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Development of an advanced cell therapy product indicated for the treatment of gonarthrosis


Gonarthrosis is the most common cause of pain and disability in middle-aged and elderly people [1, 2]. The lack of long-lasting effective treatments for repairing degenerated articular cartilage has spurred research into novel cell-based therapies aiming at reducing pain, slowing the degeneration of cartilage and, ultimately, reverting the natural history of osteoarthritis (OA) [3]. Herein we report the development of a mesenchymal stromal cell (MSC)-based therapy, from conception up to completion of a Phase I/IIa prospective, open-label, single-dose, single-arm clinical trial.

Materials and methods

All animal care and experimental procedures adhered to the recommendations of local, national, and European laws and were approved by the appropriate Ethical Committees on Human and Animal Experimentation.

A GMP-compliant bioprocess was designed for the production of the investigational cell-based medicinal product. Characterisation of MSC adhered to the minimal criteria established by the International Society for Cellular Therapy [4].

For the clinical study (EUDRA-CT: 2009-016449-24; Identifier: NCT01227694), fifteen patients with grade II/ III OA (Kellgren&Lawrence score [5]) and chronic pain were treated intraarticularly with clinical grade MSC and were followed up to 12 months. Primary endpoints were safety and tolerability. Additionally, therapeutic efficacy was measured by the Visual Analogue Scale (VAS) for daily activity and on exertion [6], Health Assessment Questionnaire (HAQ) [7], the SF-36 questionnaire [8], the Western Ontario and McMaster Universities Arthritis (WOMAC) and Lequesne functional indexes[9]. Cartilage integrity was assessed by magnetic resonance imaging (MRI) and T2 relaxation time mapping [10, 11].

Results and discussion

Along the development programme, Good Scientific Practice (GxP) quality standards were implemented gradually in our laboratory (Figure 1)[12].

Figure 1
figure 1

Schematic representation of the product development package. eGFP=enhanced Green Fluorescent Protein; GCP=Good Clinical Practice; GLP=Good Laboratory Practice; GMP=Good Manufacturing practice; MSC=Mesenchymal Stromal Cell.

The preclinical package included a proof-of-principle study in a large animal model of chronic OA and three regulatory preclinical studies in murine animal models (Table 1 Figure 1). The intra-articular injection of autologous MSC was safe, as judged by the lack of local or systemic adverse effects and evidence of regeneration of articular cartilage and meniscus was found in specific macroscopic and histological parameters [13]. Three further regulatory preclinical studies were performed in murine animal models in order to 1) assess subchronic toxicology, 2) analyse the biodistribution of human MSC, and 3) investigate dose:response relationship. Our results highlighted the safety of MSC either administered intra-articularly (up to 6x105MSC/knee in rats) or intravenously (IV, 1.3x107 MSC/kg in mice) and the persistence of IV-infused MSC in liver, kidney and spleen, at 3 months post-administration. No tumours were detected in any of the animals during the observation period. IV transplanted hMSC were principally found in the liver, kidneys and spleen of immunocompromised mice. The lungs, in spite of receiving a considerable number of cells immediately after administration, did not appear to be a welcoming environment adequate for MSC survival, thus confirming other author's observations [14].

Table 1 Summary of the product development package for a MSC-based medicinal for the treatment of gonarthrosis.

Previous data in large translational animal models [15], and investigations on the role of MSC in cartilage [16, 17] and bone [18] regeneration, provided further support with respect to the safety and regenerative qualities of MSC.

For the clinical testing in humans, the drug product consisted in 40.9x106 ± 0.4x106 viable MSC in 10.0 ± 0.3 mL of saline solution. The phenotypic characteristics of the human MSC used in the study were 99.7% ± 0.2% CD45-CD105+, 99.0% ± 0.6% CD31-CD73+, 99.9 ± 0.3% CD90 and 15.5% ± 14.8 HLA-DR+. The combination of differentiation assays, growth profiles, morphology assessment and cytometric phenotype confirmed the MSC nature of the cells used in our studies. MSC suspensions tested negative for bacteria, mycoplasma and endotoxin before infusion into humans. The analgesic effect of the intra-articular infusion of MSC was remarkable, with all patients showing some degree of improvement in daily life physical activity and on exertion at month 12. Indeed all WOMAC, Lequesne and VAS indexes decreased in a similar manner over time, the most significant changes being observed at 6 and 12 months after treatment. A significant improvement was observed at 12 months in the vitality scale and at 3 months in the global health scale. HAQ decreased significantly from 0.38 at the basal visit to 0.2 at 12 months (p<0.05), thus indicating a global improvement of the perceived health status.

With respect to cartilage integrity, T2 values decreased significantly over time in all patients. These results may be indicative of regeneration of the articular cartilage in all patients at 1-year post-treatment. The fact that no pathological values were observed at 12 months in prior healthy areas highlighted the preventive effect of MSC on further degeneration.


We successfully designed and executed a reproducible GMP-compliant bioprocess for the manufacture of cell-based therapeutics. The clinical procedure involved a minimally invasive intervention, which was feasible and safe, resulting in pain relief and preventing further degeneration of articular cartilage.


The authors would like to express their sincere gratitude to F. Gòdia, J.J. Cairó, and L. Orozcoand his team for their support in this project. This work was supported by grants ''Ministerio de Economía y Competitividad'' (IPT-300000-2010-0017), ''Ministerio de Ciencia e Innovación'' (PSE-010000-2007-4//PSE-010000-2008-4, BIO2008-01985), Spanish Cell Therapy Network(TerCel, RD12/0019/0015) and by the European Regional Development Fund, within the National Plan for Scientific Research, Development and Innovation 2008-2011.


  1. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, et al: Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990?2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012, 380: 2197-2223.

    Article  Google Scholar 

  2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, et al: Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012, 380: 2163-2196.

    Article  PubMed  Google Scholar 

  3. Huey DJ, Hu JC, Athanasiou KA: Unlike bone, cartilage regeneration remains elusive. Science. 2012, 338: 917-921.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  4. Dominici M, Le Blanc K, Mueller I, Slaper-Cortenbach I, Marini F, Krause D, Deans R, Keating A, Prockop D, Horwitz E: Minimal criteria for defining multipotent mesenchymal stromal cells. The International Society for Cellular Therapy position statement.Cytotherapy. 2006, 8: 315-317.

    CAS  Google Scholar 

  5. Kellgren JH, Lawrence JS: Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957, 16: 494-502.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  6. Huskisson EC: Measurement of pain. Lancet. 1974, 2: 1127-1131.

    Article  PubMed  CAS  Google Scholar 

  7. Esteve-Vives J, Batlle-Gualda E, Reig A: Spanish version of the Health Assessment Questionnaire: reliability, validity and transcultural equivalency. Grupo para la Adaptacion del HAQ a la Poblacion Espanola J Rheumatol. 1993, 20: 2116-2122.

    CAS  Google Scholar 

  8. Kosinski M, Keller SD, Ware JE, Hatoum HT, Kong SX: The SF-36 Health Survey as a generic outcome measure in clinical trials of patients with osteoarthritis and rheumatoid arthritis: relative validity of scales in relation to clinical measures of arthritis severity. Med Care. 1999, 37: MS23-39.

    PubMed  CAS  Google Scholar 

  9. Faucher M, Poiraudeau S, Lefevre-Colau MM, Rannou F, Fermanian J, Revel M: Assessment of the test-retest reliability and construct validity of a modified WOMAC index in knee osteoarthritis. Joint Bone Spine. 2004, 71: 121-127.

    Article  PubMed  Google Scholar 

  10. Trattnig S, Mamisch TC, Welsch GH, Glaser C, Szomolanyi P, Gebetsroither S, Stastny O, Horger W, Millington S, Marlovits S: Quantitative T2 mapping of matrix-associated autologous chondrocyte transplantation at 3 Tesla: an in vivo cross-sectional study. Invest Radiol. 2007, 42: 442-448.

    Article  PubMed  Google Scholar 

  11. Crema MD, Roemer FW, Marra MD, Burstein D, Gold GE, Eckstein F, Baum T, Mosher TJ, Carrino JA, Guermazi A: Articular cartilage in the knee: current MR imaging techniques and applications in clinical practice and research. Radiographics. 2011, 31: 37-61.

    Article  PubMed  Google Scholar 

  12. Vives J, Oliver-Vila I, Pla A: Quality compliance in the shift from cell transplantation to cell therapy in non-pharma environments. Cytotherapy. 2015

    Google Scholar 

  13. Caminal M, Fonseca C, Peris D, Moll X, Rabanal RM, Barrachina J, Codina D, Garcia F, Cairo JJ, Godia F, et al: Use of a chronic model of articular cartilage and meniscal injury for the assessment of long-term effects after autologous mesenchymal stromal cell treatment in sheep. N Biotechnol. 2014, 31: 492-498.

    Article  PubMed  CAS  Google Scholar 

  14. Vilalta M, Degano IR, Bago J, Gould D, Santos M, Garcia-Arranz M, Ayats R, Fuster C, Chernajovsky Y, Garcia-Olmo D, et al: Biodistribution, long-term survival, and safety of human adipose tissue-derived mesenchymal stem cells transplanted in nude mice by high sensitivity non-invasive bioluminescence imaging. Stem Cells Dev. 2008, 17: 993-1003.

    Article  PubMed  Google Scholar 

  15. Fonseca C, Caminal M, Peris D, Barrachina J, Fabregas PJ, Garcia F, Cairo JJ, Godia F, Pla A, Vives J: An arthroscopic approach for the treatment of osteochondral focal defects with cell-free and cell-loaded PLGA scaffolds in sheep. Cytotechnology. 2014, 66: 345-354.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  16. Caminal M, Moll X, Codina D, Rabanal RM, Morist A, Barrachina J, Garcia F, Pla A, Vives J: Transitory improvement of articular cartilage characteristics after implantation of polylactide:polyglycolic acid (PLGA) scaffolds seeded with autologous mesenchymal stromal cells in a sheep model of critical-sized chondral defect. Biotechnol Lett. 2014, 36: 2143-2153.

    Article  PubMed  CAS  Google Scholar 

  17. Caminal M, Peris D, Fonseca C, Barrachina J, Codina D, Rabanal RM, Moll X, Morist A, Garcia F, Cairo JJ, et al: Cartilage resurfacing potential of PLGA scaffolds loaded with autologous cells from cartilage, fat, and bone marrow in an ovine model of osteochondral focal defect. Cytotechnology. 2015

    Google Scholar 

  18. Velez R, Hernandez-Fernandez A, Caminal M, Vives J, Soldado F, Fernandez A, Pla A, Aguirre M: Treatment of femoral head osteonecrosis with advanced cell therapy in sheep. Arch Orthop Trauma Surg. 2012, 132: 1611-1618.

    Article  PubMed  Google Scholar 

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Correspondence to Joaquim Vives.

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Vives, J., Blanco, M., Caminal, M. et al. Development of an advanced cell therapy product indicated for the treatment of gonarthrosis. BMC Proc 9 (Suppl 9), O9 (2015).

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  • Articular Cartilage
  • Mesenchymal Stromal Cell
  • Health Assessment Questionnaire
  • Human Mesenchymal Stromal Cell
  • Cartilage Integrity