Ch 24 _clinical_trials_and_family_banking_of_perinatal_stem_cells

1. Chapter 24
Clinical Trials and Family Banking of
Perinatal Stem Cells
Frances Verter and Pedro Silva Couto
Parent’s Guide to Cord Blood Foundation, Brookeville, MD, United States
Chapter Outline
Connections Between Trials and Banks of Perinatal Cells 321
First Decade of Advanced Cell Therapy Clinical Trials Using
Perinatal Stem Cells 323
Therapeutic Opportunities for Perinatal Stem Cells 327
Survey of Perinatal Cell Storage Offered by Family Cord
Blood Banks 329
Survey of Cord Tissue Processing Methods Used by
Family Banks 330
Tissue Storage 331
Both Tissue and Cellular Storage 332
Cellular Storage 332
Survey of Cord Tissue Storage Services 332
Summary Points 333
References 334
CONNECTIONS BETWEEN TRIALS AND BANKS OF PERINATAL CELLS
Readers of this book realize that all of the blood and tissues once considered merely the “afterbirth” are rich sources of
stem and progenitor cells that we refer to collectively as “perinatal stem cells” [1e3]. Three different lineages of stem cells
can be found in perinatal sources: hematopoietic stem cells (HSCs) are found in the blood that remains in the umbilical
cord and placenta [4,5]. Mesenchymal stem/stromal cells (MSCs) are present throughout all of the perinatal tissues and
even in the amniotic fluid [6e13]. Epithelial stem cells are present in the amniotic membrane that sheaths the placenta and
umbilical cord lining [14e16].
In this chapter we endeavor to review two topics that can each stand alone, but are intertwined with each other. The first
topic is the history of advanced cell therapy with perinatal stem cells over the decade 2005e15. We present the first
database of all registered clinical trials from this time period that used perinatal cells to perform advanced cell therapy. A
reader who is interested purely in the trial statistics can read that section alone. Our second topic is a survey of private cord
blood banks that provide perinatal cell storage for family use. We present the only survey of laboratory practices at these
banks compiled from direct interviews of the banks. In this section we explain how these two topics are intertwined.
Research advances that drive clinical trials usually begin purely in academic settings. However, the existence of family
banks that provide personal storage of cells from perinatal sources has played a significant role in the advancement of
clinical trials with perinatal cells, partly by providing a source of autologous cells and also by inspiring the companies that
own banks to sponsor trials that will help justify the personal banking market.
Cord blood is an exception to the rules that govern other perinatal cells. The primary reason is that traditional he-
matopoietic stem cell transplants (HSCTs) with HSCs from cord blood have required typing of human leukocyte antigens
(HLAs) to partially match the patient and donor [17,18]. By comparison, MSCs that are harvested from adults or perinatal
sources are considered immunoprivileged or at least immune-evasive [19,20]. The ability to deliver MSCs as a cell therapy
that is not matched by HLA type or tissue of origin is precisely the reason that MSCs are being studied to develop off-the-
shelf regenerative medicine therapies. Similarly, amniotic membranes have been successfully applied for over a century to
improve wound healing because they inhibit scarring without any donorepatient matching [21,22].
Perinatal Stem Cells. https://doi.org/10.1016/B978-0-12-812015-6.00024-8
Copyright © 2018 Elsevier Inc. All rights reserved.
321

2. The unique immunological status of cord blood HSCs is highly ironic. When cord blood is compared with bone marrow
as a graft source for HSCTs, cord blood does not require as close an HLA match [17,18], and thanks to this relaxed
matching criteria, patients of minority racial heritage are more likely to receive cord blood transplants [23,24]. But when
comparing clinical trials of regenerative medicine therapies with perinatal cells, cord blood is the only cell type that has
required partial HLA matching in many of the trials to date.
The history of perinatal cell banking can be divided into cord blood banking versus all the other perinatal sources such
as cord tissue, amniotic membrane, or placenta. The use of HSCs from umbilical cord blood as a graft source for HSCTs
started in 1988, and to date over 35,000 cord blood transplants have been performed worldwide [25]. The need to build an
inventory of cord blood donations that can cover the HLA diversity of transplant patients has led to the establishment of
public cord blood banks that currently have an inventory of over 700,000 cord blood units [26]. Scholars have studied the
optimum cord blood inventory to match the patient population [23,24] and the economics of managing public cord blood
banks [27].
The history of cord blood banking actually has two branches, because in addition to the public banks that are needed to
provide units for transplants, there is also an industry of private cord blood banks that store cord blood and other perinatal
tissues for family therapy. The family cord blood banks serve as a surrogate for public banks in those countries that lack a
public banking network, especially when the country has a high incidence of inherited blood disorders treatable by HSCTs,
such as thalassemia [28]. However, much of the growth of family banks has been inspired by clinical trials that are testing
cord blood as a therapy for cerebral palsy and autism, childhood disorders that are ten to a hundred times more prevalent
than all pediatric indications for HSCTs [29,30]. As a result of successful marketing, the inventory of family cord blood
banks grew 14-fold over the decade from 2003 to 2013, and by early 2017 the worldwide inventory of family cord blood
banks is over 5 million [31] (Fig. 24.1).
The history of banking other perinatal cells and tissues has been very limited until recently. These cells do not require
HLA matching, and therefore they do not require prior banking to build an inventory to be searched for a match. The
numerous academic centers and clinics that are using perinatal cells in therapies each have their own pipeline of sourcing
raw material, their own processing procedures, and their own small cache of cells that are ready for therapy. This cottage
FIGURE 24.1 Growth of inventory in cord blood banks, public and private/family.
322 SECTION j IV Clinical and Industry Perspective

3. industry approach to biobanking allows for a great deal of diversity in the characteristics of the final therapeutic products,
and as this field matures, it is necessary to establish standards.
The largest repositories of stored perinatal cells and tissues currently exist in family cord blood banks that offer
expectant parents perinatal banking services. One bank in the United States has been storing blood perfused from the
placenta since 2006 (LifebankUSA, private communication), and additional banks began offering umbilical cord tissue
storage since 2010 (Cryo-Save, private communication). Currently, several family banks have accumulated tens of
thousands of clients who have stored cord tissue, and no one has surveyed the total worldwide inventory of umbilical cord
tissue storage yet.
The scientific motivation for private banking of perinatal cells comes from studies that argue that MSCs from perinatal
tissues have advantages over adult sources of MSCs that can be obtained later:
1. Harvesting MSCs from perinatal sources spares adult patients an invasive procedure.
2. Perinatal sources of MSCs have lower risk of infection when compared with adult MSC sources [32].
3. Isolation of MSCs from cord tissue is straightforward and has high success rates [33,34].
4. The proliferation ability of MSCs from cord tissue is higher than MSCs from the adult sources bone marrow or adipose
tissue [35e37].
5. With age, the prevalence of MSCs decreases in the human body and their senescence is accelerated [38].
6. Some research groups have found that MSCs from perinatal sources might have greater immune-modulating activity
than MSCs from adult sources [39].
When perinatal banking is marketed to expectant parents, they are not educated in all of these scientific subtleties. The
marketing pitch is usually simplified to “more cell types means more treatment options.” Despite the simplification, it is
still a valid argument. The storage of HSCs from cord blood and MSCs from perinatal tissues is a complimentary medical
service. This dual storage option also improves the business model of the bank because those cord blood banks that offer
additional services have additional sources of revenue.
In the West, the practice of cord tissue banking is usually marketed as an add-on service at cord blood banks, although
in our survey of bank practices (Survey of Perinatal Cell Storage Offered by Family Cord Blood Banks section) we found
that 13% of cord blood and tissue banks offered tissue banking alone. In China, there are 18 banks offering parents cord
tissue banking as a separate service, and they are competing against the 7 regional banks that are licensed to offer private
cord blood banking (Yijia Li, private communication). Given the size of this market, we feel that our survey of how private
cord blood banks process cord tissue is relevant to explore the potential future of this inventory as a source of therapies.
FIRST DECADE OF ADVANCED CELL THERAPY CLINICAL TRIALS USING PERINATAL
STEM CELLS
We have compiled the first database of all clinical trials that were registered worldwide over the years 2005e15 that used
perinatal cells to perform advanced cell therapies. It is important to define “advanced cell therapy” and clarify our inclusion
criteria before presenting any results of this study.
Advanced cell therapies are any therapies in which cells are either more than minimally manipulated or their action is
not homologous. Our terminology is consistent with the regulatory category that the European Medicines Agency calls
Advanced Therapy Medicinal Product and the United States Food and Drug Administration (FDA) calls a Human Cells
and Tissues Product (HCT/P) under section 351 of the FDA regulatory code [40,41].
The definition of advanced cell therapy excludes the oncology applications of cord blood transplants because in HSCTs
the cells perform homologous reconstitution of the blood and immune system. However, we do include transplants with
expanded cord blood cells or special populations of cord blood cells in which the cells are more than minimally
manipulated.
The definition of advanced cell therapy includes regenerative medicine but is more general. Regenerative medicine is
defined as therapy that “replaces or regenerates human cells, tissue or organs, to restore or establish normal function” [42].
Advanced cell therapy also includes immune therapy where cells are administered to trigger the action of other immune
cells, tissue engineering where a matrix is seeded with cells, and gene therapy where cells are genetically modified to
repair/modify local tissues.
We found a total of 278 clinical trials worldwide over the years 2005e15 that used perinatal cells to perform advanced
cell therapies. We searched a dozen international registries of clinical trials, starting with the US registry ClinicalTrials.gov,
and also including the EU clinical trials registry, the WHO international registry, and the national registries of Japan,
Clinical Trials and Family Banking of Perinatal Stem Cells Chapter | 24 323

4. China, the Netherlands, Australia and New Zealand, India, Iran, Germany, and South Korea (listed in the order that they
were founded). Based on multiple keywords, we found over 19,000 candidate trials and each one was examined by at least
one scientist to winnow the field down to the final 278 trials.
Fig. 24.2 graphs the number of perinatal trials registered per year, with separate lines for different cell types. It is
conventional for biobanks and many authors to group trials according to their source material: cord blood versus cord
tissue, etc. We found that this classification is very misleading because 21% of the trials in our study that use cord blood as
the cell source were isolating MSCs. We therefore prefer to classify trials by the cell type that is presumed to provide the
mechanism of action. Cumulatively, over the decade 2005e15, the most common source of perinatal cells for advanced
cell therapy was cord blood in 44% trials, but the most commonly used cell type was perinatal MSCs in 54% of the trials.
The first well-known instance of regenerative medicine with perinatal cells was the use of autologous cord blood to
treat cerebral palsy and other acquired neurological disorders, beginning in 2005 [43]. During the first half of the decade
2005e15, trials with cord blood cells were dominant, but since 2010, trials with MSCs from various perinatal sources have
been the dominant form of advanced cell therapy with perinatal cells.
Perhaps the most dramatic trend in our decadal study is that only three countries accounted for 78% of the clinical trials:
36% were in China, 29% in the United States, and 13% in South Korea. To go a step further, each of these countries has its
own paradigm for how they perform research with perinatal cells. The accompanying pie charts display how the trials
break down by geographic region and by cell source: either cord blood (Fig. 24.3), cord tissue (Fig. 24.4), or other perinatal
sources (Fig. 24.5). Two caveats about these pie charts: one is that the trials are characterized by cell source and not by cell
type, and second is that trials using multiple cell sources are not displayed.
In China, 26% of the advanced cell therapy trials in this decadal study were only registered on their national database
Chinese Clinical Trial Registry (ChiCTR) and were not cross-posted to the US registry ClinicalTrials.gov. This illustrates
the inaccuracy of trial compilations that rely only on Clinicaltrials.gov to track clinical trials worldwide. The leading type
of advanced cell therapy with perinatal cells in China is trials that utilize MSCs from cord tissue. China strongly dominates
the world in this category, hosting 78% of all clinical trials that use cord tissue as a cell source. As a result of their intense
push to advance perinatal cell therapy, China has more late-stage clinical trials with perinatal cells than any other country.
Although the Chinese hold 36% of all perinatal trials, they hold 50% of trials that are phases 2/3 through 4.
In the United States, advanced cell therapy with perinatal cells is strong in the categories of both cord blood and other
perinatal sources. The United States holds 41% of all clinical trials that utilize cord blood as a cell source. Among the
United States trials that use cord blood as their cell source, 45% are researching manipulated cord blood cells, primarily to
improve the engraftment of cord blood transplants for hematological malignancies. The United States also dominates the
nascent field of advanced cell therapy with perinatal cells from the placenta and amniotic membrane; it is the only country
that has more than five trials with perinatal sources other than cord blood or cord tissue, and they hold 56% of the total
clinical trials in this category. By comparison, the United States has very little cord tissue research, with only three trials
over the decade in this study.
FIGURE 24.2 The number of advanced cell therapy perinatal trials registered per year, by cell type.
324 SECTION j IV Clinical and Industry Perspective

5. In South Korea, the advanced cell therapy with perinatal cells uses cord blood as the cell source almost exclusively
(only one trial was not cord blood) and the South Koreans hold 28% of all clinical trials with cord blood as cell source.
However, the research paradigms in South Korea are very different from both China and the United States. Whereas the
Chinese are leaders in trials that extract MSCs from umbilical cord tissue, the South Koreans are leaders in extracting
MSCs from cord blood. They hold 80% of all trials with MSCs extracted from cord blood. In fact, additional two trials in
the United States that use MSCs from cord blood are sponsored by Medipost of South Korea, so we could say they are
responsible for 88% of trials with this combination of cell type and source.
Fig. 24.6 explores how many patients were expected to enroll in the advanced cell therapy trials with perinatal cells
2005e15. Projected patient enrollment can only be approximate because a trial may close before reaching its original target
enrollment. In addition, in trials that have multiple arms, up to half of the patients may have received a placebo instead of
cell therapy. Finally, some trials do not state their target enrollment. Based on the data that was available, we found that
growth in trial enrollment has been slow but steady in most countries, so that over the last 4 years of the study, about 1000
FIGURE 24.4 Pie chart of advanced cell therapy perinatal trials during 2005e15 with cells from the source cord tissue, by geographic region.
FIGURE 24.3 Pie chart of advanced cell therapy perinatal trials during 2005e15 with cells from the source cord blood, by geographic region.
Clinical Trials and Family Banking of Perinatal Stem Cells Chapter | 24 325

6. patients per year participated in advanced cell therapy trials with perinatal cells outside of China. Within China, the trials
tend to enroll larger numbers of patients, and therefore a difference of a few trials can make a big difference in enrollment.
The total target enrollment over the years 2005e15 was over 12,000 patients, with 54% of the target enrollment in China.
Among trials with a target of 100 patients or more, 62% are in China.
Another way to examine the growth of advanced cell therapy with perinatal cells is by profiling the companies that have
sponsored clinical trials. Fig. 24.7 displays the number of trials registered per year sponsored by industry. Over the past
decade, 105 clinical trials of advanced cell therapy with perinatal cells have been sponsored by 30 companies in 11
countries. The fraction of trials sponsored by industry is 21% in China, 50% in the United States, and 60% in South Korea.
Some companies are notable for sponsoring numerous clinical trials of a particular treatment modality. Below we describe
those companies that have sponsored five or more clinical trials.
Companies based in the United States (colored shades of dark blue through purple) have sponsored 37 trials of
advanced cell therapies with perinatal cells. LifebankUSA (until 2016 a part of Celgene) has sponsored 14 clinical trials,
mostly devoted to trials with placental cells but also exploring immunotherapy with cord blood cells. Next in the United
States are three companies that have five trials each: Cord Blood Registry funds trials of regenerative medicine with cord
blood, Fate Therapeutics until 2017 funded trials that incubated cord blood stem cells before transplant, and NuTech
Medical (acquired by Organogenesis in March 2017) has explored applications of amniotic fluid and membrane.
FIGURE 24.5 Pie chart of advanced cell therapy perinatal trials during 2005e15 with cells from other perinatal sources, by geographic region.
FIGURE 24.6 Projected enrollment of advanced cell therapy perinatal trials registered each year, color-coded by geographic region.
326 SECTION j IV Clinical and Industry Perspective

7. Companies based in China (colored shades of red) have sponsored 21 trials of advanced cell therapies with perinatal
cells. Shenzhen Bieke and collaborators have sponsored eight trials, primarily using MSCs derived from cord tissue,
sometimes in combination with cord blood stem cells. This does not include trials in Taiwan (colored pink).
In South Korea the industry-sponsored trials of perinatal cells are dominated by Medipost and collaborators (colored
shades of orange), who together account for 16 trials of advanced cell therapies, every one of them using MSCs derived
from cord blood.
The last company with five or more trials is Gamida Cell in Israel (colored shades of light blue) that has sponsored
seven clinical trials in which cord blood stem cells are manipulated to improve cord blood transplants. Israel is the only
nation beyond the leading three countries, China, the Untied States, and South Korea, where companies have sponsored
more than 10 trials of advanced cell therapy with perinatal cells. However, Israel is an exporter of clinical trials, with many
of the patients enrolled at medical centers in multiple other countries. The remaining geographic regions holding com-
panies that sponsored perinatal trials are Australia (shades of yellow and tan), Latin America (shades of dark green), and
the European Union (shades of gray).
The advanced perinatal cell therapies sponsored by industry could best be described as existing in silos. Each company
has a treatment modality that they are pushing through a pipeline of trials, with the eventual goal of obtaining regulatory
approval in their home country. One company may focus on MSCs derived from cord tissue, whereas another focuses on
MSCs derived from cord blood. There is unlikely to ever be a head-to-head comparison of these MSC therapies from
different cell sources until they reach the marketplace. One can bemoan the lack of head-to-head comparisons that would
be valuable for patients, but this is the reality of how companies must function to finance the process of translating a
therapy from bench to bedside.
We predict continued growth in the field of advanced cell therapies with newborn stem cells, as more clinicians embrace
the ease of obtaining relatively large quantities of immunologically naive stem and progenitor cells from perinatal sources.
THERAPEUTIC OPPORTUNITIES FOR PERINATAL STEM CELLS
We adopt the premise that any regenerative medicine that is currently performed with MSCs can be performed with MSCs
from perinatal sources. To showcase the potential size of the market for perinatal MSCs, we look at two examples of
advanced cell therapies: cardiac clinical trials and orthopedic clinical trials. We have a complete database of all clinical
trials conducting advanced cell therapy (not just with perinatal cells) that were registered during 2011e16 [44]. We
compiled this database over a period of years by searching multiple keywords in a dozen trial registries and having two
trained scientists examine each candidate trial.
Vita 34
Kiadis Pharma
ATIGEN-CELL
Novo Cellular Medicine Inst.
United Therapeutics
Mesoblast
Translational Biosciences
Pluristem
Gamida Cell
Samsung Medical Center
Medipost
Kang Stem Biotech
CHA Biotech
Stem Cyte
Shenzhen Hornetcorn Bio-tech
Shenzhen Beike & CytoMed
Shenzhen Beike Bio-Technology
Jinan Tianhe Stem Cell Biotech.
Ivy Institute of Stem Cells
Cellonis Biotechnology
Alliancells Bioscience
Viacell
PerkinElmer
NuTech Medical
Novartis
LifebankUSA (Celgene)
Janssen Research & Develop.
Fate Therapeutics
Cord Blood Registry
Aldagen
2007 2008 2009 2010 2011 2012 2013 2014 2015
Genesis Limited
20
18
16
14
12
10
8
6
4
2
0
FIGURE 24.7 The number of advanced cell therapy perinatal trials registered per year sponsored by industry, color-coded by company.
Clinical Trials and Family Banking of Perinatal Stem Cells Chapter | 24 327

8. There were 114 clinical trials performing advanced cell therapy for cardiac conditions (not cardiovascular, just purely
cardiac) during the 6-year period 2011e16. In Fig. 24.8 we display the number of trials registered per year color-coded by
the cell type used in the therapy. The use of advanced cell therapy for cardiac conditions seems to be on a downward trend
overall, with 27 trials in 2011 and only 10 in 2016. The most common sources of cells are autologous bone marrow or
adipose tissue, and many trials do not fully isolate MSCs from these sources. The fraction of these trials that used MSCs
varied from 24% to 52% over these years. Among those MSC trials, the fraction that used MSCs from perinatal sources
varied from 13% to 33% each year. Therefore perinatal cells only play a minority role in the use of MSCs for cardiac cell
therapy, and this could be an opportunity to increase applications of perinatal cells.
There were 215 clinical trials performing advanced cell therapy for orthopedic conditions during the 6-year period
2011e16. In Fig. 24.9 we display the number of trials registered per year color-coded by the cell type used in the therapy.
The use of advanced cell therapy for orthopedic conditions is clearly a growing field, increasing steadily from 20 trials in
2011 to 47 in 2016. The most common sources of cells are autologous bone marrow or adipose tissue, and many trials do
not fully isolate MSCs from these sources. The fraction of these trials that used MSCs varied from 34% to 50% over these
years, but the perinatal fraction of those MSC trials was only between 0% and 21% each year. This is also an opportunity
for more clinical use of perinatal cells.
FIGURE 24.8 The number of advanced cell therapy trials for cardiac conditions registered per year, color-coded by cell type.
FIGURE 24.9 The number of advanced cell therapy trials for orthopedic conditions registered per year, color-coded by cell type.
328 SECTION j IV Clinical and Industry Perspective

9. It is interesting that there are more orthopedic than cardiac trials of advanced cell therapy, yet fewer of the orthopedic
trials exploit cells from perinatal sources. One likely explanation is that orthopedic trials, which include sports injuries,
have a healthier patient base than cardiac trials, and therefore most of the orthopedic patients have little difficulty un-
dergoing autologous cell harvests that yield sufficient cells for clinical efficacy. However, it is a rule of medicine that when
a therapy is successful, it is tried on successively more frail patients. If cell therapy becomes a standard of care in or-
thopedic medicine, then we can expect to see more applications to older patients. Over half of people above the age of
65 years have arthritis, and about a fifth of older women have osteoporosis [45,46]. Hence older patients present greater
need for orthopedic therapy that can save joints, but at the same time they are not ideal candidates for stem cell harvests
from bone marrow, presenting an unexplored opportunity for more clinical use of perinatal cells.
SURVEY OF PERINATAL CELL STORAGE OFFERED BY FAMILY CORD BLOOD BANKS
As we saw in Therapeutic Opportunities for Perinatal Stem Cells section, clinical trials for both cardiac and orthopedic
conditions often rely on the cellular activity of MSCs, yet they rarely use MSCs from perinatal sources. Should clinical
trials shift toward greater utilization of MSCs from perinatal sources, it will shift attention to the location and condition of
the exiting repositories of perinatal cells. In this section we review the status of perinatal cell banking in family cord blood
banks.
During the summer of 2015, we conducted a survey of all family cord blood banks worldwide, interviewing each one
about their practices [47]. We identified 214 laboratories that offer private cord blood banking, some of them through
dozens of marketing outlets in multiple countries. In the following we use the words “bank” and “laboratory” inter-
changeably, but it is important to note that we do not consider a marketing company without a laboratory to be a “bank.”
Fig. 24.10 shows how many of the family cord blood banks offer additional types of personal biobanking. The same
bank may appear more than once in this figure, for each service that it offers. Exactly half of the family cord blood banks,
107 laboratories, offer some form of storage of umbilical cord tissue, whereas all of the other biobanking options each
represent less than 10% of the banks. Among the 107 banks offering cord tissue storage, 13% allow parents to purchase
cord tissue storage as a stand-alone service, without cord blood banking. In addition, 9% of the banks offer more than one
option for tissue storage, so that among the 107 laboratories that store cord tissue, there are 121 storage protocols for cord
tissue.
Fig. 24.11 displays the geographic distribution of banks that offer cord blood and cord tissue storage. Today, family
cord blood banks can be found in 56 countries, and those that also offer cord tissue storage are in 40 countries, with the
percentage offering this service being 54% in the United States and Canada, 73% in Western Europe, 46% in Eastern
Europe, 53% in Asia and Oceania, 30% in Central and South America, and 36% in the Middle East and Africa. The
FIGURE 24.10 The number of family cord blood banks worldwide that offer various storage services.
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10. practice of cord tissue storage was first introduced in Western Europe, so it is not surprising that it is most popular in that
region, but it has been adopted by banks around the world.
We found that the ability to earn additional revenue from sales of combined cord blood and tissue storageeenabled
banks to lower their prices on the basic cord blood service. The mean cord blood prices (and standard deviation) are USD
3061 (standard deviation 982) for single-service banks versus USD 2711 (standard deviation 1029) for multiservice banks.
In this comparison, if a bank offered more than one service, we used its lowest price for each service. This difference is
statistically significant (after taking a natural log of the prices to normalize their distributions for the test, Student’s t-test
has P-value ¼ .003). The implication of this price comparison is that offering more forms of perinatal banking enables a
family cord blood bank to be more competitive in the biobanking market, both in terms of choices and prices.
Banks that offer cord tissue storage in addition to family cord blood banking tend to be more highly accredited than
laboratories that only offer cord blood banking. This can be seen from Fig. 24.12. Sadly, the most common accreditation
among family cord blood banks is None, at 36%. Next most popular, 30% of private bank laboratories only carry ISO
accreditation, which is not actually a cell therapy certification. The most popular accreditation that is specific to cord blood
cell processing is AABB at 22% of laboratories, followed by 7% of banks that are regulated by a national authority that
requires inspections (this includes UK’s HTA, Australia’s TGA, German GMP, Swissmedic, and New Zealand). By
comparison, among the 107 laboratories that also store cord tissue, the most common cord blood accreditation is AABB at
32% and None is reduced to third place at 25%.
It should be noted that quality control is fundamentally different for processing of cord blood versus cord tissue. In the
case of cord blood, it is typical for banks to analyze total nucleated cell count, CD34þ cell count, and the colony-forming
unit assay [48]. In the case of tissue product storage, it is necessary to first thaw the product and isolate cells before those
cells can be characterized. The official definition of MSCs requires the measurement of multiple surface markers [19].
The standards agency AABB began in 2015 to offer accreditation specifically for banking of somatic cells such as
MSCs [49]. As of April 2017, 18 facilities have achieved this accreditation, and over half of them are family cord blood
banks [50]. When launching this new accreditation, AABB cautioned, “The protocols for isolation and culture expansion
of MSC vary from laboratory to laboratory as the field has not yet matured to reach consistency among either collection
methods and procedures or products. Clinical trials with MSC have not only used different laboratories to prepare the
cellular product, but have also relied on different tests to characterize the final MSC product.” [49].
SURVEY OF CORD TISSUE PROCESSING METHODS USED BY FAMILY BANKS
Families who have cord tissue in personal storage may one day want to retrieve MSCs from those tissues for regenerative
medicine therapies. To explore the feasibility of that goal, we review the laboratory practices used to store cord tissue at
family cord blood banks.
FIGURE 24.11 The number of family cord blood banks and the number of those banks that offer cord tissue storage by geographic region.
330 SECTION j IV Clinical and Industry Perspective

11. When family cord blood banks offer parents “tissue storage,” they are not all selling the same service [51]. In fact, it
may be the case that no two banks are selling the same service. The two main categories of tissue storage on the market are
procedures that result in either a tissue product or a cellular product. This is illustrated by the schematic in Fig. 24.13. First
we briefly explain the various processing methods in the schematic, and then we present the results of our survey of cord
tissue processing at family cord blood banks.
Tissue Storage
In the simplest version of cord tissue storage, the umbilical cord is collected, washed, immersed within a solution con-
taining a cryoprotectant agent, and then cryopreserved. Sometimes the cord is cut into segments, but it is basically the same
procedure. When whole tissue or dissected tissue is stored, MSCs are not isolated before cryopreservation. Very few
laboratories have validated that they can retrieve viable MSCs from frozen segments of tissue [52].
Many cord blood laboratories use the “explants” cell isolation method, which begins by mincing the umbilical tissue
into tiny pieces and growing them in a culture medium. In theory, this allows MSCs to be isolated because they adhere to
FIGURE 24.12 Accreditation percentages of family cord blood banks: all 214 laboratories on the left compared with 107 laboratories that also offer cord
tissue storage on the right.
FIGURE 24.13 Schematic of cord tissue services.
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12. the surface of the culture dishes. In practice, most family cord blood banks do not fully perform the explants method of cell
isolation. After mincing the cord into pieces, they do not wait for cells to culture and adhere; instead the cord pieces are
immediately placed in a cryoprotectant agent and cryopreserved. Under these conditions the cells are not fully isolated and
the bank is actually storing a minced tissue product, not a cellular product.
The most advanced version of tissue storage is the patented protocols from Tissue Regeneration Therapeutics that
dissect the umbilical cord to remove the blood vessels and the surrounding MSC-rich perivascular zone [53]. The retrieval
of viable cells from frozen tissue has been validated for this method [54].
Both Tissue and Cellular Storage
The AC:Px device from Auxocell isolates cells from an entire cord purely by mechanical mincing, with no enzymes, and
yields two products from one process: both isolated cells and minced tissue [55]. AC:Px is the only device in the world that
allows user to obtain a cell product and a tissue product in a single run of the equipment. In addition, the device greatly
reduces the technician labor required in the traditional cell isolation methods.
Cellular Storage
Methods of cell isolation invariably start out with mincing the cord into pieces but then diverge. One method of cell
isolation is to perform the complete “explants” method, where the pieces of tissue are plated and cultured in a medium over
a period of time until a layer of adherent cells can be isolated. Once cells are isolated, they can be cryopreserved with the
standard procedures for cryopreserving stem cells.
Another cell isolation method is to place the minced pieces into enzymes that can digest the collagen matrix of the cord
tissue. The enzymatic digestion is followed by several steps to wash, filter, and centrifuge the separated cells. This method
results in a solution that carries fully isolated cells.
Finally, the process of isolating cells can be semiautomated with the gentleMACS device from Miltenyi Biotec [56].
This isolates cells from a section of cord by “dissociation” in an automated chamber, with or without optional enzymes,
after which the chamber contents are filtered to remove undissociated tissue and leave a final product of isolated cells.
Survey of Cord Tissue Storage Services
During the summer of 2015, we conducted a survey of all family cord blood banks worldwide, interviewing each one about
their cord tissue processing [47]. We identified 107 laboratories in 40 countries offering a total of 121 cord tissue storage
services to parents. We asked these banks a set of standard questions about their cord tissue handling procedures. In the
remainder of this section, the survey responses are always a percentage of the 121 services (not the 107 banks).
Fig. 24.14 shows the percentages of the banks that store cellular products versus tissue products. The largest group,
40.5% of respondents, indicated that they are storing a tissue product, whereas 26.4% said they are storing a cellular
product. There is an overlap where 5.8% of the services offer to store both products as part of their service package
(Fig. 24.15).
When asked the question, “Are you storing a segment of the umbilical cord or the whole cord that you receive?”, 49%
of the services answered that they store a segment and 15% store as much cord as they collect. The rationale behind storing
more cord is to obtain more cells. However, it has been argued that the MSC content of an entire umbilical cord is still less
than the clinical dose for most therapies, and therefore cell expansion will usually be required [53].
FIGURE 24.14 Venn diagram showing the cell products and tissue products within the 121 cord tissue services in the family cord blood banks.
332 SECTION j IV Clinical and Industry Perspective

13. When asked the question, “Are you freezing intact cord without any other further processing?”, only 8% of the services
said Yes. It has been reported that without mincing to reduce the size of the tissue pieces, it is difficult for cryoprotectant to
penetrate the tissue, which can lead to low viability and low cell yield postthaw [57] (Fig. 24.16).
When asked the question, “Are you mincing the cord tissue during any stage of the process?”, 40% of the services
answered Yes whereas 25% said No. It is puzzling that 25% answered No, given that in the previous question, only 8% of
services had admitted to storing the cord intact. Based on this answer and the responses of sales representatives to parent
inquiries, it is likely that considerably more than 8% of services store the cord intact.
When asked the question, “Are you using enzymatic solutions during any stage of the process?”, 17% of services said
Yes. This is roughly half of the services that say they are mincing the cord. Mincing is the first step toward a variety of
storage procedures, ranging from cryopreservation of the minced pieces with no processing to cell isolation via explants
cultures or enzymatic digestion. Mincing is helpful for enzymatic digestion because smaller tissue pieces can be digested
with lower enzyme concentrations and shorter incubation time.
SUMMARY POINTS
l To date, cord blood is the only perinatal cell type that has required HLA matching in clinical trials of regenerative med-
icine therapies.
l The existence of family cord blood banks that provide personal storage of perinatal cells has played a significant role in
the advancement of clinical trials with perinatal cells, partly by providing a source of autologous cells and also by
inspiring the companies that own banks to sponsor trials.
FIGURE 24.15 Two answer pies from the cord tissue processing survey: “Are you storing a segment of the umbilical cord or the whole cord that you
receive?” and “Are you freezing intact cord without any other further processing?” (left and right, respectively).
FIGURE 24.16 Two answer pies from cord tissue processing survey: “Are you mincing the cord tissue during any stage of the process?” and “Are you
using enzymatic solutions during any stage of the process?” (left and right, respectively).
Clinical Trials and Family Banking of Perinatal Stem Cells Chapter | 24 333

14. l The simultaneous banking of HSCs from cord blood and MSCs from perinatal tissue is a win-win for both the clients
and the bank: for the clients, more cells means more therapies, and for the bank, more cells means more sources of
revenue.
l When characterizing clinical trials with perinatal cells, it is important to distinguish between statistics by cell source and
statistics by cell type. Cumulatively, over the past decade, the most common source of perinatal cells for advanced cell
therapy was cord blood at 44%, but the most commonly used cell type was perinatal MSCs in 54% of the trials.
l In our survey of advanced cell therapy trials with perinatal cells during 2005e15, only three countries accounted for
78% of the clinical trials: 36% were in China, 29% in the United States, and 13% in South Korea. To go a step further,
each of these countries has its own paradigm for how they perform research with perinatal cells.
l The target enrollment of the perinatal trials in our decadal study was over 12,000 patients, with 54% of the target enroll-
ment in China. Over the last 4 years of the study, about 1000 patients per year participated in advanced cell therapy
trials outside of China.
l The fraction of advanced cell therapy trials with perinatal cells sponsored by industry is 21% in China, 50% in the
United States, and 60% in South Korea.
l We adopt the premise that any regenerative medicine that is currently performed with MSCs can be performed with
MSCs from perinatal sources. The area of orthopedic medicine presents many unexplored opportunities.
l At present, half of family cord blood banks also offer cord tissue storage, and they currently hold the world’s largest
inventory of stored cord tissue. Those cord blood banks that offer cord tissue storage tend to have higher accreditation
and lower prices for their basic cord blood service.
l We surveyed the 107 laboratories in 40 countries that offer cord tissue storage to parents. Their storage procedures
differ widely, which will present great challenges for client access to therapy with this biological resource.
l We predict continued growth in the field of advanced cell therapies with newborn stem cells, as more clinicians
embrace the ease of obtaining relatively large quantities of immunologically naive stem and progenitor cells from peri-
natal sources.
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