0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Autologous Mesenchymal Stem Cells Foster Revascularization of Ischemic Limbs in Systemic Sclerosis: A Case Report

Serena Guiducci, MD; Francesco Porta, MD; Riccardo Saccardi, MD; Stefano Guidi, MD; Lidia Ibba-Manneschi, MD; Mirko Manetti, PhD; Benedetta Mazzanti, BSc; Simone Dal Pozzo, BSc; Anna Franca Milia, PhD; Silvia Bellando-Randone, MD; Irene Miniati, MD; Ginevra Fiori, MD; Rossana Fontana, MD; Laura Amanzi, HP; Francesca Braschi, HP; Alberto Bosi, MD; and Marco Matucci-Cerinic, MD, PhD
[+] Article and Author Information

From Azienda Ospedaliero-Universitaria Careggi and University of Florence, Florence, Italy.


Acknowledgment: The authors thank the patient for her readiness to help others by allowing her case to be the focus of this article.

Grant Support: By Fondazione Cassa di Risparmio di Pistoia e Pescia (partial funding).

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1756.

Reproducible Research Statement:Study protocol and statistical code: Not available. Data set: Available from Dr. Guiducci (e-mail, s.guiducci@hotmail.com) after establishing a written agreement with the authors.

Requests for Single Reprints: Serena Guiducci, MD, Department of Biomedicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi, Denothe Center, University of Florence, viale Pieraccini 18, 50139 Florence, Italy; e-mail, s.guiducci@hotmail.com.

Current Author Addresses: Drs. Guiducci, Porta, Milia, Bellando-Randone, Miniati, Fiori, Fontana, Amanzi, Braschi, and Matucci-Cerinic: Department of Biomedicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi, Denothe Center, University of Florence, viale Pieraccini 18, 50139 Florence, Italy.

Drs. Saccardi, Guidi, and Bosi; Ms. Mazzanti; and Ms. Dal Pozzo: Bone Marrow Transplantation Unit, Azienda Ospedaliero-Universitaria Careggi, viale Morgagni 85, 50134 Florence, Italy.

Drs. Ibba-Manneschi and Manetti: Department of Anatomy, Histology, and Forensic Medicine, University of Florence, viale Morgagni 85, 50134 Florence, Italy.

Author Contributions: Conception and design: S. Guiducci, R. Saccardi, I. Miniati, R. Fontana, A. Bosi, M. Matucci-Cerinic.

Analysis and interpretation of the data: S. Guiducci, F. Porta, R. Saccardi, L. Ibba-Manneschi, M. Manetti, A.F. Milia, M. Matucci-Cerinic.

Drafting of the article: S. Guiducci, F. Porta, L. Ibba-Manneschi, M. Manetti, A.F. Milia.

Critical revision of the article for important intellectual content: S. Guiducci, R. Saccardi, L. Ibba-Manneschi, M. Manetti, M. Matucci-Cerinic.

Final approval of the article: S. Guiducci, F. Porta, R. Saccardi, L. Ibba-Manneschi, M. Manetti, B. Mazzanti, S. Dal Pozzo, A.F. Milia, S. Bellando-Randone, G. Fiori, R. Fontana, L. Amanzi, F. Braschi, A. Bosi, M. Matucci-Cerinic.

Provision of study materials or patients: S. Guidi, B. Mazzanti, S. Bellando-Randone, I. Miniati, F. Braschi.

Obtaining of funding: S. Guiducci, M. Matucci-Cerinic.

Administrative, technical, or logistic support: S. Dal Pozzo, G. Fiori, L. Amanzi, F. Braschi.

Collection and assembly of data: F. Porta, L. Ibba-Manneschi, M. Manetti, B. Mazzanti, S. Dal Pozzo, A.F. Milia, S. Bellando-Randone, L. Amanzi, F. Braschi.


Ann Intern Med. 2010;153(10):650-654. doi:10.7326/0003-4819-153-10-201011160-00007
Text Size: A A A

Background: Mesenchymal stem cells can differentiate into endothelial cells and participate in angiogenesis in adults. In experimental models of acute myocardial infarction, mesenchymal stem cells led to the recovery of cardiac function through the formation of a new vascular network.

Objective: To describe treatment with intravenous infusions of expanded autologous mesenchymal stem cells in 1 patient with critical limb ischemia due to systemic sclerosis.

Design: Case report.

Setting: The rheumatology unit at the University of Florence, Florence, Italy.

Patient: A woman, aged 34 years, with systemic sclerosis who developed acute gangrene of the upper and lower limbs.

Intervention: 3 intravenous pulses of expanded autologous mesenchymal stem cells.

Measurements: Angiography, skin histopathology, and immunohistochemistry.

Results: Areas of necrotic skin were reduced after the first mesenchymal stem-cell infusion. After the third infusion, angiography showed revascularization of the patient's extremities. Skin section analysis revealed cell clusters with tubelike structures, and angiogenic factors were strongly expressed.

Limitation: Causality cannot be established by a single case.

Conclusion: In patients with systemic sclerosis who have severe peripheral ischemia, intravenous infusion of expanded autologous mesenchymal stem cells may foster the recovery of the vascular network, restore blood flow, and reduce skin necrosis.

Primary Funding Source: Fondazione Cassa di Risparmio di Pistoia e Pescia (partial funding).

Figures

Grahic Jump Location
Figure 1.
Patient's lower limbs at admission (A) and after receiving 3 cycles of expanded autologous bone marrow–derived mesenchymal stem cells by intravenous infusion (B).
Grahic Jump Location
Grahic Jump Location
Figure 2.
Angiography of patient at admission (A) and after receiving 3 cycles of expanded autologous bone marrow–derived mesenchymal stem cells by intravenous infusion (B).

Arrows highlight principal areas of change, with clear blood flow in the arteries of the upper and lower limbs.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 1.
Schematic representation of the time course of treatments and main outcomes at follow-up.

Despite drug administration, skin necrosis rapidly increased before MSC infusion was started. The timing of MSC infusions, angiography, and skin biopsy are shown, as well as the pharmacologic treatments that the patient continued to receive during the MSC infusions and follow-up. MSC = mesenchymal stem cell.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 2.
Angiopoietin-1 and -2 and vascular endothelial growth factor immunostaining of skin biopsies of the leg.

The immunoreaction was performed by an indirect immunoperoxidase method, with 3,3′-diaminobenzidine tetrahydrochloride substrate used as chromogen (brown staining). The skin sections shown in panels A to C were counterstained with hematoxylin (blue staining). A. Clusters of cells arranged in a tubelike structure (arrows) show angiopoietin-1 expression at the dermoepidermal junction. Perivascular cells show angiopoietin-1 immunopositivity in the subpapillary plexus (stain; original magnification, ×20). B. Higher magnification view of panel A (stain; original magnification, ×40). C. In the papillary dermis, endothelial cells of newly formed vessels (arrows) express angiopoietin-2 (stain; original magnification, ×20). D. Endothelial cells of microvessels (arrow) display strong positivity for vascular endothelial growth factor in the papillary dermis (stain; original magnification, ×25). Inset. Higher magnification view that shows vascular endothelial growth factor–positive microvascular endothelial cells (stain; original magnification, ×60).

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Mesenchymal Stem Cells in Systemic Sclerosis
Posted on November 21, 2010
Jeong H Yun
Albert Einstein Medical Center
Conflict of Interest: None Declared

This case report presents the therapeutic potential of autologous mesenchymal stem cell (MSC) for systemic sclerosis. The authors suggest that factors expressed from MSCs as well as differentiation of MSCs to endothelial and vascular smooth-muscle cells account for the observed revascularization (1). Another potential function of MSCs that may have contributed to the positive outcome is the immunosuppressive effect of MSCs. It is well documented that MSCs suppress inflammation through both soluble factors and direct physical contact affecting innate as well as adaptive immune system(2). It is reported that this feature is retained in systemic sclerosis patients (3). Less is known whether MSCs have intact function in terms of endothelial differentiation and promoting angiogenesis in systemic sclerosis. Given reports showing defects of endothelial progenitors in systemic sclerosis patients (4), it would be interesting to test the immunomodulatory function as well as endothelial differentiating capacity of the MSCs derived from the patient to obtain further insight of the mechanism of MSC treatment.

References

1. Guiducci S, Porta F, Saccardi R, Guidi S, Ibba-Manneschi L, Manetti M et al. Autologous mesenchymal stem cells foster revascularization of ischemic limbs in systemic sclerosis. Ann Intern Med. 2010; 153:650-654.

2. Kode JA, Mukherjee S, Joglekar MV, Hardikar AA. Mesenchymal stem cells: immunobiology and role in immunomodulation and tissue regeneration. Cytotherapy 2009; 11: 377-391.

3. Bocelli-Tyndall C, Bracci L, Spagnoli G, Braccini A, Bouchenaki M, Ceredig R et al. Bone marrow mesenchymal stromal cells (BM-MSCs) from healthy donors and auto-immune disease patients reduce the proliferation of autologous- and allogeneic-stimulated lymphocytes in vitro. Rheumatology (Oxford) 2007; 46:403-408.

4. Del Papa N, Quirici N, Soligo D, Scavullo C, Cortiana M, Borsotti C et al. Bone marrow endothelial progenitors are defective in systemic sclerosis. Arthritis Rheum 2006; 54: 2605-2615.

Conflict of Interest:

None declared

Re:Mesenchymal Stem Cells in Systemic Sclerosis
Posted on February 22, 2011
Serena Guiducci
Department of Biomedicine, Division of Rheumatology, Azienda Ospedaliero-Universitaria Careggi, Den
Conflict of Interest: None Declared

We agree with Dr. Yun's observation that an immunosuppressive effect of expanded autologous mesenchymal stem cells (MSCs) may have contributed to the positive outcome in our patient with systemic sclerosis (SSc). Previous data suggest that subpopulations within MSCs may have an immunomodulating role in the host, without provoking immunologic responses from alloreactive T cells or other effector cells (1). Moreover, MSCs may also have a "regenerative" role thus contributing to the repair of damaged vessels. Recent studies have shown that bone marrow-derived MSCs from patients with SSc exhibit the same phenotypic, proliferative, and differentiative potential and immunosuppressive properties as healthy MSCs, thus making them attractive in a therapeutic autologous setting (2). Experimental data have also provided evidence that MSCs can produce a variety of cytokines and chemokines involved in the regulation of cell migratory properties, differentiation, and proliferation (3). MSCs may also play a crucial role in the modulation of angiogenesis (3). The proangiogenic effect of MSCs was demonstrated in a murine model of hindlimb ischemia (3). In addition, cultured MSCs produce and release high amounts of proangiogenic and antiapoptotic factors which inhibit apoptosis of endothelial cells cultured under hypoxic conditions and promote the formation of capillary-like structures in vitro (3). Recently, bone marrow -derived MSCs have been shown to support the formation of vessel-like structures by endothelial cells in vitro in a medium devoid of vascular endothelial growth factor and basic fibroblast growth factor (3). In this system, MSCs provided, in addition to soluble proangiogenic factors, extracellular matrix components that serve as a substrate for sprouting endothelial cells (3). Furthermore, the potential transition of MSCs to pericytes on newly formed vessels may serve to stabilize the neo-forming vasculature (3). As Dr. Yun correctly pointed out, previous studies showed that MSCs from SSc patients failed to differentiate into endothelial cells in vitro (4). Therefore, autologous SSc MSCs might not be able to incorporate into damaged or newly formed vessels, but rather could participate to vascular repair through paracrine effects by releasing a wide array of proangiogenic factors. Recent experimental data from our group demonstrate that MSCs from SSc patients, including the one described in our case report, highly produce and release proangiogenic factors, such as vascular endothelial growth factor and stromal cell-derived factor 1, and potentiate dermal endothelial cell angiogenesis in vitro (Guiducci S. et al., unpublished data). The possible involvement of MSCs in wound repair and their possible topical delivery still remain an unexplored area and a future challenge in SSc (5). In the perspective of the therapeutic use of autologous MSCs for the treatment of SSc, further functional studies will be necessary to investigate the participation of MSCs in different mechanisms of the disease, such as the angiogenic, fibrotic, and immune processes.

REFERENCES

1) Kassis I, Vaknin-Dembinsky A, Karussis D. Bone marrow mesenchymal stem cells: agents of immunomodulation and neuroprotection. Curr Stem Cell Res Ther 2011;6:63-8.

2) Larghero J, Farge D, Braccini A, Lecourt S, Scherberich A, Fois E, et al. Phenotypical and functional characteristics of in vitro expanded bone marrow mesenchymal stem cells from patients with systemic sclerosis. Ann Rheum Dis 2008;67:443-449.

3) da Silva Meirelles L, Fontes AM, Covas DT, Caplan AI. Mechanisms involved in the therapeutic properties of mesenchymal stem cells. Cytokine Growth Factor Rev 2009;20:419-427.

4) Del Papa N, Quirici N, Soligo D, Scavullo C, Cortiana M, Borsotti C et al. Bone marrow endothelial progenitors are defective in systemic sclerosis. Arthritis Rheum 2006; 54: 2605-2615.

5) Sorrell JM, Caplan AI. Topical delivery of mesenchymal stem cells and their function in wounds. Stem Cell Res Ther 2010;1:30.

Conflict of Interest:

None declared

Letter to Editor
Posted on August 10, 2011
George M Weisz
Univ of NSW, sydney
Conflict of Interest: None Declared

The re-birth of human angiogenesis was documented in the November 2010 issue of your Journal. With delay, but with more enthusiasm, I react to this pioneering development. (1). Mesenchymal cells have been used for the genesis of various tissues such as those used in experimental bone healing (2); myocardial revascularisation (3); revascularisation of cerebral ischemia. (4) to name a few. The stem cells, obtained from various sources (umbilical, embryonic, bone marrow or adult kidney) were used in animals such as swine and rats. Harvested from human bone marrow, mesenchymal cells were used in anti- lymphoma experiment in mice, in 2010, reported from Padova (appropriately from the birth place of Modern Medicine). A detailed list of completed and 'in process' clinical studies mainly on atherosclerotic ischemic limbs, does not mention trials on other vascular diseases.(5). Stem cell therapy was applied in Systemic Sclerosis, with angiographic proof of the rebirth of vascularisation, (appropriately reported from Florence, the birth place of Renaissance). The article "Autologous Mesenchymal Stem Cells Foster Revascularisation of Ischemic Limbs in Systemic Sclerosis" presented an optimistic message, offered by a large group of researchers, with the senior author M. Matucci -Cerinic (1). The promising Matucci technique, seemingly the first "in vivo" succes, ought to be applied to other micro-vascular diseases such as diabetes, Burger's . Equally in the growing number of neuro-vascular- lathyrism cases ,a devastating ischemic limbs' condition, resulting from the innocent ingestion of grass-pea backed bread in Third World countries (Ethiopia, Bangladesh, Nepal, etc), where this intoxinating plant, lathyrus, is growing wildly and is free.

George M. Weisz MD, FRACS(ortho),

References

1. Guiducci et al: Autologous Mesenchymal Stem Cells Foster Revascularisation of Ischemic Limbs in Systemic Sclerosis" ; Annals of Int. Med. 2010; 153(10): 650-552.

2. Kasper G et al: "Mesenchymal Stem Cells Regulate Angiogenesis According to their Mechanical Environment" . Stem Cells:2007;25(4):903-10.

3. Poncelet AJ. Et al: "Intracardiac allogeneic mesenchymal stem cell transplantation elicits neo-angiogenesis". Eur. J. Cardiothorac. Surg. 2010; 38:781-7.

4. Bao X. et al: "Transplantation of Flk-1+ human bone marrow-derived mesenchymal stem cells promotes angiogenesis and neurogenesis after cerebral ischemia in rats" Eur. J. Neurosciences. 2011; 34(1):87-98. 5. Lasala G.P, Minguell J.J.: "Vascular disease and stem cell therapies". Br. Med. Bull, 2011; 98(1):187-197.

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)