Post on 22-Aug-2019
1998
Año 2000: El año de las células madre
Terapia Celular y Medicina Regenerativa
• Curar con células
• Regenerar órganos y funciones
¿Qué son las células madre?
• Son células capaces de dividirse indefinidamente y diferenciarse en otros tipos de células especializados (reproducción asimétrica)
¿Qué son las células madre?
Stem cells
• Stem cells are cells that either self-renew by mitotic division or continue the differentiation pathway for which they have been programmed; thus, producing more adult functional tissues, perfectly differentiated according to their multipotential level
¿Dónde encontrar células madre?
En el blastocisto embrionario
Problemas para el uso clínico de células madre embrionarias
• Capacidad de inducción de tumores (Teratomas malignos)
• Rechazo (diferencias en los antígenos de histocompatibilidad entre embrión y receptor)
• Necesidad de inmunosupresión o “clonación terapétutica” (transferencia nuclear)
• Necesaria mucha tecnología (más costos) para el manejo
¿Dónde encontrar células madre?
En el tejido fetal/cordón umbilical
En el blastocisto embrionario
Cord Blood Stem Cells
¿Dónde encontrar células madre?
En el tejido fetal/cordón umbilical
En el blastocisto embrionario
En el Adulto
Stem Cells in adults!
• Bone Marrow
• Blood
• Cornea
• Retina
• Brain
• Muscle
• Liver
• Skin
• Pancreas
• GI tract
• Fat
• ….
▪ Adult SC found in almost every organ
▪ Limited proliferative and differentiation potential
▪ Not always functional in vivo
▪ No teratomas
▪ Autologous transplantation
A. Proliferation/Self renewal
C. Repopulatingin vivo capacity
WB
C
XRT
B. Multilineage differentiation
Garcia Verdugo, Nature 2004
Multipotent Stem Cells(Adult Stem Cells)
Fibroblastoratón/humano
Célula Pluripotente inducida (iPS)
Línea celular empaquetadoraproductora de retrovirus
Infección retroviral
Oct4, Sox2, Klf4, Myc
Células Madre Inducidas (iPS) Año 2006
The Nobel Prize in Physiology or Medicine 2012Shinya Yamanaka
Daño cerebralDefectos en aprendizaje
IctusAlzheimer Parkinson
Parkinson
Cicatrización de heridas
Trasplante de médula ósea
(protocolos ya aplicados)
Lesión médula espinal
Artritis reumatoide
Osteoartritis
Reemplazamiento óseo
Enfermedad de Chron
Cáncer
Diabetes
Distrofiamuscular
Infarto demiocardio
Esclerosis lateral amiotrófica
Sordera
Ceguera
Alopecia
Aplicaciones de la Terapia Celular
Directivas comunitarias (BOE 12 de diciembre de 2003) sobre medicamentos de terapia celular somática de origen humano
Nuevas normas para ensayos clínicos en los que ya se contemplan los ensayos clínicos con medicamentos de terapia celular somática (BOE 7 de febrero de 2004)
Real Decreto 176/2004 (B.O.E. 31/01/04) en el que se aprueba el Estatuto del Centro Nacional de Transplantes y Medicina Regenerativa
Células = Medicamento
Medicamentos de Terapias Avanzadas
Clinical Trial Process
Ensayos clínicos en terapia celular (clinicaltrials.gov- July’2016)
0
1000
2000
3000
4000
5000
60002004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Ensayos
Clinical trials using Stem Cells
(clinicaltrials.gov)
SPAIN: 223
698
986
209
0 200 400 600 800 1000 1200
phase I
Phase II
Phase III
Clinical trials using Stem Cells
Open Studies:2033 (July’2016)
Phase III Completed Studies
28
Bioseguridad y resultyados:
30
Cell Therapy clinical trialsTherapeutic areas (Non hematopoietic cells)
• Taking into account cells different from hematopoietic cells
Source: Clinical trials.gov. Companies web pages
CSC
MSC
Acute and chronic MI
MIOBLASTOS
ESC/iPS
MO ADSC
Stem Cells with Cardiac Potential
Cell Types
– BM, Adipose cells, SkM, EPC, Cardiac Progenitors
Manufacturing
– Culture, isolation, differentiation
Disease
– Acute and Chronic MI
Delivery of the cells
– Intracoronary, percutaneous, surgical
Clinical Studies
Clinical Studies
Nat Med. 2008; 14:213-21
Building a heart
TCP-β
PRP carrier celular
preop postop 7m 11m
Tratamientos de las lesiones focales: trasplante de condrocitos autólogos
Agentes etiológicos
Primarios
Hereditarios:
Aniridia, Stevens-Johnson
Neoplásicos:
Neoplasia intraepitelial
Degenerativos:
Pterigion recidivante
Secundarios
Físicos: Ácidos, agresión térmica,
Traumatismos
Anoxia: Lentes de contacto
Inflamaciones crónicas
Lesiones Corneales
Tratamiento
1. Restaurar la defensa de la superficie ocular
2. Transplante autológo de limbo
3. Transplante alogénicode limbo
4. Transplante de membrana amniótica
5. Transplante autólogo de células progenitoras
Tratamiento
Trasplante de CM Limbocorneales
Futuro: Cornea Artificial
Progenitores en la insuficiencia hepática aguda
Nature, July 2013 ORGANOIDES
Spinal Cord Injury: 127 Studies
Potential applications of ASCs
Our choice: Wound HealingBy Courtesy of Prof. Castellanos Escrig
Revolutions in Surgery 1846-1982
1982 . Cyclosporin A
Healing Control: a pending revolution
…Healing is a “cell-based” process
May a stem-cells supplement improve healing?
Stem Cells from Adipose TissueAdvantages
Adipose derived mesenchymal stem cells:
• Higher yield (between 100 and 1000 times higher yield than bone marrow)• BM stimulation is not required (G-CSF)
• Expendable and accessible: Simple liposuction• Biosafety: No chromosomal alterations/ tumorigenic behavior after long term ex vivo
cultures• Wide range of potential applications
52
2003 heart
2001 Grasa
1999 brain
1993 Muscle
Hematopoetic (bone marrow) 1986
1990 Intestine
1992Liver
1993Skin
1999Mesenchymal cells (bone marrow)
2001MAPC (bone marrow)
2003Pancreas
Adipose tissue
Cells extraction by liposuction
• Local anaestesia.(mepivacaina al 1%)
• Little incisión (0,5 cm.)
• Aesthetical value
Technologies involved in Adipose Derived Stem Cells (ASC) Therapy
ASC Implant
ASC Obtention
Liposuction isolation
Cryopreservation
In vitro culture
Cell expansion
ASC manipulation
Master CellBank
Clinical Trials on Stem Cells for fistulae
"The long and winding road" from the bench to the bedside.
An unmet medical need!
• INCONTINENCE• RECURRENCE
Why using Stem-Cells to treat Fistula?
The fistula Dilemma
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof ofConcept
Phase I
Phase II
Phase III207 cases
20 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
Autologous
Allogenic
278 cases
ADMIRE 30 centers
80 cases
5 centersFISPACX
10 casesRVF
1 center
10 casesULTRA1 center
1 case1 center
10 casesEntero-Cut
1 center
ADMIRE II
58
2002 2003 2004 2005 2006 2007 2008 2009 2010
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof of Concept
Phase I
Phase II
Phase III207 cases
10 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
OngoingCompleted
Autologous Allogenic
59
Clinical Proof of ConceptSuccessful cell treatment of a young woman with a recurrent recto-vaginal Crohn’s fistula unresponsive to medical treatment
60
2002 2003 2004 2005 2006 2007 2008 2009 2010
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof of Concept
Phase I
Phase II
Phase III207 cases
10 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
OngoingCompleted
Autologous Allogenic
61
Phase I clinical trial
TRIAL SUMMARY
Trial Location La Paz Hospital, Madrid
Start April 2002
Enrollment 5 patients (total of 8 fistulas)
Design Open Label; Feasibility / Safety Study
Administration Intralesional use
Duration First evaluation of endpoint: 8 weeks
Controlled No
Endpoint Complete closure/healing of the fistula clinically assessed
Results 75% success
Fistula closure
Phase I Patients Treatments Rejection Complete Partial
n 5 8 0 6 2
NO SEVERE ADVERSE EVENTSNO TUMOROGENIC EVENTS
62
2002 2003 2004 2005 2006 2007 2008 2009 2010
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof of Concept
Phase I
Phase II
Phase III207 cases
10 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
OngoingCompleted
Autologous Allogenic
63
Phase II clinical trial Design
Experimental Treatment Group
Cx401 + Fibrin glue
Control GroupFibrin glue
Randomise
25 patients 25 patients
50 patients
Primary Outcome
Secondary Outcome
24 patients (ITT) 25 patients (ITT)
Experimental Treatment Group Cx401 + Fibrin glue
Control GroupFibrin glue
❖ Cell inyection: ½ cell dose in the fistula wall
❖½ cell dose in internal opening
❖ Internal opening closure
❖ Tract identification
❖ Curetage
❖ Tract sealant
Administration of Adipose Derived Stem Cells was effective in inducing healing in patients with complex fistula-in-ano including Crohn’s disease, and this procedure can be considered safe
70%
70%
85%
• Phase 1: Screening for safety
• Phase 2: Establishing the efficacy of the drug, usually against a placebo
• Phase 3: Final confirmation of safety and efficacy
• Phase 4: Sentry studies during sales
Designing a Clinical Trial Process
70
2002 2003 2004 2005 2006 2007 2008 2009 2010
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof of Concept
Phase I
Phase II
Phase III207 cases
10 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
OngoingCompleted
Autologous Allogenic
Page ▪ 71
FATT1 Non-Crohn Population Efficacy 24 weeks COMMITTEE
All cases
0
10
20
30
40
50
A (Cells Alone) B (Cells+FibrinGlue) C (FibrinGlue)
No statistical significance
Efficacy 24 weeks COMITTEE
0
10
20
30
40
50
60
70
80
90
A (Cells Alone) B (Cells+FibrinGlue) C (FibrinGlue)
All Cases
La Paz
Others
Why?P<0.0001
Patient distribution by “Complexity Score” and center (Median)
4
5
6
7
8
9
La Paz Others
P<0.001
Design Error
Efficacy 24 weeks COMITTEE
0
10
20
30
40
50
60
70
80
90
A (Cells Alone) B (Cells+FibrinGlue) C (FibrinGlue)
All
La Paz
Others
Why?
Technical survey
We detect a large numbers of mistakes during the surgical procedure in “others hospitals”: use of hydrogen peroxide (H2O2), cell shake, cells spilling..
• This is a “Living medicament” and hence a careful management is a key point.
What have we learned?
Clinical Trials Peculiarities in Cell Therapy
What have we learned?
Clinical Trials Peculiarities in Cell Therapy
• Surgical procedure for Cell delivering :• Enviroment
• Aggressiveness
• Scrub
• Needle
• …
Long Term Efficacy (Fistula Closed)
0
10
20
30
40
50
60
A (Cells Alone) B (Cells+Fibrin Glue) C (Fibrin Glue)
FATT1
LTS (PP, begining)
LTS (PP, 24 w)
No statistical significance
“Living medicament”
GARNET CURVE
Our Sponsor lost the interest in autologous ADSCs
81
2002 2003 2004 2005 2006 2007 2008 2009 2010
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof of Concept
Phase I
Phase II
Phase III207 cases
10 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
OngoingCompleted
Autologous AllogenicX
Allogenic Use Cells Bank
MSCsOther cell types
Surface antigens • High levels of MHC I (HLA-A, B, C)• MHC II: depending on cell type• Co-stimulatory molecules
• Depending on cell type
• CD55 and CD59: depending on cell type
Other Factors• Lack of IDO induction
Surface antigens• Low levels of Mayor
Histocompatibility Complex Class I (HLA-A, B, C)
• Lack of Mayor Histocompatibility Complex Class II (HLA-DR, DQ, DP)
• Lack of co-stimulatory molecules • CD40 (TNFR), CD80 (B7-1), CD86
(B7-2)• High levels of CD55 (DAF) and CD59
(Protectin) => protectors of complement associated lysis
Other Factors• Strong IDO induction
Immunogenicity (ADSCs/Mesenchymal)Privileged Cells
Allogenic ASCs Multicenter Phase I/IIa Study to assess
the safety and Efficacy of Expanded Allogenic Adipose-Derived Stem Cells (eASCs), for treatment of Complex Perianal Fistulas in Crohn’sDisease.
Starting: December 2009
Results: December 2011
CX601
84
63,2
36,8
46,753,3
0
10
20
30
40
50
60
70
80
90
100
perc
enta
ges
After 12 weeks After 24 weeks
None One
Percentage of subjects in whom at 12 and 24 weeks the external openings of treated perianal fistula have closed – Per Protocol set
N=19 N=15
7 8
12
7
Allogenic ASCs A Phase I/IIa Study to assess the safety
and Efficacy of Expanded AllogenicAdipose-Derived Stem Cells (eASCs), for treatment of Recto-Vaginal Fistulas in Crohn’s Disease.
Starting: December 2009
Results: December 2011
CX601
86
Percentage of woman in whom at first doses and second doses the recto vaginal wall have closed – Per Protocol set
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
1 case1 center
8 cases1 center
ASC Clinical Development in fistula
50 cases3 centers
Preclinical
Proof ofConcept
Phase I
Phase II
Phase III207 cases
20 centersFATT1
210 cases
22 centersFATT2
24 cases
3 centersCX601
10 cases
1 centerRVGF
Autologous
Allogenic
278 cases
ADMIRE 30 centers
X
1 case1 center
• Products: Cx-601.
• Source: Adipose Derived Stem Cells (mesenchymals)
• Use: Allogenic
• Via: Intralesional
• Doses: 120 millions of cells
52 Centers at 8 Countries
“Living medicament”
Mesenchymal stem cells for fistula treatment is the first application of cell therapy that completed a whole course of clinical trials…
First in Human; A successful Phase III Clinical Trial in the field of Cell Therapy
2002-2016
Clinical Trial Process according to FDA
2002-2016
What we need to do in order to improve?
• Safety Profile Excellent
• DOSE INCREASE
• Cell Mortality• IMPROVING METHODS FOR DELIVERING
• Soft effects• CELL INGENIERING
• CELL EMPOWERING (FUCOSILACION, BMPs, SCAFFOLDS…)
NEXT GENERATION( Cells 2.0)
NEXT GENERATION( Cells 2.0)
• Cell transplantation to overcome healing problems seems to be a new surgical tool and careful evaluation of this new modality might provide an opportunity to define a new era in the treatment of surgical challenges associated with healing disorders.
Look to the future…
Biocirugía