By Chris Roberts
By Joe Eskenazi
By Albert Samaha
By Mike Billings
By Rachel Swan
By Erin Sherbert
By Joe Eskenazi
By Albert Samaha
"I've seen a picture of one that was removed from somebody's ovary, and you can see where they got their name," he says, padding around the lab in blue booties slipped over his sneakers to guard against contaminating the room's vats, vials, and flasks. "It was a white, ghostly thing with teeth and hair. It was the ugliest thing I've ever seen in my life, like something from a Hollywood movie. And then you think, "That was cut out of somebody.'" Cullen slides a plastic container of red liquid under the microscope and peers at a clump of cells his lab has grown from one such monster. He grins. "When I tell my buddies these stories over dinner, it's a winner."
There are other stories about teratocarcinomas, the strangest tumor in the human body. Because they grow from sperm or eggs in the testicles or ovaries, these tumors bloom quickly, like diabolical embryos, sometimes swelling as large as grapefruits. Grotesquely mimicking the development of a normal embryo, teratocarcinomas can chaotically sprout all sorts of different tissue: blood vessels, teeth, hair; perverse approximations of eyes, arms, livers, kidneys. Some scientists say they've seen teratocarcinoma cells beat like miniature hearts, that the little monsters respond to a poke with a nervous shudder.
But for all their monstrous qualities, teratocarcinomas have one unique, very valuable characteristic: They contain stem cells, not unlike those found in an embryo or fetus, capable of developing into any number of types of tissue. And for Cullen and his colleagues at Layton BioScience Inc. in Sunnyvale, one particular teratocarcinoma -- removed in the 1970s from a dying 22-year-old man in New York -- is more than just a freak of nature. In the words of the company's CEO, it's a gift from God.
While the national debate over stem cells raged this summer, doctors at Stanford and the University of Pittsburgh quietly entered the second phase of a clinical trial to determine whether it's safe and effective to implant what seem to be neurons, derived from teratocarcinoma cells in the Layton lab, into the brains of stroke patients. If the therapy works, manufactured neurons will replace and repair damaged brain tissue, helping patients regain the motor functions they lost to stroke. The hope is that the cells could eventually be used to treat a variety of neurological disorders, including Parkinson's disease, Alzheimer's, and Huntington's.
But no one knows whether these cells actually repair the brains of stroke patients. Indeed, several researchers outside the study question the sanity of putting once-cancerous cells into human brains. Some suggest that Layton's trial, the only clinical study using such cells to treat stroke, has moved way too fast, without proving that the cells -- not physical therapy, the placebo effect, or brain surgery itself -- are responsible for the changes that patients are perceiving as improvement. They accuse Layton, a 10-year-old private company that has banked its future on these cells, of whipping up hype to attract investors. The hype, after all, is working: Red Herring named Layton one of its 100 companies to watch in 2001, and the still-unprofitable biotech firm has collected $30 million from friends, family, and venture capitalists, with an eye toward raising about $40 million more.
But the proof will be in the patients, many of whom report significant progress -- dead arms rising, fingers unfurling -- since receiving the cells. Whereas the controversial research on embryonic and fetal stem cells lingers at the promising stage, Layton's patients have literally opened their minds to the hope and hype.
Cullen, tossing his used booties into a trash bin and snapping off his latex gloves, puts it this way: "Stem cells are in the realm of the theoretical. What we're doing is in the realm of reality."
On Aug. 9, with the blue sky and flat ranchland of Crawford, Texas, as a serene backdrop, President Bush took to prime-time television to address a controversy he called one of the most profound of our time. At issue was whether the federal government should fund research on stem cells culled from discarded embryos and fetuses. After months of listening to scientists, abortion foes, politicians, talking heads, and dying patients, Bush finally made up his mind. He announced that the government would pay for research on existing stem cell lines, prohibiting subsidies for studies that created or destroyed more embryos, effectively alienating both the scientific and anti-abortion communities, satisfying no one.
In the wake of all the national soul-searching about the use of incipient or possible humans to produce stem cells for research, scientists involved in Layton's study coyly describe their work as "stem cell-like." Embryonic stem cells develop soon after a sperm cell fertilizes an ovum; as they divide, these stem cells can change form, or differentiate, into hundreds of types of tissue-specific fetal cells, which then become the mature cells that make up the body's tissues and organs. When transplanted into damaged sections of the body, scientists believe, such stem cells could become chameleons and interpreters, forming the tissue and molecular connections needed for repair and renewal. The ethical catch is obvious: These early-development cells can only be obtained from a spare embryo or fetus -- that is, from living tissue with at least the theoretical possibility of developing into a human being.
But the United States Conference of Catholic Bishops, a leading critic of stem cell research, says it has no moral objections to the science practiced by Layton, since it obtains stem cells from a tumor that merely behaves like (but is not) a human embryo.
Researchers first began studying this particular tumor in the late 1970s precisely because it behaved so much like an embryo; they were trying to determine how and why embryonic cells, which are all the same, differentiate to become skin, or heart, or kidney, or brain cells. They found, almost by accident, that this tumor's quasi-embryonic stem cells showed an astonishing determination to become part of the central nervous system. The finding surprised researchers: Teratocarcinomas usually don't display devotion to one part of the body.
More research revealed that retinoic acid, a chemical relative of vitamin A and now a common cancer treatment, acted as a kind of master switch for the tumor. The chemical not only turned off many of the stemlike cells' malignant propensity to divide endlessly; retinoic acid also caused those cells to differentiate. When scientists threw the switch, the resulting cells looked an awful lot like neurons, the cells that transmit the electrical energy of thought.
Layton originally formed to license the manufacturing technology from the University of Pennsylvania, then patented the cells under the name LBS-Neurons (for Layton BioScience), and now stores clones of the original teratocarcinoma cells in large vats of liquid nitrogen at minus 196 degrees Celsius. In addition to treating the cells with retinoic acid, Layton also soaks them with what are known, in the jargon of cell science, as mitotic inhibitors, or drugs that kill cancer by interfering with cell division.
After about six weeks, a flask containing tumor cells holds a mixture of neuronal cells, which shine brightly under a microscope, and non-neuronal cells that, for some reason, didn't get the itch to become neurons. Using enzymes, Layton separates the neuronal cells from the others, then returns the new cells to liquid nitrogen until they're needed for a clinical trial.
"This cell has very good growth properties, probably as good as any cell I've worked with," says Michael McGrogan, Layton's vice president of research and development, who uses a PowerPoint computer presentation to explain the science. "You're not limited by pampering them."
But Layton is limited by the Food and Drug Administration, which, by all accounts, expressed a great deal of skepticism before finally allowing Layton to proceed with its study. Even then, Layton had to restrict its testing pool to patients whose strokes occurred in the basal ganglia, a set of large structures in the center of the brain that control motor function. More animal tests will be required before the study can expand to other brain sections.
The 12 patients in Layton's first clinical trial, conducted between July 1998 and March 1999, received either 2 million or 6 million neuronal cells in as many as nine different locations within the stroke-damaged area of the brain. The surgery, which lasts about four hours, is fairly simple: The patient remains awake while a frame steadies the head. Doctors drill a small hole in the top of the skull and insert a long-needled syringe into the basal ganglia.
After the cell transfusion, the doctors wait and watch while the patient undergoes two months of physical therapy to stimulate the new cells. The two-hour workouts, conducted three times a week, build dexterity, balance, and strength. It's not a complicated regimen -- opening doors, stacking cones, gripping forks, riding a stationary bike -- but if the patient doesn't attempt new exercises, the cells might not be able to help. "The study is a combination of cells and stimulation," says Dr. Alan Jacobs, Layton's former medical director, who helped design the trial. "More than just the number of cells, it's how they're administered."
In the first trial, seven patients showed substantial improvement, as measured by their own reports, doctor evaluations of their motor skills, and brain scans. Two have died of unrelated causes.
The second phase, now under way, escalates the dosage and dispenses the cells to wider areas of the brain. Six patients have already received 5 or 10 million cells, and a seventh will have surgery soon. If this phase shows progress, doctors will conduct a double-blind trial in which neither the doctors nor the patients know whether the cells, or a placebo of non-neuronal cells, are being administered.
If the double-blind trial produces improved patients, Layton will begin large-scale production, selling vials of LBS-Neurons to doctors and medical centers. Conceivably, neuronal transplantation could become the preferred treatment for stroke within five to 10 years. But Dr. Barry Hoffer, a drug and stroke expert at the National Institutes of Health, cautions that successful animal data does not always predict what works to fight stroke in humans. "On paper the science looks great, but I've seen a lot of very different, promising things not make it in the clinic," Hoffer says. "The hope is that this is not one of those."
After all, Layton's success with teratocarcinoma cells is the exception, not the rule. Even Dr. Peter Andrews, the scientist who first caused these cancer cells to differentiate by introducing them to retinoic acid in the early 1980s, points out that Layton's neuronal cells are "screwed up genetically." For some reason, they have about 60 chromosomes instead of the normal human complement of 46.
"People do have concerns about potential consequences of their genetic abnormality," Andrews says. "In the long run, cells derived by differentiation of normal human embryonic stem cells seem a better prospect. Nevertheless, I think the human teratocarcinoma cell work has provided valuable groundwork on which to build the studies of human embryonic stem cells."
For now, cell therapy scientists remain enamored of the promise of embryonic and fetal stem cells, which display more versatility and are thought to be less risky for transplantation than cancer-derived cells. That could change, however, with Layton's findings.
"At the end of the day, we don't know whether this is going to work," Sean Cullen says. "But we do know already that it's safe. We do know already that it's feasible -- we can make them. If you look at stem cells, we're asking: "Can we make them? Are they safe? And do they work?' It's like somebody trying to guess 50 years ago when we're going to put somebody on the moon. There are so many unknowns."
On a warm August afternoon almost four months after Bill Perrin received some of Layton's cancer-created, neuronlike cells, the study in his Hollister home is filled with sunlight, the tweeting of backyard birds, and stacks upon stacks of medical books. Stroke-related magazines and pamphlets lie everywhere. Even a baseball autographed by his one-time neighbor Don Larson (the only pitcher to toss a perfect game in a World Series) sits on a stack of scientific journals, perched on a bookcase stuffed full of medical encyclopedias and weighty tomes like Gray's Anatomy. The homemade library backs up the 59-year-old's claim that his stroke turned him into an expert on neurology; it also provides plenty of textbook examples to illustrate stroke's ability to debilitate.
"When it hits you, when you look in the mirror, you know you're not the same," says Perrin, whose 1996 stroke causes him to speak with a slight slur. As he recalls those first frightening months after his stroke, confined to a wheelchair with a right arm and leg that wouldn't budge, his smile wanes and his stocky frame sags in the armchair. "I had a hell of a time. You read a paragraph or two, a minute later it's gone. I'd get lost in stores, disoriented. I didn't trust myself. You find yourself asking, "Which way is out?' That's pretty bad."
So are the statistics. Stroke, one of the leading causes of adult disability in the United States, attacks about 750,000 Americans a year and claims almost 160,000 lives. The country's third leading cause of death, stroke costs the government roughly $30 billion annually in research, treatment, and lost work-force productivity.
But for a disease as studied and severe as stroke, doctors have come up with remarkably few treatments. Strokes comprise several complex events, beginning when the brain's blood supply gets cut off or when a vessel in the brain bursts, spilling blood into the spaces surrounding the cells. Brain cells die when they no longer receive oxygen and nutrients from blood. The loss of neurons is crippling; neurons don't divide and regenerate. When they die, they're gone for good.
The only effective drug to fight stroke is tissue plasminogen activator, tPA for short, which breaks up blood clots, but it must be administered within three hours of the attack and only to patients whose strokes are clot-related. Researchers are trying to develop drugs to combat cell death and inflammation, and Stanford doctors are testing whether freezing the brain prevents further injury, but these are experiments, not therapies.
Perrin, a physician's assistant who has lent a hand in countless minor surgeries, had never gone under the knife before May 1. He gleefully parts his thinning hair -- blond on top and gray over the ears -- to show off the slim scar that remains from the brain surgery. "It made me my old self again," he says. Well, not quite. Straining like a man lifting a 50-pound boulder, he now can raise his right arm and hold it, quivering, above his head. He can grip a pen, use a spoon, steady the steering wheel. He can even assist in surgeries, although he can't stitch up wounds.
But even this minimal progress has convinced him that he made the right decision by enlisting in Layton's study. He has no doubt: This science works.
"It's the beginning of all help," Perrin says. "It's the only thing we can do for a problem that we couldn't do anything about before."
Two days after the terrorist attacks in New York and Washington, the plaza outside the Stanford Medical Center buzzes with white-gowned nurses, blue-gowned doctors, patients still attached to their IV stands, and perplexed construction workers drawn to the commotion from nearby sites. Word spreads quickly: Someone called in a bomb threat on the Stanford Hospital emergency room.
Twenty minutes later, authorities have scanned the buildings and are allowing the crowd to trickle back in. Despite the interruption to his hectic schedule, Dr. Gary Steinberg, chairman of Stanford's department of neurosurgery, appears unfazed by -- and uninterested in -- the bomb scare. Sipping a Coke in his office, the co-leader of Layton's clinical study projects the confidence, competence, and calm his patients ascribe to him. Perrin says two minutes in Steinberg's presence convinced him of the study's promise. In other words, Steinberg exudes the serenity and self-assurance you look for in a guy who wants to drill a hole in your head and fill it with experimental cells made from a cancer.
"Once a stroke occurs, there's no good way to repair it," says Steinberg, who has no affiliation with Layton other than the study. "With the advances in molecular biology and stem cell biology, the potential for repairing damaged tissue in stroke patients has become a reality. It's just that nobody knows which cell is going to be the best transplant. This is the first clinical trial to test it."
But if the patients aren't apprehensive, many doctors in the stroke-studying community are. And Steinberg is well-acquainted with his colleagues' skepticism. The same August 2000 issue of Neurology that published enthusiastic findings from the first Layton trial phase also featured an editorial headlined, "Cell transplant therapy for stroke -- hope or hype?" The editorial, by Dr. Justin Zivin of the University of California at San Diego, cautioned against the conclusion that patients' functional improvement was due to Layton's cells, and hinted that the company expedited the article's publication to attract potential investors. Zivin's central concern, reiterated in an interview with SF Weekly and shared by many of his colleagues closely watching the Layton trial, is that the study has progressed into humans without proving its central thesis: that Layton's cells are legitimate neurons.
"Are these even neurons they're implanting?" Zivin says. "You're not at all sure they're going to hook up properly. The article you should be writing is how much hype this study is getting when it's still a long way from proving its worth."
"We don't know how the cells are working," Steinberg admits. "We don't know whether they're making connections and acting like replacement neurons or whether they're secreting some kind of neurotransmitter, trophic factor, or growth substance that enhances the activity of the neurons that survived the stroke."
Steinberg's counterpart at the University of Pittsburgh, Dr. Douglas Kondziolka, is equally honest about the study's unknowns. But, like Steinberg, he points to brain scans that show a slight increase in patients' metabolic activity to suggest the Layton cells are wiring properly into the brain. If the stroke-damaged brain areas are using more sugar after the surgery, he says, it could mean the injected cells are surviving and fueling their repair efforts with glucose.
"There's no direct proof of anything," says Kondziolka. "But a duck looks like a duck. These cells look like neurons. They behave like neurons, they release the appropriate transmitters, they have the potential to talk to each other. They do all these things that we expect neurons to do."
Skeptics say that's an optimistic interpretation of the study's findings. They argue that the brain surgery itself might be responsible for stimulating existing neurons, that the uptake in metabolic activity could be due to inflammation following the insertion of a needle.
"You can't say that has anything to do with the cells that were transplanted. If they tell you that, they're bullshitting you," says Scott Whittemore, a professor of neurology at the University of Louisville. "They could put any cell in there, and it might give them the same effect. There's a general sense among researchers that the clinical trials were premature and that we don't understand what the effects are yet."
The source of Layton's cells is another concern. If these cells were once cancerous, who's to say they won't revert to a tumorigenic state after they've been implanted?
"In the 25 years this cell line has been studied, there has never been a tumor formed in animals or in people," says Steinberg, adding that embryonic or fetal stem cells probably have more potential to become cancerous. "These are pure neurons. They are primitive neurons. They will differentiate, mature into different neuronal types, but they don't mature into other cell types that divide," the way stem cells do.
Dr. Gregory del Zoppo, a professor at the Scripps Research Institute in La Jolla, Calif., and a spokesman for the American Stroke Association, says the scientific community needs more and varied animal studies to be convinced of the cells' viability. "There's a concern that perhaps enthusiasm is taking the upper hand here," del Zoppo says. "If I were involved in the study, I'd be excited, too. I don't think anyone is saying we shouldn't explore this, but I think human experiments are beyond where we should be right now. It's over the top. I would encourage the company to proceed with caution."
"Maybe we're wrong," says Layton CEO Gary Snable, a 64-year-old with a thicket of white hair and the habit of winking when he's trying to drive home a point. "Here we've purposely implanted tumor cells in someone's brain expecting they'll be benign, and they turn out not to be. Even though everybody knows this is not a risk-free procedure, we'd feel just awful."
The window in Snable's office looks out on shrubbery and parking spaces. For the first five years, when Layton was based in tiny facilities in Atherton and Gilroy, Snable's was the only name on the payroll. Now the company has about 30 employees, who work in a low brick building at the rear of a Sunnyvale research park, tucked deep into the shade of trees.
"We're still proving our supposition that these cells are safe," he says, with a deep sigh that suggests he's covered this terrain many, many times. "But the upside is worth the risk. When you think of the number of problems we can address using cellular therapy, it's mind-boggling. It's vision, it's hearing, it's spinal cord injury, Huntington's, stroke, Parkinson's, epilepsy, Alzheimer's." Wink. "Potentially, it's a real home run."
Snable gave the company the maiden name of his mother, who died of Alzheimer's a year before he and researchers at the University of Pennsylvania formed Layton. "We thought it might be nice to name the company after her, rather than Neuroscience Company Number 43 or whatever," he says.
Ten years later, everyone in the cellular therapy field knows Layton's name. Layton has the only human cancer cell that can be differentiated into neurons, which can then be produced in large quantities. Despite the success in the laboratory, however, Snable has had less luck in the boardroom.
"Though venture capitalists like to consider themselves venturesome, few are," says Snable, who calls fund-raising his priority, not his greatest joy. "They like to invest in something that's been proven a little bit and tweaked, rather than something that's unproven. And with anything that's new, there are no guarantees. When you don't get funded, it's like a house sitting on the market for a long time.
"People look at it and say, "It sounds good to me, but there must be something wrong with it. Why haven't they raised the money?'"
Toucan Capital Corp. of Bethesda, Md., is one of the venture capital firms that took a chance on Layton, contributing $3 million. "We specialize in early-stage investing, so we have nerves of steel and stomachs of iron," says Linda Powers, a managing director with Toucan. "They're way, way out in front of everybody else. They've been working on it for 10 years and they're actually getting somewhere."
Although still not profitable, Layton finances much of its research through the sale of Inversine, a nicotine substitute that battles Tourette's syndrome. Astonishingly, Layton expects to go commercial with LBS-Neurons in the fourth quarter of 2004. But even Steinberg says it's too early to know whether that target date is realistic. "I don't know that we can say we'll be treating patients in a few years with this cell line," he says.
Despite outside criticism of the company's push to enter human clinical trials, doctors working with Layton insist the firm is moving cautiously. Dr. David Tong, a Stanford neurologist who conducts patients' physical therapy evaluations, admits he has "huge safety concerns" about administering the formerly cancerous cells. But he defends the pace and precaution of the study.
"Stroke has been a problem for thousands of years -- we're not going to cure it in five," Tong says. "The company, to its credit, has been good about listening to the scientific advisers. Everybody wants to go as fast as possible. Fortunately, they've used academic centers to run these trials. Too many times, these drug companies push their own agendas, and the academics are taken along for a ride. That's not the case here."
If Layton ever wants a reminder to proceed with care, it need look no further than Charlestown, Mass. That's the home base of Diacrin Inc., a biotech firm that launched a clinical study in September 1999 to treat stroke patients with fetal pig cells. But after surgeons implanted the cells in just five patients, one experienced brain swelling and another suffered severe seizures. The company blames the large tube it used to inject the cells, but the FDA halted the trial in the spring and has not allowed it to proceed.
Matt Fredericks limps through the door of Stanford Medical Center's neurology department and exclaims, "Hi honey, I'm home."
Today, home is a drab exam room with the requisite table/bed, sink, latex-glove dispenser, and poster on the wall extolling the benefits of anti-epileptic drugs. From 9 a.m. until late afternoon, Fredericks is prodded, questioned, and tested. Dressed in a tan jacket, tan button-down shirt, and tan slacks, Fredericks -- a slight man with a mustache and cropped brown hair -- responds to the evaluations with a healthy dose of sarcasm. When a nurse asks if his vision is blurry, Fredericks replies: "Only when I take my glasses off." He compares the wait line snaking out of the Blood Drawing and Specimen Collection Lab to the crush of bodies waiting for a spot on one of the Titanic's lifeboats. When a doctor hands Fredericks a copy of Islands magazine and asks him to describe the cover photo of three scantily clad Polynesian women steering a raft, his insight consists of: "Beautiful composition."
But away from the spotlight, Fredericks makes it clear that his attempts at comedy are merely a means of coping, not a sign that he's approaching the study with a cavalier attitude. Fredericks, an engineer who lives in Southern California, was only 35 when he had his stroke five years ago. Thoroughly unprepared for the deep bouts of depression that followed, Fredericks descended into suicidal despair.
"Why, when you're committing suicide, do you put five rounds in the chamber? It's only going to take one click, and all that suffering and misery will be over." As he waits to have his blood drawn, and for the STAT! notation on his form to register with the receptionist, Fredericks stuffs his dead left arm into his pants pocket and lowers his voice. "The stroke takes away so much of you, but it leaves just enough to realize your life is over. Three months after the stroke I sat there with a handgun to my head. I have a wife and two children, but you're living in misery, and they're living in misery ... it'll just take a second to pull the trigger. And having been down the path of suicide, it still lurks, it still sits there as you go to tie your shoe and you realize you can't."
Fredericks tried anti-depressants, but it took the Layton study to permanently lift him from his funk. Like Perrin, Fredericks had done his homework, and when Layton interviewed him as a potential candidate, he rattled off statistics about previous patients and animal studies. Although Fredericks says his family and friends thought the experiment would kill him, Fredericks knew Layton's science made sense. And, of course, meeting Dr. Steinberg, "my favorite doctor in the entire world," didn't hurt either.
Almost four months after surgery, Fredericks waits in Room 16 for Steinberg's arrival. The doctor is even more eagerly anticipated than usual, because today he plans to unveil a spectroscopy report on Fredericks' brain. The X-rays will compare the health of brain cells before and after surgery, and Fredericks wants his suspicions confirmed: The cells work, but he needs more.
Steinberg sweeps in and slaps a series of X-rays against a glowing wall unit. "Remarkable," he says. Areas of Fredericks' brain that recorded baseline readings of cell health before surgery now sport moderate peaks. "Very encouraging."
To a doctor, maybe, but to a patient, these minimal leaps of progress are more frustrating than fulfilling. Before Steinberg leaves, Fredericks peppers him with sly requests for more cells. By Fredericks' math, based on the results of rat studies, he needs about 80 million to fully recover from his stroke. The FDA, however, needs more than just Fredericks' projections to give the go-ahead on increased dosages.
"I'm sure we've got the solution here," Fredericks says. "And if I risk myself on the front end of this, and we discover it's 50 million neurons to win the game, I'm coming back for more.
"For free," he adds, limping slowly down the hospital hallways toward more tests and trials. "After all, Layton is going to get rich on this someday."