Cell therapy

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Adoptive T-cell therapy. Cancer specific T-cells can be obtained by fragmentation and isolation of tumour infiltrating lymphocytes, or by genetically engineering cells from peripheral blood. The cells are activated and grown prior to transfusion into the recipient (tumour bearer). Adoptive T-cell therapy.png
Adoptive T-cell therapy. Cancer specific T-cells can be obtained by fragmentation and isolation of tumour infiltrating lymphocytes, or by genetically engineering cells from peripheral blood. The cells are activated and grown prior to transfusion into the recipient (tumour bearer).

Cell therapy (also called cellular therapy, cell transplantation, or cytotherapy) is a therapy in which viable cells are injected, grafted or implanted into a patient in order to effectuate a medicinal effect, [1] for example, by transplanting T-cells capable of fighting cancer cells via cell-mediated immunity in the course of immunotherapy, or grafting stem cells to regenerate diseased tissues.

Contents

Cell therapy originated in the nineteenth century when scientists experimented by injecting animal material in an attempt to prevent and treat illness. [2] Although such attempts produced no positive benefit, further research found in the mid twentieth century that human cells could be used to help prevent the human body rejecting transplanted organs, leading in time to successful bone marrow transplantation as has become common practice in treatment for patients that have compromised bone marrow after disease, infection, radiation or chemotherapy. [3] In recent decades, however, stem cell and cell transplantation has gained significant interest by researchers as a potential new therapeutic strategy for a wide range of diseases, in particular for degenerative and immunogenic pathologies.

Background

Charles-Edouard Brown-Sequard - tried to stop aging by injecting animal testicle extract. Charles-Edouard Brown-Sequard.jpg
Charles-Édouard Brown-Séquard  – tried to stop aging by injecting animal testicle extract.

Cell therapy can be defined as therapy in which cellular material is injected or otherwise transplanted into a patient. [1] The origins of cell therapy can perhaps be traced to the nineteenth century, when Charles-Édouard Brown-Séquard (1817–1894) injected animal testicle extracts in an attempt to stop the effects of aging. [2] In 1931 Paul Niehans (1882–1971) – who has been called the inventor of cell therapy – attempted to cure a patient by injecting material from calf embryos. [1] Niehans claimed to have treated many people for cancer using this technique, though his claims have never been validated by research. [1]

In 1953 researchers found that laboratory animals could be helped not to reject organ transplants by pre-inoculating them with cells from donor animals; in 1968, in Minnesota, the first successful human bone marrow transplantation took place. [3] In more recent work, cell encapsulation is pursued as a means to shield therapeutic cells from the host immune response. Recent work includes micro-encapsulating cells in a gel core surrounded by a solid, but permeable, shell. [4]

Bone marrow transplants are the most common and well established cell transplantation therapies. The first recording of a successful bone marrow transplant, dates back to 1956 by dr. E Donnall Thomas, who treated a leukemia patient with their twin-siblings bone marrow. [5] In general, for patients presenting damaged or destroyed bone marrow, for example after chemotherapy and/or radiation for acute myeloid leukemia (AML), bone marrow derived cells can be infused into the patients blood stream. Here the injected cells are able to home into the affected bone marrow, integrate, proliferate and recover or re-establish its biological function e.g. the haematopoiesis. Annually an estimated 18,000 patients require potentially life-saving bone marrow transplants in the US. [6] For a long time, bone marrow transplantation was the only clinically applicable method of cell transplantation, however, since the 1990s, cell therapy has been investigated for a wide scale of pathologies and disorders. Cell therapy provided a novel approach to effectuate therapeutic efficacy. Previously, medical agents could only be effective by directing and inducing the patients own cells. However, in many diseases and disorders, cell are compromised by e.g. senescence, limited blood supply (ischemia), inflammation, or simply a reduction in the number of cells. Cell therapy offers a new strategy that supports the introduction of new and active cells to restore previously compromised or deteriorated tissue- and organ structures. As such, in recent times, cell therapy has been recognized as an important field in the treatment of human disease, [7] and investigations are ongoing in articular cartilage, [8] brain tissue, [9] spine, [10] heart, [11] cancers, [12] etc. As a consequence cell therapy as a strategy has been attracting significant investments by commercial entities which suggest strong prospects for future growth. [13] [14]

In 2021 Atara biotherapeutics became the first ever allogeneic T cell therapy company to be reviewed by any regulatory agency in the world (EMA)

Mechanisms of action

Cell therapy is targeted at many clinical indications in multiple organs and by several modes of cell delivery. Accordingly, the specific mechanisms of action involved in the therapies are wide-ranging. However, there are two main principles by which cells facilitate therapeutic action:

  1. Stem, progenitor, or mature cell engraftment, differentiation, and long-term replacement of damaged tissue. In this paradigm multipotent or unipotent cells differentiate into a specific cell type in the lab or after reaching the site of injury (via local or systemic administration). These cells then integrate into the site of injury, replacing damaged tissue, and thus facilitate improved function of the organ or tissue. An example of this is the use of cells to replace cardiomyocytes after myocardial infarction, [15] [16] to facilitate angiogenesis in ischemic limb disease, [17] or the production of cartilage matrix in intervertebral disc degeneration. [18] [19]
  2. Cells that have the capacity to release soluble factors such as cytokines, chemokines, and growth factors which act in a paracrine or endocrine manner. These factors facilitate self-healing of the organ or region by inducing local (stem) cells or attracting cells to migrate towards the transplantation site. Early cell passages have been shown to be more efficient paracrine activity than later passages. [20] [21] The delivered cells (via local or systemic administration) remain viable for a relatively short period (days-weeks) and then die. This includes cells that naturally secrete the relevant therapeutic factors, or which undergo epigenetic changes or genetic engineering that causes the cells to release large quantities of a specific molecule. Examples of this include cells that secrete factors which facilitate angiogenesis, anti-inflammation, and anti-apoptosis. [22] [23] [24] This mode of action is proposed by companies such as Pluristem and Pervasis that use adherent stromal cells or mature endothelial cells to treat peripheral artery disease and arteriovenous access complications. [25] [26]

Cell therapy strategies

Allogeneic

In allogeneic cell therapy the donor is a different person to the recipient of the cells. [27] In pharmaceutical manufacturing, the allogenic methodology is promising because unmatched allogenic therapies can form the basis of "off the shelf" products. [28] There is research interest in attempting to develop such products to treat conditions including Crohn's disease [29] and a variety of vascular conditions. [30]

Autologous

In autologous cell therapy, cells are transplanted that are derived from the patients own tissues. Multiple clinical studies are ongoing that obtain stromal cells from bone-marrow, adipose tissue, or peripheral blood to be transplanted at sites of injury or stress; which is being actively explored for e.g. cartilage [31] and muscle [32] repair. It could also involve the isolation of matured cells from diseased tissues, to be later re-implanted at the same or neighboring tissues; a strategy being assessed in clinical trials for e.g. the spine in preventing disc reherniation or adjacent disc disease. [33] [34] The benefit of an autologous strategy is that there is limited concern for immunogenic responses or transplant rejection. Nevertheless, an autologous strategy is often costly due to patient-by-patient processing, thus preventing the option to create large quality-controlled batches. Moreover, autologous strategies generally do not allow for product quality and effectiveness testing prior to transplantation, as it is highly donor (thus patient) dependent. This is a particular concern as often the patient functioning as donor is diseased, and this can impact cell potency and quality.

Xenogeneic

In xenogeneic cell therapies, the recipient will receive cells from another species. For example, the transplantation of pig derived cells to humans. Currently, xenogeneic cell therapies primarily involve human cell transplantation into experimental animal models for assessment of efficacy and safety, [17] however future advances could potentially enable xenogeneic strategies to humans as well. [35]

Types of cells

Human embryonic stem cells

Research into human embryonic stem cells is controversial, and regulation varies from country to country, with some countries banning it outright. Nevertheless, these cells are being investigated as the basis for a number of therapeutic applications, including possible treatments for diabetes [36] and Parkinson's disease. [37]

Neural stem cell therapy

Neural stem cells (NSCs) are the subject of ongoing research for possible therapeutic applications, for example for treating a number of neurological disorders such as Parkinson's disease and Huntington's disease. [38]

Mesenchymal stem cell therapy

MSCs are immunomodulatory, multipotent and fast proliferating and these unique capabilities mean they can be used for a wide range of treatments including immune-modulatory therapy, bone and cartilage regeneration, myocardium regeneration and the treatment of Hurler syndrome, a skeletal and neurological disorder. [39]

Researchers have demonstrated the use of MSCs for the treatment of osteogenesis imperfecta (OI). Horwitz et al. transplanted bone marrow (BM) cells from human leukocyte antigen (HLA)-identical siblings to patients with OI. Results show that MSCs can develop into normal osteoblasts, leading to fast bone development and reduced fracture frequencies. [40] A more recent clinical trial showed that allogeneic fetal MSCs transplanted in utero in patients with severe OI can engraft and differentiate into bone in a human fetus. [41]

Besides bone and cartilage regeneration, cardiomyocyte regeneration with autologous BM MSCs has also been reported recently. Introduction of BM MSCs following myocardial infarction (MI) resulted in significant reduction of damaged regions and improvement in heart function. Clinical trials for treatment of acute MI with Prochymal by Osiris Therapeutics are underway. Also, a clinical trial revealed huge improvements in nerve conduction velocities in Hurler's Syndrome patients infused with BM MSCs from HLA-identical siblings. [42]

Hematopoietic stem cell transplantation

Hematopoietic stem cells (HSCs), derived from bone marrow or blood, are cells with the abilities to self-renew and to differentiate into all types of blood cells, especially those involved in the human immune system. Thus, they can be used to treat blood and immune disorders. Since human bone marrow grafting was first published in 1957, [43] there have been significant advancements in HSCs therapy. Following that, syngeneic marrow infusion [44] and allogeneic marrow grafting [45] were performed successfully. HSCs therapy can also render its cure by reconstituting damaged blood-forming cells and restoring the immune system after high-dose chemotherapy to eliminate disease. [46]

There are three types of HSC transplantation: syngeneic, autologous, and allogeneic transplants. [39] Syngeneic transplantations occur between identical twins. Autologous transplantations use the HSCs obtained directly from the patient and hence avoid complications of tissue incompatibility; whereas allogeneic transplantations involve the use of donor HSCs, either genetically related or unrelated to the recipient. To lower the risks of transplant, which include graft rejection and graft-versus-host disease (GVHD), allogeneic HSCT must satisfy compatibility at the HLA loci (i.e. genetic matching to reduce the immunogenicity of the transplant).

In addition to bone marrow-derived HSCs, the use of alternative sources such as umbilical cord blood (UCB) and peripheral blood stem cells (PBSCs) has been increasing. In comparison with bone marrow-derived HSC recipients, PBSC recipients who had myeloid malignancies reported a faster engraftment and better overall survival. [47] The use of UCB requires less stringent HLA loci matching, although the time of engraftment is longer and graft failure rate is higher. [48] [49]

Differentiated or mature cell transplantation

Alternative to stem- or progenitor cells, investigations are exploring the transplantation of differentiated cells that only possess low or no proliferation ability. This tends to involve specialized cells able to facilitate specific function in the patients body (for example, transplantation of cardiomyocytes [50] to repair heart function or islet cell transplantation [51] for establishing insulin homeostasis in diabetes patients) or support/regenerate the extracellular matrix production of specific tissues (for example intervertebral disc repair by transplanting chondrocytes [10] ).

Alternative medicine

In alternative medicine, cell therapy is defined as the injection of non-human cellular animal material in an attempt to treat illness. [1] Quackwatch labels this as "senseless", since "cells from the organs of one species cannot replace the cells from the organs of other species" and because a number of serious adverse effects have been reported. [52] Of this alternative, animal-based form of cell therapy, the American Cancer Society say: "Available scientific evidence does not support claims that cell therapy is effective in treating cancer or any other disease. It may in fact be lethal ...". [1]

Manufacturing

Despite being one of the fast growing areas within Life Sciences, [53] the manufacturing of cell therapy products is largely hindered by small scale batches and labour-intensive processes. [54]

A number of manufacturers are turning to automated methods of production, eliminating human involvement and risk of human error. Automated methods of cell therapy manufacturing have opened up larger scale production of higher quality products at lower cost. [55]

Supply chain

Logistics departments of biopharma companies experience new obstacles because of the introduction of new cell and gene therapy products, such as CAR T-cell therapies and allogeneic therapies. Cell and gene therapies require manufacturer and distributors alike to implement new systems and processes in order to ensure safe handling and delivery. Additionally, on-demand inventory therefore becomes more and more important, especially with regard to unforeseeable events like the COVID-19 pandemic, so that supply chain interruptions can be prevented. [56] Furthermore recent changes as a result of the COVID 19 pandemic and political instability in Europe, secondary to Brexit, have further impacted the logistics chain for cellular therapies. [57]

See also

Related Research Articles

<span class="mw-page-title-main">Stem cell</span> Undifferentiated biological cells that can differentiate into specialized cells

In multicellular organisms, stem cells are undifferentiated or partially differentiated cells that can differentiate into various types of cells and proliferate indefinitely to produce more of the same stem cell. They are the earliest type of cell in a cell lineage. They are found in both embryonic and adult organisms, but they have slightly different properties in each. They are usually distinguished from progenitor cells, which cannot divide indefinitely, and precursor or blast cells, which are usually committed to differentiating into one cell type.

<span class="mw-page-title-main">Bone marrow</span> Semi-solid tissue in the spongy portions of bones

Bone marrow is a semi-solid tissue found within the spongy portions of bones. In birds and mammals, bone marrow is the primary site of new blood cell production. It is composed of hematopoietic cells, marrow adipose tissue, and supportive stromal cells. In adult humans, bone marrow is primarily located in the ribs, vertebrae, sternum, and bones of the pelvis. Bone marrow comprises approximately 5% of total body mass in healthy adult humans, such that a man weighing 73 kg (161 lbs) will have around 3.7 kg (8 lbs) of bone marrow.

<span class="mw-page-title-main">Hematopoietic stem cell transplantation</span> Medical procedure to replace blood or immune stem cells

Hematopoietic stem-cell transplantation (HSCT) is the transplantation of multipotent hematopoietic stem cells, usually derived from bone marrow, peripheral blood, or umbilical cord blood in order to replicate inside of a patient and to produce additional normal blood cells. It may be autologous, allogeneic or syngeneic.

<span class="mw-page-title-main">Graft-versus-host disease</span> Medical condition

Graft-versus-host disease (GvHD) is a syndrome, characterized by inflammation in different organs. GvHD is commonly associated with bone marrow transplants and stem cell transplants.

A cord blood bank is a facility which stores umbilical cord blood for future use. Both private and public cord blood banks have developed in response to the potential for cord blood in treating diseases of the blood and immune systems. Public cord blood banks accept donations to be used for anyone in need, and as such function like public blood banks. Traditionally, public cord blood banking has been more widely accepted by the medical community. Private cord blood banks store cord blood solely for potential use by the donor or donor's family. Private banks typically charge around $2,000 for the collection and around $200 a year for storage.

<span class="mw-page-title-main">Regenerative medicine</span> Field of medicine involved in regenerating tissues

Regenerative medicine deals with the "process of replacing, engineering or regenerating human or animal cells, tissues or organs to restore or establish normal function". This field holds the promise of engineering damaged tissues and organs by stimulating the body's own repair mechanisms to functionally heal previously irreparable tissues or organs.

Cord blood is blood that remains in the placenta and in the attached umbilical cord after childbirth. Cord blood is collected because it contains stem cells, which can be used to treat hematopoietic and genetic disorders such as cancer. There is growing interest from cell therapeutics companies in developing genetically modified allogenic natural killer cells from umbilical cord blood as an alternative to CAR T cell therapies for rare diseases.

<span class="mw-page-title-main">Adult stem cell</span> Multipotent stem cell in the adult body

Adult stem cells are undifferentiated cells, found throughout the body after development, that multiply by cell division to replenish dying cells and regenerate damaged tissues. Also known as somatic stem cells, they can be found in juvenile, adult animals, and humans, unlike embryonic stem cells.

Stem-cell therapy is the use of stem cells to treat or prevent a disease or condition. As of 2016, the only established therapy using stem cells is hematopoietic stem cell transplantation. This usually takes the form of a bone-marrow transplantation, but the cells can also be derived from umbilical cord blood. Research is underway to develop various sources for stem cells as well as to apply stem-cell treatments for neurodegenerative diseases and conditions such as diabetes and heart disease.

Articular cartilage, most notably that which is found in the knee joint, is generally characterized by very low friction, high wear resistance, and poor regenerative qualities. It is responsible for much of the compressive resistance and load bearing qualities of the knee joint and, without it, walking is painful to impossible. Osteoarthritis is a common condition of cartilage failure that can lead to limited range of motion, bone damage and invariably, pain. Due to a combination of acute stress and chronic fatigue, osteoarthritis directly manifests itself in a wearing away of the articular surface and, in extreme cases, bone can be exposed in the joint. Some additional examples of cartilage failure mechanisms include cellular matrix linkage rupture, chondrocyte protein synthesis inhibition, and chondrocyte apoptosis. There are several different repair options available for cartilage damage or failure.

Articular cartilage repair treatment involves the repair of the surface of the articular joint's hyaline cartilage, though these solutions do not perfectly restore the articular cartilage. These treatments have been shown to have positive results for patients who have articular cartilage damage. They can provide some measure of pain relief, while slowing down the accumulation of damage, or delaying the need for joint replacement surgery.

Mesenchymal stem cells (MSCs) are multipotent cells found in multiple human adult tissues, including bone marrow, synovial tissues, and adipose tissues. Since they are derived from the mesoderm, they have been shown to differentiate into bone, cartilage, muscle, and adipose tissue. MSCs from embryonic sources have shown promise scientifically while creating significant controversy. As a result, many researchers have focused on adult stem cells, or stem cells isolated from adult humans that can be transplanted into damaged tissue.

<span class="mw-page-title-main">Mesenchymal stem cell</span> Multipotent, non-hematopoietic adult stem cells present in multiple tissues

Mesenchymal stem cells (MSCs) also known as mesenchymal stromal cells or medicinal signaling cells are multipotent stromal cells that can differentiate into a variety of cell types, including osteoblasts, chondrocytes, myocytes and adipocytes.

Adult mesenchymal stem cells are being used by researchers in the fields of regenerative medicine and tissue engineering to artificially reconstruct human tissue which has been previously damaged. Mesenchymal stem cells are able to differentiate, or mature from a less specialized cell to a more specialized cell type, to replace damaged tissues in various organs.

Graft-versus-tumor effect (GvT) appears after allogeneic hematopoietic stem cell transplantation (HSCT). The graft contains donor T cells that can be beneficial for the recipient by eliminating residual malignant cells. GvT might develop after recognizing tumor-specific or recipient-specific alloantigens. It could lead to remission or immune control of hematologic malignancies. This effect applies in myeloma and lymphoid leukemias, lymphoma, multiple myeloma and possibly breast cancer. It is closely linked with graft-versus-host disease (GvHD), as the underlying principle of alloimmunity is the same. CD4+CD25+ regulatory T cells (Treg) can be used to suppress GvHD without loss of beneficial GvT effect. The biology of GvT response is still not fully understood but it is probable that the reaction with polymorphic minor histocompatibility antigens expressed either specifically on hematopoietic cells or more widely on a number of tissue cells or tumor-associated antigens is involved. This response is mediated largely by cytotoxic T lymphocytes (CTL) but it can be employed by natural killers as separate effectors, particularly in T-cell-depleted HLA-haploidentical HSCT.

<span class="mw-page-title-main">Haematopoietic system</span>

The haematopoietic system is the system in the body involved in the creation of the cells of blood.

Guo Mei is a hematologist and associate director of 307th Hospital of Chinese People’s Liberation Army and deputy director of Radiation Research Institute.

<span class="mw-page-title-main">Shimon Slavin</span> Israeli professor of medicine

Shimon Slavin is an Israeli professor of medicine. Slavin pioneered the use of immunotherapy mediated by allogeneic donor lymphocytes and innovative methods for stem cell transplantation for the cure of hematological malignancies and solid tumors, and using hematopoietic stem cells for induction of transplantation tolerance to bone marrow and donor allografts.

Craniofacial regeneration refers to the biological process by which the skull and face regrow to heal an injury. This page covers birth defects and injuries related to the craniofacial region, the mechanisms behind the regeneration, the medical application of these processes, and the scientific research conducted on this specific regeneration. This regeneration is not to be confused with tooth regeneration. Craniofacial regrowth is broadly related to the mechanisms of general bone healing.

<span class="mw-page-title-main">Stem cell fat grafting</span>

Stem cellfat grafting is autotransplantation of adipose-derived stem cells (ADSCs) extracted from fat-abundant donor sites to other areas such as the face, breast, and hip to reconstruct the operative areas into desirable shapes. ADSCs are multipotent stem cells found in adipose tissues, displaying similar differentiation potentials to bone marrow-derived mesenchymal stem cells (BM-MSCs).

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