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Preliminary Communication
November 1, 2016

Safety and Wound Outcomes Following Genetically Corrected Autologous Epidermal Grafts in Patients With Recessive Dystrophic Epidermolysis Bullosa

Author Affiliations
  • 1Department of Dermatology, School of Medicine, Stanford University, Stanford, California
  • 2Lucile Packard Children’s Hospital, Stanford University, Stanford, California
  • 3Now with Department of Dermatology, University of Pennsylvania, Philadelphia
  • 4Shriners Hospital for Children, Portland, Oregon
  • 5Veterans Affairs Medical Center, Palo Alto, California
JAMA. 2016;316(17):1808-1817. doi:10.1001/jama.2016.15588
Key Points

Question  Can gene therapy be safely used to restore type VII collagen expression to recessive dystrophic epidermolysis bullosa (RDEB) wounds?

Findings  In this phase 1 clinical trial, autologous RDEB keratinocytes transduced with a retroviral vector containing full-length human COL7A1 were assembled into epidermal sheet grafts and applied to 6 wounds on 4 patients. All grafts were well tolerated without serious adverse events. Some but not all grafts showed improved wound healing as well as type VII collagen expression in anchoring fibrils at the dermal-epidermal basement membrane.

Meaning  Autologous type VII collagen gene–corrected grafts may have potential in the molecular and clinical correction of RDEB skin.

Abstract

Importance  Recessive dystrophic epidermolysis bullosa (RDEB) is a devastating, often fatal, inherited blistering disorder caused by mutations in the COL7A1 gene encoding type VII collagen. Support and palliation are the only current therapies.

Objective  To evaluate the safety and wound outcomes following genetically corrected autologous epidermal grafts in patients with RDEB.

Design, Setting, and Participants  Single-center phase 1 clinical trial conducted in the United States of 4 patients with severe RDEB with a measured area of wounds suitable for grafting of at least 100 cm2. Patients with undetectable type VII collagen keratinocyte expression were excluded.

Interventions  Autologous keratinocytes isolated from biopsy samples collected from 4 patients with RDEB were transduced with good manufacturing practice–grade retrovirus carrying full-length human COL7A1 and assembled into epidermal sheet grafts. Type VII collagen gene–corrected grafts (approximately 35 cm2) were transplanted onto 6 wounds in each of the patients (n = 24 grafts).

Main Outcomes and Measures  The primary safety outcomes were recombination competent retrovirus, cancer, and autoimmune reaction. Molecular correction was assessed as type VII collagen expression measured by immunofluorescence and immunoelectron microscopy. Wound healing was assessed using serial photographs taken at 3, 6, and 12 months after grafting.

Results  The 4 patients (mean age, 23 years [range, 18-32 years]) were all male with an estimated body surface area affected with RDEB of 4% to 30%. All 24 grafts were well tolerated without serious adverse events. Type VII collagen expression at the dermal-epidermal junction was demonstrated on the graft sites by immunofluorescence microscopy in 9 of 10 biopsy samples (90%) at 3 months, in 8 of 12 samples (66%) at 6 months, and in 5 of 12 samples (42%) at 12 months, including correct type VII collagen localization to anchoring fibrils. Wounds with recombinant type VII collagen graft sites displayed 75% or greater healing at 3 months (21 intact graft sites of 24 wound sites; 87%), 6 months (16/24; 67%), and 12 months (12/24; 50%) compared with baseline wound sites.

Conclusions and Relevance  In this preliminary study of 4 patients with RDEB, there was wound healing in some type VII collagen gene–corrected grafts, but the response was variable among patients and among grafted sites and generally declined over 1 year. Long-term follow-up is necessary for these patients, and controlled trials are needed with a broader range of patients to better understand the potential long-term efficacy of genetically corrected autologous epidermal grafts.

Trial Registration  clinicaltrials.gov Identifier: NCT01263379

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