**5. Clinical application: Cell therapy as a new therapeutic approach for COPD**

Due to the high prevalence and significant economic and social impact caused by COPD, there are, as already presented, several researches in cell therapy, described in animal models, which sustain the use of ASC in human patients with COPD.

The results arising out of the basic research in animal models of COPD cell therapy, at our laboratory, have shown regeneration of the pulmonary parenchyma both in the qualitative and in the quantitative forms, as demonstrated by the histological analyses and by the measurement of the Lm. These results were the grounds for the preparation of a research project submitted to the National Committee of Ethics in Research (CONEP-Brazil) in April 2008. The clinical protocol was approved in April 2009 (registration nº 14764, CONEP 233/2009) and, on May 11th, 2009, the first patient, with CPOD in advanced stage, was submitted to BMMC pool infusion (Ribeiro-Paes et al., 2011).

This first work corresponds to a phase 1 clinical screening for the evaluation of safety concerning SC infusion in COPD patients and it was registered with Clinical Trials – NIH – USA (NTC01110252). The experimental outlining consists, basically, of the autologous

Cell Therapy in Chronic Obstructive Pulmonary Disease: State of the Art and Perspectives 467

4) detected immunosuppressive illnesses, including HIV; 5) hepatitis B or C; 6) smoking habit; 7) carrier of known neoplasies; 8) pregnancy; 9) noncompliance with established medical protocol; 10) psychosocial problems, including drug or alcohol abuse; 11) lack of family support. After the selection, the participants received written and verbal information explaining the study and written consent was obtained from all participants before the

After a thorough clinical evaluation, bone marrow of the voluntary patients was collected, processed and the BMMC pool achieved after isolation in Ficoll density gradient. The infusion of the achieved mononuclear fraction was made by peripheral IV (brachial medial) way and the clinical evolution of patients after the transplant has been monitored until the

The use of BMMC pool for cell therapy in COPD patients has shown to be quite safe. No intercurrent disease occurred that could put the research's voluntary subjects in clinically

All the voluntary subjects of the research had some kind of clinical improvement. The spirometry tests showed a very slight improvement, as shown in Figure 7. The VEF 1

Fig. 7. Spirometry absolute values from 3 research patients included in clinical protocol and

Likewise, the increase in the CVF and CV parameters occurred in all patients after 30 days had lapsed from the procedure (Figure 7). However, after this period, there was a decrease

beginning of the procedure.

present date by the conduction of pulmonary function tests.

showed an improvement in all patients after thirty days.

submitted to autologous BMMC transplantation.

serious situations or long lasting discomfort.

transplant of Bone Marrow Mononuclear Cells (BMMC) pool in patients with COPD in advanced stage, higher than 3 according to the Modified Medical Research Council (MRC) Dyspnea Scale Score (Curley, 1997; Mahler & Wells, 1988). The study design is shown in Figure 6.

Fig. 6. Clinical protocol adopted for cell therapy in patients with advanced pulmonary emphysema (Ribeiro-Paes et al., 2011).

In the pre-procedure period, the selected patients were submitted to a full pulmonary and cardiac evaluation. Routine laboratory tests were also performed and the Dyspnea Scale Score test, modified according to the British MRC, was also conducted.The selection criteria is presented below.

**Inclusion criteria:** 1) age between 40 and 76 years; 2) severe obstructive pulmonary disease; 3) ineffective clinical treatment; 4) limited life expectancy; 4) limitation in daily physical activities; 5) possibility of pulmonary rehabilitation physiotherapy; 6) acceptable nutritional condition; 7) acceptable cardiac function; 8) no tobacco use for at least six months; 9) satisfactory psychosocial and emotional profile and family support and 10) Dyspnea Scale Score greater than 3.

**Exclusion criteria:** 1) active pulmonary or extra-pulmonary infection; 2) serious coronaropathy and/or ventricular dysfunction; 3) significant renal illness and/or hepatitis;

transplant of Bone Marrow Mononuclear Cells (BMMC) pool in patients with COPD in advanced stage, higher than 3 according to the Modified Medical Research Council (MRC) Dyspnea Scale Score (Curley, 1997; Mahler & Wells, 1988). The study design is shown in

Fig. 6. Clinical protocol adopted for cell therapy in patients with advanced pulmonary

In the pre-procedure period, the selected patients were submitted to a full pulmonary and cardiac evaluation. Routine laboratory tests were also performed and the Dyspnea Scale Score test, modified according to the British MRC, was also conducted.The selection criteria

**Inclusion criteria:** 1) age between 40 and 76 years; 2) severe obstructive pulmonary disease; 3) ineffective clinical treatment; 4) limited life expectancy; 4) limitation in daily physical activities; 5) possibility of pulmonary rehabilitation physiotherapy; 6) acceptable nutritional condition; 7) acceptable cardiac function; 8) no tobacco use for at least six months; 9) satisfactory psychosocial and emotional profile and family support and 10) Dyspnea Scale

**Exclusion criteria:** 1) active pulmonary or extra-pulmonary infection; 2) serious coronaropathy and/or ventricular dysfunction; 3) significant renal illness and/or hepatitis;

emphysema (Ribeiro-Paes et al., 2011).

is presented below.

Score greater than 3.

Figure 6.

4) detected immunosuppressive illnesses, including HIV; 5) hepatitis B or C; 6) smoking habit; 7) carrier of known neoplasies; 8) pregnancy; 9) noncompliance with established medical protocol; 10) psychosocial problems, including drug or alcohol abuse; 11) lack of family support. After the selection, the participants received written and verbal information explaining the study and written consent was obtained from all participants before the beginning of the procedure.

After a thorough clinical evaluation, bone marrow of the voluntary patients was collected, processed and the BMMC pool achieved after isolation in Ficoll density gradient. The infusion of the achieved mononuclear fraction was made by peripheral IV (brachial medial) way and the clinical evolution of patients after the transplant has been monitored until the present date by the conduction of pulmonary function tests.

The use of BMMC pool for cell therapy in COPD patients has shown to be quite safe. No intercurrent disease occurred that could put the research's voluntary subjects in clinically serious situations or long lasting discomfort.

All the voluntary subjects of the research had some kind of clinical improvement. The spirometry tests showed a very slight improvement, as shown in Figure 7. The VEF 1 showed an improvement in all patients after thirty days.

Fig. 7. Spirometry absolute values from 3 research patients included in clinical protocol and submitted to autologous BMMC transplantation.

Likewise, the increase in the CVF and CV parameters occurred in all patients after 30 days had lapsed from the procedure (Figure 7). However, after this period, there was a decrease

Cell Therapy in Chronic Obstructive Pulmonary Disease: State of the Art and Perspectives 469

As proposed by Osiris Therapeutics "Preclinical and clinical data suggest that Prochymal's unique mechanism of action may provide a first-in-class treatment option with the ability to reverse the underlying disease". However, there is no publication to date reporting the results arising out of the screening made in 62 patients. By virtue of the lack of results from the use of PROCHYMAL cell therapy in COPD, it is not possible to check and uphold the effect of regression of chronic inflammation in lungs as a response to the MSC treatment. Therefore, no critical evaluation may be made about the results of the protocol proposed by

More recently, a phase 1 clinical study sponsored by Leiden University Medical Center (Leiden, Netherlands) was registered with Clinical Trials.gov (NCT01306513). The clinical protocol consists of the autologous transplant of bone-marrow-derived MSC in patients with COPD (MRC 3) before the surgery to reduce pulmonary volume. The purpose of the work, still in progress, is the evaluation of the cell therapy safety, as well as the feasibility of

The results achieved by our group, as well as the registration of clinical protocols concerning cellular therapy by other research centers, have led to the opening of new strategies of therapeutic investigation. Thus, it is possible to establish ew perspectives in regard to the formulation of cell therapy experimental designs which will be surely incorporated into future research projects for the purpose of optimizing the clinical effect and the quality of

COPD represents a serious public health problem, which, according to the latest projections of the World Health Organization, should gradually change for the worse in the coming

The incorporation of new drugs having more effectiveness and longer effect unquestionably has contributed to the improvement in quality of life of the patients; however, up to now, no significant change in the natural history of the disease has been achieved. In this context, cell therapy turns out as a potentially promising treatment option, which, perhaps, may represent a change of paradigm in therapeutics and in the natural course of the disease.

The results achieved at our laboratory and by several other coworkers, at different research centers, have shown a morphological recovery of the pulmonary parenchyma in animals with experimentally-induced emphysema by the employment of proteases and/or cigarette smoke. From said results, a pioneer treatment with BMMC pool was administered for patients with emphysema in advanced stage. It is a project in an initial phase and the sample of treated patients is still small, which limit the analyses from the statistical point of view. At our research center, a new project will soon start. It will comprehend a larger sample (about

Notwithstanding the statistical limitations, the pioneer publication of the results by our research group (Ribeiro-Paes *et al*., 2011), has afforded the preparation of some logical inferences and methodological suggestions which will be incorporated into future projects. The use of MSC obtained from adipose tissue has disclosed a highly promising future perspective. Furthermore, the feasibility of establishing a protocol with repeated SC infusions should also be taken into account, just like in chronic treatments with drugs.

40 patients) and the employment of a new methodology, which the use of MSC.

Osiris Therapeutics.

cultivating MSC.

life of COPD patients.

**6. Perspectives and challenges** 

years, with a great impact on the economy, on a global scale.

in CVF; in spite of this fact, an important aspect is that the functional parameters remained always higher than the ones found before the procedure.

An interesting information turned out in the long term results, approximately 2 years of clinical monitoring. The spirometry parameters along the post transplantation period, by and large, maintain a certain regularity and similarity to those found before the procedure. One of the research subject disclosed a significant increase in the forced vital capacity, after 1 year and 3 months of treatment (Figure 8); The analysis of this parameter suggests a proximity to normality and reduction of the severity of the disease.

Fig. 8. Percentage of predicted and absolute values from a patient spirometry until 1 year and 3 months after BMMC autologous transplant.

The results from this clinical protocol show the procedure should be conducted at an earlier stage, that is, at a less advanced stage of the pathology. As mentioned, the laboratorial analysis, confirmed by clinical response, has reported a significant improvement in all patients, chiefly in the first 30 days after the procedure was carried out. After this period, laboratory tests displayed a tendency to decrease; however they did not drop to the base values obtained before the BMMC therapy treatment. These results advance the possibility that cell therapy may be applied in repeated doses from time to time for the purpose of stimulating pulmonary regeneration.

Another protocol under registration with Clinical Trials (NTC00683722) corresponds to a multicenter, double-blind, placebo controlled phase II study for patients with moderate to severe COPD. The clinical protocol, sponsored by Osiris Therapeutics Inc. (Columbia, MD), concerns the employment of *ex vivo* cultured adult human SC (PROCHYMAL) in the treatment of pulmonary emphysema. The purpose comprehends the evaluation of safety and efficacy of MSC multiple infusion.

As proposed by Osiris Therapeutics "Preclinical and clinical data suggest that Prochymal's unique mechanism of action may provide a first-in-class treatment option with the ability to reverse the underlying disease". However, there is no publication to date reporting the results arising out of the screening made in 62 patients. By virtue of the lack of results from the use of PROCHYMAL cell therapy in COPD, it is not possible to check and uphold the effect of regression of chronic inflammation in lungs as a response to the MSC treatment. Therefore, no critical evaluation may be made about the results of the protocol proposed by Osiris Therapeutics.

More recently, a phase 1 clinical study sponsored by Leiden University Medical Center (Leiden, Netherlands) was registered with Clinical Trials.gov (NCT01306513). The clinical protocol consists of the autologous transplant of bone-marrow-derived MSC in patients with COPD (MRC 3) before the surgery to reduce pulmonary volume. The purpose of the work, still in progress, is the evaluation of the cell therapy safety, as well as the feasibility of cultivating MSC.

The results achieved by our group, as well as the registration of clinical protocols concerning cellular therapy by other research centers, have led to the opening of new strategies of therapeutic investigation. Thus, it is possible to establish ew perspectives in regard to the formulation of cell therapy experimental designs which will be surely incorporated into future research projects for the purpose of optimizing the clinical effect and the quality of life of COPD patients.
