings that were draining at baseline, by Week 24 Other secondary endpoints PDAI, CDAI, IBDQ Time to combined remission, relapse, time to relapse, van Assche score BL, baseline; CDAI, Crohn s Disease Activity Index; IBDQ, Inflammatory Bowel Disease Questionnaire; MRI, magnetic resonance imaging; PDAI, Perianal Disease Activity Index. Panés J, et al. Lancet. 2016;388:

68 Patients, % Primary Endpoint: Combined Remission a at Week 24 ITT, mitt, and primary PP Populations Cx601 Placebo =15.2% 97.5% CI, P= =15.8% 97.5% CI, P=0.021 A significantly greater proportion of patients in Cx601 group than placebo group achieved primary endpoint of combined remission at week 24 in ITT and mitt populations These results were confirmed in the PP population ( =20.1%; 97.5% CI, ; P=0.010) 0 53/107 36/105 53/103 36/101 ITT Population mitt Population a Defined as clinical assessment of closure of all treated external openings that were draining at baseline, despite gentle finger compression, and absence of collections >2 cm of treated perianal fistulas in 2 of 3 dimensions, confirmed by masked central MRI. ITT, intention-to-treat; mitt, modified intention-to-treat; MRI, magnetic resonance imaging; PP, per protocol. Panés J, et al. Lancet. 2016;388:

69 Primary Endpoint: Combined Remission a at Week 24 According to Randomization Stratification Factors mitt Population, N=204 Cx601 Placebo =20.0% 95% CI, P=0.47 across randomization strata =9.7% 95% CI, =1.5% 95% CI, =33.1% 95% CI, /27 14/30 17/36 12/32 5/16 6/20 13/24 4/19 Anti-TNFs + Immunomodulators Anti-TNFs Immunomodulators Neither a Defined as clinical assessment of closure of all treated external openings that were draining at baseline, despite gentle finger compression, and absence of collections >2 cm of treated perianal fistulas in 2 of 3 dimensions, confirmed by masked central MRI. mitt, modified intention-to-treat; MRI, magnetic resonance imaging. Panés J, et al. Lancet. 2016;388:

70 Probability of Clinical Remission Number at Risk Cx601 Placebo Time to Clinical Remission ITT Population, n=212 Cx601 Placebo Censored Weeks Median time to clinical remission was shorter with Cx601 (6.7 weeks, 95% CI, ) compared with placebo (14.6 weeks, 95% CI, ; HR 0.57, 95% CI ) HR, hazard ratio; ITT, intention-to-treat. Panés J, et al. Lancet. 2016;388: Suppl. 70

71 Secondary Endpoints: CDAI and IBDQ at Week 24 For total and subdomain CDAI scores, there were no significant differences between treatment groups For total and subdomain IBDQ scores, there were no significant differences between treatment groups Panés J, et al. Lancet. 2016;388:

72 Treatment-Emergent Adverse Events to Week 24 Safety Population, n=205 Cx601 n=103 Placebo n=102 Overall, n (%) 68 (66) 66 (65) TEAS leading to study withdrawal, n (%) 5 (5) 6 (6) TEAS in 5% of patients a, n (%) Proctalgia 13 (13) 11 (11) Anal abscess 12 (12) 13 (13) Nasopharyngitis 10 (10) 5 (5) Diarrhea 7 (7) 3 (3) Abdominal pain 4 (4) 6 (6) Fistula b 3 (3) 6 (6) Treatment-related AEs, n (%) 18 (17) 30 (29) Treatment-related AES in 2% of patients a, n (%) Anal abscess 6 (6) 9 (9) Proctalgia 5 (5) 9 (9) Procedural pain 1 (1) 2 (2) Fistula discharge c 1 (1) 2 (2) Induration 0 2 (2) Most TEAEs were mild or moderate in intensity a In either treatment group; b New fistula, reopening of closed fistula; c Fistula discharge in a closed fistula. AEs, adverse events; TEAEs, treatmentemergent adverse events. Panés J, et al. Lancet. 2016;388:

73 Serious Treatment-Emergent Adverse Events to Week 24 Safety Population, n=205 Cx601 n=103 Placebo n=102 Serious TEAEs a, n (%) 18 (17) 14 (14) Serious TEAEs in 2% of patients b, n (%) Anal abscess 9 (9) 7 (7) Serious treatment-related AEs, n (%) 5 (5) 7 (7) Anal abscess 5 (5) 5 (5) Proctalgia 0 1 (1) Anal inflammation 0 1 (1) Liver abscess 0 1 (1) No deaths occurred during the study a Any AE that at any dose resulted in death, was life-threatening, caused permanent incapacity or disability, resulted in hospital admission or prolonged a hospital stay, was a medically significant event, or was a suspected transmission of an infectious drug; b In either treatment group. AEs, adverse events; TEAEs, treatment-emergent adverse events. Panés J, et al. Lancet. 2016;388:

74 Donor-specific Antibodies At baseline: 10 of 63 (16%) patients in the Cx601 group and 9 of 60 patients (15%) in the placebo group had pre-existing IgG HLA class I antibodies At week 12: 18 (34%) of 53 Cx601-treated patients and none of the 51 placebo-treated patients who tested negative at baseline generated anti-hla class I antibodies There were no immune reactions or TEAEs associated with the development of donor-specific antibodies, and no association between positivity for donor-specific antibodies and therapeutic response Panés J, et al. Lancet. 2016;388:

75 Discussion: Strengths and Added Value of the Study This is the first large-scale, randomized, placebo-controlled clinical trial combining clinical assessment of fistula closure and MRI assessment of absence of abscesses, as recommended by ECCO Primary endpoint of combined remission more stringent than other studies Other clinical studies of perianal fistulas in CD typically assessed response or complete response (ie, 50% or 100% in # of draining fistulas, respectively) The secondary efficacy analyses reinforce the clinical benefit of Cx601. With Cx601, the time to clinical remission and response was rapid, occurring in about half of the time of that in the placebo group The favourable safety profile might represent an advantage over anti-tnf treatments, which are associated with several serious safety concerns Panés J, et al. Lancet. 2016;388:

76 Discussion: Limitations of the study The lack of significant difference in clinical remission rates between the Cx601 and placebo groups might be in part related to a substantially higher placebo effect (43%) 1 than expected and reported in previous studies (13 19%) 2-4 Fistula curettage, surgical drainage, and internal orifice closure might have increased the placebo response (as well as the response to Cx601) 1 Furthermore, concomitant immunomodulator or anti-tnf treatment, or both, are likely to have had a beneficial effect in both treatment groups 1 No differences have been found in IBDQ and CDAI scores between treatment groups. This could be explained by: Low CDAI score (an inclusion criterion) and high IBDQ score at baseline Furthermore, these instruments have been validated for the overall evaluation of Crohn s disease, and not to assess the severity of complex perianal fistulas. 1. Panés J, et al. Lancet. 2016;388: Sands BE, et al. N Engl J Med. 2004;350: Present DH, et al. N Engl J Med. 1999;340: Colombel JF, et al. Gut. 2009;58:

77 Discussion: Limitations of the study Safety data: Whether TEAEs were related to Cx601 or to the associated preparation procedures was not established Future studies should assess the safety and efficacy of repeat Cx601 doses Long-term follow-up of the patients to 2 years are underway Exclusion of the following patient populations: Younger patients Patients with more than two internal and three external openings Patients with other types of treatment-refractory fistulas (eg, rectovaginal or abdominal) Patients with previous surgery other than drainage and seton placement Panés J, et al. Lancet. 2016;388:

78 Summary and Conclusion Summary Cx601 demonstrated significantly greater efficacy vs placebo in achieving the primary endpoint, combined remission at Week 24, in both ITT (P=0.024) and mitt (P=0.021) populations; results were confirmed in primary PP population A numerically higher proportion of patients treated with Cx601 vs placebo met the key secondary endpoints of clinical remission and response at Week 24 in ITT, mitt, and secondary PP populations Cx601 was well tolerated in the study population Conclusion Cx601 is an effective and safe treatment In a difficult-to-treat study population of patients who had Crohn s disease with complex perianal fistulas and had not responded to conventional or biological treatment,or both Local treatment with Cx601 might offer patients with CD who have treatment-refractory complex perianal fistulas a novel and minimally invasive closure alternative to avoid the need for systemic immunosuppression orsurgery ITT, intention-to-treat; mitt, modified intention-to-treat; PP, per protocol. Panés J, et al. Lancet. 2016;388:

79 ?????????? MSC source: autologous vs allogenic MSC tissue: bonne marrow vs Adipose Mode of delivery Optimal dose Repeat injection Combine therapy (+ plugs or glues) Translation into systemic therapy MSC donor variability Cost/benefit