The mesenchymal stromal cells dilemma-does a negative phase III trial of random donor mesenchymal stromal cells in steroid-resistant graft-versus-host disease represent a death knell or a bump in the road?

The use of cryopreserved unmatched allogeneic mesenchymal stromal cells (MSCs) for treatment of steroid-resistant graft-versus-host disease has become medical practice in many European jurisdictions. The enthusiasm for use of MSCs in transplantation medicine builds on compelling phase II clinical trial data published by European collaborative groups in the past few years. Notwithstanding, it was reported in 2009 that a large multicenter phase III clinical trial (NCT00366145) conducted in the USA examining the use of an industrial MSC product (Prochymal; Osiris Therapeutics, Inc., Columbia, MD, USA) failed to meet its primary clinical endpoint of achieving a significant increase of complete response of steroid-resistant graft-versus-host disease lasting at least 28 days compared with placebo. Although peer-reviewed publication of the trial and its results are not in public domain at the time of this writing, it is worthwhile to reflect on the apparent discrepancy between the European experience and this industry-sponsored phase III study. This review presents a heuristic failure analysis focusing on the potential variables affecting MSCs and their utility as a cellular pharmaceutical.