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Di Rocco M, Forleo-Neto E, Pignolo RJ, Keen R, Orcel P, Funck-Brentano T, Roux C, Kolta S, Madeo A, Bubbear JS, Tabarkiewicz J, Szczepanek M, Bachiller-Corral J, Cheung AM, Dahir KM, Botman E, Raijmakers PG, Al Mukaddam M, Tile L, Portal-Celhay C, Sarkar N, Hou P, Musser BJ, Boyapati A, Mohammadi K, Mellis SJ, Rankin AJ, Economides AN, Trotter DG, Herman GA, O'Meara SJ, DelGizzi R, Weinreich DM, Yancopoulos GD, Eekhoff EMW, Kaplan FS. Garetosmab in fibrodysplasia ossificans progressiva: a randomized, double-blind, placebo-controlled phase 2 trial. Nat Med 2023; 29:2615-2624. [PMID: 37770652 PMCID: PMC10579054 DOI: 10.1038/s41591-023-02561-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 08/23/2023] [Indexed: 09/30/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare disease characterized by heterotopic ossification (HO) in connective tissues and painful flare-ups. In the phase 2 LUMINA-1 trial, adult patients with FOP were randomized to garetosmab, an activin A-blocking antibody (n = 20) or placebo (n = 24) in period 1 (28 weeks), followed by an open-label period 2 (28 weeks; n = 43). The primary end points were safety and for period 1, the activity and size of HO lesions. All patients experienced at least one treatment-emergent adverse event during period 1, notably epistaxis, madarosis and skin abscesses. Five deaths (5 of 44; 11.4%) occurred in the open-label period and, while considered unlikely to be related, causality cannot be ruled out. The primary efficacy end point in period 1 (total lesion activity by PET-CT) was not met (P = 0.0741). As the development of new HO lesions was suppressed in period 1, the primary efficacy end point in period 2 was prospectively changed to the number of new HO lesions versus period 1. No placebo patients crossing over to garetosmab developed new HO lesions (0% in period 2 versus 40.9% in period 1; P = 0.0027). Further investigation of garetosmab in FOP is ongoing. ClinicalTrials.gov identifier NCT03188666 .
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Affiliation(s)
- Maja Di Rocco
- Department of Pediatrics, Unit of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | | | - Richard Keen
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Philippe Orcel
- Department of Rheumatology - DMU Locomotion, Assistance Publique - Hôpitaux de Paris, Paris, France
- INSERM Université Paris Cité, Paris, France
| | - Thomas Funck-Brentano
- Department of Rheumatology - DMU Locomotion, Assistance Publique - Hôpitaux de Paris, Paris, France
- INSERM Université Paris Cité, Paris, France
| | - Christian Roux
- Department of Rheumatology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sami Kolta
- Department of Rheumatology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Annalisa Madeo
- Department of Pediatrics, Unit of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Judith S Bubbear
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Jacek Tabarkiewicz
- Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów University, Rzeszów, Poland
| | - Małgorzata Szczepanek
- Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów University, Rzeszów, Poland
| | | | - Angela M Cheung
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn M Dahir
- Vanderbilt University Medical Center, Program for Metabolic Bone Disorders, Nashville, TN, USA
| | - Esmée Botman
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC), Vrije Universiteit, Amsterdam UMC Expert Center in Rare Bone Disease, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mona Al Mukaddam
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lianne Tile
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Peijie Hou
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - E Marelise W Eekhoff
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC), Vrije Universiteit, Amsterdam UMC Expert Center in Rare Bone Disease, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Frederick S Kaplan
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Kotb MM, Omar UF, Kaliya-Perumal AK. Living with Fibrodysplasia Ossificans Progressiva: Radiological Images of a Patient with Extensive Heterotopic Ossification. Diagnostics (Basel) 2023; 13:diagnostics13101711. [PMID: 37238196 DOI: 10.3390/diagnostics13101711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an exceptionally rare genetic disorder characterized by the progressive formation of heterotopic bone in soft tissues. Here, we present the radiological findings of an 18-year-old female diagnosed with FOP who had severe spinal and right-upper-limb abnormalities. Her SF-36 scores suggested significant impairment in physical function, affecting work and other regular daily activities. Radiographic evaluation with X-rays and CT scans revealed scoliosis and total fusion of almost all levels of the spine, with only a few disc spaces spared. A large mass of heterotopic bone was observed, corresponding to the location of the paraspinal muscles in the lumbar region, branching upwards and fusing with the scapulae on both sides. On the right side, this exuberant heterotopic bone mass fused with the humerus, resulting in a fixed right shoulder, while the rest of the upper and lower limbs are spared and have a range of motion. Our report highlights the extensive ossification that can manifest in patients with FOP, resulting in restricted mobility and a poor quality of life. While there is no definite treatment that can reverse the effects of the disease, preventing injuries and minimizing iatrogenic harm is of critical importance in this patient as inflammation is known to play a key role in triggering heterotopic bone. Meanwhile, ongoing research into therapeutic strategies holds the key to unlocking a potential cure for FOP in the future.
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Affiliation(s)
- Mohammed Mostafa Kotb
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut 71526, Egypt
| | - Usama Farghaly Omar
- Department of Orthopaedic Surgery, Hand and Reconstructive Microsurgery Service, Khoo Teck Puat Hospital, Singapore 768828, Singapore
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Hsiao EC, Keen R, Al Mukaddam M, Le Quan Sang KH, Wilson A, Marino R, Strahs A, Kaplan FS. The natural history of fibrodysplasia ossificans progressiva: A prospective, global 36-month study. Genet Med 2022; 24:2422-2433. [PMID: 36152026 DOI: 10.1016/j.gim.2022.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE We report the first prospective, international, natural history study of the ultra-rare genetic disorder fibrodysplasia ossificans progressiva (FOP). FOP is characterized by painful, recurrent flare-ups, and disabling, cumulative heterotopic ossification (HO) in soft tissues. METHODS Individuals aged ≤65 years with classical FOP (ACVR1R206H variant) were assessed at baseline and over 36 months. RESULTS In total, 114 individuals participated; 33 completed the study (mean follow up: 26.8 months). Median age was 15.0 (range: 4-56) years; 54.4% were male. During the study, 82 (71.9%) individuals reported 229 flare-ups (upper back: 17.9%, hip: 14.8%, shoulder: 10.9%). After 84 days, 14 of 52 (26.9%) imaged flare-ups had new HO at the flare-up site (mean new HO volume: 28.8 × 103 mm3). Mean baseline low-dose whole-body computed tomography (excluding head) HO volume was 314.4 × 103 mm3; lowest at 2 to <8 years (68.8 × 103 mm3) and increasing by age (25-65 years: 575.2 × 103 mm3). The mean annualized volume of new HO was 23.6 × 103 mm3/year; highest at 8 to <15 and 15 to <25 years (21.9 × 103 and 41.5 × 103 mm3/year, respectively) and lowest at 25 to 65 years (4.6 × 103 mm3/year). CONCLUSION Results from individuals receiving standard care for up to 3 years in this natural history study show the debilitating effect and progressive nature of FOP cross-sectionally and longitudinally, with greatest progression during childhood and early adulthood.
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Affiliation(s)
| | - Geneviève Baujat
- Département de Génétique, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, Paris, France
| | - Matthew A Brown
- Department of Medicine and Molecular Genetics, Faculty of Life Sciences and Medicine, School of Basic and Medical Biosciences, King's College London, London, United Kingdom; Genomics England, London, United Kingdom
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edyth Broad Institute for Regeneration Medicine, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California San Francisco, San Francisco, CA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, Paris, France
| | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Pignolo RJ, Baujat G, Hsiao EC, Keen R, Wilson A, Packman J, Strahs AL, Grogan DR, Kaplan FS. Palovarotene for Fibrodysplasia Ossificans Progressiva (FOP): Results of a Randomized, Placebo-Controlled, Double-Blind Phase 2 Trial. J Bone Miner Res 2022; 37:1891-1902. [PMID: 35854638 PMCID: PMC9804935 DOI: 10.1002/jbmr.4655] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/15/2022] [Accepted: 07/16/2022] [Indexed: 01/07/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder characterized by progressive heterotopic ossification (HO), often heralded by flare-ups, leading to reduced movement and life expectancy. This placebo-controlled, double-blind trial (NCT02190747) evaluated palovarotene, an orally bioavailable selective retinoic acid receptor gamma agonist, for prevention of HO in patients with FOP. Patients experiencing a flare-up were enrolled in two cohorts: (1) patients ≥15 years were randomized 3:1 to palovarotene 10/5 mg (weeks 1-2/3-6) or placebo; (2) patients ≥6 years were randomized 3:3:2 to palovarotene 10/5 mg, palovarotene 5/2.5 mg (weeks 1-2/3-6), or placebo. Cohort data were pooled. The primary endpoint was the proportion of responders (no/minimal new HO at flare-up body region by plain radiograph) at week 6. Change from baseline in HO volume and new HO incidence were assessed by computed tomography (CT) at week 12. Tissue edema was assessed by magnetic resonance imaging (MRI) or ultrasound. Forty patients (aged 7-53 years) were enrolled (placebo: n = 10; palovarotene 5/2.5 mg: n = 9; palovarotene 10/5 mg: n = 21). Disease history was similar between groups. In the per-protocol population, the proportion of responders at week 6 by plain radiograph was 100% with palovarotene 10/5 mg; 88.9% with palovarotene 5/2.5 mg; 88.9% with placebo (Cochran-Armitage trend test: p = 0.17). At week 12, the proportions were 95.0% with palovarotene 10/5 mg; 88.9% with palovarotene 5/2.5 mg; 77.8% with placebo (Cochran-Armitage trend test: p = 0.15). Week 12 least-squares mean (LSmean) new HO volume, assessed by CT, was 3.8 × 103 mm3 with palovarotene 10/5 mg; 1.3 × 103 mm3 with palovarotene 5/2.5 mg; 18.0 × 103 mm3 with placebo (pairwise tests versus placebo: p ≤ 0.12). Palovarotene was well-tolerated. No patients discontinued treatment or required dose reduction; one patient had dose interruption due to elevated lipase. Although these findings were not statistically significant, they support further evaluation of palovarotene for prevention of HO in FOP in larger studies. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Robert J Pignolo
- Department of Medicine, Divisions of Geriatric Medicine and Gerontology, Hospital Internal Medicine, and Endocrinology, Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, USA
| | - Geneviève Baujat
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, UCSF Metabolic Bone Clinic, Institute for Human Genetics, Institute for Regeneration Medicine, and the Program for Craniofacial Biology, University of California-San Francisco, San Francisco, CA, USA
| | - Richard Keen
- Consultant Rheumatologist & Honorary Senior Lecturer in Metabolic Bone Disease, The Royal National Orthopaedic Hospital, Stanmore, UK
| | | | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, and The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Warner SE, Kaplan FS, Pignolo RJ, Smith SE, Hsiao EC, De Cunto C, Di Rocco M, Harnett K, Grogan D, Genant HK. Whole-body Computed Tomography Versus Dual Energy X‑ray Absorptiometry for Assessing Heterotopic Ossification in Fibrodysplasia Ossificans Progressiva. Calcif Tissue Int 2021; 109:615-625. [PMID: 34331548 PMCID: PMC8531122 DOI: 10.1007/s00223-021-00877-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder that leads to heterotopic ossification (HO), resulting in progressive restriction of physical function. In this study, low-dose, whole-body computed tomography (WBCT) and dual energy X-ray absorptiometry (DXA) were evaluated to determine the preferred method for assessing total body burden of HO in patients with FOP. This was a non-interventional, two-part natural history study in patients with FOP (NCT02322255; date of registration: December 2014). In Part A (described here), WBCT and DXA scans were individually assessed for HO presence and severity across 15 anatomical regions. All images were independently reviewed by an expert imaging panel. Ten adult patients were enrolled across four sites. The sensitivity to HO presence and severity varied considerably between the two imaging modalities, with WBCT demonstrating HO in more body regions than DXA (76/138 [55%] versus 47/113 [42%]) evaluable regions). Inability to evaluate HO presence, due to overlapping body regions (positional ambiguity), occurred less frequently by WBCT than by DXA (mean number of non-evaluable regions per scan 1.2 [standard deviation: 1.5] versus 2.4 [1.4]). Based on the increased sensitivity and decreased positional ambiguity of low-dose WBCT versus DXA in measuring HO in patients with FOP, low-dose WBCT was chosen as the preferred imaging for measuring HO. Therefore, low-dose WBCT was carried forward to Part B of the natural history study, which evaluated disease progression over 36 months in a larger population of patients with FOP.
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Affiliation(s)
- Sarah E Warner
- Scientific and Medical Services, PAREXEL International (dba Calyx), Billerica, MA, USA.
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Stacy E Smith
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, and The Neil and Elise Wallace STRATUS Center for Medical Simulation, Harvard Medical School, Boston, MA, USA
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California-San Francisco, San Francisco, CA, USA
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | | | | | - Harry K Genant
- Departments of Radiology, Medicine and Orthopaedic Surgery, University of California, San Francisco, CA, USA
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Pignolo RJ, Hsiao EC, Baujat G, Lapidus D, Sherman A, Kaplan FS. Prevalence of fibrodysplasia ossificans progressiva (FOP) in the United States: estimate from three treatment centers and a patient organization. Orphanet J Rare Dis 2021; 16:350. [PMID: 34353327 PMCID: PMC8340531 DOI: 10.1186/s13023-021-01983-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP), an ultra-rare, progressive, and permanently disabling disorder of extraskeletal ossification, is characterized by episodic and painful flare-ups and irreversible heterotopic ossification in muscles, tendons, and ligaments. Prevalence estimates have been hindered by the rarity of FOP and the heterogeneity of disease presentation. This study aimed to provide a baseline prevalence of FOP in the United States, based on contact with one of 3 leading treatment centers for FOP (University of Pennsylvania, Mayo Clinic, or University of California San Francisco), the International Fibrodysplasia Ossificans Progressiva Association (IFOPA) membership list, or the IFOPA FOP Registry through July 22, 2020. RESULTS Patient records were reviewed, collected, and deduplicated using first and last name initials, sex, state, and year of birth. A Kaplan-Meier survival curve was applied to each individual patient to estimate the probability that he or she was still alive, and a probability-weighted net prevalence estimate was calculated. After deduplication, 373 unique patients were identified in the United States, 294 of whom who were not listed as deceased in any list. The average time since last contact for 284 patients was 1.5 years. Based on the application of the survival probability, it is estimated that 279 of these patients were alive on the prevalence date (22 July 2020). An adjusted prevalence of 0.88 per million US residents was calculated using either an average survival rate estimate of 98.4% or a conservative survival rate estimate of 92.3% (based on the Kaplan-Meier survival curve from a previous study) and the US Census 2020 estimate of 329,992,681 on prevalence day. CONCLUSIONS This study suggests that the prevalence of FOP is higher than the often-cited value of 0.5 per million. Even so, because inclusion in this study was contingent upon treatment by the authors, IFOPA membership with confirmed clinical diagnosis, and the FOP Registry, the prevalence of FOP in the US may be higher than that identified here. Thus, it is imperative that efforts be made to identify and provide expert care for patients with this ultra-rare, significantly debilitating disease.
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Affiliation(s)
- Robert J Pignolo
- Geriatric Medicine & Gerontology, Robert and Arlene Kogod Professor of Geriatric Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Edward C Hsiao
- Robert L. Kroc Chair in Rheumatic and Connective Tissue Diseases III, Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA.,Department of Medicine, Institute for Human Genetics, University of California, San Francisco, CA, USA.,Program in Craniofacial Biology, University of California, San Francisco, CA, USA
| | - Genevieve Baujat
- Department of Clinical Genetics, INSERM U1163, Paris-Descartes University, Imagine Institute, Necker-Enfants Malades Hospital, Paris, France
| | | | - Adam Sherman
- The International FOP Association, North Kansas City, MO, USA
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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7
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Kannu P, Levy CE. Improving the Diagnosis of Fibrodysplasia Ossificans Progressiva. J Pediatr 2021; 232S:S3-S8. [PMID: 33896450 DOI: 10.1016/j.jpeds.2021.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/11/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Kannu
- The Hospital for Sick Children and Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada; University of Alberta, Toronto, Ontario, Canada.
| | - Charles E Levy
- Center for Arts in Medicine, College of the Arts, University of Florida, Gainesville, FL
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Peng K, Karunakaran KD, Labadie R, Veliu M, Cheung C, Lee A, Yu PB, Upadhyay J. Suppressed prefrontal cortex oscillations associate with clinical pain in fibrodysplasia ossificans progressiva. Orphanet J Rare Dis 2021; 16:54. [PMID: 33516233 PMCID: PMC7847608 DOI: 10.1186/s13023-021-01709-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pain is a highly prevalent symptom experienced by patients across numerous rare musculoskeletal conditions. Much remains unknown regarding the central, neurobiological processes associated with clinical pain in musculoskeletal disease states. Fibrodysplasia ossificans progressiva (FOP) is an inherited condition characterized by substantial physical disability and pain. FOP arises from mutations of the bone morphogenetic protein (BMP) receptor Activin A receptor type 1 (ACVR1) causing patients to undergo painful flare-ups as well as heterotopic ossification (HO) of skeletal muscles, tendons, ligaments, and fascia. To date, the neurobiological processes that underlie pain in FOP have rarely been investigated. We examined pain and central pain mechanism in FOP as a model primary musculoskeletal condition. Central nervous system (CNS) functional properties were investigated in FOP patients (N = 17) stratified into low (0–3; 0–10 Scale) and high (≥ 4) pain cohorts using functional near-infrared spectroscopy (fNIRS). Associations among clinical pain, mental health, and physical health were also quantified using responses derived from a battery of clinical questionnaires. Results Resting-state fNIRS revealed suppressed power of hemodynamic activity within the slow-5 frequency sub-band (0.01–0.027 Hz) in the prefrontal cortex in high pain FOP patients, where reduced power of slow-5, prefrontal cortex oscillations exhibited robust negative correlations with pain levels. Higher clinical pain intensities were also associated with higher magnitudes of depressive symptoms. Conclusions Our findings not only demonstrate a robust coupling among prefrontal cortex functionality and clinical pain in FOP but lays the groundwork for utilizing fNIRS to objectively monitor and central pain mechanisms in FOP and other musculoskeletal disorders.
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Affiliation(s)
- Ke Peng
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Département en Neuroscience, Centre de Recherche du CHUM, l'Université de Montréal, Montreal, QC, Canada
| | - Keerthana Deepti Karunakaran
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Labadie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Miranda Veliu
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chandler Cheung
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arielle Lee
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul B Yu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jaymin Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, USA.
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9
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Lee DS. In Reply to Murgic et al. Int J Radiat Oncol Biol Phys 2020; 108:1394. [DOI: 10.1016/j.ijrobp.2020.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 11/28/2022]
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10
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Haga N, Nakashima Y, Kitoh H, Kamizono J, Katagiri T, Saijo H, Tsukamoto S, Shinoda Y, Sawada R, Nakahara Y. Fibrodysplasia ossificans progressiva: Review and research activities in Japan. Pediatr Int 2020; 62:3-13. [PMID: 31774601 DOI: 10.1111/ped.14065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 04/11/2019] [Accepted: 05/15/2019] [Indexed: 01/08/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic skeletal disorder manifesting progressive heterotopic ossification (HO) and congenital malformation of the great toes. Since 2007, we have conducted research on FOP. Here, we review the findings on FOP published to date, including the results of our research. Epidemiological studies in Japan have indicated that FOP has nearly the same prevalence in Japan as in the rest of the world. Basic research on its pathoetiology has progressed rapidly since the identification of the causal gene in 2006. Clinical and radiological findings have been thoroughly researched, including early radiological signs, and diagnostic criteria were established, designating FOP as an intractable disease in Japan. In patients with FOP, the progression of HO is associated with numerous disabilities, often manifesting in vicious cycles that can lead to early mortality. Through cross-sectional and short-term longitudinal studies, we have explored patient education, quality of life, and activities of daily living among Japanese patients. The management of FOP requires education of patients and caregivers, the use of medications to settle inflammation and flare-ups, instructions to ensure proper oral care, and other compensatory approaches that aid in rehabilitation. An avoidance of medical intervention, which may cause HO to progress, is also important. The advent of new drugs to prevent HO could have clinical benefit.
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Affiliation(s)
- Nobuhiko Haga
- Department of Rehabilitation Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Hiroshi Kitoh
- Department of Orthopaedic Surgery, Aichi Children's Health and Medical Center, Obu, Japan
| | - Junji Kamizono
- Emergency Care Services, Children's Medical Center, Kitakyushu City YAHATA Hospital, Kitakyushu, Japan
| | - Takenobu Katagiri
- Division of Pathophysiology, Research Center for Genomic Medicine, Saitama Medical University, Saitama, Japan.,Project of Clinical and Basic Research for FOP, Saitama Medical University, Saitama, Japan
| | - Hideto Saijo
- Department of Oral and Maxillofacial Surgery, The University of Tokyo, Tokyo, Japan
| | - Sho Tsukamoto
- Division of Pathophysiology, Research Center for Genomic Medicine, Saitama Medical University, Saitama, Japan.,Project of Clinical and Basic Research for FOP, Saitama Medical University, Saitama, Japan
| | - Yusuke Shinoda
- Department of Rehabilitation Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryoko Sawada
- Department of Rehabilitation Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuo Nakahara
- Department of Rehabilitation, Teikyo University, Tokyo, Japan
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Colmenares-Bonilla D, Gonzalez-Segoviano A. Bone Resection Osteotomy in Fibrodysplasia Ossificans Progressiva. J Orthop Case Rep 2018; 8:39-43. [PMID: 29854691 PMCID: PMC5974675 DOI: 10.13107/jocr.2250-0685.990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Fibrodysplasia ossificans progressiva (FOP) is the severest disease of ossification in the human. It forms an exoskeleton gradually. This process is started for a nodule that ossifies as days goes by. The initial pathway cannot be stopped unless early immunosuppress management is started very early after the aggression has been received. These aggressions may vary from contusions, viral illnesses, surgery, and other minor trauma. Because of this process, the FOP patient gradually worsens and decreases its autonomy as described from ability to walk, dress, or even to eat and breathe. Case Report: An 11-year-old female comes to evaluation for multiple ossifications, which worsen her autonomy and the ability to walk. The last ossification keeps the knee bent at 90° by a bony bridge from the femur to the tibia. To try to walk, it is necessary to flex hip, and ankle, with tilting of the pelvis, with pain and loss of autonomy. Due to the characteristic ossification pattern, FOP is diagnosed and the possibility of surgery to prolong autonomic gait is suggested. The procedure is performed under immunosuppression, and the knee is extended to a position that allows the patient to walk again freely. The steroid management is continued the convenient time to avoid exacerbation of the disease at a distance, and suspend it definitively afterward. Conclusions: The FOP is adding an exoskeleton and its episodes of exacerbation end in new ossifications that deteriorate the quality of life. Once the ossifications have appeared, it is not possible to stop or reverse the process. Performing an osteotomy to prolong gait is a risky procedure. However, the present study shows that final ossification is expected at the point of resection of the extracted bone and suggests that immunosuppressing the patient could prevent distant exacerbations. The risk-benefit ratio of the procedure may be favorable if it is performed at a quiescent stage of the disease.
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Affiliation(s)
- Douglas Colmenares-Bonilla
- Department Pediatric Orthopedic, Hospital Regional de Alta Especialidad del Bajio, Leon, Guanajuato, Mexico
| | - Alejandra Gonzalez-Segoviano
- Fellow in Pediatric Orthopedic Surgery Course, Hospital Regional de Alta Especialidad del Bajio, Leon, Guanajuato, Mexico
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