Preface

Chapter 7 **Impact of the Donor KIR Genotype on the Clinical Outcome of**

Chapter 8 **Hematopoietic Stem Cell Transplantation for Acute**

Chapter 9 **Post-Transplantation Management Strategies 195**

Paramjit Singh Dhot and Mayurika S. Tyagi

**with Ischemic Heart Disease 225** Andrei Cismaru and Gabriel Cismaru

Mohammad Hosein Amirzade-Iranaq

**Manufacturing 223**

Hoffmeister

Şahin

**Center Experience 143**

Marcenò

**VI** Contents

**Hematopoietic Stem Cell Unrelated Transplants: A Single**

Francesco Ingrassia, Valentina Cappuzzo, Rosalba Bavetta, Serena Mistretta, Maria Igea Vega, Paola Bruna Affaticati, Maria Blando, Floriana Bruno, Emanuela Collura, Giovanna Regina, Valentina Randazzo, Alessandro Indovina, Felicia Farina and Raimondo

**Lymphoblastic Leukemia in the Era of Novel Therapies 159** Eshrak Alshibani, Zeyad AlShaibani and Khalid Ahmed Al-Anazi

Muhammad Waqas Khan, Ahmed Elmaaz and Zartash Gul

Chapter 10 **New Horizons in Regenerative Medicine in Organ Repair 215**

**Section 4 Tissue Engineering Mechanisms and Stem Cell Based Product**

Chapter 11 **Optimal Delivery Strategy for Stem Cell Therapy in Patients**

Chapter 12 **Landscape of Manufacturing Process of ATMP Cell Therapy Products for Unmet Clinical Needs 245**

Chapter 13 **Tissue Engineering Applications in Maxillofacial Surgery 271**

Chapter 14 **Human Adipose-Derived Stem Cells for Tissue Engineering**

Chapter 15 **Tissue Engineering for Skin Replacement Methods 315**

**Approaches: Current Challenges and Perspectives 293** Sorina Dinescu, Anca Hermenean and Marieta Costache

Ralf Pörtner, Shreemanta K. Parida, Christiane Schaffer and Hans

Seied Omid Keyhan, Hamidreza Fallahi, Alireza Jahangirnia, Seyed Mohammad Reza Masoumi, Mohammad Hossein Khosravi and

Özge Sezin Somuncu, Ceren Karahan, Salih Somuncu and Fikrettin

#### *Dedicated to my demised father and Innovations and Solutions AMET University Global*

Every individual faces many injuries and recoveries over a period of time. In fact, healing occurs due to a proliferation of stem cells capable of restoring the injured tissue. These stem cells contain regenerative potential with enormous impact on clinical applications. The re‐ generative potential may arise from stem cell self-renewal, multipotency, and paracrine functions (restoration). The paracrine secretion of growth factors or cytokines from retained stem cells leads to endogenous progenitor cells capable of biotransforming in the desired tissue cells (rejuvenation).

Stem cells are progenitor cells originating from a small number of natural cells from tissues. These progenitor cells may be cultured in desired media conditions to grow and differenti‐ ate to transform in different tissues of desired organs with improved physiological functions by tissue engineering, pronounced "**The-i-su En-ge-ni-ea-ring.**" The art of differentiation and tissue regeneration and putting cells at endogenous injury sites is called transplanta‐ tion, pronounced "**Tren-s-phlen-te-san.**" These stem cells may be categorized into four types: embryonic, induced pluripotent, mesenchymal, and allogenic cells.

The last decade has seen the growing popularity of stem cell treatment and tissue engineer‐ ing applications in regenerative medicine as a lifeline to patients suffering from cancer and incurable diseases. However, a number of public health concerns are still obstructing this lucrative treatment in clinical centers and hospitals due to ethical and political preferences. In spite of this, the clinical needs of engineered, induced pluripotent stem cells have extend‐ ed to successful organ transplantation and tissue reconstruction for organ repair. Recent es‐ timations indicate that stem cell transplantation for organ repair may be useful in 80% of stem cell clinical centers around the globe to treat diseases, including stem cell experimental research that surprisingly has created great public concern. However, globally, different fed‐ eral and government agencies have shown their concern over the safe and proper use of stem cells in privately run stem cell clinics or health laboratories as "basic right to get benefit of existing art" available as unfounded words from mouth as projected in introductory chapter. Stem cells are used as an autograft means of self-renewing undifferentiated cloni‐ genic transplantation in organ repair or regeneration to bring tissue functionality back to normal for the long-term survival of patients with permanent endogenous organ damage.

Some cells differentiate into pluripotent cells. Induced pluripotent cells have a unique ca‐ pacity to differentiate into desired cell types that may be grown into specific organ types. Stem cells are successfully grown for the regeneration and reconstruction of neural, skin,

platelet, cardiac, maxillofacial, kidney, bone cartilage, adipose tissue, eye, hair, abdominal, and gastrointestinal tissue regenerative medicine. Further, new prospects for transplantation are continuously being discovered in almost every part of the human body.

conditioning regimens depending upon disease type. The predictive role of chimerism anal‐ ysis is a choice in monitoring the early risks of graft versus host disease (GvHD) develop‐ ment, minimal residual disease (MRD), graft failure or rejection, and disease relapse.

Preface IX

Chapter 5 describes optimal delivery strategy for stem cell therapy in patients with ischemic heart disease. The administration of stem cells to the heart is described using three preferred approaches by intracoronary, intramyocardial, and epicardial injection for optimal delivery. Advantages and disadvantages of optimal injection delivery methods and limitations of NOGA clinical systems are analyzed in the light of advances in the last 5 years, with future prospects. The authors believe that a combined intracoronary artery and intracoronary sinus injection approach could reduce washout and increase adhesion to the necrosed area with high clinical success using stem cell therapy administrated for ischemic heart disease.

Chapter 6 introduces *in vivo* evaluation of cardiovascular remodeling and dynamic monitor‐ ing for successful repair of myocardial viability by molecular noninvasive imaging methods. Several methods, including cardiovascular 900 MHz or 21 tesla magnetic resonance microi‐ maging, bioluminescence or radionuclide gene reporter methods, may be useful in differen‐ tiating stem cells. Ultra-high magnetic field cardiovascular magnetic resonance has possible preclinical prospects for *in vivo* noninvasive molecular imaging or restorative monitoring of the reporters of rejuvenating stem cell genes to evaluate the success of transplantation and cardiac repair. Smart magnetic resonance spectroscopy imaging sequences with improved magnetic resonance imaging-sensitive, specific stem cell differentiation may detect rejuvena‐ tion by targeting energy metabolites, myocardial viability, and vital physiochemical mole‐ cules. The author believes that with the help of stem cell imaging and monitoring, transplantation of stem cells will eventually be optimized for the effective long-lasting thera‐

Chapter 7 describes a single center study on the **impact of the donor** killer cell immunoglobu‐ lin-like receptor **(KIR) genotype on the clinical outcome of hematopoietic stem cell unrelat‐ ed transplants. The authors proposed a** "KIR B-content score" based on the number of centromere and telomeric Group B KIR haplotype gene-content motifs to evaluate clinical outcome when patients with acute myeloid leukemia received a hematopoietic stem cell transplant from unrelated Group B KIR haplotype donors. The authors reported a significant role of KIR genotypes, natural killer cells, and HSCT in acute myeloid leukemia to enhance overall survival, relapse, and incidence of acute GvHD for longer disease-free survival.

Chapter 8 describes hematopoietic stem cell transplantation for acute lymphoblastic leuke‐ mia with an account of novel therapies. The authors have reviewed various modalities of stem cell therapies in different types of acute lymphoblastic leukemias among children and adults with closely related issues of graft versus tumor effect, MRD, and conditioning thera‐ pies such as haploidentical stem cell transplantation and allogenic stem cell transplantation in T-cell Ph+ leukemia types. The authors comment on relapse before and after stem cell transplantation therapies, including immunotherapies by tyrosine kinase inhibitors imati‐ nib, dasatinib, nilotinib, ponatinib, nelarabine, and blimatumomab; however, integration of other therapeutic interventions before and after transplantation will further improve the

Chimerism analysis is the preferred method for monitoring the outcome of HSCT.

Section 3 focuses on the current practice of stem cells in medical practice.

py of myocardial infarction and heart failure.

outcome of patients.

This book is an attempt to compile and highlight the need for basic information on stem cells, differentiation behavior in cultures, experimental data on host–pluripotent cell interac‐ tion, and investigative and conclusive evaluation of successful endogenous organ or tissue repair with post-transplantation management issues in a timely fashion. The knowledge of stem cells, transplantation methods, evaluation, monitoring, and post-transplantation man‐ agement will certainly enrich the scope of stem cell therapy among clinicians, scientists, en‐ trepreneurs, academic politicians, physicians, and health authorities with global acceptance of an "enriched fountain of youth" in future years as a boon to humankind. With this goal, the book is divided into four sections comprising 15 chapters.

Section 1 introduces the purpose of stem cell therapy and tissue engineering.

Chapter 1 introduces readers to the origin of stem cells and types, purpose, and regulation of stem cell therapy with clinical applications in current medical practice around the globe. A panoramic account of legal permissions is presented on stem cell research with limited use of stem cells in regenerative medicine, restoration, rejuvenation, or tissue reconstruction to treat certain diseases at presently available clinical centers in Europe, the United States, Asia, and other countries. The objectives of successful pluripotent stem cell therapy, ethical and regulatory oversight, and its public concern highlight the present paradigm shift from the practice of unestablished stem cell treatments to extensive research on stem cell and tis‐ sue engineering products used in their preclinical and clinical trials within permitted regula‐ tory limits before use in medical practice. The scope of regenerative medicine is reviewed with the emerging role of stem cell therapy at different clinical centers under the stringent supervision of federal authorities.

Section 2 focuses on mechanisms of stem cell differentiation and tissue engineering.

Chapter 2 presents the current view of hematopoiesis and beyond. The stem cells originating from embryos and migrating to bone marrow are shown to develop hematopoietic environ‐ ments participating in interactions such as stem cell survival, self-renewal, and differentiation to hematopoiesis, and regulate the proliferation, differentiation, and mobilization of stem cells. The authors highlight the trafficking of stem cells in various tissues and organs for re‐ generation, and hematopoietic speedy recovery in diseases such as leukemia and aplastic ane‐ mia after chemotherapy for hematopoietic reconstruction after stem cell transplantation.

Chapter 3 witnesses the aging factor of stem cells that contributes to stem cell-based thera‐ py, as well as in tissue engineering procedures. Different mechanisms of aging are described such as molecular chromatin-based oxidative stress, mitochondrial biogenesis and mito‐ chondrial DNA mutation, nuclear damage, telomere shortening, epigenetic changes and gene expression dysregulation, microRNA changes, RNA splicing, proteostasis, cell polarity changes, nutrient sensing, niche deterioration, stem cell exhaustion, and senescence in the adult stem cell aging processes responsible for self-renewal and differentiation essential during rejuvenation. These stem cell aging mechanisms will answer various queries related to current cell-based therapies and design future counter aging longevity procedures.

Chapter 4 describes the monitoring of chimerism levels in post-hematopoietic stem cell transplantation (HSCT) for immune system reconstitution. The chimerism levels are specific conditioning regimens depending upon disease type. The predictive role of chimerism anal‐ ysis is a choice in monitoring the early risks of graft versus host disease (GvHD) develop‐ ment, minimal residual disease (MRD), graft failure or rejection, and disease relapse. Chimerism analysis is the preferred method for monitoring the outcome of HSCT.

Section 3 focuses on the current practice of stem cells in medical practice.

platelet, cardiac, maxillofacial, kidney, bone cartilage, adipose tissue, eye, hair, abdominal, and gastrointestinal tissue regenerative medicine. Further, new prospects for transplantation

This book is an attempt to compile and highlight the need for basic information on stem cells, differentiation behavior in cultures, experimental data on host–pluripotent cell interac‐ tion, and investigative and conclusive evaluation of successful endogenous organ or tissue repair with post-transplantation management issues in a timely fashion. The knowledge of stem cells, transplantation methods, evaluation, monitoring, and post-transplantation man‐ agement will certainly enrich the scope of stem cell therapy among clinicians, scientists, en‐ trepreneurs, academic politicians, physicians, and health authorities with global acceptance of an "enriched fountain of youth" in future years as a boon to humankind. With this goal,

Chapter 1 introduces readers to the origin of stem cells and types, purpose, and regulation of stem cell therapy with clinical applications in current medical practice around the globe. A panoramic account of legal permissions is presented on stem cell research with limited use of stem cells in regenerative medicine, restoration, rejuvenation, or tissue reconstruction to treat certain diseases at presently available clinical centers in Europe, the United States, Asia, and other countries. The objectives of successful pluripotent stem cell therapy, ethical and regulatory oversight, and its public concern highlight the present paradigm shift from the practice of unestablished stem cell treatments to extensive research on stem cell and tis‐ sue engineering products used in their preclinical and clinical trials within permitted regula‐ tory limits before use in medical practice. The scope of regenerative medicine is reviewed with the emerging role of stem cell therapy at different clinical centers under the stringent

are continuously being discovered in almost every part of the human body.

Section 1 introduces the purpose of stem cell therapy and tissue engineering.

Section 2 focuses on mechanisms of stem cell differentiation and tissue engineering.

Chapter 2 presents the current view of hematopoiesis and beyond. The stem cells originating from embryos and migrating to bone marrow are shown to develop hematopoietic environ‐ ments participating in interactions such as stem cell survival, self-renewal, and differentiation to hematopoiesis, and regulate the proliferation, differentiation, and mobilization of stem cells. The authors highlight the trafficking of stem cells in various tissues and organs for re‐ generation, and hematopoietic speedy recovery in diseases such as leukemia and aplastic ane‐ mia after chemotherapy for hematopoietic reconstruction after stem cell transplantation.

Chapter 3 witnesses the aging factor of stem cells that contributes to stem cell-based thera‐ py, as well as in tissue engineering procedures. Different mechanisms of aging are described such as molecular chromatin-based oxidative stress, mitochondrial biogenesis and mito‐ chondrial DNA mutation, nuclear damage, telomere shortening, epigenetic changes and gene expression dysregulation, microRNA changes, RNA splicing, proteostasis, cell polarity changes, nutrient sensing, niche deterioration, stem cell exhaustion, and senescence in the adult stem cell aging processes responsible for self-renewal and differentiation essential during rejuvenation. These stem cell aging mechanisms will answer various queries related to current cell-based therapies and design future counter aging longevity procedures.

Chapter 4 describes the monitoring of chimerism levels in post-hematopoietic stem cell transplantation (HSCT) for immune system reconstitution. The chimerism levels are specific

the book is divided into four sections comprising 15 chapters.

supervision of federal authorities.

VIII Preface

Chapter 5 describes optimal delivery strategy for stem cell therapy in patients with ischemic heart disease. The administration of stem cells to the heart is described using three preferred approaches by intracoronary, intramyocardial, and epicardial injection for optimal delivery. Advantages and disadvantages of optimal injection delivery methods and limitations of NOGA clinical systems are analyzed in the light of advances in the last 5 years, with future prospects. The authors believe that a combined intracoronary artery and intracoronary sinus injection approach could reduce washout and increase adhesion to the necrosed area with high clinical success using stem cell therapy administrated for ischemic heart disease.

Chapter 6 introduces *in vivo* evaluation of cardiovascular remodeling and dynamic monitor‐ ing for successful repair of myocardial viability by molecular noninvasive imaging methods. Several methods, including cardiovascular 900 MHz or 21 tesla magnetic resonance microi‐ maging, bioluminescence or radionuclide gene reporter methods, may be useful in differen‐ tiating stem cells. Ultra-high magnetic field cardiovascular magnetic resonance has possible preclinical prospects for *in vivo* noninvasive molecular imaging or restorative monitoring of the reporters of rejuvenating stem cell genes to evaluate the success of transplantation and cardiac repair. Smart magnetic resonance spectroscopy imaging sequences with improved magnetic resonance imaging-sensitive, specific stem cell differentiation may detect rejuvena‐ tion by targeting energy metabolites, myocardial viability, and vital physiochemical mole‐ cules. The author believes that with the help of stem cell imaging and monitoring, transplantation of stem cells will eventually be optimized for the effective long-lasting thera‐ py of myocardial infarction and heart failure.

Chapter 7 describes a single center study on the **impact of the donor** killer cell immunoglobu‐ lin-like receptor **(KIR) genotype on the clinical outcome of hematopoietic stem cell unrelat‐ ed transplants. The authors proposed a** "KIR B-content score" based on the number of centromere and telomeric Group B KIR haplotype gene-content motifs to evaluate clinical outcome when patients with acute myeloid leukemia received a hematopoietic stem cell transplant from unrelated Group B KIR haplotype donors. The authors reported a significant role of KIR genotypes, natural killer cells, and HSCT in acute myeloid leukemia to enhance overall survival, relapse, and incidence of acute GvHD for longer disease-free survival.

Chapter 8 describes hematopoietic stem cell transplantation for acute lymphoblastic leuke‐ mia with an account of novel therapies. The authors have reviewed various modalities of stem cell therapies in different types of acute lymphoblastic leukemias among children and adults with closely related issues of graft versus tumor effect, MRD, and conditioning thera‐ pies such as haploidentical stem cell transplantation and allogenic stem cell transplantation in T-cell Ph+ leukemia types. The authors comment on relapse before and after stem cell transplantation therapies, including immunotherapies by tyrosine kinase inhibitors imati‐ nib, dasatinib, nilotinib, ponatinib, nelarabine, and blimatumomab; however, integration of other therapeutic interventions before and after transplantation will further improve the outcome of patients.

Chapter 9 describes post-transplantation management strategies for hematologic malignan‐ cies treated with bone marrow transplantation. The most effective and safest drug mainte‐ nance therapies are best suited to the post-transplantation management of multiple myeloma, chronic myeloid leukemia, Philadelphia chromosome positive acute lymphoblas‐ tic leukemia, acute myeloid leukemia, Hodgkin lymphoma, and non-Hodgkin lymphoma diseases. The authors reviewed the beneficial effects of maintenance therapy by thalido‐ mide, lenalidomide, and bortezomib to enhance patient survival, relapse, and longevity.

rhinoplasty as effective oral and facial procedures. The authors carefully conclude the Food and Drug Administration denial of engineered products, chances of oncogenesis, and diffi‐

Preface XI

Chapter 14 describes human adipose-derived stem cells for tissue engineering applications with current challenges and future perspectives. Different 3D scaffolds made of gelatin–algi‐ nate–polyacrylamide and collagen–sericin are proposed. The authors introduce human adi‐ pose-derived stem cell products, their source, properties, and different adipogenic, osteogenic, chondrogenic, neurogenic, retinal, corneal, cardiac, and hepatic differentiation potentials in current clinical practice and research trials with a note on risks and future per‐ spectives. Controlled use of these cells could become a very powerful tool to increase the quality of life in patients with different tissue defects and are the ultimate advance in regen‐

Chapter 15 reviews the current status of tissue engineering for *in vivo* and *ex vivo* skin re‐ placement methods and manufactured skin scaffold biomaterials. The authors introduce skin structure, skin substitutes, dermal stem cells, *in vivo* autologous skin transfer, skin tis‐ sue alternatives with *in vitro* dermal stem cell experimental application models, prospects of skin gene therapy, and chitosan, hyaluronic acid, collagen, silk, fibrin glue, and artificial pol‐ ymeric scaffold biomaterials with vast future scenarios of pluripotent stem cell reprogram‐

The editor presents this volume as a textbook-cum-ready reckoner guide book in a lucid, effective, simple, and user-friendly manner for novice researchers, teachers, stem cell scien‐ tists, and medical experts in regenerative medicine clinical practice. For interested readers, physicians, researchers, and health care authorities, available resources on stem cell treat‐ ments and the legal status of clinical practice are included as an introductory chapter.

1. The Clinical Practice of Stem-Cell Transplantation. Volume 1, 1st Edition. 1998. Editors: Barrett J and Treleaven J, Isis Medical Media. ISBN: 9781899066704,

2. Stem Cell Transplantation: A Clinical Trial Textbook. 1st Edition. 2000. Editors: Buchel PC and Kapustay PM, Oncology Nursing Society Publishers.

1. Santostefano KE, Hamazaki T, Biel NM, Jin S, Umezawa A, Terada N. A practical guide to induced pluripotent stem cell research using patient samples. Laborato‐

ISBN-10: 1890504157, ISBN-13: 978-1890504151.

http://www.nature.com/articles/labinvest2014104.pdf 2. The past, present and future of stem cell clinical trials for ALS. www.sciencedirect.com/science/article/pii/S0014488614000739 3. Heart disease and stem cells publications. Stem Cell Institute, Panama. https://www.cellmedicine.com/heart-disease-and-stem-cells/

ry Investigation (2015), 95, 4–13.

culties of compatible transplantable scaffolds.

erative medicine.

ming within scaffolds.

**Books, monograms**

**Articles**

1899066705

Chapter 10 reviews the new horizons of regenerative medicine in organ repair with strin‐ gent pathological evaluation of clinical use or its success. The latest evidence based on pathological evaluation is presented as an indicator of tissue reconstruction success in ure‐ thral defects, retinal and corneal damage, orthopedic injury, bronchomalacia, skin transplan‐ tation in bullosa, and amniotic cell grafting. However, investigative studies are suggested on the mechanisms of endogenous injury and interactions at organ or tissue cell interface with activated endogenous progenitor cell populations to explain how progenitor cells behave with cells of the immune system.

Section 4 focuses on tissue engineering mechanisms and stem cell-based product manufac‐ turing.

Chapter 11 describes human-induced pluripotent stem cell-derived engineered cardiac tis‐ sues in cardiac disease remodeling and regeneration. The authors describe different availa‐ ble technologies, including cell sheet technology, embedded cardiac biomaterials, spongy polymeric scaffolds, and decellularized tissues to regenerate cardiac tissue. The authors highlight a method of human pluripotent stem cell maturation in cardiac-transplanted sites and evaluate electromechanical properties and mechanical load conditions in stem cell ma‐ trix conditions with a detailed account of the use of engineered cells in drug testing for posttransplantation, disease modeling, and establishing its mechanism of cardiorejuvenation. A properly designed manufacturing process and stem cell behavior during maturation may likely expand the scalability and reduce the cost of generating these novel engineered *in vi‐ tro* myocardial tissues.

Chapter 12 proposes an improved manufacturing process of immune cells as advanced ther‐ apy medicinal products for current clinical needs of stem cell treatment at clinical centers. Currently available different products and bioreactor systems are described such as T-lym‐ phocyte cells, natural killer cells, apheresis, tumor infiltrating lymphocytes, chimeric antigen receptors—T cells, and mesenchymal stem cells in reported clinical trials with a detailed account of withdrawn products from global markets. To maintain the high-quality medical practice of natural killer cells and mesenchymal stem cells, the authors emphasize a detailed characterization of *ex vivo* immune cell receptor subtypes and ligands on the cell surface as a highly recommended protocol in expanded immune cell population with information of pattern and amount of secreted effector molecules over time, with influences from *in vivo* components on them.

Chapter 13 presents a survey of tissue engineering in oral and maxillofacial complexes with an emphasis on the advantages and clinical applications to restore, maintain, and stabilize facial tissue functions. The authors describe the principles of oral and facial tissue engineer‐ ing with the introduction of mandibular, bone, oral skin, oral mucosa, temporomandibular joint disc, condyle, fibrocartilage, and salivary gland defects with limited success of different transplantation procedures using maxillary sinus augmentation and dorsal augmentation in rhinoplasty as effective oral and facial procedures. The authors carefully conclude the Food and Drug Administration denial of engineered products, chances of oncogenesis, and diffi‐ culties of compatible transplantable scaffolds.

Chapter 14 describes human adipose-derived stem cells for tissue engineering applications with current challenges and future perspectives. Different 3D scaffolds made of gelatin–algi‐ nate–polyacrylamide and collagen–sericin are proposed. The authors introduce human adi‐ pose-derived stem cell products, their source, properties, and different adipogenic, osteogenic, chondrogenic, neurogenic, retinal, corneal, cardiac, and hepatic differentiation potentials in current clinical practice and research trials with a note on risks and future per‐ spectives. Controlled use of these cells could become a very powerful tool to increase the quality of life in patients with different tissue defects and are the ultimate advance in regen‐ erative medicine.

Chapter 15 reviews the current status of tissue engineering for *in vivo* and *ex vivo* skin re‐ placement methods and manufactured skin scaffold biomaterials. The authors introduce skin structure, skin substitutes, dermal stem cells, *in vivo* autologous skin transfer, skin tis‐ sue alternatives with *in vitro* dermal stem cell experimental application models, prospects of skin gene therapy, and chitosan, hyaluronic acid, collagen, silk, fibrin glue, and artificial pol‐ ymeric scaffold biomaterials with vast future scenarios of pluripotent stem cell reprogram‐ ming within scaffolds.

The editor presents this volume as a textbook-cum-ready reckoner guide book in a lucid, effective, simple, and user-friendly manner for novice researchers, teachers, stem cell scien‐ tists, and medical experts in regenerative medicine clinical practice. For interested readers, physicians, researchers, and health care authorities, available resources on stem cell treat‐ ments and the legal status of clinical practice are included as an introductory chapter.

#### **Books, monograms**


#### **Articles**

Chapter 9 describes post-transplantation management strategies for hematologic malignan‐ cies treated with bone marrow transplantation. The most effective and safest drug mainte‐ nance therapies are best suited to the post-transplantation management of multiple myeloma, chronic myeloid leukemia, Philadelphia chromosome positive acute lymphoblas‐ tic leukemia, acute myeloid leukemia, Hodgkin lymphoma, and non-Hodgkin lymphoma diseases. The authors reviewed the beneficial effects of maintenance therapy by thalido‐ mide, lenalidomide, and bortezomib to enhance patient survival, relapse, and longevity. Chapter 10 reviews the new horizons of regenerative medicine in organ repair with strin‐ gent pathological evaluation of clinical use or its success. The latest evidence based on pathological evaluation is presented as an indicator of tissue reconstruction success in ure‐ thral defects, retinal and corneal damage, orthopedic injury, bronchomalacia, skin transplan‐ tation in bullosa, and amniotic cell grafting. However, investigative studies are suggested on the mechanisms of endogenous injury and interactions at organ or tissue cell interface with activated endogenous progenitor cell populations to explain how progenitor cells behave

Section 4 focuses on tissue engineering mechanisms and stem cell-based product manufac‐

Chapter 11 describes human-induced pluripotent stem cell-derived engineered cardiac tis‐ sues in cardiac disease remodeling and regeneration. The authors describe different availa‐ ble technologies, including cell sheet technology, embedded cardiac biomaterials, spongy polymeric scaffolds, and decellularized tissues to regenerate cardiac tissue. The authors highlight a method of human pluripotent stem cell maturation in cardiac-transplanted sites and evaluate electromechanical properties and mechanical load conditions in stem cell ma‐ trix conditions with a detailed account of the use of engineered cells in drug testing for posttransplantation, disease modeling, and establishing its mechanism of cardiorejuvenation. A properly designed manufacturing process and stem cell behavior during maturation may likely expand the scalability and reduce the cost of generating these novel engineered *in vi‐*

Chapter 12 proposes an improved manufacturing process of immune cells as advanced ther‐ apy medicinal products for current clinical needs of stem cell treatment at clinical centers. Currently available different products and bioreactor systems are described such as T-lym‐ phocyte cells, natural killer cells, apheresis, tumor infiltrating lymphocytes, chimeric antigen receptors—T cells, and mesenchymal stem cells in reported clinical trials with a detailed account of withdrawn products from global markets. To maintain the high-quality medical practice of natural killer cells and mesenchymal stem cells, the authors emphasize a detailed characterization of *ex vivo* immune cell receptor subtypes and ligands on the cell surface as a highly recommended protocol in expanded immune cell population with information of pattern and amount of secreted effector molecules over time, with influences from *in vivo*

Chapter 13 presents a survey of tissue engineering in oral and maxillofacial complexes with an emphasis on the advantages and clinical applications to restore, maintain, and stabilize facial tissue functions. The authors describe the principles of oral and facial tissue engineer‐ ing with the introduction of mandibular, bone, oral skin, oral mucosa, temporomandibular joint disc, condyle, fibrocartilage, and salivary gland defects with limited success of different transplantation procedures using maxillary sinus augmentation and dorsal augmentation in

with cells of the immune system.

*tro* myocardial tissues.

components on them.

turing.

X Preface

1. Santostefano KE, Hamazaki T, Biel NM, Jin S, Umezawa A, Terada N. A practical guide to induced pluripotent stem cell research using patient samples. Laborato‐ ry Investigation (2015), 95, 4–13.

http://www.nature.com/articles/labinvest2014104.pdf


#### **Stem cell clinical research**

1. Donnelly EM, Lamanna J, Boulis NM. Stem cell therapy for the spinal cord. Stem Cell Research & Therapy (2012), 3, 24.

**US patent Title of patent**

20160051729 Reparative cell isolation and delivery

method 20150216911 Multipotent prenatal stem cells

factors

RNA delivery

ing same

cancer

suppressive agents

colony forming cells

20140178422 Primary mesenchymal stem cells as a vaccine platform

20140017787 Mesenchymal stem cells and related therapies

ative medicine applications 20160010113 Compositions and methods for engineering cells

20150238532 Methods to isolate human mesenchymal stem cells

tion and immunomodulation

20150166959 Immortalized mesenchymal stem cell from adipose tissue

20160022739 Closed system separation of adherent bone marrow stem cells for regener‐

Preface XIII

20160008401 Protection of the vascular endothelium from immunologically mediated cytotoxic reactions with human CD34-negative progenitor cells

20150265677 Recruitment of mesenchymal stem cells using controlled release systems

20150231244 Regenerative cell and adipose-derived stem cell processing system and

20150216908 Quadri-positive stromal cells (QPSC) population for superior cell protec‐

20150216908 Methods for generating mesenchymal stem cells which secrete neurotropic

20150175971 Multipotent cells having mesenchymal and endothelial lineage potential

20150157666 Methods, systems and compositions for cell-derived/vesicle-based micro‐

20150139963 Isolated populations of renal stem cells and methods of isolating and us‐

20150037882 Scalable process for therapeutic cell concentration and residual clearance 20140341870 Biocomposite for regeneration of injured tissue and organ, a kit for mak‐ ing the biocomposite, and a method of treating injuries

20140220597 Neuregulin-1-based prognosis and therapeutic stratification of colorectal

20140220053 Microvesicles isolated from mesenchymal stem cells for use as immuno‐

20140193473 Materials and methods for controlling vasculogenesis from endothelial

20130345289 Adult stem cells, molecular signatures, and applications in the evaluation,

diagnosis, and therapy of mammalian conditions

20130338092 Compounds and methods for targeting leukemic stem cells

20140322356 CTC biomarker assay to combat breast cancer brain metastasis 20140227339 Regenerative tissue grafts and methods of making sames

20160000835 Human uterine cervical stem cells population and uses thereof 20160000835 Human uterine cervical stem cells population and uses thereof 20150320833 Ossification-inducing compositions and methods of use thereof


#### **US Patents on stem cell therapy 2007-2018. Patents can be downloaded by clicking the first column:**



**Stem cell clinical research**

XII Preface

**first column:**

**US patent Title of patent**

B2

cells

thereon

Cell Research & Therapy (2012), 3, 24.

5. http://www.jci.org/articles/view/40543

1. Donnelly EM, Lamanna J, Boulis NM. Stem cell therapy for the spinal cord. Stem

2. Beato Coelho MB, Cabral JMS, Karp JM. Intraoperative stem cell therapy. Annual

3. Yu D, Silva GA. Stem cell sources and therapeutic approaches for central nervous system and neural retinal disorders. Neurosurgery Focus (2008), 24(3–4), E11. 4. Hayashi T, Onoe H. Neuroimaging for optimization of stem cell therapy in Par‐ kinson's disease. Expert Opinion on Biological Therapy (2013), 13(12), 1631–1638.

**US Patents on stem cell therapy 2007-2018. Patents can be downloaded by clicking the**

20130259843 Skeletal muscle regeneration using mesenchymal system cells US 9757419

20160296637 Method for improving survival after radiation exposure using mesenchy‐

mal stem cells as vehicles for extracellular superoxide dismutase delivery

https://stemcellres.biomedcentral.com/articles/10.1186/scrt115

Review of Biomedical Engineering (2012), 14, 325–349.

20179610430 Cell spraying device, method and sprayed cell suspension

20160206660 Composition of stem cells having highly expressed FAS ligand 20160199414 Use of mesenchymal stem cells for the treatment of oral inflammation 20160184366 Compositions comprising stem cells expressing mesenchymal and neuro‐

nal markers and uses to treat neurological disease 20160184364 Management of osteoarthritis using pooled allogeneic mesenchymal stem

20160158292 Method and apparatus for recovery of umbilical cord tissue derived re‐

20160123980 Multicolor flow cytometry method for identifying population of cells, in

20160106781 High telomerase activity bone marrow mesenchymal stem cells, methods

20160082042 Use of mesenchymal stem cell-educated macrophages to treat and prevent graft versus host disease and radiation-induced injury 20160060319 Development of protein-based biotherapeutics that induced osteogenesis

pro-osteogenic compositions comprising the same

of producing the same and pharmaceuticals and treatment methods based

for bone healing therapy: cell-permeable BMP2 and BMP7 recombinant proteins (CP-BMP2 & CP-BMP7), polynucleotides encoding the same and

20160287642 Methods of treating or preventing a lung disorder 20160228537 Reverse vaccination therapy of multiple sclerosis

20160161483 Method of distinguishing mesenchymal cells

generative cells and uses thereof 20160130556 Enhanced differentiation of mesenchymal stem cells

particular mesenchymal stem cells


**US patent Title of patent**

therapeutic use

ing same

20110256058 Novel peptides and uses thereof

method of use

nephropathy

diac tissue damage

optic neuropathy

stem cells

20120027860 Encapsulated adipose-derived stem cells, methods for preparation and

20110311984 Composition for diagnosing Parkinson's disease containing adipose tis‐

20110311495 Isolated populations of renal stem cells and methods of isolating and us‐

20110287534 Automated filling of flexible cryogenic storage bags with therapeutic cells

20110229970 Dual-chamber perfusion bioreactor for orthopedic tissue interfaces and

20110217363 Two-step targeted tumor therapy with prodrug encapsulated in nanocarrier 20110195054 Preparation and use of stromal cells for treatment of cardiac diseases 20110142805 Method of renal repair and regeneration and the treatment of diabetic

20100278790 Mesenchymal stem cells, compositions and methods for treatment of car‐

20100222877 Tissue engineered human pulmonary valves with cyclic pressure bioreac‐

20100062038 Markers, antibodies and recombinant scFvs for mesenchymal stem cell

20100003674 Adult stem cells, molecular signatures, and applications in the evaluation,

20090214485 Stem cell therapy for the treatment of diabetic retinopathy and diabetic

20080081370 Directed differentiation of human embryonic stem cells into mesenchymal

Ex-Scientist at University of Texas, Houston and Columbia University, NY, USA

**Rakesh Sharma, MS-PhD**

Preface XV

M.Tech-I, PhD (Indian Institute of Technology, Delhi) CEO, Innovations and Solutions Inc. Global, USA

Research Professor, AMET University, Chennai, India

Consultant at Hindurao Hospital, Delhi, India

Consultant Professor, Florida State University Foundation, USA Consultant Professor at Saraswathi Hospital, Hapur, India

20080075699 Method for isolating and/or identifying mesenchymal stem cells (MSC)

20070128722 Human mesenchymal stem cells and culturing methods thereof

20110318414 Regenerative tissue grafts and methods of making the same

sue-derived mesenchymal stromal cell

20110104100 Compositions and methods of stem cell therapy of autism

sub-populations and osteoclasts

diagnosis, and therapy of mammalian

20090214484 Stem cell therapy for the treatment of CNS disorders

20110014701 Protection of progenitor cells and regulation of their differentiation

tor accelerated seeding strategies and methods

20110263001 Compositions and methods for engineering cells


**US patent Title of patent**

XIV Preface

thereon

thereof

the same

equines

mal stem cell

reconstruction

stem cells using WNT6

conditions

tumors

lines

20130149245 Novel peptides and uses thereof

20130251690 Stem cell differentiation using keratin biomaterials

ative medicine applications

ative medicine applications 20130040304 Compositions and methods for engineering cells 20130034525 Beta islets-like cells derived from whole bone marrow

20130330300 High telomerase activity bone marrow mesenchymal stem cells, methods

20130251670 Treatment of macular edema utilizing stem cell and conditioned media

20130101561 Closed system separation of adherent bone marrow stem cells for regener‐

20130101561 Closed system separation of adherent bone marrow stem cells for regener‐

20120294836 High yield method and apparatus for volume reduction and washing of

20120276066 Peptide linked cell matrix materials for stem cells and methods of using

20120270826 Adult stem cells, molecular signatures, and applications in the evaluation,

20120269787 Systemic, allogenic stem cell therapies for the treatment of diseases in

20120269785 Systemic, allogenic stem cell therapies for the treatment of diseases in fe‐

20120219632 Methods for monitoring cellular states and for immortalizing mesenchy‐

20120201786 Methods for use of stem cells and stem cell factors in the treatment of skin

20120128636 Gingiva derived stem cell and its application in immunomodulation and

20120100117 Method for chondrogenic differentiation of pluripotent or multipotent

20120094304 Method of preparing human lung tissue stem cells and inducing differen‐

20120087901 Engineered mesenchymal stem cells and methods of using same to treat

20120052049 Systemic, allogenic stem cell therapies for treatment of diseases in animals

tiation into human alveolar epithelial cells

20120087983 Orthopedic application of encapsulated stem cells

20130251689 Keratin compositions for the treatment of bone deficiency or injury

20130190729 Derivation of hematopoietic cells from adult mesenchymal stem cells

20130031645 Method for hepatic differentiation of definitive endoderm cells 20130012921 System and methods for preparation of adipose-derived stem cells

therapeutic cells using tangential flow filtration

diagnosis, and therapy of mammalian conditions

20120224053 Method and apparatus for quantitative microimaging

of producing the same and pharmaceuticals and treatment methods based

#### **Rakesh Sharma, MS-PhD**

M.Tech-I, PhD (Indian Institute of Technology, Delhi) CEO, Innovations and Solutions Inc. Global, USA Ex-Scientist at University of Texas, Houston and Columbia University, NY, USA Consultant Professor, Florida State University Foundation, USA Consultant Professor at Saraswathi Hospital, Hapur, India Consultant at Hindurao Hospital, Delhi, India Research Professor, AMET University, Chennai, India

**Section 1**

**Stem Cell Therapy and Tissue Engineering**

**Stem Cell Therapy and Tissue Engineering**

**Chapter 1**

**Provisional chapter**

**Introductory Chapter: Stem Cells and Tissue**

**Introductory Chapter: Stem Cells and Tissue** 

DOI: 10.5772/intechopen.74219

Stem cell transplant research and tissue engineering, in present time, have emerged as a legalized and regulated stem cell treatment option globally, but, scientifically, their success is unestablished. Novel stem cell-based therapies have evolved as innovative and routine clinical solutions by commercial companies and hospitals across the world. Such rampant spread of stem cell clinics throughout UK, US, Europe, and Asia reflect the public encouragement of benefits to incurable diseases. However, ever growing stem cell therapy developments need constant dogwatch and careful policy making by government regulatory bodies for prompt action in case of any untoward public concern. Therefore, researchers and physicians must keep themselves abreast of current knowledge on stem cells, tissue engineering devices in treatment and its safe legal limits. With this aim, stem cell scientific developments, treatment options, and legal scenario are introduced here to beginner or actively involved scientists and physicians. Introduction to stem cell therapy will provide basic information to beginner researchers and practice physicians on engineered stem cell research concepts and present stem cell therapy federal regulations in different North American, European, and Asian countries. FDA, CDC, EU, ICMR government policies in different countries includes information on the current legal position, ethical policies, regu-

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

The word "eais-te-am" cell refers to the progenitor cell or human body's master cell means first original embryonic cell with rejuvenating and restorative capability of regenerating any body tissue cell(s) typically called as "Fountain of Youth." Stem cells can divide and develop

**Engineering in Medical Practice**

**Engineering in Medical Practice**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.74219

latory oversight, and relevant laws.

Rakesh Sharma

**1. Introduction**

Rakesh Sharma

#### **Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice**

DOI: 10.5772/intechopen.74219

Rakesh Sharma Rakesh Sharma

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.74219

### **1. Introduction**

Stem cell transplant research and tissue engineering, in present time, have emerged as a legalized and regulated stem cell treatment option globally, but, scientifically, their success is unestablished. Novel stem cell-based therapies have evolved as innovative and routine clinical solutions by commercial companies and hospitals across the world. Such rampant spread of stem cell clinics throughout UK, US, Europe, and Asia reflect the public encouragement of benefits to incurable diseases. However, ever growing stem cell therapy developments need constant dogwatch and careful policy making by government regulatory bodies for prompt action in case of any untoward public concern. Therefore, researchers and physicians must keep themselves abreast of current knowledge on stem cells, tissue engineering devices in treatment and its safe legal limits. With this aim, stem cell scientific developments, treatment options, and legal scenario are introduced here to beginner or actively involved scientists and physicians. Introduction to stem cell therapy will provide basic information to beginner researchers and practice physicians on engineered stem cell research concepts and present stem cell therapy federal regulations in different North American, European, and Asian countries. FDA, CDC, EU, ICMR government policies in different countries includes information on the current legal position, ethical policies, regulatory oversight, and relevant laws.

The word "eais-te-am" cell refers to the progenitor cell or human body's master cell means first original embryonic cell with rejuvenating and restorative capability of regenerating any body tissue cell(s) typically called as "Fountain of Youth." Stem cells can divide and develop

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

different cell types during early life and help in repair the body by replenishing the damaged cells in disease, wear, and injury.

**2.2. Why human embryonic stem cells are in active research?**

was reported in the United Kingdom for blindness repair [3].

**2.4. New embryonic stem cell line for each research project?**

**2.3. What is origin of embryonic stem cell lines?**

untreatable and life threat.

human embryonic stem cell lines.

tight legal controls.

embryonic stem cell research.

Stem cell research offers great hope to repair serious life-threatening diseases. The first clinical trial took place in the United States for spinal cord injury repair [2]. The first European study

Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice

http://dx.doi.org/10.5772/intechopen.74219

5

From biologist's standpoint, embryonic stem cell research offers as a tool to understand the tissue maintenance and repair in health, how disease develops, and its possible treatment. The molecular basis of embryonic stem cells growing in three-dimensional culture environments has explored the molecular control of gut development and associated organs to understand the genetic control of fragile-X syndrome. Other example is Parkinson's disease, currently

All human embryonic stem cell lines originate from a 4- to 5-day-old blastocyst. A blastocyst is a hollow ball of around 100 cells. Blastocyst is a left over egg from *in vitro* fertilization (IVF). Some blastocysts are implanted into the woman's uterus, while the rest are stored in a deepfreezer. After implantation, couple decides what to do with remaining blastocysts. They can continue to store blastocysts for research. Only these donated blastocysts are the source of

For research, cells are harvested from one 4- to 5-day-old blastocyst. Blastocyst cell multiplies in the laboratory to create a "cell line" able to produce an infinite number of embryonic stem cells. All these cells have same genetic make-up. Many cell lines are kept in not-for-profit stem cell banks. Banks supply these stem cells for research all over the world. Existing cell lines are also exchanged at no cost between laboratories in the context of research programs, under

**3. Purpose and global regulatory norms for stem cell research**

**3.1. What position do member states take on human embryonic stem cell research?**

Different countries have different legislative provisions among different states on human

In the United States of America, 26 states have active stem cell research legislation policy, while other states have loose policy or no legislative rules for stem cell research and treatment. So far, no state has permitted any stem cell product for medical treatment as valid. FDA only approved cord blood-derived hematopoietic progenitor cells (blood forming stem cells) for certain indications including certain blood cancers and some inherited metabolic and immune system disorders. Last year, a bill HB 810 passed by Texas Governance Springer has taken first

Stem cell therapy uses mainly human pluripotent stem cells to restore functions of tissues or organs, to maintain or repair the damaged human tissues or organs caused by trauma, genetic disease, or metabolic disease. The stem cell engineered products are at large available and paradigm shift shows a much greater investment in novel stem cell scaffolds, designing new matrices, grafts to treat chronic and incurable diseases.

Four major considerations for successful stem cell therapy and research are:


Stem cell types and need of human embryogenic cell research and tissue engineering are introduced in Section 2. Purpose and global regulatory norms for stem cell research are summarized in Section 3. Present status of stem cell therapy and clinical practice limitations or alternatives is reviewed with government guidelines in Section 4. Global scenario of stem cell clinical centers to treat different diseases and human organs are tabulated in Section 5. Major introduction is how government regulatory authorities define policies, frame guidelines, and keep watch public concerns and clinical practices at treatment centers globally.

### **2. Introduction to stem cell**

Stem cells are progenitor cells. There are three types of stem cells: adult stem cells (from umbilical cord blood), human embryogenic cells (from embryo from fertilized eggs), and induced-pluripotent cells (by reprograming adult stem cells to differentiate into specific tissue cells). These stem cells share common properties: (1) survive long periods to make more stem cells; (2) up-specialized but capable to develop into specific cells; (3) develop to do specific work in the body.

#### **2.1. What are human embryonic stem cells?**

Human embryonic stem cells were first isolated and cultured in year 1998 to confirm their unique capabilities. They can transform into any human tissues up to 200 different cell types found in the body. Under the right conditions, they behave as evergreen, everlasting, and able to multiply indefinitely to form immortal cell line. This amazing capacity of embryonic stem cells to give rise to any type of tissue has intensified the search for adult stem cells to assume paracrine functions [1]. Stem cells have plasticity, means they circulate throughout the body and reside wherever needed to promote regeneration of local tissue.

#### **2.2. Why human embryonic stem cells are in active research?**

different cell types during early life and help in repair the body by replenishing the damaged

Stem cell therapy uses mainly human pluripotent stem cells to restore functions of tissues or organs, to maintain or repair the damaged human tissues or organs caused by trauma, genetic disease, or metabolic disease. The stem cell engineered products are at large available and paradigm shift shows a much greater investment in novel stem cell scaffolds, designing new

cells in disease, wear, and injury.

4 Stem Cells in Clinical Practice and Tissue Engineering

**2. Introduction to stem cell**

**2.1. What are human embryonic stem cells?**

cific work in the body.

matrices, grafts to treat chronic and incurable diseases.

• Why stem cell clinics need regulation and legalization?

• Purpose and global regulatory norms for stem cell research. • Reliable stem cell treatment and tissue engineering products.

Four major considerations for successful stem cell therapy and research are:

• Concerns on stem cell treatment regulations and role of government approvals.

keep watch public concerns and clinical practices at treatment centers globally.

Stem cell types and need of human embryogenic cell research and tissue engineering are introduced in Section 2. Purpose and global regulatory norms for stem cell research are summarized in Section 3. Present status of stem cell therapy and clinical practice limitations or alternatives is reviewed with government guidelines in Section 4. Global scenario of stem cell clinical centers to treat different diseases and human organs are tabulated in Section 5. Major introduction is how government regulatory authorities define policies, frame guidelines, and

Stem cells are progenitor cells. There are three types of stem cells: adult stem cells (from umbilical cord blood), human embryogenic cells (from embryo from fertilized eggs), and induced-pluripotent cells (by reprograming adult stem cells to differentiate into specific tissue cells). These stem cells share common properties: (1) survive long periods to make more stem cells; (2) up-specialized but capable to develop into specific cells; (3) develop to do spe-

Human embryonic stem cells were first isolated and cultured in year 1998 to confirm their unique capabilities. They can transform into any human tissues up to 200 different cell types found in the body. Under the right conditions, they behave as evergreen, everlasting, and able to multiply indefinitely to form immortal cell line. This amazing capacity of embryonic stem cells to give rise to any type of tissue has intensified the search for adult stem cells to assume paracrine functions [1]. Stem cells have plasticity, means they circulate throughout the body

and reside wherever needed to promote regeneration of local tissue.

Stem cell research offers great hope to repair serious life-threatening diseases. The first clinical trial took place in the United States for spinal cord injury repair [2]. The first European study was reported in the United Kingdom for blindness repair [3].

From biologist's standpoint, embryonic stem cell research offers as a tool to understand the tissue maintenance and repair in health, how disease develops, and its possible treatment. The molecular basis of embryonic stem cells growing in three-dimensional culture environments has explored the molecular control of gut development and associated organs to understand the genetic control of fragile-X syndrome. Other example is Parkinson's disease, currently untreatable and life threat.

#### **2.3. What is origin of embryonic stem cell lines?**

All human embryonic stem cell lines originate from a 4- to 5-day-old blastocyst. A blastocyst is a hollow ball of around 100 cells. Blastocyst is a left over egg from *in vitro* fertilization (IVF). Some blastocysts are implanted into the woman's uterus, while the rest are stored in a deepfreezer. After implantation, couple decides what to do with remaining blastocysts. They can continue to store blastocysts for research. Only these donated blastocysts are the source of human embryonic stem cell lines.

#### **2.4. New embryonic stem cell line for each research project?**

For research, cells are harvested from one 4- to 5-day-old blastocyst. Blastocyst cell multiplies in the laboratory to create a "cell line" able to produce an infinite number of embryonic stem cells. All these cells have same genetic make-up. Many cell lines are kept in not-for-profit stem cell banks. Banks supply these stem cells for research all over the world. Existing cell lines are also exchanged at no cost between laboratories in the context of research programs, under tight legal controls.

### **3. Purpose and global regulatory norms for stem cell research**

#### **3.1. What position do member states take on human embryonic stem cell research?**

Different countries have different legislative provisions among different states on human embryonic stem cell research.

In the United States of America, 26 states have active stem cell research legislation policy, while other states have loose policy or no legislative rules for stem cell research and treatment. So far, no state has permitted any stem cell product for medical treatment as valid. FDA only approved cord blood-derived hematopoietic progenitor cells (blood forming stem cells) for certain indications including certain blood cancers and some inherited metabolic and immune system disorders. Last year, a bill HB 810 passed by Texas Governance Springer has taken first lead to legalize stem cell treatment as "Right to Have Trial" as unproven therapies at their own risk and cost in its report (https://legiscan.com/TX/text/HB810/2017). Another bill HB 661 permits chronic ill persons to try early stage approved clinical trial. New bill HB 3236 permits companies to charge patients for unproven therapies. Earlier, Obama Governance declared policy for operating 570 stem cell treatment clinics across country including Beverly Hills, CA, New York, San Antonio, Los Angeles, Austin, Texas, Phoenix, and Scottsdale, AZ [1].

Tissue Practice (GTP) with guidelines how biologic drug and device regulations apply to cellular and genetic therapies [11]. FDA developed a regulatory framework in three areas: (1) preventing use of contaminated cells or tissues; (2) preventing the cell and tissue contamination by adequate processing; and (3) clinical safety of all cells and tissues. All these areas of framework control both cell and tissue-based products as mass produced drugs [12]. However, several agencies, like American Red Cross, American Society of Clinical Oncology, and Society of Assisted Reproductive Techniques, clarified the role of FDA limited to allogeneic tissue transplants to control spread of communicable diseases means the stem cell transplantations are medical procedures. FDA division "Center for Biologics Evaluation and Research (CBER)" regulates cell-based therapy, and already approved several ApliGraf®, Carticel®, and Epicel® products. The manipulated autologous cells for somatic cell therapy need approval as investigational new drug (IND). However, ATMP minimally manipulated, labeled, or advertised for homologous use, not combined with drug or device, do not require FDA approval. Of course, FDA has wide regulatory coverage including isolation of stem cell rich fractions for orthopedic use, breast augmentation, and 5-day blastocyst transfer as equivalent drug mass production. In general, regulation applies to cells and tissues (HCT/Ps) used

Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice

http://dx.doi.org/10.5772/intechopen.74219

7

for implementation, transplantation, infusion, and transfer into human recipient.

Two regulatory guides for industries were released by FDA. In the year 2007, "Guidance for industry: Regulation of HCT/Ps-Small Entity Compliance Guide" and other in the year 2009, "Guidance for industry on Current Good Tissue Practice and Additional Requirements for Manufacturers of HCT/Ps" [13]. Clinical trials using mesenchymal stem cells fall in the IND category. In FDA regulation policy, physicians may administer stem cell-based products in patients by two ways: (1) compassionate use or expanded access to investigational drugs and biological products without interfering conduct of clinical investigations; (2) off-label prescription of FDA approved stem cell products at full discretion of physician. A new draft 21 CFR 1271 15(b) guideline for industry "Same Surgical Procedure Exception" states three criteria advised to physicians: (1) autologous use or remove HCT/Ps from individual and implant them into same individual; (2) implant the HCT/Ps within same surgical procedure; (3) HCT/Ps must remain in their original form (rinsing, cleaning, sizing, shaping, and manufacturing is permitted). All guidelines, 21 CFR 1271(a), 14(b), and 15(b) exceptions, prohibit the claim of "practice of medicine" of 361 products without FDA compliance. To date, FDA has not approved any stem cell medical product in market place. Moreover, physicians claim of performing innovative surgical procedures (as practice of medicine art not directly regulated by FDA) falling under regulatory exception mentioned in 21CFR 1271 Section 361 Public Health Service (PHS) Act for human cell-tissue-based products (HCT/Ps) in practice of medicine without spreading communicable disease [14]. In contrast, Section 351 of PHS Act defines the premarketing review and FDA approval of drugs, biological products or medical devices. In the year 2014, two new draft guidelines amended 21CFR 1271.10 and 21CFR 1271.20 regarding Section 361 enacted autologous HCT/Ps only if they are "minimally manipulated" for advertisement or labeling purpose (using of water, crystalloids, sterilizer, or storage preservative) without any clinical safety concern. For example, lipoaspirate SVF for adipose derived stem cell treatments (by autologous HCT/Ps) of Parkinson disease and multiple sclerosis fail to comply 21 CFR 1271.10 for homologous use because processing HCT/Ps breaks down and eliminates

All 18 countries in the European Union (EU) have stem cell research legislative policy involving human embryonic stem cells, three countries prohibit it (Poland, Latvia, and Slovakia) and the rest have no specific legislation [2, 3]. The EU has no competence to harmonize the legal situation in Member States. Legislation on cell therapy is based on three directives: (1) directive 2003/63/EC defines cell therapy products as clinical products; (2) directive 2001/20/ EC emphasizes clinical trials mandatory for all cell therapy products; (3) directive 2004/23/ EC establishes standard quality, donation safety, harvesting, tests, processing, preservation, storage, distribution of human tissues and cells. In year 2008, regulation 1394/2007/EC on Advanced Therapy Medicinal Products (ATMP) includes gene therapy medicinal products, somatic cell therapy products, and tissue engineered products (by manipulation, change in physiological or structural functions for therapeutic use) under Committee for Advanced Therapies (CAT) to provide opinion on safety, quality, efficacy of ATMPs acceptable as stem cell-based medical product by marketing authorization [4].

#### **3.2. What are regulations and the policy toward the use of human embryonic stem cells and stem cell products for research and clinical use?**

In view of the different legal situations and practices in US, EU member States and Asia, both US and EU have own clear ethical and legal framework on human embryonic stem cell research funded from respective budget. Major regulatory consideration in policy is on batch consistency, product stability, safety, efficacy, and quality of stem cell-based tissue engineered products through pre-clinical, clinical, and marketing authorization.

In US, FDA and CDC government bodies have laid down stringent guidelines on the use of stem cell treatment. Food and Drug Authority (FDA) keeps dog watch over the performance, standard, and any public concern related with stem cell treatment abuse, defective quality, options of tissue engineering for right purpose. In case of non-compliance, irregularities, illicit, and unlawful gain, FDA warns stem cell center, and may take precautionary or prohibitive action. Major stem cell clinics are opened for certain organ diseases to recover them. Notable examples are bone and joint disease, erectile dysfunction, neck and back pain, oral and maxillofacial surgery, tendons, and arthritis [5–10]. For stem cell therapy, FDA approves stem cell clinic for transplantation purpose. FDA defines and regulates different stem cell-based therapies and different stem cell products for safe use.

Code of Federal Regulation 21 CFR defined sections for use of cell therapy products: IND regulations (21 CFR 312), Biologics regulations (21 CFR 600), and cGMP (21 CFR 211), autologous cells, tissues, cell- or tissue-based products HCT/Ps (CFR, Part 1271) in year 2006. Public Health Service Act (PHSA) refers as "361 products" and "351 products." Food and Drug Administration (FDA) codified 361 cells and tissue products for therapeutic use under Good Tissue Practice (GTP) with guidelines how biologic drug and device regulations apply to cellular and genetic therapies [11]. FDA developed a regulatory framework in three areas: (1) preventing use of contaminated cells or tissues; (2) preventing the cell and tissue contamination by adequate processing; and (3) clinical safety of all cells and tissues. All these areas of framework control both cell and tissue-based products as mass produced drugs [12]. However, several agencies, like American Red Cross, American Society of Clinical Oncology, and Society of Assisted Reproductive Techniques, clarified the role of FDA limited to allogeneic tissue transplants to control spread of communicable diseases means the stem cell transplantations are medical procedures. FDA division "Center for Biologics Evaluation and Research (CBER)" regulates cell-based therapy, and already approved several ApliGraf®, Carticel®, and Epicel® products. The manipulated autologous cells for somatic cell therapy need approval as investigational new drug (IND). However, ATMP minimally manipulated, labeled, or advertised for homologous use, not combined with drug or device, do not require FDA approval. Of course, FDA has wide regulatory coverage including isolation of stem cell rich fractions for orthopedic use, breast augmentation, and 5-day blastocyst transfer as equivalent drug mass production. In general, regulation applies to cells and tissues (HCT/Ps) used for implementation, transplantation, infusion, and transfer into human recipient.

lead to legalize stem cell treatment as "Right to Have Trial" as unproven therapies at their own risk and cost in its report (https://legiscan.com/TX/text/HB810/2017). Another bill HB 661 permits chronic ill persons to try early stage approved clinical trial. New bill HB 3236 permits companies to charge patients for unproven therapies. Earlier, Obama Governance declared policy for operating 570 stem cell treatment clinics across country including Beverly Hills, CA,

All 18 countries in the European Union (EU) have stem cell research legislative policy involving human embryonic stem cells, three countries prohibit it (Poland, Latvia, and Slovakia) and the rest have no specific legislation [2, 3]. The EU has no competence to harmonize the legal situation in Member States. Legislation on cell therapy is based on three directives: (1) directive 2003/63/EC defines cell therapy products as clinical products; (2) directive 2001/20/ EC emphasizes clinical trials mandatory for all cell therapy products; (3) directive 2004/23/ EC establishes standard quality, donation safety, harvesting, tests, processing, preservation, storage, distribution of human tissues and cells. In year 2008, regulation 1394/2007/EC on Advanced Therapy Medicinal Products (ATMP) includes gene therapy medicinal products, somatic cell therapy products, and tissue engineered products (by manipulation, change in physiological or structural functions for therapeutic use) under Committee for Advanced Therapies (CAT) to provide opinion on safety, quality, efficacy of ATMPs acceptable as stem

New York, San Antonio, Los Angeles, Austin, Texas, Phoenix, and Scottsdale, AZ [1].

**3.2. What are regulations and the policy toward the use of human embryonic stem** 

In view of the different legal situations and practices in US, EU member States and Asia, both US and EU have own clear ethical and legal framework on human embryonic stem cell research funded from respective budget. Major regulatory consideration in policy is on batch consistency, product stability, safety, efficacy, and quality of stem cell-based tissue engineered

In US, FDA and CDC government bodies have laid down stringent guidelines on the use of stem cell treatment. Food and Drug Authority (FDA) keeps dog watch over the performance, standard, and any public concern related with stem cell treatment abuse, defective quality, options of tissue engineering for right purpose. In case of non-compliance, irregularities, illicit, and unlawful gain, FDA warns stem cell center, and may take precautionary or prohibitive action. Major stem cell clinics are opened for certain organ diseases to recover them. Notable examples are bone and joint disease, erectile dysfunction, neck and back pain, oral and maxillofacial surgery, tendons, and arthritis [5–10]. For stem cell therapy, FDA approves stem cell clinic for transplantation purpose. FDA defines and regulates different stem cell-based therapies and

Code of Federal Regulation 21 CFR defined sections for use of cell therapy products: IND regulations (21 CFR 312), Biologics regulations (21 CFR 600), and cGMP (21 CFR 211), autologous cells, tissues, cell- or tissue-based products HCT/Ps (CFR, Part 1271) in year 2006. Public Health Service Act (PHSA) refers as "361 products" and "351 products." Food and Drug Administration (FDA) codified 361 cells and tissue products for therapeutic use under Good

cell-based medical product by marketing authorization [4].

6 Stem Cells in Clinical Practice and Tissue Engineering

**cells and stem cell products for research and clinical use?**

different stem cell products for safe use.

products through pre-clinical, clinical, and marketing authorization.

Two regulatory guides for industries were released by FDA. In the year 2007, "Guidance for industry: Regulation of HCT/Ps-Small Entity Compliance Guide" and other in the year 2009, "Guidance for industry on Current Good Tissue Practice and Additional Requirements for Manufacturers of HCT/Ps" [13]. Clinical trials using mesenchymal stem cells fall in the IND category. In FDA regulation policy, physicians may administer stem cell-based products in patients by two ways: (1) compassionate use or expanded access to investigational drugs and biological products without interfering conduct of clinical investigations; (2) off-label prescription of FDA approved stem cell products at full discretion of physician. A new draft 21 CFR 1271 15(b) guideline for industry "Same Surgical Procedure Exception" states three criteria advised to physicians: (1) autologous use or remove HCT/Ps from individual and implant them into same individual; (2) implant the HCT/Ps within same surgical procedure; (3) HCT/Ps must remain in their original form (rinsing, cleaning, sizing, shaping, and manufacturing is permitted). All guidelines, 21 CFR 1271(a), 14(b), and 15(b) exceptions, prohibit the claim of "practice of medicine" of 361 products without FDA compliance. To date, FDA has not approved any stem cell medical product in market place. Moreover, physicians claim of performing innovative surgical procedures (as practice of medicine art not directly regulated by FDA) falling under regulatory exception mentioned in 21CFR 1271 Section 361 Public Health Service (PHS) Act for human cell-tissue-based products (HCT/Ps) in practice of medicine without spreading communicable disease [14]. In contrast, Section 351 of PHS Act defines the premarketing review and FDA approval of drugs, biological products or medical devices.

In the year 2014, two new draft guidelines amended 21CFR 1271.10 and 21CFR 1271.20 regarding Section 361 enacted autologous HCT/Ps only if they are "minimally manipulated" for advertisement or labeling purpose (using of water, crystalloids, sterilizer, or storage preservative) without any clinical safety concern. For example, lipoaspirate SVF for adipose derived stem cell treatments (by autologous HCT/Ps) of Parkinson disease and multiple sclerosis fail to comply 21 CFR 1271.10 for homologous use because processing HCT/Ps breaks down and eliminates structural cushion and support components so altered original relevant reconstruction, repair, or replacement characteristics of stem cells. It puts them in drug, device, and biological product 361 category requiring premarketing FDA approval. However, combination standards (minimum manipulation and homologous use) allow drugs, device, biological products as exempted investigational new drug or device for premarketing approval with assurance of conducting premarketing trial with safety and efficacy. Companies can advertise FDA-cleared investigational new drugs or device exemptions to gain profits from sale in compliance with federal regulations without known safety and efficacy of products. For interested readers, "minimal manipulation" means "processing that does not alter the original relevant characteristics of tissues related to tissue utility for reconstruction, repair, or replacement." In the year 2014, third draft regulation "HCT/Ps from Adipose Tissue: Regulatory Considerations" states that processing to isolate nonadipose tissue (without subsequent cell culture or expansion) is more than minimal manipulation. Stem cell business centers and clinics may operate sale of unproven and unlicensed cell-based interventions without FDA compliance using three said guidelines. Now, it requires considerable FDA effort to design final regulatory draft.

The current framework in EU was adopted in year 2007 and subsequently renewed as HORIZON 2020 for the duration (2014–2020) to frame the EU's new research and innovation program "triple lock system."


The program operates on a bottom-up basis. European Commission does not publish calls for proposals specifically for research using human embryonic stem cells. Scientists propose the methods and materials for a particular study. EU research allows fair comparison of different stem cell types to find the best cell source for a particular research or clinical application.

Regulatory framework in Asia has no well-defined regulation and policy on stem cell-based products and clinical use. It amounts the risk to patients of physical harm and high financial exploitation. Currently, clinics and pharma companies do not follow clinical trials under regulatory framework or have no national guidelines to follow. Some guides were released as guidelines to clinical trials shown in **Table 1**.

#### *3.2.1. Ethical guidelines for biomedical research in India on human subjects: section V*

Stem cell research and therapy (by Indian Council of Medical Research, ICMR 2006) defines the clinical grade stem cells for clinical trial approved by institution committee for Stem Cell Research and Therapy (IC-SCRT) at multinational companies or from abroad. Collaboration is approved by hierarchy of National Apex Committee and Institutional Committee for Stem Cell Research and Therapy, Institutional Ethics Committee, Drug Controller general of India, Health Ministry

Screening Committee, and funding agency. Investigators should assure that stem cell lines are in accordance with appropriate Material Transfer Agreement based on country's guidelines on Good Medical Practices. ICMR, Department of Biotechnology laid down "Guidelines for Stem Cell Research and Therapy" in the year 2007 on mechanism of review and monitoring research

**Country Current legal position on embryonic cell** 

Austrıa Banned. imported cell lines permissible Austrian Bioethics Commission [24, 25]

Fınland Permitted IVF embryos, somatic Medical Research Act 2001 [27] Cell nuclear transfer Finnish National Advisory Board

France **Permitted research** Agence de la Biomédicine [20, 28]

Germany Permitted research Embryonenschutzgesetz) 1991 [22]

Law 3305/2005 National Transplantation

Ireland No specific legislation Irish Council of Bioethics (ICB), 2002

Greece Permitted IVF embryos Hellenic National Bioethics

Lıthuanıa Prohibited any embryo research Law on Ethics of Biomedical

Portugal Permitted cell lines from IVF embryos Law 32/2006 medically assisted

UK **HEFA** regulated stem cell research only Fertilisation and Embryology

Spaın Regulatory framework embryonic stem cells Law 14/2007 for embryo theranostics [37, 38] Sweden Embryonic cells from IVF/SCNT Act on Genetic Integrity 2005 [39]

USA, Canada Stem cell clinics for limited use 21CFR 1271 sections [41]

**Table 1.** Present rules, restrictions, and regulatory mandate enforced in European and Western world.

Italy Permitted imported stem cell lines Law 40

Bulgarian Health Act SG83/19,2003. Central Ethics Commission (CEC) [26]

**Reproductive** cloning is banned Czech R&D Council [15]

1991

2002 Stem Cell Act Central Ethics Commission (ZES) [29–31]

Commission

Organization

Report

Research

procreation

Act 2001

(LBC)

Fr National Committee of Ethics

Assisted Human Reproduction

Lithuanian Bioethics Committee

Comitato Nazionale per la Bioetica) [34]

[32]

[33]

[35]

[36]

[40]

(Fortpflanzungsmedizingesetz) 2004 2009 opinion Bulgarıa Permitted IVF treatment. Bulgarian Centre for Bioethics

**Ethical/regulatory oversight Reference**

http://dx.doi.org/10.5772/intechopen.74219

9

Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice

**lines**

Czech Republıc


structural cushion and support components so altered original relevant reconstruction, repair, or replacement characteristics of stem cells. It puts them in drug, device, and biological product 361 category requiring premarketing FDA approval. However, combination standards (minimum manipulation and homologous use) allow drugs, device, biological products as exempted investigational new drug or device for premarketing approval with assurance of conducting premarketing trial with safety and efficacy. Companies can advertise FDA-cleared investigational new drugs or device exemptions to gain profits from sale in compliance with federal regulations without known safety and efficacy of products. For interested readers, "minimal manipulation" means "processing that does not alter the original relevant characteristics of tissues related to tissue utility for reconstruction, repair, or replacement." In the year 2014, third draft regulation "HCT/Ps from Adipose Tissue: Regulatory Considerations" states that processing to isolate nonadipose tissue (without subsequent cell culture or expansion) is more than minimal manipulation. Stem cell business centers and clinics may operate sale of unproven and unlicensed cell-based interventions without FDA compliance using three said guidelines. Now,

The current framework in EU was adopted in year 2007 and subsequently renewed as HORIZON 2020 for the duration (2014–2020) to frame the EU's new research and innovation

• First and foremost, national legislation is respected—EU projects must follow the laws of

• In addition, all projects must be scientifically validated by peer review and must undergo

• Finally, EU funds may not be used for derivation of new stem cell lines, or for research that

The program operates on a bottom-up basis. European Commission does not publish calls for proposals specifically for research using human embryonic stem cells. Scientists propose the methods and materials for a particular study. EU research allows fair comparison of different stem cell types to find the best cell source for a particular research or clinical application. Regulatory framework in Asia has no well-defined regulation and policy on stem cell-based products and clinical use. It amounts the risk to patients of physical harm and high financial exploitation. Currently, clinics and pharma companies do not follow clinical trials under regulatory framework or have no national guidelines to follow. Some guides were released as

Stem cell research and therapy (by Indian Council of Medical Research, ICMR 2006) defines the clinical grade stem cells for clinical trial approved by institution committee for Stem Cell Research and Therapy (IC-SCRT) at multinational companies or from abroad. Collaboration is approved by hierarchy of National Apex Committee and Institutional Committee for Stem Cell Research and Therapy, Institutional Ethics Committee, Drug Controller general of India, Health Ministry

destroys embryos (blastocysts)—including for the procurement of stem cells.

*3.2.1. Ethical guidelines for biomedical research in India on human subjects: section V*

it requires considerable FDA effort to design final regulatory draft.

program "triple lock system."

8 Stem Cells in Clinical Practice and Tissue Engineering

rigorous ethical review;

the country in which research is carried out;

guidelines to clinical trials shown in **Table 1**.

**Table 1.** Present rules, restrictions, and regulatory mandate enforced in European and Western world.

Screening Committee, and funding agency. Investigators should assure that stem cell lines are in accordance with appropriate Material Transfer Agreement based on country's guidelines on Good Medical Practices. ICMR, Department of Biotechnology laid down "Guidelines for Stem Cell Research and Therapy" in the year 2007 on mechanism of review and monitoring research and therapy at national level and institution level. Central Drug Standards Control Organization (CDSCO) defined guidelines on new biological/biotechnology products. However, regulation of stem cell products as drugs does not exist for clinical trials. As a result, national committee is proposed as "Cell Biology Based Therapeutic Drug Evaluation Committee" by ICMR to approve the therapeutic products of human gene manipulation, xerotransplant technology, and stem cells in market since year 2011. However, till date no registration requirement technical guidelines of human stem cell-based products are formulated.

antibiotics, bioactive proteins, colony stimulating factors, cell division regulatory factors, gene regulation, signal molecules, enzymes, hormones, and energy available to intracellular metabolism. All these factors function and act in unison for stem cell treatment to become success in regenerative medicine otherwise stem cells do not grow in the desired manner due to one or the other

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11

Any product derived from stem cells or containing stem cells is referred as "stem cell-based product" (SCBP), including tissue engineering biomaterials in cell- and tissue-based therapy. Around the world, autologous stem cell clinics or hospitals are spreading in China, India, Mexico, Panama, Ukraine, European Union member states to perform stem cell facelifts, sport orthopedics, breast augmentation, treatment of muscle dystrophy, Alzheimer's disease, Parkinson's disease, and multiple sclerosis. In US alone, development of tissue engineering methods have shown significant progress in success of stem cells as therapeutic tools of regenerative medicine in different states of Ohio, Kansas, Minnesota, Wisconsin, and Mayo. These clinics and centers maintain *in vitro* stem cells in cultures that can be transplanted by fixing them at desired site in Matrigel®. With time, stem cells grow in the desired pre-programed manner and regenerate the defective part of the tissue or the organ [18]. Stem cell treatment centers charge prospective patients privately for simple stem cell therapy by bone marrow or peripheral blood liposuction, enzyme digestion, ultrasonic cavitation to prepare stromal vascular fraction (mixture of fibroblasts, endothelial progenitor cells, pericytes, mesenchymal stroma cells, and adipocytes) as therapeutic injection given to said patients or industries manufacture commercial stem cell

For clinical and commercial use, regulatory challenges are safety testing, *in vitro* functional assays, potency assays, pre-clinical, or clinical trials. The safety testing includes assays for microbial, fungal, endotoxin, mycoplasma, viral contamination, karyotyping testing, and enriched cell population. *In vitro* functional and potency assays act a surrogate measure of clinical effectiveness and validity to meet standards and control. In support, pre-clinical trial on experimental toxicity animal models such as immuno-compromised or tumorigenic animals, *in vitro* manipulation, administration route, and clinical trials with complete safety and sound ethics are necessary [19]. These characteristics establish the potential of these cells for tissue repair after injury or disease so called "stem cell therapies" as stem cell medicinal products made out of minimal manipulation of any target cell type destined for clinical application to improve defective function in the body. Presently, human embryonic stem cells (hESCs) are used in 13% of cell therapy procedures; fetal stem cells in 2%, umbilical cord stem cells in 10%, and adult stem cells in 75% of treatments [20]. Any use of such cell-based medicines is subject to authorization and controls, including their manufacture.

Study design should demonstrate safety endpoints, efficacy, and its action for proposed clinical trial of new investigational medicinal product (EMEA/CHMP/SWP/28367/07). Safety endpoints may be defined on theoretical basis or any toxicity endpoint. The efficacy assessment should be related to pharmacodynamic effect of ATMP.A safe and minimal effective treatment dose should be identified. The presence of stem cells intended at desired location should be investigated by selected differentiation biomarkers to facilitate *in vivo* monitoring the stem cells during the time of administration in patients and their follow-up *in vivo* effect to establish long-term efficacy.

deficiency and stem cell treatment becomes a myth [16, 17].

therapy products without any product regulatory information to patients.

**4.2. Clinical development for first-in-man study plan**

#### *3.2.2. International unanimous opinion*

International Society of Stem Cell Research (ISSCR) and Hinxton group have published "guidelines on clinical translation of stem cell" to emphasize: (1) quality controlled stem cells with known characteristics; (2) *a priori* information of delivery efficacy, safety of stem cells in animal model; (3) peer reviewed clinical protocols in pre-clinical research; (4) awareness of tumorigenic risk without evidence of clinical benefit evidences at the time of voluntary informed recipient consent to perform clinical trial [15]. In spite of all, ISSCR recommendations remain as undefined code of professional conduct to assure safety due to no harmony between laboratory-based research and use of approved stem cell-based products with policy differences in different continents [16]. Legislation must regulate scientific progress from lab to clinic in public interest. Public must have confidence in clinical benefits. The public interests may be protected by guidelines for: (1) stem cell-based product is safe, pure, potent for general practice GTP, GMP, and GCP requirements; (2) pre-clinical evidence available on proof-of-principle and safety in animal models; (3) new non-invasive biodistribution monitoring by markers and tumors for clinical trials; (4) preference to patient safety by risk-based approach in granting regulatory approval with conditional marketing authorization.

#### **3.3. How much have the US and EU spent on human embryonic stem cell research?**

In the years 2007–2017, the EU has funded 27 collaborative health research projects involving the use of human embryonic stem cells with an EU contribution of about €157 million. Human embryonic stem cell research projects represent approximately one-third of health projects on all forms of stem cells.

In addition, the European Research Council has funded 10 projects for an EU financial contribution of about €19 million, and there have been 24 Marie Skłodowska-Curie actions involving human embryonic stem cell research worth €23 million.

### **4. Stem cell treatment and tissue engineering products**

#### **4.1. Stem cell therapy: a success or a myth**

Stem cell treatment is a new option of organ transplantation or tissue and cell transplantation. Stem cells in culture behave differently from the tissue cells behave inside body. As a result, the progenitor cells and embryonic cell behavior entirely depends on media conditions, physiology of cultured cells, environment of breeding, action of added growth factors, vital molecules, additives, antibiotics, bioactive proteins, colony stimulating factors, cell division regulatory factors, gene regulation, signal molecules, enzymes, hormones, and energy available to intracellular metabolism. All these factors function and act in unison for stem cell treatment to become success in regenerative medicine otherwise stem cells do not grow in the desired manner due to one or the other deficiency and stem cell treatment becomes a myth [16, 17].

and therapy at national level and institution level. Central Drug Standards Control Organization (CDSCO) defined guidelines on new biological/biotechnology products. However, regulation of stem cell products as drugs does not exist for clinical trials. As a result, national committee is proposed as "Cell Biology Based Therapeutic Drug Evaluation Committee" by ICMR to approve the therapeutic products of human gene manipulation, xerotransplant technology, and stem cells in market since year 2011. However, till date no registration requirement technical guidelines of

International Society of Stem Cell Research (ISSCR) and Hinxton group have published "guidelines on clinical translation of stem cell" to emphasize: (1) quality controlled stem cells with known characteristics; (2) *a priori* information of delivery efficacy, safety of stem cells in animal model; (3) peer reviewed clinical protocols in pre-clinical research; (4) awareness of tumorigenic risk without evidence of clinical benefit evidences at the time of voluntary informed recipient consent to perform clinical trial [15]. In spite of all, ISSCR recommendations remain as undefined code of professional conduct to assure safety due to no harmony between laboratory-based research and use of approved stem cell-based products with policy differences in different continents [16]. Legislation must regulate scientific progress from lab to clinic in public interest. Public must have confidence in clinical benefits. The public interests may be protected by guidelines for: (1) stem cell-based product is safe, pure, potent for general practice GTP, GMP, and GCP requirements; (2) pre-clinical evidence available on proof-of-principle and safety in animal models; (3) new non-invasive biodistribution monitoring by markers and tumors for clinical trials; (4) preference to patient safety by risk-based

approach in granting regulatory approval with conditional marketing authorization.

**3.3. How much have the US and EU spent on human embryonic stem cell research?**

In the years 2007–2017, the EU has funded 27 collaborative health research projects involving the use of human embryonic stem cells with an EU contribution of about €157 million. Human embryonic stem cell research projects represent approximately one-third of health projects on

In addition, the European Research Council has funded 10 projects for an EU financial contribution of about €19 million, and there have been 24 Marie Skłodowska-Curie actions involv-

Stem cell treatment is a new option of organ transplantation or tissue and cell transplantation. Stem cells in culture behave differently from the tissue cells behave inside body. As a result, the progenitor cells and embryonic cell behavior entirely depends on media conditions, physiology of cultured cells, environment of breeding, action of added growth factors, vital molecules, additives,

ing human embryonic stem cell research worth €23 million.

**4.1. Stem cell therapy: a success or a myth**

**4. Stem cell treatment and tissue engineering products**

human stem cell-based products are formulated.

*3.2.2. International unanimous opinion*

10 Stem Cells in Clinical Practice and Tissue Engineering

all forms of stem cells.

Any product derived from stem cells or containing stem cells is referred as "stem cell-based product" (SCBP), including tissue engineering biomaterials in cell- and tissue-based therapy. Around the world, autologous stem cell clinics or hospitals are spreading in China, India, Mexico, Panama, Ukraine, European Union member states to perform stem cell facelifts, sport orthopedics, breast augmentation, treatment of muscle dystrophy, Alzheimer's disease, Parkinson's disease, and multiple sclerosis. In US alone, development of tissue engineering methods have shown significant progress in success of stem cells as therapeutic tools of regenerative medicine in different states of Ohio, Kansas, Minnesota, Wisconsin, and Mayo. These clinics and centers maintain *in vitro* stem cells in cultures that can be transplanted by fixing them at desired site in Matrigel®. With time, stem cells grow in the desired pre-programed manner and regenerate the defective part of the tissue or the organ [18]. Stem cell treatment centers charge prospective patients privately for simple stem cell therapy by bone marrow or peripheral blood liposuction, enzyme digestion, ultrasonic cavitation to prepare stromal vascular fraction (mixture of fibroblasts, endothelial progenitor cells, pericytes, mesenchymal stroma cells, and adipocytes) as therapeutic injection given to said patients or industries manufacture commercial stem cell therapy products without any product regulatory information to patients.

For clinical and commercial use, regulatory challenges are safety testing, *in vitro* functional assays, potency assays, pre-clinical, or clinical trials. The safety testing includes assays for microbial, fungal, endotoxin, mycoplasma, viral contamination, karyotyping testing, and enriched cell population. *In vitro* functional and potency assays act a surrogate measure of clinical effectiveness and validity to meet standards and control. In support, pre-clinical trial on experimental toxicity animal models such as immuno-compromised or tumorigenic animals, *in vitro* manipulation, administration route, and clinical trials with complete safety and sound ethics are necessary [19]. These characteristics establish the potential of these cells for tissue repair after injury or disease so called "stem cell therapies" as stem cell medicinal products made out of minimal manipulation of any target cell type destined for clinical application to improve defective function in the body. Presently, human embryonic stem cells (hESCs) are used in 13% of cell therapy procedures; fetal stem cells in 2%, umbilical cord stem cells in 10%, and adult stem cells in 75% of treatments [20]. Any use of such cell-based medicines is subject to authorization and controls, including their manufacture.

#### **4.2. Clinical development for first-in-man study plan**

Study design should demonstrate safety endpoints, efficacy, and its action for proposed clinical trial of new investigational medicinal product (EMEA/CHMP/SWP/28367/07). Safety endpoints may be defined on theoretical basis or any toxicity endpoint. The efficacy assessment should be related to pharmacodynamic effect of ATMP.A safe and minimal effective treatment dose should be identified. The presence of stem cells intended at desired location should be investigated by selected differentiation biomarkers to facilitate *in vivo* monitoring the stem cells during the time of administration in patients and their follow-up *in vivo* effect to establish long-term efficacy.

#### **4.3. Are there alternatives to embryonic stem cells?**

Embryonic stem cells have peculiar properties and functions uncommon in other natural cell types. Induced-pluripotent stem cell discovery as an alternative was awarded Nobel Prize in the year 2012 confirming many similar properties common with embryonic stem cells [21]. These cells are in use since then for drug development and screening new medicines. It is believed that drug development will be up to the clinical standard for therapeutic purposes in the future. In recent years, development of induced-pluripotent stem cells has opened new vista of stem cell restoration, repair, rejuvenation, and treatment research as adjuvant therapy.

Globally, the present major focus is on stem cell therapy in finding new options of incurable

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13

• to develop methods for detecting the presence of gene or chromosome abnormalities

• to enable any such knowledge to be applied in developing treatments for serious disease.

Licensed research is permitted on embryos created *in vitro* for its limited use in fertility treatment research within 14 days of harvesting cells. Human Reproductive Cloning Act (2001) does not permit cell nuclear replacement, or any other technique, to create a child or human reproductive cloning. The Human Tissue Act 2004 [42] regulates the use of human biological materials.

The regulatory Human Tissue Authority (HTA), the HFEA and the Medicines and Healthcare products Regulatory Agency (MHRA), Gene Therapy Advisory Committee (GTAC) are research ethics bodies examine and issue reports on ethical issues relating to stem cell research [43].

All the human embryonic stem cell lines currently in use come from 4- to 5-day-old embryos left over from *in vitro* fertilization (IVF) procedures. In IVF, researchers mix a man's sperm and a woman's eggs together in a lab dish. Some of those eggs get fertilized. At about 5 days, the egg divides to become a hollow ball of roughly 100 cells called a blastocyst. These early

For research, unused blastocysts are stored in the IVF clinic freezer for following use in future:

• Choice to donate the frozen embryos for research. These donated embryos are the main

**5.2. Major concerns of stem cell therapy and loopholes in stem cell research**

• **Where do the embryos come from to create stem cell lines for clinical use?**

embryos (blastocyst) are implanted into the woman's uterus to develop pregnancy.

• Defrosting the embryos, which destroys them, so, they are kept in freezer

diseases with following objectives:

• to promote advances in the treatment of infertility

• to increase knowledge about the causes of congenital disease

• to increase knowledge about the causes of miscarriages • to develop more effective techniques of contraception

• to increase knowledge about the development of embryos

• to increase knowledge about serious disease

• Continue paying to store the embryos in freezer

• Donation of the embryos for supervised adoption

source of human embryonic stem cell lines.

*5.1.1. Ethical and regulatory oversight*

Major concerns are:

There are various types of "tissue-specific" or "adult" stem cells. These cells are useful in specific applications. They make the limited number of cells found in the tissue from which they were isolated. So, they are limited in their potential as a clinical application of research. The expansion of adult stem cells in culture may be the answer, but extensive cultures of human adult cells may change their intrinsic properties *in vivo*, rendering them unfit for restoring injured or diseased tissue in patients.

### **5. Concerns on stem cell treatment regulations**

There are concerns raised in the media about uncertain differentiation and matched neotissue functions after stem cell therapy treatment. The unconfirmed outcome of new techniques offers new possibilities of successful treatment in patients with difficult or untreatable conditions. Stem cell therapy techniques have benefits and risks. Specific rules were introduced in the European Union (EU) in 2007 [22] to ensure appropriate authorization, supervision, and control of cell therapy medicines to reduce and manage the risks.

Recent media reports highlight the need of public authorities' attention to enforce their legal responsibilities in favor of patients taking restricted or limited treatment in compliance with relevant quality standards, material authenticity, treatment protocols, and supervised patient follow-up measures. The protection of patients is the core rule. Safety and efficacy of stem cell transplant products rule the quality and engineered tissue manufacturing of these products that are set out in good-manufacturing-practice (GMP) requirements. These are globally recognized standards for quality assurance in the production and control of stem cell products. Security and control of medicines derived from stem cell manipulation is tightly controlled by the FDA in US and EU [23].

Present time, manufacturers avoid compliance with quality standards. Inappropriate unapproved treatment definition or reclassification without mandate of competent authorities for control of stem cell products, may expose patients to cross-contaminated cell preparations, and result in short- and long-term risks to individual patients.

#### **5.1. How is stem cell treatment clinics regulated in different countries?**

In a very short span of 10 years, over 600 stem cell clinics were opened with unproven claims and unapproved treatment definition in the name of some benefits to individual diseases. Competent authorities in different countries have laid down ethical or regulatory policies.

Globally, the present major focus is on stem cell therapy in finding new options of incurable diseases with following objectives:


Licensed research is permitted on embryos created *in vitro* for its limited use in fertility treatment research within 14 days of harvesting cells. Human Reproductive Cloning Act (2001) does not permit cell nuclear replacement, or any other technique, to create a child or human reproductive cloning. The Human Tissue Act 2004 [42] regulates the use of human biological materials.

#### *5.1.1. Ethical and regulatory oversight*

The regulatory Human Tissue Authority (HTA), the HFEA and the Medicines and Healthcare products Regulatory Agency (MHRA), Gene Therapy Advisory Committee (GTAC) are research ethics bodies examine and issue reports on ethical issues relating to stem cell research [43].

#### **5.2. Major concerns of stem cell therapy and loopholes in stem cell research**

Major concerns are:

**4.3. Are there alternatives to embryonic stem cells?**

12 Stem Cells in Clinical Practice and Tissue Engineering

injured or diseased tissue in patients.

by the FDA in US and EU [23].

**5. Concerns on stem cell treatment regulations**

control of cell therapy medicines to reduce and manage the risks.

and result in short- and long-term risks to individual patients.

**5.1. How is stem cell treatment clinics regulated in different countries?**

Embryonic stem cells have peculiar properties and functions uncommon in other natural cell types. Induced-pluripotent stem cell discovery as an alternative was awarded Nobel Prize in the year 2012 confirming many similar properties common with embryonic stem cells [21]. These cells are in use since then for drug development and screening new medicines. It is believed that drug development will be up to the clinical standard for therapeutic purposes in the future. In recent years, development of induced-pluripotent stem cells has opened new vista of stem cell restoration, repair, rejuvenation, and treatment research as adjuvant therapy. There are various types of "tissue-specific" or "adult" stem cells. These cells are useful in specific applications. They make the limited number of cells found in the tissue from which they were isolated. So, they are limited in their potential as a clinical application of research. The expansion of adult stem cells in culture may be the answer, but extensive cultures of human adult cells may change their intrinsic properties *in vivo*, rendering them unfit for restoring

There are concerns raised in the media about uncertain differentiation and matched neotissue functions after stem cell therapy treatment. The unconfirmed outcome of new techniques offers new possibilities of successful treatment in patients with difficult or untreatable conditions. Stem cell therapy techniques have benefits and risks. Specific rules were introduced in the European Union (EU) in 2007 [22] to ensure appropriate authorization, supervision, and

Recent media reports highlight the need of public authorities' attention to enforce their legal responsibilities in favor of patients taking restricted or limited treatment in compliance with relevant quality standards, material authenticity, treatment protocols, and supervised patient follow-up measures. The protection of patients is the core rule. Safety and efficacy of stem cell transplant products rule the quality and engineered tissue manufacturing of these products that are set out in good-manufacturing-practice (GMP) requirements. These are globally recognized standards for quality assurance in the production and control of stem cell products. Security and control of medicines derived from stem cell manipulation is tightly controlled

Present time, manufacturers avoid compliance with quality standards. Inappropriate unapproved treatment definition or reclassification without mandate of competent authorities for control of stem cell products, may expose patients to cross-contaminated cell preparations,

In a very short span of 10 years, over 600 stem cell clinics were opened with unproven claims and unapproved treatment definition in the name of some benefits to individual diseases. Competent authorities in different countries have laid down ethical or regulatory policies.

#### • **Where do the embryos come from to create stem cell lines for clinical use?**

All the human embryonic stem cell lines currently in use come from 4- to 5-day-old embryos left over from *in vitro* fertilization (IVF) procedures. In IVF, researchers mix a man's sperm and a woman's eggs together in a lab dish. Some of those eggs get fertilized. At about 5 days, the egg divides to become a hollow ball of roughly 100 cells called a blastocyst. These early embryos (blastocyst) are implanted into the woman's uterus to develop pregnancy.

For research, unused blastocysts are stored in the IVF clinic freezer for following use in future:


Some embryonic experimental stem cell lines also come from embryos carrying harmful genetic mutations like cystic fibrosis or Tay Sachs disease. These are discovered by genetic testing prior to implantation. People who donate leftover embryos for research go through an extensive consent process. Under national and international regulations, no human embryonic stem cell lines can be created without explicit consent from the donor and without stringent regulatory protocols.

**Disease/Problems Benefits claimed Stem Cell Clinics posted on Internet webpages\***

Blood transfusion Increased counts https://www.cancer.net/navigating-cancer-care/how-

Pain Treatment Improved ECM https://www.stemcellcenters.com/conditions/orthopedicpain-management/

https://www.villarbajwa.com/**stem-cell-therapy**-hip.shtml

MedicalPolicies/policies/Stem\_Cell\_Ortho.aspx

knee-surgery-alternative/

therapy-repair-regenerate-body.aspx

Partial ossification http://www.jfas.org/article/S1067-2516(16)00027-2/fulltext

https://www.regenexx.com/the-regenexx-procedures/

cancer-treated/bone-marrowstem-cell-transplantation/ what-stem-cell-transplant-bone-marrow-transplant

https://stemcellres.biomedcentral.com/articles/10.1186/scrt81

https://www.stemcellcenters.com/conditions/neuropathy-pain/

https://r3stemcell.com/conditions/shoulder-and-elbow-arthritis/

http://www.startstemcells.com/crohns-disease-treatment.html

http://renovationstemcellinstitute.com/stem-cell-treatment-fibromyalgia

written-testimony-of-david-a-prentice-ph-d-in-support-of-sb-334/

https://www.stemcellmexico.org/kidney-disease-treatments

www.**medical**newstoday.com/articles/264892.php


therapy-westchester-oakbrook-hinsdale-il/ www.newyorkhandsurgery.com/services.html

Better skin looks http://www.startstemcells.com/anti-aging-treatment-naturally.html

https://www.regen-center.com/lupus.html

Better eraction https://dasilvainstitute.com/stem-cell-therapy-erectile-dysfunction/

therapies-for-advanced-kidney-cancer/ www.neural**stem**.com/**cell**-therapy-for-sci

https://lozierinstitute.org/

Asthma Better physiological http://stemcellrevolution.com/currently-studying/pulmonary/asthma/

COPD improvement http://www.startstemcells.com/COPD-treatment.html

Kidney Disease Improved KFT https://www.kidneycancer.org/get-information/

https://www.stemcellfusion.com/post/stem-cell-therapy-for-neck-arthritis/

https://www.ncbi.nlm.nih.gov/pubmed/17598490

https://www.wellmark.com/Provider/MedpoliciesAndAuthorizations/

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https://articles.mercola.com/sites/articles/archive/2017/06/04/stem-cell-

http://www.observer.com/2016/06/**stem-cells**-andrews-institute/

Partial ossification Partial ligament repair

Knee and Hip problems

Back arthritis/ spine disease

Shoulder, elbow, and hand problems

Lupus Erythromatosus

Erectile Dysfunction

Anti-aging and skin rejuvenation

Neck arthritis Partial ligament repair

Crohn's Disease Abdominal pain relief

Fibromyalgia Softer muscle,

joints

Disc degeneration Ligament tears

#### • **Do embryonic stem cell lines come from aborted fetuses?**

No. Embryonic stem cells only come from 4- to 5-day-old blastocysts or younger embryos otherwise it is bad criminal clinical practice.

#### • **Does creating embryonic stem cell lines destroy the embryo?**

In most cases, Yes. The hollow blastocyst—source of embryonic stem cells—contains a cluster of 20–30 cells called the "inner cell mass." These are the cells that become embryonic stem cells in a lab dish. The process of extracting these cells destroys the embryo. There is a second method that creates embryonic stem cell lines without destroying the embryo. Instead, scientists take a single cell from a very early stage IVF embryo and can use only one cell to develop a new line. The process of removing one cell from an early stage embryo has been done for many years as a way of testing the embryo for genetic predisposition to diseases such as Tay Sachs. This process is called "preimplantation genetic testing."

#### **5.3. Alternatives of embryonic stem cells**

New alternatives are emerging to replace controversial embryonic stem cells. Notably, adult stem cells, pluripotent cells are promising sources.

#### • **Are adult stem cells as good—or better—than embryonic stem cells?**

Adult stem cells unlike embryonic stem cells can grow only to follow certain cell paths. The adult stem cells do not grow indefinitely in the lab, unlike embryonic stem cells, and they are not as flexible in the types of diseases they can treat. To establish the claims, large trials with both adult and embryonic stem cells are needed to know the value of adult stem cells.

#### • **Do iPS cells eliminate the need to use embryos in stem cell research?**

Induced-pluripotent stem cells, or iPS cells, represent another type of cells that could be used for stem cell research. The iPS cells are adult skin cells. They can be genetically "reprogramed" to appear like embryonic stem cells. The technology to generate human iPS cells was pioneered by Shinya Yamanaka in 2007 [44].

• Stem cell research may not lead to human cloning because significant regulatory and advisory body has restrictions on reproductive cloning throughout world.

#### **5.4. Scope of stem cell therapy: what clinics offer benefits from stem cell therapy?**

Stem cell therapy, in some clinics, is making claims of healing based on new investigational personalized trials. Some clinical conditions are claimed to have limited benefit from stem cell therapies in recent years are mentioned in **Table 2**.


Some embryonic experimental stem cell lines also come from embryos carrying harmful genetic mutations like cystic fibrosis or Tay Sachs disease. These are discovered by genetic testing prior to implantation. People who donate leftover embryos for research go through an extensive consent process. Under national and international regulations, no human embryonic stem cell lines can be created without explicit consent from the donor and without stringent regulatory protocols.

No. Embryonic stem cells only come from 4- to 5-day-old blastocysts or younger embryos

In most cases, Yes. The hollow blastocyst—source of embryonic stem cells—contains a cluster of 20–30 cells called the "inner cell mass." These are the cells that become embryonic stem cells in a lab dish. The process of extracting these cells destroys the embryo. There is a second method that creates embryonic stem cell lines without destroying the embryo. Instead, scientists take a single cell from a very early stage IVF embryo and can use only one cell to develop a new line. The process of removing one cell from an early stage embryo has been done for many years as a way of testing the embryo for genetic predisposition to diseases such as Tay

New alternatives are emerging to replace controversial embryonic stem cells. Notably, adult

Adult stem cells unlike embryonic stem cells can grow only to follow certain cell paths. The adult stem cells do not grow indefinitely in the lab, unlike embryonic stem cells, and they are not as flexible in the types of diseases they can treat. To establish the claims, large trials with

Induced-pluripotent stem cells, or iPS cells, represent another type of cells that could be used for stem cell research. The iPS cells are adult skin cells. They can be genetically "reprogramed" to appear like embryonic stem cells. The technology to generate human iPS cells was

• Stem cell research may not lead to human cloning because significant regulatory and advi-

Stem cell therapy, in some clinics, is making claims of healing based on new investigational personalized trials. Some clinical conditions are claimed to have limited benefit from stem cell

both adult and embryonic stem cells are needed to know the value of adult stem cells.

• **Do embryonic stem cell lines come from aborted fetuses?**

• **Does creating embryonic stem cell lines destroy the embryo?**

Sachs. This process is called "preimplantation genetic testing."

• **Are adult stem cells as good—or better—than embryonic stem cells?**

• **Do iPS cells eliminate the need to use embryos in stem cell research?**

sory body has restrictions on reproductive cloning throughout world.

**5.4. Scope of stem cell therapy: what clinics offer benefits from stem cell therapy?**

otherwise it is bad criminal clinical practice.

14 Stem Cells in Clinical Practice and Tissue Engineering

**5.3. Alternatives of embryonic stem cells**

pioneered by Shinya Yamanaka in 2007 [44].

therapies in recent years are mentioned in **Table 2**.

stem cells, pluripotent cells are promising sources.


and treatment while federal authorities are plagued by false promises of medical experts under influence of stem cell and tissue engineering product manufacturers. Investigators and

Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice

http://dx.doi.org/10.5772/intechopen.74219

17

researchers have to lot of homework and hard efforts to solve this problem.

2 Florida State University Research Foundation, Tallahassee, FL, USA

Available from: http://cordis.europa.eu/home\_en.html

jsp?curl=pages/regulation/ general/general\_content\_000295.jsp

mission. http://www.bka.gv.at/site/3575/default.aspx

2007:324:0121:0137:en:PDF

BLA\_2004\_I\_163

Source and Contributed by: Stem Cell Awareness Task Force Team, AMET University, Chennai, India with Innovations and Solutions Inc. Global, Jacksonville, FL 10032, USA;

[1] Ratajczak MZ, Kucia M, Jadczyk T, et al. Pivotal role of paracrine effects in stem cell therapies in regenerative medicine: Can we translate stem cell-secreted paracrine factors and microvesicles into better therapeutic strategies? Leukemia. 2012;**26**(6):1166-1173

[2] European Commission. Community Research and Development Information Service.

[3] European Commission. International Cooperation and Development. Available from: http:// ec.europa.eu/europeaid/work/funding/beneficiaries/index.cfm?lang=en&mode=SM&type

[4] EUR-LEX.Available from: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:

[5] European Medicines Agency. Available from: http://www.ema.europa.eu/ema/index.

[6] Reproductive Medicine Act Amendment 2004. FmedGNov 2004 [Fortpflanzungsmedizingesetz geändert wird (Fortpflanzungsmedizingesetz-Novelle 2004 – FMedGNov 2004)]. http://www.ris.bka.gv.at/Dokument.wxe?Abfrage=BgblAuth&Dokumentnummer=BG

[7] Research on human embryonic stem research. Opinion of the Austrian Bioethics Commission. 16 March 2009. Bunderkanzleramt Österriech. Austrian Bioethics Com-

[8] Ethical aspects of the development and use of assistive technologies. Opinion of the Austrian Bioethics Commission. 13 July 2009. Bunderkanzleramt Österriech. Austrian

Bioethics Commission. http://www.bka.gv.at/DocView.axd?CobId=39411

\*Address all correspondence to: rksz2009@gmail.com 1 Innovations and Solutions Inc., Tallahassee, FL, USA

e-mail: rksz2009@gmail.com; Tel: 011-91-7534899120.

**Author details**

Rakesh Sharma1,2\*†

**References**

†

**Table 2.** Several stem cell therapy clinics claim the benefits are shown on internet websites\* (right click active).

For investigational treatment, consumers need to discuss with doctor to know the potential risks and benefits out of SCBP-based treatment with clear information of mandatory EU or FDA or country approval and regulation for clinical trial study before giving consent to participate in study. Consumers often do not know about SCBP product safety and efficacy outside EU and USA. Consumers should be aware of regulatory authority guidelines and safety, efficacy regulations (risk/benefit evaluation) covering SCBPs in countries before taking decision of treatment in those countries. Safety concerns of SCBPs mainly are: possible cell migration from site of administration to differentiate into inappropriate cell types at unexpected tissue sites, excessive new cell growth and tumor, or cancer development.

In nutshell, there is a mixed claim of stem cell therapy success, because of unfounded theory, trials, misguided treatments, and no clinical established research to justify the therapy and treatment while federal authorities are plagued by false promises of medical experts under influence of stem cell and tissue engineering product manufacturers. Investigators and researchers have to lot of homework and hard efforts to solve this problem.

### **Author details**

Rakesh Sharma1,2\*†

\*Address all correspondence to: rksz2009@gmail.com

1 Innovations and Solutions Inc., Tallahassee, FL, USA

2 Florida State University Research Foundation, Tallahassee, FL, USA

† Source and Contributed by: Stem Cell Awareness Task Force Team, AMET University, Chennai, India with Innovations and Solutions Inc. Global, Jacksonville, FL 10032, USA; e-mail: rksz2009@gmail.com; Tel: 011-91-7534899120.

### **References**

For investigational treatment, consumers need to discuss with doctor to know the potential risks and benefits out of SCBP-based treatment with clear information of mandatory EU or FDA or country approval and regulation for clinical trial study before giving consent to participate in study. Consumers often do not know about SCBP product safety and efficacy outside EU and USA. Consumers should be aware of regulatory authority guidelines and safety, efficacy regulations (risk/benefit evaluation) covering SCBPs in countries before taking decision of treatment in those countries. Safety concerns of SCBPs mainly are: possible cell migration from site of administration to differentiate into inappropriate cell types at unexpected

Better wound repir https://books.google.co.in/books?isbn=111997139X

**Table 2.** Several stem cell therapy clinics claim the benefits are shown on internet websites\* (right click active).

In nutshell, there is a mixed claim of stem cell therapy success, because of unfounded theory, trials, misguided treatments, and no clinical established research to justify the therapy

tissue sites, excessive new cell growth and tumor, or cancer development.

treatment.html

**Disease/Problems Benefits claimed Stem Cell Clinics posted on Internet webpages\***

stem-cells.html

www.drlox.com/

https://www.placidway.com/package/3477

http://alsworldwide.org/research-and-trials/category/stem-cells http://www.healthyhabitswellness.net/**stem-cell**-regenerative/

**https://www.hindawi.com/journals/bmri/2014/951512/.pdf**

https://**treating**pain.com/**treatment**/regenexx-**stem-cell-therapy**

http://ocsportsmed.com/wp-content/uploads/2015/07/trifold.pdf

topeka-physician-adds-adult-derived-stem-cell-treatment-practice

http://www.whatisstemcelltherapy.com/Regenerative-Medicine/

https://www.cryo-cell.com/cord-blood-treating-diseases www.faim.org/why-cant-we-use-our-own-**stem-cells**

http://www.allelebiotech.com/cell-therapy/cell-banking/

http://www.orangecountyhairrestoration.org/stem-cell-therapy-hair-loss-

www.greensidevet**practice**.co.uk/**stem-cell-therapy**/

http://www.cjonline.com/news/2016-12-03/

Regenerative-Medical-Technology

https://www.paindoctor.com/Pain\_Treatments

https://www.thenewatlantis.com/publications/ appendix-b-the-promise-of-stem-cell-therapies

Hair growth https://www.bioinformant.com/product/stem-cell-fact-sheet/ https://www.bioinformant.com/product/ guide-accelerated-regulatory-pathways/

http://www.nymag.com/daily/intelligencer/2015/06/gordie-howe-protocol-

https://www.macquariestemcells.com/stem-cell-treatment-for-arthritis/

Multiple Sclerosis Parkinson's Disease

Osteoarthritis Osteoporosis Psoriatic Arthritis, Neck Arthritis Rheumatoid Arthritis

Back arthritis and spine disease Pain Treatment Oral Maxillofacial Densistry TMJ

Hair loss (in both men and women)

Regenerative medicine

Loss in lesions Better motor function

16 Stem Cells in Clinical Practice and Tissue Engineering

Slow bone loss Osteogenesis Ossification -do- -do-

Neural recovery Bone repair

Ulcerative Colitis Colon repair https://www.cirm.ca.gov/


[9] Collecting stem cells from umbilical cord blood. Ruling of the Bioethics Commission. 16 March 2009. Bunderkanzleramt Österriech. Austrian Bioethics

[22] Act ensuring Protection of Embryos in connection with the importation and use of human embryonic stem cells [Gesetz zur Sicherstellung des Embryonenschutzes im Zusammenhang mit Einfuhr und Verwendung menschlicher embryonaler Stammzellen Stammzellgesetz (StZG- Stem Cell Act]. 14 August 2008. Available from: http://bundes-

Introductory Chapter: Stem Cells and Tissue Engineering in Medical Practice

http://dx.doi.org/10.5772/intechopen.74219

19

[23] Central Ethics Commission for Stem Cell Research [Zentrale Ethik-Kommission für Stammzellenforschung - ZES]. https://www.eurostemcell.org/regulation-stem-cell-

[24] Research on human embryonic stem research. Opinion of the Austrian Bioethics Commission. 16 March 2009. Bunderkanzleramt Österriech. Austrian Bioethics Com-

[25] Ethical aspects of the development and use of assistive technologies. Opinion of the Austrian Bioethics Commission. 13 July 2009. Bunderkanzleramt Österriech. Austrian Bioethics Commission. Available from: http://www.bka.gv.at/DocView.axd?CobId=39411

[26] Law on the Transplantation of Organs, Tissues and Cells (Promulgated in the State Gazette, issue No. 83/19 September 2003, entered into force on 1 January 2004). Available

[27] Finnish National Ethics Committee. Opinion on EU Research Funding on Stem Cells. The Act on the Medical Use of Organs and Tissues (2.2.2001/101) [Laki lääketieteellisestä käytöstä elimien ja kudoksien (2.2.2001/101)]. Available from: http://www.finlex.fi/

[28] Law on Bioethics, Law n.2004-800, 6 Aug 2004 [Loi n. 2004-800 du 6 Août 2004 relative à la bioéthique]. Available from: http://ec.europa.eu/research/biosociety/pdf/french\_law.pdf; http://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000000441469&dateTexte

[29] Law 3089/2002 on Medically Assisted Human Reproduction. Chapter Eight: Medically Assisted Human Reproduction. Official Gazette of the Hellenic Republic [3089/2002 νόμος για την ιατρική υποβοήθηση στην ανθρώπινη αναπαραγωγή, Κεφάλαιο Οκτώ: Ιατρική Υποβοήθηση στην Ανθρώπινη Αναπαραγωγή, 23 του Δεκεμβρίου 2002]. 23 December 2002. Available from: http://www.bioethics.gr/media/pdf/biolaw/human/law\_3089\_ en.pdf; http://www.bioethics.gr/media/pdf/biolaw/human/assisted\_reproduction\_gr.pdf

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research-germany


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[9] Collecting stem cells from umbilical cord blood. Ruling of the Bioethics Commission. 16

[10] The Health Act (Promulgated in the State Gazette, Issue No. 70/10 August 2004, entered into force on 1 January 2005). Available from: http://solicitorbulgaria.com/index.php/

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[16] Act on Medical Research (9.4.1999/488) [Laki lääketieteellisestä tutkimuksesta (9.4.1999/ 488) Suomi]. Available from: http://www.finlex.fi/fi/laki/alkup/1999/19990488

[17] Finnish National Ethics Committee Report. Opinion on EU research funding on stem

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[19] Law on Bioethics, Law no. 2004-800 of 6 August 2004 [Loi n. 2004-800 du 6 Août 2004 relative à la bioéthique]. Available from: http://ec.europa.eu/research/biosociety/pdf/ french\_law.pdf and http://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT

[20] Law on Bioethics, LOI n° 2011-814 du 7 juillet 2011 relative à la bioéthique. Available from: http://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000024323102

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&fastPos=2&fastReqId=823265692&categorieLien=cid&oldAction=rechTexte

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bulgarian-health-act-part-2

18 Stem Cells in Clinical Practice and Tissue Engineering

http://lex.bg/en/laws/ldoc/2135566887

10 October 2011]

aspx?idsekce=16247

fi/laki/alkup/2001/20010102

000000441469&dateTexte

constitutionnel.fr/decision/1994/94343dc.htm


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**Section 2**

**Mechanisms of Stem Cell Differentiation and**

**Tissue Engineering**


**Mechanisms of Stem Cell Differentiation and Tissue Engineering**

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[40] House of Lords Select Committee on Stem Cell Research. 2002. Available from: http:// www.parliament.the-stationery-office.co.uk/pa/ld200102/ldselect/ldstem/83/8301.htm

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(CNECV)]. Available from: http://www.cnecv.pt/pareceres.php

showdoc\_l?p\_id=326057

20 Stem Cells in Clinical Practice and Tissue Engineering

tes\_docs/ma/tpb\_MA\_4022.pdf

dias/2007/07/04/pdfs/A28826-28848.pdf

es/buscar/doc.php?id=BOE-A-2010-18654

stamcellsforskning/

part-1271

contents

php?-381039724

**Chapter 2**

**Provisional chapter**

**Current View on Hematopoiesis and Beyond**

**Current View on Hematopoiesis and Beyond**

DOI: 10.5772/67050

Hematopoietic stem cells (HSCs) have the ability to self-renew and give rise to all lineages of blood cells while remain the capacity of regenerative in hematopoiesis. As the only stem cell type in routine clinical use, HSCs can be isolated from bone marrow, peripheral blood and umbilical cord blood. Stem cells transplantation is mainly used in HSCs while the trans-differentiation ability broadens the research of HSCs in regenerative medicine. Here, we focus on the current view on hematopoiesis and beyond and summarize the clinical application and the regulation of the fate of HSCs. We intend to outline recent advances in the human HSCs research area and review the characteristic of HSCs from definition through development to their clinical applications and future

**Keywords:** hematopoietic stem cells, stem cell niche, migration, transplantation, regenerative medicine, clinical application, bone marrow, microenvironment,

Hematopoietic stem cells (HSCs) identification was confirmed in the 1950s after the first successful transplant was performed by Thomas et al. [1]. This transplantation involved identical twins, one of whom had leukemia. In 1968, the first major landmark in HSCs transplantation occurred with successful allogeneic transplantations [2]. In 1988, Irving Weissman et al. developed reliable methods to identify HSCs population based on a set of protein markers on the surface of mouse blood cells with flow cytometry and fluorescence-activated cell sorting (FACS) [3]. The technologic advances on HSCs researches, FACS and methods for in vitro assays have extended to the whole field of stem cell researches, such as embryonic stem cells, induced pluripotent stem cells, adult stem cells and cancer stem cells, which directly lead to fast forward the translational applications of stem cell. Four years later, Weissman lab

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Jiaying Shen, Hongyan Tao and Zongjin Li

Jiaying Shen, Hongyan Tao and Zongjin Li

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67050

**Abstract**

prospect.

**1. Introduction**

trans-differentiation

**Provisional chapter**
