Tissue Engineering of Trachea-like Cartilage Grafts by Using Chondrocyte Macroaggregate: Experimental Study in Rabbits

An Injectable Platform of Engineered Cartilage Gel and Gelatin Methacrylate to Promote Cartilage Regeneration

Cell–hydrogel constructs are frequently used as injectable platforms for irregular cartilage regeneration. However, cell–hydrogel constructs have obvious disadvantages, such as long culture times, high probability of infection, and poor cartilage formation capacity, significantly limiting their clinical translation. In this study, we aimed to develop a novel injectable platform comprising engineered cartilage gel (ECG) and gelatin methacrylate (GelMA) to improve cartilage regeneration. We first prepared an ECG by cutting the in vitro engineered cartilage sheet into pieces. The chondrocytes and ECG were evenly encapsulated into GelMA to form Cell-GelMA and ECG-GelMA constructs. The ECG-GelMA construct exhibited preferred gel characteristics and superior biocompatibility compared with the Cell-GelMA construct counterpart. After subcutaneous implantation in nude mice and goat, both gross views and histological evaluations showed that the ECG-GelMA construct achieved more homogenous, stable, and mature cartilage regeneration than the Cell-GelMA construct. Immunological evaluations showed that ECG-GelMA had a mitigatory immunologic reaction than the Cell-GelMA construct. Overall, the results suggest that the ECG-GelMA is a promising injectable platform for cartilage regeneration that may advance clinical translation.

Isolation of multipotent progenitor cells from pleura and pericardium for tracheal tissue engineering purposes

Tissue engineering (TE) of long tracheal segments is conceptually appealing for patients with inoperable tracheal pathology. In tracheal TE, stem cells isolated from bone marrow or adipose tissue have been employed, but the ideal cell source has yet to be determined. When considering the origin of stem cells, cells isolated from a source embryonically related to the trachea may be more similar. In this study, we investigated the feasibility of isolating progenitor cells from pleura and pericard as an alternative cells source for tracheal tissue engineering. Porcine progenitor cells were isolated from pleura, pericard, trachea and adipose tissue and expanded in culture. Isolated cells were characterized by PCR, RNA sequencing, differentiation assays and cell survival assays and were compared to trachea and adipose‐derived progenitor cells. Progenitor‐like cells were successfully isolated and expanded from pericard and pleura as indicated by gene expression and functional analyses. Gene expression analysis and RNA sequencing showed a stem cell signature indicating multipotency, albeit that subtle differences between different cell sources were visible. Functional analysis revealed that these cells were able to differentiate towards chondrogenic, osteogenic and adipogenic lineages. Isolation of progenitor cells from pericard and pleura with stem cell features is feasible. Although functional differences with adipose‐derived stem cells were limited, based on their gene expression, pericard‐ and pleura‐derived stem cells may represent a superior autologous cell source for cell seeding in tracheal tissue engineering.

Replacement of a 5-cm intrathoracic trachea with a tissue-engineered prosthesis in a canine model

BACKGROUND

Critical obstacles must be addressed before clinical application of artificial tracheas. The major complications of long tracheal replacement include anastomotic dehiscence and stenosis owing to poor vascularity and incomplete re-epithelialization. The objective of this report was to clarify whether pre-incubation of the prosthesis in the omentum could be applicable for reconstruction of a long segment of the intrathoracic trachea in a canine model.

METHODS

The framework of an artificial trachea was fabricated from a polypropylene mesh tube and coated with 1% neutral atelocollagen inside and outside the lumen. The prosthesis was placed in the omentum of nine healthy male beagle dogs for 3 weeks. Then, the pedicled prosthesis was used to replace a 50 mm long section of intrathoracic trachea. Results were evaluated bronchoscopically, macroscopically, and histologically.

RESULTS

After 3 weeks of abdominal incubation, the prostheses were incorporated into the host tissue. None of the dogs showed dehiscence of the anastomosis or infection of the prostheses during the postoperative period. Seven of the nine dogs survived for more than 1 year. One dog died of a bowel obstruction resulting from a diaphragmatic hernia 3 months after replacement, and another died due to reasons unrelated to the prosthesis at 6 months. Bronchoscopic examination revealed no stenosis or dehiscence, and microscopic examination of all dogs showed that the luminal surface was covered by newly regenerated connective tissue and respiratory epithelium.

CONCLUSIONS

Pedicled omentum-prosthesis complexes may allow successful reconstruction of a long segment of the intrathoracic trachea.

Tissue Engineering toward Organ Replacement: A Promising Approach in Airway Transplant

Autologous tissue transfer, allografts and prosthetic replacements have so far failed to offer functional solutions for the treatment of long circumferential tracheal defects. Because of the shortcomings related with these strategies, interest has turned increasingly to the field of tissue engineering which applies the principles of engineering and life sciences in an effort to develop in vitro biological substitutes able to restore, maintain, or improve tissue and organ function. The advances in this field during the past decade have thus provided a new attractive approach toward the concept of functional substitutes and may represent an alternative to the shortage of suitable grafts for reconstructive airway surgery. This article gives an overview of the tissue engineering approach and of the encouraging strategies attempted so far in trachea regeneration.

Tissue engineering of a composite trachea construct using autologous rabbit chondrocytes

The repair of large tracheal segmental defects remains an unsolved problem. The goal of this study is to apply tissue engineering principles for the fabrication of large segmental trachea replacements. Engineered tracheal replacements composed of autologous cells (neotracheas) were tested in a New Zealand White rabbit model. Neotracheas were formed in the rabbit neck by wrapping a silicone tube with consecutive layers of skin epithelium, platysma muscle, and an engineered cartilage sheet and allowing the construct to mature for 8-12 weeks. In total, 28 rabbits were implanted and the neotracheas assessed for tissue morphology. In 11 cases, neotracheas deemed sufficiently strong were used to repair segmental tracheal defects. Initially, the success rate of producing structurally sound neotracheas was impeded by physical disruption of the cartilage sheets during animal handling, but by the end of the study, 15 of 18 neotracheas (83.3%) were structurally sound. Of the 15 structurally sound neotracheas, 11 were used for segmental reconstruction and were left in place for up to 21 days. Histological examination showed the presence of variable amounts of viable epithelium, a vascularized platysma flap, and a layer of safranin O-positive cartilage along with evidence of endochondral ossification. Rabbits that had undergone segmental reconstruction showed good tracheal integration, had a viable epithelium with vascular support, and the cartilage was sufficiently strong to maintain a lumen when palpated. The results demonstrated that viable, trilayered, scaffold-free neotracheas could be constructed from autologous cells and could be integrated into native trachea to repair a segmental defect.

Tissue-engineered trachea: A review

Tracheal replacement is performed after resection of a portion of the trachea that was impossible to reconnect via direct anastomosis. A tissue-engineered trachea is one of the available options that offer many advantages compared to other types of graft. Fabrication of a functional tissue-engineered trachea for grafting is very challenging, as it is a complex organ with important components, including cartilage, epithelium and vasculature. A number of studies have been reported on the preparation of a graftable trachea. A laterally rigid but longitudinally flexible hollow cylindrical scaffold which supports cartilage and epithelial tissue formation is the key element. The scaffold can be prepared via decellularization of an allograft or fabricated using biodegradable or non-biodegradable biomaterials. Commonly, the scaffold is seeded with chondrocytes and epithelial cells at the outer and luminal surfaces, respectively, to hasten tissue formation and improve functionality. To date, several clinical trials of tracheal replacement with tissue-engineered trachea have been performed. This article reviews the formation of cartilage tissue, epithelium and neovascularization of tissue-engineered trachea, together with the obstacles, possible solutions and future. Furthermore, the role of the bioreactor for in vitro tracheal graft formation and recently reported clinical applications of tracheal graft were also discussed. Generally, although encouraging results have been achieved, however, some obstacles remain to be resolved before the tissue-engineered trachea can be widely used in clinical settings.

Chm-1 gene-modified bone marrow mesenchymal stem cells maintain the chondrogenic phenotype of tissue-engineered cartilage

BACKGROUND

Marrow mesenchymal stem cells (MSCs) can differentiate into specific phenotypes, including chondrocytes, and have been widely used for cartilage tissue engineering. However, cartilage grafts from MSCs exhibit phenotypic alternations after implantation, including matrix calcification and vascular ingrowth.

METHODS

We compared chondromodulin-1 (Chm-1) expression between chondrocytes and MSCs. We found that chondrocytes expressed a high level of Chm-1. We then adenovirally transduced MSCs with Chm-1 and applied modified cells to engineer cartilage in vivo.

RESULTS

A gross inspection and histological observation indicated that the chondrogenic phenotype of the tissue-engineered cartilage graft was well maintained, and the stable expression of Chm-1 was detected by immunohistological staining in the cartilage graft derived from the Chm-1 gene-modified MSCs.

CONCLUSIONS

Our findings defined an essential role for Chm-1 in maintaining chondrogenic phenotype and demonstrated that Chm-1 gene-modified MSCs may be used in cartilage tissue engineering.

Prefabricated, ear-shaped cartilage tissue engineering by scaffold-free porcine chondrocyte membrane

BACKGROUND

Ear defects caused by traumatic injury, tumor ablation, and congenital deficiency are still challenging problems for the plastic and reconstructive surgeon. The authors developed a scaffold-free, ear-shaped cartilage by tailoring a multilayered chondrocyte membrane on an ear-shaped titanium alloy model and investigated the possibility of long-term ear-shaped maintenance in nude mice.

METHODS

High-density chondrocytes (approximately 30 × 10 cells) were seeded to produce chondrocyte membranes after cultivation under chondrogenic medium for 2 weeks. Then, three-layer chondrocyte membranes were tailored on the ear-shaped titanium mold and fixed by 6-0 nylon. The constructs were implanted onto the dorsal pockets of nude mice for 8 and 24 weeks. The chondrocyte membrane, 8- and 24-week implants were analyzed by safranin O, toluidine blue, elastica van Gieson, and collagen type II immunohistochemistry stains and quantitative measurement of glycosaminoglycan and total collagen compared with native cartilage. Mechanical strength was compared by compressive Young's modulus.

RESULTS

Results showed that the chondrocyte membrane was durable and nonfragile and easily manipulated by forceps. The composite of chondrocyte membrane and titanium alloy maintained the stable ear-like shape after 8 and 24 weeks of subcutaneous implantation. Histologic examination verified that the newly formed tissue at the implant construct was elastic cartilage at both 8 and 24 weeks by safranin O, toluidine blue, elastica van Gieson, and collagen type II immunohistochemistry stains. The Young's modulus was only half of and similar to normal cartilage in 8- and 24-week implants, respectively.

CONCLUSION

This study demonstrated that an ear-shaped elastic cartilage could be regenerated by a scaffold-free chondrocyte membrane shaped by a prefabricated, three-dimensional, ear-shaped titanium mold.

Electrospun gelatin/polycaprolactone nanofibrous membranes combined with a coculture of bone marrow stromal cells and chondrocytes for cartilage engineering

Electrospinning has recently received considerable attention, showing notable potential as a novel method of scaffold fabrication for cartilage engineering. The aim of this study was to use a coculture strategy of chondrocytes combined with electrospun gelatin/polycaprolactone (GT/PCL) membranes, instead of pure chondrocytes, to evaluate the formation of cartilaginous tissue. We prepared the GT/PCL membranes, seeded bone marrow stromal cell (BMSC)/chondrocyte cocultures (75% BMSCs and 25% chondrocytes) in a sandwich model in vitro, and then implanted the constructs subcutaneously into nude mice for 12 weeks. Gross observation, histological and immunohistological evaluation, glycosaminoglycan analyses, Young’s modulus measurement, and immunofluorescence staining were performed postimplantation. We found that the coculture group formed mature cartilage-like tissue, with no statistically significant difference from the chondrocyte group, and labeled BMSCs could differentiate into chondrocyte-like cells under the chondrogenic niche of chondrocytes. This entire strategy indicates that GT/PCL membranes are also a suitable scaffold for stem cell-based cartilage engineering and may provide a potentially clinically feasible approach for cartilage repairs.

An ectopic approach for engineering a vascularized tracheal substitute

Tissue engineering can provide alternatives to current methods for tracheal reconstruction. Here we describe an approach for ectopic engineering of vascularized trachea based on the implantation of co-cultured scaffolds surrounded by a muscle flap. Poly(L-lactic-co-glycolic acid) (PLGA) or poly(ε-caprolactone) (PCL) scaffolds were seeded with chondrocytes, bone marrow stem cells and co-cultured both cells respectively (8 groups), wrapped in a pedicled muscle flap, placed as an ectopic culture on the abdominal wall of rabbits (n = 24), and harvested after two and four weeks. Analysis of the biochemical and mechanical properties demonstrated that the PCL scaffold with co-culture cells seeding displayed the optimal chondrogenesis with adequate rigidity to maintain the cylindrical shape and luminal patency. Histological analysis confirmed that cartilage formed in the co-culture groups contained a more homogeneous and higher extracellular matrix content. The luminal surfaces appeared to support adequate epithelialization due to the formation of vascularized capsular tissue. A prefabricated neo-trachea was transferred to the defect as a tracheal replacement and yielded satisfactory results. These encouraging results indicate that our co-culture approach may enable the development of a clinically applicable neo-trachea.

Cell sources for trachea tissue engineering: past, present and future

Trachea tissue engineering has been one of the most promising approaches to providing a potential clinical application for the treatment of long-segment tracheal stenosis. The sources of the cells are particularly important as the primary factor for tissue engineering. The use of appropriate cells seeded onto scaffolds holds huge promise as a means of engineering the trachea. Furthermore, appropriate cells would accelerate the regeneration of the tissue even without scaffolds. Besides autologous mature cells, various stem cells, including bone marrow-derived mesenchymal stem cells, adipose tissue-derived stem cells, umbilical cord blood-derived mesenchymal stem cells, amniotic fluid stem cells, embryonic stem cells and induced pluripotent stem cells, have received extensive attention in the field of trachea tissue engineering. Therefore, this article reviews the progress on different cell sources for engineering tracheal cartilage and epithelium, which can lead to a better selection and strategy for engineering the trachea.

Tissue-engineered airway: a regenerative solution

The use of synthetic degradable or permanent polymers and biomaterials has not yet helped to achieve successful clinical whole-airway replacement. A novel, clinically successful approach involves tissue engineering (TE) replacement using three-dimensional biologic scaffolds composed of allogeneic extracellular scaffolds derived from nonautologous sources and recellularized with autologous stem cells or differentiated cells. In this paper, we discuss this novel approach and review information that can lead to a better understanding of stem cell recruitment and/or mobilization and site-specific tissue protection, which can be pharmacologically boosted in humans.

Translating tissue-engineered tracheal replacement from bench to bedside

There are a variety of airway diseases with different clinical settings, which may extend from a surgical approach to total organ replacement. Tissue engineering involves modifying cells or tissues in order to repair, regenerate, or replace tissue in the body and seems to be a promising approach for airway replacement. The successful implantation of stem-cell-based tissue-engineered trachea in a young woman with end-stage post-tuberculosis left main bronchus collapse serves as a prototype for the airway tissue-engineered-based approach. The trachea indeed could represent a perfect model system to investigate the translational aspects of tissue engineering, largely due to its low-oxygen needs. This review highlights the anatomy of the airways, the various disease conditions that cause damage to the airways, elaborates on the essential components of the tissue-engineering approach, and discusses the success of the revolutionary trachea transplantation approach.

Moving towards in situ tracheal regeneration: the bionic tissue engineered transplantation approach

In June 2008, the world's first whole tissue-engineered organ - the windpipe - was successfully transplanted into a 31-year-old lady, and about 18 months following surgery she is leading a near normal life without immunosuppression. This outcome has been achieved by employing three groundbreaking technologies of regenerative medicine: (i) a donor trachea first decellularized using a detergent (without denaturing the collagenous matrix), (ii) the two main autologous tracheal cells, namely mesenchymal stem cell derived cartilage-like cells and epithelial respiratory cells and (iii) a specifically designed bioreactor that reseed, before implantation, the in vitro pre-expanded and pre-differentiated autologous cells on the desired surfaces of the decellularized matrix. Given the long-term safety, efficacy and efforts using such a conventional approach and the potential advantages of regenerative implants to make them available for anyone, we have investigated a novel alternative concept how to fully avoid in vitro cell replication, expansion and differentiation, use the human native site as micro-niche, potentiate the human body's site-specific response by adding boosting, permissive and recruitment impulses in full respect of sociological and regulatory prerequisites. This tissue-engineered approach and ongoing research in airway transplantation is reviewed and presented here.

Tissue-engineered tracheal transplantation

Regenerative medicine offers new tools with which to tackle disorders for which there is currently no good therapeutic option. The trachea is an ideal organ in which to explore the clinical potential of tissue engineering because severe large airway disease is poorly managed by conventional treatments, and the success of a graft is determined only by its ability to conduct air lifelong: that is, whether it can become a sustainable biological conduit. We define the component parts of tissue engineering and review the experimental methods used to produce airway implants to date, including a recent successful, first-in-man experience.

In vitro construction of scaffold-free cylindrical cartilage using cell sheet-based tissue engineering

PURPOSE

Tissue-engineered cartilage may offer a solution for the treatment of serious airway disease. This study developed a novel procedure to fabricate a scaffold-free cylindrical cartilage under in vitro conditions, while also evaluating the effect of a dynamic culture on the engineered construct.

METHODS

Auricular chondrocytes were harvested from New Zealand white rabbits and cultivated under high-density conditions to form a chondrocyte sheet. The sheet was looped around a silicon tube and cultivated for 6 weeks in dynamic or static conditions. The engineered cylindrical cartilages were evaluated macroscopically and histologically. The expression of collagen, glycosaminoglycan content and mechanical properties were determined.

RESULTS

The cylindrical cartilage was sufficiently elastic and stiff to maintain the structure without disruption. Histologically, the construct contained a Safranin-O positive cartilaginous matrix accompanied by the expression of type II collagen. The glycosaminoglycan content increased and reached 72% of the native tracheal cartilage after 6 weeks of cultivation.

CONCLUSION

A novel procedure was developed for fabricating engineered cartilage, which maintained the shape and a proper level of rigidity and flexibility, under in vitro conditions using sheet-based tissue engineering techniques. This procedure may allow for the development of a tailor-made autograft and a functionally engineered trachea.

A double-chamber rotating bioreactor for the development of tissue-engineered hollow organs: from concept to clinical trial

Cell and tissue engineering are now being translated into clinical organ replacement, offering alternatives to fight morbidity, organ shortages and ethico-social problems associated with allotransplantation. Central to the recent first successful use of stem cells to create an organ replacement in man was our development of a bioreactor environment. Critical design features were the abilities to drive the growth of two different cell types, to support 3D maturation, to maintain biomechanical and biological properties and to provide appropriate hydrodynamic stimuli and adequate mass transport. An analytical model was developed and applied to predict oxygen profiles in the bioreactor-cultured organ construct and in the culture media, comparing representative culture configurations and operating conditions. Autologous respiratory epithelial cells and mesenchymal stem cells (BMSCs, then differentiated into chondrocytes) were isolated, characterized and expanded. Both cell types were seeded and cultured onto a decellularized human donor tracheal matrix within the bioreactor. One year post-operatively, graft and patient are healthy, and biopsies confirm angiogenesis, viable epithelial cells and chondrocytes. Our rotating double-chamber bioreactor permits the efficient repopulation of a decellularized human matrix, a concept that can be applied clinically, as demonstrated by the successful tracheal transplantation.

Experimental repair of tracheal defect using a bioabsorbable copolymer

BACKGROUND

We investigated epithelialization and newly formed cartilage in an artificial trachea constructed using a bioabsorbable copolymer.

MATERIALS AND METHODS

Fifteen male Japanese white rabbits (2.5-2.8 kg) were divided into three groups. A full-thickness anterior defect (4 mm x 10 mm) was created in the trachea. The defect was implanted with one of the following bioabsorbable copolymers: caprolactone-lactide copolymer sponge sheet reinforced with poly(glycolic acid) fiber mesh (Cop) (n = 6, group A), Cop-incorporating gelatin hydrogel (n = 4, group B), and Cop-incorporating gelatin hydrogel with 100 microg of basic fibroblast growth factor (n = 5, group C). Each trachea was reinforced with an external nondegradable polymer stent. Three rabbits in each group were sacrificed at 1, 3, and 6 mo postoperatively and the trachea was evaluated histologically; other animals were sacrificed up to 12 mo postoperatively.

RESULTS

In groups A, B, and C there were two, one, and one postoperative deaths, respectively. In group A, epithelialization was recognized from 1 mo to 12 mo postoperatively, but no new cartilage was formed during the 12 mo following implantation. In group B, epithelialization was recognized 3 and 6 mo postoperatively, and new cartilage was detected at 6 mo after the operation. In group C, newly formed cartilage and epithelialization were observed 3, 6, and even 12 mo postoperatively. Furthermore, neovascularization was observed in groups B and C.

CONCLUSIONS

A bioabsorbable copolymer incorporating gelatin hydrogel induces tracheal epithelialization and formation of cartilage and vessels in tracheal defects, and could be available for clinical use in children.