UMBILICAL CORD BLOOD STEM CELLS EXPANDED IN THE PRESENCE OF NICOTINAMIDE (NICORD) PROVIDE LONG TERM MULITI-LINEAGE ENGRAFTMENT Mitchell E. Horwitz, MD Duke University Medical Center Duke Cancer Institute Durham, NC Gamida Cell Ltd. Jerusalem, Israel International Society of Cellular Therapy Philadelphia Pa. September 9, 213
Limitations of Umbilical Cord Blood Transplantation Low stem cell dose Graft failure 1-2% Highest in adult population Delayed immunologic recovery Delayed hematopoietic recovery Modulation or expansion of UCB stem cells may address these limitations
Source of Problem Donor Graft Comparison (adult recipients) Bone Marrow Umbilical Cord Peripheral Blood Nucleated Cells 1-5 x 1 8 /kg.15-1 x 1 8 /kg 1-4 x 1 8 /kg CD34+ cells.5-2 x 1 6 /kg.5-.2 x 1 6 /kg 2-2 x 1 6 /kg T-Lymphocytes 1 x 1 8 1 x 1 8 1 x 1 8
Cumulative Incidence, % 5-DCB; Phase II Multicenter Myeloablative Dual UCB Transplantation 1 89% (8-96) at day 1 1 8 6 86% (76-93) at day 42 8 6 4 4 2 2 25 5 75 1 Days Barker J et al. 213 In Preparation
Goals of Ex Vivo Graft Manipulation 1. Augment Migration and Homing 2. Supplement Committed Progenitor Cell Content 3. Preserve or Increase Pleuripotent Stem Cell Numbers* Blood Endothelium Migration 1. Rolling 2. Integrin Activation 3. Arrest 4. Transendothelial Migration Homing & Retention Self renewal Differentiation Hematopoietic Stem Cell (HSC)
NiCord Cord Blood Expansion Technology NiCord active molecule; Nicotinamide (NAM) Vitamin B3 derivative Precursor of NAD Potent inhibitor of enzymes that utilize NAD as a cofactor Combined with stem cell early active cytokines TPO, IL-6, FLT-3 ligand, SCF Cultured in media containing FBS
Migration (%) No. of CD34 + cells NAM NAM Stimulates Augments the Migration Migration and Bone and BM Marrow Homing Homing Efficacy of Ex Vivo of Ex Vivo Expanded Expanded CD34 + Cells CD34 + Cells A Migration of CD34+ cells in response to SDF-1 5 *P <.2 **P =.5 B BM homing of CD34+ cells 18 15 *P <.1 * 4 ** * 12 9 2 6 3 Noncultured Cultured Cultured + NAM Noncultured Cultured Cultured + NAM B Mice transplanted with 1x1 6 cells/mouse Human progenitor cells (CFSE+CD34+) evaluated 24 hrs. post transplantation Peled T et al. Exp. Heme 212; 4: 342
Increased Engraftment Efficacy of HPC Expanded with Cytokines (Cyt) + NAM vs. Cyt only in SCID/NSG Mice % from human CD45 + cells About 1 fold increase in the number of SRC Limiting dilution experiments PB Myeloid and lymphoid reconstitution by NAM expanded HPC in NSG mice (12 weeks) 3 x 1 3 2 15 6 x 1 3 1 5 CD3 CD3/4 CD3/8 CD56 CD15 CD11 CD41 CD33 CD19
NiCord Cord Blood Expansion Technology Heat Map construct: clusters of genes differentially expressed in CD133 + cells expanded ±NAM for 3-weeks vs. non-cultured CD133 + cells
% from total cells CD34 NAM Mechanism of Action Sir2 enzymes are suggested as the primary target of NAM NAM (mm) EX527 (µm) NAM: Potent inhibitor of enzymes that utilize NAD as a co-factor. Sir2 (SIRT1-7): class-iii NAD-dependent histone-deacetylases. *EX527: Specific inhibitor of SIRT1 6 5 SDF-1 induced migration Inhibition of differentiation.2% 62% 53% Cyt 4 3 2 4.4% 22% 16% NAM 1 Cytokines only + NAM 2.5 mm +EX527 25 µm 3.4% 24% 15% EX527 CD38 CD14 CD11
NiCord Phase I/II Trial; Hematologic Malignancies Study Design Duke University Medical Center/Loyola University Adult patients with high risk hematological malignancies Myeloablative conditioning regimen Total body irradiation (135cGy) Fludarabine 16mg/m 2 Cyclophosphamide 12mg/kg (optional; n=2) Double cord configuration: NiCord + Unmanipulated unit GvHD prophylaxis: tacrolimus/mycophenolate mofetil Minimum pre-freeze TNC dose requirement NiCord unit; 1.5 x 1 7 /kg Unmanipulated unit of 2.5 x 1 7 /kg Outcomes compared to Duke Historical Controls
Patient and Graft Characteristics Characteristics Subjects n=11 Historical Controls n = 17 Age (years) Median 45 31 Range 21-61 23-55 Weight (kg) Median 83 77 Range 59-1 47-112 Diagnosis (%) AML or MDS 8 (73) 1 (58) ALL 1 (9) 4 (24) CML 1 (6) Lymphoma 2 (18) 2 (12) Disease status at time of transplantation (%) Complete remission First Remission 4(36) 2(12) Second or subsequent remission 3(28) 12(71) Active disease 4(36) 3(17) Preparative Regimen TBI 135cGy/Fludarabine 9 17 TBI 135cGy/Fludarabine/Cyclophosphamide 2 Donor-recipient HLA compatibility NiCord + Unmanipulated Unmanip. Unmanip. 6/6 + 6/6 1 5/6 + 6/6 1 2 5/6 + 5/6 1 1 4/6 + 5/6 2 5/6 + 4/6 1 6 4/6 + 4/6 6 7
NiCord Graft Processing and Transplantation Schema CD133+ Fraction CD133- Fraction II. NiCord non-cultured Fraction (NF) Day -21: cryopreserved I. NiCord cultured fraction (CF) Day -21: Cultured with cytokines (FLT3, SCF, TPO, IL-6) + Nicotinamide (2.5mM) in cultured bags for 21± 2 days Day : Cells harvested, safety and quality tested Hand delivery to clinical site (18hr stability) CONDITIONING: Day -9 to TRANSPLANTATION I. NiCord CF II. NiCord NF III. Unmanipulated CBU FOLLOW UP -21-14 -9-7 -4 MMF 6 18 Tacrolimus ARRIVAL OF NiCord NF TO CLINICAL SITE ARRIVAL OF NiCord CF TO CLINICAL SITE
CD34/kg (x1 6 ) TNC/kg (x1 7 ) TNC/kg (x1 7 ) Cell Dose Comparison Cryopreserved Cell Dose Infused Cell Dose A. B. 3 2.5 2 1.5 1.5.25.2.15.1.5 (1 9-4 3) Unmanipulated ( 3-23) p=ns p=ns Unmanipulated (1 7-3 8) NiCord (Pre-expansion) ( 5-34) NiCord (Preexpansion) C. CD3/kg (x1 6 ) CD34/kg (x1 6 ) E. 3.5 3 2.5 2 1.5 1.5 4 3 2 P=.3 (1 4-2 9) Unmanipulated (1 9-4 67) (1 49-7 87) NiCord Cultured + Negative Fractions D. 6 ( 9-18 3) 5 4 P<.1 3 2 1 ( 3 48) Unmanipulated NiCord Cultured Fraction P=.9 ( 49-5 81) (1-6 4) NiCord Cultured Fraction ( 28-1 47) NiCord Negative Fraction 1 Unmanipulated NiCord Negative Fraction
WBC NiCord Engraftment Shortens Hospitalization Avg. hospitalization days Patients engrafted with NiCord : 23.5 (Day 14 discharge) Patients engrafted with the unmanipulated CBU: 4 (Day 31 discharge) Duke control cohort (n=17) average 42.2 (Day 29 discharge) Rapid PB WBC Reconstitution in Patients Engrafted with NiCord 5. 4.5 4. 3.5 3. 2.5 2. 1.5 1..5. ANC>5 (median) ANC>5 (average) ANC>5 (median) NiCord engrafted (n=8) Unmanipulated engrafted (n=2) Duke controls (n=17) 1 2 3 4 5 6 7 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 Days post transplantation
Whole Blood Chimerism
Myeloid Chimerism
T-cell Chimerism
White Blood Cell Count Durable Myeloid Hematopoiesis 12 1 8 6 Neutrophil Engraftment (median day) NiCord; 11 Duke Controls; 25 P= 1 4 2 2 4 6 8 1 12 14 16 18 2 22 24 26 28 3 32 34 36 38 4 42 44 46 48 5 18 365 73 Days Following Transplantation NiCord engrafted (n=8) Unmanipulated engrafted (n=2) Duke controls (n=17)
Platelet Count (x 1 3 ) Durable Platelet Hematopoiesis 18 16 14 12 1 8 6 4 2 NiCord engrafted (n=7) Unmanipulated engrafted (n=2) Duke controls (n=17) Platelet Engraftment (median day) NiCord; 3 Duke Controls; 41 2 4 6 8 1 12 14 16 18 2 22 24 26 28 3 32 34 36 38 4 42 44 46 48 5 18 365 73 Days Following Transplantation
Lymphoid Immune Reconstitution
Summary of Clinical Data 11 patients have received NiCord - containing dual UCB transplantation Median follow-up 1 months NiCord expanded HSC s outcompeted unmanipulated HSC s in 8 of 11 recipients NiCord engraftment is stable, hematopoiesis robust NiCord engraftment shortens hematopoietic recovery (Historical Controls) Neutrophils >5 (mean days); 25 11 Platelets > 2K (mean days); 41 31 No adverse events attributable to NiCord infusion Immunologic recovery comparable to dual UCBT controls Grade I/II agvhd; 4 patients No patients experienced grade III/IV agvhd Limited chronic GvHD; n=2 2yr overall survival; 68% 2yr progression-free survival; 65%
Potential Impact of ex vivo UCB Stem Cell Expansion 54y/o 8kg male, high risk AML in 1 st complete remission. No matched siblings. Umbilical cord blood transplantation proposed NMDP Cord Blood Search #1 4/6 (HLA-A,B, DRB1) matched; TNC-2.4 x1 7 /kg #2 4/6 (HLA-A,B, DRB1) matched; TNC-2.1 x1 7 /kg #3 5/6 (HLA-A,B, DRB1) matched; TNC-1.6 x1 7 /kg Option 1 (Current Standard) Unit selection: #1+#2; #1+#3 Myeloablative Conditioning UCB unit costs GvHD Hospital stay Hematopoietic Recovery Blood Product Utilization - - Option 2 Unit selection; #3 (Expanded) Myeloablative Conditioning UCB unit costs GvHD Hospital stay Hematopoietic Recovery Blood Product Utilization
Conclusions 1. Results provided justification for use of NiCord as a single umbilical cord blood graft for transplantation of adults with hematologic malignancies 1. Results provide justification for use of NiCord for umbilical cord blood transplantation in patients with hemoglobinopathies
Acknowledgements Duke Adult BMT Program Nelson Chao Joanne Kurtzberg Gwynn Long David Rizzieri Cristina Gasparetto Keith Sullivan John Chute Carolyn McDonald Janet Adcock Jackie McPherson Barbara Waters-Pick Loyola BMT Program Patrick Stiff Gamida-Cell Ltd. Tony Peled David Snyder Einat Galamidi Mirit Dekel Orna Srur-Kidron Yael Karasik Emmes Corp. Steven Wease Laura Devillier