Central nervous system stem cell transplantation for children with neuronal ceroid lipofuscinosis

Clinical article

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Object

Infantile and late-infantile neuronal ceroid lipofuscinoses (NCLs) are invariably fatal lysosomal storage diseases associated with defects in lysosomal enzyme palmitoyl-protein thioesterase 1 (PPT-1) or tripeptidyl peptidase 1 (TPP1) activity. Previous preclinical studies have demonstrated that human CNS stem cells (HuCNS-SCs) produce both PPT-1 and TPP1 and result in donor cell engraftment and reduced accumulation of storage material in the brain when tested in an NCL mouse model.

Methods

HuCNS-SC transplantation was tested in an open-label dose-escalation Phase I clinical trial as a potential treatment for infantile and late-infantile NCL. Study design included direct neurosurgical transplantation of allogeneic HuCNS-SCs into the cerebral hemispheres and lateral ventricles accompanied by 12 months of immunosuppression.

Results

Six children with either the infantile or late-infantile forms of NCL underwent low- (3 patients) and high- (3 patients) dose transplantation of HuCNS-SCs followed by immunosuppression. The surgery, immunosuppression, and cell transplantation were well tolerated. Adverse events following transplantation were consistent with the underlying disease, and none were directly attributed to the donor cells. Observations regarding efficacy of the intervention were limited by the enrollment criteria requiring that patients be in advanced stages of disease.

Conclusions

This study represents the first-in-human clinical trial involving transplantation of a purified population of human neural stem cells for a neurodegenerative disorder. The feasibility of this approach and absence of transplantation-related serious adverse events support further exploration of HuCNS-SC transplantation as a potential treatment for select subtypes of NCL, and possibly for other neurodegenerative disorders. Clinical trial registration no.: NCT00337636 (ClinicalTrials.gov).

Abbreviations used in this paper:BSID-II = Bayley Scales of Infant Development II; CAS = Callier-Azusa G-Scale; DMC = Data Monitoring Committee; EEG = electroencephalography; HuCNS-SC = human CNS stem cell; INCL = infantile NCL; LINCL = late-infantile NCL; MMF = mycophenolate mofetil; NCL = neuronal ceroid lipofuscinosis; OHSU = Oregon Health & Science University; PCR = polymerase chain reaction.

Article Information

Address correspondence to: Nathan R. Selden, M.D., Ph.D., Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Mail Code CH8N, 3303 SW Bond Avenue, Portland, Oregon 97239. email: seldenn@ohsu.edu.

Please include this information when citing this paper: published online April 12, 2013; DOI: 10.3171/2013.3.PEDS12397.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Cross-correction of enzyme deficiency in vivo using HuCNS-SCs. Artist's conceptualization of cell-based cross-correction as a potential therapeutic strategy. With this experimental approach, PPT-1 and TPP1 are secreted by transplanted HuCNS-SCs and absorbed by host neurons through the mannose 6-phosphate receptor pathway. Cross-correction involves the uptake of these soluble enzymes, resulting in the reduction or stabilization of the accumulating harmful intracellular metabolites. Printed with permission from Andrew J. Rekito.

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    Magnetic resonance images pre– and post–HuCNS-SC transplantation. Representative T2-weighted axial MR images at the midventricular level for all patients at screening and 12 months (6 months in Case 2) after HuCNS-SC transplantation. Case numbers are in the upper left corner of each image. The progressive cerebral atrophy noted between the pre- and post-transplantation images is consistent with the stage of disease for each patient. The posttransplantation MR images did not reveal any delayed adverse reaction to the surgery or cell transplantation.

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    Case 5. Analysis of HuCNS-SC engraftment using nested PCR and duplex quantitative PCR in the postmortem brain. A: Artist's rendering shows axial slice position, 2 needle tracks (anterior frontal and parietal), and tissue sample block locations subjected to PCR analysis. Cross-hatching indicates samples in which HuCNS-SCs were detected by PCR. B: HLADRB1* 01- and HLA-DRB1*04-nested PCR of genomic DNA isolated from the second and fourth frozen brain slices. Gel labels indicate tissue samples corresponding to areas shown in the whole brain diagram (A), HLA-DRB1*01 and HLA-DRB1*04 PCR products (left), and DNA ladder markers (right). Chromosome X PCR (lane 1) was the positive control in all PCRs. C: Duplex quantitative PCR enumerates donor cells per 100,000 host cells in the tissue blocks specified in the schematic (A) by detecting HLA-DRB1*01 (donor cells) and human chromosome X gene sequences simultaneously. The data represent the mean values of three independent PCR quantification experiments performed in triplicate. AF1 and AF2 = anterior frontal blocks 1 and 2; BG = basal ganglia (genu of the internal capsule); C = control tissue from far anterior frontal tip; DF = deep anterior frontal; DP = deep posterior parietal; P = parietal; PF = posterior frontal. Illustration printed with permission from Andrew J. Rekito.

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    Case 2. Low (upper) and high (lower) magnification of a typical surgical artifact from needle insertion and cell suspension injection at 11 months posttransplantation of human CNS stem cells (HuCNS-SCs). Visible changes related to insertion of the needle for cell deposition were minimal. Gliotic changes in the area immediately adjacent to the residual needle track were negligible as shown in the higher magnification. No inflammatory cells collected to suggest any localized immune reaction to the cell transplant. Similarly, no infarction, hemorrhage, cyst formation, neoplasm, or abnormal host cell reaction was evident. The findings of generalized reactive astrocytes, microglia, and enlarged neurons typical of infantile neuronal ceroid lipofuscinosis (INCL) were noted and were considered consistent with the patient's diagnosis and disease course. H & E.

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    Neuropsychological assessment. Change in Bayley Scales of Infant Development II (BSID-II) and Callier-Azusa G-Scale (CAS) mean developmental age from screening to 6 and 12 months posttransplantation. The patient in Case 1 was unable to undergo BSID-II evaluation after screening. The patient in Case 2 died before the 12-month assessment.

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    Case 2. Analysis of HuCNS-SC engraftment using nested polymerase chain reaction (PCR) in the postmortem brain. A: Diagram of the right hemisphere. Blue lines indicate horizontal cuts, red vertical lines and X's indicate needle tracks, green rectangles indicate samples collected for PCR analysis, and green plus signs indicate areas where HuCNS-SCs were detected by nested PCR. Left hemisphere diagram not shown. B: Chromosome Y–nested PCR of genomic DNA isolated from paraffin block samples from each brain hemisphere (Areas A, B, and C). Gel labels indicate tissue samples corresponding to areas shown in the right hemisphere diagram (A), chromosome Y PCR products (left), and DNA ladder markers (right). Tissue samples analyzed from the left hemisphere were selected from nonspecific locations (diagram not shown). Chromosome X PCR was the positive control in all PCRs. Illustration printed with permission from Andrew J. Rekito.

  • View in gallery

    Case 1. Analysis of HuCNS-SC engraftment using nested PCR in the postmortem brain. A: Diagram of the right hemisphere. Tissue samples from the estimated areas of donor cell transplant were collected from 2 frozen axial sections from the right hemisphere. B: The tissues were assayed for HuCNS-SCs by nested PCR for the HLA DRB1*01 allele. The PCR methodology is described in the Methods Appendix. Illustration printed with permission from Andrew J. Rekito.

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Mendez IDagher AHong MHebb AGaudet PLaw A: Enhancement of survival of stored dopaminergic cells and promotion of graft survival by exposure of human fetal nigral tissue to glial cell line–derived neurotrophic factor in patients with Parkinson's disease. Report of two cases and technical considerations. J Neurosurg 92:8638692000

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