Gene therapy has proven its potential to cure diseases of the hematopoietic system. However, severe adverse events observed in clinical trials have demanded improved gene-transfer conditions. Whereas progress has been made to reduce the genotoxicity of integrating gene vectors, the role of pretransplantation cultivation is less well investigated. We
IntroductionHematopoietic stem cells (HSCs) are characterized by their ability to self-renew and differentiate into all cell types of the hematopoietic system. At physiologic steady-state conditions, only a limited number of HSCs are active at any given time, thus preserving a large fraction of quiescent cells as a reservoir for long-term regeneration. 1 As demonstrated by retroviral gene marking in transplanted mice or nonhuman primates, cycling HSCs are either periodically replaced (clonal succession), maintained as a constant minor pool (clonal maintenance), or follow a mixture of succession, maintenance, and cyclic reactivation (clonal fluctuation). [2][3][4][5] The latter depends on a rich HSC pool and thus requires optimized HSC culture and gene-transfer conditions to be maintained in gene-therapy protocols.Targeting HSCs with integrating gene vectors guarantees lifelong expression of the therapeutic transgene in all progeny cells, and has been effective for the cure of monogenetic diseases such as X-linked severe combined immunodeficiency, chronic granulomatous disease, adenosine deaminase deficiency, and adrenoleukodystrophy. [6][7][8][9] In the first 2 conditions, murine leukemia virus-derived gammaretroviral vector integrations in the vicinity of protooncogenes have led to premalignant clonal dominance and malignant transformation, 7,8 and similar observations have been made in murine models. 10,11 Some of the integration sites that mediate malignant transformation in humans (eg, EVI1, CCND2, and LMO2) can also be found in the Retroviral Tagged Cancer Gene Database, 12 a collection of integration sites of mouse tumors induced by replicating murine leukemia virus. Genes identified in multiple independent tumors are referred to as common insertion sites and are potentially linked to tumor initiation.To improve transduction of quiescent HSCs, HIV-1-derived lentiviral vectors have been developed and evaluated in preclinical and clinical studies. 9,13,14 In contrast to gammaretroviral vectors, which preferentially integrate close to transcription start sites, CpG islands, and DNaseI-hypersensitive sites, lentiviral vectors preferentially integrate within active transcription units. 15,16 In assays detecting transformed mutants, this pattern was found to be 3-to 10-fold safer than the gammaretroviral preferences, 17,18 most likely related to a reduced frequency of enhancer-mediated gene activation.The ability of lentiviral vectors to transduce nondividing cells allows for the use of short, "stemness"-preserving protocols for genetic modification of HSCs. 19 Interestingly, recently described cytokine cocktails such as STIF (stem cell factor [SCF], thrombopoietin ...