G-CSF Fails to Improve Long-Term Clinical Outcomes in REVIVAL-2 Trial


Granulocyte-Colony Stimulating Factor (G-CSF) is a glycoprotein (protein with sugars attached to it) that signals to the bone marrow to produce granulated white blood cells (specifically neutrophils), and to release stem cells and progenitor cells into the peripheral circulation.

This function of G-CSF makes it a candidate treatment for patients who have recently experienced a heart attack, since the release of stem cells from the bone marrow could, in theory, bring more stem cells to the damaged heart to heal it. Additionally, G-CSF is known to induce the proliferation and enhance the survival of heart muscle cells.

In several experiments with laboratory animals showed that G-CSF treatments after a heart attack significantly reduced mortality (Moazzami K, Roohi A, and Moazzimi B. Cochrane Database Systematic Reviews 2013; 5: CD008844. However, in a clinical trial known as the REVIVAL-2 trial, a double-blind, placebo-controlled study, G-CSG treatment failed to influence the performance of the heart six months after administration.

Now Birgit Steppich and others have published a seven-year follow-up of the subjects in the original REVIVAL-2 study to determine if G-CSF had long-term benefits that were not revealed in the short-term study. These results were published in the journal Thrombosis and Haemostasis (115.4/2016).

Of the initially enrolled 114 patients, 106 patients completed the seven-year follow-up. The results of this trial showed that G-CSF treatment for five days in successfully revascularized heart attack patients did not alter the incidence of death, recurrent heart attacks, stroke, or secondary adverse heart events during the seven-year follow-up.

These results are similar to those of the STEMMI trial, which treated patients with G-CSF for six days 10-65 hours after the reperfusion. In a five-year follow-up of 74 patients, there were no differences in the occurrence of major cardiovascular events between the G-CSF-treated group and the placebo group (Achili F, et al., Heart 2014; 100: 574-581).

Therefore, it appears that even though G-CSF worked in laboratory rodents that had suffered heart attacks, this treatment does not consistently benefit human heart attack patients. Although why it does not work will almost certainly require more insights than we presently possess.

CAR Immune Cells to Treat Childhood Cancers


In clinical trials, cancer treatments that use genetically modified versions of a patient’s own cells to specifically target the disease have remarkable results. The next step for these companies that spent enormous amounts of time, capital, and intellectual energy inventing and designing these treatments is to get them into hospitals despite their enormous price tags.

Novartic CAR T-Cell therapy

In two separate clinical trials, one sponsored by the Swiss company Novalis AG and another by the Seattle-based biotech company Juno Therapeutics Inc., close to 90% of all patients saw their leukemia completely disappear after being given experimental “CAR” or “chimeric antigen receptor” T-cell therapies.

Both trials examined small numbers of patients (22 children in the Novartis trial and 16 adults in the Juno trial). These patients had acute lymphoblastic leukemia, which is the most common childhood cancer. All of them had also not responded to the available standard treatments. Consequently, both companies are now conducting larger trials.

“CAR T cells are probably one of the most exciting concepts and fields to come out in cancer in a very, very long time,” says Dr. Daniel DeAngelo, a Boston-based hematologist and associate professor of medicine at Harvard Medical School, who wasn’t involved in either study.

Usman Azam, head of cell and gene therapies at Novartis, calls the therapies “critically important” for Novartis. “I think that a cure for cancers such as leukemia and lymphoma through a CAR technology is plausible,” said Dr. Azam in an interview with The Wall Street Journal. “Our job is to get this into patients as soon as we feasibly can.”

Novatis created a new research unit headed by Dr. Azam. Novartis’ rationale is to accelerate the advent of CAR T-Cell Therapy to medical markets. The U.S. Food and Drug Administration (US FDA) granted Novartis’ leading CAR therapy “breakthrough” designation in July of 2014. Presently Novartis wants to file it with regulators in 2016.

CAR therapies use the patient’s own immune system to fight the cancer, but with a genetic-engineering twist. “Immunotherapies,” culture immune cells from the patient and manipulate them in culture to sensitize them to the cancer. CAR therapies extract T-cells, which are disease-fighting white blood cells, from a patient’s blood. These T-cells are then genetically engineered and grown in a laboratory for around 10 days and reintroduced into the patient.

The T-cells are usually infected with a hamstrung virus that can introduce genes into cells but cannot productively infect them. These recombinant viruses endows the T-cells with genes that encode chimeric antigen receptors, or CARs. CARS bind specifically to proteins on the surface of malignant cancer cells. Once attached to the cancer cells, the T-cells can kill them very effectively.

Both Novartis and Juno are tapping academic scientists to develop their treatments. For example, Novartis has teamed with the University of Pennsylvania and Juno has formed a formal relationships with scientists at Memorial Sloan-Kettering Cancer Center in New York, Seattle Children’s Hospital and the Fred Hutchinson Cancer Research Center, which is also in Seattle.

Even though Novartis and Juno will probably be the first to bring their immunotherapies to the market, other companies are also in the hunt to bring similar therapies to medical markets. Pfizer Inc., Kite Pharma Inc., and Celgene Corp., which is working in collaboration with Bluebird Bio Inc. all are developing competing strategies.

“Competition will keep all of the companies involved on their toes,” said Hans Bishop, Juno’s chief executive.

Unfortunately, CAR therapies still have a few unanswered questions surrounding them. For example: “How long do they last?” Given the small numbers of patients who have been treated with these treatments to date, it is very hard to tell with the available data. Another confounding factor is that those patients in the previous clinical trials whose cancer went into remission after the CAR therapies then became eligible for stem-cell transplants, which can also prolong survival.

Secondly, a potentially dangerous side effect called “cytokine-release syndrome,” shows the therapy is working, but can cause a sharp drop in blood pressure and a surge in the heart rate. The deaths of two patients in a Juno-backed Sloan-Kettering trial in March caused a temporary halt in the study because of worries over these particular adverse reactions.  “Patients need to be healthy enough to combat that side effect,” says Mr. Bishop, who thinks it is now manageable. Patients are once again being recruited for this trial, and patients with a risk of heart failure are excluded, and the modified cell dose for patients with very advanced leukemia also has been lowered.

But largest hurdle of all will probably be the cost of these therapies. Since they are a genetically engineered product, CAR T-cells are very complex to manufacture; each batch is composed of unique, personalized T-cells that were made from a patient’s own blood cells. The inability to mass-produce CAR T-cells will definitely increase the price companies charge for them.

“What we’re talking about here is a single, very expensive therapy that’s used once for a specific patient and is not generalizable,” says Dr. Malcolm Brenner, director of the Center for Cell and Gene Therapy at the Texas Children’s Hospital in Houston, who, in MArch, signed an agreement to commercialize his own CAR research with Celgene.

Novartis and Juno both insist that it is too early to speculate on the price of the treatment, but Dr. Usman agrees the challenge is getting the manufacturing process to “a viable level where it’s both affordable and attractive.”

Citigroup believes CAR therapies could cost in excess of $500,000 per patient, which it notes is roughly in line with the cost of a stem cell transplant, even though most analysts think it is too early to estimate potential revenue or price.

“This technology needs to be widely developed and accessible to patients,” says Dr. DeAngelo. “If the cost is going to be a hindrance, it’s going to be a really sad day.”

Scalability and cost are one reason Pfizer is taking a different approach to this field. “We would like to take it to the next level, where CAR therapies become a more standardized, highly controlled treatment,” said Mikael Dolsten, Pfizer’s head of global research and development.

Working with French biotech Cellectis SA, Pfizer wants to develop a generic CAR therapy for use in any patient. While this will certainly lower the cost of the treatment, since it is the result of a mass-produced, off-the-shelf-product, this work is still at the preclinical stages and may not work in humans.

Global head of health-care research at Société Générale, Stephen McGarry, thinks that the revolutionary treatments being developed by Novartis and Juno could justify “astronomical” prices, he believes health-care payers and patients will probably protest such high prices. “When you look at the initial data with the Novartis therapy, you’re getting cures in some kids—what do you charge for that?” he asks.

Kyoto University Scientist Plans iPSC Clinical Trial for Parkinson’s Disease Patients


According to the Japan Times, Kyoto University’s Jun Takahashi and his team have plans to launch a clinical study for Parkinson’ disease patients that will utilize cells derived from induced pluripotent stem cells made from the patient’s own cells.

In an interview with Takahashi, the Japan Times reported on Wednesday of this week that he hopes to develop the induced Pluripotent Stem Cell (iPSCs) treatment as soon as possible so that Kyoto University Hospital can provide this treatment by fiscal year 2018 as a designated advanced medical technique that can be used in combination with other conventional treatments and medicines already covered by various insurance policies. Takahashi also expressed his hope that by fiscal year 2023, public health insurance will pay for his treatment.

For this clinical study, Parkinson’s disease patients whose conditions have progressed to the point where their medications are no longer effective will be the primary targeted group.  “It will take a long time” to establish an effective treatment for the progressive disorder, which is incurable at present, Takahashi said, stressing the importance of maintaining a positive attitude toward development and not losing hope.

Parkinson’s disease causes the nerve cells in the brain that utilize the neurotransmitter dopamine to die off.  The death of these dopaminergic neurons adversely affects voluntary muscle movement.

The design of this clinical study will include the production of iPSCs from adult cells collected from participating patients.  These stem cells will be differentiated into neural stem cells that make dopaminergic neurons.  These dopaminergic neuron precursor cells will be transplanted back into the midbrains of the donors before they develop into nerve cells, according to Takahashi.  This way, all injected cells will still have the capacity to divide and migrate once implanted into the brain, but they will still have the capacity to form dopaminergic neurons.

Takahashi’s team will also seek to develop a method for producing a nerve cell drug created from cells taken out of healthy people, to ease the financial burden on patients, he said, since the derivation of iPSCs remains prohibitively expensive.

Takahashi also said he aims to being clinical trials by March 2019.

Five-Year Follow-up of REPAIR-AMI Clinical Trial


The REPAIR-AMI clinical trial was a double-blind placebo-controlled trial in which 204 recent heart attach patients received either an infusion of bone marrow stem cells or a placebo. The results of this clinical trial have been published in three different papers (Schächinger, et al., N Engl J Med 2006 355: 1210-1221; Schächinger, et al., Eur Heart Journal 2006 27: 2775-2783; Schächinger, et al., Nat Clin Pract Cardvasc Med 2006 3(Suppl 1): 523-528).

This clinical trial showed that the bone marrow-treated group showed significant functional improvements over the placebo group. However, a long-term follow-up of these patients was required to demonstrate that the benefits conferred by the stem cell treatments were long-lasting and not merely transient.

Upon 5-year examination, the stem cell-treated group showed lower rates of a second heart attack, hospitalization, strokes, cancer, surgical interventions to open blocked vessels and death. Thus, the stem cell-treated group fared better in almost all the major categories.

There was, however, an additional experiment that gave a truly remarkable result. After each patient had their bone marrow extracted, the stem cells were subjected to individual tests, one of which were mobility tests. When this research group examined the stem cell motility data and correlated it to the five-year follow-up, they discovered a very tight association between the motility of the bone marrow stem cells and the absence of cardiac events. More active bone marrow cells provided greater recovery and fewer post-procedural events.

These data show that the quality of the bone marrow is a significant factor in the success of the stem cell treatment.

This also brings up another question: Can be beef up the quality of the bone marrow some how? Culturing stem cells can expand them, but it can also significantly change them. Therefore, this remains a fertile field for research and development, and the bone marrow quality may also explain why bone marrow transplants into the heart work so well or some patients and not at all for others.

New US Phase IIa Trial and Phase III Trial in Kazakhstan Examine CardioCell’s itMSC Therapy to Treat Heart Attack Patients


The regenerative medicine company CardioCell LLC has announced two new clinical trials in two different countries that utilize its allogeneic stem-cell therapy to treat subjects with acute myocardial infarction (AMI), which is a problem that faces more than 1.26 million Americans annually. The United States-based trial is a Phase IIa AMI clinical trial that is designed to evaluate the clinical safety and efficacy of the CardioCell Ischemia-Tolerant Mesenchymal Stem Cells or itMSCs. The second clinical trial in collaboration with the Ministry of Health in Kazakhstan is a Phase III AMI clinical trial on the intravenous administration of CardioCell’s itMSCs. This clinical trial is proceeding on the strength of the efficacy and safety of itMSCs showed in previous Phase II clinical trials.

CardioCell’s itMSCs are exclusively licensed from CardioCell’s parent company Stemedica Cell Technologies Inc. Normally, when mesenchymal stem cells from fat, bone marrow, or some other tissue source are grown in the laboratory, the cells are provided with normal concentrations of oxygen. However, CardioCell itMSCs are grown under low oxygen or hypoxic conditions. Such growth conditions more closely mimic the environment in which these stem cells normally live in the body. By growing these MSCs under these low-oxygen conditions, the cells become tolerant to low-oxygen conditions (ischemia-tolerant), and if transplanted into other low-oxygen environments, they will flourish rather than die.

Another advantage of itMSCs for regenerative treatments over other types of MSCs is that itMSCs secrete higher levels of growth factors that induce the formation of new blood vessels and promote tissue healing. These clinical trials have been designed to help determine if CardioCell’s itMSC-based therapies stimulate a regenerative response in acute heart attack patients.

“CardioCell’s new Phase IIa AMI study is built on the excellent safety data reported in previous Phase I clinical trials using our unique, hypoxically grown stem cells,” says Dr. Sergey Sikora, Ph.D., CardioCell’s president and CEO. “We are also pleased to report that the Ministry of Health in Kazakhstan is proceeding with a Phase III CardioCell-therapy study following its Phase II study that was highly promising in terms of efficacy and safety. Our studies target AMI patients who have depressed left ventricular ejection fraction (LVEF), which makes them prone to developing extensive scarring and therefore to the development of chronic heart failure. CardioCell hopes our itMSC therapies will inhibit the development of extensive scarring and, thus, the occurrence of chronic heart failure in these patients.”

The United States-based Phase IIa clinical trial will take place at Emory University, Sanford Health and Mercy Gilbert Medical Center. The CardioCell Phase IIa AMI trial is a double-blinded, multicenter, randomized study designed to assess the safety, tolerability and preliminary clinical efficacy of a single, intravenous dose of allogeneic mesenchymal bone-marrow cells infused into subjects with ST segment-elevation myocardial infarction (STEMI).

“While stem-cell therapy for cardiovascular disease is nothing new, CardioCell is bringing to the field a new, unique type of stem-cell technology that has the possibility of being more effective than other AMI treatments,” says MedStar Heart Institute’s Director of Translational and Vascular Biology Research and CardioCell’s Scientific Advisory Board Chair Dr. Stephen Epstein. “Evidence exists demonstrating that MSCs grown under hypoxic conditions express higher levels of molecules associated with angiogenesis and healing processes. There is also evidence indicating they migrate with greater avidity to various cytokines and growth factors and, most importantly, home more robustly to ischemic tissue. Studies like those underway using CardioCell’s technology are designed to determine if we can evoke a more potent healing response that will reduce the extent of myocardial cell death occurring during AMI and thereby decrease the amount of scar tissue resulting from the infarct. A therapy that could achieve this would have a major beneficial impact in reducing the occurrence of chronic heart failure.”

Kazakhstan’s National Scientific Medical Center is conducting a Phase III AMI clinical trial using CardioCell’s itMSCs, which are sponsored by local licensee Altaco. This clinical trial is entitled, “Intravenous Administration of itMSCs for AMI Patients,” and is proceeding based on a completed Phase II efficacy and safety study. However, the results of this previous Phase II study are preliminary because the sample group was so small. Despite these limitations, the findings demonstrated statistically significant elevation (more than 12 percent over the control group) in the ejection fraction of the left ventricle of the heart in patients who had received itMSCs. Also, a significant reduction in inflammation was also observed, as ascertained by lower CRP (C-reactive protein) levels in the blood of treated patients in comparison to control groups. Thus, Dr. Daniyar Jumaniyazov, M.D., Ph.D., principal investigator in Kazakhstan clinical trials states: “In our clinical Phase II trial for patients with AMI, treatment using itMSCs improved global and local myocardial function and normalized systolic and diastolic left ventricular filling, as compared to the control group. We are encouraged by these results and look forward to confirming them in a Phase III study.”

CardioCell’s treatment is the first to apply itMSC therapies for cardiovascular indications like AMI, chronic heart failure and peripheral artery disease. Manufactured by CardioCell’s parent company Stemedica and approved for use in clinical trials, itMSCs are manufactured under Stemedica’s patented, continuous-low-oxygen conditions and proprietary media, which provide itMSCs’ unique benefits: increased potency, safety and scalability. itMSCs differ from competing MSCs in two key areas. itMSCs demonstrate increased migratory ability towards the place of injury, and they show increased secretion of growth and transcription factors (e.g., VEGF, FGF and HIF-1), as demonstrated in a peer-reviewed publication (Vertelov et al., 2013). This can potentially lead to improved regenerative abilities of itMSCs. In addition, itMSCs have significantly fewer HLA-DR receptors on the cell surface than normal MSCs, which might reduce the propensity to cause immune responses. As another benefit, itMSCs are highly scalable. A single donor specimen can currently yield about 1 million patient treatments, and this number is expected to grow to 10 million once full robotization of Stemedica’s facility is complete.

Three New Clinical Trials Examine Bone Marrow-Based Stem Cells To Treat Heart Failure


In April of 2013, the results of three clinical trials that examined the effects of bone marrow-derived stem cell treatments in patients with acute myocardial infarction (translation – a recent heart attack) or chronic heart failure. These trials were the SWISS-AMI trial, the CELLWAVE trial, and the C-CURE trial.

The SWISS-AMI trial (Circulation. 2013;127:1968-1979), which stands for the Swiss Multicenter Intracoronary Stem Cells Study in Acute Myocardial Infarction trial, was designed to examine the optimal time of stem cell administration at 2 different time points: early or 5 to 7 days versus late or 3 to 4 weeks after a heart attack. This trial is an extension of the large REPAIR-AMI, which showed that patients who tended to receive bone marrow stem cell treatments later rather than earlier had more pronounced therapeutic effects from the stem cell treatments.

SWISS-AMI examined 60 patients who received standard cardiological care after a heart attack, 58 who received bone marrow stem cells 5-7 days after a heart attack, and 49 patients who received bone marrow stem cells 3-4 weeks after their heart attacks. All stem cells were delivered through the coronary arteries by means of the same technology used to deliver a stent.

When the heart function of all three groups were analyzed, no significant differences between the three groups were observed. Those who received stem cell 5-7 days after a heart attack showed a 1.8% increase in their ejection fractions (the percentage of blood that is ejected from the ventricle with each beat) versus an average decrease of 0.4% in those who received standard care, and a 0.8% increase in those who received their stem cells 3-4 weeks after a heart attack. If these results sound underwhelming it is because they are. The standard deviations of each group so massive that these three groups essentially overlap each other. The differences are not significant from a statistical perspective. Thus the results of this study were definitely negative.

The second study, CELLWAVE (JAMA, April 17, 2013—Vol 309, No. 15, 1622-1631), was a double-blinded, placebo-controlled study conducted among heart attack patients between 2005 and 2011 at Goethe University Frankfurt, Germany. In this study, the damaged area of heart was pretreated with low-energy ultrasound shock waves, after which patients in each group were treated with either low dose stem cells, high-dose stem cells, or placebo. Patients also received either shock wave treatment or placebo shock wave treatment. Thus this was a very well-controlled study. Stem cells were administered through the coronary arteries, just as in the case of the SWISS-AMI study.

The results were clearly positive in this study. The stem cell + shock wave treatment groups showed definite increases in heart function above the placebo groups, and showed fewer adverse effects. The shock wave treatments seem to prime the heart tissue to receive the stem cells. The shock waves induce the release of cardiac stromal-derived factor-1, which is a potent chemoattractor of stem cells.  This is an intriguing procedure that deserves more study.

The third study, C-CURE, is definitely the most interesting of the three (Bartunek et al. JACC Vol. 61, No. 23, June 11, 2013:2329–38). In this trial, mesenchymal stromal cells (MSCs) were isolated from bone marrow and primed with a cocktail of chemicals that pushed the stem cells towards a heart muscle fate. Then the cells were transplanted into the heart by direct injection into the heart muscle as guided by NOGA three-dimensional imaging of the heart.

After initially screening 320 patients with chronic heart failure, 15 were treated with standard care and the other 32 received the stem cell treatment. After a two-year follow-up, the results were remarkable: those who received the stem cell treatment showed an average 7% increase in ejection fraction versus 0.2% for receiving standard care, an almost 25 milliliter reduction in end systolic volume (measures degree of dilation of ventricle – not a good thing and the fact that it decreased is a very good thing) versus a 9 milliliter decrease for those receiving standard care, and were able to walk 62 meters further in 6 minutes as opposed to standard care group who walked 18 meters less in 6 minutes.

While these studies do not provide definitive answers to the bone marrow/heart treatment debate, they do extend the debate. Clearly bone marrow stem cells help some patients and do not help others. The difference between these two groups of patients continues to elude researchers. Also, how the bone marrow is processed is definitely important. When the cells are administered also seems to be important, but the exact time slot is not clear in human patients. It is also possible that some patients have poor quality bone marrow in the first place, and might be better served by allogeneic (someone else’s stem cells) treatments rather than autologous (the patient’s own stem cells) stem cell treatments.

Also, stem cell treatments for heart patients will probably need to be more sophisticated if they are to provide greater levels of healing. Heart muscle cells are required, but so are blood vessels to feed the new heart muscle. If mesenchymal stem cells work by activating resident heart stem cells, then maybe mesenchymal transplants should be accompanied by endothelial progenitor cell transplants (CD117+, CD45+ CD31+ cells from bone marrow) to provide the blood vessels necessary to replace the clogged blood vessels and the new heart muscle that is grown.

Stem Cell Therapy Following Meniscus Knee Surgery Reduces Pain and Regenerates Meniscus


According to a new study published in the January issue of the Journal of Bone and Joint Surgery (JBJS), a single stem cell injection after meniscus knee surgery can provide pain relief and aid in meniscus regrowth.

In the US alone, over one million knee arthroscopy procedures are performed each year. These surgeries are usually prescribed to treat tears to the wedge-shaped piece of cartilage on either side of the knee called the “meniscus.” The meniscus acts as an important shock absorber between the thighbone (femur) and the shinbone (tibia) at the knee-joint.

Knee-Ligament-Pain-and-Strains-Meniscus-Tear-and-Pain

This novel study, “Adult Human Mesenchymal Stem Cells (MSC) Delivered via Intra-Articular Injection to the Knee, Following Partial Medial Meniscectomy,” examined 55 patients who had undergone a surgical removal or all or part of a torn meniscus (known as a partial medial meniscectomy). Each patient was randomly assigned to one of three treatment groups: Groups A, B and C. The 18 patients in group A received a “low-dose” injection of 50 million stem cells within seven to 10 days after their meniscus surgery. Another 18 patients in group B received a higher dose of 150 million stem cells seven to ten days after their knee surgery. The controls group consisted of 19 patients who received injections of sodium hyaluronate only (no stem cells). All patients were evaluated to determine the safety of the procedure, the degree of meniscus regeneration (i.e. with MRI and X-ray images), the overall condition of the knee-joint, and the clinical outcomes through two years. Most of the patients enrolled in this study had some arthritis, but patients with severe (level three or four) arthritis, were excluded from the study.

Most of the patients who had received stem cell treatments reported a significant reduction in pain. 24 percent of the patients in one MSC group and 6 percent of the other showed at least a 15 percent increase in meniscal volume at one year. Unfortunately, there was no additional increase in meniscal volume at year two.

“The results demonstrated that high doses of mesenchymal stem cells can be safely delivered in a concentrated manner to a knee-joint without abnormal tissue formation,” said lead study author C. Thomas Vangsness, Jr., MD. “No one has ever done that before.” In addition, “the patients with arthritis got strong improvement in pain” and some experienced meniscal regrowth.

The key findings of this study are that there no abnormal (ectopic) tissue formation or “clinically important” safety issues identified. Also, 24 percent of the patients in the low-dose injection group (A) and six percent of the high-dose injection group (B) at one year showed “significantly increased meniscal volume,” as determined by an MRI, and this increase did not continue into the second year, but remained stable (should future studies try a second injection of MSCs?). Third, none of the patients in the control group (non-MSC group) showed significant meniscus regrowth. Finally, patients with osteoarthritis experienced a reduction in pain in the stem cell treatment groups, but there was no reduction in pain in the control (non-MSC group).

“The results of this study suggest that mesenchymal stem cells have the potential to improve the overall condition of the knee joint,” said Dr. Vangsness. “I am very excited and encouraged” by the results. With the success of a single injection, “it begs the question: What if we give a series of injections?”