HEMATOPOIETIC STEM CELL TRANSPLANTATION IN SYSTEMIC SCLEROSIS

The European Group for Blood and Marrow Transplantation

Pr Dominique Farge, Hôpital St Louis, UH04Paris 7 Denis Diderot University, France,

Groupe Français de Recherche sur la SclérodermieADWP EBMT Chair

EUSTAR

Diffuse Cutaneous

Limited Cutaneous

pulmopnary hypertensionmalabsorption

IntermediateLate

LateIntermediate

joint contractures,GI, lung, heart, kidney

5 10 20

SK

IN T

HIC

KN

ES

SS Sc:1m / 3- 8f; prevalence 7–500 / Million

Arthr Rhum Steen 2000

N riskfactors

Total no. of pts

Nb / RR of deaths

0 509 12 7.1

1 349 45 22.8

2 168 55 54.8

3 23 7 100.0

J. Fransen, D. EUSTAR 2010

Skin thickness progression rate: a predictor of mortality and early internal organ involvementDomsic R T Ann Rheum Dis , 2010

CORTICOSTEROIDS

1960 1970 1980 1990 2000

AZATHIOPRINECYCLO AATG NEORAL

CPM po, iv

1995

Anti TNF, Anti-CD20, Anti-BlysMMF

HSCT (HSCT (BM, PBSC, MSC,CBBM, PBSC, MSC,CB) ) :: RESET of TOLERANCE ?RESET of TOLERANCE ?

MTX

SSC: 5 yrs Survival (skin+ lung / heart / kidney)30% ≈≈≈≈ 40%

HSCT HSCT ………………………………..

2010

MSC

2005

HEMATOPOIETIC STEHEMATOPOIETIC STEHEMATOPOIETIC STEHEMATOPOIETIC STEM CELL TPM CELL TPM CELL TPM CELL TP: 1996 : 1996 : 1996 : 1996 ---- 2011201120112011

A NEW THERAPA NEW THERAP EUTIC OPTION EUTIC OPTION ::Depend HSC (exp, AB ) => RESET IR RESET IR Resistant to classical tt = > New INDICATIONSNew INDICATIONS

Feasibility established: Feasibility established: TRM 5% risk / benefit Benefit from myeloablation+IS

HSC? BM, PBSC, MSc…CB

Auto / Allo : remission /cure => Conditioning regimen : ATG? Irradiation? Conditioning regimen : ATG? Irradiation?

= > CD34+ Cell selection ? = > MAINTENANCE TherapyMAINTENANCE Therapy

SHORT and LONG TERM EFFICACY:SHORT and LONG TERM EFFICACY:2 phase 3 trials recruitment completedCost effectiveness

New trials

Combined efforts: EBMT, US, Asia

1. Mobilisation

2. Leukapheresis3. Ex-vivo graft manipulation

4. Conditioning

5. Transplantation

Normal mice AI- prone mice

Normal miceA.l. mice

A.l. mice Normal mice

BMCs from

T-cell dysfunction is associated with both the involutionary changes occuring in the thymus of the AI-prone mice and to abnormalities that reside in the stem cells =>

BMT ? to be considered as an approach for treating life threatening AD in humans

T-cell dysfunction is associated with both the involutionary changes occuring in the thymus of the AI-prone mice and to abnormalities that reside in the stem cells =>

BMT ? to be considered as an approach for treating life threatening AD in humans

Newborn thymus fromNewborn thymus from RecipientRecipient Thymic atrophyand AIDs

Thymic atrophyand AIDs

A.l. miceNormal miceIkehara PNAS 1985

PRECLINICAL EXPERIMENTSV BEKKUM Best Pract Res 2004; 17; 201

1985 *1985 * : 1st successfull treatment by allogeneic BMT in LUPUS mice: 1st successfull treatment by allogeneic BMT in LUPUS mice((better results with fetal bone fragments: stromal c ells? or MSCbetter results with fetal bone fragments: stromal c ells? or MSC ))

(syngeneic BMT : Negative ? Controls)(syngeneic BMT : Negative ? Controls)

••1 Inflammatory AID 1 Inflammatory AID ◄◄ initiated + maintained by activated T cells initiated + maintained by activated T cells ! Eliminate! Eliminate. 2 Cy alone < Cy + TBI. 2 Cy alone < Cy + TBI. 3 Relapse . 3 Relapse ◄◄ memory T cells memory T cells !! Radiation > CyRadiation > Cy. 4 Search for specific lymphocytolytic agents: Fl udarabine , A. 4 Search for specific lymphocytolytic agents: Fl udarabine , A TG?TG?. 5 Immune reconstitution (? stem cell): recapitul ation of onto. 5 Immune reconstitution (? stem cell): recapitul ation of onto genesis genesis

Special report Blood and marrow stem cell transplants in auto-immune disease: a consensus report written on behalf of the EULAR and the EBMT A Tyndall and A Gratwohl BMT 1997

Haematopoietic stem cell transplantation (HSCT) in severe auto-immune diseases: updated guidelines written on behalf of the EBMT ADWP and PDWP

J Snowden, R Saccardi, M Allez, S Ardizzone, R Arnold, R Cervera, C Denton, JM van Laar, M Labopin, G Mancardi, R Martin, JJ Moore, J Passweg, C Peters, M Rabusin, M Rovira, D Farge

(BMT 2011 in press)

Per Ljungmann BMT 2009 Level II = at least one well designed clinical trial without randomisation: cohort or case controlled analytical studies (preferably > one centre), multiple time series studies

Disease Sib donor Well matched unrelated Mismatched donor Autologous

MS D/III GNR/III GNR/III CO/IICO/II

SSc D/III GNR/III GNR/III CO/IICO/II

SLESLE D/III GNR/III GNR/III CO/IICO/II

Crohn ’s GNR/III GNR/III GNR/III CO/IICO/II

RA GNR/III GNR/III GNR/III CO/II

Vasculitis GNR/III GNR/III GNR/III CO/II

Polymyositis-Dermatomyositis

GNR/III GNR/III GNR/III CO/II

CIPD GNR/III GNR/III GNR/III CO/II

Cytopenia CO/II D/III GNR/III CO/II

T1D GNR/III GNR/III GNR/III D/III

RCD Type II GNR/III GNR/III GNR/III D/III

Number of HSCT per year: EBMT Registry*All transplants not yet registered for 2011

107104108

8285

59

7583

95

143

128

98

25

0

40

80

120

160

19992000

20012002

20032004

20052006

20072008

20092010

2011

Number of HSCT: 1357 HSCT (1254 autologous)Centres /Countries 215/31Overall Follow up 2.9y (<1-24)

MULTIPLE SCLEROSIS 476 CONNECTIVE TISSUE D. 427SScSSc 283283SLE SLE 102 102 PM-DM 18Sjogren 3Antiphosph. syndrome 3Other/Unknown 15ARTHRITIS 163Rheumatoid arthritis 80Juvenile chronic arthritis :

- Systemic JIA 49 - Other JIA 18- Polyarticular JIA 10

Psoriatic arthritis 3Other 4INFLAMMATORY BOWEL 79Crohn's disease 68 Ulcerative colitis 4 Other 7

HAEMATOLOGICAL 80ITP 26Evan’s 19AIHA 18Other 17

VASCULITIS 41Wegener’s 10Behcet’s 8Takayasu 2 Microscopic poly. nodosa 3 Classical poly. nodosa 1 Churg-Strauss 2 Other/Unknown 14

OTHER NEUROLOGICAL 38Myasthenia gravis 5 Other/Unknown 33

INSULIN DEPENDANT DIABETES 10

OTHER/UNKNOWN/MISSING29

ADs: HSCT per Country September 2011**All transplants not yet registered for 2011

108 107464848566070

1824243194102

169

277

0

100

200

300

Italy

German

y

United K

ingdomFrance

Netherl ands ...

Spain

Sweden

Austral i

a

Czech

Republic

Greece

China

Russia

Belg ium

Hungary

PolandIs rael

Farge D et al: Autologous stem cell transplantation in scleroderma: an extended report from the

EULAR / EBMT registry. Ann Rheum Diseases 2004; 63 : 974-981

1019303740N =

Months

36241260

% c

hang

e in

ski

n sc

ore +100

+75

+50

+25

0

-25

-50

-75

-100

TRM 4% (8.7%)

Durable response 66%

1. LEARNING CURVE FOR SSc: 1996-1999Extended report from the EBMT registry n 57 pts

RODNAN SKIN SCORE, n = 26 RODNAN SKIN SCORE, n = 26 p p = 10= 10--3 up to 7 years : 3 up to 7 years : ���� 11.2 first year and 2.5 / yr thereafter11.2 first year and 2.5 / yr thereafter

Vonk et al Ann Rheum Dis 2008

Performance status n = 26 SSc at 7 yearsPerformance statut

0% 20% 40% 60% 80% 100%

0

1

2

3

4

5

6

7

Yea

r

Percentage

0 1 2 3 4

Vonk et al sAnn Rheum 2008

0 1 2 3 4 5 6 7

y ea r

25

50

75

1 00

1 25

1 50

VC

* *

*

VCBox plot of Vital Capacity values as % of predicted for each year of follow-up after AHSCTFEV1Box plot of Forced Expiratory Volume 1 values in % of expected for all follow-up years.DLCOBox plot of Carbon Dioxide Diffusion Lung Capacity values in % of predicted for all years of follow-up after AHSCT* p< 0.05

0 1 2 3 4 5 6 7

y e a r

0

3 0

6 0

9 0

1 2 0

1 5 0

F E V 1

* *

0 1 2 3 4 5 6 7

year

0

20

40

60

80

100

DLC

O

VC* DLCO

FEV1

Vonk et al Ann Rheum Dis 2008 (n=26)

Characteristics Baseline 6 mths 1 yr 2 yrs 3 yrs 4 yrs 5 yrs

Nb of pts 9 9 9 8 7 7 7

NYHA dyspnea I/II/III/IV 3/4/2/0 4/4/0/1 5/3/1/0 4/4/0/0 5/2/0/0 3/4/0/0 5/2/0/0

mRSS 36* 24* 25* 11* 11* 6* 6*

Pulmonary function

VC, % 72 74 76 83ζ 74 68 60

TLC, % 82 80 74 86 77 75 73

DLCO, % 46 51 42 44 40 41 40

CT scan patterns

Disease extent10

(0-45)4

(0-36)*6

(0-39)12

(0-32.5)16

(1-38.8)13

(1-32)15

(1-33)

Ground-glass opacification, %

50 30 42 37 20 17 20

Coarseness score 8.1 10 8.3 10 10 10 10

Grade 1/2/3, n 2/2/2 1/2/3 1/5/2 0/5/2 0/3/4 0/4/3 0/3/4

Improvement/Stability/Worsening on serial HRCT

- 5/4/0 1/3/5 2/2/4 2/2/3 4/2/1 2/2/3

QUANTITATIVE HIGH RESOLUTION CT OF THE CHEST SCORING AFTER AHSCT

IN SSc Launay D et al J Rheumatol 2009;36(7):1460-3.

Grathwohl A et al for the AID WP EBMT BMT 2005; 35: 869

3 yrs survival (n = 414)

99 +3 % in 70 RA, 72 +13 % in 71 SSc 92 +5 % in 150 MS, 58 +13 % in 51 SLE

**

3. PATIENT SELECTION :3. PATIENT SELECTION :

. STEP 1 : Clinic + ECG (conduction ab arrhythmias) X-ray + renal function (CEI in SSc)

. STEP 2 :Doppler- echocardiography: LVEF <50% , diastolic dysfunction, VIT, PHT, pericardial effusion >5 mm

Holter monitoring : 24 hr , weekVEB rate >100 per hour, NSVT >3 beats, VT, atrial tachyarrythmias >30 secs, 2- 3°heart block + defibrillating PM

. STEP 3 :Right heart KT

(n = 483)

Overall Survival at 3 yrs (n= 900)

543210

1,0

0,8

0,6

0,4

0,2

0,0

98 +2 % RA (n = 89)93 +2 % MS (n = 345)87+4 % SLE (n = 85)82 +5 % JIA (n = 65)80 + 7 % HIC (n=37)80 +3% SSc (n = 137)

Progression Free SurvivalProgression Free Survival at 3 yrs (n=900)

543210

1,0

0,8

0,6

0,4

0,2

0,0

63 +4 % SSc (n = 137)55 +3 % MS (n = 345)54+6 % SLE (n = 85)52 +7% JIA (n = 65)34 + 9 % HIC (n=37)23 +5 % RA (n = 89)

Farge et al Hematologica 2010

% Day 100 TRM or Non Relapse Mortality*Non Relapse Mortality* : 5 ± 1%Time to death without relapse/progression (EBMT guidelines)

TRM Day 100

MS 2±1

SSc 6±2

RA 1±1

JIA 11±4

SLE 11±3

HIC 8±5

% TRM

Univariate Multivariate

Age>35Age<35

4±16±1

p=0.45

Year TX<2001

Year TX ≥ 2001

5±1

4±1

p=0.53

Nb AHSCT AD >13Nb AHSCT AD ≤13

3±17±1

p=0.004 p=0.003, HR: 0.3295%CI (0.16-0.69)

TBI

No TBI

3±2

5±1

p=0.58

Conditioning-Low-Intermediate-High-Not specified

4±13±15±26+1

p=0.51

Farge et al Haematologica 2010* N = 900 (ASTIS included) * N = 900 (ASTIS included)

P = 0.03

DETERMINANTS PFS : 3 yrs 55 DETERMINANTS PFS : 3 yrs 55 ±± 3%3% 5 yrs 45 5 yrs 45 ±± 4 %4 %Time to objective disease progression or deathTime to objective disease progression or death (EBMT guidelines)

3 yrs PFS

SSc 63±4

MS 55±3

RA 23±5

JIA 52±7

SLE 54±6

HICOTHER

34±946+6

3 yrs PFS %

Univariate Multivariate

Age>35Age<35

46±356±3

p=0.001 p=0.04, HR 1.3795%CI (1.1-1.7)

Year TX < 2001Year > 2001

43±359±3

p<0.001 p=0.008, HR 1.4795%CI (1.16-1.86)

Nb AHSCT AD >13Nb AHSCT AD ≤13

53±348±3

P=0.45

Purge

No purge

55±7

51+3

p=0.37

TBI

No TBI

55±7

50±2

p=0.26

Conditioning-Low

-Intermediate

-High-Not specified

46±457±346±649+4

p=0.011

P < 0.0007

Potsdam, March

DETERMINANTS 0S : 85 DETERMINANTS 0S : 85 ++ 1 % at 5 yrs1 % at 5 yrs

3 yrs 0S

MS 93±

SSc 80±

RA 98±

JIA 82±

SLE 87±

HICOTHER

80±83+

3 yrs 0S %

Univariate Multivariate

Age>35Age<35

87±2

89±2

p=0.13 p=0.01, HR 1.7295%CI (1.1-2.6)

Year TX < 2001Year > 2001

86±2

89±2

p=0.27 p=0.008, HR 1.4795%CI (1.16-1.86)

Nb AHSCT AD >13Nb AHSCT AD ≤13

83±292±1

P=0.0001 p=0.005, HR 2.5295%CI (1.33-4.79)

Bone Marrow

PBSC80±5

88+1

p=0.07 p=0.005, HR 2.5295%CI (1.33-4.79)

Diagnosis / AHSCT < median

> median

84±2

90±2

p=0.007p=0.06, HR 1.4595%CI (0.98-2.14)

Conditioning-Low

-Intermediate-High

-Not specified

87±490±383±687+4

p=0.23P < 0.0001

Potsdam, March

EBMT RETROSPECTIVE STUDIESEBMT RETROSPECTIVE STUDIES

SECONDARY AIDsBlood 2007 n = 6 /155

16 % (4/25) alemtuzumab, 1.9% (2/102) ATG 0% (0/28) no lympho-depleting A

NEJM 2007, Human Immunol 2010

⇒ Daikeler (Bood 20111)7.9 + 1 % at 3 yrs, 9.2 + 2 % at 5 yrs

LATE VIRAL INFECTIONS:VZVn= 5 / 36 (Nash Blood 2007), n= 2 /18 ISAMAIR

MYELODYSPLASIA :n= 1 at 76 mths (Nash Blood 2007)

4. SUCCESSFUL PREGNANCY1 case St Louis H 1 case St Louis H ( Clin EXp Rheum 2008) ( Clin EXp Rheum 2008)

0

500

1000

1500

2000

2500

-5 0 5 10 15 20 25 30 35 40 45 50 55 60

Time after BMT (Months)

Lym

ppho

cyte

s/bl

ood

mm

3

CD3

CD3/CD4

CD3/CD8

CD4/CD45RA

CD4/CD45RO

0

2000

4000

6000

8000

10000

sjTR

EC

/bloodm

m3

sjTREC/mm3

0 12 17 60

Bv1Bv2Bv3Bv4Bv5ABv5BBv6Bv7Bv8Bv9Bv11Bv12Bv13ABv13BBv14Bv15Bv16Bv17Bv18Bv20Bv21Bv22Bv23Bv24Bv25

PolyclonalOligoclonal

Negative

0 12 17 60

BV13A

BV9

BV17

A B

Immune Reconstitution analysisperipheral immunophenotyping,TCR excision circles values

T-cell repertoire analysisbefore and after HSCT

New onset of Myasthenia Gravis after treatment of SSc by Autologous HSCT in the context of oligoclonal T-cell expansion.sustained autoimmunity or inadequate reset of tolerance ? Deligny C et AL Human Immunology 2010

3. PATIENT SELECTION :3. PATIENT SELECTION :ORIGINAL DISEASE - STATUS before TP

• HETEROGENEITY : AID

SScSSc : visceral involvement

MS MS : reversible disability,

LEDLED : intrinsic + treatment induced Immunodefiency

• ACTIVITY vs LESION ?

COMMON EXCLUSION

CRITERIA

• PHT > 50 mmHg

• DLCO < 40% pred

• Creat cl < 40 ml/min

• LVEF < 45%, uncontrolled arrhythmia, tamponade

• Infection, cancer

• Previous CY (> 5 g)

DETERMINANTS OF CLINICAL RESPONSE ?

Verrecchia F Rheumatology 2007

Farge Arthr Rheum 2005

Launay D J Rheumatol 2009Aschwanden Daikeler et al ARD 2008

IISAMAIR SAMAIR ((SNFMI SNFMI -- SFGM) : 1998 SFGM) : 1998 –– 20032003SSc: 2 evolution patterns

0 9 months9 months

24 months

Immunosuppression

2 GROUPS OF PATIENTS (Farge BJH 2002; 119: 1-14)

• MR + ØØ relapse after 9 monthsrelapse after 9 months

•• PR or NR, immunosuppressive treatment after 9 monthsPR or NR, immunosuppressive treatment after 9 months

No Immunosuppression

9 months

24 months

No Immunosuppression

T CELL RECONSTITUTION : 3 monthsT CELL RECONSTITUTION : 3 months

1. LYMPHOCYTE IMMUNOPHENOTYPING : 1. LYMPHOCYTE IMMUNOPHENOTYPING : Flow cytometry:: absolute value + % / inclusion NaiveNaive TLTL : long half life (->20 yrs, Weng PNAS 1995) Memory TL reverse naive phenotype:Memory TL reverse naive phenotype:CD45RA+ LFA-1highCCR7low

2. IMMUNOSCOPE PROFILE:IMMUNOSCOPE PROFILE: TC R β chain spectratypingchain spectratypingGraft : T cell number + diversity + T depletionRecipient: residual T cells, thymic function,

Immunosupressive drugs, adverse side effects

3. THYMIC FUNCTION ex vivo: quantification 3. THYMIC FUNCTION ex vivo: quantification TRECs (PCR)TRECs (PCR)

Farge Farge Arth Rheum 2005; 52: 1555

AT INCLUSION: AT INCLUSION: AA (+ R(+ Responseesponse) vs ) vs BB (NR or relapse)(NR or relapse)

PATIENTS : nsRodnan : 17 +10 vs 43 +7, p < 0.03SHAQ : 0.8 +0.7vs 2.3 +0.2, p < 0.05

GRAFT : nsCD3+ cells (103 cells/kg) 4.11 +1.23

CD34+ (106 cells/kg) 7.14 +2.23

CFU-GM cells (104 cells/kg) 36.33 +41.94

Number days < 0.5 109/l WB 10 +2

Number days < 0.25 109/l Plat 9 +2

Farge Farge Arth Rheum 2005; 52: 1555

5. IMMUNE RECONSTITUTION AFTER ABMT IN SSC AA (CR, PR) vs (CR, PR) vs BB (NR, relapse)(NR, relapse) (n=14 CY alone) Farge Arthr Rheum 2005; 52: 1555Farge Arthr Rheum 2005; 52: 1555

CD19+ et CD20+ et AC anti SCL70 (r = 0.27, p<0.05)T CELL LYMPHOPENIA after HSCT predominant on CD4+, CD4+CD45RA+ :favourable SSc

*

**

**

*

5. T CELL REPERTOIRE and TREC values AFTER ABMT IN SSCAA (CR, PR) vs (CR, PR) vs BB (NR, relapse)(NR, relapse) (n=14 CY alone) Farge Arthr Rheum 2005; 52: 1555Farge Arthr Rheum 2005; 52: 1555

TREC /CRP: r = TREC /CRP: r = -- 0.41, p< 0.001, TREC / CD19+: r = 0.35, p< O.OO1 (0.41, p< 0.001, TREC / CD19+: r = 0.35, p< O.OO1 ( RA , SEP)

Sustained altered T cell homeostasis Sustained altered T cell homeostasis and abnormal R epertoire ( Crit Rev Immunol 1995) Persistence of underlying disease mechanism after H SCT?maintenanceimmunosuppression

IMMUNE RECONSTITUTION :IMMUNE RECONSTITUTION :YES WE CAN INDUCE REST OF TOLERANCEYES WE CAN INDUCE REST OF TOLERANCE

Radbruch A Ann Rheum Dis 2004; 63: 96

Immune reconstitution after AHSCT: renewal of the immune repertoire Type I : replacement of mature T/B memory repertoire with naïve, non-pathogenic cells)

Type II : reinstatement of Immune Regulation increased nb and/or function of regulatory cells

© Imperial College London

Muraro and Douek, 2006Naïve Memory Senescent

1

2

3

Pts rapidly progressive or severe SSc (n = 156 )≤≤≤≤ 4 yrs + skin score ≥≥≥≥ 15 (0-51) + involvement heart/lung/kidney

≤≤≤≤ 2 yrs + skin score ≥≥≥≥ 20 + ESR>25mm/1st hr and/or Hb<11 gr/dL

ASTIS: 2001-2011

Immunoablation + AST =

1. Mobilisation CYC4 g/m 2 ,G-CSF 10 µ g/kg2. Leukapheresis /CD34-selection

3. Conditioning C YC 200 mg/kg, ATG 7.5 mg/kgReinfusion CD34+ cells

Standard-therapy

12x monthly

i.v. pulse CYC 750 mg/m2

EFS = survival minus persistent major organ failure (heart, lung, kidney)

Exclusion criteria: Exclusion criteria: Exclusion criteria: Exclusion criteria: PHT > 50 mmHg, DLCO < 40%, creat.cl. < 40 ml/min.

LVEF < 45%; uncontrolled arhythmia; cardiac tamponade

infection, etc. previous treatment with CYCLO: >5 gr iv, >3 mths po

Accrual per centre

0

5

10

15

20

25

30

ParisLeiden

Nijmegen

Florence

AmsterdamBase

lHern

e-Trier

TubingenStra

sbourgLeedsVienna

Marseille

Grenoble

Freiburg

ToulouseWurzb

urgBordeauxClerm

FerrFerra

raFrankfu

rtLeuve

nLille

Montreal

Montpellie

r

Thessalo

nikiMilan

Middlesbrough

Accrual ASTIS trial

0

25

50

75

100

125

150

3/22

/200

13/

22/2

002

3/22

/200

33/

22/2

004

3/22

/200

53/

22/2

006

3/22

/200

73/

22/2

008

3/22

/200

9

date

num

ber of

pat

ient

s

France: 49; Netherlands: 54Germany: 20; Italy: 16Switzerland: 7, UK: 5Austria:3, Belgium :1 Canada: 1Greece: 1

156 SSc: 79 SCT+77 controls in 27 centers

Randomized (n=156)Randomized (n=156)Randomized (n=156)Randomized (n=156)Not started treatment (n=6):Not started treatment (n=6):Not started treatment (n=6):Not started treatment (n=6):---- Low DLCO (n = 2)

- Died (n = 1; disease progression)- MOF (n=1)

- Withdrawal (n=2) → died later (1)

Early Termination (n=32):Early Termination (n=32):Early Termination (n=32):Early Termination (n=32):---- Died (n=15):Died (n=15):Died (n=15):Died (n=15):

▪ Disease progression (n=5)▪ Procedure-related (n=8)▪ Others (n=2)

---- NonNonNonNon----compliance (n=7 , 2 died later)compliance (n=7 , 2 died later)compliance (n=7 , 2 died later)compliance (n=7 , 2 died later)---- AEs (n=6AEs (n=6AEs (n=6AEs (n=6→→→→ 3 died later )3 died later )3 died later )3 died later )---- MOF (n=4MOF (n=4MOF (n=4MOF (n=4 →→→→ 3 died later )3 died later )3 died later )3 died later )

Started Treatment Started Treatment Started Treatment Started Treatment (n=150)(n=150)(n=150)(n=150)

Completed 24M Completed 24M Completed 24M Completed 24M Study (n=95)Study (n=95)Study (n=95)Study (n=95)

Still in 24M FU Still in 24M FU Still in 24M FU Still in 24M FU (n=23)(n=23)(n=23)(n=23)

Completed 84M Completed 84M Completed 84M Completed 84M Study (n=17Study (n=17Study (n=17Study (n=17))))

Died >24M et < 84M (n=9):Died >24M et < 84M (n=9):Died >24M et < 84M (n=9):Died >24M et < 84M (n=9):▪▪▪▪ Disease progression (n=3)▪ MOF (n=4)▪ Sudden death (n=2)

Still in 84M FU Still in 84M FU Still in 84M FU Still in 84M FU (n=69)(n=69)(n=69)(n=69)

Died >84M FU (n=1): Died >84M FU (n=1): Died >84M FU (n=1): Died >84M FU (n=1):

Secondary leukaemia

Overall survival ASTIS

-cohort, Oct 2010AE episodes ~ WHO toxicity AE episodes ~ WHO toxicity AE episodes ~ WHO toxicity AE episodes ~ WHO toxicity

grading grading grading grading Grade 0 32Grade I 40Grade II 119Grade III 53Grade IV 44 incl

2x EBV lymphoma (1 fatal, 1 treated),Respiratory failure due to ATG

Number of pts with SAENumber of pts with SAENumber of pts with SAENumber of pts with SAE23/43 in TP group vs 16/48 in control group

METANALYSIS CYCLO orally or iv Nanini C Arthritis Research & Therapy 2008

A new Bone Marrow Transplantation Method for Stem cell Disorders…PERFUSION METHOD + INTRA BONE IKEHARA S Ann N Y Acad Sci 2009; 1173: 774

A new concept for AD disorders

MSC in AID: Multipotent Mesenchymal Stromal CellTripotential for differentiation into: osteo. adipo and chondrogenic cells

Friedenstein,AJ Exp Hematol 1976 -> Horowitz and Le Blanc Cytotherapy, 2005

• Adherent (CFU-F)• Fibroblast- like morphology• (+) Adhesion molecules:CD73, CD 90, CD105

• (-) Hematopoietic cell markers: CD14/CD11a, CD34, CD 45,CD19, HLA-II

MSC in AID: WHICH RATIONALE ?Growth factors and cytokines synthesis

• Sources:Bone marrow, Fat,

Umbilical cord,

Placental membranes,

Amniotic fluid epithelial

Synovial membrane

• Self renewal+ differentiation capacities

CSM

SDF-1, PDGF, FGF-2, IL-6, IL-7, IL-8, IL-11, SCF, MCP-1, TGFb, M-CSF, GM-CSF

Hematopoïesis

Cellular interactions

Angiogenesis

Modulation IR

Regenerative medicine : repair of damaged tissue ? Immunomodulation : homing to inflammed tissue then antiinflammatory effects

MSC TO TREAT AID? REGULATION OF THE IMMUNE RESPONSE

(-) T cell proliferation

(-) B cellsproliferation and differenciation

(-) DCdifferenciation and maturation

Depending on MSC dose

Soluble factorsTGF-β, β, β, β, PGE2

IDO, HGF

Cellular contacts

(-) entry In phase S

stop cell cycle in phase G0/G1 Soluble factors

dependant

↓ expression chemokines (CXCR4/CXCL12CXCR5/CXCL13)

MSC

Treg induction

(-) NK cellsproliferation and cytotoxicity

Soluble factorsPGE2 , TGF-ββββ

IDO

Cellular contacts

↓ IFN-gproduction

↓ CD11c, CD83,CMH classe II

expression

Ssoluble factorsIL-6, PGE2

M-CSF stop cell cycle in phase G0/G1

↓ TNF-αααα, IFN-γ γ γ γ and IL-12 synthesis

0

20

40

60

80

100

120

1/250 1/50 1/10 1/2MSC/PBMC ratio

%P

BM

C re

sidu

alpr

olife

ratio

n B

0

20

40

60

80

100

120

1/250 1/50 1/10 1/2MSC/PBMC ratio

%P

BM

C re

sidu

alpr

olife

ratio

n B

0

20

40

60

80

100

120

1/250 1/50 1/10 1/2MSC/PBMC ratio

%P

BM

C re

sidu

alpr

olife

ratio

n B

SSc MSCs

ADIPOGENIC LINEAGEADIPOGENIC LINEAGE

OSTEOGENIC LINEAGEOSTEOGENIC LINEAGE

SSc

PATIENTS

CONTROLS

Normal MSC in Systemic Sclerosis (12 pts + 9 C) :phenotype, proliferation (CFU-F)+bFGF, differentiat ion, (-) CML, support hematopoiesis

0

10

20

30

40

50

C1 C2 C3 C1 C2 C3 C1 C2 C3 C1 C2 C3 C1 C2 C3

week 1 week 2 week 3 week 4 week 5

CF

C p

er w

ell

controls

patients

Controls Patients

Larghero J Ann Rheum Dis 2007

PHRC 2011 Etude observationnelle de phase I muticentrique.TRAITEMENT DES SCLERODERMIES SYSTEMIQUES SEVERES

REFRACTAIRES PAR INJECTION DE CSM ALLOGENIQUES.Objectif principal. faisabilité et tolérance des CSM allogéniques pour tt SSc réfractaireObjectifs secondaires.1) Tolérance > 3 mois après injection (pathologies malignes) morbidité survie jusqu'à 2 ans 2) Réponse clinique et efficacité sur l'évolutivité SSc: 3, 6, 9 et 12 mois après la procédure 3) Action immunomodulatrice: phénotype, numération sous populations lymphocytaires,

réponse anticorp, réponse cytokinique tous les 3 mois pendant un an puis à M18 et M24 Donneur sain, allogénique, intrafamilial.Dose de CSM injectée.1x106 CSM par kg de poids de receveur. production selon le

procédé actuellement validé et autorisé par l’Afssaps.Sélection des patients.SSc grave résistante au cyclophosphamide iv à fortes doses (soit en

bolus mensuels au moins 6 mois soit par intensification et autogreffe de Cellules Souches Hématopoïétiques) ou SSc avec atteinte pulmonaire fibrosante menaçant le pronostic vital avec exclusion d’une possible greffe pulmonair

20 patients inclus sur 3 ans.Analyse Statistique.10 ts à la dose initiale de 1x106 CSM par kg de poids de receveur seront inclus. 10 patients suivants seront inclus à la dose :- 0.5x106 CSM par kg si il y a une haute probabilitéde toxicité excessive à la dose 1x106

CSM par kg - 3x106 CSM par kg si il y a une faible probabilité de toxicité excessive 1x106 CSM par kg - 1x106 CSM par kg si aucun des critères précédent n’est rempli

3 non interventional studies : MS, SSc, Crohn’s

5 Retrospective studies : Infection, Pediatrics, Immune Biology, HLA, Economy

5 prospective trials: 3 on-going or closed Phase II IASTIC (36 /48 Recruiting closed) on Crohn’s disease

ASTIS on scleroderma (156 pts recruited, end of follow up: Oct 2011) ASTIMS on multiple sclerosis (21 pts recruited, end of follow up: June)

2 in preparationASTIL Phase II (EBMT approved 80 000€ credited, ethics committee submission)

ASTID Phase III on diabetes (50 000 €) with Chicago and Brazil

ADWP prospective clinical trials: www.ebmt.org+ EULAR + ECCO + ECTRIMS + CIBMTR + CHICAGO + ASIA

GENEVE EBMT 15 DECEMBER 2011

THANKS EBMT OFFICERSParis, London, Barcelona, Leyden