Mesenchymal stromal cells (MSC) therapyfor the regeneration of radio-induced proctitis“from bench to bedside”

marc.benderitter@irsn.fr

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