Marrow-Derived Autologous Stromal Cells for the Restoration of Salivary Hypofunction (MARSH): A pilot, first-in-human study of interferon gamma-stimulated marrow mesenchymal stromal cells for treatment of radiation-induced xerostomia

Abstract

Background aims: Xerostomia, or the feeling of dry mouth, is a significant side effect of radiation therapy for patients with head and neck cancer (HNC). Preliminary data suggest that mesenchymal stromal/stem cells (MSCs) can improve salivary function. We performed a first-in-human pilot study of interferon gamma (IFNγ)-stimulated autologous bone marrow-derived MSCs, or MSC(M), for the treatment of radiation-induced xerostomia (RIX). Here we present the primary safety and secondary efficacy endpoints.

Methods: A single-center pilot clinical trial was conducted investigating the safety and tolerability of autologous IFNγ-stimulated MSC(M). The study was conducted under an approved Food and Drug Administration Investigational New Drug application using an institutional review board-approved protocol (NCT04489732). Patients underwent iliac crest bone marrow aspirate and MSC(M) were isolated, cultured, stimulated with IFNγ and cryopreserved for later use. Banked cells were thawed and allowed to recover in culture before patients received a single injection of 10 × 10⁶ MSC(M) into the right submandibular gland under ultrasound guidance. The primary objective was determination of safety and tolerability by evaluating dose-limiting toxicity (DLT). A DLT was defined as submandibular pain >5 on a standard 10-point pain scale or any serious adverse event (SAE) within 1 month after injection. Secondary objectives included analysis of efficacy as measured by salivary quantification and using three validated quality of life instruments. Quantitative results are reported as mean and standard deviation.

Results: Six patients with radiation-induced xerostomia who had completed radiation at least 2 years previously (average 7.8 years previously) were enrolled in the pilot study. The median age was 71 (61-74) years. Five (83%) patients were male. Five patients (83%) were treated with chemoradiation and one patient (17%) with radiation alone. Grade 1 pain was seen in 50% of patients after submandibular gland injection; all pain resolved within 4 days. No patients reported pain 1 month after injection, with no SAE or other DLTs reported 1 month after injection. The analysis of secondary endpoints demonstrated a trend of increased salivary production. Three patients (50%) had an increase in unstimulated saliva at 1 and 3 months after MSC(M) injection. Quality of life surveys also showed a trend toward improvement.

Conclusions: Injection of autologous IFNγ-stimulated MSC(M) into a singular submandibular gland of patients with RIX is safe and well tolerated in this pilot study. A trend toward an improvement in secondary endpoints of salivary quantity and quality of life was observed. This first-in-human study provides support for further investigation into IFNγ-stimulated MSC(M) injected in both submandibular glands as an innovative approach to treat RIX and improve quality of life for patients with HNC.

Keywords: head and neck cancer; mesenchymal stromal cells; radiation; xerostomia.

Figure 1:

Secondary endpoints of salivary quantity and quality of life. A) Graph of all six patients’ mean unstimulated saliva produced at baseline, 1 month and 3 months after injection of autologous IFNγ-stimulated MSC(M) showing trend of increasing unstimulated salivary production, bars are standard deviation. Graph of individual patients’ unstimulated saliva demonstrating the large increase in saliva production seen in patient 5 and the ability of patient 4 to produce unstimulated saliva after injection of MSC(M). B) Graph of all six patients’ mean stimulated saliva produced at baseline, 1 month and 3 months after injection of autologous IFNγ-stimulated MSC(M) showing small trend of increasing stimulated salivary production, bars are standard deviation. Graph of individual patients’ stimulated saliva. C) Box and whisker plots overlayed on line graphs of individual patient’s QoL scores from all three surveys showing the trend for improvement in xerostomia-specific QoL. The box and whisker plots show the 5–95% range. Three validated, xerostomia-specific QoL surveys were used: the University of Michigan Xerostomia Related Quality of Life (XeQOL) scale, the visual analog scale (VAS) xerostomia questionnaire, and the MD Anderson Dysphagia Index (MDADI). For VAS and XeQoL lower scores represent better QoL and less severe xerostomia, for MDADI higher scores represent better QoL.