Treatment of Oral Chronic Graft-versus-host Disease With Human Umbilical Cord Mesenchymal Stem Cell Dressing
Phase: PHASE4
Conditions: Mesenchymal Stem Cells
Sponsor: Southwest Hospital, China

Version: v1.0
Date: September 13, 2023
Treatment of Oral Chronic Graft-versus-host Disease With Human
Umbilical Cord Mesenchymal Stem Cell Dressing
Principal Investigator: Gao Lei
Research Institution: Second Affiliated Hospital of Army Medical
University (formerly Third Military Medical University)
Department: Hematology
Participating
Institution
and
Responsible
Person:
Chongqing
Southwest Hospital，ShiCangYu
Confidentiality Statement:
The information contained in this research proposal is provided
solely for the review by the researchers, ethics committee, and
relevant institutions of this project. Without the approval of the
Principal Investigator (PI), it is strictly prohibited to disclose any
information to third parties unrelated to this research.

Version: v1.0
Date: September 13, 2023
1.Research Background
Allogeneic-hematopoietic stem cell transplantation (allo-HSCT) is an important
protocol for the treatment of benign and malignant hematological diseases such as
acute leukemia, severe aplastic anemia, thalassemia, etc. chronic graft versus host
disease (cGVHD) is a clinicopathological syndrome caused by donor lymphocytes
attacking the recipient's organs in the process of reestablishing donor immunity after
allo-HSCT, with an incidence of about 30%-70%[1,2]. The clinical manifestations of
cGVHD are diverse, individual differences are large, and the course of the disease is
prolonged, which may affect the quality of life of patients at least, and affect the
long-term survival at worst. Among them, oral cGVHD is the most common type,
which mainly presents with lichen planus, oral ulcers, mucosal atrophy, erythema and
pain. At present, the treatment of oral cGVHD is based on systemic treatment and local
hormone-containing gargling solution and local photochemotherapy [3]. The former is
prone to be complicated by local oral fungal infection, while the latter has no such
equipment in China at present. Therefore, it is urgent to establish a simple, effective
and low-toxicity local treatment for oral cGVHD.
Recent studies have found that the expression of Th2 cytokines (such as IL-4 and
IL-5) is associated with a large number of T lymphocyte infiltration and severe tissue
damage in oral lesions of patients with cGVHD, and is involved in the occurrence and
development of oral cGVHD [4]. Inhibiting the accumulation and secretion of Th2
cells in the oral cavity may be an effective method to treat oral cGVHD. mesenchymal
stem cells (MSCs) are a kind of pluripotent stem cells with the ability of self-renewal
and multidirectional differentiation [5]. It is one of the most widely used cell products
in clinic at present. Combined application with hematopoietic stem cells can improve
the success rate of transplantation and accelerate hematopoietic reconstruction [6]. The
applicant team previously completed a national multi-center clinical study on MSCs
prevention of cGVHD, which proved that sequential infusion of MSCs can effectively
reduce the incidence of cGVHD, and the mechanism is that MSCs regulate Th1: Th2
balance and promote the differentiation of T cells to Th1 direction [7]. Our previous
mechanism study provides an important theoretical basis for MSCs treatment of oral
cGVHD. According to the clinical needs and the rich experience of our research group
in the field of MSCs clinical research, we plan to use dressing containing MSCs for the
local treatment of oral cGVHD, so as to improve the lesion degree of oral cGVHD and
improve the quality of life of allo-HSCT patients, and provide clinical experience for
reference for the local treatment of MSCs graft-versus-host disease.
[1] Friedenstein AJ, Petrakova KV, Kurolesova AI, et al. Hetero typic transplants
of bone marrow: analysis of precursor cells for osteogenic and hematopoietic tissues.
Transplantation, 1968, 6 (2): 230-247.
[2] Cheng L, Qasba P, Vanguri P, et al. Human mesenchymal stem cells support
megacaryocyte and prop latelet formation from CD34+ hematopoietic progenitor cells.
J Cell Physiol, 2000, 184 (1) : 58-59.
[3] Cammarota F, Laukkanen MO. Mesenchymal stem/stromal cells in stromal
evolution and cancer progression. Stem cell Int. 2015; 2015: 427350

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Date: September 13, 2023
[4] Cheng Zhang, Shi-Jie Yang, Qin Wen, Jiang F Zhong, Xue-Lian Chen, Andres
Stucky, Michael F Press, Xi Zhang.Human-derived normal mesenchymal stem/stromal
cells in anticancer therapies, Journal of Cancer, 2017; 8(1): 85-96
[5]
Li
Gao
et
al,
The
immunosuppressive
properties
of
non-cultured
dermal-derived mesenchymal stromal cells and the control of graft-versus-host disease.
Biomaterials 2014,(35):3582-3588
[6] Peilong Lai, Jianyu Weng, Liyan Guo, et al. Novel insights into MSC-EVs
therapy for immune diseases. Biomarker Research, 2019,7:6.
[7] Zhang B, Yin Y, Lai RC, Tan SS, Choo AB, Lim SK. Mesenchymal stem cells
secrete immunologically active exosomes. Stem Cells Dev. 2014;23(11):1233–44
2.Clinical Trial Objective
Local treatment of oral cGVHD with MSCs dressing can improve the lesion degree of
oral cGVHD and improve the quality of life of allo-HSCT patients.
3.Clinical Trial Design
To design a single-center, prospective, open, self-controlled clinical trial to explore the
efficacy of human umbilical cord mesenchymal stem cell dressings in the treatment of
chronic oral graft-versus-host disease.
4.Study Population
4.1 Number of Cases
A total of 38 patients will be enrolled.
Paired Wilcoxon sign-rank test was used: unilateral test α=0.05, 1-β=0.9, superior
efficacy limit δ=1, actual difference between groups δ=1.4, and paired difference
standard deviation σ=0.7. Calculated n=30, according to the 20% shedding rate, the
actual sample size needs N=38.

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Date: September 13, 2023
4.2 Inclusion Criteria
The following criteria must be met for patient inclusion:
Allo-HSCT occurrence score ≥2 points in patients with oral cGVHD (refer to
2014NIHcGVHD standards and 2021cGVHD expert consensus), and met the
following inclusion criteria:
Patients undergoing allogeneichematopoietic stem cell transplantation. Both genders,
aged ≥18 and ≤60.
Karnofsky Performance Status (KPS) score >60, estimated survival period >3 months.
No severe systemic impairment of vital organ function.
No contraindications to other hematopoietic stem cell transplantation. Voluntary
participation and informed consent.
4.3 Exclusion Criteria
Patients meeting any of the following criteria are not eligible for inclusion: Severe
heart, kidney, or liver dysfunction.
Patients requiring treatment for other malignancies.
Clinical
symptoms of brain dysfunction or
severe psychiatric disorders that affect
comprehension or compliance with the study protocol.
Patients unable to complete the required treatment plans and follow-up observations.
Patients with severe acute allergic reactions.
Clinically uncontrolled active infections.
Patients currently participating in other clinical trials.
Participants deemed unsuitable for the clinical trial by the researchers.
4.4 Criteria for Removal or Dropout:
Patients experiencing disease progression unrelated to the experimental factors or
death during the treatment and follow-up period will be unable to continue the
observation.
4.5 Termination Criteria:
Occurrence of severe adverse reactions or intolerability.
Participant's voluntary withdrawal.
Disease progression or relapse during the trial period.
Participants deemed unsuitable for further treatment by the researchers.
5.Treatment Protocol
5.1 Methods of stem cell administration
The patient's mouth (including buccal mucosa, tongue and lip) was applied with MSCs:
MSCs (1×10^9/ml) dressing was applied 4 times/day for 2 weeks.
5.2 Raw materials and preparation process of stem cell dressing

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Date: September 13, 2023
(1) Raw materials: The absorbable gelatin sponge commonly used in clinic is used as
the raw material for dressing. In clinic, gelatin sponge has been widely used in local
hemostasis including the mouth, nasal cavity and other parts.
(2) Ingredients: Absorbable gelatin sponge is a collagen product with a protein content
of 70%.
(3) Properties: white or yellowish, light, soft and porous sponge, with water absorption;
Although it is rubbed heavily, it will not crumble and is insoluble in water.
(4) Usage and dosage: MSCs (1 × 109/ml) solution was dropped on the surface of
gelatin sponge, and then applied locally to the oral lesions, so that MSCs could stay in
the lesions for a longer time and better play the role of MSCs in the treatment of
chronic oral graft versus host disease.
(5)Specifications: According to the size of the lesion, there are two specifications to
choose from: ①3cm×3cm×1cm; ②2cm×2cm×1cm.
5.3 Indicator Observation
The oral lesions of patients were recorded every 2 days during treatment and scored.
Oral saliva was retained for cytokine detection (destroyed after the study); Observe
and record possible complications of treatment; Whole-body cGVHD score was
performed at the end of treatment to record infection status. After treatment, oral
cGVHD score and systemic cGVHD score were performed every 2, 4 and 6 weeks to
evaluate safety, and the changes of infection, disease status and survival were recorded.
6.Evaluation criteria of curative effect
Effectiveness evaluation: The effective criterion was to reduce the oral cGVHD score
by 1 point at the end of treatment. Safety evaluation basis Safety will be measured
and evaluated by daily recording of potential adverse reactions to the treatment, and
patients will be tested for potential toxicity that may come from the treatment through
medical history, physical examination, blood tests, etc.
7.Adverse reactions and serious adverse events
In this study, there were no significant expected adverse reactions to topical treatment,
and adverse events during treatment were recorded. All adverse events were followed
until resolved, stabilized, or until it was confirmed that study treatment or participation
was not a problem. Any serious adverse events occurring after the study that may be
related to the study treatment or study participation need to be recorded and reported
promptly.
8.Statistical analysis
If the measurement data followed the normal distribution, the mean ±
standard
deviation was used to describe it, the paired T-test was used for comparison between
groups, and 95% confidence interval was calculated for cGVHD score difference
between groups. Repeated measurement design ANOVA was used for repeated
measurement data. If the measurement data did not follow normal distribution, the
median (P25,P75) was used to describe the inter-group comparison, and the Wilcoxon

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Date: September 13, 2023
signed rank sum test was used for inter-group comparison. Counting data were
described by component ratio, and comparison between groups was performed by
McNemar test. Kaplan-Meier method was used to calculate OS and EFS. SPSS 27 and
R 4.2 were used as statistical software.
9.Follow-up plan and implementation measures
During the treatment, the oral lesions of the patients were recorded and scored by
taking photos every 2 days, and oral saliva was retained for cytokine detection
(destroyed at the end of the study). The records were kept for 2 weeks, and the
self-control was made before and after treatment. After treatment, oral cGVHD score
and systemic cGVHD score were performed every 2, 4 and 6 weeks to evaluate safety,
and the changes of infection, disease status and survival were recorded.
10.Test management
This study will be conducted in accordance with the National Medical Products
Administration of China (NMPA) on the Management of Drug Clinical Trials (GCP).
Subject's personal information is confidential. Samples collected will be identified by
study number number and subject name and will not be disclosed to members outside
the study group. When the results of the study are published, no identifying
information about the subjects will be disclosed.
11.Ethics in relation to research
This study will be conducted in accordance with the GCP of the National Drug
Administration of China (NMPA) and after obtaining the approval of the Clinical trial
Ethics Committee of the Army Military Medical University for the trial protocol,
informed consent, subject recruitment method/process, case report form, etc. Pilot
program will be registered on http://ClinicalTrials.gov.
The investigator must ensure that the subject or his legal representative is clear and
fully informed about the purpose, content, benefits, and risks of the clinical study, and
that each subject will sign an informed consent form approved by the Ethics
Committee before entering the study.
12.The expected schedule and completion date of the clinical trial
2023.09 - 2023.12: Passed ethical review and registered Clinical Research number
2024.01- 2024.12: Enrolled patients, interim data analysis
2025.01- 2025.12: Completed patient enrollment and condition observation, statistical
analysis of data, and wrote articles