Stem Cells And The Future of Regenerative Medicine Dipnarine Maharaj, M. D., FACP The following potential conflict of interest relationships are germane to my presentation. Employment: South Florida Bone Marrow Stem Cell Transplant Institute Speakers Bureau: NA Stock Shareholder: NA Grant/Research Support: Daphne Seybolt Culpepper Memorial Foundation, Inc. Consultant: NA Status of FDA devices used for the material being presented NA Status of off-label use of devices, drugs or other materials that constitute the subject of this presentation NA
Stem Cells And The Future of Regenerative Medicine Dipnarine Maharaj, M. D., FACP Medical Director, South Florida Bone Marrow Stem Cell Transplant Institute
Stem Cells A stem cell is an unspecified cell that can both self-renew (reproduce itself) and differentiate into mature tissues such as heart, lung, liver,etc.
Major technologic Stem Cell Achievements 1961 Till and McCulloch: Unequivocal existence of Hemopoietic Stem Cells 1998 Thomson: Isolation of human embryonic stem cells 2006 Yamanaka: Induced pluripotent stem cells
Stem Cells Adult Stem Cells are collected from: Bone Marrow (bone marrow stem cells) Peripheral Blood (peripheral blood stem cells) Cord Blood (cord blood stem cells) Embryonic stem cells are collected from a fertilized egg or an embryo.
Stem Cells Embryonic stem cells are obtained from the inner cell mass of a blastocyst(4-5 days) Can form any of the 200 different types of tissues in the human body
Development of Human Embryonic Tissue
Current or Potential Embryonic Stem Cell Problems Difficult to establish and maintain Difficulty in obtaining pure cultures in the dish Potential for tumor formation and tissue destruction Questions regarding functional differentiation Problem of immune rejection Genomic instability Few and modest success in animals, no clinical treatments Ethically contentious
Stem cells Pluripotential Stem cells - Embryonic - Nuclear programmed - Induced Multipotent stem cells - eg.hemopoietic (Bone marrow,cord blood) - Mesenchymal
Major technologic Stem Cell Achievements 1961 Till and McCulloch: Unequivocal existence of Hemopoietic Stem Cells 1998 Thomson: Isolation of human embryonic stem cells 2006 Yamanaka: Induced pluripotent stem cells
Induction of Pluripotency: From Mouse to Human Turning Human Skin Cells into Stem Cells Holmes Zaehres and Hans R. Scholer Max Planck Institute for Molecular Biomedicine, Dept. of Cell and Developmental Biology, Munster, NRW 48149, Germany
What are the Roadblocks? Requirement for virus vectors means cells are genetically modified Mechanisms of reprogramming not understood Quality of reprogramming and functional implications Most appropriate sources for cells
Adult Stem Cells Adult stem cells are obtained from tissues after birth and the majority will differentiate into a narrower range of tissues. They exhibit plasticity and can repair the tissues of the body by replenishing specialised cells.
Current Treatments with Adult Stem Cells Since the 1960 s, adult stem cells have been used successfully to treat: - Blood cancers - Blood disorders - Disorders of the immune system This treatment is mainstream medicine today, providing curative protocols and extending lives
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Prognostic Groups Based on Cytogenetic Findings De novo AML in young patients Bloomfield ASH 2006 Favorable-Risk Group: Balanced structural rearrangements: t(15;17)(q22;q12-21) t(8:21)(q22;q22) inv(16)(p13q22)/t(16;16)(p13;q22) Intermediate-Risk Group: Normal karyotype (40 to 50%) Balanced structural rearrangements: t(9;11)(p22;q23) Unbalanced structural rearrangements: del(7q); del(9q); del(11q); del(20q) Numerical aberrations: Y, +8, +11, +21 Unfavorable-Risk Group: Complex karyotype (3 or more abnormalities) Balanced structural rearrangements: inv(3); t(6;9); t(6;11); t(11:19) Unbalanced structural rearrangements: del(5q) Numerical aberrations: 5, 7
Probability of Continuous Complete Remission of Previously Untreated Patients with AML According to Chromosomal Groups (Leukemia. 1995;9:1491-1498)
Hematopoietic Stem Cell Transplantation (HSCT) HSCT is a procedure in which progenitor cells, capable of reconstituting normal bone marrow function, are administered to a patient This procedure is often performed as part of a therapy to eliminate a bone marrow infiltrative process, such as leukemia, or to correct nonmalignant disorders
Hematopoietic Stem Cell Transplantation (HSCT) Allogeneic: donor & recipient are not genetically identical, but may be histocompatible Syngeneic: genetically identical individuals e.g. monozygotic twins Autologous: derived from recipient receiving graft
Types of Hematopoietic Stem Cell Transplantation Autologous transplants Allogeneic transplants: - HLA matched sibling - HLA matched unrelated donor - unmatched donors - cord blood transplants Mini allogeneic transplants
Common Indications for Allogeneic Transplantation Malignant Disorders: Nonmalignant Disorders: - Acute myelogenous leukemia (AML) - Aplastic anemia - Non-Hodgkin s lymphoma (NHL) - Thalassemia major - Hodgkin s disease - Severe combined - Acute lymphoblastic leukemia (ALL) immunodeficiency - Chronic myeloid leukemia (CML) - Myelodysplastic - Multiple myeloma (MM) syndromes - Chronic lymphocytic leukemia (CLL) - Sickle cell anemia
Common Indications for Autologous Transplantation Malignant Disorders: Nonmalignant Disorders: - Multiple myeloma - Autoimmune disorders - AML - Amyloidosis - NHL - Hodgkin s disease - Germ-cell tumors - Neuroblastoma
Adult Stem Cells Peripheral Blood Stem Cells are easier and less painful to collect than Bone Marrow Stem Cells. A Growth Factor Drug is administered prior to collection to stimulate the release of stem cells into the blood stream
Collection Process Peripheral Blood yields more Adult Stem Cells than Bone Marrow. The collection process is safe. An Apheresis machine is used and it takes about 3 hours (similar to platelet collection). The patient is able to read or watch TV during the entire process.
Indications for Hematopoietic Stem Cell Transplantation
Survival After BMT for Multiple Myeloma According to Donor Type
Survival Post Autologous BMT for AML According to Disease Status
Survival Post Allogeneic BMT for AML According to Disease Status
Survival Post Autologous BMT for High Grade NHL According to Disease Status
Survival Post Autologous BMT for Hodgkin s Lymphoma According to Disease Status
Survival Rates Post Autologous Transplantation (5-year Disease Free Survival) AML (1 st CR*) 40 % AML (2 nd CR*) 30 % AML Advanced 10 % Multiple myeloma 40 % High grade Non-Hodgkin s Lymphoma 50 % Hodgkin s Lymphoma (1 st CR*) 60 % *CR = Complete Remission Source: Latest data from the CIBMTR (www.marrow.org)
Survival Rates Post Allogeneic Transplantation (5-year Disease Free Survival) AML (1 st CR*) 55 % AML (2 nd CR*) 45 % AML advanced 20 % Multiple myeloma 35 % ALL (1 st CR*) 40 % ALL (2 nd CR*) 25 % Non-Hodgkin s Lymphoma 25% CML (chronic phase 1 st year) 68 % CML (chronic phase >1 st year) 53 % *CR = Complete Remission Source: Latest data from the CIBMTR (www.marrow.org)
Early lymphocyte recovery predicts superior survival after autologous hematopoietic stem cell transplantation in multiple myeloma or non-hodgkin lymphoma Figure 3. Overall survival of 104 patients with non-hodgkin lymphoma after ASCT as a function of ALC recovery at day 15. Median overall survival time for patients with an ALC less than 500 cells/µl was 6 months. For patients with an ALC greater than or equal to 500 cells/µl, the median overall survival has not been reached (P <.0001).
Early lymphocyte recovery predicts superior survival after autologous hematopoietic stem cell transplantation in multiple myeloma or non-hodgkin lymphoma Figure 4. Progression-free survival of 104 patients with non-hodgkin lymphoma after ASCT as a function of ALC recovery at day 15. Median progression-free survival for patients with an ALC less than 500 cells/µl was 4 months. For patients with an ALC greater than or equal to 500 cells/µl, the median progression-free survival has not been reached (P <.0001).
Figure 1 Early lymphocyte recovery predicts superior survival after autologous stem cell transplantation in non-hodgkin lymphoma: a prospective study (A)OS of patients with an ALC-15 500 cells/μl versus patients with an ALC-15 <500 cells/μl. The median OS was not reached in the group of patients with an ALC-15 500 cells/μl and in 5.4 months with the group of patients with an ALC-15 <500 cells/μl. The OS rates at 3 years were 80% and 37%, respectively (P <.0001). (B) PFS of patients with an ALC-15 500 cells/μl versus patients with an ALC- 15 <500 cells/μl. The median PFS was not reached in the group of patients with an ALC-15 500 cells/μl and in 3.3 months with the group of patients with an ALC-15 <500 cells/μl. The PFS rates at 3 years were 63% and 13%, respectively (P <.0001).
Figure 2 Early lymphocyte recovery predicts superior survival after autologous stem cell transplantation in non-hodgkin lymphoma: a prospective study Actuarial risk of relapse for ALC-15 lymphocyte subsets.
Figure 3 Early lymphocyte recovery predicts superior survival after autologous stem cell transplantation in non-hodgkin lymphoma: a prospective study (A) OS of patients with an NK-15 80 cells/μl versus patients with an NK-15 <80 cells/μl. The median OS was not reached in the group of patients with an NK-15 80 cells/μl and 5 months with the group of patients with an NK-15 <500 cells/μl. The OS rates at 3 years were 76% and 36%, respectively (P <.0001). (B) PFS of patients with an NK-15 80 cells/μl versus patients with an NK-15 <80 cells/μl. The median PFS was not reached in the group of patients with an NK-15 80 cells/μl and 3 months with the group of patients with an NK-15 <500 cells/μl. The OS rates at 3 years were 57% and 9%, respectively (P <.0001).
Early lymphocyte recovery after autologous stem cell transplantation predicts superior survival in mantle-cell lymphoma Overall survival for 42 patients with MCL after ASCT as a function of recovery of the absolute number of lymphocytes at day 15. Median OS for patients with ALC 500 cells/ l was not reached and median OS for patients with ALC <500 cells/ l was 30 months (P=0.01, log-rank test).
Early lymphocyte recovery after autologous stem cell transplantation predicts superior survival in mantle-cell lymphoma Progression-free survival for 42 patients with MCL after ASCT as a function of recovery of the absolute number of lymphocytes at day 15. Median OS for patients with ALC 500 cells/ l was not reached and median OS for patients with ALC <500 cells/ l was 16 months (P=0.0006, log-rank test).
Early Lymphocyte Recovery Predicts Superior Survival after Autologous Hematopoietic Stem Cell Transplantation for Patients with Primary Systemic Amyloidosis A, Kaplan-Meier estimates of OS of patients infused with an A-ALC 0.5 109 lymphocytes/kg versus patients infused with an A-ALC < 0.5 109 lymphocytes/kg post- ASCT in AL.
Prognostic Analysis of Early Lymphocyte Recovery in Patients with Advanced Breast Cancer Receiving High-Dose Chemotherapy with an Autologous Hematopoietic Progenitor Cell Transplant Effect of day +15 absolute lymphocyte count (ALC) on freedom from relapse of metastatic breast cancer patients per stem cell source.
Prognostic Analysis of Early Lymphocyte Recovery in Patients with Advanced Breast Cancer Receiving High-Dose Chemotherapy with an Autologous Hematopoietic Progenitor Cell Transplant Freedom from relapse (P = 0.0001; A) and overall survival (P = 0.007; B) in metastatic breast cancer patients with high (>1000/mm3), intermediate (300 1000/mm3), and low (<300/mm3) day +15 absolute lymphocyte count (ALC).
Early lymphocyte recovery is a predictive factor for prolonged survival after autologous hematopoietic stem cell transplantation for acute myelogenous leukemia Figure 1 Overall survival according to absolute lymphocyte recovery (ALC).
Early lymphocyte recovery is a predictive factor for prolonged survival after autologous hematopoietic stem cell transplantation for acute myelogenous leukemia Figure 2 Leukemia-free survival according to absolute lymphocyte recovery (ALC).
South Florida Bone Marrow Stem Cell Transplant Institute (SFBMSCTI) 1. Freestanding Outpatient Bone Marrow Stem Cell Transplant Center 2. JCAHO Accredited 3. American Association of Blood Banks Accreditation 4. FDA Registered
SFBMSCTI 1. Stem Cell transplants for blood cancers 2. High (HDC) and intermediate dose (Mob/IDC) chemotherapy 3. Evolving stem cell therapies for cardiac and neurological diseases 4. Immunotherapy for cancer
Why outpatient transplants? Significant decrease in hospital-acquired infections in patients who are severely immunosuppressed An improvement in other chemotherapyrelated toxicities
Relative Risk of Severe Sepsis in Hematological Tumors, Total Cancer Patients and Non-Cancer Patients 70 Williams et al. - Critical Care 2004, Vol 8: R291-R298 65.15 (63.95-66.36) 60 50 40 33.61 (32.87-34.38) 30 25.62 (21.5-30.6) 20 18.4 (17.97-18.84) 15.71 (15.55-15.88) 10 0 10.26 (10.08-10.44) Non- Hodgkins Lymphoma Lymphocytic Leukemia 4.07 (3.87-4.27) Hodgkin's Disease Multiple Myeloma Myeloid Leukemia Monocytic Leukemia Total Hematologic Tumor 1.81 (1.79-1.82) Total Solid Tumors 3.96 (3.94-3.99) Total Cancer Patients 1 Non-Cancer
SFBMTI Data Mob/IDC Cycles (n=83) % 100 90 80 70 60 50 40 30 20 10 0 Stomatitis and Infection (%) 17% 6% Stomatitis 0% 0% 1% 6% 7% Infection 0% Grade 0/1 2 3 4
SFBMTI Data HDC Cycles (n=102) % 100 90 80 70 60 50 40 30 20 10 0 Stomatitis and Infection (%) 20% 8% Stomatitis 4% 0% 1% 7% 9% Infection 1% Grade 0/1 2 3 4
SFBMTI Data Total Cycles (n=102) % 100 90 80 70 60 50 40 30 20 10 0 Nausea and Vomiting (%) 29% 22% 9% Nausea 1% 14% 14% Vomiting 4% 1% Grade 0/1 2 3 4
Outpatient stem cell transplants Reduce the incidence of infections and the risk of sepsis Proactive interventions decreases the toxicities associated with high dose chemotherapy: Hand washing is strictly adhered Prophylactic medications to prevent the known toxicities Early intervention and treatment to prevent hospitalization The same healthcare professionals through all phases of treatment Decreases or eliminates complications and the need for multiple consultant physicians and staff attending Psychologically, patients do better The patient satisfaction is high
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Private Stem Cell Banking Likelihood of need is greater than previously reported of 1 in 2700 Recent report by Horowitz et al (2007) showed lifetime probabilty of undergoing hemopoietic stem cell transplantation is 1 in 200 to 1 in 400
Private Stem Cell Banking Cell source for gene therapy of cancers and other diseases including genetic disorders at biological age when cells were collected and stored.
Stem Cells for Cardiac Repair
Addressing the Needs of Stem Cell Therapies Neurological Disorders: Parkinson s Stroke Spinal Cord Injury
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Stem Cells for Diabetes Mellitus
Pathogenesis Insulin Resistance and pancreatic Beta- Cell defects: Increased apoptosis due to glucotoxicity and lipotoxicity. Increased oxidative stress and inflammation.
Several new therapies in the last 10 years but complication rates in Diabetes Mellitus have not decreased. and Optimal glycemic control is still elusive.
Autologous Stem Cell Therapies for Diabetes Mellitus Emerging therapies with promising results and low side effect profiles. Easily accessible and avoid histocompatability issues.
Newer Therapies Which: A. Prevent B-cell damage and or lead to B- cell regeneration. B. Achievable life style changes which prevent or ameliorate DM. C. Decrease the incidence and progression of chronic complications. D. Improve the general health and quality of life of patients with DM.
Hyperbaric oxygen chamber
STEM CELL MOBILIZATION
U.S. Patent Application No. 1612-2U US Utility Patent for TREATMENT OF DIABETES USING G- CSF AND HYPERBARIC OXYGEN Inventor: Dipnarine Maharaj
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Conclusions 1. Stem cell therapy - an established indication which is being performed on a totally outpatient basis in a free-standing facility 2. Stem cell therapy for chronic diseases 3. Stem cell therapy for future use