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760 Ex Vivo Gene Therapy: Transplantation of Neurotrophic [Frontiers in Bioscience 11, 760-775, January 1, 2006] Ex vivo gene therapy: transplantation of neurotrophic factor-secreting cells for cerebral ischemia Takao Yasuhara 1, 2, Cesario V. Borlongan 2, 3, and Isao Date 1 1 Department of Neurological Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1, Shikata-cho, Okayama, 700-8558, Japan, 2Department of Neurology, Medical College of Georgia, 1120, 15th street, BI-3080, Augusta, GA, 30912, 3 Research and Affiliations Service Line, Augusta VA Medical Center, Augusta, GA 30912 TABLE OF CONTENTS 1. Abstract 2. Introduction 3. Strategy for cerebral ischemia using neurotrophic factor 3.1. Neurotrophic factors and stroke 3.2. Protective and regenerative properties of neurotrophic factors in stroke 3.3. Neurotrophic factor delivery 3.3.1. Surgical route of neurotrophic factor delivery 3.3.2. Protein manipulation, and in vivo and ex vivo gene manipulation of neurotrophic factors 3.3.3. Timing of neurotrophic factor delivery 3.4. Ex vivo gene therapy 3.4.1. Encapsulated cell transplantation 3.4.2. Neurotrophic factor-secreting stem cell transplantation 4. Perspective 5. Acknowledgements 6. References 1. ABSTRACT 2. INTRODUCTION Expressions of various neurotrophic factors or Regenerative medicine has been explored in the their receptors fluctuate after stroke, which in part regenerative organs such as skin, blood (1) and liver (2) or prompted investigations into the efficacy of neurotrophic in the ischemia-tolerant organs such as kidney (2) and factors as treatment modality for stroke. The methods to cornea. Heart and brain are considered as non-regenerative deliver neurotrophic factors into the brain can be and ischemia-intolerant organs. During the last decade, categorized into: 1) the surgical route of administration, regenerative medicine for myocardial infarct has been such as intracerebral, intraventricular, intra-arterial, or examined. Vascular endothelial growth factor (VEGF) gene intravenous systemic administration and 2) the transfer using interventional techniques revealed increased manipulation of the therapeutic molecules via ex vivo or in myocardial perfusion, suggesting the prospective vivo techniques. With ex vivo method, genetically therapeutic option for myocardial ischemia (3). In addition, engineered cells, including the use of autologous cells, have endothelial cell progenitors were isolated from human been explored. In this review, the potent therapeutic peripheral blood (4) with subsequent transplant study applications of neurotrophic factors in stroke are described, leading to clinical application (5). Arguably, based on with emphasis on ex vivo methods, especially recent publications, regenerative medicine for the heart transplantation of encapsulated stem cells modified with appears more advance than for the brain. Nonetheless, adenovirus. Neurotrophic factor delivery, combined with ex regenerative medicine for the brain has achieved equally vivo method, poses as novel treatment for stroke, although important milestones. Neural stem cells with potency for additional safety and efficacy studies remain to be multiple lineage differentiation and self-renewal have been examined. shown to exist in adult mammalian forebrain (6, 7), 760 Ex vivo gene therapy for stroke indicating that the brain also has the capacity to regenerate. drastic catastrophic cascade within a short time; 3) Two major pillars of regenerative medicine using stem cells Ischemic penumbra is secondary damaged following have emerged, namely exogenous stem cell transplantation ischemic core formation, sometimes partly by reperfusion and stimulation of endogenous neurogenesis. The source of injury. In view of these pathological conditions, an acute exogenous neural stem cells consists of embryonic stem therapy for protection or repair of the global brain tissue cells (8), fetal or adult brains (9, 10), bone marrow (11, 12), including pan neural, glial, and endothelial cells, would umbilical cord (13), or other organs through seem a logical choice for stroke therapy. In this review, we transdifferentiation or cell fusion (10, 14, 15, 16, 17). described the utility of neurotrophic factors in stroke, its delivery system with emphasis on ex vivo gene therapy, Regenerative medicine for stroke has been which is the current focus of our laboratory. recently examined in the laboratory. Transplantation of mesenchymal stromal cell (MSC) from bone marrow to an 3. STRATEGY FOR CEREBRAL ISCHEMIA USING animal model of stroke revealed the differentiation of NEUROTROPHIC FACTOR MSCs into endothelial cells or neurons (18). Transplantation at 24 hours after middle cerebral artery 3.1. Neurotrophic factors and stroke occlusion (MCAO) demonstrated behavioral improvement, Expressions of cytokines, neurotrophic factors, although few MSCs differentiated into neuronal cells their receptors and related molecules involved in signaling suggesting that transplanted cells might have exerted pathways vary every second from the onset of ischemic neurorescue effects via secretion of neurotrophic factors. insult to cell death and ultimately the formation of the MSC transplantation has also been shown to result in ischemic lesion. Some exert protective effects on angiogenesis, which appears to precede neurogenesis (19, environmental structure in accordance with homeostasis 20). Thus, stem or progenitor cell transplantation stands as system, although some accelerate cell death. Almost all a potent therapy for stroke. Indeed, the neural progenitor neurotrophic factors are categorized under the former. cell line human NT2N cells, derived from human teratocarcinoma and fully differentiated into non-dividing One of the earliest neurotrophic factors neuron-like cells following treatment with retinoic acid and implicated in stroke is brain-derived neurotrophic factor mitotic inhibitors (21, 22), have been transplanted in stroke (BDNF), which was extracted from porcine brain (32). patients (23, 24). Two to ten million cells were transplanted BDNF was shown to induce neuroprotective effects on to patients with a chronic infarct of basal ganglia. ischemic brain via the receptor, TrkB (33). It was also Following positron emission tomography with [18F] demonstrated that BDNF mRNA was upregulated at 2 fluorodeoxyglucose revealed improvement in glucose hours post-MCAO (34) or at four hours post-photochemical metabolic activity correlated with motor function (25). stroke in the hippocampus and cortex of rat brains Subsequently, histological estimation from one postmortem especially in regions high in N-methyl D-aspartate brain confirmed survival of transplanted cells without (NMDA) receptors (35). Recent studies have revealed the tumorigenesis for at least two years in the human brain mechanisms underlying BDNF neuroprotection. (26). Kiprianova and colleagues demonstrated interaction of BDNF and fibroblast growth factor 2 (FGF2), which is also Despite scientific advances in our understanding upregulated after MCAO in stroke (36). FGF2 knock-out of the disease, the incidence of stroke is increasing mice exacerbated infarct volumes partly due to worldwide (27). To date, the FDA-approved therapy using downregulation of BDNF and TrkB in hippocampal recombinant tissue plasminogen activator is only effective neurons, as well as due to lack of neuroprotective potencies to less than 5% of ischemic stroke patients when related to FGF2 itself. Chen and colleagues demonstrated administered within 3 hours of disease onset (28, 29). that endothelial nitric oxide synthase (eNOS) knock-out Because of this limited therapeutic window, mice displayed functional deterioration after MCAO neuroprotection of the stroke brain specifically the compared to normal mice (37). In their study, eNOS was penumbra during the acute stage of the disease should be revealed to increase BDNF expression in the ischemic brain explored for protection and regeneration of injured, but still and surprisingly have a strong influence on stem cell viable neurons. Neurotrophic factors have been shown to proliferation as well as VEGF-induced angiogenic potency. possess both protective and regenerative properties (30, It is interesting to note that FGF2 and eNOS, both bearing 31). angiogenic potency, appear related to neuroprotection by BDNF. Additionally, serial expression of BDNF was In contemplating with combined stem cell and observed after bilateral common carotid artery occlusion neurotrophic factor therapy, some essential points need to (BCCAO), a model of moderate ischemia in the rat be considered: 1) Various phenotypes of neurons, glial cells forebrain (38). Transient BDNF mRNA upregulation at 6 and endothelial cells are damaged and lose their functions hours post-BCCAO and the return to the control level at following stroke which differ from the single- day 1 after stroke was seen in the hippocampus, suggesting neurotransmitter cell depletion pathology seen in that the change of cerebral blood flow in the beginning of neurodegenerative diseases (e.g., dopaminergic neurons in stroke might affect BDNF gene expression. Parkinson’s disease or gamma aminobutyric acid [GABA] neurons in Huntington’s disease) wherein stem cell and In addition to BDNF, VEGF expression recently neurotrophic factor treatment have been shown to be has been explored extensively in stroke. In a cerebral effective; 2) Ischemic insult usually occurs suddenly with ischemia model of postnatal rat, expression of hypoxia- 761 Ex vivo gene therapy for stroke inducible factor 1alpha (HIF1alpha),
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