Applying extracellular vesicles based therapeutics in clinical trials – an ISEV position paper

Figures & data

Table I. Current and past NIH registered clinical trials investigating EV-based therapeutics

Disease Number of patients clinical trial (CT) phase	Source cell-type/application route	Isolation/purification	Modified/unmodified vesicle type	Results	Reference
Melanoma Stage III/IV, metastatic n=15 CT Phase I, open label	Autologous monocyte-derived dendritic cell EVs. s.c. inj.	Ultrafiltration/UC sucrose cushion	MAGE3 loaded DC-EVs	Proof of Feasibility & Safety; Toxicity<Grade II Maximum tolerated dose not reached,1 partial, 1 minor, 1 mixed response and 2 stable disease	Escudier et al. (15)
Non-Small Cell Lung Cancer Stage IIIb, n=4 Stage IV, n=9 CT Phase I, open label	Autologous monocyte-derived dendritic cell EVs. s.c. and intradermal inj.	Filtration/UC sucrose cushion	Peptide loaded	Feasibility & Safety; Toxicity<Grade I-II, 9/13 completed therapy, DTH against MAGE peptides in 3/9, specific T cell response in 1/3, NK lytic activity increased in 2/4	Morse et al. (16)
Colon Cancer Stage III or IV n=40 CT Phase I, open label	Autologous ascites-derived EVs (Aex) s.c. inj.	UC sucrose cushion	Unmodified±GM-CSF	Feasibility & Safety, Toxicity Grade I-II, TU-specific Cytotoxic T Cell Response in Aex+GM-CSF group (n=2)	Dai et al. (30)
Colon Cancer n=35 (estimated enrolment) CT Phase I, open label	Plant nanovesicles not mentioned in NCT registry: route of application	Not mentioned	Curcumin, exogenous loading		NCT01294072
Type I Diabetes n=20 (estimated enrolment) CT Phase I, open label	Umbilical cord blood (allogeneic) MSC-EVs not mentioned in NCT registry: route of application	Not mentioned	Unmodified		NCT02138331
Non-small cell lung cancer n=22 CT Phase II, open label	Autologous IFN-γ matured monocyte-derived dendritic cell EVs intradermal inj.	Ultrafiltration/UC sucrose cushion	Peptide loaded	One patient exhibited a grade 3 hepatotoxicity. Seven patients (32%) experienced stabilization of >4 months: the primary endpoint (≥50% patients >4months) was not reached. No induction of T cell responses, but an increase in NKp30-dependent NK cell functions were evidenced in a fraction of these NSCLC patients presenting with defective NKp30 expression.	NCT01159288 Besse et al. (22)
Malignant Pleural Effusion n=30 (estimated enrolment) CT Phase II, open label	Tumour cell–derived microparticles used as vectors for chemotherapeutic drugs pleural or peritoneal cavity.	Not mentioned	Chemotherapeutic drugs, exogenous loading		NCT01854866

Aex, Ascites-derived exosomes; CT, clinical trials; DTH, delayed type hypersensitivity; DC, dendritic cells; GM-CSF, granulocyte-macrophage colony-stimulating factor; NIH, National Institute of Health; NK, natural killer; MAGE, melanoma antigen; s.c.inj, subcutaneous injection; TU, tumour.

Fig. 1.  Pharmaceutical categories and a suggested classification of EV-based therapeutics. Chart depicts the Categories of Medicinal Products with respect to their origin (chemical, biological, herbal). Medicinal Products (according to DIRECTIVE 2001/83/EC) include any substance or combination of substances for treating or preventing disease in humans. Any substance or combination of substances which may be administered to humans with a view to making a medical diagnosis or to restoring, correcting or modifying physiological functions in humans is likewise considered a medicinal product. The suggested classification of EV-based therapeutics within the class of biological medicinal products is provided (grey fields). Bold indicates categories from which existing legislation is recommended to be considered for preclinical and clinical development of EV-therapeutics.

Table II. To be defined and established by investigators before (or concomitant to) clinical application of EV-based therapeutics

- Source of the starting material
- Donor inclusion/exclusion, donor release criteria
- Autologous, allogeneic, xenogeneic, bacterial, pathogen or plant EVs
- EV-source characterization (donors, donor cells/tissues/fluids, culture reagents)
- EV isolation and storage
- Isolation techniques and standardization
- Purity and impurities
- Scalability of technology
- Storage conditions
- Adequate quality of reagents and materials
- In-process controls
- Quality control
Molecular and physical characterization
- Quantitative Analyses (counts and size)
- Qualitative Analyses (presence of EV marker(s), purity)
- Composition (surrogate marker)
- Contamination (viral, microbiological, endotoxins, toxins, allergens)
In vitro biological characterization
- Complexity and heterogeneity
- Mode of Action
- Potency of EVs (in vitro bioassays)
- Quality release criteria
-  In vivo analyses/EV application
- Selection of relevant animal models (disease specificity?/species specificity?)
- Dose selection (single/multiple applications)
- Route of application (local, systemic)
- Pharmacokinetics/ADME: Absorption – Distribution – Metabolism – Excretion
- Toxicity
- Immunogenicity, Immunotoxicity
- Tumourigenicity
- Biodistribution
- Potency of EVs (in vivo bioassays)
- Before clinical trial
- Informed consent of donors and host
- Study protocol
- Investigational medicinal product dossier
- Investigators brochure
- Ethics committee approval
- Register Entry (EMA, EudraCT or NIH, www.ClinicalTrials.gov)

Escudier B, Dorval T, Chaput N, Andre F, Caby MP, Novault S, etal. Vaccination of metastatic melanoma patients with autologous dendritic cell (DC) derived-exosomes: results of thefirst phase I clinical trial. J Transl Med. 2005; 3: 10.

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Morse MA, Garst J, Osada T, Khan S, Hobeika A, Clay TM, etal. A phase I study of dexosome immunotherapy in patients with advanced non-small cell lung cancer. J Transl Med. 2005; 3: 9.

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Dai S, Wei D, Wu Z, Zhou X, Wei X, Huang H, etal. Phase I clinical trial of autologous ascites-derived exosomes combined with GM-CSF for colorectal cancer. Mol Ther. 2008; 16: 782–90.

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Besse B, Charrier M, Lapierre V, Dansin E, Lantz O, Planchard D, etal. Dendritic cell-derived exosomes as maintenance immunotherapy after first line chemotherapy in NSCLC. Oncoimmunology. 2016; 5:in press doi: http://dx.doi.org/10.1080/2162402X.2015.1071008.

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