Two-Year Safety and Clinical Outcomes in Chronic

Ischemic Stroke Patients after Implantation of Human

Modified Bone Marrow Derived Mesenchymal Stem Cells

(SB623): A Phase 1/2A Study

Gary K Steinberg, MD, PhD*, Douglas Kondziolka, MD†, Lawrence Wechsler,

MD†, Dade Lunsford, MD†, Anthony S Kim, MD^, Jeremiah N Johnson, MD*,

Damien Bates, MD, PhD#, Gene Poggio,MD‡, Casey Case, PhD#, Michael

McGrogan, PhD#, Ernest W. Yankee, PhD#, Neil E Schwartz, MD, PhD*

*Departments of Neurosurgery and Neurology and Stanford Stroke Center

Stanford University, Stanford, CA

†Departments of Neurological Surgery and Neurology, University of Pittsburgh,

Pittsburgh, PA

^Department of Neurology, University of California, San Francisco, CA

‡Biostatistical Consulting, Inc, Lexington, MA

#SanBio, Inc, Mountain View, CA

International Stroke ConferenceLos Angeles, CA 1/25/18

Disclosures

• NIH NINDS (grants)

• California Institute for Regenerative Medicine (grant)

• Peter Lazic US, Inc (consultant)

• Qool Therapeutics (consultant)

• NeuroSave (consultant)

Transfection

and Selection

MASC Cells

Expansion

Expression Vector

Cryopreserved

SB623 Cells

3

pN-27879 bp

Transcription Start - 743

XhoI - 1091

NICD ATG - 1104

SacII - 1475

Stop Codon - 3513

XbaI - 3521

AATAAA - 3573

Transcription Stop - 3723

CMV ProIn

NIC

D

pAf1 Ori

SV40 Pr

Neo

Synthe

tic p

A

Am

p

SanBio SB623 Phase 1/2a Clinical Study

1st intracerebral stem cell stroke trial in North America

Clinical Outcomes of Transplanted Modified Bone

Marrow–Derived Mesenchymal Stem Cells in Stroke:

A Phase 1/2a StudyGary K. Steinberg, MD, PhD; Douglas Kondziolka, MD; Lawrence R. Wechsler, MD;

L. Dade Lunsford, MD; Maria L. Coburn, BA; Julia B. Billigen, RN, BS;

Anthony S. Kim, MD, MAS; Jeremiah N. Johnson, MD; Damien Bates, MD, PhD;

Bill King, MS; Casey Case, PhD; Michael McGrogan, PhD; Ernest W. Yankee, PhD;

Neil E. Schwartz, MD, PhD

Stroke. 2016;47:00-00. DOI: 10.1161/STROKEAHA.116.012995

Adult bone marrow derived stromal cells

Transient Notch Transfection Causes Changes in the Differentiated State

4

The pN-2 Plasmid is Lost During Propagation of SB623 Cells

0

0.5

1

1.5

2

2.5

3

Neg. Cont. P1 P2 P3 P4

pN

-2 C

opie

s p

er

Genom

e

5

SB623 Cells do not have a Transformed Phenotype

Telomerase activity in SB623

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10 11

Pos

cells

MSC

D51

MSC

D51 HI

SB623

D51

SB623

D51 HI

Pos

cells

Pos

cells +

SB623

D51

SB623

D41

SB623

D41

(0.1)

NTC MTC

am

ole

s/u

l

Growth on Soft Agar

Karyotype Telomerase Activity

6

Bone Marrow

Derived

Stem Cells

Trophic/Growth

Factors

Exogenous Bone Marrow

Derived Stem Cells

Enhanced endogenous brain repair

mechanisms and plasticity

Axonal/Dendritic Sprouting

Angiogenesis/Vasculogenesis

Neurogenesis

Gliogenesis

Synaptogenesis

↓ Inflammation/ Immunomodulation

Mechanisms of recovery from stroke after transplanted MSCs

7

Oligodendrocytes

Neurons

Neural

Progenitor

Cells

Astrocytes

X

Endothelial Cells

X

Custom antibody array

(RayBiotech)

30 cytokines

Secretion of Protein Factors in Conditioned Medium

BDNF HGF

BMP-4 IGF-I

BMP-6 IL-1a

BMP-7 IL-6

b-NGF IL-8

CNTF LIF

DKK-1 MCP-1

DKK-4 MMP-1

EGF NT-3

Erythropoietin R PDGF-AA

FGF-2 SDF-1

FGF-7 TGFa

GCSF TGFb

GDNF TNFa

HB-EGF VEGF

8

SB623 Cells are Present 1 Month Post-implant, but not at 2 Months

Human

Nuclear

Matrix Ab

qPCR

9

SB623 Cells are Phagocytosed by Activated Microglia (Host Innate Immunity)

10

Overall Design

Open-label safety study

18 pts (3 dose levels, 6 pts each)—Stanford and Univ Pittsburgh− Standard, staggered escalation paradigm (2.5M, 5M, 10M)

6-month efficacy, 2-year follow-up

SanBio SB623 Phase 1/2a Clinical Study

Stereotactic Frame Positioning

Needle tracks for cell implantation and suggest implant sites

Needle tracks for cell implantation

and implant sitesStereotactic Frame Positioning

Inclusion

18-75 years old (33-75 yo tx)

Ischemic stroke in subcortical region of MCA or lenticulostriates with or without cortical involvement

6- 60 mos post-stroke (7-36 mos); stable for > 3 weeks prior

Modified Rankin Score 3 or 4

NIHSS Score >7

12

Key inclusion/exclusion criteria

Exclusion

Cerebral infarct size >100 cm3 (on MRI)

History of > 1 stroke

Presence of serum antibodies to donor SB623 cells (HLA Class I or II)

Safety

WHO toxicity scale

Periodic MRIs

2 years post-implantation follow-up

Efficacy

Primary

− European Stroke Scale (ESS) and FDG-PET at 6 months post-implant

Secondary

− ESS, NIHSS, Fugl-Meyer, mRS, and cognitive questionnaire scores at multiple timepoints

− FDG-PET imaging at multiple timepoints

13

Primary endpoints

KH JG JS

CF

VJ

CH LT NB

9/14/11

2.5 M modified adult bone

marrow stem cells

2 years after Rt bg stroke

SanBio/Stanford

18 pts treated6 with 2.5M, 6 with 5M

6 with 10M

12 Stanford

6 Univ Pittsburgh

Treatment Emergent Adverse Events (TEAEs)

Procedural Headache (89%)

Nausea/Vomiting (33%/22%)

Depression (22%)

Muscle Spasticity (22%) Fatigue (17%) UTI (17%)

Constipation (17%) Pain in Extremity (17%)

C-reactive protein ↑ (17%) Blood glucose ↑ (17%)

No dose limiting toxicities or deaths

None probably or definitely related to the cells; many related to the procedure

Most TEAEs of mild (11%) or moderate (50%) intensity

Serious Adverse Events (SAEs) (requiring hospitalization)

1) Seizure (70d after transplant)

2) Asymptomatic subdural hygroma/hematoma (drained)

3) Pneumonia

4) Stenting of cervical carotid artery for asymptomatic stenosis

5) UTI/sepsis

6) TIA (worsened facial droop & dysarthria; 11 mos post transplant)

7) Paresthesias/dysphagia

No patient withdrew 2º to adverse events; all resolved without sequelae

None related to cells; only subdural definitely related to surgery

No correlation between SAEs and cell dosage

Yr 1

Yr 2

No clinically meaningful change from baseline in plasma:

Cytokines (TNF-α, IL-6, and IFN-γ)

Antibody levels to donor SB623 cell HLA antigens

Peripheral blood mononuclear count (PBMC) function

Other biochemical parameters

ESS Total Score

0 1 2 3 4 5 6 7 8 9 10 11 120.0

2.0

4.0

6.0

8.0

10.0

24

**

**

******

**

**

***

A

n=18 n=16 n=16 n=16 n=15

*

n=17

Post Treatment (Months)

B

aseli

ne (

SE

M)

NIHSS Total Score

0 1 2 3 4 5 6 7 8 9 10 11 12-3.0

-2.0

-1.0

0.0

24

*

*

****

***

*

**

B

n=18

n=17

n=16 n=16 n=16 n=15

**

Post Treatment (Months)

B

aseli

ne (

SE

M)

F-M Total Score

0 1 2 3 4 5 6 7 8 9 10 11 120.0

10.0

20.0

30.0

24

****

***

*

*****

***

C

***

n=18

n=17 n=16

n=17 n=16 n=14n=15

Post Treatment (Months)

B

aseli

ne (

SE

M)

F-M Motor Function Total Score

0 1 2 3 4 5 6 7 8 9 10 11 120.0

5.0

10.0

15.0

20.0

24

***

*****

**

******

**

D

n=18

n=17 n=16

n=17 n=16 n=14n=15

**

Post Treatment (Months)

B

aseli

ne (

SE

M)

2 year clinical outcome

Post Hoc Analysis(F-M Motor Function Score)

• 13/18 (72%) pts achieved clinically meaningful recoveryF M M S : T i m e t o F i r s t A c h i e v e m e n t o f C l i n i c a l l y M e a n i n g f u l I m p r o v e m e n t ( 1 0 P o i n t s )

1 2 3 4 9 1 2 2 4

0

1 0

2 0

3 0

4 0

5 0

6 0

A

n = 3

n = 6

n = 1n = 1

n = 2

P o s t T r e a t m e n t ( M o n t h s )

Pe

rc

en

t o

f P

atie

nts

w

ho

A

ch

ie

ve

d

Clin

ic

ally

M

ea

nin

gfu

l Im

pr

ov

em

en

t

M e a n F M M S C h a n g e f r o m B a s e l i n e f o r P a t i e n t s W h o A c h i e v e d V e r s u s

D i d N o t A c h i e v e C l i n i c a l l y M e a n i n g f u l I m p r o v e m e n t ( 1 0 P o i n t s )

0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2

- 5

0

5

1 0

1 5

2 4

M e a n F M M S f o r P a t i e n t s w h o A c h ie v e d C l in i c a l l y M e a n i n g f u l I m p r o v e m e n t

M e a n F M M S f o r P a t ie n t s w h o d id n o t A c h ie v e C l i n i c a l l y M e a n in g f u l I m p r o v e m e n t

B

n = 1 3

n = 1 3

n = 1 3

n = 1 3n = 1 2

n = 1 2 n = 1 2

n = 1 1

n = 4

n = 4

n = 4

n = 4

n = 4

n = 3n = 3

n = 3

P o s t T r e a t m e n t ( M o n t h s )

Me

an

F

MM

S C

ha

ng

e fr

om

B

as

elin

e

N u m b e r o f

T E A E s

C e l l

T r e a t m e n t

S u r g i c a l

P r o c e d u r e

N u m b e r o f S A E s

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

N u m b e r o f T E A E s / S A E s a t 0 t o 1 Y e a r a n d > 1 t o 2 Y e a r s

> 1 t o 2 Y e a r s

0 t o 1 Y e a r

n = 1

n = 4

n = 7 4

n = 2 8

n = 0

n = 4

n = 7

n = 2

n = 4 6

Nu

mb

er

o

f T

EA

Es

/S

AE

s

N u m b e r o f T E A E s

1 2 3 4 5 6 7 8C o l u m n s

C

Clinically Meaningful Recovery

≥10 point (of 100 points) improvement in the

F-M motor function total score is a clinically

meaningful benefit in chronic stroke (Feys, 1998; van der Lee, 1999 & 2001; Page, 2009)

Those with “clinically meaningful” improvement achieve 75% of maximal

improvement by 3 mos

Pts without this degree of clinically meaningful improvement, improve later:

6 mos (p < .05)

Cell dose levels did not show any clear dose-response

relationships with clinical outcome

No association between improvement in clinical outcome

measures and either baseline stroke severity or baseline

patient age

39 yo ♀, 2y s/p Lt MCA stroke

39 yo ♀, 2y s/p Lt MCA stroke

2.6 months Post Transplant

Benefit sustained at 4.7 yrs post transplant

2.6 months Post Transplant

Benefit sustained at 4.7 yrs post transplant

Benefit sustained at 4.7 yrs post transplant

Benefit sustained at 4.7 yrs post transplant

Day 1 post-transplant T2 FLAIR Week 1 post-transplant T2 FLAIR

(DWI negative)Month 2 post-transplant T2 FLAIR

Pre-transplant T2 FLAIR

39 yo ♀, 2y s/p Lt MCA stroke

Pre-transplant T2 FSE

Newly appearing T2 FLAIR transient lesions14/18 pts

Primarily in or adjacent to premotor cortex

Appears at 1-2 weeks; resolves by 1-2 months

Significant correlations between size of the initial post-transplant

FLAIR signal changes and neurological recovery at 12 mos (p<0.001, ESS; p< 0.01 NIHSS, FM & FM Motor Fn)

& 24 mos (p< 0.05, ESS; p< 0.01, NIHSS)

Conclusions

Intraparenchymal transplantation of human modified bone

marrow derived stromal cells in chronic stroke patients is

Safe and Feasible

This study showed significant neurologic improvement at 6, 12

and 24 months following transplant

Circuits not irreversibly damaged!

Precise mechanisms still being elucidated

Conclusions

• Cell transplantation therapy for stroke holds great promise

• Investigation of neurotransplantation still in early stages

• Many fundamental issues need to be resolved in pre-clinical

studies

Multicenter Phase 2B study (156 US pts); initiated Jan, 2016

Double blind, randomized controlled study

2.5M, 5.0M, sham (1:1:1 randomization)

Enrollment/treatment complete 12/21/17; 1 yr f/u

Also Phase 2 Chronic TBI study

Stroke Neurology

Greg Albers, MD

Maarten Lansberg, MD, PhD

Neil Schwartz, MD, PhD

Nirali Vora, MD

Neuroanesthesiology

Richard Jaffe, MD, PhD

Mark Burbridge, MD

Nurse Coordinators

Teresa Bell-Stephens, RN

Mary Marcellus, RN

Joli Vavao, RN, NP

Melissa Lewis, RN, NP

JJ Baumann, RN

Clinical Fellows

Troels Nielsen, MD, PhD

Kumar Abhinav, MD

Nicholas Telischak, MD

Adi Iyer, MD, MD

Catherine Legault, MD

Chris Southwood, MD

Research Staff

Maria Coburn, BS

Stephanie Casal, RN

Kathy McDonald, BS

Stanford Cerebrovascular Team 2018Cerebrovascular Surgery

Gary Steinberg, MD, PhD

Steve Chang, MD

Rob Dodd, MD, PhD

Intervent Neuroradiology

Michael Marks, MD

Huy Do, MD

Rob Dodd, MD, PhD

Jeremy Heit, MD

Radiosurgery

Steve Chang, MD

John Adler, MD

Intraoperative Monitoring

Jaime Lopez, MD

Charlie Cho, MD

Leslie Lee, MD

Viet Nguyen, MD

Scheherezade Le, MD

Neuro ICU

Chitra Venkatasubramanian, MD

Anna Finley, MD

Marion Buckwalter, MD, PhD

Karen Hirsch, MD

Paul George, MD, PhD

Stanford University