Interview

Deep in talk with PI

Step1: Brainstorm
Since the team set up, the members of experiment group had read a lot of literatures and had several times’ brainstorm, during witch three themes were determined, PTEN-LONG, CAR-T and MSCs，which are hot in biological field in recent years.

Step2: Consultation
Members were divided into three small teams to contact teachers who expert at the themes respectively. In the end, Professor Xiang Peng was interested in our idea and was willing to offer laboratory to us. More luckily, he became our PI finally.

Step3: Hospital investigation
Before deeper discussion, we decided to investigate how MSCs show effectiveness in clinical using. We went to Nanfang Hospital for a visit and had interviews with 2 patients and a doctor involving in MSCs clinical trial. The result showed that MSCs do have effectiveness but cannot replace the regular anti-inflammatory medicine, which lead us to find a way to enhance the effectiveness of MSCs.

Step 4: Further discussion with PI
The main method of MSCs therapy is intravenous injection and we wonder what these cells become after they play the role of anti-inflammation. Will they become tumor cell? Professor Xiang said that this is a question that confused him too. It’s hard to say whether the ‘old’ MSCs would harm the human body. It would be perfect if the MSCs can kill themselves after anti-inflammatory effect. So we try our best to find a way to realize it and at last we designed a switch.

Interview Doctor and Patient

• Doctor – Fan Zhiping

HP: How is MSCs clinical trial going on recently?
Dr. Fan: Wei Zexi incident is such a shock to us.
HP: Does Wei Zexi incident influence the treatment of patients?
Dr. Fan: Of course have. Many patients have not keep MSCs treatment since that event because lack of MSCs. The government prohibited the MSCs clinical researches and then selected 50 institutions that have qualification to do MSCs clinical research.
HP: Your hospital is one of them, right?
Dr. Fan: No, all the cells for treatment are from Stem Cell Center of SYSU and The Third Affiliated Hospital of SYSU, which are approved as members of the 50 institutions.
HP: What is the inclusion criterion of the patients?
Dr. Fan: Mainly obliterans bronchitis caused by graft-versus-host disease (GVHD). We treat the patients with MSCs combined with regular anti-inflammatory drugs.
HP: Why not drug alone?
Dr. Fan: We studied a lot of MSCs clinical research and found that drug alone is not that effective. So we use MSCs combined with regular anti-inflammatory drugs. For example, a patient with three-concave sign, the respiratory system function improves after MSCs treatment. However, disadvantages exist too, the curative effect cannot last long, and we can only maintain the situation without curing the disease at present.
HP: Were patient afraid of clinical trail?
Dr. Fan: No, they didn’t. Instead, they held a positive attitude towards it.
HP: Did you explain the informed consent to them?
Dr. Fan: Yes, we did. All the patients had sign the informed consent. But we could not explain the details, because we didn’t have enough time.
HP: Where does the money of your clinical trial come from?
Dr. Fan: Guangzhou government offers us to do this research. Although the nation doesn’t have any approval regulations, Guangzhou is on the move.

• Patient-Miss Zhu

HP: Why did you come to the hospital?
Miss Zhu: I was diagnosed as GVHD concomitant with obliterans bronchitis in September 2015.In the past, I gasped heavily. When I came to find doctor Fan, he suggested me to try the MSCs therapy, and I felt much better now.
HP: Did you take any medicine before the therapy?
Miss Zhu: Yes, I did, but it was unsatisfactory.
HP: Do you have a knowledge about clinical trail or cell therapy?
Miss Zhu: I don’t know much about it. I just follow my doctors’ advice.
HP: Thank you for your cooperation, I hope you can recover soon.

• Patient-Miss Zhang

HP: Why did you come to the hospital?
Miss Zhang: I was diagnosed as B cell lymphoma. At the beginning, my legs were uncomfortable, lack strength, but routine blood test was normal. And the doctor suggested me to do bone puncture, but I was afraid of it, so I didn’t follow the doctor’s advice. After a period of time, I couldn’t move when something constricted the nerves. And then, after a surgery, I was diagnosed. After bone marrow transplantation, I got immunologic rejection, therefore, my doctor advised us to receive MSCs therapy.
HP: Do you read the informed consent carefully before signing on it?
Miss Zhang: No, I didn’t. Because I had xerophthalmia, I couldn’t read for a long time. And, considering my condition, I had no choice.
HP: Is MSCs therapy necessary or a supplementary in your opinion?
Miss Zhang: I think it is a supplementary. And anti-rejection medicine is necessary.
HP: Thank you for your cooperation, I hope you can recover soon.

Interview Professor Zhang Qi

The visit of hospital mingled hope or fear. The hope is that MSCs do have effectiveness on patients; the fear is that the ethic problems during the clinical trial in China. To get more authoritative information, we made an appointment for interviewing Professor Zhang, the head of Biological Treatment Center of The Third Affiliated Hospital, Sun Yat-sen University. Finally we schedule the time of Cell Therapy Annual Meeting.

Q1: We had talked with some patients and a doctor in Nanfang Hospital and found some phenomenon that confused us. When we asked the patient if they sign a consent form of this clinical trial, they show surprised look and asked us whether they were treated like mice in the lab, which also confused us. So we asked more for details and found they just heard MSCs therapy from the doctor and sign the consent form without hesitate. Then doctor explained to us that on the one hand, most patients know little about medicine, they use the ‘clinical research’ instead of ‘clinical trials’ when explaining to the patients avoiding misunderstanding. On the other hand, the patient number is too large and doctor demand exceeds supply that it is nearly impossible to explain in detail to every patient. We can understand it but we don’t think it is a good phenomenon in clinical trials and we want to ask for your opinions.
Zhang Qi: You did a very good job and this is a good question. My opinion is that no matter how busy the doctors are, they should offer every detail of clinical trials for them to choose. Firstly, clinical trials mean that MSCs treatment research is still at early phage in China. For patients, benefits coexist with risks. Secondly, the 21st century is an era of information. Patients prefer search all kinds of information on the Internet. As you know, the information on the Internet is quite a mixed bag, without basic theory training, patients could not gain what they really need. So the explanation of clinical trials is truly important for the doctors and the patients.

Q2: Then how do you think of our project?
Zhang Qi: Just like smart CAR-t, smart TCRT, I hope MSCs could become MSCs Plus or as you say MSCavalry. Why? MSCavalry has better chemotaxis than non-modified MSCs. As we know that about 90% of vein injected MSCs are tracked in the lung, witch is a huge disadvantage of MSCs therapy and what you are doing is a good solution to this problem.

Q3: Thank you! But gene modified MSCs seem to have more safety problem comparing to general ones. How do you think of the safety issue of our project?
Zhang Qi: You need to take it easy. We all know that most MSCs are still at clinical trial stage. What you are doing is such a small step in MSCs therapy research. Gene modified MSCs need a lot of tests and regular animal experiments and primate animal experiments, then go into clinical trial etc. Grate work needs time accumulation. You need to go the distance.

Cell Therapy Annual Meeting

Cell Therapy Annual Meeting
Since we made our decision to study Mesenchymal Stem Cells (MSCs), we have keep eyes on every detail about MSCs therapy. We searched a lot about ethics, laws, products and more and more questions came up when we dig deeper. For example, how to ensure our products is safe enough for human, can our experimental products become economical products, is the product a kind of technic or a kind of drug etc. We found that Guangdong Cell Therapy Annual Meeting was going to hold on August and our PI – Professor XIANG is one of the organizers and experts of laws and legislation would attend it. We thought that attending this meeting could save much time and energy comparing to interview those experts one by one. So we discussed with our PI to get the chance to attend this meeting.

We set a booth there to introduce our project where there were many biological company existed. So we had communication to many biological companies there. DAAN Gene was one of them. What makes this company special is that we met the chairman of DAAN Gene there and he seemed interested in our project. The meeting lasted two days and we had an interview with him on the second day.

What we got from this meeting mainly contains:
1. Safety — Stem Cell Quality control
2. Laws and Legislation on Stem Cell
3. Idea of Product Analysis

Safety — Stem Cell Quality Control
Because our products will be used to treat patients in the future, it is even important to consider the safety about MSCs quality control. On the one hand, quality control reflects core competitiveness of product research. On the other hand, it promotes the government to administrate MSCs more rigorously.

What we have considered is mainly the safety before, during and after the experiment and some about products for patient use by studying two significant profiles form National Health and Family Planning Commission of the People’s Republic of China (NHFPC) and China Food and Drug Administration (CFDA), which are Stem Cell Clinical Research Management Approach and Stem Cell Preparation Quality Control and Pre-clinical Research Guiding Principle. During the meeting, speech by Dr. Yuan Baozhu on Stem Cell Quality control gave us a future look of MSCs products’ safety.

What we have studied before the meeting – general quality control of MSCs

1. General quality attributes of cell biology
Cell identification: morphology, heredity, metabolic enzymes analysis, surface marker, special gene product etc.
Survival rate and growth activity: viable cell counts, colony forming efficiency, doubling time, cell cycle, telomerase activity, etc.
Purity and uniformity: surface markers, genetic polymorphism and specific biological activities. Control interspecific and intraspecific cross contamination. Induced differentiation products of embryonic stem cells and iPS must be detected for purity and uniformity.

2. Microbiological safety
Detecting techniques: direct detection (nucleic acid, protein), in vitro cell inoculation test and animal inoculation test
Contents: Sterility test, Mycoplasma test, detection of internal and external source of pathogenic factors and endotoxin.

3. Biological safety
Abnormal immunological reaction: Heterologous cells, total lymphocyte proliferation, response among different subsets of immune cell, release of related inflammatory cytokines.
Oncogenicity: heterologous cells, homologous cells of complex treatments, intradermal inoculation tumorigenic test of immunodeficiency animals (nude mice and SCID mice), related animal models or administrating methods for correlations; soft AGAR cloning formation rate; Detection of telomerase activity
Abnormal differentiation: invalid or inefficient differentiation; Differentiation to non-target cells and ectopic differentiation.

4. Biological effectiveness test
Potential of multiple differentiation: MSCs derived from different tissue should undergo differentiation test to three lineages（osteoblasts, adipocytes and chondrocytes）
Immunoregulatory effect: regulation of immunocytes subsets( CD4+: Th1,Th17 ，Treg ;CD4/CD8 ）; regulation of cytokine secretion (TNF-α, etc.) ; expression or activity of Immunosuppressive cytokines (PGE2, IDO1, etc.)
Regeneration: in vitro experiments including anti-apoptosis, angiogenesis, macrophage polarization, tissue repair related factors (e.g., HGF, SDF1, BDNF, etc.), proliferation and differentiation of endogenous precursor cells; in vivo experiments of general animal models.

Real stuffs — problem exposed from “Quality Control”
1. Cells identification：
Misconception in batch definition;
Cell cross-contamination
Unexpected flow profile (e.g. CD105 <85%; accompanied by severe cell senescence)
2. Microbiological safety (Mycoplasma contamination is the most common microbiological issue)
3. Significant discrepancy of biological
Effectiveness (immunomodulation, Differentiation potential)
Correlation (Quality correlation, Clinical application)

Conclusion
Quality control is an important part in safety control. During our experiment, cell cross-contamination and microbiological contamination also happens sometimes. Through Dr. Yuan’s speech, members of experiment group can concerns more about the quality control of MSCs.

Laws and Legislation on Stem Cell

During the research of clinical trials, we found that several team has finished clinical trials in China. As we all know that there exist about 10 MSCs drugs in the world, but none of them is approved in China, which confused us that why there is no MSCs product approved in China. We studied the administration measures of different countries and compared them with that of China, and asked legislation experts some questions during the meeting, hoping to know how far our project would go and find a proper way for development of MSCs therapy in China.

What we have studied before the meeting - Administration measures of different countries

Pearls from the speech
• MSCs therapy belongs to medicine instead of medical technic

6-2.4.3.1
• MSCs clinical research need to follow
- Record System – Medical institutions are subject of liability in MSCs clinical research

6-2.4.3.2

• Key point of auditing applications record in Record System
- Condition
- Procedure
- Basis (safety, ethics, necessity)
- Research plan
- Feasibility

• Outlet of MSCs clinical research

6-2.4.3.3

• Challenges
- Hard to realize examine the products batch by batch;
- How to administrate medical institution in detail;
- It is quite a long time for new drug approval;
- Real complicated approval procedure.

Q&A
In the Q&A part, we had a chance to ask a question that really important to us.

HP: Thank you for your speech and we really learned a lot. I studied some stem cell laws and found that there exists Conditional Approval in some countries, I wonder if this kind of approval can be carried out in China?
Mr. Yin: This is a good question. Conditional Approval means that if a kind of cell therapy’s effectiveness and safety both are very good during the phase I and/or II clinical trial, the government can allow it to list. The clinical trial phase III and IV will finish after appearing on the market and the medical institution and company will be regularly inspected.

But from the happen of ‘Death of Wei Zexi’ incident to calling off of all cell therapy clinical trials, we are much more careful in administration of cell therapy research. What’s more, Conditional Approval is carried out only in a few countries such like Korea. In many other countries, MSCs therapy administration is as rigorous as China. So the degree of open attitude is different in different countries.

We are considering enacting new laws for MSCs development in China and Conditional Approval is one of the considerations. So far, MSCs therapy seems to behave safe in clinical trials, but it still has risks. For the safety of patients, we prefer to be more conservative. And I hope you can do more meaningful work and we will try our best to serve your research.

Idea of Product Analysis
New drug approval is really hard and it takes an even long time. We had searched and studied the MSCs laws in China and find that even if we have a good experiment result, we hardly have chance to put it on the market. So we wondered whether it is meaningful enough to do product analysis.

However, the study that Academician Zuze Wu do gave us much confidence to keep going with our work.

His team is working on a ‘Human Allogenic Dental Pulp Stem Cell Injection’ to treat paradentitis, which is co-engineering by Capital University of Medical Sciences Oral Translational Medicine Research Institute, Military Medical Sciences Radioactive Medicine Research Institute and Beijing Sanly Heze (SH)Biotech Inc. They have finished pre-clinical research and clinical trials phase I-IV, which means they are now just waiting for the approval by CFDA. Additionally, they are now doing research on the next generation product – MSCs Modified by HGF gene, which is similar to our project. We saw the possibility of putting our product on the market in the near future and it is significant to do the product analysis.

Latest news
It is inspiring that the product mentioned above was accepted by Beijing Drug Administration on 26th September 2016, which is one month after the Annual Meeting. We believe that it won’t be too long for our product.

Interview DAAN Gene

To see prospect of our project, we had a talk with Mr. Shen Yutian, the chairman of DAAN Gene, who we met at Cell Therapy Annual Meeting.

(DAAN Gene is a high-tech enterprise oriented in molecular diagnostic techniques. With the Certificate of GMP, DAAN Gene is consistently committed to R&D, production and service of in-vitro diagnostic products, including PCR, TRF, ELISA and RAPID diagnostic kits and equipment. )

HP: What products that related to MSCs do DAAN have?
Mr. Shen: Not yet, but we are planning to have. Actually there is no stem-cell drug in China. Since 2015, the Government has never approved stem cell drug clinical trials. What’s worse, ‘Death of Wei Zexi’ was a major blow to the development of MSCs research in China. In retrospect, however, it also pushed the government to enact laws to administrate MSCs research.

HP: Yes, we agree with that. It encouraged us a lot that the product that Academician Zuze Wu introduced yesterday —— ‘Human Allogenic Dental Pulp Stem Cell Injection’. We thought it would take a very long time to have a MSCs drug in China. Is your company be interested in develop MSCs drug?
Mr. Shen: Of course, actually we have been cooperating with Stem Cell Center of your university to develop MSCs medicine although it just at the beginning. We think MSCs medicine has vast commercial potential.

HP: Really? So surprising! Actually, as far as we know that there are no genetically modified stem cell products on the market, while our project is to use genetically engineering technology to enhance the homing of MSC. As a businessman, would you like to share your opinions of our project?
Mr. Shen: The regulations on cell therapy clearly say that the future direction of genetically modified cells such as CAR-T and other stem cells is to be used as drugs. For the current clinical experiment with stem cell is very rigorous, in this way, it must be difficult and has a long way to go. However, because of the high threshold in this direction, so as an academic study, it still has potential. You are a group of youths with dreams, so I am very optimistic about your future and your project. We are also interested in cooperation and investment. Young people need to have a dream through their own efforts and contribute to the country's scientific research and industrialization, rather than empty slogans. Hard work brings prosperity to our motherland. The direction you choose is more advanced and pilot, and it deserves a try.