Mesenchymal stromal cells (MSC) therapyfor the regeneration of radio-induced proctitis“from bench to bedside”
CONRAD 2013, MunichMay 13-16, 2013
1- Abdomino-pelvic radiotherapy50% of patients (90 000/year)cervix, endometrium, prostate, rectum, …
3- Clinical manifestations of RT side effects Early response
80% of patients Affects the quality of life (abdominal pain,
diarrhoea/constipation, malabsorption,…) Affects the therapeutic efficacy
Late response3 to 5% of patients (5 years) More severe pathologies (fibro-necrosis, fistula, haemorrhage,
bowel obstruction, …) : Pelvic Radiation DiseaseSignificant clinical impact : chronicity, morbidity, mortality
2- Organ at risk in the irradiation field small intestine, colon, rectum, blabber
OAR=
rectum
Prostateadenocarcinoma
=target volume
Abdomino-pelvic radiotherapy
CONRAD 2013, Munich, May 13-16, 2013
Clincialconsequences
Epinal Radiotherapy Accident (2004-2005)
• Accident linked to errors in the treatment process
• 425 patients treated for a prostate adenocarcinoma (IMRT)received an excess of dose (8-20%)
• 24 patients with great anatomic and physiologic dilapidations
•Beyond any conventional therapy (Corticotherapy, Pentoclo)
• Stem cell therapy as an alternative treatment option !
•Expected benefit : Limitation of rectal bleeding – pain -inflammation
Existingtherapeutic
options
CONRAD 2013, Munich, May 13-16, 2013
MSC and clinical trials
SkinLataillade et al. 2007
ArthrosisGrande et al. 1995
Intestine Crohn diseaseGarcia Olmo et al. 2005
GVHDLeblanc et al. 2004Noch et al. 2007
TendonYoung et al. 2005
HeartWang et al. 2000Katritsis et al. 2000
Bone marrow microenvironnement Fouillard et al. 2008
CartilageWakita et al. 2002
Bone reconstruction Bruder et al. 1994Haynesworth et al. 1992
BrainKin et al. 2008
CONRAD 2013, Munich, May 13-16, 2013
DW Fink Jr, Science (2009) 324; 1662-1663 “ FDA regulation of stem sell-based products”
Risk assessment of stem cell-based products
CONRAD 2013, Munich, May 13-16, 2013
Repetitive systemic
injections of MSC
ratMSC
culture
7 days
Rat SD
(2cmx3cm)colorectal
27 Gy (60Co)
IRC
Therapeutic benefit of Mesenchymal stromal cells in rodent models
BM-MNC collection
stem cell production(IRSN)
Safety assurance(Sterility, cell count, CFU-
F,cell growth kinetics, differentiation potential,
purity : phenotype karyotype)
0
0,5
1
1,5
2
2,5
IR IR+CSM
Scor
e cl
iniq
ue P<0.05
CSM increase the healing of radio-induced bowel
ulceration and reverse bowel obstruction
CONRAD 2013, Munich, May 13-16, 2013
IR+CSM
Ulcerated areaMargin area
0,0
0,5
1,0
1,5
2,0
2,5
IR IR + MSC
Lesi
on s
core
(α-
SMA
)
** **
IR
C
IR+CSM
T
IR
IR+MSC
Cch10-6 M
p<0.05
NS
Tonu
s (%
Kcl
)Cch concentration(Ach non selective agonist)
EC50C : 3.4 10-6 MIrr: 7.7 10-6 M
Irr +MSC: 3.6 10-6 M
1e-9 1e-8 1e-7 1e-6 1e-5 1e-4 1e-30
50
100
150
200
Control IrradiationIrradiation + MSC
Therapeutic benefit of Mesenchymal stem cells in rodent models (SD rat model)
MSC improve muscle regeneration and increase circularsmooth muscle contractibility. MSC reduce the process ofradiation-induced pseudo-obstruction
CONRAD 2013, Munich, May 13-16, 2013
MSC detection in the sub-mucosa (microvasculature proximity)
Muscularis mucosa
CONRAD 2013, Munich, May 13-16, 2013
9/20
T lymphocyte regulation by MSC
CSM
T regulator cells IDO
PGE2TGFβ
sHLA-G5
IDO
IL-10
sHLA-G5
PGE2
Lymphocyte T8+
ProliferationCytotoxicity
CONRAD 2013, Munich, May 13-16, 2013
PGE2HLA-G
TGFβIDO
Lymphocyte T4+
ProliferationPolarisationTh1, Th2, Th17
HGF
iNOS
HOI
• MSC induceMucosal wound healingMuscle regeneration/contractibilityReduce pseudo-obstruction
• Selective MSC implantation in the irradiated area
Low differentiation capacityLow proliferation capacityParacrine effect (inflammationmodulation, anti-fibrotic, pro-angiogenic)
“Cell drug”•Clinical protocolsOptimal MSC concentration : 2.106kg-1
Repetitive injection>single injectionPreventive injection = curative injectionFrozen CSM ≤ fresh CSM
Mechanismp<0.05
NS
Tonu
s (%
Kcl
)
Cch concentration(Ach non selective agonist)
EC50C : 3.4 10-6 MIrr: 7.7 10-6
MIrr +MSC: 3.6
10-6 M
1e-9 1e-8 1e-7 1e-6 1e-5 1e-4 1e-30
50
100
150
200
Control IrradiationIrradiation + MSC
Proliferation
non regenerativeulcerative lesion
IR + MSC
NIAID-IRSN meeting - March 28th, 2013
IV mpMSCinjection
mpMSC culture
BM-MNC collection
10 days
stem cell production(IRSN-CTSA)
From bench to bedside
NIAID-IRSN meeting - March 28th, 2013
Irradiated 3 injectionsControl
Safety assurance(Sterility, cell count, CFU-
F,cell growth kinetics, differentiation potential,
purity : phenotype karyotype)
•MSC genetic transformation during the culture process ?
•MSC effect on carcinogenesis ?
Potentialside effects
link toMSC injection
Pro‐tumour effect Anti‐tumour effect
CONRAD 2013, Munich, May 13-16, 2013
Colorectal carcinogenesis
chemical induction
(MNNG instillation)
Tumor induction
ACF: Aberrant Crytpt Foci and tumour
N-Méthyl-N’-Nitro-N-Nitrosoguanidine
Potential side effects of MSC
CONRAD 2013, Munich, May 13-16, 2013
GFP-MSC
IV MSCinjection
MSC culture
BM-MNC collection
10 days
stem cell unit(CTSA-Percy hospital)
Compassionate clinical treatment with MSC injection for 4 patients from Epinal
CONRAD 2013, Munich, May 13-16, 2013
Safety assurance(Sterility, cell count,
CFU-F,cell growth kinetics, differentiation
potential, purity : phenotype karyotype)
• Patient selection : rectitis (grade III/IV, CTCAE v0.3 scale) with painful necrotic lesion and bleedingcompatible donor in the familyexclusion of patient with prostate recurrence
• Injection protocol : single IV (2.106 MSC/kg)allogenic
• AFFSAPS authorisation for 3 first +1 patients
• Clinical benefit : Excellent tolerance, absence of side effectsPain disappear rapidlyBleeding was stopDiarrhea frequency was reducedPelvic necrosis was stabilizedQuality of life was ameliorated
Compassionate clinical treatment with MSC injection for 4 patients from Epinal
CONRAD 2013, Munich, May 13-16, 2013
‐ 3 months after transplantation of MSC there is a change in the frequencies of bleeding per week.
‐ 28 % of frequencies are greater than or equal to 0.27 and 72 % are less than 0.27.
After MSC injections, frequencies of bleeding were strongly reduced
‐3 months after transplantation of MSC there is a change in the frequencies of Normal
Feces per week.
‐50 % of frequencies are greater than or equal to 3 and 50% are less than 3.
After MSC injections, frequencies of diarrhea were strongly reduced
What is the effect of MSC infusions?
CONRAD 2013, Munich, May 13-16, 2013
•Treatment of radiotherapy side effects A medical alternative for the overdosed patient from Epinal! Compassionnal situation for 3+1 patients from the Epinal
accident.
•Towards a phase II clinical trial
Clinicalproof
of concept
CONRAD 2013, Munich, May 13-16, 2013
Essai thérapeutique de phase II évaluant l’efficacité de l’injection de Cellules StromalesMésenchymateuses (CSM) sur la symptomatologie de complications radiques abdomino-pelviennes,après échec des thérapeutiques conventionnelles
PRISM (Pelvic Radiotherapy-Induced Syndrom and Mesenchymal stem cells) Efficacité de l’injection de CSM sur les complications radiques abdomino-pelviennes
PRISME
•Institute of Radioprotection and Nuclear Safety
•Hospitals- Saint Antoine public hospital (APHP, Paris), Hematology
department, Dr J Voswinkel, Pr NC Gorin
- La Pitié Salpetrière public hospital (APHP, Paris) Oncology
Department, Dr JM Simon
- Percy military hospital (HIA, Clamart), Department of
Hematology, Pr T De Revel
- Percy military hospital (HIA, Clamart), Plastic surgery
Department, Pr E Bey
- Blood transfusion military center (CTSA, Clamart) Cellular
therapy unit, Pr JJ Lataillade
- Institut Gustave Roussy (IGR), Radiotherapy department,
Pr E Deutsch
•International Institution- WHO, (Geneva), Dr Z Carr
- IAEA-IEC, (Vienna), Dr E Buglova
Clinicalnetwork
CONRAD 2013, Munich, May 13-16, 2013