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Accepted Manuscript

Title: Cord Blood Transplantation and Stem Cell Regenerative Potential

Authors: Yanling Liao, Mark B. Geyer, Albert J. Yang, Mitchell S. Cairo

PII:

S0301-472X(11)00009-9

Reference:

EXPHEM 2716

To appear in:

Experimental Hematology

Received Date: 28 September 2010

Revised Date:

Accepted Date: 8 January 2011

6 January 2011

Revised Date: Accepted Date: 8 January 2011 6 January 2011 Please cite this article as: Liao

Please cite this article as: Liao Y, Geyer MB, Yang AJ, Cairo MS. Cord Blood Transplantation and Stem Cell Regenerative Potential, Experimental Hematology (2011), doi: 10.1016/j.exphem.2011.01.002

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Cord Blood Transplantation and Stem Cell Regenerative Potential Yanling Liao 1 , Mark B. Geyer

Cord Blood Transplantation and Stem Cell Regenerative Potential

Yanling Liao 1 , Mark B. Geyer 1 , Albert J. Yang 1 , and Mitchell S. Cairo 1, 2, 3 Department of 1 Pediatrics, 2 Medicine and 3 Pathology and Cell Biology, New York-

Medicine and 3 Pathology and Cell Biology, New York- Presbyterian Morgan Stanley Children’s Hospital, Columbia

Presbyterian Morgan Stanley Children’s Hospital, Columbia University, New York,

New York

Correspondence and reprint requests:

Mitchell S. Cairo, MD

Chief, Division of Pediatric Blood and Marrow Transplantation

Professor of Pediatrics, Medicine, Pathology and Cell Biology

of Pediatrics, Medicine, Pathology and Cell Biology New York-Presbyterian Morgan Stanley Children’s Hospital

New York-Presbyterian Morgan Stanley Children’s Hospital

Columbia University

3959 Broadway, CHN 10-03

New York, NY 10032

email: mc1310@columbia.edu

Tel: 212-305-8316

Fax: 212-305-8428

Category: Stem Cell Transplantation

Word count: 9,265

Abstract The past twenty years of experience with umbilical cord blood transplantation have demonstrated that

Abstract

The past twenty years of experience with umbilical cord blood transplantation have

demonstrated that cord blood is effective in the treatment a spectrum of diseases

including hematological malignancies, bone marrow failure, hemoglobinopathies and

malignancies, bone marrow failure, hemoglobinopathies and inborn errors of metabolism. Cord blood can be obtained with

inborn errors of metabolism. Cord blood can be obtained with ease and then safely

cryopreserved for either public or private use, without loss of viability. As compared

to other unrelated donor cell sources, cord blood transplantation allows for greater

HLA disparity without a corresponding increase in graft-versus-host disease (GVHD).

Moreover, cord blood has a lower risk of transmitting infections by latent viruses and

is less likely to carry somatic mutations than other adult cells. Recently, multiple

populations of stem cells with primitive stem cell properties have been identified from

primitive stem cell properties have been identified from cord blood. Meanwhile, there is an increasing interest

cord blood. Meanwhile, there is an increasing interest in applying cord blood

mononuclear cells or enriched stem cell populations to regenerative therapies.

Accumulating evidence has suggested functional improvements following cord blood

transplantation in various animal models for treatments of cardiac infarction, diabetes,

neurological diseases etc. In this review, we will summarize the most recent updates

on clinical applications of cord blood transplantation, and the promises and

limitations of cell-based therapies for tissue repair and regeneration.

Keywords: Cord blood, regeneration, stem cells, transplantation, cord blood banking

Cord Blood Transplantation Allogeneic stem cell transplantation (AlloSCT) has been employed for more than 40

Cord Blood Transplantation

Allogeneic stem cell transplantation (AlloSCT) has been employed for more than 40

years and offers the best potential for curing numerous malignant and non-malignant

diseases in children and adults. While human leukocyte antigen (HLA)-matched

and adults. While human leukocyte antigen (HLA)-matched sibling bone marrow transplantation (BMT) was previously the

sibling bone marrow transplantation (BMT) was previously the predominant modality

of transplantation, only some 25% of patients in need of AlloSCT have a fully

matched sibling donor available. Related and unrelated umbilical cord blood (UCB)

has emerged as an alternative source of hematopoietic stem cells (HSCs) to the

majority of patients that are unable to identify a fully matched donor. The first

umbilical cord blood transplant (UCBT) was performed in 1988 in a 5 year-old boy

with Fanconi anemia, who underwent UCBT from his HLA-identical newborn sister

who underwent UCBT from his HLA-identical newborn sister [1]. Since that time, more than 10,000 total

[1]. Since that time, more than 10,000 total UCBTs have been performed, with more

than 300,000 UCB units (UCBU) available in more than 40 UCB banks [2].

The Center for International Blood and Marrow Transplant Research

(CIBMTR) notes that an increasing percentage of CIBMTR-registered allogeneic

transplants utilize UCB grafts. The number of CIBMTR-registered UCBTs has

increased considerably since the 1990s, and in 2008, 898 UCBTs were facilitated by

the National Marrow Donor Program (NMDP)[3-4]. In both pediatric and adult

patients, the use of bone marrow in unrelated donor transplants has decreased.

However, while some 40% of unrelated donor transplants in patients 20 years of age

now employ UCB, the use of UCB has increased more modestly in patients >20 years

of age to only 7% of unrelated donor transplants [4]. Median search times for

unrelated bone marrow or peripheral blood stem cell (PBSC) donors through the

NMDP are 51 days, compared with less than two weeks for unrelated UCBCs [5].

Early Experience with Related and Unrelated UCBT Early experiences with UCBT were reported by several

Early Experience with Related and Unrelated UCBT

Early experiences with UCBT were reported by several groups in the mid-

1990s. Wagner et al. reported early success in 44 children undergoing sibling UCBT

for leukemias, marrow failure syndromes, congenital immunodeficiencies, and inborn

failure syndromes, congenital immunodeficiencies, and inborn errors of metabolism, with 46% and 78% event-free survival

errors of metabolism, with 46% and 78% event-free survival (EFS) observed for those

receiving 5/6 or 6/6 HLA-matched grafts, respectively [6]. Kurtzberg, as well as

Wagner and Cairo, subsequently reported on the use of unrelated UCBT in children

and adolescents for malignant and non-malignant diseases, noting delayed

engraftment compared to bone marrow transplantation, low risk of severe graft-

versus-host disease (GVHD), delayed engraftment, and encouraging early survival [7-

9]. In the late 1990s, the New York Blood Center (NYBC) and the

In the late 1990s, the New York Blood Center (NYBC) and the Eurocord/European Blood and Marrow

Eurocord/European Blood and Marrow Transplant (EBMT) group reported more

extensive experiences with UCBT. The Eurocord/EBMT group, which analyzed

outcomes following 143 related- and unrelated-donor UCBTs, demonstrated higher 1-

year overall survival (OS) in patients with malignant and non-malignant diseases

undergoing related vs. unrelated donor UCBT (63 vs. 29%) [10]. A later review of

562 unrelated donor UCBTs revealed survival rates similar to those observed

following unrelated donor BMT, with 1-year relapse risk of 30%, 18%, and 24% in

children with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and

acute lymphoblastic leukemia (ALL), respectively. Day 100 transplant-related events

(graft failure, re-transplant, death) occurred in 46% [11].

UCBT in Pediatric Patients with Malignant Diseases

Hematological malignancies are the most common indication for AlloSCT in

children. Unrelated UCBT has been used successfully in the treatment of ALL, AML, CML, myelodysplastic

children. Unrelated UCBT has been used successfully in the treatment of ALL, AML,

CML, myelodysplastic syndrome, neuroblastoma, Hodgkin lymphoma (HL), non-

Hodgkin lymphoma (NHL), and other malignant diseases. The Eurocord/EBMT

group reported 2-year OS and leukemia-free survival (LFS) of 49% and 42%,

2-year OS and leukemia-free survival (LFS) of 49% and 42%, respectively, in 95 children receiving unrelated

respectively, in 95 children receiving unrelated UCBT for AML. Two-year LFS was

significantly better among those transplanted in first or second complete remission

(CR) (59% and 51%, respectively) than those in relapse (21%) [12]. However, Wall et

al. reported 2-year LFS of only 28% among 32 infants and young children, with no

significant differences in outcomes observed between those transplanted in CR1 or

CR2 [13]. The Cord Blood Transplantation (COBLT) study, a prospective,

multicenter study using public UCB banks, enrolled 191 pediatric patients with

using public UCB banks, enrolled 191 pediatric patients with hematological malignancies, including 109 patients with ALL

hematological malignancies, including 109 patients with ALL and 51 with AML.

Cumulative incidence of relapse at 2 years was 19.9% and 2-year OS was 49.5%.

Fully HLA-matched UCBT was associated with superior outcomes, though long-term

survival was observed among some patients receiving only 2/6 or 3/6-matched UCBT

[14].

Randomized studies of unrelated UCB vs. bone marrow or PBSCs are lacking.

However, several retrospective studies have suggested that outcomes of unrelated

donor transplantation are similar, regardless of cell source (Table 1). Eapen et al.

reported outcomes in 267 patients diagnosed with ALL or AML before 18 months of

age who subsequently underwent matched-sibling marrow transplant (n=101),

unrelated marrow transplant (n=85), or UCBT (n=81). Transplant-related mortality

(TRM) was significantly higher among UCBT recipients (31%) compared to related

marrow (15%) or matched-sibling marrow (6%) recipients, due in part to the higher

risk of death from infections in the UCB group. However, no differences in OS were

risk of death from infections in the UCB group. However, no differences in OS were

evident between these groups [15]. A larger retrospective study of 785 children ages

0-16 years with acute leukemia compared outcomes in 503 unrelated UCBT recipients

to 282 unrelated marrow recipients. Five-year LFS was similar among patients

marrow recipients. Five-year LFS was similar among patients receiving fully matched unrelated marrow transplant compared

receiving fully matched unrelated marrow transplant compared to those receiving one

or two antigen-mismatched UCBT, and possibly higher in patients receiving fully

matched UCBT (Figure 1). However, two-antigen UCBT recipients had significantly

higher risk of TRM when compared to recipients of fully matched bone marrow [16].

These data support the efficacy of UCB grafts in the treatment of ALL and AML and

suggest that mismatched UCB grafts lead to acceptable outcomes in patients with

acute leukemia. The benefits derived from greater graft-versus-leukemia effect in

derived from greater graft-versus-leukemia effect in mismatched UCB transplant may balance the greater risks of

mismatched UCB transplant may balance the greater risks of TRM in mismatched

UCBT recipients.

UCBT in Adults with Malignant Diseases

While early studies of UCBT focused predominantly on pediatric patients, UCBT has

begun to establish itself as a feasible treatment strategy in adults with hematologic

malignancies. Simultaneously published reports from the NYBC and the

Eurocord/EBMT group described the feasibility of single UCBT in adults with

leukemia or myelodysplastic syndrome (Table 1). Rocha et al. compared 98 adults

receiving UCBT to 568 adults receiving matched unrelated BMT. UCBT recipients

were slower to engraft, had lower risk of grade II-IV acute GVHD, and had similar

risk of relapse to unrelated marrow recipients. While a trend toward superior 2-year

OS (42% vs. 36%) and LFS (38% vs. 33%) for UBMT vs. UCBT was observed in the

univariate analysis, no difference was appreciated in the multivariate analysis [17]. Laughlin et al. compared

univariate analysis, no difference was appreciated in the multivariate analysis [17].

Laughlin et al. compared one- and two-antigen mismatched UCBT recipients (n=150)

to those receiving matched (n=367) or one-antigen mismatched (n=83) unrelated bone

marrow. Patients receiving mismatched UCBT or unrelated BMT had slower

receiving mismatched UCBT or unrelated BMT had slower engraftment and higher risk of TRM, treatment failure,

engraftment and higher risk of TRM, treatment failure, and overall mortality

compared to recipients of fully matched unrelated marrow; groups did not differ with

respect to relapse [18]. However, median cell dose among UCBT recipients was only

2.2 x 10 7 /kg in this report. The authors concluded that UCBT is an acceptable

alternative to mismatched unrelated BMT in adults with hematological malignancies,

with the advantage of faster availability of UCBUs. A very recent CIBMTR analysis

of 1525 adults with acute leukemia also demonstrated increased risk of TRM (37%)

acute leukemia also demonstrated increased risk of TRM (37%) following matched or mismatched UCBT compared to

following matched or mismatched UCBT compared to fully matched unrelated BMT

(22%) or PBSCT (24%), but similar to one antigen-mismatched unrelated BMT

(34%) and PBSCT (38%) (Figure 2); no differences in risk of relapse or LFS were

evident[19]. Another large study from Japan compared outcomes in 100 adult

unrelated UCBT recipients (one- to four-antigen mismatched) to 71 matched or

mismatched related marrow or PBSC transplantation recipients with hematologic

malignancies after MAC. TRM, relapse, and disease-free survival (DFS) did not

differ with respect to graft source [20]. Recently, the University of Minnesota has

reported excellent 3-year OS (61%) among 19 adults treated with UCBT for ALL [21]

A report from the Japan Marrow Donor Program (JMDP) reported similar 2-year OS

among 336 adults with ALL undergoing UCBT (52%) vs. matched related marrow

(53%), further corroborating the use of UCBT as a frontline alternative to unrelated

marrow in these patients [22]. Ooi et al. noted 2-year and 5-year EFS of 73.5% and

62.8% in 77 adult UCBT recipients with AML [23]. Though the JMDP noted superior 2-year

62.8% in 77 adult UCBT recipients with AML [23]. Though the JMDP noted superior

2-year LFS in matched unrelated BMT recipients (54%) compared to UCBT

recipients (36%) in 484 adults with AML, a significantly larger proportion of UCBT

recipients had advanced leukemia [22]. Rodrigues et al. recently reported 1-year and

leukemia [22]. Rodrigues et al. recently reported 1-year and 2-year EFS of 40% and 36%, respectively,

2-year EFS of 40% and 36%, respectively, in 104 adult patients with HL, NHL, or

chronic lymphocytic leukemia who underwent single or double UCBT. Superior 1-

year progression free survival (PFS) was observed in those with chemosensitive

disease, those who received a higher TNC dose/kg, and recipients of conditioning

regimens containing low-dose TBI [24]. Small prior studies of single-unit RTC

UCBT in adults with advanced HL or NHL had demonstrated 1-year PFS of 25-50%

[25-26]. While the place of UCB in selecting a graft source for adults with

the place of UCB in selecting a graft source for adults with hematological malignancies is unknown,

hematological malignancies is unknown, UCBT (up to two-antigen mismatched)

appears to be acceptable when a fully matched unrelated adult donor is unavailable

and in some cases may be considered a feasible alternative to unrelated BMT.

UCBT in Patients with Non-Malignant Diseases

UCBT has been used successfully in the treatment of bone marrow failure syndromes,

hemoglobinopathies and inborn errors of metabolism. Children with Fanconi anemia,

Blackfan Diamond anemia, severe aplastic anemia, severe combined

immunodeficiency, Wiskott-Aldrich syndrome, osteopetrosis, Hurler syndrome,

adrenoleukodystrophy, and thalassemia were among the initial cohorts reported by the

NYBC and Eurocord/EBMT groups [10-11]. In a retrospective review from

Eurocord/EBMT of 93 children and adults with Fanconi anemia treated with UCBT, a

high incidence of primary graft failure (40%) was observed, with 40% of patients

alive at 3 years post-UCBT; younger age, higher cell dose and fludarabine-based conditioning were associated

alive at 3 years post-UCBT; younger age, higher cell dose and fludarabine-based

conditioning were associated with superior outcomes. The success of fludarabine in

these patients may reflect the critical importance of adequate immunosuppression in

patients heavily transfused before transplant, such as those with Fanconi anemia [27].

before transplant, such as those with Fanconi anemia [27]. A handful of reports have discussed UCBT

A handful of reports have discussed UCBT from matched sibling donors in the

treatment of sickle cell disease, following either myeloablative conditioning (MAC)

or reduced toxicity conditioning (RTC) [10, 28-31]. MAC followed by UCBT from a

related donor appears to be associated with a low incidence of graft failure, high

levels of donor chimerism, and excellent OS [29]. Unrelated UCBT in children with

sickle cell disease remains a challenge due to non-engraftment and TRM [32].

Recently, investigators from Duke University Medical Center have reported

from Duke University Medical Center have reported their experience with UCBT in the treatment of inherited

their experience with UCBT in the treatment of inherited metabolic disorders,

particularly the lysosomal and peroxisomal storage disorders [33-34]. In such

patients, the goal of UCBT is replacement of the missing enzyme. One-year, 3-year,

and 5-year survival probabilities of 79.0%, 62.7%, and 58.2%, respectively, were

observed in a group of 159 pediatric patients with inherited metabolic disorders

treated using UCBT. Among patients with diseases for which leukocyte or plasma

enzyme level measurements exist, 97% achieved normal levels. Patients undergoing

transplantation as newborns and those with less progressive juvenile forms of disease

experienced superior functional outcomes to those transplanted with early infantile

forms of disease and progressive symptoms. Specifically, among 45 children

transplanted for severe Hurler syndrome, all experienced disease stabilization and

most demonstrated cognitive improvement. The median age of patients at transplant

was 1.5 years, with 57% of patients under 2 years of age. Poorer survival outcomes

were observed among those patients with worse baseline performance status and recipients of UCB grafts

were observed among those patients with worse baseline performance status and

recipients of UCB grafts with fewer colony forming units.

Advantages and Disadvantages (Table 2)

forming units. Advantages and Disadvantages (Table 2) Since the early days of UCBT, investigators have noted

Since the early days of UCBT, investigators have noted a higher risk of graft failure

in UCBT recipients than in those receiving marrow or PBSCs. An early report from

Wagner et al. noted an 18% risk of primary graft failure among 44 pediatric UCBT

recipients [6]. The increased incidence of graft failure in UCBT recipients compared

to marrow and PBSC recipients continued to be observed in larger studies, with the

NYBC and EBMT groups reporting 18-19% of patients failed to engraft neutrophils

[10-11]. Studies continue to note rates of neutrophil engraftment ranging from 60-

to note rates of neutrophil engraftment ranging from 60- 87% following unrelated UCBT [12, 14, 16,

87% following unrelated UCBT [12, 14, 16, 19, 24, 27, 33, 35]. Eapen et al. noted

that 85% of recipients of fully matched unrelated UCB engrafted neutrophils by 42

days post-transplant, compared to 76% of recipients of two-antigen mismatched UCB

[16]. Moreover, time to hematopoietic recovery is delayed following UCBT, with

median times to neutrophil and platelet recovery of 25 and 59 days, respectively,

compared to 19 and 27 days, respectively, following unrelated marrow transplant

[16]. Prasad et al. and Kurtzberg et al. reported neutrophil and platelet engraftment at

a median of 27 and 174 days following UCBT in a large series of pediatric patients

with hematological malignancies, and at 22 and 87 days, respectively, in a large series

of pediatric recipients with non-malignant diseases [14, 33]. Delayed engraftment

leaves the UCBT recipient in an extended state of profound immunocompromise,

particularly following myeloablative conditioning. Indeed, Rocha et al. found that

death from opportunistic infection and hemorrhage were more common following

matched sibling UCBT than matched sibling BMT, 33% and 21%, respectively (p=0.05)[36]. Possible explanations for

matched sibling UCBT than matched sibling BMT, 33% and 21%, respectively

(p=0.05)[36]. Possible explanations for the delay in hematopoietic recovery following

UCBT compared to BMT include decreased number of total[14] and CD34 + cells in

the graft[37], more immature CD34 + progenitors (thus requiring more cell division for

+ progenitors (thus requiring more cell division for differentiation and engraftment), and lack of a

differentiation and engraftment), and lack of a subpopulation specializing in

engraftment and homing effects[38]. A COLBT study led by Cairo et al. suggested

that lower numbers of CD34 + /CD41 + cells in UCB compared to peripheral blood may

be responsible for the delay in platelet recovery following UCBT[39]. Consistent with

increased rates of graft failure and severe post-transplant infection and prolonged

inpatient stays, Majhail et al. further demonstrated that the cost of hospitalization

following UCBT is greater than the cost following matched related BMT, with the

than the cost following matched related BMT, with the median cost per day estimated to be

median cost per day estimated to be $2,082 vs. $1,016, respectively [40].

In the COBLT study, total nucleated cell (TNC) dose of greater than 5.1 x

10 7 /kg was associated with significantly faster engraftment of neutrophils and

platelets. TNC dose of less than 2.5 x 10 7 /kg was associated with significantly

reduced OS as well [14]. Wagner et al. originally noted CD34 + dose less than 1.7 x

10 5 /kg was associated with inferior outcomes in engraftment, TRM, and OS in 102

pediatric and adult UCBT recipients [41]. Stycynski et al. also reported greater CD34 +

dose was independently predictive of greater OS among 29 UCBT pediatric recipients

(median CD34 + dose 2.3 x 10 5 /kg) treated at Columbia University Medical Center

[42]. As evidence suggests greater HLA disparity can be overcome, in part, by greater

cell dose, different minimum cell doses have been proposed for differing levels of

HLA disparity: 2.5-3.0 x 10 7 /kg for fully matched UCBT, 4.0 x 10 7 /kg for 5/6 HLA

match, and 5.0 x 10 7 /kg for 4/6 HLA match [43-44].

A recent review from the NYBC addressed the effects of cell dose and HLA disparity

A recent review from the NYBC addressed the effects of cell dose and HLA

disparity in 1061 recipients (mostly pediatric patients) of MAC followed by single-

unit UCBT.[45] TNC dose was associated with higher probability and rate of

neutrophil and platelet engraftment in a dose-response manner. Recipients of fully

engraftment in a dose-response manner. Recipients of fully matched UCBT had significantly greater neutrophil and

matched UCBT had significantly greater neutrophil and platelet engraftment than

mismatched UCBT recipients. However, two-antigen mismatched UCBT recipients

showed similar rates of engraftment to one-antigen-mismatched UCBT recipients

[45]. Large studies have previously demonstrated a relationship between greater HLA

disparity and higher TRM in patients undergoing UCBT [11]. In the NYBC study,

TNC dose and HLA match were independently predictive of TRM and OS (Figure 3).

Increasing HLA disparity was associated with higher risk of severe (grade III-IV)

was associated with higher risk of severe (grade III-IV) acute GVHD. There was no association between

acute GVHD. There was no association between HLA disparity and relapse. The

lowest risk of TRM was observed in patients receiving a fully matched UCBT,

regardless of cell dose. Similar survival outcomes were observed among recipients of

two-antigen mismatched UCBUs with TNC 5.0 x 10 7 /kg and recipients of one-

antigen mismatched UCBUs with TNC 2.5 to 4.9 x 10 7 /kg [45]. Future studies will be

needed to determine whether prioritizing HLA match in selecting UCB grafts, while

maximizing cell dose by transplanting two units, will allow for faster engraftment

while preserving the benefits associated with lower HLA disparity.

Unrelated marrow and PBSC transplantation is limited by a high risk of acute

and chronic GVHD; this risk is further exacerbated with increasing HLA disparity

[46]. UCBT allows for greater HLA disparity than other unrelated donor cell sources

without a corresponding increase in GVHD. Eapen et al. noted a significantly reduced

incidence of grade II-IV acute GVHD following matched unrelated UCBT (24%)

compared to matched unrelated BMT (46%) or one- or two-antigen mismatched unrelated BMT (60%); the

compared to matched unrelated BMT (46%) or one- or two-antigen mismatched

unrelated BMT (60%); the incidence of grade II-IV acute GVHD was 42% following

one-antigen mismatched UCBT with high cell dose and 41% following two-antigen

mismatched UCBT [16]. Similar risks were reported in other recent studies, with an

Similar risks were reported in other recent studies, with an overall incidence of grade II-IV acute

overall incidence of grade II-IV acute GVHD of 25-45% in cohorts of patients with

mainly one-antigen or two-antigen mismatched UCB grafts [12, 14, 17-18, 24, 33-34,

42, 47].

In utero trafficking of HLA molecules between mother and fetus may lead to

tolerance to non-inherited maternal HLA antigens; this has potential implications for

mismatched UCBT when a donor’s noninherited maternal antigen (NIMA) matches

with the recipient’s HLA-disparate antigen. Van Rood et al. reported on the impact of

antigen. Van Rood et al. reported on the impact of NIMA on transplant outcomes in pediatric

NIMA on transplant outcomes in pediatric patients undergoing UCBT for

hematological malignancies. Retrospectively, they identified 79 patients receiving

mismatched unrelated UCBT that had a NIMA identical to the mismatched antigen of

the recipient, and 980 recipients of no NIMA-matched UCBT. The probability of

TRM was significantly lower in NIMA-matched UCBT recipients of all ages, though

the difference was most striking in those patients 10 years of age, who also had a

lower risk of overall mortality and treatment failure than no NIMA-matched UCBT

recipients. A trend toward lower rates of relapse in patients with AML/CML was

appreciated in the NIMA-matched group as well. The authors speculate that

upregulation of anti-NIMA immunity following re-exposure may reduce the risk

malignant relapse without increasing the risk of GVHD, specifically through fetal

development of CD4 + T-cells exerting relapse-reducing effects, anti-minor

histocompatibility antigen cytlolytic T-cells, and regulatory T-cells from the CD4 +

and CD8 + compartments. Further studies may help to elucidate the role of NIMA matching

and CD8 + compartments. Further studies may help to elucidate the role of NIMA

matching in the selection of UCBUs [48].

Double UCBT

Limited numbers of cells in single UCB grafts has limited the widespread use of

cells in single UCB grafts has limited the widespread use of UCBT in adult patients [4].

UCBT in adult patients [4]. In a retrospective review of 102 pediatric and adult UCBT

recipients, those receiving less than 1.7 x 10 5 CD34 + cells/kg had significantly poorer

survival outcomes [41]. Co-transplantation of two UCBUs (D-UCBT) from different

donors increases the available cell dose and allows for UCBT in patients for whom no

single UCBU would have sufficient cell dose. There is no universally accepted

algorithm for unit selection in D-UCBT with respect to HLA matching. However, the

in D-UCBT with respect to HLA matching. However, the published “Minnesota algorithm” recommends at least

published “Minnesota algorithm” recommends at least partial HLA matching between

the transplanted units; HLA disparities between each unit and the recipient and

between the two units need not be identical.[49] In practice, many studies have

required units to be two or fewer locus HLA-mismatched with one another and with

the patient.[50-54] Barker et al. reported 21 older adolescent and adult patients

undergoing MAC and D-UCBT for hematological malignancies. All patients

engrafted neutrophils; 65% developed grade II-IV acute GVHD [50]. Ballen et al.

subsequently reported on 21 adult patients with predominantly malignant disease

receiving reduced intensity conditioning with fludarabine, melphalan, and ATG

followed by D-UCBT; >90% of patients engrafted neutrophils, 40% developed grade

II-IV acute GVHD, TRM was 19% at 6 months, and 2-year DFS was 55% [51]. In a

larger series of 110 adults with malignant and non-malignant diseases receiving non-

myeloablative conditioning with cyclophosphamide, TBI, and ATG, significantly

higher 3-year EFS was observed in D-UCBT recipients (39%) compared to single UCBT recipients (24%),

higher 3-year EFS was observed in D-UCBT recipients (39%) compared to single

UCBT recipients (24%), with a lower incidence of relapse observed in D-UCBT

recipients [52]. Additionally, among 177 adults and children receiving MAC followed

by UCBT for acute leukemia, use of a double UCB graft compared to a single UCB

leukemia, use of a double UCB graft compared to a single UCB graft was independently associated

graft was independently associated with significantly reduced incidence of relapse for

patients in CR1 or CR2[53]. Rodrigues et al. noted the use D-UCBT vs. single UCBT

was the sole independent predictor of reduced risk of relapse (13% vs. 38%, p=0.009

in univariate analysis, p=0.02 in multivariate analysis) in 104 adults with HL, NHL,

and chronic lymphocytic leukemia [24]. A higher incidence of grade II-IV acute

GVHD has been noted in D-UCBT compared to single UCBT recipients (58% vs.

39%); however, no corresponding increase in TRM has been reported in those

no corresponding increase in TRM has been reported in those undergoing D-UCBT [55]. D-UCBT is a

undergoing D-UCBT [55]. D-UCBT is a feasible strategy to extend the availability of

UCBT to adolescents and adults. Moreover, larger ongoing studies may ultimately

demonstrate significant long-term benefits in DFS and OS in patients receiving D-

UCBT vs. single UCBT.

Following D-UCBT, a single unit generally ultimately serves as the source for

hematopoiesis. Though initial engraftment of both units may be observed,

engraftment usually skews progressively such that one unit predominates [50-52, 55-

56]. Despite the eventual predominance of a single UCBU, the non-engrafting unit

may hasten and facilitate engraftment through yet-unknown immunologic

mechanisms. The mechanism by which a single unit predominates is also

incompletely understood. Multiple reports have noted that the first unit to be infused

is more likely to dominate than the second; in addition, Haspel et al. noted that the

predominant unit had significantly higher TNC and CD34 + dose in a series of 38

adults undergoing reduced-intensity D-UCBT [51, 57]. Scaradavou et al. recently reported that among 44 D-UCBT

adults undergoing reduced-intensity D-UCBT [51, 57]. Scaradavou et al. recently

reported that among 44 D-UCBT recipients who engrafted a single unit, CD34 +

viability was significantly higher in the engrafting unit and that units with CD34 +

viability <75% were extremely unlikely to engraft [56]. One possible explanation for

unlikely to engraft [56]. One possible explanation for the predominance of the first unit is that

the predominance of the first unit is that this unit has the first opportunity to fill the

HSC niche, reducing the niche space available for the second unit infused; increased

cell dose may increase the probability of successful occupation of this niche space.

This niche space can be thought of as the area of the marrow responsible for

maintenance of HSCs; the osteoblast is the support cell of the niche [58-60]. Recently,

Gutman et al. described the development of CD8 + T-cells derived from the dominant

UCBU specific for alloantigens present on the non-engrafting unit in 14 adult D-

present on the non-engrafting unit in 14 adult D- UCBT recipients. This population of effector cells

UCBT recipients. This population of effector cells produces IFN-γ in response to the

non-dominant unit; no IFN-γ secreting cells were identified when peripheral blood

mononuclear cells (MNCs) were stimulated against cells derived from the engrafting

unit; in patients with mixed chimerism, CD8 + T-cells tolerated cells from either unit

without significant IFN-γ production [61]. The exact antigenic specificity of this

CD8 + T-cell population and the role (if any) of CD4 + T-cells in graft-versus-graft

effects is unknown. Interactions between the two units infused may contribute to

graft-versus-leukemia effects by enhanced alloreactivity. Future studies are needed to

understand the biology of D-UCBT to correlate with clinical observations of

enhanced engraftment and reduced leukemic relapse in these patients.

Umbilical Cord Blood Expansion

TNC and CD34 + cell dose are strong predictors of clinical outcomes following UCBT

as previously described. UCBUs contain approximately 1x10 9 TNC on average and only 12% of

as previously described. UCBUs contain approximately 1x10 9 TNC on average and

only 12% of the current public UCB inventory contains sufficient cell dosage for a 60

kg patient. The goal of umbilical cord blood expansion is to increase the number of

progenitor cells capable of rapid repopulation in vivo to improve the kinetics of

of rapid repopulation in vivo to improve the kinetics of hematopoietic recovery following UCBT. Currently, ex

hematopoietic recovery following UCBT. Currently, ex vivo expansion utilizes three

methods: cytokine-containing liquid expansion, co-culture expansion with stromal

cell hematopoietic microenvironment, and continuous perfusion in ‘bioreactors’ rather

than static cultures[62]. Ex vivo expansion of peripheral blood progenitor cells using

growth factors in liquid culture has been shown to expedite neutrophil recovery

following autologous stem cell transplantation[63]. However, most UCB ex vivo

expansion studies to date have only shown that it is plausible but have yet to yield a

have only shown that it is plausible but have yet to yield a significant impact on

significant impact on myeloid engraftment rate[64-66]. This is thought to be

secondary to cellular defects acquired during expansion including cell cycle

abnormalities, homing defects and induction of apoptosis[67]. However, Delaney and

colleagues recently reported that transplantation of an unmanipulated UCBU along

with Notch-mediated ex vivo expanded UCB progenitor cells resulted in faster

neutrophil engraftment compared to a control group receiving unmanipulated D-

UCBT (median 16 days vs. 26 days)[68]. Additional clinical trials are needed to

confirm these encouraging results, and identification of molecular pathways that

mediate cell homing and proliferation will need to be discovered to improve methods

of ex vivo expansion.

Conditioning Regimens

Most studies of UCBT reported to date have employed MAC prior to transplant.

Successful engraftment has been observed with total body irradiation (TBI)- containing and non-TBI containing regimens.

Successful engraftment has been observed with total body irradiation (TBI)-

containing and non-TBI containing regimens. The initial EBMT experience with

UCBT used TBI/cyclophosphamide or busulfan/cyclophosphamide conditioning [10].

Anti-thymocyte globulin (ATG) and other anti-T-cell antibodies have been

globulin (ATG) and other anti-T-cell antibodies have been incorporated into conditioning regimens for

incorporated into conditioning regimens for immunosuppression in unrelated UCBT

recipients. While conditioning consisting of busulfan, melphalan, and ATG has been

demonstrated to be well-tolerated among very young UCBT recipients, unusually

delayed engraftment and a high incidence of graft failure were observed [13]. Day

100

TRM of 15-50% has been observed in MAC UCBT recipients, depending on the

underlying disease and disease status prior to transplant [7-9, 11-12, 14, 29, 36, 42,

47, 69-72]. Significant causes of day 100 TRM include infection, organ failure, acute

of day 100 TRM include infection, organ failure, acute GVHD, and hepatic veno-occlusive disease. RTC and

GVHD, and hepatic veno-occlusive disease.

RTC and unrelated AlloSCT have been used successfully in the treatment of

malignant and non-malignant diseases in children and adults, with decreases in

transplant-related morbidity and mortality observed. Our group previously reported

preliminary results of RTC and UCBT in 21 children and adolescents with malignant

and non-malignant diseases [73]. We recently analyzed clinical outcomes among 88

patients undergoing MAC (n=49) or RTC (n=39) prior to UCBT at Columbia

University Medical Center; all RTC regimens were fludarabine-based (150-180

mg/m 2 ). Primary graft failure was observed in nine patients; MAC vs. RTC recipients

did not differ with respect to graft failure or speed of engraftment. Day 100 TRM was

only 2.6% in the RTC group, compared with 29.3% in the MAC group; in univariate

and multivariate analyses, MAC vs. RTC was the only significant predictor of day

100 TRM and was a significant predictor of 1-year OS [73-74]. Other fludarabine-

based reduced intensity regimens, some of which incorporate low-dose TBI, have been successfully used in

based reduced intensity regimens, some of which incorporate low-dose TBI, have

been successfully used in adult patients, with day 180 TRM less than 20% [25-26, 51-

52].

patients, with day 180 TRM less than 20% [25-26, 51- 52]. Immune Reconstitution Immune reconstitution in

Immune Reconstitution

Immune reconstitution in pediatric AlloSCT recipients appears to take longer

following MAC and UCBT than following matched sibling AlloSCT. NK- and B-cell

recovery is rapid and robust following UCBT, with a median of approximately 3

months and 6 months post-transplant needed to achieve age-related normal levels,

respectively. However, the median time needed to achieve normal cytolytic T-cell

counts is approximately 8-9 months and for total and helper T-cell counts, approaches

months and for total and helper T-cell counts, approaches 12 months [75-78]. T-cell reconstitution after unrelated

12 months [75-78]. T-cell reconstitution after unrelated donor UCBT is further

delayed compared to related donor UCBT. Cytolytic T-cell recovery after UCBT is

markedly delayed compared to other stem cell sources, where CD8 + T-cell recovery is

often observed within 1-3 months post-transplant [75, 77]. T-cell recovery following

AlloSCT derives from peripheral expansion of mature, post-thymic donor cells (the

thymic-independent pathway) and pre-thymic cells that must undergo differentiation

in the host (the thymic-dependent pathway) [79]. Given the low number of mature

donor lymphocytes transferred in UCBT, less robust thymic-independent T-cell

proliferation may be expected compared to related or unrelated BMT [75]. UCBT

recipients are at particular risk of infection in the first 100 days post-transplant. In a

large comparison of patient outcomes after AlloSCT according to donor source,

Laughlin et al. noted the proportion of infection-related outcomes within the first 100

days post-transplant was significantly higher among UCBT recipients than among

recipients of either matched or mismatched related BMT; proportions were similar among the groups after

recipients of either matched or mismatched related BMT; proportions were similar

among the groups after 100 days [18]. However, T-cell receptor (TCR) diversity is

ultimately greater at 2 years post-UCBT than following matched sibling donor BMT,

as measured by TCR excision circles [80]. Parkman et al. noted an association

excision circles [80]. Parkman et al. noted an association between successful immune reconstitution following UCBT in

between successful immune reconstitution following UCBT in children and decreased

risk of leukemic relapse and improved relapse-free survival. Specifically, robust

antigen-specific T-cell proliferation in response to cytomegalovirus, herpes simplex

virus or varicella zoster virus was a strong predictor of relapse-free survival (Figure

4). In addition, those without robust T-cell responses were more likely to die of

infectious causes [81].

We recently analyzed immune reconstitution in 88 consecutive pediatric

analyzed immune reconstitution in 88 consecutive pediatric UCBT recipients at Columbia University Medical Center. At

UCBT recipients at Columbia University Medical Center. At day +100/180/365 post-

transplant, the percentages of patients who had achieved normal CD3, CD4, CD8,

CD19, and CD56 counts according to age-specific reference ranges were 0/0/54%,

0/14/71%, 3/5/58%, 53/67/92%, and 78/71/83%, respectively. While most patients

achieved normal natural killer (NK) cell counts by day 100 and normal B-cell counts

by day 180, T-cell recovery was delayed. Lymphocyte subset counts and

immunoglobulin levels did not differ significantly between patients receiving MAC

vs. RTC prior to UCBT [82]. Strategies to enhance T-cell recovery in the early post-

transplant period in UCBT recipients warrant particular attention.

Cord Blood Banking

Discussion of specific UCB banking procedures is beyond the score of this review. A

standard operating procedure of UCB collection, processing, and cryopreservation

was developed by the COBLT program (summarized in [83]). Matters of ongoing controversy include procedures

was developed by the COBLT program (summarized in [83]). Matters of ongoing

controversy include procedures for obtaining informed maternal consent, cost-benefit

analysis of increasing the number of publically-available UCBUs [84], the role of

UCB directed donor (private) banking, cultural considerations regarding the

(private) banking, cultural considerations regarding the placenta’s role [85], and the use of pre-implantation HLA

placenta’s role [85], and the use of pre-implantation HLA typing [86].

Cord Blood Stem Cell Regenerative Potential and Properties

Stem cell therapy has emerged as a novel and potential therapy for a variety of

genetic, acquired and degenerative diseases. Stem cells from various sources,

embryonic, bone marrow, UCB and adult tissues, have been extensively studied

preclinically in similar settings. Human embryonic stem (ES) cells, due to their

settings. Human embryonic stem (ES) cells, due to their indefinite capacity for self-renewal and pluripotency, hold

indefinite capacity for self-renewal and pluripotency, hold great promise in

regenerative medicine. However, in addition to ethical considerations, the therapeutic

use of ES derived cells is challenged with the high risk of teratoma formation as a

result of potential contamination with undifferentiated ES cells. Moreover, human ES

cells can only be used as an allogeneic source [87]. The recent development of

induced pluripotent stem (iPS) cells has potentially circumvented the problems of

ethical considerations and allogeneicity [88-89]. However, the standard production of

iPS cells involves viral transduction, which in itself creates the issue of insertional

mutagenesis, although efforts are currently being made to excise the integrated viral

constructs or to induce pluripotency by small molecules or proteins [90-93].

Meanwhile, the threat of teratoma formation remains.

Adult tissue specific stem cells are practical alternatives to ES cells for cell-

based therapy. Compared to other adult stem cells, human UCB stem cells have

unique properties; developmentally, they are only at 9 months of gestational age and have a

unique properties; developmentally, they are only at 9 months of gestational age and

have a longer telomere length, which correlates to their higher proliferative potential

[94]. Importantly, UCB cells have not been exposed to immunological challenge and

are less likely to carry somatic mutations than other adult cells. These unique

carry somatic mutations than other adult cells. These unique properties have elicited special interest in using

properties have elicited special interest in using UCB for tissue regeneration and also

as a starting cell type for the preparation of iPS cells (Figure 5). Indeed, the CD133 +

fraction of human UCB can be reprogrammed efficiently to iPS cells with retroviral

transduction of only two factors, Oct4 and Sox2, as compared to four genes that are

required in the case of reprogramming adult somatic cells [95]. iPS cells can also be

generated easily from CD34 + CB stem cells through the addition of p53 inhibition

under standard reprogramming conditions [96]. These data have demonstrated the

conditions [96]. These data have demonstrated the plasticity and primitive nature of human UCB. UCB is

plasticity and primitive nature of human UCB.

UCB is a rich source of progenitors and stem cells (Figure 5). In addition to

HSCs, UCB also gives rise to another widely used stem cell population, mesenchymal

stem cells (MSC). The therapeutic values of MSCs have been related to their ability to

differentiate into cells mainly within mesoderm lineages as well as their

immunomodulatory function [97]. Moreover, MSCs exhibit low level of MHC I and

are negative for MHC II antigens, indicating their immune evasion in the allogeneic

setting [98]. These properties have elicited great interest in utilizing MSCs as an “off-

the-shelf” product or as “universal donors” in cell-based therapy. However, the

derivation efficiency of MSCs from UCB seemed to be lower than those from bone

marrow and adipose (30% verse 100% of UCB units, respectively) [99]. This

observation can be explained at least partially by a recent report, which showed that

MSCs were 10 times more frequent in the UCB of 24-28 wk gestational age infants

than 29-32 wk gestational age UCB and even higher than 37-40 wk gestational age UCB

than 29-32 wk gestational age UCB and even higher than 37-40 wk gestational age

UCB [100]. By comparison, endothelial colony forming cells (ECFC), identified

based on the outgrowth of cobblestone like adherent colonies between day 7 and 14

following plating of UCB MNCs on collagen I coated plastics, are more enriched in

UCB MNCs on collagen I coated plastics, are more enriched in full term (37-40 wk gestational

full term (37-40 wk gestational age) UCB [100-101]. The ECFCs have shown the

ability to form de-novo blood vessels when seeded in either a collagen fibronectin or

matrigel matrix and implanted subcutaneously in immunocompromised mice,

suggesting their potential therapeutic treatment of patients with impaired vascular

function (Yoder MC, et.al. blood 2007, 109:1801-1809; Melero-Martin JM, etal.

Blood 2007, 109:4761-4768).

Melero-Martin JM, etal. Blood 2007, 109:4761-4768). CB-derived primitive stem cells Besides these committed

CB-derived primitive stem cells

Besides these committed multi-potent stem or progenitor cells, accumulating data

have indicated the existence of multiple populations of more primitive stem cells in

UCB. These stem cells were identified using different methods. However, they carry

similar capabilities to differentiate into cell types representative of all three germ

layers, or express the embryonic stem cell markers, similar to human ES cells.

Moreover, animal studies indicated that they do not have the risk to form teratomas,

in contrast to human ES cells [94, 102]. Therefore, these primitive stem cells could be

made readily available from UCB and used as either an autologous source or HLA-

matched allogeneic alternative to ES cells in tissue regeneration.

The first identified UCB stem cell population with intrinsic pluripotent

differentiation potential is named unrestricted somatic stem cells (USSCs) [102].

These CD45 neg /CD34 neg cells were isolated from UCB based on their outgrowth in the

presence of dexamethasone. USSCs can be differentiated in vitro into bone, cartilage, adipocytes, hematopoietic cells

presence of dexamethasone. USSCs can be differentiated in vitro into bone, cartilage,

adipocytes, hematopoietic cells and neural cells, and in vivo into myocardial cells,

purkinje fibers and hepatic cells [102]. Following the identification of USSCs,

extensive animal studies have shown these cell’s potential therapeutic applications in

shown these cell’s potential therapeutic applications in the promotion of bone healing, relief of neural injury

the promotion of bone healing, relief of neural injury and improvement of recovery

from myocardial infarction, although other investigations indicated a lack of

functional efficacy following infusion of USSCs to an infarcted heart. These

discrepancies might be due to the difference in timing and route of stem cell injection,

as will be discussed more below [103-108]. USSCs have been considered an earlier

cell type of MSCs and can be distinguished from MSCs by their broader

differentiation capability, expression of DLK1 and a restricted adipogenic

capability, expression of DLK1 and a restricted adipogenic differentiation potential [109]. Recently, expression of a

differentiation potential [109]. Recently, expression of a set of Hox genes, especially

HOXA9, HOXB7, HOXC10 and HOXD8, has been proposed as candidate markers to

discriminate MSCs from USSCs [110]. MSCs isolated from both bone marrow and

UCB are HOX-positive, whereas USSCs resemble H9 ES cells and are HOX-negative

[110]. In addition, USSCs possess immuno-modulatory effects, similar to MSCs [111-

112]. They have also been shown to produce functionally significant amounts of

hematopoiesis-supporting cytokines and are superior to the bone marrow derived

MSC in expansion of CD34 positive cells from UCB [113]. Moreover, co-

transplantation of USSCs in NOD/SCID mice enhanced in vivo homing of both

unselected and selectively amplified CD34 positive UCB cells, suggesting that

USSCs could potentially be used clinically in UCB transplantation to facilitate

homing and engraftment of donor cells [114]. As a step further to their future clinical

application, USSCs can now be produced and expanded at a GMP-grade [115].

In collaboration with BioE, Cairo et al. also characterized a population of multi-lineage progenitor cells

In collaboration with BioE, Cairo et al. also characterized a population of

multi-lineage progenitor cells (MLPC) from CB by non-particular based negative cell

selection followed by plastic adherence[94]. MLPCs exhibit two distinct

morphologies in cell surface phenotypes, a leukocyte-like morphology on freshly

surface phenotypes, a leukocyte-like morphology on freshly isolated cells (positive for CD45, CD34, CD133, CD13, CD29,

isolated cells (positive for CD45, CD34, CD133, CD13, CD29, CD44, CD73, CD90,

CD105, CD9 and SSEA-3/4) and a fibroblastic morphology (CD45 - , CD34 - , CD133 - ,

CD13 + , CD29 + , CD44 + , CD73 + , CD90 + , CD105 + , CD9 + ) upon continued culturing.

MLPCs can be differentiated into cell types representative of all three germinal layers.

Comparative microarray analyses indicated that MLPCs were also more quiescent and

primitive, and less committed to lineage than MSCs. Moreover, standard in vitro

culture in nondifferentiating media resulted in no instances of spontaneous

media resulted in no instances of spontaneous differentiation and initial animal tests have not resulted

differentiation and initial animal tests have not resulted in teratoma formation.

Instead of deriving primitive stem cells by colony appearance from UCB

MNCs as described above, other methods involve either positive or negative selection

based on the expression of cell surface antigens. For example, embryonic-like stem

cells can be isolated by immunomagnetic removal of CD45, CD33, CD7 and CD235a

positive cells [116-118]. The resultant lineage negative cells, which represent 0.1-1%

of total MNCs of each UCB, express embryonic stem cell markers Oct4, Sox2 and

SSEA3/4, in addition to embryonic extracellular matrix components TRA-1-60 and

TRA1-81. A similar stem cell fraction, isolated by depletion of CD34-positive cells

(UCB-MNC CD34- ) was also characterized to express Oct4, Sox2 and Rex1 genes

[119]. These cells further undergo spontaneous aggregation and differentiation toward

neural lineage. From this point, neural stem cell lines could be derived by sequentially

passaging only the floating cells from the epithelial growth factor-stimulated culture

[120]. Recently, a population of very small embryonic-like (VSEL) stem cells (CXCR4 + lin -

[120].

Recently, a population of very small embryonic-like (VSEL) stem cells

(CXCR4 + lin - CD45 - ) has been identified from not only UCB, but also from human

peripheral blood and bone marrow by multiparameter FACS analysis [121-122]. This

bone marrow by multiparameter FACS analysis [121-122]. This rare population is rich in the expression of

rare population is rich in the expression of CD34 and CD133 and represents about

0.02% of total MNCs. Single cell characterization after FACS indicated that they

express SSEA-4, Oct4 and Nanog. The promoter region of the Oct4 gene has

consistently been shown to be hypomethylated and to adopt an open chromatin

structure [123]. Moreover, it has been demonstrated that VSEL could be mobilized

from bone marrow into peripheral blood in patients after a stroke and acute

myocardial infarction, implying their contribution to tissue regeneration [124-125].

their contribution to tissue regeneration [124-125]. However, VSELs purified from murine bone marrow do not

However, VSELs purified from murine bone marrow do not proliferate if cultured

alone and can only be activated to form embroyoid body-like structures and

differentiate by co-culturing with other cells such as bone marrow MNCs or

myoblasts C2C12 [121]. This suggests that VSELs are a quiescent cell population,

which could be further explained by its unique DNA methylation patterns at

imprinted genes, similar to the epiblast-derived primordial germ cells [123].

In summary, several populations of primitive stem cells with multilineage

differentiation capacity have been reported from UCB. This demonstrates the

plasticity of UCB and underscores the value of UCB in cell-based therapies.

However, it should be noted that these cells generally exist at low cell numbers and

the efficiency of derivation may vary between different UCB samples. For instance,

the generation efficiency of USSCs is about 35% from fresh UCB, and only one to

eleven USSC colonies would be initiated in the cases of successful derivation, with a

median frequency of four colonies per UCB [126]. The efficiency of isolating USSCs from cryopreserved

median frequency of four colonies per UCB [126]. The efficiency of isolating USSCs

from cryopreserved UCB is even lower, and may be influenced by the procedures

involved in cryopreservation (un-separated or volume- reduced) and after-thawing

(Ficoll density gradient separation or ammonium chloride lysis) [126]. Therefore, the

separation or ammonium chloride lysis) [126]. Therefore, the role of these rare stem cells in promoting

role of these rare stem cells in promoting tissue regeneration upon whole UCBT is yet

to be determined. It can be speculated, however, that more significant therapeutic

application of these primitive-potent stem cells is to be used as HLA typed universal

donor cells alone or together with whole UCB in transplantation.

Regenerative application of UCB and UCB-derived stem cells

As discussed earlier, UCB has now been routinely used to treat hematopoietic

UCB has now been routinely used to treat hematopoietic malignancies, marrow failure, metabolic diseases and

malignancies, marrow failure, metabolic diseases and immunodeficiency disorders.

The plasticity of UCB and its readily accessibility have now encouraged its broader

regenerative applications such as the treatment for spinal cord injury and chronic

wounds [127-128]. Meanwhile, more clinical trials are in place to infuse UCB for the

treatment of other non-hematopoietic diseases, such as epidermolysis bullosa (our

center), and neonatal hypoxic ischemic encephalopathy (personal communications).

Most of the clinical studies apply un-fractionated UCB with a primary goal to

determine the safety and/or efficacy of UCB. The mechanism of action, the optimal

therapeutic window and the best route of UCB infusion for each disease remain

unknown and can only be inferred from animal studies.

Recently, UCBT has been actively explored in animal models of cardiac

infarction, diabetes and various neurological diseases including stroke, amyotrophic

lateral sclerosis, spinal cord injury, Huntington’s disease, Parkinson’s disease and

hypoxic ischemic encephalopathy. In most of the studies, beneficial effects have been observed following UCBT,

hypoxic ischemic encephalopathy. In most of the studies, beneficial effects have been

observed following UCBT, although inconsistent or in some cases conflicting results

exist. Importantly, it has been clear that the route and timing of transplantation

influence the mechanism of action for the transplanted cells and may explain the

of action for the transplanted cells and may explain the discrepant outcomes between different studies. Here

discrepant outcomes between different studies. Here we will discuss the multifaceted

effects of UCB in the context of two most extensively studied experimental models,

stroke and myocardial infarction.

Stroke

UCBT in animal models for strokes was first reported in 2001. In that initial study,

intravenous administration of UCB MNCs 24 hours after transient middle cerebral

of UCB MNCs 24 hours after transient middle cerebral artery occlusion in a rat stroke model

artery occlusion in a rat stroke model significantly improved neurological functioning

[129]. Moreover, the UCB MNCs were able to migrate to the ischemic boundary of

the injured hemisphere and some of these cells underwent neural differentiation as

demonstrated by their immunoreactivity to neural markers such as GFAP (6%), MAP-

2 (2%) and NeuN (2%). However, even though surviving UCB cells were identified

in the ischemic boundary, they only represented about 1% of the total MNCs

administered.

Since this initial report, more animal studies have been conducted to compare

the effects of routes and timing of transplantation on graft survival and functional

recovery. The route of cell delivery is an important factor to consider in determining

the balance between the best therapeutic efficacy and minimal pain to the patients.

Intravenous administration is noninvasive to patients and has resulted in functional

improvement in various neurological diseases in both preclinical and clinical studies.

However, it is also likely that cells could be trapped to other organs before entering

However, it is also likely that cells could be trapped to other organs before entering

the brain if delivered intravenously. Indeed, a non-quantitative comparative study

indicated that more donor cells were found in the damaged striatum with intracerebral

administration of neural precursors than with intracerebroventricular delivery and the

than with intracerebroventricular delivery and the intravenous injection yielded fewest donor cell engraftment

intravenous injection yielded fewest donor cell engraftment [130-131]. Still, similar

degrees of improvement were observed between the animals receiving UCB either

intrastriatally or intravenously 24 hours after permanent middle cerebral artery

occlusion [132]. Furthermore, no UCB cells were observed within striatum after

either intravenous or intrastriatal delivery. Surprisingly, intravenous delivery

appeared to be even more effective than striatal delivery in producing long-term

functional benefits, as there were less cellular debris and infiltrate in the brains of the

less cellular debris and infiltrate in the brains of the animals with intravenous injection. Therefore, according

animals with intravenous injection. Therefore, according to this report, intravenous

administration of CB has more advantages than intrastriatal delivery [132].

In addition to the route of injection, the timing of transplantation and stem cell

dose also affect the efficacy of transplantation [133-134]. It has been demonstrated

that stroke-induced chemokines, which attract stem cells to the site of injury, began to

be up-regulated at about 24h post-stroke [135-136]. Therefore, intravenous injection

of UCB immediately after stroke may not provide an optimal time window for the

cells to migrate to the injured brain. However, the transplanted cells could still

perform neuroprotective function by the releasing of trophic factors [137]. In support

of these findings, it was later demonstrated that the timing of UCB intravenous

delivery determines therapeutic efficacy and maximum improvements were observed

with transplantation 48 hours post-stroke [138]. It appears that the transplanted cells

at the acute phase play a neuroprotective role by relieving inflammation and/or

promoting endogenous neurogenesis. In contrast, in a delayed stage with diminished inflammation, the cell engraftment

promoting endogenous neurogenesis. In contrast, in a delayed stage with diminished

inflammation, the cell engraftment may become important, in addition to the

paracrine effect, in improving long-term neurological functions. Additionally,

transplantation of bone marrow stromal cells even a month after a stroke has resulted

stromal cells even a month after a stroke has resulted in functional recovery [139]. Overall, multiple

in functional recovery [139].

Overall, multiple mechanisms have been postulated for functional recovery

after transplantation of UCB. The first mechanism involves the release of trophic or

neuroprotective factors, such as glial cell line-derived neurotrophic factor, nerve

growth factor and brain-derived neurotrophic factor from UCB. It has been

demonstrated that central nervous system entry of peripherally injected UCB cells

was not required for neuroprotection in strokes, provided that neurotrophic factors

in strokes, provided that neurotrophic factors released from UCB could enter the brain [137]. The elevated

released from UCB could enter the brain [137]. The elevated levels of trophic factors

consequently promote neovascularization and/or induce sprouting of nerve fibers

from the non-damaged hemisphere into the ischemic side of the brain [140-141]. The

second mechanism is associated with the anti-inflammatory function of UCB. UCB

transplantation has been shown to significantly decrease the number of

CD45 + /CD11b + (microglia/macrophage) and CD45 + /B220 + (B cell) cells in the brain

that are usually at elevated levels after permanent middle cerebral artery occlusion

[142]. A recent in vitro study further demonstrated that CD11b + - or CD19 + -UCB cells

decrease the survival of microglia [143]. Besides the anti-inflammatory effect, UCB

has also been postulated to modulate stroke-induced peripheral immune responses, as

measured by its ability to oppose stroke-induced spleen weight loss and alterations in

spleen T-cell subset and proliferation [144]. The immuno-modulatory function of

UCB was also implicated in an animal model of amyotrophic lateral sclerosis, where

an increase in spleen mass was observed following UCBT [145]. The last potential mechanism relates

an increase in spleen mass was observed following UCBT [145]. The last potential

mechanism relates to the ability of UCB to migrate, engraft and possibly differentiate

at the sites of lesion. Similar migratory effects have also been observed with

transplantation of neural precursor cells and in other animal models such as hypoxic

precursor cells and in other animal models such as hypoxic ischemic encephalopathy, amyotrophic lateral sclerosis and

ischemic encephalopathy, amyotrophic lateral sclerosis and Huntington’s disease

[131, 146-149]. In addition to intravenous injection, intraperitoneal injection of UCB

24 hours after hypoxic infarction in a rat model of hypoxic ischemic encephalopathy

also led to migration of the transplanted cells in the ischemic hemisphere [150]. The

targeted migration is likely to be mediated by ischemia-induced chemokines, such as

stromal-derived factor-1, monocytes chemoattractant protein-1 and macrophage

inflammatory protein (MIP-alpha) [131, 146, 151-152]. However, as only a small

(MIP-alpha) [131, 146, 151-152]. However, as only a small percentage of the transplanted cells could reach

percentage of the transplanted cells could reach the injury location and the number of

cells undergoing neural differentiation was even lower, the mechanism by “cell

replacement” may not play a major role in the observed functional improvement

following UCBT. Moreover, graft survival does not guarantee neurological

improvement, as suggested by a transplantation study with human

neuroteratocarcinoma neurons. In that study, no functional improvement was

observed in the experimental animals despite clear evidence of cell survival and

neurite extension [153]. Therefore, functional integration of the transplanted cells into

the resident tissue appears to be more important than mere graft survival in

regenerating the damaged brain tissue.

Myocardial infarction (MI)

Various cell sources, i.e., MSCs, HSCs, endothelial progenitor cells, skeletal

myoblasts, cardiac stem cells, ES cells and unfractionated bone marrow MNCs have been explored in

myoblasts, cardiac stem cells, ES cells and unfractionated bone marrow MNCs have

been explored in preclinical and clinical cell based therapy for MI [154]. Generally

beneficial effects, such as angiogenesis, decrease of infarction size and improvement

of left ventricular (LV) ejection fraction have been observed. However massive donor

ejection fraction have been observed. However massive donor cell death has generally been observed. Accordingly,

cell death has generally been observed. Accordingly, survival and further

differentiation of the transplanted cells have been limited and the mechanisms of

action have mainly been attributed to paracrine effects on injured myocardium.

The use of UCB for the treatment of MI has also been actively investigated. In

animal models of MI, direct injection of CD34 + , CD133 + or MNCs from UCB into the

necrotic myocardium or the border of the infarction following acute permanent

coronary artery ligation, resulted in reduced infarction size and improved LV function

resulted in reduced infarction size and improved LV function [155-157]. Meanwhile, migration of the cells to

[155-157]. Meanwhile, migration of the cells to the damaged heart has been observed

following intravenous injection of UCB CD133 + cells or MNCs, 7 days and 1 day

after MI, respectively [155, 158-159]. Moreover, enhanced angiogenesis and

reduction in infarction size have also been achieved following intravenous injection

[155, 158-159]. Later, an elegant study was conducted to compare the effects of the

administration of UCB MNCs by intramyocardial, intracoronary or intravenous

injections, as well as the dose, on the infarction size in rats with acute MI [160]. The

authors concluded that all three administration methods resulted in significant

reductions in infarct size without host immune suppression, as compared to Isolyte-

treated infracted hearts. Among these methods, intramyocardial injection of UCB

most effectively reduced infarct size and required the least number of cells (4 x 10 6 ).

In comparison, 16 x 10 6 cells are the optimal dose for intravenous injection. The

authors also observed a plateau in infarction size reduction with each route of

injection and suggested that use of extremely large number of cells is not necessary and

injection and suggested that use of extremely large number of cells is not necessary

and in some cases may be detrimental. In the same study, intracoronary injection of

32 x 10 6 cells produced cardiac arrhythmias and sudden death in four of the

experimental rats, most likely due to myocardial microinfarcts as a result of stem cell

due to myocardial microinfarcts as a result of stem cell clumping and coronary arterial emboli. In

clumping and coronary arterial emboli.

In addition to the CD34 + or CD133 + fraction and MNCs of UCB, UCB

derived USSCs have also been applied to treat MI in animal models. In a chronic

porcine model of MI, direct injection of 10 8 USSCs to the border of infarction 4

weeks post MI resulted in decrease in infarct size, reduction in end-diastolic volume

and improvement in LV ejection fraction [106]. Meanwhile, the engrafted USSCs

could be detected 4 weeks after transplantation. In contrast, in an acute porcine model

transplantation. In contrast, in an acute porcine model of MI, myocardial injection of 1.3 x 10

of MI, myocardial injection of 1.3 x 10 7 USSCs led to a surprising, complete

prevention of scar formation and dramatic functional improvements [161]. However,

long-term survival of the transplanted cells and donor-based regeneration of

myocardium were not observed. The authors concluded that differentiation, apoptosis

and macrophage mobilization at the infarct site were not the mechanisms for the

observed cardiac improvement. Instead, they suggested that the improvement was

due to the paracrine effects on preserving/promoting the regeneration of recipient

myocardium. Recently, encouraging results have also been reported on

intramyocardial transplantation of USSCs into immunodeficient rats with acute MI

[107]. In this study, transplantation of USSCs (10 5 or 10 6 ) dose-dependently

preserved LV function. In addition, human specific cardiomyocytes, smooth muscle

cells and endothelial cells have been detected in the ischemic rat myocardium, in a

mechanism that is independent of cell fusion. This suggested vasculogenic and

cardiomyogenic potential of USSCs and shed a light on their clinical application for MI. Despite

cardiomyogenic potential of USSCs and shed a light on their clinical application for

MI.

Despite all these promising results showing the efficacy of USSCs on MI,

negative results have also been reported. In a similar porcine model of MI, Moelker

been reported. In a similar porcine model of MI, Moelker and coworkers injected 10 8 USSCs

and coworkers injected 10 8 USSCs into the infarct-related coronary artery 1 week

post MI, mimicking the clinical scenario of an ongoing clinical trial of BMT [104].

MRI analysis failed to document any improvement in regional or global LV function.

The transplanted cells survived only in the infarct border zone at 5 weeks and did not

express any cardiomyocyte or endothelial markers. Indeed, intracoronary

transplantation of USSCs resulted in more extensive infarcts, accompanied by

increases in inflammatory cell infiltration and calcification in the infarct zone,

cell infiltration and calcification in the infarct zone, compared to medium treated swine. The major difference

compared to medium treated swine. The major difference between this negative study

and previous positive studies is the route of administration. While intracoronary

injection theoretically allows the transplanted cells to follow the blood flow to the

perfused region, it also runs the risk of causing coronary obstruction. With a size of

approximately 25µm, which is about twice as big as freshly isolated MNCs from bone

marrow or UCB, it is not surprising that USSCs cause the formation of micro-

infarctions. Similar observation has been reported with intracoronary injection of

bone marrow derived MSCs [162]. To further explore the risk of USSCs in micro-

embolization, Moelker and coworkers injected 50 x 10 6 USSCs in the artery of

normal healthy myocardiums and observed similar extensive micro-infarction in the

injected area [104]. Therefore, although it is likely safe to transplant MNCs via

intracoronary injection using an optimal dose, transplantation of ex vivo expanded

cells such as USSCs and MSCs needs to proceed with caution and administration by

the route of intracoronary injection should be avoided. In a later study, the abilities of

the route of intracoronary injection should be avoided. In a later study, the abilities of

UCB-derived USSCs and MNCs to rescue MI were also evaluated in a rat model of

MI by permanent coronary artery occlusion and by ischemia/reperfusion injury,

following either intravenous or intramyocardial injection [108]. Except for a few

or intramyocardial injection [108]. Except for a few changes in the expression of the extracellular matrix

changes in the expression of the extracellular matrix and cytokines in the infarct area,

there was no sign of cardiac regeneration. Improvement in heart function or

attenuation on LV dilatation was also not observed in this study.

Conclusions based on preclinical regenerative application of UCB

While encouraging results have been obtained in many preclinical studies of

UCB cell therapy, challenges remain and these challenges are not specific to UCB per

se,

remain and these challenges are not specific to UCB per se, but applicable to transplantation of

but applicable to transplantation of other stem cell sources as well.

Although the original idea of stem cell therapy is to replace the damaged cells

and regenerate the affected organs, significant donor cell engraftment and functional

integration of the survived donor cells have rarely been reported. While functional

improvements have been observed in the absence of the evidence for donor cell

engraftment, mainly in the studies with transplantation following acute insults, long-

term survival of the transplanted cells and their functional integration to the recipient

tissue will likely further enhance the beneficial effects of transplantation. Strategies to

promote donor cell survival, such as preconditioning the cells with cytokines or

genetically modifying the donor cells are now being actively explored [163]. It can

also be expected that in a severe degenerative scenario, such as a cyst formation as a

result of hypoxic ischemia, transplantation of stem cells supported by bioengineered

matrix would help retain donor cells and enhance their reciprocal interactions with the

recipient tissue, as has been suggested in an earlier study [164]. In addition, non- invasive

recipient tissue, as has been suggested in an earlier study [164]. In addition, non-

invasive measures for stem cell tracking via MRI, bioluminescence, or fluorescence

resonance energy transfer (FRET), will also provide a quantitative evaluation on the

survival and fate of the transplanted cells.

on the survival and fate of the transplanted cells. Lastly, extensive animal studies have suggested that

Lastly, extensive animal studies have suggested that route of administration

and timing of stem cell therapy affect the mechanism of action for the transplanted

cells. Meanwhile, the dose and choice of the donor cells may also have immediate

effects on the outcomes.

Summary

UCB has now been routinely used as an alternative source of HSCs to bone marrow

used as an alternative source of HSCs to bone marrow for the treatment of a variety

for the treatment of a variety of malignant and nonmalignant diseases, including

hematologic malignancies (most prominently acute leukemias), marrow failure

syndromes, hemoglobinopathies, and inherited lysosomal and peroxisomal storage

diseases. Compared to UBMT, UCBT offers enhanced ability to cross donor-recipient

HLA barriers without increased risk of GVHD, but is limited by increased risk of

graft failure and life-threatening infection. Greater TNC dose and closer HLA match

appear to be independently predictive of decreased TRM and enhanced OS. Strategies

to expedite hematopoietic recovery and reduce TRM include D-UCBT and ex vivo

expansion, which are under active clinical investigation and help extend UCBT to

larger recipients; D-UCBT may additionally lower risks of malignant relapse.

UCB stem cells offer many practical advantages such as relative ease of procurement,

minimal risk to the donors and the ability to bank the screened and HLA-typed

samples for public uses. Moreover, UCB also possesses a primitive ontogeny, has not

been exposed to immunological challenges and is expected to carry minimal somatic mutations. Further, there

been exposed to immunological challenges and is expected to carry minimal somatic

mutations. Further, there has been accumulating evidence for the existence of very

primitive stem cells that share ES cell properties yet do not pose the risk of teratoma

formation upon transplantation. Therefore, these primitive UCB-derived stem cells

Therefore, these primitive UCB-derived stem cells could be a suitable alternative to ES cells for tissue

could be a suitable alternative to ES cells for tissue regeneration.

Acknowledgements

Supported in part by grants from the Pediatric Cancer Research Foundation,

‘Dream.Discover.Cure.’, Marisa Fund, Sonia Scaramella Fund, Andrew J. Gargiso, Jr.

Foundation, Paul Luisi Foundation, Brittany Barron Fund, and the Doris Duke

Luisi Foundation, Brittany Barron Fund, and the Doris Duke Charitable Foundation. Support and Financial Disclosure

Charitable Foundation.

Support and Financial Disclosure Declaration

No financial interest/relationships with financial interest relating to the topic of this

article have been declared.

References [1] reconstitution in a patient with Fanconi's anemia by means of umbilical-cord blood from

References

[1]

reconstitution in a patient with Fanconi's anemia by means of umbilical-cord blood

from an HLA-identical sibling. N Engl J Med. 1989;321:1174-1178.

[2]

for pediatric patients. Bone marrow transplantation. 2008;41:207-214.

[3]

[4]

transplantation. Part I: CIBMTR summary slides. CIBMTR Newsletter. 2009;1:7-11.

[5]

Program; 2009.

[6]

Allogeneic sibling umbilical-cord-blood transplantation in children with malignant and non-malignant disease. Lancet. 1995;346:214-219.

[7]

source of hematopoietic stem cells for transplantation. Blood. 1997;90:4665-4678.

[8]

HLA-matched and HLA-mismatched umbilical cord blood from unrelated donors:

Gluckman E, Broxmeyer HA, Auerbach AD, et al. Hematopoietic

Rocha V, Locatelli F. Searching for alternative hematopoietic stem cell donors

F. Searching for alternative hematopoietic stem cell donors Trends in Allogeneic Transplants. National Marrow Donor

Trends in Allogeneic Transplants. National Marrow Donor Program; 2009. Pasquini MC, Wang Z. Current use and outcome of hematopoietic stem cell

Unrelated Donor Search Process, Step by Step. National Marrow Donor

Wagner JE, Kernan NA, Steinbuch M, Broxmeyer HE, Gluckman E.

Cairo MS, Wagner JE. Placental and/or umbilical cord blood: an alternative

Wagner JE, Rosenthal J, Sweetman R, et al. Successful transplantation of

Kurtzberg J, Laughlin M, Graham ML, et al. Placental blood as a source of

Laughlin M, Graham ML, et al. Placental blood as a source of analysis of engraftment and

analysis of engraftment and acute graft-versus-host disease. Blood. 1996;88:795-802.

[9]

hematopoietic stem cells for transplantation into unrelated recipients. N Engl J Med.

1996;335:157-166.

[10]

transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group. N Engl J Med. 1997;337:373-

381.

[11]

of placental-blood transplants from unrelated donors. N Engl J Med. 1998;339:1565-

Gluckman E, Rocha V, Boyer-Chammard A, et al. Outcome of cord-blood

Rubinstein P, Carrier C, Scaradavou A, et al. Outcomes among 562 recipients

Michel G, Rocha V, Chevret S, et al. Unrelated cord blood transplantation for

Wall DA, Carter SL, Kernan NA, et al. Busulfan/melphalan/antithymocyte

1577.

[12]

childhood acute myeloid leukemia: a Eurocord Group analysis. Blood.

2003;102:4290-4297.

[13]

globulin followed by unrelated donor cord blood transplantation for treatment of infant leukemia and leukemia in young children: the Cord Blood Transplantation study (COBLT) experience. Biol Blood Marrow Transplant. 2005;11:637-646.

[14]

Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematologic malignancies. Blood.

Kurtzberg J, Prasad VK, Carter SL, et al. Results of the Cord Blood

2008;112:4318-4327.

[15]

unrelated and HLA-matched sibling donor hematopoietic stem cell transplantations

for acute leukemia in children younger than 18 months. J Clin Oncol. 2006;24:145-

Eapen M, Rubinstein P, Zhang MJ, et al. Comparable long-term survival after

151.

[16] unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: a

[16]

unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: a comparison study. Lancet. 2007;369:1947-1954.

[17]

Eapen M, Rubinstein P, Zhang MJ, et al. Outcomes of transplantation of

Rocha V, Labopin M, Sanz G, et al. Transplants of umbilical-cord blood or

bone marrow from unrelated donors in adults with acute leukemia. N Engl J Med.

2004;351:2276-2285.

[18]

cord blood or bone marrow from unrelated donors in adults with leukemia. N Engl J Med. 2004;351:2265-2275.

[19]

haemopoietic stem-cell transplantation in adults with acute leukaemia: a retrospective analysis. Lancet Oncol. 2010;11:653-660.

Laughlin MJ, Eapen M, Rubinstein P, et al. Outcomes after transplantation of

M, Rubinstein P, et al. Outcomes after transplantation of Eapen M, Rocha V, Sanz G, et

Eapen M, Rocha V, Sanz G, et al. Effect of graft source on unrelated donor

Takahashi S, Ooi J, Tomonari A, et al. Comparative single-institute analysis of

[20]

cord blood transplantation from unrelated donors with bone marrow or peripheral blood stem-cell transplants from related donors in adult patients with hematologic

malignancies after myeloablative conditioning regimen. Blood. 2007;109:1322-1330.

[21]

transplantation in adult acute lymphocytic leukemia: impact of donor source on survival. Biol Blood Marrow Transplant. 2008;14:1394-1400.

[22]

unrelated cord blood transplantation compared with unrelated bone marrow

Kumar P, Defor TE, Brunstein C, et al. Allogeneic hematopoietic stem cell

Atsuta Y, Suzuki R, Nagamura-Inoue T, et al. Disease-specific analyses of

transplantation in adult patients with acute leukemia. Blood. 2009;113:1631-1638.

[23]

after myeloablative conditioning in adults with acute myelogenous leukemia. Biol Blood Marrow Transplant. 2008;14:1341-1347.

[24]

outcomes after unrelated cord blood transplantation in adults with lymphoid malignancies: a study by the Eurocord-Netcord and lymphoma working party of the

by the Eurocord-Netcord and lymphoma working party of the Ooi J, Takahashi S, Tomonari A, et

Ooi J, Takahashi S, Tomonari A, et al. Unrelated cord blood transplantation

Rodrigues CA, Sanz G, Brunstein CG, et al. Analysis of risk factors for

European group for blood and marrow transplantation. J Clin Oncol. 2009;27:256-

263.

[25]

Comparable results of umbilical cord blood and HLA-matched sibling donor

Majhail NS, Weisdorf DJ, Wagner JE, Defor TE, Brunstein CG, Burns LJ.

hematopoietic stem cell transplantation after reduced-intensity preparative regimen for advanced Hodgkin lymphoma. Blood. 2006;107:3804-3807.

[26]

transplantation for patients with advanced malignant lymphoma. Biol Blood Marrow Transplant. 2005;11:314-318.

[27]

transplant in fanconi anemia patients: risk factor analysis for engraftment and survival. Biol Blood Marrow Transplant. 2007;13:1073-1082.

[28]

Outcome of hematopoietic cell transplantation in children with sickle cell disease, a single center's experience. Bone marrow transplantation. 2009.

[29]

transplantation in patients with thalassemia and sickle cell disease. Blood.

2003;101:2137-2143.

Yuji K, Miyakoshi S, Kato D, et al. Reduced-intensity unrelated cord blood

Gluckman E, Rocha V, Ionescu I, et al. Results of unrelated cord blood

Majumdar S, Robertson Z, Robinson A, Starnes S, Iyer R, Megason G.

Locatelli F, Rocha V, Reed W, et al. Related umbilical cord blood

[30] Ablative Conditioning (NAC) with Busulfan (Bu), Fludarabine (Flu) and Alemtuzumab followed by Allogeneic Stem

[30]

Ablative Conditioning (NAC) with Busulfan (Bu), Fludarabine (Flu) and Alemtuzumab followed by Allogeneic Stem Cell Transplantation (AlloSCT) to Induce Mixed Donor Chimerism in Patients with Sickle Cell Disease (SCD). Biology

of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2008;14:82-83.

[31]

Conditioning (RI) with Busulfan (Bu), Fludarabine (Flu), and Alemtuzumab Followed by Allogeneic Stem Cell Transplantation (AlloSCT) to Induce Sustained Mixed Donor Chimerism in Patients With Symptomatic Sickle Cell Disease (SCD). Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2009;15:23-24.

Bhatia M, Morris E, Moore V, et al. A Pilot Study of Reduced Intensity

Bhatia M, Baldinger L, Billote G, et al. 221: Preliminary Results of Non-

L, Billote G, et al. 221: Preliminary Results of Non- [32] transplantation in children with sickle

[32]

transplantation in children with sickle cell disease: review of four-center experience. Pediatric transplantation. 2007;11:641-644.

[33]

blood transplantation for inherited metabolic disorders in 159 pediatric patients from a single center: influence of cellular composition of the graft on transplantation outcomes. Blood. 2008;112:2979-2989.

Adamkiewicz TV, Szabolcs P, Haight A, et al. Unrelated cord blood

Prasad VK, Mendizabal A, Parikh SH, et al. Unrelated donor umbilical cord

[34]

transplantation study (COBLT): outcomes of unrelated donor umbilical cord blood

Martin PL, Carter SL, Kernan NA, et al. Results of the cord blood

transplantation in pediatric patients with lysosomal and peroxisomal storage diseases. Biol Blood Marrow Transplant. 2006;12:184-194.

[35]

Transplant Outcomes in Adults with Acute Leukemia: A Comparison of Unrelated Bone Marrow (BM), Peripheral Blood (PB) and Cord Blood (CB). ASH Annual Meeting Abstracts. 2008;112:151-.

[36]

children who have received a cord-blood or bone marrow transplant from an HLA- identical sibling. Eurocord and International Bone Marrow Transplant Registry Working Committee on Alternative Donor and Stem Cell Sources. N Engl J Med.

on Alternative Donor and Stem Cell Sources. N Engl J Med. Eapen M, Rocha V, Scaradavou

Eapen M, Rocha V, Scaradavou A, et al. Effect of Stem Cell Source on

Rocha V, Wagner JE, Jr., Sobocinski KA, et al. Graft-versus-host disease in

2000;342:1846-1854.

[37]

survival in adult recipients of umbilical-cord blood from unrelated donors. N Engl J Med. 2001;344:1815-1822.

[38]

unrelated cord blood transplant: guidelines for donor choice. Exp Hematol.

Laughlin MJ, Barker J, Bambach B, et al. Hematopoietic engraftment and

Gluckman E, Rocha V, Arcese W, et al. Factors associated with outcomes of

2004;32:397-407.

[39]

cord blood hematopoietic progenitor cells and lymphocyte subsets and correlation

Cairo MS, Wagner EL, Fraser J, et al. Characterization of banked umbilical

with ethnicity, birth weight, sex, and type of delivery: a Cord Blood Transplantation (COBLT) Study report. Transfusion. 2005;45:856-866.

[40]

hematopoietic cell transplantation: comparison of umbilical cord blood and matched related donor transplantation and the impact of posttransplant complications. Biol Blood Marrow Transplant. 2009;15:564-573.

Majhail NS, Mothukuri JM, Brunstein CG, Weisdorf DJ. Costs of

[41] umbilical cord blood in 102 patients with malignant and nonmalignant diseases: influence of CD34

[41]

umbilical cord blood in 102 patients with malignant and nonmalignant diseases:

influence of CD34 cell dose and HLA disparity on treatment-related mortality and

survival. Blood. 2002;100:1611-1618.

[42]

transplantation in pediatric recipients. Bone marrow transplantation. 2004;34:129-

Wagner JE, Barker JN, DeFor TE, et al. Transplantation of unrelated donor

Styczynski J, Cheung YK, Garvin J, et al. Outcomes of unrelated cord blood

136.

YK, Garvin J, et al. Outcomes of unrelated cord blood 136. [43] Blood Transplantation Symposium, Los

[43]

Blood Transplantation Symposium, Los Angeles, California, June 5-6, 2009. Biol Blood Marrow Transplant. 2009;16:12-27.

[44]

2006;12:808-812.

[45]

dose and HLA match on transplantation outcome in 1061 cord blood recipients with hematologic malignancies. Blood. 2010;115:1843-1849.

[46]

transplantation from unrelated and HLA-mismatched related donors. Transfus Sci.

Wagner JE, Laughlin M, Petz L. Seventh Annual International Umbilical Cord

Gluckman E. Cord blood transplantation. Biol Blood Marrow Transplant.

Barker JN, Scaradavou A, Stevens CE. Combined effect of total nucleated cell

Anasetti C, Hansen JA. Effect of HLA incompatibility in marrow

1994;15:221-230.

[47]

Survival after transplantation of unrelated donor umbilical cord blood is comparable to that of human leukocyte antigen-matched unrelated donor bone marrow: results of a matched-pair analysis. Blood. 2001;97:2957-2961.

[48]

Reexposure of cord blood to noninherited maternal HLA antigens improves transplant outcome in hematological malignancies. Proc Natl Acad Sci U S A. 2009;106:19952-

Barker JN, Davies SM, DeFor T, Ramsay NK, Weisdorf DJ, Wagner JE.

JN, Davies SM, DeFor T, Ramsay NK, Weisdorf DJ, Wagner JE. van Rood JJ, Stevens CE,

van Rood JJ, Stevens CE, Smits J, Carrier C, Carpenter C, Scaradavou A.

19957.

[49]

transplantation. Curr Opin Immunol. 2006;18:571-575.

[50]

matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood. 2005;105:1343-1347.

[51]

umbilical cord blood transplantation in adults. Biol Blood Marrow Transplant.

Majhail NS, Brunstein CG, Wagner JE. Double umbilical cord blood

Barker JN, Weisdorf DJ, DeFor TE, et al. Transplantation of 2 partially HLA-

Ballen KK, Spitzer TR, Yeap BY, et al. Double unrelated reduced-intensity

2007;13:82-89.

[52]

transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood. 2007;110:3064-3070.

[53]

Brunstein CG, Barker JN, Weisdorf DJ, et al. Umbilical cord blood

Verneris MR, Brunstein CG, Barker J, et al. Relapse risk after umbilical cord

blood transplantation: enhanced graft-versus-leukemia effect in recipients of 2 units. Blood. 2009;114:4293-4299.

[54]

for children and adolescents. Ann Hematol. 2010.

[55]

disease after unrelated donor umbilical cord blood transplantation: analysis of risk factors. Blood. 2009;113:2410-2415.

MacMillan ML, Weisdorf DJ, Brunstein CG, et al. Acute graft-versus-host

Kang HJ, Yoo KH, Lee JW, et al. Double umbilical cord blood transplantation

[56] Scaradavou A, Smith KM, Hawke R, et al. Cord blood units with low CD34+

[56]

Scaradavou A, Smith KM, Hawke R, et al. Cord blood units with low CD34+

cell viability have a low probability of engraftment after double unit transplantation. Biol Blood Marrow Transplant;16:500-508.

[57]

predominant unit in the setting of reduced-intensity double cord blood transplantation. Bone marrow transplantation. 2008;41:523-529.

[58]

Cell Rev. 2006;2:81-86.

[59]

haemopoietic stem cell. Blood Cells. 1978;4:7-25.

[60]

niche and control of the niche size. Nature. 2003;425:836-841.

[61]

unit umbilical cord blood transplantation coincides with a specific CD8+ T-cell response against the nonengrafted unit. Blood. 2010;115:757-765.

[62]

blood. Cytotherapy. 2005;7:243-250.

Haspel RL, Kao G, Yeap BY, et al. Preinfusion variables predict the

Haspel RL, Ballen KK. Double cord blood transplants: filling a niche? Stem

KK. Double cord blood transplants: filling a niche? Stem Schofield R. The relationship between the spleen

Schofield R. The relationship between the spleen colony-forming cell and the

Zhang J, Niu C, Ye L, et al. Identification of the haematopoietic stem cell

Gutman JA, Turtle CJ, Manley TJ, et al. Single-unit dominance after double-

Robinson S, Niu T, de Lima M, et al. Ex vivo expansion of umbilical cord

McNiece I, Jones R, Bearman SI, et al. Ex vivo expanded peripheral blood

de Lima M, McMannis J, Gee A, et al. Transplantation of ex vivo expanded

J, Gee A, et al. Transplantation of ex vivo expanded Jaroscak J, Goltry K, Smith A,

Jaroscak J, Goltry K, Smith A, et al. Augmentation of umbilical cord blood

Shpall EJ, Quinones R, Giller R, et al. Transplantation of ex vivo expanded

Hofmeister CC, Zhang J, Knight KL, Le P, Stiff PJ. Ex vivo expansion of

Delaney C, Heimfeld S, Brashem-Stein C, Voorhies H, Manger RL, Bernstein

Cairo MS, Rocha V, Gluckman E, Hale G, Wagner J. Alternative allogeneic

Gluckman EG, Roch VV, Chastang C. Use of Cord Blood Cells for Banking

Rocha V, Cornish J, Sievers EL, et al. Comparison of outcomes of unrelated

[63]

progenitor cells provide rapid neutrophil recovery after high-dose chemotherapy in

patients with breast cancer. Blood. 2000;96:3001-3007.

[64]

cord blood cells using the copper chelator tetraethylenepentamine: a phase I/II clinical trial. Bone Marrow Transplant. 2008;41:771-778.

[65]

(UCB) transplantation with ex vivo-expanded UCB cells: results of a phase 1 trial using the AastromReplicell System. Blood. 2003;101:5061-5067.

[66]

cord blood. Biol Blood Marrow Transplant. 2002;8:368-376.

[67]

umbilical cord blood stem cells for transplantation: growing knowledge from the hematopoietic niche. Bone Marrow Transplant. 2007;39:11-23.

[68]

ID. Notch-mediated expansion of human cord blood progenitor cells capable of rapid myeloid reconstitution. Nat Med. 2010;16:232-236.

[69]

donor sources for transplantation for childhood diseases: unrelated cord blood and haploidentical family donors. Biol Blood Marrow Transplant. 2008;14:44-53.

[70]

and Transplant. Oncologist. 1997;2:340-343.

[71]

bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood. 2001;97:2962-2971.

[72]

donors in patients with Hurler's syndrome. N Engl J Med. 2004;350:1960-1969.

[73]

umbilical cord blood transplantation in children and adolescent recipients with

Staba SL, Escolar ML, Poe M, et al. Cord-blood transplants from unrelated

Bradley MB, Satwani P, Baldinger L, et al. Reduced intensity allogeneic

malignant and non-malignant diseases. Bone marrow transplantation. 2007;40:621- 631. [74] Satwani P, Tallamy B, Jin

malignant and non-malignant diseases. Bone marrow transplantation. 2007;40:621-

631.

[74]

Satwani P, Tallamy B, Jin Z, et al. Reduced Intensity Conditioning (RIC)

Allogeneic Stem Cell Transplantation (AlloSCT) In Children and Adolescent Recipients is Associated With Very Low Regimen Related and Non-Relapse Mortality (NRM): However, Chemonaive Patients Following Umbilical Cord Blood Transplant (UCBT) have a Higher Incidence of Primary Graft Failure (PGF). Biology

a Higher Incidence of Primary Graft Failure (PGF). Biology of blood and marrow transplantation : journal

of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2009;15:75-76.

[75]

subset reconstitution after either related or unrelated cord blood transplantation in children -- a Eurocord analysis. Br J Haematol. 2001;114:42-48.

[76]

after cord blood transplantation is characterized by impaired thymopoiesis and late memory T-cell skewing. Blood. 2007;110:4543-4551.

[77]

versus-host disease, and immune recovery following unrelated donor cord blood transplantation. Blood. 2000;96:2703-2711.

[78]

immune reconstitution. Seminars in hematology;47:22-36.

[79]

to lymphocytes. Biol Blood Marrow Transplant. 2006;12:42-46.

[80]

an efficient thymic function indicate a favorable long-term immune reconstitution after cord blood stem cell transplantation. Blood. 2002;99:1458-1464.

[81]

decreases leukemic relapse and improves survival in recipients of unrelated cord blood transplantation. Biol Blood Marrow Transplant. 2006;12:919-927.

Niehues T, Rocha V, Filipovich AH, et al. Factors affecting lymphocyte

Komanduri KV, St John LS, de Lima M, et al. Delayed immune reconstitution

Thomson BG, Robertson KA, Gowan D, et al. Analysis of engraftment, graft-

Szabolcs P, Cairo MS. Unrelated umbilical cord blood transplantation and

Crooks GM, Weinberg K, Mackall C. Immune reconstitution: from stem cells

K, Mackall C. Immune reconstitution: from stem cells Talvensaari K, Clave E, Douay C, et al.

Talvensaari K, Clave E, Douay C, et al. A broad T-cell repertoire diversity and

Parkman R, Cohen G, Carter SL, et al. Successful immune reconstitution

[82]

(RTC) Compared to Myeloablative Conditioning (MAC) Prior to Unrelated Cord

Freedman J, George D, Jacobson J, et al. Reduced Toxicity Conditioning

Blood Transplantation (UCBT) in Pediatric Recipients Was Associated with Similar but Also Delayed Time to Immune Reconstitution and a Concomitant Significant Decrease in Grade II-IV Agvhd. ASH Annual Meeting Abstracts. 2009;114:2304.

[83]

(COBLT): cord blood bank standard operating procedures. J Hematother. 1998;7:521-

561.

[84]

to determine inventory size for a national cord blood bank. Med Decis Making.

Fraser JK, Cairo MS, Wagner EL, et al. Cord Blood Transplantation Study

Howard DH, Meltzer D, Kollman C, et al. Use of cost-effectiveness analysis

2008;28:243-253.

[85]

promotion of ethical research with human biologic material. J Lab Clin Med.

2005;145:118-124.

[86]

Preimplantation HLA testing. JAMA. 2004;291:2079-2085.

[87]

derived cells. Trends Biotechnol. 2004;22:136-141.

Jenkins GL, Sugarman J. The importance of cultural considerations in the

Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M, Kuliev A.

Drukker M, Benvenisty N. The immunogenicity of human embryonic stem-

[88] from adult human fibroblasts by defined factors. Cell. 2007;131:861-872. [89] embryonic and adult fibroblast

[88]

from adult human fibroblasts by defined factors. Cell. 2007;131:861-872.

[89]

embryonic and adult fibroblast cultures by defined factors. Cell. 2006;126:663-676.

Feng B, Ng JH, Heng JC, Ng HH. Molecules that promote or enhance

reprogramming of somatic cells to induced pluripotent stem cells. Cell Stem Cell.

2009;4:301-312.

[91]

pluripotent stem cells from mouse embryonic fibroblasts by Oct4 and Klf4 with small-molecule compounds. Cell Stem Cell. 2008;3:568-574.

[92]

HIV-1 TAT recombinant proteins OCT4, SOX2, KLF4 and c-MYC. Mol Biol

Rep;37:2117-2124.

[93]

induction of pluripotency and subsequent excision of reprogramming factors. Nature.

2009;458:771-775.

[94]

umbilical cord blood multipotent stem cells for nonhematopoietic tissue and cell regeneration. Exp Hematol. 2007;35:1753-1765.

[95]

stem cells from human cord blood using OCT4 and SOX2. Cell Stem Cell.

2009;5:353-357.

[96]

generation of iPS cells from CD34+ cord blood cells by inhibition of p53. Exp

[90]

Takahashi K, Tanabe K, Ohnuki M, et al. Induction of pluripotent stem cells

Takahashi K, Yamanaka S. Induction of pluripotent stem cells from mouse

Yamanaka S. Induction of pluripotent stem cells from mouse Shi Y, Desponts C, Do JT, Hahm

Shi Y, Desponts C, Do JT, Hahm HS, Scholer HR, Ding S. Induction of

Pan C, Lu B, Chen H, Bishop CE. Reprogramming human fibroblasts using

Kaji K, Norrby K, Paca A, Mileikovsky M, Mohseni P, Woltjen K. Virus-free

van de Ven C, Collins D, Bradley MB, Morris E, Cairo MS. The potential of

Giorgetti A, Montserrat N, Aasen T, et al. Generation of induced pluripotent

N, Aasen T, et al. Generation of induced pluripotent Takenaka C, Nishishita N, Takada N, Jakt

Takenaka C, Nishishita N, Takada N, Jakt LM, Kawamata S. Effective

Hematol;38:154-162.

[97]

immunobiology and role in immunomodulation and tissue regeneration. Cytotherapy.

Kode JA, Mukherjee S, Joglekar MV, Hardikar AA. Mesenchymal stem cells:

2009;11:377-391.

[98]

cells. Cytotherapy. 2003;5:485-489.

[99]

mesenchymal stem cells from bone marrow, umbilical cord blood, and adipose tissue. Exp Biol Med (Maywood). 2008;233:901-913.

[100]

mesenchymal stem cells are enriched at different gestational ages in human umbilical cord blood. Pediatr Res. 2008;64:68-73.

[101]

endothelial progenitor cells using human peripheral and umbilical cord blood. Blood.

Le Blanc K. Immunomodulatory effects of fetal and adult mesenchymal stem

Rebelatto CK, Aguiar AM, Moretao MP, et al. Dissimilar differentiation of

Javed MJ, Mead LE, Prater D, et al. Endothelial colony forming cells and

Ingram DA, Mead LE, Tanaka H, et al. Identification of a novel hierarchy of

2004;104:2752-2760.

[102]

placental cord blood with intrinsic pluripotent differentiation potential. J Exp Med.

2004;200:123-135.

[103]

axis-mediated tropism of cord blood-derived unrestricted somatic stem cells for neuronal injury. J Biol Chem. 2008;283:32244-32253.

Kogler G, Sensken S, Airey JA, et al. A new human somatic stem cell from

Trapp T, Kogler G, El-Khattouti A, et al. Hepatocyte growth factor/c-MET

[104] cord blood derived unrestricted somatic stem cells is not suitable to improve LV function

[104]

cord blood derived unrestricted somatic stem cells is not suitable to improve LV function after myocardial infarction in swine. J Mol Cell Cardiol. 2007;42:735-745.

[105]

healing and migration of cord blood-derived stem cells into a critical size femoral defect after xenotransplantation. J Bone Miner Res. 2007;22:1224-1233.

[106]

ventricular function after a myocardial infarction: a preclinical study of human

Moelker AD, Baks T, Wever KM, et al. Intracoronary delivery of umbilical

Jager M, Degistirici O, Knipper A, Fischer J, Sager M, Krauspe R. Bone

Kim BO, Tian H, Prasongsukarn K, et al. Cell transplantation improves

H, Prasongsukarn K, et al. Cell transplantation improves Iwasaki H, Kawamoto A, Willwerth C, et al.

Iwasaki H, Kawamoto A, Willwerth C, et al. Therapeutic potential of

Rabald S, Marx G, Mix B, et al. Cord blood cell therapy alters LV remodeling

Kluth SM, Buchheiser A, Houben AP, et al. DLK-1 as a marker to distinguish

Liedtke S, Buchheiser A, Bosch J, et al. The HOX Code as a "biological

Ebrahimi H, Soleimani M, Kazemi Arababadi M, et al. An in vitro assay to

Ebrahimi H, Soleimani M, Kazemi Arababadi M, et al. An in vitro assay to

Winter M, Wang XN, Daubener W, et al. Suppression of cellular immunity by

Kogler G, Radke TF, Lefort A, et al. Cytokine production and hematopoiesis

Chan SL, Choi M, Wnendt S, et al. Enhanced in vivo homing of uncultured

Aktas M, Buchheiser A, Houben A, et al. Good manufacturing practice-grade

McGuckin C, Jurga M, Ali H, Strbad M, Forraz N. Culture of embryonic-like

McGuckin CP, Forraz N, Baradez MO, et al. Production of stem cells with

unrestricted somatic stem cells in a porcine model. Circulation. 2005;112:I96-104.

[107]

unrestricted somatic stem cells isolated from placental cord blood for cardiac repair post myocardial infarction. Arterioscler Thromb Vasc Biol. 2009;29:1830-1835.

[108]

and cytokine expression but does not improve heart function after myocardial infarction in rats. Cell Physiol Biochem. 2008;21:395-408.

[109]

unrestricted somatic stem cells and mesenchymal stromal cells in cord blood. Stem Cells Dev.

[110]

fingerprint" to distinguish functionally distinct stem cell populations derived from cord blood. Stem Cell Res.

[111]

evaluate the immunomodulatory effects of unrestricted somatic stem cells. Iran J

Immunol;7:30-38.

[112]

cord blood-derived unrestricted somatic stem cells is cytokine-dependent. J Cell Mol Med. 2009;13:2465-2475.

[113]

supporting activity of cord blood-derived unrestricted somatic stem cells. Exp Hematol. 2005;33:573-583.

[114]

and selectively amplified cord blood CD34+ cells by cotransplantation with cord blood-derived unrestricted somatic stem cells. Stem Cells. 2007;25:529-536.

[115]

production of unrestricted somatic stem cell from fresh cord blood.

Cytotherapy;12:338-348.

[116]

stem cells from human umbilical cord blood and onward differentiation to neural cells

in vitro. Nat Protoc. 2008;3:1046-1055.

[117]

embryonic characteristics from human umbilical cord blood. Cell Prolif. 2005;38:245-

255.

[118]

McGuckin C, Forraz N, Baradez MO, et al. Embryonic-like stem cells from

umbilical cord blood and potential for neural modeling. Acta Neurobiol Exp (Wars).

2006;66:321-329.

[119]

Domanska-Janik K. Early appearance of stem/progenitor cells with neural-like

Habich A, Jurga M, Markiewicz I, Lukomska B, Bany-Laszewicz U,

characteristics in human cord blood mononuclear fraction cultured in vitro. Exp Hematol. 2006;34:914-925. [120] Neural

characteristics in human cord blood mononuclear fraction cultured in vitro. Exp Hematol. 2006;34:914-925.

[120]

Neural stem-like cell line derived from a nonhematopoietic population of human umbilical cord blood. Stem Cells Dev. 2006;15:391-406.

[121]

like (VSEL) CXCR4(+)SSEA-1(+)Oct-4+ stem cells identified in adult bone marrow.

Leukemia. 2006;20:857-869.

[122]

characterization of novel population of CXCR4+ SSEA-4+ Oct-4+ very small embryonic-like cells purified from human cord blood: preliminary report. Leukemia.

2007;21:297-303.

[123]

control pluripotency and quiescence of adult bone marrow-derived Oct4(+) very small embryonic-like stem cells. Leukemia. 2009;23:2042-2051.

[124]

embryonic-like stem cells are mobilized into peripheral blood in patients after stroke. Stroke. 2009;40:1237-1244.

[125]

derived Oct-4+ SSEA-4+ very small embryonic-like stem cells in patients with acute myocardial infarction. J Am Coll Cardiol. 2009;53:1-9.

[126]

of pluripotent unrestricted somatic stem cells with mesenchymal stem cells from human cord blood. Exp Hematol. 2006;34:1589-1595.

[127]

patient, transplanted of multipotent stem cells from human UC blood, with improved

Buzanska L, Jurga M, Stachowiak EK, Stachowiak MK, Domanska-Janik K.

Kucia M, Reca R, Campbell FR, et al. A population of very small embryonic-

R, Campbell FR, et al. A population of very small embryonic- Kucia M, Halasa M, Wysoczynski

Kucia M, Halasa M, Wysoczynski M, et al. Morphological and molecular

Shin DM, Zuba-Surma EK, Wu W, et al. Novel epigenetic mechanisms that

Paczkowska E, Kucia M, Koziarska D, et al. Clinical evidence that very small

Wojakowski W, Tendera M, Kucia M, et al. Mobilization of bone marrow-

Kogler G, Sensken S, Wernet P. Comparative generation and characterization

S, Wernet P. Comparative generation and characterization Kang KS, Kim SW, Oh YH, et al. A

Kang KS, Kim SW, Oh YH, et al. A 37-year-old spinal cord-injured female

Valbonesi M, Giannini G, Migliori F, Dalla Costa R, Dejana AM. Cord blood

Chen J, Sanberg PR, Li Y, et al. Intravenous administration of human

Jin K, Sun Y, Xie L, et al. Comparison of ischemia-directed migration of

Kelly S, Bliss TM, Shah AK, et al. Transplanted human fetal neural stem cells

Willing AE, Lixian J, Milliken M, et al. Intravenous versus intrastriatal cord

sensory perception and mobility, both functionally and morphologically: a case study. Cytotherapy. 2005;7:368-373.

[128]

(CB) stem cells for wound repair. Preliminary report of 2 cases. Transfus Apher Sci.

2004;30:153-156.

[129]

umbilical cord blood reduces behavioral deficits after stroke in rats. Stroke.

2001;32:2682-2688.

[130]

neural precursor cells after intrastriatal, intraventricular, or intravenous transplantation in the rat. Neurobiol Dis. 2005;18:366-374.

[131]

survive, migrate, and differentiate in ischemic rat cerebral cortex. Proc Natl Acad Sci U S A. 2004;101:11839-11844.

[132]

blood administration in a rodent model of stroke. J Neurosci Res. 2003;73:296-307.

[133]

Borlongan CV, Evans A, Yu G, Hess DC. Limitations of intravenous human

bone marrow CD133+ cell grafts in stroke rats. Brain Res. 2005;1048:116-122.

[134]

Vendrame M, Cassady J, Newcomb J, et al. Infusion of human umbilical cord

blood cells in a rat model of stroke dose-dependently rescues behavioral deficits and reduces infarct volume. Stroke. 2004;35:2390-2395.

[135] in the ischemic penumbra following stroke: association with bone marrow cell homing to injury.

[135]

in the ischemic penumbra following stroke: association with bone marrow cell homing to injury. J Neuropathol Exp Neurol. 2004;63:84-96.

[136]

induced migration of human umbilical cord blood cells: time course and cytokines. Stem Cells Dev. 2005;14:576-586.

[137]

entry of peripherally injected umbilical cord blood cells is not required for neuroprotection in stroke. Stroke. 2004;35:2385-2389.

[138]

Willing AE. Timing of cord blood treatment after experimental stroke determines therapeutic efficacy. Cell Transplant. 2006;15:213-223.

[139]

cells administered 1 month after stroke. J Cereb Blood Flow Metab. 2007;27:6-13.

[140]

population of umbilical cord blood stem cells ameliorates neurological deficits associated with ischemic brain injury. Stem Cells Dev. 2005;14:722-733.

[141]

stroke enhances neurogenesis via angiogenesis in a mouse model. J Clin Invest.

2004;114:330-338.

[142]

human cord blood cells in a rat model of stroke. Stem Cells Dev. 2005;14:595-604.

[143]

Decrease Microglial Survival in Vitro. Stem Cells Dev. 2009.

[144]

induced changes in splenocyte phenotype and function. Exp Neurol. 2006;199:191-

200.

[145]

cord blood treatment in a mouse model of ALS: optimization of cell dose. PLoS One.

Hill WD, Hess DC, Martin-Studdard A, et al. SDF-1 (CXCL12) is upregulated

Newman MB, Willing AE, Manresa JJ, Davis-Sanberg C, Sanberg PR. Stroke-

Borlongan CV, Hadman M, Sanberg CD, Sanberg PR. Central nervous system

CV, Hadman M, Sanberg CD, Sanberg PR. Central nervous system Newcomb JD, Ajmo CT, Jr., Sanberg

Newcomb JD, Ajmo CT, Jr., Sanberg CD, Sanberg PR, Pennypacker KR,

Shen LH, Li Y, Chen J, et al. Therapeutic benefit of bone marrow stromal

Xiao J, Nan Z, Motooka Y, Low WC. Transplantation of a novel cell line

Taguchi A, Soma T, Tanaka H, et al. Administration of CD34+ cells after

Vendrame M, Gemma C, de Mesquita D, et al. Anti-inflammatory effects of

Gemma C, de Mesquita D, et al. Anti-inflammatory effects of Jiang L, Womble TA, Saporta S,

Jiang L, Womble TA, Saporta S, et al. Human Umbilical Cord Blood Cells

Vendrame M, Gemma C, Pennypacker KR, et al. Cord blood rescues stroke-

Garbuzova-Davis S, Sanberg CD, Kuzmin-Nichols N, et al. Human umbilical

Imitola J, Raddassi K, Park KI, et al. Directed migration of neural stem cells

Ende N, Chen R. Human umbilical cord blood cells ameliorate Huntington's

Garbuzova-Davis S, Willing AE, Zigova T, et al. Intravenous administration

Park KI, Hack MA, Ourednik J, et al. Acute injury directs the migration,

Meier C, Middelanis J, Wasielewski B, et al. Spastic paresis after perinatal

2008;3:e2494.

[146]

to sites of CNS injury by the stromal cell-derived factor 1alpha/CXC chemokine receptor 4 pathway. Proc Natl Acad Sci U S A. 2004;101:18117-18122.

[147]

disease in transgenic mice. J Med. 2001;32:231-240.

[148]

of human umbilical cord blood cells in a mouse model of amyotrophic lateral sclerosis: distribution, migration, and differentiation. J Hematother Stem Cell Res.

2003;12:255-270.

[149]

proliferation, and differentiation of solid organ stem cells: evidence from the effect of hypoxia-ischemia in the CNS on clonal "reporter" neural stem cells. Exp Neurol.

2006;199:156-178.

[150]

brain damage in rats is reduced by human cord blood mononuclear cells. Pediatr Res.

2006;59:244-249.

[151] of neural progenitors to sites of neuroinflammation. J Neurosci. 2006;26:3182-3191. [152] Migration of Human

[151]

of neural progenitors to sites of neuroinflammation. J Neurosci. 2006;26:3182-3191.

[152]

Migration of Human Umbilical Cord Blood Cells in Models of Stroke. Curr Neurovasc Res. 2008;5:118-124.

[153]

ischemic cortex: cell survival and effect on sensorimotor behavior. J Neurosci Res.

2006;83:1004-1014.

[154]

infarction: from bench to bedside. Heart. 2009;95:508-514.

[155]

for myocardial regeneration. Transplant Proc. 2006;38:771-773.

[156]

Human umbilical cord blood mononuclear cells for the treatment of acute myocardial infarction. Cell Transplant. 2004;13:729-739.

[157]

improve cardiac function after myocardial infarction. Biochem Biophys Res Commun. 2005;327:609-614.

[158]

CD133+ cells enhance function and repair of the infarcted myocardium. Stem Cells.

2006;24:772-780.

[159]

angiogenesis following myocardial infarction in NOD/scid-mice. Cardiovasc Res.

Belmadani A, Tran PB, Ren D, Miller RJ. Chemokines regulate the migration

Jiang L, Newman M, Saporta S, et al. MIP-1alpha and MCP-1 Induce

Bliss TM, Kelly S, Shah AK, et al. Transplantation of hNT neurons into the

S, Shah AK, et al. Transplantation of hNT neurons into the Mollmann H, Nef H, Elsasser

Mollmann H, Nef H, Elsasser A, Hamm C. Stem cells in myocardial

Ma N, Ladilov Y, Kaminski A, et al. Umbilical cord blood cell transplantation

Henning RJ, Abu-Ali H, Balis JU, Morgan MB, Willing AE, Sanberg PR.

Hirata Y, Sata M, Motomura N, et al. Human umbilical cord blood cells

Leor J, Guetta E, Feinberg MS, et al. Human umbilical cord blood-derived

Ma N, Stamm C, Kaminski A, et al. Human cord blood cells induce

Ma N, Stamm C, Kaminski A, et al. Human cord blood cells induce

Henning RJ, Burgos JD, Vasko M, et al. Human cord blood cells and

Ghodsizad A, Niehaus M, Kogler G, et al. Transplanted human cord blood-

2005;66:45-54.

[160]

myocardial infarction: effect of dose and route of administration on infarct size. Cell Transplant. 2007;16:907-917.

[161]

derived unrestricted somatic stem cells improve left-ventricular function and prevent

left-ventricular dilation and scar formation after acute myocardial infarction. Heart.

2009;95:27-35.

[162]

intracoronary bone-marrow-derived stem cell transplantation after ST-elevation myocardial infarction. Nat Clin Pract Cardiovasc Med. 2006;3 Suppl 1:S52-56.

[163]

preconditioning approach with stem cell transplantation. J Mol Cell Cardiol.

Bartunek J, Wijns W, Heyndrickx GR, Vanderheyden M. Timing of

Haider H, Ashraf M. Strategies to promote donor cell survival: combining

2008;45:554-566.

[164]

neural stem cells supported by scaffolds to reconstitute lost tissue. Nat Biotechnol.

Park KI, Teng YD, Snyder EY. The injured brain interacts reciprocally with

2002;20:1111-1117.

Table 1. Outcomes following unrelated umbilical cord blood transplantation vs. other stem cell sources in

Table 1. Outcomes following unrelated umbilical cord blood transplantation vs. other stem cell sources in the treatment of hematologic malignancies

Report Diseases Cell Source and HLA Match N Age Range in Years (Median) Median Time
Report
Diseases
Cell Source and
HLA Match
N
Age Range in
Years (Median)
Median Time to
Engraftment in
Days
Incidence of
Incidence
Incidence
DFS
OS
Grade II-IV
of TRM
of Relapse
aGVHD
*
*
*
2 yr:
2
yr:
2 yr:
Rocha et al., NEJM,
ALL, AML
MUBMT
584
15-59 (32)
19
39%
38%
23%
38%
42%
2004
(Ref. 17)
M/1-3MMUCBT
98
15-55 (24.5)
26
26%
44%
23%
33%
36%
*
*
*
*
*3yr:
*3yr:
Laughlin et al., NEJM,
ALL, AML,
MUBMT
367
All 16-60
18
48%
46%
23%
33%
35%
2004
(Ref. 18)
CML, MDS
1MMUBMT
83
20
52%
65%
14%
19%
20%
1-2MMUCBT
150
27
41%
63%
17%
23%
26%
*
*
*
*
*CR1 /ADV
Eapen et al., JCO, 2006
(Ref. 15)
ALL, AML
MSDT
101
│<1.5, All
17
Unspecified
6%
47% /65%
3yr, CR1 /ADV
49% /20%
3yr, CR1 /ADV
54% /35%
M/1MMUBMT
85
│ <18 months
18
15%
│24%/45%
│54%/30%
│62%/33%
M/1MMUCBT
81
22
31%
*
*
*
*
*
*5yr:
Eapen et al., Lancet,
ALL, AML
MUBMT
116
│All <16
│19 (all UBMT)
46%
21%
39%
38%
│Unspecified
2007
(Ref. 16)
1-2MMUBMT
166
60%
31%
31%
37%
MUCBT
35
│27 (all UCBT)
24%
6%
31%
60%
1MMUCBT(h)
│201
42%
29%
29%
45%
1MMUCBT(l)
36%
43%
20%
36%
2MMUCBT
267
41%
46%
19%
33%
*
*
*
*
2
yr, in CR/not
Eapen et al., Lancet
Oncology, 2010 (Ref.
ALL, AML
MUBMT
332
│All >16 (33)
│19
39%
22%
34%
52%/17%
│Unspecified
1MMUBMT
140
46%
34%
30%
41%/14%
19)
MUPBSCT
632
│(39)
│14
48%
24%
33%
50%/17%
1MMUPBSCT
256
52%
38%
30%
39%/17%
M/1-2MMUCBT
165
(28)
24
30%
37%
26%
44%/15%
*= p<0.05 between two or more compared groups, ALL= acute lymphoblastic leukemia, AML= acute myeloid leukemia, CML= chronic myeloid leukemia, MDS= myelodysplastic syndrome,
CR1= first complete response, ADV= relapse or ≥CR2, M/MM matched/mismatched (MM preceded by number of HLA mismatches), UBMT= unrelated bone marrow transplant, UCBT=
umbilical cord blood transplant, MSDT= matched sibling donor stem cell transplant, UPBSCT= unrelated peripheral blood stem cell transplant, (h) vs. (l)= cell dose > vs. ≤ 3x10 7 total
nucleated cells/kg recipient body weight, aGVHD= acute graft versus host disease, TRM= transplant-related mortality, DFS= disease free survival, OS= overall survival
Table 2. Advantages and disadvantages of unrelated cord blood vs. unrelated adult donor stem cell

Table 2. Advantages and disadvantages of unrelated cord blood vs. unrelated adult donor stem cell transplantation

Advantages of UCBT Disadvantages of UCBT Decreased risk to donor Faster procurement Lower incidence of
Advantages of UCBT
Disadvantages of UCBT
Decreased risk to donor
Faster procurement
Lower incidence of grade II-IV
acute GVHD
Enhanced ability to cross donor-
recipient HLA disparities
Difficult to achieve sufficient total nucleated cell dose in
larger recipients using single cord blood unit
Delayed engraftment and increased risk of graft failure
Delayed T-cell immune reconstitution
Increased risk of transplant-related mortality
Increased costs of hospitalization
No obvious cell source for post-transplant donor
lymphocyte infusions
Figure Legends Figure 1. Probability of leukemia-free survival after bone-marrow and cord- blood transplantation adjusted

Figure Legends

Figure 1. Probability of leukemia-free survival after bone-marrow and cord-

blood transplantation adjusted for disease status at transplantation.

Reprinted from The Lancet, Vol. 369, Eapen M, Rubinstein P, Zhang MJ, Stevens C,

Vol. 369, Eapen M, Rubinstein P, Zhang MJ, Stevens C, Kurtzberg J, Scaradavou A, et al.

Kurtzberg J, Scaradavou A, et al. Outcomes of transplantation of unrelated donor

umbilical cord blood and bone marrow in children with acute leukaemia: a

comparison study, pages 1947-54, Copyright (2007), with permission from

Elsevier.[16]

Figure 2: Probabilities of transplant-related mortality by hematopoietic stem-cell

source and donor–recipient HLA matching in adults with acute leukemias.

HLA matching in adults with acute leukemias. Reprinted from Lancet Oncology, 11/7, Eapen M., Rocha V.,

Reprinted from Lancet Oncology, 11/7, Eapen M., Rocha V., Sanz G., Scaradavou A.,

Zhang M-J., Arcese W., Sirvent A., Champlin R.E., Chao N., Gee A.P., Isola L.,

Laughlin M.J., Marks D.I., Nabhan S., Ruggeri A., Soiffer R., Horowitz M.M.,

Gluckman E., Wagner J.E., Effect of graft source on unrelated donor haemopoietic

stem-cell transplantation in adults with acute leukaemia: a retrospective analysis, 653-

660, Copyright (2010), with permission from Elsevier.”

Figure 3. Cumulative incidence of 3-year TRM following UCBT. Data are shown

by TNC dose (A), HLA-mismatch (B), TNC dose and HLA-mismatch combined (C),

and the Kaplan-Meier probability of disease-free survival (D). Recipients of units

with either 1 or 2 mismatches were analyzed by separate TNC dose categories,

whereas recipients of 0-MM units and 3-MM units were not.

Blood: journal of the American Society of Hematology by Barker JN, Scaradavou A,

Stevens CE Copyright 2010 by AMERICAN SOCIETY OF HEMATOLOGY (ASH). Reproduced with permission of AMERICAN

Stevens CE

Copyright 2010 by AMERICAN SOCIETY OF HEMATOLOGY

(ASH). Reproduced with permission of AMERICAN SOCIETY OF

HEMATOLOGY (ASH) in the format Journal via Copyright Clearance Center.[45]

in the format Journal via Copyright Clearance Center.[45] Figure 4. Cumulative incidence of leukemic relapse by

Figure 4. Cumulative incidence of leukemic relapse by positive (solid line) vs.

negative (dotted line) proliferative response status to the herpes viruses (CMV, HSV,

VZV), (p =0.003). Those with antigen-specific proliferative responses to any of the 3

viruses at any time during the 3-year observation period were considered positive.

Reprinted from Biol Blood Marrow Transplant, Vol 12/9, Parkman R, Cohen G,

Carter SL, Weinberg KI, Masinsin B, Guinan E et al. Successful immune

reconstitution decreases leukemic relapse and improves survival in recipients of

leukemic relapse and improves survival in recipients of unrelated cord blood transplantation, pages 919-927,

unrelated cord blood transplantation, pages 919-927, Copyright (2006), with

permission from Elsevier.[81]

Figure 5. Human cord blood as a stem cell source for cell-based regenerative

therapies. Human cord blood is now routinely used as an autologous or allogeneic

HSC source to treat both malignant and non-malignant diseases. Cord blood

mononuclear cells and enriched stem cell populations have both shown great potential

in preclinical cell-based therapies for various degenerative diseases such as stroke and

myocardial infarction. Cord blood contains multiple populations of tissue stem cells

and progenitors, as well as primitive stem cells, which can further be differentiated to

cells representative of all three embryonic germ layers. These primitive stem cells can

therefore be a potential alternative to ES or iPS cells for the derivation of somatic

cells for tissue regeneration.