Adipose Tissue and Mesenchymal Stem Cells: State of the Art and Lipogems® Technology Development
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Curr Stem Cell Rep DOI 10.1007/s40778-016-0053-5 STEM CELLS: POLICIES FROM THE BENCH TO THE CLINIC (AI CAPLAN AND TL BONFIELD, SECTION EDITORS) Adipose Tissue and Mesenchymal Stem Cells: State of the Art and Lipogems® Technology Development Carlo Tremolada1 & Valeria Colombo 1 & Carlo Ventura2 # The Author(s) 2016. This article is published with open access at Springerlink.com Abstract In the past few years, interest in adipose tissue as an Lipogems® product, pericytes are retained within an intact ideal source of mesenchymal stem cells (MSCs) has in- stromal vascular niche and are ready to interact with the re- creased. These cells are multipotent and may differentiate cipient tissue after transplantation, thereby becoming MSCs in vitro into several cellular lineages, such as adipocytes, and starting the regenerative process. Lipogems® has been chondrocytes, osteoblasts, and myoblasts. In addition, they used in more than 7000 patients worldwide in aesthetic med- secrete many bioactive molecules and thus are considered icine and surgery, as well as in orthopedic and general surgery, Bmini-drugstores.^ MSCs are being used increasingly for with remarkable and promising results and seemingly no many clinical applications, such as orthopedic, plastic, and drawbacks. Now, several clinical trials are under way to sup- reconstructive surgery. Adipose-derived MSCs are routinely port the initial encouraging outcomes. Lipogems® technology obtained enzymatically from fat lipoaspirate as SVF and/or is emerging as a valid intraoperative system to obtain an opti- may undergo prolonged ex vivo expansion, with significant mal final product that may be used immediately for regenera- senescence and a decrease in multipotency, leading to unsat- tive purposes. isfactory clinical results. Moreover, these techniques are ham- pered by complex regulatory issues. Therefore, an innovative Keywords Mesenchymal stem cell . Lipogems® . Adipose technique (Lipogems®; Lipogems International SpA, Milan, tissue . Regenerative medicine . Adipose tissue-derived Italy) was developed to obtain microfragmented adipose tis- mesenchymal stem cell . Adult stem cells sue with an intact stromal vascular niche and MSCs with a high regenerative capacity. The Lipogems® technology, pat- ented in 2010 and clinically available since 2013, is an easy- Introduction to-use system designed to harvest, process, and inject refined fat tissue and is characterized by optimal handling ability and More than a century has passed since the first definition of a great regenerative potential based on adipose-derived stem cells as ancestral cells of the germ line [1], and since MSCs. In this novel technology, the adipose tissue is washed, then, a significant number of studies and discoveries emulsified, and rinsed and adipose cluster dimensions gradu- concerning their potential and application in regenerative ally are reduced to about 0.3 to 0.8 mm. In the resulting medicine and surgery have been published. In particular, more than 40,000 articles may be found on Medline by searching This article is part of the Topical Collection on Stem Cells: Policies from for human adult mesenchymal stem cells (MSCs) derived the Bench to the Clinic from bone marrow, dental pulp, fetal membrane, and term placenta. In vitro and in vivo experimental studies have dem- * Carlo Tremolada onstrated that human MSCs may differentiate in vitro into [email protected] several cell lineages, such as osteoblasts, chondrocytes, myocytes, and adipocytes [2]. 1 Image Institute, Milan, Italy In the past 15 years, it has been shown that human MSCs 2 Stem Wave Institute for Tissue Healing (SWITH)—Ettore Sansavini also can promote vasculogenesis, the main mechanism in- Health Science Foundation, Lugo, Ravenna, Italy volved in tissue repair effectiveness, cardiovascular Curr Stem Cell Rep differentiation, and myocardial repair [3], and have improved Bmedicinal signaling cells^ that can receive signals of in- islet graft revascularization in diabetic rats, enhancing engraft- jury from the environment and then respond by secreting ment success [4]. All the aforementioned discoveries inspired the appropriate molecules [22]. Dental pulp is considered the studies regarding Lipogems® (Lipogems International an effective MSC source for orthopedic and maxillofacial SpA, Milan, Italy) technology. reconstructions, because these MSCs can generate miner- Attention increasingly is being focused on MSCs de- alized tissue, extracellular matrix, and other connective rived from human and animal adipose tissue because of tissue, such as dentine, dental pulp, and periodontal liga- their abundance and ease of access. These multipotent ment [23].AlthoughMSCsclearlymaybeusedtoregen- cells can differentiate into mature adipocytes as well as erate the dental pulp itself [24, 25]andmayalsoinfluence chondrocytes, osteoblasts, myocytes, hepatocytes, the pathogenic pathways of some chronic brain and gut neuronal-like and endothelial cells, and other lineages, diseases (e.g., Parkinson’s and Alzheimer’s) [26], a treat- as suggested by in vitro, ex vivo, and in vivo evidence ment based on these cells is not yet available. Indeed, [5–14], and this potential may be used to regenerate dam- evidence obtained so far has been gathered only by using aged tissues. In addition, MSCs secrete a variety of bio- nonhuman xenotransplants and in vitro models. Bone active molecules that act in a paracrine fashion to prime marrow-derived MSCs also have been studied extensively and sustain angiogenic, antifibrotic, antiapoptotic, and im- for their great regeneration capability and their immuno- munomodulatory responses in target tissue [2, 15•]. suppressive capacity [27]. Several protocols for cell cul- Adipose-derived MSCs routinely are obtained enzymati- ture and expansion have been established, and many ef- cally and may undergo prolonged ex vivo expansion, with forts have been aimed at finding optimal conditions for significant senescence and a decline in multipotency. In addi- clinical-scale production of MSCs for cellular and gene tion, the technique is fraught with complex regulatory issues. therapy for inherited and acquired diseases [28]. This review presents an overview of the knowledge and Although many ex vivo and in vitro protocols have been clinical applications of adult MSCs, highlighting the role proposed, only a few studies have been done on the clinical Lipogems® technology has played in regenerative medicine applications of MSCs. The benefit of bone marrow MSC ther- so far. The urgent need to find new therapies for chronic im- apy in improving liver fibrosis was described in 11 patients munologic and degenerative diseases prompted many investi- with alcoholic cirrhosis [29]. Another study in two patients gators to search for products containing progenitor cells while with compensated cirrhosis investigated whether intraportal avoiding the problems and restrictions related to enzymatic injection of autologous bone marrow-derived MSCs com- manipulation and cell expansion in accordance with good bined with pioglitazone could stop or reduce liver fibrosis. manufacturing practice (GMP) rules [16, 17]. Although the results were encouraging, studies with more The availability of minimally manipulated products based patients are needed to prove the effectiveness of this clinical on adequate MSC content has resulted in shorter procedure application [30, 31]. times and the ability to apply autologous grafts in a one-step In 2010, Mazzini and Ferrero [32] began the first intervention. The Lipogems® technology guarantees both clinical trial to use bone marrow-derived MSCs to treat these requirements in an easy-to-use, rapid, and disposable amyotrophic lateral sclerosis and obtained promising re- adipose tissue transfer device and represents a very promising sults regarding the safety and usefulness of this proce- approach. dure. Moreover, a recent review on the treatment of spi- nal cord injuries with bone marrow MSC transplantation MSCs, the Medicine of the Future: Sources and Purposes in 20 patients reported convincing functional improve- ment [33]. More recently, multiple intramedullary and MSCs can proliferate in vitro and have multipotent differenti- intradural transplantations of MSCs were shown to ation properties. They also are strong immune modulators, achieve more satisfying results versus a single transplant inhibiting proinflammatory processes and stimulating anti- [34]. In 2005, a preliminary clinical trial using adipose- inflammatory mechanisms. These features may be exploited derivedMSCstotreatCrohn’s fistula was described, but to treat specific degenerative and inflammatory diseases in the further studies with larger patient samples are needed to near future; thus, research into the isolation, manipulation, and prove the feasibility of this application [35]. expansion of MSCs is increasing. All the aforementioned clinical trials were hampered by MSCs can be selected in culture from almost any tissue, complex and time-consuming enzymatic manipulation of including dental pulp, periodontal ligament, bone marrow, MSCs, as well as the extra centrifugation step(s) needed to fetal membranes, and placenta [18, 19]. Recently, obtain an adequate amount of cells. Because of the need to they were recognized in vivo as being derived from avoid these cumbersome procedures, the search for newer and perivascular cells [20, 21] and hence Binjury-specific^ better sources and processing strategies became increasingly cells. Indeed, MSCs detach from vessels