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Novel Bone Marrow ‘Ingredient’ To Help Arthritic Horses The Horse –

By daniellenierenberg

Regenerative therapies such as stem cells and platelet-rich plasma already play an important role in managing osteoarthritis (OA). Nonetheless, veterinarians have found that response to even these therapies is less than ideal in many cases, prompting researchers to continuously seek novel therapies for this all-too-common musculoskeletal disorder. One of the newest to be unveiled is called bone marrow mononuclear cell (BMNC) therapy. One researcher who presented at the 2020 American Association of Equine Practitioners Convention, held virtually, reported that the equine industry is in critical need for therapies that resolve joint inflammation but preserve tissue healing, and BMNC appears a promising candidate.

Much more than stem cells classically sought for cartilage healing, bone marrow is rich in macrophage progenitor cells, explained James B. Everett, DVM, MS, previously of the Virginia-Maryland College of Veterinary Medicine, who now works at the Equine Surgical Center at ThorSport Farm,in Murfreesboro, Tennessee. Macrophages are a type of white blood cell that play a role in tissue repair and cartilage integrity, and produce the anti-inflammatory mediators, including interleukin-10 (IL-10).

Everett said macrophages in the synovial (joint) membrane are essential for joint health, clearing aggressors, secreting key molecules required for optimal joint function, and forming a shield that protects tissues undergoing repair, similar to a wound scab. However, when the amount of tissue damage overwhelms these housekeeping functions, macrophages stimulate inflammation as a means of recruiting more cells, especially more macrophages, to cope with increased demands for repair.

If this response is efficiently accomplished, macrophages then produce, among other things, high concentrations of IL-10 and resolve the inflammatory process, returning the joint to a healthy state, he said.

Everett emphasized that not all inflammation is bad. This acute inflammation is essential to establish a resolving response, and anti-inflammatory therapies can negatively interfere.

As presented by Everetts colleague Bruno Menarim, DVM, PhD, in a separate session, studies show that BMNCs promote the endogenous resolution of experimentally induced inflammation. To see if these promising features translated to naturally occurring inflammation in live horses, Everetts research team studied 19 horses, dividing them into three treatment groups:

The selected horses were diagnosed with OA in a single joint, and the team injected those joints once with the saline, triamcinolone, or BMNCs. The BMNCs were autologous, meaning veterinarians collected them from each patients own bone marrow aspirate. They processed the aspirate in-house, and the isolated mononuclear cells, composed predominantly of macrophages, were ready to inject into the affected joint within three hours of aspiration.

We found that while objectively assessed lameness (via Lameness Locator) decreased in all three groups, it was only significant in the BMNC-treated horses, said Everett. Further, the treatment was well-tolerated with no adverse events appreciated in this study.

He said that using BMNCs can help reduce the need for chronic use of non-steroidal anti-inflammatory drugs and corticosteroids, which produces potentially harmful consequences. Further, BMNCs preserve the production of molecules such as interleukins and cytokines that are essential for restoring joint homeostasis. Corticosteroids often inhibit these molecules.

The researchers noted that these results support a larger clinical trial using BMNCs in clinical cases of equine OA.

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Why Cynata is hopeful its COVID treatment trial will succeed where others have failed – Business News Australia

By daniellenierenberg

Cynata Therapeutics (ASX: CYP), founded by two clever stem cell researchers and one wise Australian techpreneur, is in the process of developing a treatment for COVID-19.

Using its in-house stem cell technology Cymerus, the ASX-listed biotech hopes to treat one of the deadliest complications of COVID-19 -acute respiratory distress syndrome (ARDS).

In doing so Cynata would achieve what competitor Mesoblast (ASX: MSB) couldn't with FDA approval.

By deploying an industrialised approach to stem cell therapeutics, Cynata CEO Ross Macdonald (pictured) is confident the clinical trial process won't leave the company hamstrung.

In 1981 scientists discovered a way to derive embryonic stem cells from early mouse embryos.

The discovery thrilled scientists, and eventually led to the development of a method to do the same in lab-grown human embryos by 1998.

While there have been plenty of discussions surrounding the ethics of using of embryonic stem cells, these major scientific movements have pushed researchers to discover new and inventive ways of treating a whole raft of diseases and infections.

One such researcher, Dr Ian Dixon, saw potential for the use of mesenschymal stem cells (MSCs) - a type of stem cell that can differentiate into a variety of cell types enabling the treatment of many diseases and infections.

However there was still an obstacle to overcome: how do you mass produce enough cells needed to commercialise a treatment?

Luckily, two researchers at the University of Wisconson, Professor Igor Slukvin and Dr Maksym Vodyanik, had invented a biotechnological breakthrough called Cymerus.

The technology was able to do exactly what Dixon needed: the consistent manufacture of MSCs on an ultra-large scale; basically what Henry Ford did to the industrialisation of the auto industry, but for stem cells.

So in 2003 Dixon partnered with the two researchers to start Cynata - now an ASX-listed biotechnology company trialing a number of different treatments for a wide variety of ailments.

Most recently, Cynata's focus has been on developing a treatment for a complication of COVID-19 called acute respiratory distress syndrome (ARDS).

The complication ravages COVID-19 infected patients, destroying their organs through what is known as a cytokine storm. The complication is estimated to kill up to half of COVID-19 patients that suffer from it.

Melbourne-based Cynata is currently in the very early stages of its investigation into whether its MSCs will be able to treat the coronavirus complication overwhelming hospitals globally.

If this all sounds familiar, you might be thinking of another ASX-listed biotech called Mesoblast (ASX: MSB).

In March last year Mesoblast, also based in Melbourne, saw its shares surge after announcing plans to evaluate its stem cell treatment solutions on COVID-19 patients.

The group commenced the arduous clinical trial process to see if its remestemcel-L therapy could treat ARDS by using bone marrow aspirate from healthy donors - a similar approach the company had already taken to treat a condition many suffer from after receiving bone marrow transplants.

Mesoblast was riding high on the ASX following positive announcements surrounding the clinical traila process, especially back in April 2020 when a trial at New York City's Mt Sinai hospital found its remestemcel-L therpay achieved "remarkable" results.

Serious attention gathered around Mesoblast, with the company even securing $138 in funds from investors to continue its important research.

The company went so far as to sign a commercialisation deal for the COVID-19 treatment with Novartis, and the US Food and Drugs Administration (FDA) fast tracked the approvals process for the potential game-changing treatment.

However, in December 2020, Mesoblast hit a stumbling block.

Mesoblast's COVID-19 treatment flunked the test - its remestemcel-L therapy failed to show a lower mortality rate for patients in the prescribed 30-day timeframe of treatment.

At that point Cynata had commenced research into its own ARDS treatment. But did Mesoblast's failure unnerve Cynata CEO Ross Macdonald? Not a chance.

"I'm more confident that our trial will be successful where theirs was a failure," Macdonald said.

"If you use a process like we have developed - we don't rely on multiple different [stem cell] donations. You start with exactly the same material every time."

To explain, Macdonald used the analogy of a local caf; you normally expect a coffee from one caf to taste more or less exactly the same every time you go there - the same beans are used every time.

Whereas Macdonald said Mesoblast's process is like going to the same caf every day, but each visit they use different beans from a different supplier which leads to inconsistency in taste and flavour.

Cynata's approach with its MSCs is in line with the first example - what you get the first time from them will be replicated in each and every dose of the drug - while MSB's is like the latter.

"Yes, you still got the coffee, but the experience of the taste is totally different than it was yesterday," he said.

"The FDA said to Mesoblast, well you've got a manufacturing problem that is reliant upon multiple donors prepared to donate bone marrow and that is flawed.

"So with that in mind it's perhaps not surprising that they had a pretty disappointing result in the clinical trials."

Additionally, Macdonald said the initial investor reactions to MSB's early COVID-19 trail results were overblown.

"The initial data from their trial that got everybody excited was, in my view, quite flawed, because they said "look at how many patients are dying in intensive care units with COVID compared the patients that we treated," he said.

"But the reality of the situation was quite different. The control group at that time - the death rate was way, way higher than you would typically see for ARDS, whether its COVID or anything else. And it was simply because of the chaos that existed in intensive care units in New York in the first wave.

"So we think that the initial enthusiasm was perhaps a little misguided."

When asked why Mesoblast is receiving so much attention compared to Cynata, especially considering the above, Macdonald said it was simply because MSB is bigger and has been around for longer. For context, MSB has a market capitalisation of $1.46 billion, whereas Cynata's is just $94.56 million.

"I'd love to know why there is less attention, and how we can get our market cap above a billion dollars," joked Macdonald.

"I think the answer though is that they've been around for a lot longer than we have, they have spent a hell of a lot more money than we've spent - their monthly spend is more than we've spent for pretty much our entire existence.

"But I think the fundamental reason why is that data drives value in biotech, so the more clinical data you generate that shows your product works, the more attention you attract from investors."

That's not to say Cynata is being totally ignored in favour of the larger Mesoblast.

The company secured a $15 million placement led by $10 million from healthcare investor BioScience Managers in December.

The funds will be used to expand Cynata's clinical development pipeline and scale their operations in Australia.

As such, the company is preparing to expand its clinical development pipeline to include idiopathic pulmonary fibrosis, renal transplantation, and diabetic foot ulcers.

"So we're starting to garner that attention now that says two things - one, cell therapies are definitely a medical revolution and two, Cynata is part of that new generation of companies," Macdonald said.

As for the company's pipeline, in addition to the COVID treatment trials, Cynata is planning on launching three new clinical candidates that will get under way this year.

There's also Cynata's osteoarthritis trial, which Macdonald describes as significant for the biotech company; with 2 million patients in Australia and 30 million in the United States the company is hoping to tap into an $11 billion plus addressable market.

"It will ultimately show whether MSCs are useful in that particularly devastating condition," he said.

"It doesn't just affect people who want to go and play golf or tennis, it affects, particularly manual labourers who can no longer work.

"So the cost to the economy of osteoarthritis is quite significant, which is of course one of the reasons why the Australian Government is funding this trial."

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Helping others helps Havard through sickness | Community | – The Franklin Sun

By daniellenierenberg

As an athlete, Courtlynn Havard has always set goals for herself to improve her game whether on the soccer or softball field. She has worked toward those goals through hard work and perseverance.

Now her goals have shifted slightly.

Courtlynn, a sophomore at Franklin Parish High School, currently has two main goals: to beat aplastic anemia and paroxysmal nocturnal hemoglobinuria (PNH) and to help others.

Helping others for Courtlynn brightens her day, strengthens her and gives her hope for a better tomorrow.

From that desire to help others, the Havard family is sponsoring a bone marrow drive at Life Church in Winnsboro Feb. 20 from 10 a.m. until 2 p.m.

The drive will be administered by DKMS, an international nonprofit organization, whose goal is to find bone marrow donors for people like Havard.

It is simple as a swab in your cheek, said Jaimie Havard, Courtlynns mother. That could save a life. It only takes a minute and is so easy for you to give somebody a second chance on life.

Anyone 18-55 with good health can participate in the drive. Participates stay in their car, watch a video on their phone and fill out a short form, said Amy Roseman of DMKS.

They are given a kit with a swap for their cheeks. The whole process takes 7-10 minutes.

Interested people can also go to to order a free kit.

In October, Courtlynn went to the doctor with kidney stones. When doctors took her blood, they found her blood count was low.

Her mother and Courtlynn met with an oncologist who gave them disturbing news.

At first the oncologist thought it was leukemia, Jaimie said. You feel like your whole world is collapsing. I didnt know what to say or do. Courtlynn was devastated and crying. I was trying to be strong for her.

The Havards were then sent to LSU Health Shreveport. The medical professionals there performed a bone marrow biopsy and found she had aplastic anemia and PNH.

You never think it can be your child, Jaimie said. It is really an unbelievable, indescribable feeling.

Aplastic anemia is a condition that occurs when your body stops producing enough new blood cells, according to the Mayo Clinic. The condition leaves a person fatigued and more prone to infections and uncontrolled bleeding.

A rare and serious condition, aplastic anemia can develop at any age. It can occur suddenly, or it can come on slowly and worsen over time and can be mild or severe.

Treatment for aplastic anemia might include medications, blood transfusions or a stem cell transplant, also known as a bone marrow transplant.

PNH is a rare acquired, life-threatening disease of the blood. The disease is characterized by destruction of red blood cells (hemolytic anemia), blood clots (thrombosis), and impaired bone marrow function (not making enough of the three blood components).

PNH affects 1-1.5 persons per million of the population and is primarily a disease of younger adults. The median age of diagnosis is 35-40 years of age, with occasional cases diagnosed in childhood or adolescence. PNH is closely related to aplastic anemia.

Courtynns world use to evolve around sports, mud riding with her friends and being very social.

Now because of her weak immune system, she has to be careful and stay at home with her English Spaniel, Old Mack, and go to school virtually. Courtlynn talks to her friends via cell phone, computer and occasionally gets a visit from one that sits on her porch while she socially distances.

I missed my friends the most, Courtlynn said. I am one of those people that get up and go. I dont stay still.

She also goes to doctors whether it be locally to get her blood count tested, or Shreveport to receive platelets and blood or Memphis to St. Judes.

Saving people around the world

One thing that drives Courtlynn through this situation is keeping up with other kids situations, Jaimie said. There are so many stories out there of kids looking for bone marrow transplants.

The Feb. 20 bone marrow drive is a way Courtlynn and her family can help others.

DKMS has been finding matching bone marrow donors for 30 years. They are now in the United States, Germany, Poland, India and South Africa.

Sadly, only 2 percent of Americans have signed up as potential donors, Roseman said. We are hoping we will have really nice support for Courtlynn and the other patients looking for donors.

Reasons vary for the low percentage of potential donors, but Roseman attributes not knowing the need and ease of the process.

You fill out contact information, swap your cheeks and you are put in a data base that is only seen by medical teams searching for donors, Roseman said. We call it, youre a hero in waiting.

The biggest misconception is the donation of bone marrow if you are a match.

You are asked to donate stem cells from the blood stream, Roseman said. It is a very easy process. It is very similar to donating plasma or platelets and takes a morning or afternoon.

Blood is taken from one arm, and the blood is put back into the other arm, Roseman, said. Stem cells lost in the process will regenerate.

You have given someone a second chance in life, Roseman said.

A person may be asked to donate actual bone marrow if he or she is matched to a three year old or younger. This procedure is done in a hospital and takes less than an hour. DKMS pays for the hospital visit and time loss from work.

It is amazing to think about giving someone a second chance on life by giving up a just morning of your time, Roseman said.

A community comes together

The Franklin Parish community has come together in support of Courtlynn and the Havard family.

Boutique shops, individuals and restaurants have come together to raise money for her cause.

During the Feb. 20 bone marrow drive at Life Church a BBQ chicken plate lunch will be on sale for $10. T-shirts will also be on sale at the event. Keep up with all drives and Courtlynns journey on her Facebook page: Courtlynns Compass.

We have a really amazing group of friends and family that have come together, Jaimie said. Our local community has stepped up big time. Complete strangers are showing so much love and support for my baby. It speaks volumes for our little town we live in.

Helping others helps Havard through sickness | Community | - The Franklin Sun

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Anti-Emetic Drug Effectively Blocks CD93 Signaling in Preclinical Evaluations, Suggesting Suitability in CML – Cancer Therapy Advisor

By daniellenierenberg

The anti-emetic agent metoclopramide blocked CD93 signaling in cell culture and delayed leukemia development in mice, according to data from a preclinical study published in Cell Reports. The results indicate that CD93 signaling, which is an important regulator of self-renewal and proliferation of murine and human leukemia stem cells (LSCs), could be a potential therapeutic target for the elimination of LSCs in chronic myeloid leukemia (CML).

To characterize the function of CD93 in CML, the researchers first demonstrated that all subsets of LSCs expressed CD93 while more differentiated leukemia granulocytes did not. Though CD93 was shown to encourage self-renewal and proliferation of murine and human LSCs, it notably had no such effect on hematopoietic stem cells.

In an experiment, the investigators injected mice with LSCs that were either proficient or deficient in CD93. Mice with CD93-deficient LSCs were found to incorporate bromodeoxyuridine, which is used to detect proliferating cells, at a lower rate than mice with CD93-proficient LSCs. The finding suggests that proliferation of LSCs is impaired when CD93 is absent.

Next, a drug library was used to screen for compounds that could block CD93 signaling. Among the 240 compounds evaluated in vitro, 10 blocked CD93 signaling; one of the compounds was the anti-emetic agent metoclopramide.

Mice were then treated with either vehicle or metoclopramide. Notably, metoclopramide-treated mice had delayed leukemia development and lived longer than vehicle-treated mice. Among the metoclopramide-receiving mice, most genes were downregulated in the LSCs, particularly genes that promote stem cell maintenance and myeloid differentiation, cell proliferation and survival, response to cytokine signaling, and gene expression.

In vitro exposure to metoclopramide was found to disrupt colony formation in human bone marrow CML stem/progenitor cells. A control experiment showed that metoclopramide had no effect on hematopoietic stem/progenitor cells from humans with healthy bone marrow.

The study authors reasoned that because metoclopramide is a very well-tolerated and cheap anti-emetic drug, its LSC-eradicating activity in patients with CML can be directly tested in clinical drug repurposing studies.


Riether C, Radpour B, Kallen NM, et al. Metoclopramide treatment blocks CD93-signaling-mediated self-renewal of chronic myeloid leukemia stem cells. Cell Rep. 2021;34(4):108663. doi:10.1016/j.celrep.2020.108663

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Anti-Emetic Drug Effectively Blocks CD93 Signaling in Preclinical Evaluations, Suggesting Suitability in CML - Cancer Therapy Advisor

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[Full text] Retrospective Study on Implantation of Autologous-Cultured Osteoblasts | ORR – Dove Medical Press

By daniellenierenberg


Osteonecrosis of the femoral head is a progressive disorder that causes pain and often progresses to hip joint collapse, finally resulting in disabling arthritis.1,2 It occurs between 30 to 50 years of age, and prevails at a relatively younger age in Asians compared to their western counterparts.3 It is estimated that approximately 20,00030,000 new cases of osteonecrosis are diagnosed in the United States each year, accounting for 10% of total hip arthroplasties performed.4 The Indian Society of Hip and Knee Surgeons has reported that more than 50% of all hip replacements in India are performed for osteonecrosis.5 Many studies have reported osteonecrosis to be more prevalent in men compared to women (3 or 5:1).3 The underlying pathophysiology of osteonecrosis remains unclear; however, it is multifactorial and several traumatic and nontraumatic etiological factors may contribute to its development. Traumatic events that may cause osteonecrosis include femoral neck/head fracture, hip dislocation, or slipped capital femoral epiphysis. Nontraumatic factors include use of steroids, alcoholism, metabolic disorders such as Cushings syndrome, and inherited disorders such as sickle cell disease.6,7 Besides the known traumatic and nontraumatic causes, some cases of osteonecrosis are idiopathic.1,8

Osteonecrosis of the femoral head may progress to secondary arthritis, and degeneration of articulating surface from advanced osteonecrosis necessitates total hip arthroplasty (THA). A primary treatment target of osteonecrosis of femoral head is to delay/prevent progression to osteoarthritis. Core decompression (CD) is the most widely used procedure in clinical practice; however, it has shown poor clinical outcomes, with up to 40% of patients having to undergo THA despite undergoing core decompression procedure.8 Therefore, a more pathophysiological approach may be required to treat osteonecrosis of femoral head. Osteonecrosis is characterized by a reduction in the osteogenic progenitor cells, an increase in osteoblast death, and altered intramedullary vascular supply due to trauma.1 It was observed that the number and function of mesenchymal cells in hematopoietic tissue and stroma of the bone marrow decreased in osteonecrosis patients.2 This observation indicated potential for using bone marrow stromal cells for the treatment of osteonecrosis, and consequently, several clinical studies have demonstrated encouraging results.2 A meta-analysis also showed that treatment with cell therapy compared to core decompression alone increased Harris hip score, decreased necrotic area of femoral head and collapse of femoral head, and reduced THA conversion rate.9 However, a recent randomized study has shown that bone marrow cell implantation in addition to core decompression did not improve THA conversion rate in patients with grade 3 osteonecrosis.10 The ideal treatment goal for osteonecrosis is to facilitate new bone formation in the place of dead bone that can provide pain relief, cease disease progression, prevent joint collapse, and preserve the joint. The fact thatbone marrow aspirate consists of mesenchymal stem cells raised a possibility if bone marrow cells could be differentiated into bone forming cells or osteoblasts and characterized by bone alkaline phosphatase. In a randomized trial, autologous osteoblast implantation was shown to significantly delay the evolution to subchondral fracture and reduce pain compared to bone marrow aspirate.11

OSSGROW (Regrow Biosciences Pvt Ltd., Mumbai, India) is a commercially available technology that involves implantation of autologous adult live-cultured osteoblasts (AALCO) derived from mesenchymal stem cells sourced from the bone marrow aspirate for osteonecrosis of the hip that received conditional marketing approval in India in March 2017.12 Here, we evaluated the efficacy of OSSGROW implantation technique by assessing retrospective data from patients with osteonecrosis who underwent the procedure. We also evaluated the correlation between Ficat-Arlet stages of osteonecrosis and clinical outcomes of the AALCO implantation procedure.

This retrospective, observational, non-comparative study was conducted at 37 centers in India. We retrospectively reviewed the data of patients with osteonecrosis of the femoral head who had undergone OSSGROW (AALCO) from 2010 to 2015. Key inclusion criteria were patients aged 12 years with a confirmed diagnosis of osteonecrosis in one or both hip joints who had undergone AALCO implantation. Diagnosis, analysis, and classification of osteonecrosis were done according to Ficat-Arlet based on radiography, computed tomography (CT) scans, and magnetic resonance imaging (MRI) findings. Patients whose medical records were not complete or were lost to follow-up were excluded from the study.

The protocol was approved by the Institutional Ethics Committee - Regrow Biosciences Pvt Ltd. and as this study was a retrospective study, informed consent was not required to review medical records. We also sought permission from the head of the institutes/departments before data collection. Patient data confidentiality was maintained in this study.

All the patients had undergone AALCO implantation on the recommendation of their consulting orthopedic surgeon after having received an explanation of the complications of osteonecrosis, the therapeutic options available, and the risks involved with the implantation procedure. Osteoblasts from patients were obtained from bone marrow aspiration from the posterior/superior iliac crest. Mesenchymal stem cells from the bone marrow were isolated and differentiated ex vivo into osteoblasts. Osteoblasts were then cultured for approximately 4 weeks under stringent laboratory conditions and multiplied up to 48 million osteoblasts (Figure 1). The cultured cells were implanted using a gel (Tisseel kit from Baxter) at the site of osteonecrosis through a minimally invasive surgery in a 3-step procedure: core decompression, curettage, and injection of osteoblasts (Figure 2).

Figure 1 Microscopic image of osteoblast in culture used for the final cell product before cell implantation.

Figure 2 Steps of osteoblasts implantation. (A) Step 1 Insertion of guide wire in center of lesion as identified on the MRI. (B) Step 2 Guide wire and 8mm cannulated drill for core decompression. The entry point of the guide wire is near the vastus ridge, to prevent a fracture due to stress-riser, greater width of femur and faster healing due to cancellous bone. (C) Step 3 Curettage: a variety of angulated curettes is used to do forage (curettage to remove necrotic bone). This bone is sent for biopsy.

Patients were operated on under spinal anesthesia. Core decompression tunnels were created into the subchondral necrotic lesion of the femoral head, approximately 23 mm away from the joint cartilage, by using 2.0-mm K-wires under fluoroscopic guidance through the greater trochanter and the femoral neck, and over drilled using trephine was performed by the centrally positioned K-wire. Cultured osteoblasts were injected following the curettage, and necrotic tissues were removed.

The patients had to undergo appropriate rehabilitation therapy after the implantation, which included complete bed-rest for 4 weeks post-implantation. After 4 weeks, passive lower limb exercises were performed for 2 weeks following post-implantation. Accordingly, non-weight bearing, partial weight bearing, and full weight bearing exercises were suggested as per the study protocol. Descriptive demographic and clinical data recorded before and after the procedure were collected from patient records. Past medical history, concomitant medications, and surgical treatments undertaken before and after the AALCO were recorded. Pre-existing risk factors for osteonecrosis such as steroid intake, alcohol consumption, comorbid conditions, or trauma were also noted.

Improvement in functional capacity and pain reduction were evaluated using Harris Hip Score (HHS) and visual analog scale (VAS) respectively at the time of pre- and post-operative consultations. Continued use of steroids or alcohol consumption after undergoing the AALCO implantation was recorded. The main outcome of the study was the need for THA (THA conversion rate). Based on these parameters, the treatment outcome was determined to be either improved (better score after AALCO implantation), stable (same condition as before AALCO implantation), or progressive (worse scores following AALCO implantation).

Continuous and quantitative variables were summarized using descriptive statistics and compared using Students t-test or nonparametric test, as applicable. Categorical data were presented as frequency count (n) and percentages (%) and were compared using the 2 test or Fishers exact test. P-values <0.05 were considered significant. All analyses were performed using the SPSS version 10.0.

Data from 64 patients were collected and analyzed as per the study protocol, and 101 hip joints were assessed. The age of patients ranged from 1270 years and BMI ranged from 20.632 kg/m2. The majority of the patients were men (79.7%). The mean duration since diagnosis of osteonecrosis was 7.4 1.6 years and the mean duration of AALCO treatment was 6.3 1.4 years (Table 1). Unilateral involvement of the hip joint was seen in 42.2% of cases. Bilateral involvement of hip joints was seen in 57.8% of patients. The majority of hips diagnosed were grade III (42.1%) and grade IV osteonecrosis (10.5%). While the exact cause for osteonecrosis was not known (idiopathic) in 25% of patients, 35.9% of cases were linked to steroid use and 26.6% to alcohol abuse. Records of concomitant medications revealed that 91.9% of patients were on analgesics, 8.1% were on ayurvedic treatment, and 1 patient took bisphosphonate.

Table 1 Demographic Characteristics

A total of 98 hip joints were assessed as data of 3 patients were not available for changes in mean VAS scores (improvement in pain), before and after the AALCO implantation. As shown in Figure 3A, the mean VAS score reduced significantly after a mean 6.3 years of AALCO treatment compared to the baseline (32.2 32.1 vs 58.8 13.8; mean difference: 26.5 35.2, p = 0.001) indicating significant improvement in pain. Similarly, HHS also improved post-operatively (47.1 12.3 vs 63.7 27.7; mean difference: 16.7 28.7, p = 0.001) showing functional improvement of patients. We categorized patients based on their HSS score (<70: poor, 7080: fair, 8090: good, 90100: excellent). At baseline, 96 hips (98%) had HSS score of <70, each of the two remaining hips had scores of <80 and <90, respectively. Improvement in HSS scores was seen at follow-up with 42 hips (43.3%) with HSS <70, 11 (11.3%) with 7080, 26 (26.8%) with 8090, and 18 (18.6%) with HSS scores of 90100.

Figure 3 (A) Changes in visual analog scale (VAS) and Harris hip scores. (B) Need for hip replacement surgery in different grades of osteonecrosis. (Osteonecrosis graded according to Association Research Circulation Osseous criteria).

The mean follow-up period since diagnosis of osteonecrosis was 6.3 years (range 49 years). Following AALCO treatment, 29 (28.7%) hips underwent THA, indicating that AALCO treatment could prevent and delay THA for 71.3% of hips. The mean time to THA was 3.2 2.0 years (range: 19 years). A total of 9 (39.1%) grade II, 11 (47.8%) grade III, and 3 (13%) grade IV hip joints required THA surgery (Figure 3B). In other words, AALCO treatment could delay THA for up to 3 years in 80% of hips in early stage osteonecrosis (Grades I and II) and 72% of hips in late stage osteonecrosis (Grades III and IV). Univariate analysis showed that the age of the patient, BMI, gender of patients, the side of osteonecrosis, and duration of disease had no effect on the clinical success of the procedure. Following AALCO treatment, 35.9% of patients continued using steroids and 29.7% continued with alcohol consumption. Of the total 29 hip joints that required surgery at follow-up, 20.7% and 41.4% had an associated etiology of alcohol consumption and steroid intake, respectively (Figure 4A). Overall, a significantly greater number of patients with underlying etiologies of alcohol consumption, smoking, or taking steroids required THA compared to those without these etiologies (14 [37.8%] vs 3 [11.1%], p = 0.017).

Figure 4 (A) Need for hip replacement stratified as per etiology of osteonecrosis. (B) Overall outcome stratified as per the grades of osteonecrosis.

Abbreviations: RA, rheumatoid arthritis; SLE, systemic lupus erythematous.

Based on the pre- and post-operative data, the condition of 65.6% of patients improved and 1.6% remained stable following AALCO treatment. Overall, the condition of 65.9% of hips (56/85) in grade I to grade III improved (Figure 4B). For quick reference, the pre- and post-operative radiograph images for a given patient are presented in Figure 5.

Figure 5 Pre- and posttransplantation MRI and X-ray images (A): pre-operative MRI (male patient [35 years]): Ficat and Arlet Stage II B with a subchondral fracture of right hip with a large anterolateral lesion(arrow) involving more than 40% of femoral head and less than 2mm depression at high risk of collapse. Etiology is post steroid AVN. (B) Post-operative MRI at 5 months post-surgery. (C) Post-operative X-ray at 4 years after surgery; anteroposterior (AP) view and lateral view.

We retrospectively studied the clinical outcomes of AALCO treatment. Our results showed that there was a reduction in pain and improvement in joint function following AALCO implantation, as was evident from a statistically significant reduction in the mean VAS score and increase in the HHS score. Of all the hips that underwent the AALCO implantation, 60% improved and 38% worsened with a THA conversion rate of 28%.

AALCO is a minimally invasive, surgical 3-step procedure with each step contributing significantly to the overall effectiveness of the treatment. The first step is core decompression that reduces pressure allowing increased blood flow. In the second step, the necrotic bone is debrided by a curette that promotes new bone formation. The third and most important step is implantation of osteoblasts that form new bone. The THA conversion rate is reported lower with core decompression compared to natural progression of disease, but approximately 40% of patients still required THA.8 Bone marrow cell therapy was shown to improve the THA conversion rate further.9 In a recent randomized trial, implantation of autologous bone marrow aspirate concentrate did not show any improvement in patients with grade 3 osteonecrosis.10 In our study, AALCO implantation avoided THA in 72% of hips in late grade osteonecrosis, suggesting that the technique may even benefit patients in advanced stages of disease; however, our results are limited by the relatively small numbers of patients belonging to each stage.

The differences in the THA conversion may not be directly comparable to those with others may be due to the diversity in the presentation of patients, differences in the follow-up period, or the AALCO technique.13,14 The THA conversion rate certainly remains low with AALCO treatment compared to 75% THA conversion rate reported in patients with natural progression to osteoarthritis resulting from osteonecrosis of the femoral head.15,16 A randomized study found autologous osteoblastic cells implantation to be more efficacious than bone marrow implantation as an adjunct to core decompression. The disease progression rate was found to be 20% in patients who had undergone autologous osteoblasts implantation vs 47% in patients in the bone marrow implantation group.11 Bone alkaline phosphatase-characterized osteoblasts have better regenerative potential compared to heterogeneous bone marrow cells.17,18 Use of these characterized cells could explain the favorable outcomes of AALCO implantation in our study.

Intake of alcohol and/or steroids is known to adversely affect bone renewal by causing an imbalance between the normal progenitor cells and the fat-storing bone marrow progenitor cells.1,19,20 The latter phenotype also leads to fat embolism and arteriosclerosis reducing the blood supply to necrotic tissues.1,19,20 In our study, alcohol and steroid intake were associated with occurrence of osteonecrosis of the femoral head in more than a quarter of patients. These results highlight the adverse impact of alcohol and steroid intake on the progression of osteonecrosis that is already evident in the literature in the pathogenesis of osteonecrosis.2125 As expected, THA conversion rate was also higher among patients who consumed alcohol and/or used steroids compared to those who did not in our study, signifying the adverse impact of alcohol and steroids on the AALCO treatment outcomes. However, a consensus on the specific mechanisms leading to these observations is yet to be reached.

A major limitation of our study was the retrospective data collection, and the lack of assessments of radiographic progression of the affected hips.

The results of this study substantiate the therapeutic potential for AALCO in improving clinical outcomes in terms of pain and functional activity, and reducing the risk of disease progression and the need for THA in patients with osteonecrosis. However, this study was limited by the small sample size and the retrospective data collection limiting the power of study for some subgroup comparisons. Further, clinical studies and long-term trials are warranted to confirm the findings of this study.

Authors acknowledge CBCC Global Research for providing medical writing and submission support funded by Regrow Biosciences Pvt. Ltd.

The authors report no conflicts of interest in this work.

1. Hernigou P, Poignard A, Zilber S, Rouard H. Cell therapy of hip osteonecrosis with autologous bone marrow grafting. Indian J Orthop. 2009;43(1):4045. doi:10.4103/0019-5413.45322

2. Gangji V, Hauzeur J-P, Matos C, De Maertelaer V, Toungouz M, Lambermont M. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells: a pilot study. J Bone Joint Surg Am. 2004;86(6):11531160. doi:10.2106/00004623-200406000-00006

3. Vardhan H, Tripathy SK, Sen RK, Aggarwal S, Goyal T. Epidemiological profile of femoral head osteonecrosis in the North Indian population. Indian J Orthop. 2018;52(2):140146. doi:10.4103/ortho.IJOrtho_292_16

4. Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. Current concepts on osteonecrosis of the femoral head. World J Orthop. 2015;6(8):590601. doi:10.5312/wjo.v6.i8.590

5. ISHKS registry. Available from: Accessed December 17, 2020. 2019.

6. Xie XH, Wang XL, Yang HL, Zhao DW, Qin L. Steroid-associated osteonecrosis: epidemiology, pathophysiology, animal model, prevention, and potential treatments (an overview). J Orthop Translat. 2015;3(2):5870. doi:10.1016/

7. Jaffr C, Rochefort GY. Alcohol-induced Osteonecrosisdose and duration effects. Int J Exp Pathol. 2012;93(1):7879. doi:10.1111/j.1365-2613.2011.00798_1.x

8. Houdek MT, Wyles CC, Martin JR, Sierra RJ. Stem cell treatment for avascular necrosis of the femoral head: current perspectives. Stem Cells Cloning. 2014;7:6570. doi:10.2147/SCCAA.S36584

9. Xu S, Zhang L, Jin H, et al. Autologous stem cells combined core decompression for treatment of avascular necrosis of the femoral head: a systematic meta-analysis. Biomed Res Int. 2017;2017:6136205. doi:10.1155/2017/6136205

10. Hauzeur JP, De Maertelaer V, Baudoux E, Malaise M, Beguin Y, Gangji V. Inefficacy of autologous bone marrow concentrate in stage three osteonecrosis: a randomized controlled double-blind trial. Int Orthop. 2018;42(7):14291435. doi:10.1007/s00264-017-3650-8

11. Hauzeur JP, Toungouz M, Lechanteur C, et al. Autologous osteoblastic cells (PREOBy) versus concentrated bone marrow implantation in osteonecrosis of the femoral head: a randomized study. Revue de Chirurgie Orthopdique et Traumatologique. 2016;102(7):S73. doi:10.1016/j.rcot.2016.08.002

12. Cuende N, Rasko JEJ, Koh MB, Dominici M, Ikonomou L. Cell, tissue and gene products with marketing authorization in 2018 worldwide. Cytotherapy. 2018;20(11):14011413. doi:10.1016/j.jcyt.2018.09.010

13. Pepke W, Kasten P, Beckmann NA, Janicki P, Egermann M. Core decompression and autologous bone marrow concentrate for treatment of femoral head osteonecrosis: a randomized prospective study. Orthop Rev (Pavia). 2016;8(1):6162. doi:10.4081/or.2016.6162

14. Zhao D, Cui D, Wang B, et al. Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells. Bone. 2012;50(1):325330. doi:10.1016/j.bone.2011.11.002

15. Hernigou P, Habibi A, Bachir D, Galacteros F. The natural history of asymptomatic osteonecrosis of the femoral head in adults with sickle cell disease. J Bone Joint Surg Am. 2006;88(12):25652572. doi:10.2106/00004623-200612000-00002

16. Tomaru Y, Yoshioka T, Sugaya H, et al. Ten-year results of concentrated autologous bone marrow aspirate transplantation for osteonecrosis of the femoral head: a retrospective study. BMC Musculoskelet Disord. 2019;20(1):410. doi:10.1186/s12891-019-2797-4

17. Birmingham E, Niebur G, McHugh PE. Osteogenic differentiation of mesenchymal stem cells is regulated by osteocyte and osteoblast cells in a simplified bone niche. Eur Cell Mater. 2012;23:1327. doi:10.22203/eCM.v023a02

18. Prins H-J, Braat AK, Gawlitta D, et al. In vitro induction of alkaline phosphatase levels predicts in vivo bone forming capacity of human bone marrow stromal cells. Stem Cell Res. 2014;12(2):428440. doi:10.1016/j.scr.2013.12.001

19. Cui Q, Wang GJ, Balian G. Steroid-induced adipogenesis in a pluripotential cell line from bone marrow. J Bone Joint Surg Am. 1997;79(7):10541063. doi:10.2106/00004623-199707000-00012

20. Hernigou P, Beaujean F, Lambotte J. Decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroid-induced osteonecrosis. J Bone Joint Surg Br. 1999;81(2):349355. doi:10.1302/0301-620X.81B2.0810349

21. Sakaguchi M, Tanaka T, Fukushima W, Kubo T, Hirota Y. Impact of oral corticosteroid use for idiopathic osteonecrosis of the femoral head: a nationwide multicenter case-control study in Japan. J Orthop Sci. 2010;15(2):185191. doi:10.1007/s00776-009-1439-3

22. Kubo T, Ueshima K, Saito M, Ishida M, Arai Y, Fujiwara H. Clinical and basic research on steroid-induced osteonecrosis of the femoral head in Japan. J Orthop Sci. 2016;21(4):407413. doi:10.1016/j.jos.2016.03.008

23. Cooper C, Steinbuch M, Stevenson R, Miday R, Watts N. The epidemiology of osteonecrosis: findings from the GPRD and THIN databases in the UK. Osteoporos Int. 2010;21(4):569577. doi:10.1007/s00198-009-1003-1

24. Fukushima W, Fujioka M, Kubo T, Tamakoshi A, Nagai M, Hirota Y. Nationwide epidemiologic survey of idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res. 2010;468(10):27152724. doi:10.1007/s11999-010-1292-x

25. Kang JS, Park S, Song JH, Jung YY, Cho MR, Rhyu KH. Prevalence of osteonecrosis of the femoral head: a nationwide epidemiologic analysis in Korea. J Arthroplasty. 2009;24(8):11781183. doi:10.1016/j.arth.2009.05.022

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[Full text] Retrospective Study on Implantation of Autologous-Cultured Osteoblasts | ORR - Dove Medical Press

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India Stem Cell Market speedy growth at US$ 1.27 Bn by 2028 with Thermofisher Scientific India, Pluristem Technologies, Becton Dickinson Private…

By daniellenierenberg

India Stem Cell Market to surpass huge revenue of USD 1.27 Billion at CAGR +13% by 2028.

Stem cell therapy in India helps in treating several diseases, including leukaemia, lymphoma, thalassemia, Parkinsons, Alzheimers, stroke, cerebral palsy, spinal cord injury, muscular dystrophy, etc. Stem cell therapy in India has shown promising results in India and as well as all over the world.

In comparison, in India it costs INR 10-20 lakh in private hospitals, while in government hospitals it is much cheaper INR 3-6 lakh depending on the type of procedure, he said

On average, private banking of stem cells derived from cord blood costs INR 50,000-70,000. Banks claim to freeze the cells in liquid nitrogen so that it can be used up to 20 years from the date of preservation.

Researchers hope stem cells will one day be effective in the treatment of many medical conditions and diseases. But unproven stem cell treatments can be unsafe so get all of the facts if youre considering any treatment. Stem cells have been called everything from cure-alls to miracle treatments.

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Key players profiled in the report includes:

Thermofisher Scientific India Pvt. Ltd., Pluristem Technologies Ltd., Becton Dickinson Private Limited, Stem Cell Technologies India Pvt. Ltd., Merck Lifescience Pvt. Ltd., Cordlife India Pvt. Ltd., LifeCell International Pvt. Ltd., StemCyte India Therapeutics Private Limited, Stempeutics Research Private Limited, ReeLabs Private Limited, CryoSave, Indu Stem Cell Bank, Path Care Labs Pvt

The aim of the report is to equip relevant players in deciphering essential cues about the various real-time market based developments, also drawing significant references from historical data, to eventually present a highly effective market forecast and prediction, favoring sustainable stance and impeccable revenue flow despite challenges such as sudden pandemic, interrupted production and disrupted sales channel in the India Stem Cell market.

Market segments on the basis of:

This research report is an amalgamation of all relevant data pertaining to historic and current market specific information that systematically decide the future growth prospects of the India Stem Cell market. This section of the report further aims to enlighten report readers about the decisive developments and catastrophic implications caused by an unprecedented incident such as the pandemic that has visibly rendered unparalleled implications across the market.

This report is well documented to present crucial analytical review affecting the India Stem Cell market amidst COVID-19 outrage. The report is so designed to lend versatile understanding about various market influencers encompassing a thorough barrier analysis as well as an opportunity mapping that together decide the upcoming growth trajectory of the market. In the light of the lingering COVID-19 pandemic, this mindfully drafted research offering is in complete sync with the current ongoing market developments as well as challenges that together render tangible influence upon the holistic growth trajectory of the India Stem Cell market.

Besides presenting a discerning overview of the historical and current market specific developments, inclined to aid a future-ready business decision, this well-compiled research report on the India Stem Cell market also presents vital details on various industry best practices comprising SWOT and PESTEL analysis to adequately locate and maneuver profit scope. Therefore, to enable and influence a flawless market-specific business decision, aligning with the best industry practices, this specific research report on the market also lends a systematic rundown on vital growth triggering elements comprising market opportunities, persistent market obstacles and challenges, also featuring a comprehensive outlook of various drivers and threats that eventually influence the growth trajectory in the India Stem Cell market.

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India Stem Cell Geographical Segmentation Includes:

North America (U.S., Canada, Mexico)

Europe (U.K., France, Germany, Spain, Italy, Central & Eastern Europe, CIS)

Asia Pacific (China, Japan, South Korea, ASEAN, India, Rest of Asia Pacific)

Latin America (Brazil, Rest of L.A.)

Middle East and Africa (Turkey, GCC, Rest of Middle East)

Some Major TOC Points:

Chapter 1. Report Overview

Chapter 2. Growth Trends

Chapter 3. Market Share by Key Players

Chapter 4. Breakdown Data by Type and Application

Chapter 5. Market by End Users/Application

Chapter 6. COVID-19 Outbreak: India Stem Cell Industry Impact

Chapter 7. Opportunity Analysis in Covid-19 Crisis

Chapter 9. Market Driving Force

And More

In this latest research publication a thorough overview of the current market scenario has been portrayed, in a bid to aid market participants, stakeholders, research analysts, industry veterans and the like to borrow insightful cues from this ready-to-use market research report, thus influencing a definitive business discretion. The report in its subsequent sections also portrays a detailed overview of competition spectrum, profiling leading players and their mindful business decisions, influencing growth in the India Stem Cell market.

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Our research reports will give you the most realistic and incomparable experience of revolutionary market solutions. We have effectively steered business all over the world through our market research reports with our predictive nature and are exceptionally positioned to lead digital transformations. Thus, we craft greater value for clients by presenting progressive opportunities in the futuristic market.

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World Cancer Day 2021: Know All About The Different Types Of Blood Cancer From Expert – NDTV Doctor

By daniellenierenberg

World Cancer Day: Blood cancer can be managed with treatments such as chemotherapy, radiation therapy

World Cancer Day 2021: This day is observed on February 4. Blood cancer originates in the blood forming tissues when abnormal blood cells start growing out of control, thereby interrupting the functioning of the normal blood cells. The normal blood cells help strengthen the immune system by fighting infection and producing new blood cells. Most blood cancers begin in the bone marrow where blood is produced. The three most common blood cancers are lymphoma, leukaemia and multiple myeloma. The common symptoms include weakness, shortness of breath, minimal injury resulting in fractures, excessive or easy bruising, bleeding gums, recurrent infections and frequent vomiting sensations. Blood cancer can be managed with treatments such as chemotherapy, radiation therapy and stem cell transplant.

Multiple myeloma

Multiple Myeloma develops in the bone marrow and affects plasma cells of the body. Plasma cells are responsible for producing antibodies that attack infections and diseases. When these cells become cancerous, they collect in the bone marrow and weaken the bones, causing pain on movement. They also produce antibodies that are useless and make the body weaker. Some common symptoms for multiple myeloma include low blood count, high calcium levels, kidney problems and spinal cord compression due to weakened bones.

Also read:Cervical Cancer During Pregnancy: Here's All You Need To Know


Lymphoma affects the lymphatic system, which is responsible for getting rid of toxins in the body. When the immune cells, or lymphocytes, grow out of control, they collect in the lymph nodes, spleen and in other tissues, and organs. The main types are Hodgkins and non-Hodgkin lymphoma. Some common symptoms for lymphomas include painful swelling in the neck, groin, and armpits, fever and drenching sweats, fatigue, unexplained weight loss and shortness of breath.


Leukaemia is cancer in the bone marrow that gradually spreads to the bloodstream. It is the most common cause of death due to cancer in India. In Leukaemia, the bone marrow produces metamorphosed cells, that outgrow the healthy blood cells gradually. There are multiple forms of leukaemia, but the diagnosis is determined based on speed of symptom development and the type of blood cells that accumulate. Some common symptoms for leukaemia include severe and frequent infections, recurrent nosebleeds, tiny red spots on the skin and excessive sweating and pain in the bones and joints.

While lymphomas and leukaemia affect both children and adults, Myeloma is more prevalent among adults.

Also read:What To Do When A Cancer Patient Tests Positive For COVID-19?

There are several therapies that can be used for treating the different kinds of blood cancer such as:

While there have been developments and advancement in therapies and treatments available for cancer, a significant portion of the future cancer burden can be prevented if we take necessary precautionary measures in the early stages. Better control on tobacco sale and consumption, dietary changes, expansion and equitable distribution of medical facilities, awareness about education programs and risks, prevention, and knowing the benefits of bone marrow donation can go a long way in reducing the burden of blood cancer.

Also read:Alarming Cancer Symptoms Men Should Not Ignore

(Dr Nitin Sood, Director, Hemato Oncology and Stem Cell Transplant Medical and Haemato Oncology, Cancer Institute, Medanta)

Disclaimer: The opinions expressed within this article are the personal opinions of the author. NDTV is not responsible for the accuracy, completeness, suitability, or validity of any information on this article. All information is provided on an as-is basis. The information, facts or opinions appearing in the article do not reflect the views of NDTV and NDTV does not assume any responsibility or liability for the same.

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MPN Efforts Set Sights on Improved Survival and Symptom Burden – OncLive

By daniellenierenberg

Combinations of JAK inhibitors and novel agents, such as epigenetic regulators, could help prolong survival in patients with myeloproliferative neoplasms (MPNs), providing patients with more than a reduction in spleen size and symptomatic relief, explained Shella Saint Fleur-Lominy, MD, PhD, who added that for patients who have already progressed on ruxolitinib (Jakafi), fedratinib (Inrebic), momelotinib, and pacritinib could be potential second-line options.

A lot of these agents will probably be used in combination with ruxolitinib for the most optimal response. Its very promising to see all those different agents emerge that have an effect on disease outcome and modulation of the bone marrow, said Saint Fleur-Lominy. For every symptomatic patient who gets diagnosed with myelofibrosis, polycythemia vera [PV], or essential thrombocythemia [ET], we need to determine if theyre a candidate for a clinical trial, because thats how we advance the treatment landscape.

In an interview with OncLiveduring a 2020 Institutional Perspectives in Cancer webinar on hematologic malignancies, Saint Fleur-Lominy, an assistant professor, Department of Medicine, at NYU Langone Healths Perlmutter Cancer Center, discussed the current landscape of MPNs and the importance of addressing disease burden and progression.

Saint Fleur-Lominy: Downstream of JAK, there are STAT dependent and independent pathways that are involved in disease modulation. A number of newer agents target those signals downstream of JAK. For example, theres the oral kinase inhibitor alisertib, which is downstream of cNeT, which is downstream of JAK. Its one of the molecules that is upregulated in this disease. The phase 1 study was very small, but when they analyzed bone marrow samples pre- and posttreatment, they saw that there was improvement in the degree of fibrosis, and preclinical data showed the same thing.

Other agents include epigenetic regulators. We have an ALS21 inhibitor. We have BT inhibitors. One was studied in combination with ruxolitinib in [JAK-inhibitor nave patients] and patients who didnt have a good response to ruxolitinib. One of the themes among these different agents is that that they modulate the disease. One of the key findings, particularly for the LSD1 inhibitor was that the bone marrow fibrosis and variant allele frequency was reduced significantly. Those diseases dont just have the JAK mutation, they have a lot of other genes that could be mutated and that have [an effect on] survival, disease progression, and response to treatment. Having drugs that target those repeated clones is very significant. Theres also a telomerase inhibitor, and there is a phase 3 trial that is being planned.

Patients can have thrombotic events like clots, and we see that across the different subtypes of PV, ET, and myelofibrosis. Patients who have a low level of fibrosis can have those complications. It doesnt matter how much fibrosis you have in the bone marrow. The risk is usually lower in younger people, but as you age, you see [patients at greater] risk.

There is also a risk of bleeding events as well, especially in ET when people have a very high platelet count. There is also a risk of leukemic transformation because MPN is a disease that has mutations in hematopoietic stem cells, and those stem cells can transform [and] acquire new high-risk mutations and other chromosomal abnormalities and transform into acute leukemia.

In terms of symptom burden, a very large study looked at the symptomatic manifestation of MPNs [and found that] the burden is really high. Approximately 80% of patients have a really high symptomatic burden, [ranging] from fatigue to other symptoms like reduced appetite, early satiety because of big spleen, or the big spleen causing abdominal discomfort. As high as 60% of patients have abdominal discomfort, or early satiety. Up to 80% of patients reported fatigue.

Other symptoms like itching and night sweats [were also common]. Itching you see more with PV. Weight loss, fever, and bone pain [are additional symptoms that patients may experience]. The severity varies, so some patients have mild symptoms, and some patients have more severe symptoms. The main thing is that patients with MPNs have a very high symptomatic burden. Thats one of the reasons [a lot of studies] evaluating drugs in this disease usually use spleen reduction size and symptomatic relief as end points.

One of the most common mutations is JAK2. These are diseases of abnormal JAK signaling. About 95% of patients with PV have the classic JAK2 V617F mutation, and the rest usually have [a JAK exon 12 or exon 14 mutation]. The JAK V617F mutation is found in up to 60% of patients with ET or myelofibrosis. MPL and CALR mutations are found in up to 30% [of patients].

Ruxolitinib was the first JAK inhibitor that was approved for the treatment of higher-risk myelofibrosis, and then later on was approved for the treatment of patients with PV who are intolerant to hydroxyurea or have not responded to hydroxyurea and are symptomatic.

[The end point that was evaluated in the pivotal trial] in myelofibrosis was reduction of spleen volume and symptomatic relief. The COMFORT-I and COMFORT-II trials were both randomized controlled trials. The COMFORT-I trial had a placebo [control] and the COMFORT-II trial had best available therapy [as the control]. Both of these studies also had significant crossover. Once the investigators realized that ruxolitinib [led to a significant improvement in] patient outcomes and symptom relief, and that there was a signal for overall survival [OS], [patients were] allowed crossover [to receive ruxolitinib]. In COMFORT-II, there wasnt really a significant [improvement in] OS, but the crossover [probably] affected that.

In terms of PV, patients were higher risk and were not responding to hydroxyurea or were intolerant to hydroxyurea. These patients were phlebotomy dependent. A significant number of patients achieved phlebotomy independence and had a reduction in spleen volume and symptoms.

Fedratinib [Inrebic] is a selective JAK2 inhibitor compared with ruxolitinib, which is a JAK1/2 inhibitor. The thought is that [fedratinib] will be better tolerated than [ruxolitinib. When the investigators did the randomized placebo-controlled trial for fedratinib, they evaluated 2 different doses of fedratinib. At the higher dose, they saw a rare but serious complication of Wernicke encephalopathy. Because of that, were using the lower dose of 400 [mg].

In terms of the decrease in spleen size and symptoms, there didnt seem to be a difference between the 400 [-mg] and the 500 [-mg] dose. Therefore, it makes sense that the 400 [-mg dose] is the one that were using. [Although fedratinib] results in less thrombocytopenia, ruxolitinib is the go-to drug for patients who can tolerate it. You can still use fedratinib post-ruxolitinib, but I dont know about the reverse [sequence].

We saw updated data [for momelotinib from the SIMPLIFY-1 and -2 studies] at the 2020 ASH Annual Meeting and Exposition. [Momelotinib] inhibits JAK1/2 and Activin receptor 1. One of the studies was a noninferiority study that randomized JAK-inhibitor nave patients to ruxolitinib or momelotinib. The outcome was about the same. The other study was designed to be a superiority trial that was against best available therapy in patients who were post-ruxolitinib. The primary end point was clinical response rate, and it met the end point. [We also saw an improvement in] the total symptom scores and transfusion independence. The sustained responses and the survival benefit [for momelotinib] makes it a very promising [agent], especially for patients post-ruxolitinib compared with best available therapy.

A lot of those patients are older, and they may not be candidates for transplant. Therefore, having something that can prolong survival and make them feel better, post-ruxolitinib, is really important. When you withdraw ruxolitinib, patients can have symptoms rebound, which also seems to have an effect on survival, so if you have another JAK inhibitor that can keep them going, thats very helpful. Im hopeful for momelotinib and pacritinib.

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World Cancer Day 2021: Know The Symptoms And Risk Factors Of Leukemia – NDTV Doctor

By daniellenierenberg

World Cancer Day 2021: Leukemia is a type of blood cancer

World Cancer Day: It is true that most of the cancers get diagnosed at a later stage and the precious time is lost to give a patient a quality life ahead. But effective screening methods implemented in the early diagnosis of blood cancer can help save lives. India ranks third highest in reporting blood cancer cases, after US and China. Almost a lakh of new cases of blood disorder are reported each year. There are several different types of blood cancer depending upon the type of blood cells it affects primarily.

There are three types of blood cancers - leukemia, lymphoma and myeloma. Leukemia occurs when one can suffers from rapid production of abnormal cancer cells in the bone marrow. Thus, due to the abnormal cancer cells, the bone marrow's ability of the production of red blood cells and platelets gets affected. Leukemia occurs most often in adults older than 55, but it is also the most common cancer in children younger than 15.

Having a risk factor, or even several risk factors, does not always mean that a person will get the disease, and many people get cancer without having any known risk factors.

While, in most of the cases, the exact cause of Leukemia is not known, but certain risk factors can attribute to the risk of Leukemia, like:

a. Radiation exposure - High-dose radiation exposure (such as being a survivor of an atomic bomb blast or nuclear reactor accident) increases the risk of developing acute myeloid leukemia (AML). Radiation treatment for cancer has also been linked to an increased risk of AML. The risk varies based on the amount of radiation given and what area is treated.

b. Previous chemotherapy for cancer

c. Smoking and drinking

Family history of leukemia - Although most cases of AML are not thought to have a strong genetic link, having a close relative (such as a parent, brother, or sister) with AML increases your risk of getting the disease. Someone who has an identical twin who got AML before they were a year old has a very high risk of also getting AML.

Genetic Disorder - e.g. Down syndrome, Fanconi anaemia

Exposure to certain chemicals - For example, long-term exposure to benzene is a risk factor for acute myeloid leukemia, a type of blood cancer. Benzene is a solvent used in the rubber industry, oil refineries, chemical plants, shoe manufacturing, and gasoline-related industries, and is also found in cigarette smoke, gasoline and motor vehicle exhaust, and some glues, cleaning products, detergents, art supplies, and paints.

World Cancer Day 2021: Leukemia can lead to shortness of breathPhoto Credit: iStock

Awareness, early diagnosis and treatment are the key:

Early diagnosis and awareness of symptoms allows for more treatment options and can improve survival rates in Leukemia. Some early cancers may show signs and symptoms but that may not always be the case. Initially, doctors make a note of family history and conduct a complete physical examination of the patient. Blood tests may include complete blood count with evaluations of liver and kidney function tests. Bone marrow examination is eventually done to diagnose blood cancers. Diagnostic imaging tests such as CT scan, PET scan, MRI, and/or X-rays may be performed to assess the extent of the disease at diagnosis, and also to assess response after treatment. There is no way to prevent Leukemia at large, but avoiding tobacco and exposure to pesticides and industrial chemicals might help in reducing the risk of Cancer. It is important to also ensure that people with cancer have access to safe and effective treatment that also includes pain relief.

There are several treatment options for blood cancer. The type of treatment depends upon the type and stage of blood cancer, age of the patients and the other underlying medical conditions. Most blood cancers generally include chemotherapy, radiation therapy, stem cell transplant (bone marrow and cord blood transplant), and immunotherapy.

Symptoms to watch for:

To spread awareness on early diagnosis, people need to be educated on various symptoms of blood cancer and seek timely intervention

(Dr. Sunil Bhat, MBBS, MD (Pediatrics) Mazumdar Shaw Cancer Centre, Narayana Health City, Bengaluru)

Disclaimer: The opinions expressed within this article are the personal opinions of the author. NDTV is not responsible for the accuracy, completeness, suitability, or validity of any information on this article. All information is provided on an as-is basis. The information, facts or opinions appearing in the article do not reflect the views of NDTV and NDTV does not assume any responsibility or liability for the same.

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GEMoaB Announces UniCAR-T-CD123 Data from its Ongoing Phase I Study in Patients with Relapsed/Refractory AML (rrAML) to be Presented at Virtual 3rd…

By daniellenierenberg

DRESDEN, Germany, Feb. 3, 2021 /PRNewswire/ -- GEMoaB, a biopharmaceutical company focused on the development of next-generation immunotherapies for hard-to-treat cancers, today announced interim data from the ongoing Phase I study of their lead asset UniCAR-T-CD123 in relapsed/refractory acute myeloid leukemia (rrAML) at the Virtual 3rd EHA-EBMT European CAR-T-Cell Meeting, which is held from February 04-06, 2021. The data are being presented as oral presentation by Dr. Martin Wermke, University Hospital Dresden, Germany (February 05, 12:20 CET) and as a poster presentation by Dr. Sabrina Kraus, University Hospital Wrzburg, Germany (Abstract 68).

"These clinical results present a promising step forward as we continue to evaluate the safety and efficacy of UniCAR-T-CD123," said Professor Gerhard Ehninger, Chief Medical Officer of GEMoaB. "We are highly encouraged by the fact that UniCAR-T-CD123 has demonstrated a favorable safety and efficacy profile in rrAML. The clinical data nicely confirm our UniCAR key platform claims and provide the clinical proof of UniCAR's rapid switch on/off and re-activation capability. We look forward to progressing our study and positioning UniCAR as a potentially superior cellular immunotherapy platform for patients with hard-to-treat advanced hematologic malignancies and solid tumors."

Data highlights for the oral presentation titled: "Proof-of-Concept for Rapidly Switchable Universal CAR-T Platform with UniCAR-T-CD123 in Relapsed/Refractory AML" include:

The poster named "Re-activation of UniCAR-T-Cells with 2nd Cycle of Targeting Module TM123 in a Patient with Relapsed/Refractory AML" is summarizing data obtained on re-activation and re-expansion of UniCAR-T cells, leading to a CRi in the respective patient.

Both presentations will be available on the GEMoaB website following the congress.

About the UniCAR-T-CD123 Phase IA Study

This first-in-human phase I study is an open-label, non-randomized, dose-finding study designed to evaluate the safety and activity of UniCAR-T-CD123 in up to 16 CD123 positive patients with relapsed/refractory AML. Its purpose is to determine the maximum tolerated dose (MTD) as well as Dose limiting toxicities (DLT) of the combined application of a single dose of UniCAR-T and the continuous infusion of TM123 over 25 days. Application follows post bridging therapy and lymphodepletion. The study also investigates response rates, response duration, persistence of UniCAR-T cells over time as well as the ability to rapidly switch UniCAR-T cells on and off in case of side effects through stopping TM infusion. The study takes place at selected Phase I, Acute Leukemia and CAR-T experienced University centers in Germany. The study is supported by a grant from the German Federal Ministry for Education and Research (project "TurbiCAR"). To learn more about the trial, please visit

About UniCAR

GEMoaB is developing a rapidly switchable universal CAR-T platform, UniCAR, to improve the therapeutic window and increase efficacy and safety of CAR-T cell therapies in challenging cancers, including acute leukemias and solid tumors. Conventional CAR-T cells depend on the presence and direct binding of cancer antigens for activation and proliferation. An inherent key feature of the UniCAR platform is a rapidly switchable on/off mechanism (less than 4 hours after interruption of TM supply) enabled by the short pharmacokinetic half-life and fast internalization of soluble adaptors termed TMs. These TMs provide the antigen-specificity to activate UniCAR gene-modified T-cells (UniCAR-T) and consist of a highly flexible antigen binding moiety, linked to a small peptide motif recognized by UniCAR-T.

About GEMoaB

GEMoaB is a privately-owned, clinical-stage biopharmaceutical company that is aiming to become a fully integrated biopharmaceutical company. By advancing its proprietary UniCAR, RevCAR and ATAC platforms, the company will discover, develop, manufacture and commercialize next-generation immunotherapies for the treatment of cancer patients with a high unmet medical need.

GEMoaB has a broad pipeline of product candidates in pre-clinical and clinical development for the treatment of hematological malignancies as well as solid tumors. Its clinical stage assets GEM333, an Affinity-Tailored Adaptor for T-Cells (ATAC) with binding specificity to CD33 in relapsed/refractory AML, and GEM3PSCA, an ATAC with binding specificity to PSCA for the treatment of castrate-resistant metastatic prostate cancer and other PSCA expressing late stage solid tumors, are currently investigated in Phase I studies and globally partnered with Bristol-Myers Squibb. Phase IA dose-finding studies of the first UniCAR assets UniCAR-T-CD123 in hematological malignancies and UniCAR-T-PSMA in solid tumors are currently recruiting patients.

Manufacturing expertise, capability and capacity are key for developing cellular immunotherapies for cancer patients. GEMoaB has established a preferred partnership with its sister company Cellex in Cologne, a world leader in manufacturing hematopoietic blood stem cell products and a leading European CMO for CAR-T cells, co-operating in that area with several large biotech companies. More information can be found at

For further information please contact Jana Fiebiger [emailprotected] Tel.: +49 351 4466-45012

Investor Contact Michael Pehl [emailprotected] Tel.: +49 351 4466-45030

Forward-looking Statements. This announcement includes forward-looking statements that involve risks, uncertainties and other factors, many of which are outside of our control, that could cause actual results to differ materially from the results and matters discussed in the forward looking statements. Forward looking statements include statements concerning our plans, goals, future events and or other information that is not historical information. The Company does not assume any liability whatsoever for forward-looking statements. The Company assumes that potential partners will perform and rely on their own independent analyses as the case may be. The Company will be under no obligation to update the Information.


GEMoaB Announces UniCAR-T-CD123 Data from its Ongoing Phase I Study in Patients with Relapsed/Refractory AML (rrAML) to be Presented at Virtual 3rd...

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Covid-19 leads to shortage of bone marrow donors – GO! and Express

By daniellenierenberg

The SA Bone Marrow Registry (SABMR) says their ability to recruit new donors has been severely limited by the outbreak of the second Covid-19 wave.

SABMR head of donor recruitment Nadia Chalkley said they typically recruit a few hundred new donors each year from the Eastern Cape.

The shrinking pool of donors has had a material impact on our ability to match patients suffering from life threatening blood diseases with suitable donors, she said.

At any given time, there are more than 200 patients in SA that need a bone marrow transplant. The fewer donors we have, the lesser the chance of finding a match. For patients with leukemia, thalassemia and other blood disorders, a bone marrow transplant is their only hope of survival.

Chalkley said the the current odds of finding a successful match is about one in 100,000 and will only get worse as the donor pool continues to shrink.

Sadly, more than 70% of patients struggle to find a stem cell match within their own families, which means many rely on strangers for a second chance at life.

If local donors are not forthcoming, we have to look overseas for potential matches, which is costly.

She said SABMR was working hard to ensure the safety of donors and patients by allowing online registration.

We also offer at-home sampling kits, which only requires a cheek swab. These kits can be delivered and collected free of charge from anywhere in the country.

Once new donors have completed the online registration form, they will be contacted by one of our consultants to discuss the easiest way of dispatching and collecting the kits.

One of the biggest misconceptions with regards to bone marrow donation, according to Chalkley, is that it involves large needles being pushed into ones spine.

However, the most common form of donation is whats called peripheral blood stem cell collection, since the same blood-forming cells found in bone marrow are also present in circulating blood.

The process is similar to donating plasma and doesnt require surgery.

In order to register as a bone marrow donor, you must be between the ages of 16 and 45 and meet the required standards listed by the SABMR.

A full list of the criteria can be found at

Each of us have a role to play. This new year, put away frivolous resolutions and rather direct your energy into making a difference by signing up as a donor. The simple act could just make someones new years wish come true, Chalkley said.

Visit the SABMR website, call 021-447-8638 or email


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What Is Leukemia: And How To Prevent It? – Technology Times Pakistan

By daniellenierenberg

Leukemia is the cancer of blood cells, usually white blood cells which fight and clears infections. It is also known as cancer of blood-forming tissues i.e lymphatic system and bone marrow. It is usually characterized by greatly increased numbers of abnormal white blood cells in circulating blood. It is a very serious disorder and the patient needs to change the blood regularly with normal blood from donors.

By Aysha Bibi

How does leukemia develop?

Our blood contains many different types of cells. These include red blood cells, white blood cells, and platelets. These cells are made on daily basis in the bone marrow. Leukemia happens when the body starts making white blood cells beyond its need. Immature white blood cells are released in the blood and these are non-functional. Moreover, as white blood cells increase in number, the number of red blood cells and platelets are not enough to maintain a healthy life and perform their normal functions.

Types of Leukemia

Leukemia has four main types

In the acute form of leukemia, cells multiply quickly in the bone marrow and enter the circulatory system too early but these cells are immature and non-functional. Chronic leukemia occurs when marrow produces mature cells and it progresses more slowly than other forms.

Lymphocytic leukemia is a type with an accumulation of apparently mature dysfunctional lymphocytes. Normally lymphocytes differentiate to form B-cells, T-cells, and natural killer cells which are the backbone of the immune system.

Myelogenous leukemia is a cancer of white blood cells usually granulocytes and monocytes. Either it is lymphocytic or myeloid, leukemia results in a compromised immune system, and the body cannot protect itself from different infections.

Acute lymphocytic leukemia(ALL) It is most common in children. It can spread to the central nervous system.

Acute myelogenous leukemia(AML) It is the second most common type of leukemia in children and also common in adults.

Chronic lymphocytic leukemia It is common in adults. This remains stable for many years but in some types, patients need treatment.

Chronic myelogenous leukemia(CML) Older people may are at higher risk for this type of leukemia.

Risk Factors

Some significant risk factors that can cause leukemia

Symptoms of Leukemia

Various types of leukemia can cause different symptoms. These symptoms usually not appear in the early stages, but they may include;

Diagnosis of Leukemia

CBC: with a blood test doctor looks at several different blood cells and their maturity. Immature cells may appear in the blood.

Bone marrow biopsy is done by taking bone marrow. With help of this doctor check the type and severity of leukemia.

CT scan and MRI are also done for the diagnosis of leukemia.

Treatment of Leukemia

Depending on the type of leukemia and its spreading, a doctor may look for the following options:

In a radiation treatment, high energy X-rays are used to kill leukemic cells. But normal cells are also affected.

In chemotherapy, different drugs are given to kill leukemic cells in blood and bone marrow. This may include a pill or injection in muscle or vein.

Targeted therapy is done to block the expression of some genes or proteins that are involved in the production of cancerous cells.

A Stem cell transplant involves a bone marrow transplant from a healthy donor. In this method, high-dose chemotherapy is done to destroy the leukemic cells of a patient. The healthy stems cells of donor are then injected to body.

Splenectomy is the removal of spleen and doctor may look for this option if spleen becomes fills with cancer cell and start affecting other body organs.

Preventing or reducing the risk of leukemia

Unfortunately, there is currently no cure for leukemia. Minimum exposure to pesticides and radiations may help to reduce the risk of leukemia. Leukemia can also be prevented by avoiding tobacco.

One can lower the risk of developing leukemia by following:

It is the best way to lower the risk of leukemia.

Studies have shown that overweight and obesity are also contributing factors to increasing the risk of developing leukemia.

Pollution, gasoline, car exhaust contains low levels of benzene. It is also found in offices and homes and found in paint, glue, etc. wearing a mask while using these may help you lower the risk of exposure.

Medical radiations like x-rays increase the risk of leukemia. Try to avoid unnecessary radiation exposure.

Your body and mind function at their best with a healthy diet. Proper nutrition provides energy fuel for body functioning, it also strengthens the immune system.


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Stem Cell Therapy Market 2021: Global Key Players, Trends, Share, Industry Size, Segmentation, Forecast To 2027 KSU | The Sentinel Newspaper – KSU |…

By daniellenierenberg

Stem Cell Therapy Market is valued at USD 9.32 Billion in 2018 and expected to reach USD 16.51 Billion by 2025 with the CAGR of 8.5% over the forecast period.

Rising prevalence of chronic diseases, increasing spend on research & development and increasing collaboration between industry and academia driving the growth of stem cell therapy market.

Scope of Stem Cell Therapy Market-

Stem cells therapy also known as regenerative medicine therapy, stem-cell therapy is the use of stem cells to prevent or treat the condition or disease. Stem cell are the special type of cells those differentiated from other type of cell into two defining characteristics including the ability to differentiate into a specialized adult cell type and perpetual self-renewal. Under the appropriate conditions in the body or a laboratory stem cells are capable to build every tissue called daughter cells in the human body; hence these cells have great potential for future therapeutic uses in tissue regeneration and repair. Among stem cell pluripotent are the type of cell that can become any cell in the adult body, and multipotent type of cell are restricted to becoming a more limited population of cells.

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The stem cell therapy has been used to treat people with conditions including leukemia and lymphoma, however this is the only form of stem-cell therapy which is widely practiced. Prochymal are another stem-cell therapy was conditionally approved in Canada in 2012 for the treatment of acute graft-vs-host disease in children those are not responding to steroids. Nevertheless, hematopoietic stem cell transplantation is the only established therapy using stem cells. This therapy involves the bone marrow transplantation.

Stem cell therapy market report is segmented based on type, therapeutic application, cell source and by regional & country level. Based upon type, stem cell therapy market is classified into allogeneic stem cell therapy market and autologous market.

Stem Cell Therapy Companies:

Stem cell therapy market report covers prominent players like,

Based upon therapeutic application, stem cell therapy market is classified into musculoskeletal disorders, wounds and injuries, cardiovascular diseases, surgeries, gastrointestinal diseases and other applications. Based upon cell source, stem cell therapy market is classified into adipose tissue-derived mesenchymal stem cells, bone marrow-derived mesenchymal stem cells, cord blood/embryonic stem cells and other cell sources

The regions covered in this stem cell therapy market report are North America, Europe, Asia-Pacific and Rest of the World. On the basis of country level, market of stem cell therapy is sub divided into U.S., Mexico, Canada, U.K., France, Germany, Italy, China, Japan, India, South East Asia, GCC, Africa, etc.

Stem Cell Therapy Market Segmentation

By Type

Allogeneic Stem Cell Therapy Market, By Application

Autologous Market, By Application

By Therapeutic Application

By Cell Source

Stem Cell Therapy Market Dynamics

Rising spend on research and development activities in the research institutes and biotech industries driving the growth of the stem cell therapy market during the forecast period. For instance, in January 2010, U. S. based Augusta University initiated Phase I clinical trial to evaluate the safety and effectiveness of a single, autologous cord blood stem infusion for treatment of cerebral palsy in children. The study is estimated to complete in July 2020. Additionally, increasing prevalence of chronic diseases creating the demand of stem cell therapy. For instance, as per the international diabetes federation, in 2019, around 463 million population across the world were living with diabetes; by 2045 it is expected to rise around 700 million. Among all 79% of population with diabetes were living in low- and middle-income countries. These all factors are fuelling the growth of market over the forecast period. On the other flip, probabilities of getting success is less in the therapeutics by stem cell may restrain the growth of market. Nevertheless, Advancement of technologies and government initiative to encourage research in stem cell therapy expected to create lucrative opportunity in stem cell therapy market over the forecast period.

Stem Cell Therapy Market Regional Analysis

North America is dominating the stem cell therapy market due increasing adoption rate of novel stem cell therapies fueling the growth of market in the region. Additionally, favorable government initiatives have encouraging the regional market growth. For instance, government of Canada has initiated Strategic Innovation Fund Program, in which gov will invests in research activities carried out for stem cell therapies. In addition, good reimbursing scheme in the region helping patient to spend more on health. Above mentioned factors are expected to drive the North America over the forecast period.

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UTV documentary tells of young Belfast woman’s lasting legacy to promote stem cell donation – The Irish News

By daniellenierenberg

EIMEAR Gooderham (ne Smyth) was just 25 when she died peacefully in hospital with her family at her bedside.

It was just a week after she had married Phillip Gooderham in hospital and she was buried in the wedding dress she never got to wear.

Almost two years on, her family hope a television documentary about Eimear - a make-up artist from the Coolnasilla area of west Belfast - will help create a positive and lasting legacy in her memory.

The programme, due to be broadcast on UTV and presented by journalist Sarah Clarke, features Eimear's own video diaries, which she had hoped would raise awareness of a campaign for stem cell donors that she launched before her death.

Ms Clarke said the documentary had aimed to "follow Eimear's journey, treatment and her recovery".

"She was very open about her battle and while a lot of the programme is distressing, it shows how courageous Eimear was," she said.

Eimear was diagnosed with stage two Hodgkins Lymphoma, a type of blood cancer, in September 2016.

She underwent 12 cycles of intensive chemotherapy and was given the all-clear in spring 2017.

But the disease returned and in December that year, Eimear was treated with an autologous stem cell transplant, intensive chemotherapy and her own stem cells returned afterwards to rescue her bone marrow from the effect of the treatment.

Months later she was given the good news she was in remission, but the Hodgkins Lymphoma returned again and doctors said her best chance of survival was another stem cell transplant - this time from a donor.

With neither of her siblings a match, she desperately needed to find a stem cell donor.

Eimear and her father Sean launched an appeal to raise awareness of the stem cell register, which allows donors of the correct tissue types to be matched with patients.

Their campaign saw the number of people joining the register in Northern Ireland soar.

Determined to use her own experience to help others, Eimear began filming videos on her phone for the UTV documentary.

Her desire to show her cancer battle as well as her upbeat outlook on life are reflected in the diaries, with many filmed as she underwent treatment.

Speaking ahead of the broadcast tonight, Ms Clarke said her own family's cancer battle had also inspired her to tell Eimear's story.

"In 2017, my nephew Jack was diagnosed with leukaemia, aged just 15," she said.

"I remember my brother Simon, who is a doctor, saying they may have to pursue a stem cell transplant. He knew how difficult it would be to find a match and to endure.

"Fortunately Jack didn't need it, but he had to undergo a year of intensive chemo and four years of maintenance chemo.

"It was rough and a very difficult period and thankfully he's now in remission, but it made me relate to Eimear and San's appeal."

On October 31 2018 - a year before Eimear and Phillip had planned to marry - she received her stem cell transplant.

A video extract of the days after the operation shows Eimear describe how "it's been really rough", as the donor's cells began attacking her cells - a condition known as graft versus host disease.

Despite being discharged from hospital, months later she became ill again with complications associated with the transplant - she was losing her brave battle.

Phillip tells the programme: "I wanted to tell her it was going to be ok, but I didn't want to lie to her. I wanted it to be over so she wasn't in pain".

In June 2019, the couple tied the knot and Eimear got "her final wish".

"We had had it planned, we had to cancel our wedding so it was, in the most horrific circumstances, the nicest way to end her life, by her getting her final wish," said Phillip.

Eimear died on June 27 2019.

Since then her family have continued to campaign to raise awareness of stem cell donation.

Her father Sean said they hope the programme will "highlight the need for more people in Northern Ireland to join the stem cell donor register, especially young men aged between 16 and 30".

Sarah also said while the documentary is "not exactly the one we set out to make, its still one of hope and courage".

"It was Eimears dying wish to raise awareness of stem cell donation and to help further research into the treatment to help others," she said.

"She was adamant she wanted people to sign the register and raise awareness. Her family feel the onus is now on them to continue this.

"The programme pays tribute to a courageous young woman and her family's desire to create a positive and lasting legacy in her memory."

Up Close: Eimears Wish is on UTV at 10.45pm.

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BrainStorm-Cell Therapeutics to Announce Fourth Quarter and Fiscal Year 2020 Financial Results and Provide a Corporate Update – Yahoo Finance

By daniellenierenberg

NEW YORK, Jan. 28, 2021 /PRNewswire/ --BrainStorm-Cell Therapeutics Inc. (NASDAQ: BCLI), a leader in developing innovative autologous cellular therapies for highly debilitating neurodegenerative diseases, announced today that the Company will hold a conference call to update shareholders on financial results for the fourth quarter and year ended December 31, 2020, and provide a corporate update, at 8:00 a.m., Eastern Time, on Thursday, February 4, 2020.

BrainStorm's CEO, Chaim Lebovits, will present a corporate update, after which, participant questions will be answered. Joining Mr. Lebovits to answer investment community questions will be Ralph Kern, MD, MHSc, President and Chief Medical Officer, Stacy Lindborg, PhD, Executive Vice President and Global Head of Clinical Research ,David Setboun, PharmD, MBA, Executive Vice President and Chief Operating Officer, Preetam Shah, PhD, MBA, Executive Vice President and Chief Financial Officer.

Participants are encouraged to submit their questions prior to the call by sending them to: Questions should be submitted by 5:00 p.m. EDT, Wednesday, February 3, 2020.

The investment community may participate in the conference call by dialing the following numbers:

Participant Numbers:

Toll Free: 877-407-9205

International: 201-689-8054

Webcast URL:

Those interested in listening to the conference call live via the internet may do so by visiting the "Investors & Media" page of BrainStorm's website at and clicking on the conference call link.

Those that wish to listen to the replay of the conference call can do so by dialing the numbers below. The replay will be available for 14 days.

Replay Number:

Toll Free: 877-481-4010

International: 919-882-2331

Replay Passcode: 39495

About NurOwn

The NurOwn technology platform (autologous MSC-NTF cells) represents a promising investigational therapeutic approach to targeting disease pathways important in neurodegenerative disorders. MSC-NTF cells are produced from autologous, bone marrow-derived mesenchymal stem cells (MSCs) that have been expanded and differentiated ex vivo. MSCs are converted into MSC-NTF cells by growing them under patented conditions that induce the cells to secrete high levels of neurotrophic factors (NTFs). Autologous MSC-NTF cells can effectively deliver multiple NTFs and immunomodulatory cytokines directly to the site of damage to elicit a desired biological effect and ultimately slow or stabilize disease progression.

Story continues

About BrainStorm Cell Therapeutics Inc.

BrainStorm Cell Therapeutics Inc. is a leading developer of innovative autologous adult stem cell therapeutics for debilitating neurodegenerative diseases. The Company holds the rights to clinical development and commercialization of the NurOwn technology platform used to produce autologous MSC-NTF cells through an exclusive, worldwide licensing agreement. Autologous MSC-NTF cells have received Orphan Drug status designation from the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of amyotrophic lateral sclerosis (ALS). BrainStorm has completed a phase 3 pivotal trial in ALS (NCT03280056); this trial investigated the safety and efficacy of repeat-administration of autologous MSC-NTF cells and was supported by a grant from the California Institute for Regenerative Medicine (CIRM CLIN2-0989). BrainStorm is in active discussions with the FDA to identify regulatory pathways that may support NurOwn's approval in ALS. BrainStorm is also conducting an FDA-approved phase 2 open-label multicenter trial in progressive multiple sclerosis (MS). The phase 2 study of autologous MSC-NTF cells in patients with progressive MS (NCT03799718) completed dosing in December 2020, and topline results are expected by the end of the first quarter 2021.

For more information, visit the company's website at

ContactsInvestor Relations:Corey Davis, Ph.D.LifeSci Advisors, LLCPhone: +1

Media:Paul TyahlaSmithSolvePhone: +

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National Institute for Health and Care Excellence (NICE) recommends lenalidomide as a maintenance therapy for people with newly diagnosed multiple mye…

By daniellenierenberg

National Institute for Health and Care Excellence (NICE) recommends lenalidomide as a maintenance therapy for people with newly diagnosed multiple myeloma who have undergone a stem cell transplant

Uxbridge, UK, 27th January 2021: Celgene, a Bristol Myers Squibb (BMS) company, today announces that NICE has issued a Final Appraisal Document (FAD) recommending REVLIMID (lenalidomide) as maintenance treatment after an ASCT for newly diagnosed multiple myeloma in adults.[iv] From today, approximately 1150 eligible patients in England will have immediate access to lenalidomide as a treatment option, with interim funding provided via the Cancer Drugs Fund (CDF) before transferring to baseline commissioning. Lenalidomide is the first treatment to be made available on the NHS in this setting and provides an alternative to the standard watch-and-wait approach, allowing patients to receive active treatment to keep their cancer in remission.

Graham Jackson, Professor of Clinical Haematology at Newcastle Upon Tyne NHS Foundation Trust said: Multiple myeloma is a relapsing remitting disease where the goal of treatment is to ensure long periods of remission and a good quality of life. Maintenance therapy is integral to achieving this, particularly for newly diagnosed patients who have received a stem cell transplant. Having lenalidomide within our treatment armoury on the NHS will transform the way we manage the early stages of multiple myeloma. In clinical studies maintenance therapy has been shown to almost double the initial period of remission for this group of patients, so it is fantastic to be able to offer active treatment which can help to keep the cancer at bay.

Multiple myeloma is a cancer that affects the production of plasma cells in the bone marrow and in turn impacts the bodys immune system.[v] It is characterised by a relapsing-remitting pattern, which means that the disease goes through periods where the cancer is active and needs treatment, followed by periods where it is under control.[vi] Each time the cancer relapses, the length of time spent in remission shortens.[vii] The objective of maintenance therapy is to control the cancer during the period of remission and delay relapse of the disease.[viii]

Laura Kerby, Chief Executive of Myeloma UK said: We are delighted with this outcome. Patients who receive lenalidomide maintenance after high-dose therapy and stem cell transplant have a significant increase in overall survival, so the decision to make this available through the NHS is fantastic news.

Across the UK, around 1,500 newly diagnosed multiple myeloma patients undergo an ASCT each year,1,2 and most of them will eventually relapse.[ix] This first remission is a critical period for people with multiple myeloma, as it can be an indicator of the overall survival of the disease and it has been shown that effective maintenance therapy could be essential to long-term survival.[x]

Lynelle Hoch, General Manager at Bristol Myers Squibb UK & Ireland commented: Todays announcement marks an important milestone for those living with multiple myeloma, with lenalidomide being the first maintenance treatment option to be made accessible to eligible patients in England. We are grateful for the continued collaboration with NICE, healthcare professionals and Myeloma UK to ensure patients can benefit from lenalidomide in this setting.

Following the publication of this guidance, the NHS in Wales is expected to provide funding and resources for lenalidomide in this setting within two months. The treatment is already available on the NHS in Scotland and in Northern Ireland.[xi],[xii]

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Every day is a success for little boy with leukaemia after life-saving transplant – Grimsby Live

By daniellenierenberg

'Every day that passes is a huge success' for the parents of a little boy who has received a life-saving stem cell transplant.

Zakk Galvin battled leukaemia for 18 months, but after his chemotherapy treatment stopped being effective, his parents were forced to appeal for a stem cell donor.

He has been offered a new lease of life after the transplant has gone ahead.

The six-year-old from Winterton is currently in a fragile condition recovering from the transplant in hospital.

It took months of searching to find a matching donor for Zakk odds that his parents compared to one in a million.

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Zakk has been staying in Sheffield Childrens Hospital since the process began on Boxing Day. It could be months until he can return home, but his parents are thankful for each day.

Dad Craig said: The first week was spent preparing Zakk to receive the cord blood transplant which involved a significant amount of chemotherapy and total body irradiation therapy.

The purpose of this was to totally eliminate any remaining cancer from his body, as well as dampen his body's natural instinct to fight anything invading.

This made Zakk very poorly, and indeed we had some of our hardest days and nights since his journey began in March 2019.

Along with this was the fragility that comes with such treatment, as his immune system and own body defences must be completely overcome in order for the grafted stem cells to not be rejected.

Zakk, who lives in Winterton, has acute lymphoblastic leukaemia, a rare form in which the bone marrow produces faulty white blood cells.

On January 4, he received the healthy stem cells which can take over.

Bone marrow is the tissue inside of bones.

It's a 'factory' which it essential to the human body, as it produces all the required blood cells.

However, it can stop working properly due to diseases like leukemia.

In these cases, the best hope is a transplant from someone with healthy bone marrow.

The actual transplant itself went ahead relatively anti-climactically, Craig said.

You would think that this monumental occasion would involve a huge theatre surgery or some fantastical machine, when in actual fact it is an IV infusion over within about 45 minutes.

But God is in the detail because what was being infused was the stem cells which would hopefully implant and give Zakk new life.

The young boy is now undergoing a vigorous schedule of daily tests and scans to monitor his health.

Due to his fragile condition, he isnt able to see his mum Elizabeth or sisters Annabelle and Eshter, who are eagerly waiting for his return home.

He is very tired, very irritable and suffering from any number of unpleasant symptoms, but we pray that through this trial a miracle is happening just waiting to break through, Craig said.

We know, and most importantly he knows, that it will be a rollercoaster ride, that tonight maybe totally different from today, tomorrow a stark contrast to yesterday.

"But still we look to the day when he will be able to leave hospital and come home to see his sisters, mother and cats.

He's too fragile to be able to see them until that time. We don't know at this time when that will be, his birthday is in late March - it would be wonderful for him to have it at home!

As his transplant consultant has said, Every day that passes is a huge success so we must thank the Lord for every day.

To help other people in urgent need of a donor, you can join the British Bone Marrow Registry or register with the DKMS .

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If I Have Cancer, Dementia or MS, Should I Get the Covid Vaccine? – Kaiser Health News

By daniellenierenberg

As public demand grows for limited supplies of covid-19 vaccines, questions remain about the vaccines appropriateness for older adults with various illnesses. Among them are cancer patients receiving active treatment, dementia patients near the end of their lives and people with autoimmune conditions.

Recently, a number of readers have asked me whether older relatives with these conditions should be immunized. This is a matter for medical experts, and I solicited advice from several. All strongly suggested that people with questions contact their doctors and discuss their individual medical circumstances.

Experts advice may be helpful since states are beginning to offer vaccines to adults over age 65, 70 or 75, including those with serious underlying medical conditions. Twenty-eight states are doing so, according to the latest survey by The New York Times.

Q: My 80-year-old mother has chronic lymphocytic leukemia. For weeks, her oncologist would not tell her yes or no about the vaccine. After much pressure, he finally responded: It wont work for you, your immune system is too compromised to make antibodies. She asked if she can take the vaccine anyway, just in case it might offer a little protection, and he told her he was done discussing it with her.

First, some basics. Older adults, in general, responded extremely well to the two covid-19 vaccines that have received special authorization from the Food and Drug Administration. In large clinical trials sponsored by drugmakers Pfizer and Moderna, the vaccines achieved substantial protection against significant illness, with efficacy for older adults ranging from 87% to 94%.

But people 65 and older undergoing cancer treatment were not included in these studies. As a result, its not known what degree of protection they might derive.

Dr. Tobias Hohl, chief of the infectious diseases service at Memorial Sloan Kettering Cancer Center in New York City, suggested that three factors should influence patients decisions: Are vaccines safe, will they be effective, and what is my risk of becoming severely ill from covid-19? Regarding risk, he noted that older adults are the people most likely to become severely ill and perish from covid, accounting for about 80% of deaths to date a compelling argument for vaccination.

Regarding safety, there is no evidence at this time that cancer patients are more likely to experience side effects from the Pfizer-BioNTech and Moderna vaccines than other people. Generally, we are confident that these vaccines are safe for [cancer] patients, including older patients, said Dr. Armin Shahrokni, a Memorial Sloan Kettering geriatrician and oncologist.

The exception, which applies to everyone, not just cancer patients: people who are allergic to covid-19 vaccine components or who experience severe allergic responses after getting a first shot shouldnt get covid-19 vaccines.

Efficacy is a consideration for patients whose underlying cancer or treatment suppresses their immune systems. Notably, patients with blood and lymph node cancers may experience a blunted response to vaccines, along with patients undergoing chemotherapy or radiation therapy.

Even in this case, we have every reason to believe that if their immune system is functioning at all, they will respond to the vaccine to some extent, and thats likely to be beneficial, said Dr. William Dale, chair of supportive care medicine and director of the Center for Cancer Aging Research at City of Hope, a comprehensive cancer center in Los Angeles County.

Balancing the timing of cancer treatment and immunization may be a consideration in some cases. For those with serious disease who need therapy as quickly as possible, we should not delay [cancer] treatment because we want to preserve immune function and vaccinate them against covid, said Hohl of Memorial Sloan Kettering.

One approach might be trying to time covid vaccination in between cycles of chemotherapy, if possible, said Dr. Catherine Liu, a professor in the vaccine and infectious disease division at Fred Hutchinson Cancer Research Center in Seattle.

In new guidelines published late last week, the National Comprehensive Cancer Network, an alliance of cancer centers, urged that patients undergoing active treatment be prioritized for vaccines as soon as possible. A notable exception: Patients whove received stem cell transplants or bone marrow transplants should wait at least three months before getting vaccines, the group recommended.

The American Cancer Societys chief medical and scientific officer, Dr. William Cance, said his organization is strongly in favor of cancer patients and cancer survivors getting vaccinated, particularly older adults. Given vaccine shortages, he also recommended that cancer patients who contract covid-19 get antibody therapies as soon as possible, if their oncologists believe theyre good candidates. These infusion therapies, from Eli Lilly and Co. and Regeneron Pharmaceuticals, rely on synthetic immune cells to help fight infections.

Q: Should my 97-year-old mom, in a nursing home with dementia, even get the covid vaccine?

The federal government and all 50 states recommend covid vaccines for long-term care residents, most of whom have Alzheimers disease or other types of cognitive impairment. This is an effort to stem the tide of covid-related illness and death that has swept through nursing homes and assisted living facilities 37% of all covid deaths as of mid-January.

The Alzheimers Association also strongly encourages immunization against covid-19, both for people [with dementia] living in long-term care and those living in the community, said Beth Kallmyer, vice president of care and support.

What I think this question is trying to ask is Will my loved one live long enough to see the benefit of being vaccinated? said Dr. Joshua Uy, medical director at a Philadelphia nursing home and geriatric fellowship director at the University of Pennsylvanias Perelman School of Medicine.

Potential benefits include not becoming ill or dying from covid-19, having visits from family or friends, engaging with other residents and taking part in activities, Uy suggested. (This is a partial list.) Since these benefits could start accruing a few weeks after residents in a facility are fully immunized, I would recommend the vaccine for a 97-year-old with significant dementia, Uy said.

Minimizing suffering is a key consideration, said Dr. Michael Rafii, associate professor of clinical neurology at the University of Southern Californias Keck School of Medicine. Even if a person has end-stage dementia, you want to do anything you can to reduce the risk of suffering. And this vaccine provides individuals with a good deal of protection from suffering severe covid, he said.

My advice is that everyone should get vaccinated, regardless of what stage of dementia theyre in, Rafii said. That includes dementia patients at the end of their lives in hospice care, he noted.

If possible, a loved one should be at hand for reassurance since being approached by someone wearing a mask and carrying a needle can evoke anxiety in dementia patients. Have the person administering the vaccine explain who they are, what theyre doing and why theyre wearing a mask in clear, simple language, Rafii suggested.

Q: Im 80 and I have Type 2 diabetes and an autoimmune disease. Should I get the vaccine?

There are two parts to this question. The first has to do with comorbidities having more than one medical condition. Should older adults with comorbidities get covid vaccines?

Absolutely, because theyre at higher risk of becoming seriously ill from covid, said Dr. Abinash Virk, an infectious diseases specialist and co-chair of the Mayo Clinics covid-19 vaccine rollout.

Pfizers and Modernas studies specifically looked at people who were older and had comorbidities, and they showed that vaccine response was similar to [that of] people who were younger, she noted.

The second part has to do with autoimmune illnesses such as lupus or rheumatoid arthritis, which also put people at higher risk. The concern here is that a vaccine might trigger inflammatory responses that could exacerbate these conditions.

Philippa Marrack, chair of the department of immunology and genomic medicine at National Jewish Health in Denver, said theres no scientifically rigorous data on how patients with autoimmune conditions respond to the Pfizer and Moderna vaccines.

So far, reasons for concern havent surfaced. More than 100,000 people have gotten these vaccines now, including some who probably had autoimmune disease, and theres been no systematic reporting of problems, Marrack said. If patients with autoimmune disorders are really worried, they should talk with their physicians about delaying immunization until other covid vaccines with different formulations become available, she suggested.

Last week, the National Multiple Sclerosis Society recommended that most patients with multiple sclerosis another serious autoimmune condition get the Pfizer or Moderna covid vaccines.

The vaccines are not likely to trigger an MS relapse or to worsen your chronic MS symptoms. The risk of getting COVID-19 far outweighs any risk of having an MS relapse from the vaccine, it said in a statement.

Were eager to hear from readers about questions youd like answered, problems youve been having with your care and advice you need in dealing with the health care system. submit your requests or tips.

Judith Graham:,@judith_graham

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[Full text] Post-Transplant Maintenance Therapy for Patients with Acute Myeloid Le | JBM – Dove Medical Press

By daniellenierenberg


Acute myeloid leukemia (AML) remains the most common acute leukemia in adults with an incidence of 34 per 100,000 person per year. AML is a genetically and phenotypically heterogeneous and biologically dynamic spectrum of diseases.1 Indeed, the clinical outcomes are largely determined by the patients characteristics such as age, performance status and comoridities, as well as the leukemia features including the subtype (de novo versus secondary) and most importantly the genomic profile.2 The recent advances in defining the molecular landscape of AML and its role in leukemogenesis have paved the way for the development and adaptation of novel targeted agents.

Following induction chemotherapy, patients achieving a morphologic leukemia-free state (complete remission (CR)) are mandated to receive a form of consolidation therapy aimed at the residual leukemic stem cells (LSCs) to prevent relapse and improve overall survival (OS).3 A risk-adapted approach for relatively young or fit AML patients in first CR (CR1) involves the assessment of this risk of relapse, leading to either chemotherapy continuation or allogeneic stem cell transplantation (ASCT), taking into account the presence of comorbidities, the donor type as well as the genetic characteristics of the disease.4 In addition to pre-treatment risk stratification, the estimation of the leukemic burden while on therapy has recently emerged as a strong, independent and dynamic tool for individualizing post-induction treatment approaches. Either polymerase chain reaction (PCR), multiparameter flow cytometry (MFC) or the novel next-generation sequencing (NGS) can evaluate this measurable residual disease (MRD)57

Up to the current date, ASCT in first CR remains the most powerful antileukemic post-remission therapy. ASCT is generally recommended upfront for properly selected patients with high-risk cytogenetic features, those with intermediate and adverse-risk molecular findings, and patients with secondary AML. Patients with induction failure, post-induction residual disease and following salvage therapy are also referred for ASCT. In addition to potentially life-threatening complications of ASCT such as graft-versus-host disease (GVHD) and opportunistic infections, survival benefits recorded with ASCT are crippled by unacceptably high disease relapse rates,810 hence the need for strategies to maintain remission and prevent relapses post-ASCT. Such interventions aim at reinforcing the graft-versus-leukemia (GVL) effect and/or eradicating persistent MRD, especially with the increasing availability of more sensitive techniques to detect any residual disease. Nevertheless, these maintenance therapies may represent over-treatment for patients with intermediate-risk disease, further subjecting them to long-term toxicities and disturbed quality of life (QoL), thereby reinforcing the need for a better selection of patients as well as strict and continuous MRD monitoring.

The transplantation field has tremendously evolved over the last two decades with refinements of indications as well as improvement in the safety profile of conditioning regimens and supportive care strategies. Nonetheless, risk factors for increasing mortality after relapse in an allografted patient still include, among others, a shorter time to recurrence and occurrence of GVHD prior to relapse11 with significant improvement of overall survival (OS) for young patients relapsing in recent years (Bazarbachi et al, 2020).12 Furthermore, a deeper understanding of factors facilitating disease relapse, such as molecular profile and role of MRD, has enabled more high-risk patients to receive post-transplant therapies to treat and even prevent relapses. Indeed, pharmacological intervention and manipulation of the disease kinetics in the early post-transplant phase could potentially collaborate with other strategies to improve overall outcomes,13 possibly through up-regulation of tumor-associated antigens (TAA),14 expansion of regulatory T-cells,15 or acceleration of T-cell reconstitution.16 With the availability of a wide array of novel and less toxic agents such as epigenetic modifiers, tyrosine kinase inhibitors (TKIs), BCL2 inhibitors and immune checkpoint inhibitors (ICPIs) among others, an intriguing strategy would be to preemptively use such molecules in an attempt to prevent relapses post-ASCT in specific subsets of high-risk patients. Nevertheless, we currently only have few randomized trials that offered a survival advantage for maintenance therapy in AML.

Conducting either retrospective studies or prospective randomized trials to construct therapeutic strategies aiming at reducing post-ASCT relapse rates has been historically hampered by the depth of remission achieved as well as the intrinsic biologic apparatus of the disease. Cytogenetic abnormalities of AML knowingly dictate both the general outcomes of standard therapies and those following ASCT.17 In view of the granular advances in the field of myeloid malignancies, considering specific subsets of AML patients for post-ASCT maintenance should therefore depend on the molecular and genomic characteristics of the disease itself at diagnosis.18 Indeed, the presence of actionable or targetable mutations such as FLT3-ITD and IDH1/2 is a valuable opportunity to incorporate the approved corresponding inhibitors in the post-ASCT maintenance strategies. Novel molecular and MRD diagnostics are therefore of utmost importance to determine those who would benefit the most from personalized therapy options. As such, MRD status in the pre-transplant phase and more importantly detection of MRD early post-ASCT are crucial factors to implement therapy as they largely impact the likelihood and pace of disease relapse.19,20

In this setting, other variables including the donor source, intensity of conditioning regimen and GVHD prophylaxis protocols (T-cell depletion and post-ASCT cyclophosphamide) might influence the risk of disease relapse.21 While the implementation of reduced-intensity conditioning (RIC) has allowed more patients to receive ASCT,22 it could potentially increase the rate of post-transplant relapse, as demonstrated by the large prospective randomized Phase III trial conducted by the Bone Marrow Transplant Clinical Trials Network.23 Well-designed trials are eagerly needed to appropriately answer these challenging situations.

In the presence of few prospective randomized trials, the decision to initiate post-ASCT maintenance therapy remains ambivalent in many situations. Early-phase studies assessing novel agents in the relapsed setting often exclude patients with prior history of ASCT given the plethora of complications they might experience, therefore resorting to agents previously approved for different indications or settings. This dilemma largely provides a protective blanket to access these drugs on an off-label indication, which could impede recruitment for prospective studies. Additionally, most currently ongoing maintenance trials using hypomethylating agents (HMA), targeted therapies and other molecules still demand rigorous eligibility criteria, thereby interfering with enrollment rate.

Starting maintenance therapy in the early post-ASCT phase should take into account the concomitant use of immunosuppressive drugs and their potential heightened hematological and organ toxicities, the risk of opportunistic infections and GVHD, as well as the possible drugdrug interactions (such as with calcineurin inhibitors), even when the acute toxicities of ASCT have seemingly resolved. An optimal maintenance approach is therefore difficult to be intercalated within the conditioning regimen itself and is reserved for a post-ASCT phase, mostly started between days 30 and 100 following transplantation. In this setting, pre- and post-ASCT MRD status could be valuable in planning and timing maintenance therapy. For those patients with impending signs of relapse by MRD testing or falling donor chimerism, a preemptive maintenance therapy could be started early post-ASCT, before overt morphological relapse.

Finally, the optimal duration of maintenance therapy has not been established for most cases, thereby affecting the QoL of these patients.

The use of HMAs such as azacitidine and decitabine remains the most commonly adopted non-targeted strategy for the prevention of post-ASCT relapse owing in part to their acceptable safety profile.24 The mechanism of action of HMAs post-ASCT is unclear, but they appear to silence tumor suppressor genes through epigenetic modification. At the preclinical level, these agents could also induce a GVL effect through stimulation of CD8+ T-cell responses to overexpressed tumor-associated antigens (TAAs) such as MAGE antigens.25 This activity has led to the investigation of HMAs in a series of small trials, especially with the advancing field of MRD detection by sensitive techniques.

For example, AML patients with imminent relapse due to decreasing CD34 chimerism received pre-emptive azacitidine that delayed disease progression according to two studies.26,27 The concurrent administration of donor lymphocyte infusion (DLI) did not, however, improve response rates or OS27 and the majority of patients eventually experienced overt disease relapse.26 In another study, azacitidine was also given sequentially with DLI and showed a low relapse rate and encouraging OS despite the presence of acute and chronic GVHD.28

In a Phase I dose-finding trial, azacitidine as monotherapy was given between on day +42 post-ASCT to 45 patients with AML (82%) and MDS, for up to four cycles at different dose levels 8, 16, 24, 32, and 40 mg/m2.29 Interestingly, two-thirds of AML patients were not in CR at the time of transplant. The recommended dose of azacitidine was reported to be 32 mg/m2 for 5 days in 30-day cycles because of dose-limiting but reversible thrombocytopenia. At 1-year follow-up, the median disease-free survival (DFS) was 58% for all enrolled patients and the 1-year OS rate was 77%. In another phase I/II study of 27 AML patients who received a RIC regimen followed by ASCT later showed that the subcutaneous administration of up to 10 cycles of azacitidine at 36 mg/m2 for 5 days in 28-day cycles beginning at day 42 post-ASCT resulted in the expansion of circulating regulatory T-cells with subsequent GVL response and no significant GVHD.15 In a retrospective study of 18 allografted patients (13 AML and 5 MDS), including 50% of patients with a high or very high disease risk index, low-dose azacitidine started at a median of 60 days post-transplant was well tolerated and resulted in one-year disease-free survival (DFS) and OS of 63% and 70%, respectively.30 A subsequent randomized phase III trial comparing azacitidine at 32 mg/m2 subcutaneously for 5 days in up to 12, 28-day cycles to no intervention in 87 patients with AML, myelodysplastic syndromes (MDS) or chronic myelomonocytic leukemia in remission was terminated early because of slow accrual.31 At a median follow-up of 4.6 years in the azacitidine arm, available data suggest no significant effect of the HMA on relapse-free survival (RFS), except for a non-statistically significant trend for improvement in those who received at least 9 cycles of therapy.

The importance of MRD-adapted therapy is highlighted in the ongoing Phase II study (RELAZA2) whereby preemptive treatment with at least 6 cycles of azacitidine (75 mg/m2 7 days) and for up to 18 additional months was evaluated.32 The study enrolled patients in CR but with detectable MRD either after conventional chemotherapy or following ASCT. This preemptive MRD risk-adapted strategy was found to prevent or significantly delay disease relapse in 58% of patients who remained in CR after 6 months (95% CI: 4472; p < 0.001). These results are encouraging and warrant further follow-up.

More recently, an oral azacitidine formulation CC-486 with extended dosing to prolong activity of azacitidine with sustained DNA hypomethylation showed promising results as maintenance therapy in a randomized trial following induction chemotherapy for AML.33 CC-486 was then evaluated in a phase I/II trial of 30 patients (26 with AML and 4 MDS) who had undergone ASCT, given at 200300 mg orally for 7 days or 150200 mg orally for 14 days in up to 12, 28-day cycles.34 The study resulted in 1-year RFS rates of 54% with the 7-day protocol and 72% with the 14-day regimen in the 28 evaluable patients, leading to estimated 1-year survival rates of 86% and 81%, respectively. The most common grade 34 treatment-related toxicities were gastrointestinal and hematologic toxicities, and two patients experienced severe chronic GVHD. A randomized, phase III trial evaluating CC-486 at the 200 mg 14-day dosing regimen as maintenance therapy post-ASCT for high-risk MDS and intermediate- or high-risk AML is currently enrolling.

On the other hand, a small study of decitabine administered at 515 mg/m2 intravenously for 5 days starting 50100 days post ASCT for up to 8, 6-week cycles also exhibited favorable results with 2-year OS of 56% and cumulative incidence of relapse reaching 28%.35 However, the majority (75%) of patients experienced grade 34 hematologic toxicities during therapy. While decitabine did not increase the rate of chronic GVHD, there was a trend for increased FOXP3 expression and T-reg cells in the lymphocyte environment in a correlative study that was not statistically meaningful.

Interpreting the results of these studies remains challenging and controversial, as they are small and mostly uncontrolled. As such, the optimal timing of HMA initiation post-ASCT and dosing need to be explored further to establish efficacy at preventing relapses and avoid unnecessary toxicities, especially in patients who can be cured with ASCT alone. In patients with detectable MRD or mixed chimerism, pre-emptive treatment with HMA could potentially delay or even prevent relapses in AML and MDS patients.36

More recently, there has been a growing interest in evaluating HMA as partners to novel promising agents such as the BCL2 inhibitor venetoclax, ICPs, FLT3 inhibitors, as well as isocitrate dehydrogenase (IDH) inhibitors and studies are ongoing (Table 1).

Table 1 Some of the Ongoing Trials Evaluating Various Targets for Post-Allogeneic Stem Cell Transplantation Strategies

The class I/II HDACi have presented as potential promising agents in AML/MDS owing to large induction effects on cell-cycle arrest and differentiation, as well as pro-apoptotic effects on myeloid cells through epigenetic modifications of histones.37 HDACi have also exhibited some antileukemic and immunomodulatory roles through the control of cytokine secretion. This is further evidenced by the panobinostat activity, a potent oral inhibitor of class 1, 2, and 4 deacetylases, in the PANOBEST trial.38 This study enrolled 42 patients with high-risk AML or MDS who had received ASCT and panobinostat was started at a median of 98 days (60150) post-ASCT. Two-thirds of these patients were transplanted in active disease. While only 22 (54%) of the 42 patients completed 1 year of therapy because of adverse events, the cumulative incidence at relapse remained 21% at 2 years, resulting in 2-year OS and DFS rates of 88% and 74%. More importantly, panobinostat was found to inhibit the suppressive function of T-regs when used at low doses and enhance their function at higher doses,39 thereby playing a possible role in reducing GVHD. As these results are intriguing, a randomized multicenter phase III trial is currently comparing panobinostat 20 mg orally three times weekly every second week to the standard of care as maintenance post-ASCT. Vorinostat, another HDACi, is also being combined with low-dose azacytidine for post-ASCT in a currently ongoing phase I dose-escalation clinical trial.

Treatment of FLT3-ITD mutated AML remains challenging due to significant relapse rates and short remissions with available therapies despite the common historical use of ASCT in first CR.40 Nevertheless, FLT3-mutated AML is a heterogeneous disease that entails diversity in the type of FLT3 mutations and their insertion site, the FLT3-ITD allelic burden, and the presence of concurrent mutations; observations that further complicated the decision to proceed to ASCT in the first CR when feasible.4143 This controversy is evidenced by the European LeukemiaNet guidelines suggesting, with some controversy, that ASCT should not be offered to patients with low-mutant allelic ratio.4446 EBMT guidelines allowed ASCT in this setting and recommended it for all patients with FLT3-mutated AML (Bazarbachi et al, 2020).47

As such, the use of multi-kinase inhibitors of various generations has led to improved outcomes and achievement of deeper responses in FLT3-mutated AML. These TKIs, together with the incorporation of MRD assessment, have enabled the installation of post-transplant therapeutic strategies,48 as the 1-year OS of patients who relapse post-ASCT drops to less than 20%.11 (Bazarbachi et al, 2020).12

The enthusiasm of using FLT3 TKIs stems not only from their direct cytotoxic properties but also involve an immunomodulatory effect synergizing with allografted T-cells. Several murine models have shown that sorafenib enhances the production of interleukin-15 (IL-15) production by leukemic cells, thereby promoting GVL effect.16 The same experiment showed that sorafenib reduced the activating transcription factor (ATF4) expression in leukemic cells, a negative regulator of IRF-7 interferon regulatory factor-7 (IRF-7) activation, which further enhances IL-15 transcription when activated. The exact mechanisms of FLT3 TKIs immunogenicity remain to be elucidated.

One of the earliest and most promising post-transplant maintenance approaches has been the administration of FLT3 inhibitors, limited to date to FLT3-ITD mutated AML patients. Despite multiple retrospective and prospective randomized trials evaluating the efficacy and safety of the use of FLT3 inhibitors as post-transplant maintenance, there is still a debate on the best agent to be used (off-label use of sorafenib versus potent second-generation FLT3 inhibitors), dosing and time of initiation. A consensus by the EBMT Acute Leukemia Working Party recommended the use of sorafenib 400 mg twice daily in the post-transplant setting in the absence of active GVHD based on available data (Bazarbachi et al, 2020).47 Previous retrospective studies have demonstrated a lower risk of disease relapse following ASCT in patients with FLT3 ITD mutated AML who received post-transplant sorafenib maintenance (Antar, et al, 2014).4953

In a phase I study involving 22 patients with FLT3-ITD AML receiving sorafenib maintenance post-ASCT, PFS at 1 year was 85% and OS was 95%.54 Encouraging results were subsequently reported in other small trials of sorafenib maintenance compared to historical controls, showing markedly lower relapse rates, improved RFS and relatively tolerable toxicities, while not significantly affecting the rates of GVHD.5153,5557 This is further supported by two registry studies from the European Society for Blood and Marrow Transplantation (EBMT) showing that post-transplant maintenance with sorafenib improved OS and leukemia-free survival (LFS) of allografted patients with FLT3-ITD positive AML (Bazarbachi et al, 2019)58 and that sorafenib combined with DLI clearly improved OS and LFS of relapsed FLT3-ITD positive AML patients following ASCT. (Bazarbachi et al, 2019)59

In a prospective phase II controlled randomized trial (SORMAIN) of 83 patients with FLT3-ITD mutated AML, the administration of sorafenib for up to 24 months resulted in superior outcomes for patients in CR and no grade 2 GVHD compared to placebo. After a long median follow-up of 42 months, the 2-year RFS was 85% in the sorafenib group compared with 53% in the placebo group (HR=0.39, p=0.01), in addition to an OS benefit for the sorafenib group (HR=0.447; p=0.03).60 Further follow-up showed that many patients will experience disease relapse when sorafenib is stopped at 24 months, suggesting a longer exposure to sorafenib might be needed to prevent late relapses. While SORMAIN trial constitutes the first placebo-controlled evidence that post-HSCT maintenance therapy could reduce the risk of relapse and death, this study enrolled patients who underwent transplantation in the first hematological CR, as well as those in the second or subsequent CR. Finally, the Chinese open-label, large randomized phase III trial assigned patients to receive sorafenib maintenance (n=100) or control (n=102) post-ASCT (Xuan et al 2020).61 At a median follow-up of 21.3 months, the 1-year cumulative incidence of relapse was 7.0% (95% CI 3.113.1) in the sorafenib group and 24.5% (16.633.2) in the control group (hazard ratio 0.25, 95% CI 0.110.57; p=0.0010), with no treatment-related deaths and acceptable GVHD rates. Based on these available data, sorafenib is recommended by many authorities as a maintenance strategy to reduce post-ASCT relapses for FLT3-ITD-mutated AML (Bazarbachi et al, 2020).47

More recent data from the RATIFY trial that led to the US Food and Drug Administration (FDA) approval of midostaurin in 2017, proposed that the outcomes of patients who received this agent prior to ASCT were particularly encouraging.62 In a phase II trial of midostaurin received as post-consolidation or post-ASCT maintenance, the 1-year relapse rate was encouragingly low at 9.2%.63 In this German-Austrian AML Study Group 1610, most patients discontinued midostaurin earlier than planned because of toxicities. This remains in line with prior reports on the drugs complex pharmacokinetic profile and drugdrug interactions that warrant close observation and dose adjustments to reduce toxicity.64,65

RADIUS is another phase II randomized study that accrued 60 patients with FLT3-ITD AML with stable engraftment post-ASCT to receive or not midostaurin for twelve 4-week cycles.66 Unsurprisingly, the median RFS was not reached for either arm as the trial was not powered to detect any statistical difference (p=0.34) between subgroups.

The prospective cooperative group international phase III randomized trial (BMT-CTN 1506; NCT02997202) is seeking to confirm the impact of post-transplant gilteritinib maintenance therapy versus placebo in patients with FLT3-mutated AML and has completed accrual at 346 patients. Gilteritinib is an effective and tolerable FLT3 inhibitor, with potent activity against both FLT3-ITD and FLT3-TKD mutations, particularly the kinase domain mutations at residue D835 and the gatekeeper mutation at residue F691.67 Gilteritinib was recently approved for use in the relapsed/refractory setting68 and was chosen for evaluation as post-ASCT maintenance owing to its safety profile and potent inhibition of FLT3 in vivo. Unfortunately, the use of placebo as control arm in this trial will not allow to answer the important question of whether Gilteritinib offers an additional benefit over sorafenib in that setting.

Quizartinib (AC220), a highly potent selective FLT3-ITD inhibitor was also studied in one small phase I trial where only 1 of 13 patients relapsed under therapy at the last follow-up.69 Furthermore, toxicities were manageable and GVHD rate was not increased. However, increasing reports about resistance through point-mutant forms have been emerging, hence limiting single-agent use.70

Crenolanib, like gilteritinib, is another potent oral type 1 FLT3 TKI with extended activity against FLT3-ITD and resistance-conferring FLT3-D835 TKD mutants.71 It is also under evaluation as a post-ASCT maintenance in a phase II trial (NCT02400255), in a cohort of patients transplanted in CR and in another group allografted with the residual disease with 10% bone marrow blasts. Crenolanib is started between days 45 to 90 after ASCT and for up to 2 years. It is important to note that phase II/III trials of post-ASCT maintenance involving the novel FLT3 TKIs do not use a first-generation inhibitor control, making it difficult to establish their superior efficacy in this setting.

Some unanswered questions remain regarding the use of FLT3 TKIs as maintenance post-ASCT. FLT3-ITD mutations, unlike BCR-ABL1 fusions,72 are not founding mutations but rather an important final step and one of many mutations found in leukemogenesis.73,74 These include WT1, IDH1, DNMT3A, as well as NUP98/NSD1 fusions, which are currently known to affect outcomes and response to therapy. Furthermore, FLT3 measuring assays are not cross-validated within trials along with considerable variability in the FLT3-ITD cut-off used (0.5 in the ELN recommendations, 0.7 in the RATIFY study) for treatment, as well as the dynamic changes that happen to this ratio over time. Until standardization of definitions, the indication of ASCT remains itself controversial in patients with low (<0.5) allelic ratio FLT3-ITD who have a concomitant NPM1 mutation and achieve MRD negative status on therapy (Bazarbachi et al, 2020).47

Ivosidenib and enasidenib have been recently approved for the treatment of IDH1 and IDH2-mutated AML, respectively.75,76 Owing to the natural history of this subtype of AML and the relative safety of these agents, they could present as a promising option for maintenance therapy post-ASCT. Some trials (NCT03515512, NCT03564821) are currently evaluating the significance of these mutations and their role in post-ASCT relapses, as well as the safety of the corresponding targeted agents in this setting.

Venetoclax is a BCL2 inhibitor that competitively binds to the BH3 domain of BCL2, an anti-apoptotic protein, releases BH3-only proteins and induces apoptosis of hematologic malignant cells.77 Venetoclax has been evaluated and is currently approved in combination with low-dose cytarabine and azacitidine or decitabine.78,79 These studies have included only a few patients who relapsed after ASCT and still achieved CR with the combination. Two prospective trials investigating the efficacy of venetoclax in combination with azacitidine at improving RFS are currently enrolling AML patients for maintenance or preemptive therapy post-ASCT.

Anomalous hedgehog (Hh) pathway signaling is involved in the survival and proliferation of leukemia stem cells,80 especially those resistant to chemotherapy.81 Glasdegib, an oral small Hh inhibitor, has been recently FDA approved in combination with low-dose cytarabine for the treatment of AML patients not eligible for intensive therapy, after showing OS benefit.82 Based on these findings, glasdegib is currently being evaluated in a phase II study for post-ASCT maintenance for AML patients at high-risk of relapse (NCT01841333).

AML and MDS with abnormal 17p or mutated p53 are known to portend dismal outcomes with the highest risk of relapse even in the post-ASCT phase.83 APR-246 is an agent that targets p53 mutation in an attempt to restore its function and showed up to 80% CR rate in an early trial of patients with myeloid malignancies.84 Based on this concept, a phase II trial studying the combination of azacytidine and APR-246 is currently enrolling allografted patients with MDS and AML and mutated p53 (NCT03931291) with a primary endpoint being 1-year RFS.

The use of antibody-drug conjugates (ADC) could achieve target specificity through inhibition of certain surface markers, such as CD33, expressed on the majority of myeloblasts. Gemtuzumab ozogamicin (GO) is a MoAb against CD33 conjugated to the toxin calicheamicin. In a small study of 10 relatively young patients allografted for high-risk AML, GO was administered with azacitidine as maintenance post-ASCT.85 After a median number of 1.5 cycles only complicated by reversible hematological toxicities, 40% of patients relapsed.

Another newer generation anti-CD33 ADC Vadastuximab talirine (SGN33a) conjugated to a pyrrolobenzodiazepine dimer was studied as maintenance in the post-ASCT setting (NCT02326584), but the phase I/II trial was terminated early because of neutropenia and thrombocytopenia.

Maintenance therapy with immune checkpoint inhibitors, such as nivolumab, is being investigated in clinical trials for patients with high-risk AML in remission post-consolidation, who are not candidates for ASCT.86 For instance, using this selective immune modulation for post-ASCT maintenance may provide similar benefits and merits investigation owing to their inherent activity in AML. Nonetheless, issues related to acute GVHD are likely to emerge, as seen with previous studies of lenalidomide in this setting,87 thereby limiting the wide adoption of these agents.8890

Other agents on the outlook in this setting include anti-chemokine (C-X-C motif) receptor 4 (CXCR4) as well as CAR T-cell therapy.

AML has increasingly presented itself as a poster child for personalized treatment approaches. ASCT by itself should not be regarded as an ultimate definitive therapy for all patients and with established poor outcomes for post-ASCT relapses, preventing one remains more beneficial than treating it. Nonetheless, we still have no simple algorithm or strategy to address post-ASCT relapses or maintenance approaches. As delineated above, most available information is derived from phase II trials of HMAs and FTL3-ITD TKIs and few randomized data. Recent development of targeted agents made their use in the post-transplant setting more exciting taking into consideration the potential risks on GVHD and immune reconstitution post-ASCT. Furthermore, better MRD assessments facilitated the optimal selection of high-risk candidates who would benefit from such strategies.

Any treatment decision should therefore involve the patients performance status, the pre-transplant disease course, the presence of actionable mutations, and the use of concurrent immunosuppressive medications as well as GVHD. Prognostication of high-risk AML patients has been recently refined, especially with the introduction of various MRD assays. These include MFC5,91 and NGS-MRD monitoring, both shown to be predictive for post-transplant relapse and survival.92,93

In our clinical practice, we utilize patient and disease characteristics coupled with pre- and post-transplant MRD assays as metrics to counsel patients about their risk of relapse. Awaiting further validation, we believe these are useful parameters, especially when conjugated to risk-stratified maintenance approaches. Nonetheless, we recommend the use of off-label FLT3-TKIs such as sorafenib because of our favorable experience and the accumulating data with this regard, which led to the EBMT recommendations (Bazarbachi et al, 2020).47 HMAs still represent a cornerstone maneuver to upregulate neoantigens and modulate immune responses post-ASCT when used alone or in various upcoming combinations (HMA+ DLI or venetoclax, etc.). One would, however, ask if pre-transplant therapy matters in this setting and whether responding favorably or not to azacitidine as initial therapy could affect the outcomes of post-ASCT maintenance. Novel agents such as ADCs and BCL2-inhibitors may provide a favorable approach despite little knowledge about the effect of these molecules on the graft and their potential toxicities. Immune stimulation with agents such as ICPs currently remains investigational awaiting well-designed clinical trials. Additionally, we must continue to explore the genetic profiling of AML and its ramifications.

Disease relapse remains a paramount endpoint to treating physicians and patients, far beyond the use of survival endpoints alone based on small single-center trials. With the recent surge of therapeutic opportunities, the priority should be to tailor randomized trials with refined conditioning regimens to post-transplant strategies while routinely incorporating MRD and genomic assays. This will require a solid partnership between the transplant community, academia and the pharmaceutical institutions for innovative and well-integrated approaches. A model trial in this setting also needs to assess the activity of a certain approach and its effect on GVHD. There is a steadily increasing number of novel agents, mostly of oral bioavailability, which could be preferred for maintenance therapy owing to their activity, dosing schedules, as well as minimal hematological toxicities. Other areas of interest include the use of MoAbs, ICP inhibitors and possibly products of cellular engineering (vaccines, modified chimeric antigen receptor T-cells, etc.). As a reflection of toxicities, we strongly support the integration of quality-of-life (QoL) metrics and patient-reported outcomes as informative endpoints in the design of these prospective randomized trials.

The authors report no conflicts of interest in this work.

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[Full text] Post-Transplant Maintenance Therapy for Patients with Acute Myeloid Le | JBM - Dove Medical Press

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Onward and Upward for Single-Use Systems in Bioprocessing – Medical Device and Diagnostics Industry

By daniellenierenberg

The single-use device market is primed for growth. Single-use systems (SUS) are now used for about 85 percent of precommercial scale (preclinical and clinical) biopharmaceutical manufacturing and increasingly for commercial products manufacturing. This shift from fixed stainless steel appears to be revolutionizing the therapeutics market.

While large-scale, fixed stainless-steel equipment-based bioprocessing facilities continue producing biopharmaceuticals, the market for SUS, composed primarily of plastic components that are sealed and sterilized using gamma irradiation, continues its rapid ascent. Medical device makers are seeing growth in single-use instruments and disposable medical devices, including process containers, tubing, connectors, baskets, and valves. According to Grand View Research, in 2019, the global SUS market was valued at $12.6 billion, with a 12.8 percent compound annual growth rate forecast through 2027, when it will top $33 billion.

Lower energy and direct-labor costs plus faster changeover times are important reasons why. Like any major change, the SUS shift brings with it challenges as pharmaceutical manufacturers and medical device makers turn to their suppliers to provide assurance that their products deploy operational best practices and are certifiably safe.

To address key challenges in the SUS market and meet the product development needs of Tier 1 pharmaceutical and medical device companies, collaboration is seen between Tier 2 system suppliers and Tier 3 components suppliers.

One such effort comes in the form of the BioPhorum Operations Group, a global collaboration comprising more than 90 Tier 1, 2 and 3 biopharmaceutical companies and suppliers; its purpose is to develop and share best practices for pharmaceutical and medical device manufacturing. For example, BioPhorum has succeeded in establishing effective testing methods for extractables and leachables to help the industry approve SUS for safe and effective use.

To select processing materials that avoid risk, its important to understand the chemical nature of extractables, which are compounds emitted from a packaging component, delivery system, or manufacturing surface during aggressive testing; and leachables, which are compounds that migrate into the drug over time from contact with the system componentry and manufacturing surfaces.

To assist suppliers with their evaluation of SUS extractables, the BioPhorum team developed testing protocols based on a set of solvents and immersion times. Adhering to such protocols helps ensure the successful use of SUS for biopharmaceutical manufacturing, though the final responsibility for confirming the safety and efficacy of the therapeutic remains that of the Tier 1 pharmaceutical companies and medical device makers, not their suppliers.

Complementing the BioPhorum extractables protocol is a best practice guide for evaluating SUS leachables. BioPhorum protocol applies to SUS components that contact the pharmaceutical product or process fluids, including but not limited to the medical device/drug delivery market:

Note: The standardized extractables testing protocol does not cover final container closure systems.

Achieving medical-grade system components requires treating the part as a medical product when it comes to cleanroom and manufacturing practices. For tubing, for example, its no longer acceptable to manufacture medical-device-grade tubing on the production floor and then attempt to sterilize it. Tubing production for any medical device must take place in ISO certified cleanrooms that adhere to FDA's Current Good Manufacturing Practices governing particulates, air pressure, and personnel practices to ensure that products meet tolerance and cleanliness requirements. This may require bioburden and endotoxin testing.

These procedures help ensure production of safe, validated products in critical areas such as the transfer of monoclonal antibodies, laboratory-produced base media for therapeutics engineered to represent the bodys immunes system and used in the development of cancer-treating therapeutics. The tubing must be bacteria-free and remain strong as it transfers the monoclonal antibodies to the bioreactor and chromatography equipment, where wanted therapeutics are filtered out.

Other single-use tubing applications include peristaltic pumps with rotating wheels that push the fluid through tubes. To withstand the rigors of the pumping process and ensure that the tubing walls remain intact, high-strength tubing is required.

Advancements in therapeutics will continue driving the development and growth of SUS and their components. One such advancementchimeric antigen receptor (CAR T) cell therapy under development by Kite, a Gilead Companytaps into the potential of personalized medicine for cancer treatments, using the patients immune system to target and attack tumors.

T-cells, a white blood cell developed from stem cells in the bone marrow, help the body to fight cancer and infections. Currently, three FDA-approved CAR T cell therapies, developed by Gilead and Novartis, are available. There is also exponential growth of other biotechnology and pharmaceutical companies actively advancing cellular immunotherapies through clinical trials.

Investigational for now, the safety and efficacy of T-cell therapy is an active area of research, and it could prove to be a game-changer. A cancer patients blood is collected and purified to select the T-cells, which are activated and expanded within the lab and transfected to express a chimeric antigen receptor, or synthetic T-cell receptor, targeting a specific tumor antigen. The T-cells grow and expand for two weeks and are then infused back into the patient where the engineered cells attack the tumors. This chain of events requires a precise timeline with all components of the process being sterile and having passed stringent testing for quality and reliability.

Unlocking the immune system to effectively fight cancer is truly exciting and serves as a great illustration of the potential medical device use of SUS in biopharmaceutical processing.

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Onward and Upward for Single-Use Systems in Bioprocessing - Medical Device and Diagnostics Industry

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