Cord blood transplant : current results and future developments

Transcription

1 Cord blood transplant : current results and future developments 8th International Donor Registries conference Shirley Nolan Memorial lecture Dublin June 2010 Hematopoietic reconstitution in a patient with Fanconi's anemia by means of umbilical cord blood from an HLAidentical sibling Gluckman E, Broxmeyer HE, Auerbach AD, Freidman HS, Douglas GW, Devergie A, Esperou H, Thierry D, Socié G, Lehn P, Cooper S, English D, Kurtzberg J, Bard J, Boyse EA. N Engl J Med 1989;321:

2 Twenty years later

3 Past and Present of Cord Blood Transplants 1988 First Cord blood transplant Clinical observation that GVHD was reduced in HLA incompatible CBT Establishment of Cord blood banks Feasibility of HLA incompatible unrelated cord blood transplants 1995 Establishment of Eurocord group 1997 Nucleated cell dose more important factor for engraftment and survival, influence of HLA on engraftment 1998 Large series of UCBT = confirmation of cell dose and HLA >2000 Retrospective comparisons between UBMT and UCBT 2002 Use of cord blood cells in adults with promising results 2003 Criteria of cord blood choice and indications 2004 Use of double cord and RIC regimen in adults Isolation of USSC from umbilical cord blood Comparable results between unrelated CBT and UBMT in adults 2006 More adults than children transplanted with cord blood cells Allele matched UBMT compared to UCBT 2009 Research on regenerative medicine Stem cells in cord blood Cord blood cells have been shown to contain a high number of hematopoietic stem cells that can be used for allogeneic transplant to treat a large variety of hematopoietic disorders Cord blood contains also non hematopoietic stem cells which might be used in the future for tissue or organ replacement

4 Differences of stem cells sources Composition Enrichment in immature stem cells which can differentiate in a large variety of stem cells Quality Younger cells have a higher capacity of engraftment and live longer, they give less immune adverse reactions Characteristics of cord blood hematopoietic stem cells High number of immature progenitors Higher clonogenicity Higher expansion potential Longer telomeres Higher gene transfection rate Different cytokines and growth factors requirement

5 Immunology of cord blood Naivete Immaturity Decreased cytokine production Suppression Consequence Less graft versus host disease Possibility of using HLA mismatched donors Cord blood transplant : progress Development of cord blood banks Criteria of donor choice based on number of cells and not on HLA Comparison with other stem cell source similar results despite HLA incompatibility New methods for graft facilitation New indications for cord blood use

6 Cord blood banks development Easy access Immediate use Can be stored for years Tested for infectious markers and HLA Absence of ethical problems Collection Miniaturisation Standard procedures Accreditation

7 Development of public cord blood banks Figure 2: Total Number of cord blood units available for transplantation Better selection of patients and timing of transplant. Improvement of clinical protocols Better selection of CB units (HLA and NC) Increase on High Quality CB units availability More than units stored and more than units transplanted WMDA 2009 Number of cord blood units (x thousand) Number of cord blood units ,000 2,750 2,500 2,250 2,000 1,750 1,500 1,250 1, Year Figure 2: Number of cord blood units provided for unrelated transplantation Year 1,126 1,791 2,086 2,743 2,825 units provided EUROCORD Number of CBT by year reported to Eurocord Unrelated CBT according to recipient age by year Related n=596 Unrelated n=6140 Children n=3287 Adults n=2770 * * *Still collecting data

8 EUROCORD Double UR CBT/ year n=1080 Reduced intensity Conditioning before UR CBT/year n=1516 * * *Still collecting data Number of CB tranplants per country

9 Origin of cord blood units Indications of CBT in Eurocord database Malignant n=4944 Non malignant n=1647

10 What did we learn from the clinical studies Engraftment is delayed and depends on number of CD34+ cells in the graft optimal dose >2x10 5 /kg GVH is reduced GVL is functional Immune reconstitution is delayed Long term survival is improved because of the better quality of hematologic and immunologic reconstitution Single CBT - children 5.6 5% 5.7

11 Progress in cord blood transplantation Overall survival (children with malignant disease) n= 276 2y OS 42±3% n= 234 2y OS 43±3% n= 347 2y OS 43±3% n= 459 2y OS 47±3% Single CBT - adults 12%

12 Overall survival after UCBT in adults by period of transplantation N=414 42% N= % N= % N=41 20%

13 Neutrophil recovery after single UCBT for patients with malignant disorders after myeloablative conditioning regimen 1,0 > 2 x10 7 /kg (n=278) 88%,8,6 < 2 x10 7 /kg (n=1349) 85%,4,2 P=0.05 0, *'+,"% "" -./!" # $ "! % & '()"

14 Transplant related mortality Role of HLA and cell dose!!! UCBT malignant disorders (n=925) Relapse according to number of HLA CI of Relapse p= or 1 HLA mismatch 2 or 3 HLA mismatches Months

15 UCBT malignant disorders (n=925) Disease-free survival according to number of HLA & '()( "## ( ( ( $ % Role of HLA in unrelated cord blood transplant Delayed hematological reconstitution Decreased risk of acute and chronic GVHD Delayed immune reconstitution Increased graft versus leukemia effect No effect on long term survival in malignant diseases Better survival with HLA matches in non malignant diseases

16 Criteria of donor choice 1. First look at the number of cells in MAC, RIC, single and double CBT : >2.5x10 7 NC/kg and or>1.5x10 5 CD34+/kg Infused >2.0x10 7 NC/kg 2. Second look at HLA matches 0-1 mm better than 2 avoid 3-4 mm Prefer class I mismatches than class II (does not matter in advanced phase of disease?) If no choice increase the number of cells It seems that in double CBT number of HLA disparities and ABO compatibility is also important 3. Then adapt to graft indication Malignant diseases: cell dose is the best prognostic factor because HLA differences reduce relapse (GVL) Non malignant diseases: increase cell dose (>4.0x10 7 NC/kg ) and find the best HLA match. Search for antibodies against HLA Summary of clinical results in hematology Outcomes after UCBT in children and mainly in adults have improved in the last 4 years Cell dose is the major factor for outcomes in children and adults. Delayed engraftment and early increased mortality are associated with higher number of HLA disparities: need to increase the donor pool Other modifiable factors such as conditioning regimen and GVHD prophylaxis can improve outcomes

17 Comparison with other sources of stem cells Unrelated matched unrelated adult bone marrow donor versus mismatched unrelated cord blood Estimate number of patients with an indication of an allogeneic hematopoietic stem cell transplants Haplo Cord Blood 27% 40% 30% 3% HLA identical sibling donor Related 1 HLA incompatible Unrelated BM or PB donor (9 or 10 out of 10) no donor

18 UCBT vs UBMT for Children with AL Multivariate analysis of early outcomes Adjusted Relative Risk 2,5 2 1,5 1 0,5 NS NS p<0.001 p<0.001 p<0.001 p=0.01 NS p=0.02 NS UBMT T-UBMT UCBT 0 Neutrophil recovery Platelets recovery Acute GVHD 100 day TRM Early Relapse V Rocha Blood 2001 UCBT vs UBMT for Children with AL Adjusted Relative Risk 1,4 1,2 1 0,8 0,6 0,4 Multivariate analysis of long term outcomes (patients surviving after day 100) p<0.001 NS p=0.07 NS UBMT T-UBMT UCBT 0,2 0 Chronic GVHD Relapse Death V Rocha Blood 2001

19 M Eapen et al, Lancet 2007 *+(,&-' *+./,&)/' $ %%&' ) ( # 0.x107/kg *+.(",&-' 13.0x107/kg*+-,&(#' " " # ( )!

20 2$ %%&' ) ( # " *+./,(' *+/,#/' *+(,.)' "3*+"(,..' 30.45*+##,./' " "#.( #) ( Eapen M et al Lancet. 2007, 369: Summary Pediatric Study Relative to matched BM Matched and 1 AG MM CB Lower GVHD Similar rates of TRM, relapse and LFS 2 AG MM CB Lower GVHD Higher rates of early TRM Lower rates of relapse Similar rates of LFS

21 1,0,9 Children with Hurler disease Disease Free Survival by type of donor and HLA HLA identical sibling 81±6% or HLA 6/6 unrelated CB 81±8%,8,7 HLA matched unrelated donor 10/10 66±7% or CB 5/6 68±6 %,6,5 Unrelated CB 4/6 57±9% ( if high CD34 cell dose EFS=73±13%),4,3 HLA matched low resolution or mismatched (antigen or allelic level) (incl. T cell depleted) 41±7%,2,1 P=0.004, Boelens J and Rocha V on behalf of Eurocord, CIBMTR, Minneapolis and Duke University *&)+,)-'-$"*,./& ),+.&) +0,(+0$,1% 2

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26 Strategy of alternative stem cell donor in adults with malignant disorders High resolution HLA typing of the adults To be considered Haplo T-depleted in AML Simultaneous search Cord Blood Banks Bone Marrow donor registries NC dose collected to be increased with number of mismatches (single or double) >2.5x10 7 /kg NC > 3.5x10 7 /kg NC >1.5x10 5 /kg CD34 >2x10 5 /kg CD34 HLA: 0-1/6 HLA: 2/6 UCBT <8/10 or >3 mths delay for AL) HLA 9 or 10/10 UBMT 2 "%""! "% # % *'+ " ->!+ %$ 7++9,./ Increase number of cells at cord blood collection and infusion Enhance homing of cord blood cells In vitro and in vivo expansion of cord blood cells Choose the best cord blood unit based on cell dose, HLA, diagnosis, screening for antibodies against HLA Modify the conditioning regimen and GVHD prophylaxis Decrease toxicity and shorten time of aplasia with reduced conditioning regimen Co-infusion of cord blood cells with accessory cells

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30 !"!!# $"!!% &''(# % #) '11 1'21 1'1 1'1 1',1!* &#+,-).# &#+-/) "01'1 1'11 1/,, 2-3, 4 (!!5,113 Overall Survival CR1 & CR2 1.0 Probability I II I I II I I I II I I II I I I I II I p = Years I I I I Double 72% (56-88%) Single I I 47% (51-75%)

31 Transient Dual Chimerism Early dual chimerism with one unit winning out winning unit is random Contribution to engraftment Unit A Unit B Host Days after double UCBT Conclusions from JE Wagner Double UCBT promotes engraftment, achieving rates comparable to single UCBT with adequate cell doses: mechanism unknown immune mediated or additive effect? Risk of grade 2-4 agvhd is higher after double UCBT (although no difference in risk of grade 3-4 agvhd) Risk of cgvhd is similar Reduced risk of relapse is associated with Double UCBT Early disease status (CR1 & 2) No Benefit from agvhd

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39 Demographics Factors SIB MUD MMUD DUCB p N Age at Transplant Median, (range) Transplant Center 40 (12-67) 31 (10-57) 31 (10-51) 25 (10-46) Minnesota 94 (46%) 14 (9%) 2 (4%) 104 (81%) <0.01 Seattle 110 (54%) 138 (91%) 50 (96%) 24 (19%) <0.01 Source of Stem Cells BM 17 (8%) 64 (42%) 18 (35%) 0 (0%) PB 187 (92%) 88 (58%) 34 (65%) 0 (0%) UCB 0 (0%) 0 (0%) 0 (0%) 128 (100%) NE 1.0 Leukemia-Free Survival by Donor Type Cumulative Proportion I I I II III II I I I I I I IIII I I I II II I I I MM URD SIB DUCB MUD I II I I I I IIIIII I I III III I I I I I I IIII I I I I I III III I I I I I I I I I I I I II I I I I IIII I I III III I I I I I I II I I I I II II I I I I I I II I I III I I I Years post-transplantation Matched Sibling* MUD MMUD DUCB ( ) 1.04 ( ) 1.00 ( ) P=.20 P=.85 P=.99

40 Cumulative Incidence Non-Relapse Mortality by Donor Type MMUD MUD DUCB SIB Years post-transplantation Relapse by Donor Type MMUD SIB DUCB MUD Years post-transplantation Matched Sibling* MUD MMUD DUCB ( ) 1.83 ( ) 2.86 ( ) P=.76 P=.06 P<0.01 Matched Sibling* MUD MMUD DUCB ( ) 0.68 ( ) 0.27 ( ) P=.32 P=.19 P<0.01 )!># # (# ( : + )5 (+#!+0>,! A B' + + (!!! # #! (! (

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43 Non hematopoietic stem cells in cord blood Possible use in regenerative medicine Sources and procurement of adult stem cells Amniotic fluid, chorionic villi, fetal tissues Cord blood, placenta, cord, Wharton jelly Adult tissues Bone marrow Adipocytes Dental pulp Skin Testis Mesenchymal cells from diverse tissues (liver, bone marrow,vessels )

44 Embryo Stem cell sources Advantages - High proliferative capacity - Can develop into all different cell types -Can be autologous (nuclear transfer) or allogeneic Disadvantages - Strong legal restrictions and ethically disputed. -Risk of Teratoma Umbilical Cord Blood - High proliferative capacity - Can develop into all different cell types - Can be autologous or allogeneic -Available immediately. - Lower risk of rejection and GVH -Low risk of infection -No ethical problems - Only available once in a lifetime - Limited quantity Adult - Relatively easy to obtain - No ethical problem -Can be autologous or allogeneic -Invasive procedure - High infection risk -Rejection in allogeneic use - Decreased proliferative capacity What is known Adult and cord blood stem cells can be used safely in many clinical indications mainly in the field of hematopoietic stem cells transplantation Cells can be isolated and differentiate in several lineages according to the culture conditions There is an increasing evidence that non hematopoietic stem cells can be used in the clinic

45 Adult Stem cells Questions to solve How different cell sources compare? What is their immunogenicity? What is their differentiation potential? What is their tumour potential? What is the potential of ips? Before going to the clinics we must Increase the Basic knowledge on stem cells biology Definition and function of stem cells: Isolation and procurement Proliferation and differentiation Self renewal and survival Homing and migration Tumorigenicity and stability Conditions of culture and cryopreservation Preclinical in vivo models

46 Perspective in clinical applications Replacement Hematopoietic stem cells Damaged tissue or organs Gene modified cells Drug like effect stem/progenitor cells Provide repair factors to provide healing factors for damaged tissues or promote stimulation of autologous stem cells Use in pharmacology and toxicology Model of human diseases

47 ES like cells in cord blood A new human somatic stem cell from placental cord blood with intrinsic pluripotent differentiation potential. Kögler G, et al. J Exp Med Jul 19;200(2): Morphological and molecular characterization of novel population of CXCR4+ SSEA-4+ Oct-4+ very small embryoniclike cells purified from human cord blood: preliminary report. Kucia M,et al. Leukemia (2): Production of stem cells with embryonic characteristics from human umbilical cord blood. McGuckin CPet al, Cell Prolif. 2005;38(4): Non hematopoietic Stem cells in cord blood ES like MSC EPC Liver Pancreatic islets Retina Neurones

48 Cord blood stem cells Desmin

49 IPS discovery and progress First described Takahashi and Yamanaka transcriptions factors: Oct3/4, Sox2, Klf4, c-myc ips in human 2007 Yamanaka, Thomson and colleagues ips from various cell sources Decreasing he number of transcription factors Oct4 Sox2 ips without viral integration plasmids, small molecules Source of ips Cord blood banks from normal donors or hereditary disorders Other somatic cells ips new development Induce somatic/stem progenitors Direct transdifferentiation of adult somatic cells Human IPS Human Induced pluripotent stem cells from blood cells of healthy donors and patients with acquired blood disorders Zhaohui YE et al Blood on line October Generation of induced pluripotent stem cells from human cord blood A. Haase et al; Cell Stem Cell 5: , 2009 Generation of Induced pluripotent stem cells from human cord blood using OCT4 and SOX2 A.Giorgetti et al Cell Stem Cell 5: 353: 2009.

50 IPS problems to solve Toward clinical therapies utilizing hematopoietic cells derived from human pluripotent stem cells DS Kaufman Blood epub august 3, 2009 Cells for transfusion medicine RBC Platelets Cells for immune therapies NK MSC T and B cells IPS for gene therapy Fanconi Hemophilia Hemoglobinopathies

51 Use of stem cells for immunotherapy T regs: decrease GVH NK : CTL: improve antitumor effect anti tumor and anti infectious MSC : engraftment decrease GVH and improve Use of cord blood for gene therapy Related Cord blood banks Collection of cord blood in families with hereditary hematopoietic or non hematopoietic diseases Non affected siblings can be used as donors for an allogeneic transplant Affected sibling cells can be corrected by gene transfer and transplanted directly or can be reprogrammed and ips used for further gene therapy protocols. Examples: Fanconi anemia Sickle cell disease ALS ALD

52 IPS for gene therapy Disease corrected haematopoietic progenitors from Fanconi anaemia induced pluripotent stem cells A. Raya et al Nature 460: 53, 2009 Treatment of sickle cell anemia mouse model with ips cells generated from autologous skin. Hanna J et al Science 318:1920, 2007 Will IPS cells enhance therapeutic applicability of cord blood cells and banking from HE Broxmeyer Cell stem cell 6:21-24, 2010 IPSc have been developed in cord blood after long term cryopreservation Cord blood cells have a proliferative advantage compared to adult cells There is some suggestion that the more immature the starting cell the easier and more efficient it may be to generate IPSc CB IPSc may harbor fewer genetic abnormalities compared to adult somatic cells decreasing the risk of malignant transformation Many problems to solve before going to the clinics

53 Current applications of stem cell use for regenerative medicine Mainly phase I trials with limited number of patients Cord blood Autologous umbilical cord blood transfusion in very young children with type 1 diabetis. MJ Haller et al Diabetis care 32:2041, 2009 Mechanism : islet maintenance regeneration, resetting the immune system Cerebral palsy autologous cord blood J. Kurtzberg et al 2009 Epidermolysis bullosa J. Wagner Other sources Peripheral vascular diseases Regeneration of bone and cartilage Corneal regeneration Stroke Myocardial infarct etc.. Native Umbilical Cord Matrix Stem Cells Express Hepatic Markers and Differentiate Into Hepatocyte-like Cells DAVID CAMPARD, PHILIPPE A. LYSY, MUSTAPHA NAJIMI, and ETIENNE MARC SOKAL HPED Department, PEDI Unit, Laboratory of Pediatric Hepatology and Cell Therapy, Université Catholique de Louvain, Brussels, Belgium GASTROENTEROLOGY 2008;134: Conclusions: We conclude that UCMSCs, with a newly demonstrated endodermic differentiation potential, might be an alternative source for liver-directed cell therapies

54 re

55 The first clinical trial of UC-MSC in Systemic sclerosis Before treatment 1 month after treatment

56 Transplant of placenta stem cells significantly improve type II diabetes Detection of insulin and C-peptide before and after treatment in patients with type II diabetes Insulin µiu/ml Before treatment After treatment * * * * * C peptide (ng/ml) Before treatment After treatment * * * * *

57 Current Clinical Trials of Adult Stem Cells Cancers Lymphomas, multiple myeloma, leukemias, breast cancer, neuroblastoma, renal cell carcinoma, ovarian cancer Autoimmune diseases multiple sclerosis, systemic lupus, rheumatoid arthritis, scleroderma, scleromyxedema, Crohn s disease Anemias (incl. sickle cell anemia) Immunodeficiencies including human gene therapy Bone/cartilage children with osteogenesis imperfecta, knee injuries Corneal scarring generation of new corneas to restore sight Stroke clinical trials in U.S., U.K., Germany Repairing cardiac tissue after heart attack bone marrow or muscle stem cells from patient Parkinson s patient s own neural stem cells, injected growth factors Growth of new blood vessels e.g., preventing gangrene in limbs Gastrointestinal epithelia regenerate damaged ulcerous tissue Skin grafts grown from hair follicle stem cells, from a few hairs from patient Wound healing bone marrow stem cells stimulated healing Spinal cord injury clinical trials currently in Portugal, Australia, Ecuador Liver failure clinical trials in U.K. Diabetes clinical trials in Brazil & U.S. 5 " " Banking for regenerative medicine from Mc Gukin and Forraz expansionn differentiation Maturation Application Neuronal 2!" 1 % C "" Hepatic "2!" ( " '4( +44( '4( Pancreatic 3 "2!" '"" "" Endothelial

58 Current barriers to clinical translation Function and integration of stem cells Clinical scale Safety Immune response Regulatory issues Economical issues, equal access Ethical issues CONCLUSION Cord blood is a unique biological resource for Hematopoietic transplantation Regenerative medicine Scientific research There is a need for increasing the number of units stored

59 Interactive website Videos on cord blood collection and processing Building a dictionary for multilingual translation of key documents Publication and analysis of european documents Development training on research and technology on cord blood Development of clinical cord blood transplant Webcasts Quality assurance regulatory quality and ethical issues Dissemination and exploitation

60 EUROCORD TEAM Dr Annalisa Ruggeri Medical Assistant Dr Andrée Laure Herr Medical Assistant Dr Vanderson Rocha Scientific Director Dr Irina Ionescu Medical Assistant David Pacheco Informatics Chantal Kenzey Data manager Dr Wagnara Chaves Medical Assistant Prof. Eliane Gluckman Project Leader Dr Karim Boudjedir Medical Assistant Arnaud Benassy Informatics Malikà Akhoudas Data manager Dr Thomas Daikeler Medical Assistant Dr Duncan Purtil Medical Assistant Dr Alessandro Crotta Medical Assistant Dr Celso Arrais Medical Assistant

61 The Eurocord Office, Hôpital Saint-Louis, Paris