1
|
Srinivasan D, Arostegui M, Goebel EJ, Hart KN, Aykul S, Lees-Shepard JB, Idone V, Hatsell SJ, Economides AN. How Activin A Became a Therapeutic Target in Fibrodysplasia Ossificans Progressiva. Biomolecules 2024; 14:101. [PMID: 38254701 PMCID: PMC10813747 DOI: 10.3390/biom14010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder characterized by episodic yet cumulative heterotopic ossification (HO) of skeletal muscles, tendons, ligaments, and fascia. FOP arises from missense mutations in Activin Receptor type I (ACVR1), a type I bone morphogenetic protein (BMP) receptor. Although initial findings implicated constitutive activity of FOP-variant ACVR1 (ACVR1FOP) and/or hyperactivation by BMPs, it was later shown that HO in FOP requires activation of ACVR1FOP by Activin A. Inhibition of Activin A completely prevents HO in FOP mice, indicating that Activin A is an obligate driver of HO in FOP, and excluding a key role for BMPs in this process. This discovery led to the clinical development of garetosmab, an investigational antibody that blocks Activin A. In a phase 2 trial, garetosmab inhibited new heterotopic bone lesion formation in FOP patients. In contrast, antibodies to ACVR1 activate ACVR1FOP and promote HO in FOP mice. Beyond their potential clinical relevance, these findings have enhanced our understanding of FOP's pathophysiology, leading to the identification of fibroadipogenic progenitors as the cells that form HO, and the discovery of non-signaling complexes between Activin A and wild type ACVR1 and their role in tempering HO, and are also starting to inform biological processes beyond FOP.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Aris N. Economides
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY 10591, USA; (D.S.); (M.A.); (E.J.G.); (K.N.H.); (S.A.); (J.B.L.-S.); (V.I.); (S.J.H.)
| |
Collapse
|
2
|
Anwar S, Yokota T. Navigating the Complex Landscape of Fibrodysplasia Ossificans Progressiva: From Current Paradigms to Therapeutic Frontiers. Genes (Basel) 2023; 14:2162. [PMID: 38136984 PMCID: PMC10742611 DOI: 10.3390/genes14122162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an enigmatic, ultra-rare genetic disorder characterized by progressive heterotopic ossification, wherein soft connective tissues undergo pathological transformation into bone structures. This incapacitating process severely limits patient mobility and poses formidable challenges for therapeutic intervention. Predominantly caused by missense mutations in the ACVR1 gene, this disorder has hitherto defied comprehensive mechanistic understanding and effective treatment paradigms. This write-up offers a comprehensive overview of the contemporary understanding of FOP's complex pathobiology, underscored by advances in molecular genetics and proteomic studies. We delve into targeted therapy, spanning genetic therapeutics, enzymatic and transcriptional modulation, stem cell therapies, and innovative immunotherapies. We also highlight the intricate complexities surrounding clinical trial design for ultra-rare disorders like FOP, addressing fundamental statistical limitations, ethical conundrums, and methodological advancements essential for the success of interventional studies. We advocate for the adoption of a multi-disciplinary approach that converges bench-to-bedside research, clinical expertise, and ethical considerations to tackle the challenges of ultra-rare diseases like FOP and comparable ultra-rare diseases. In essence, this manuscript serves a dual purpose: as a definitive scientific resource for ongoing and future FOP research and a call to action for innovative solutions to address methodological and ethical challenges that impede progress in the broader field of medical research into ultra-rare conditions.
Collapse
Affiliation(s)
| | - Toshifumi Yokota
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2H7, Canada;
| |
Collapse
|
3
|
Korableva NN, Berestnev EV, Kiselyov SM, Chipsanova NF. Fibrodysplasia Ossificans Progressiva: Literature Review and Case Report. CURRENT PEDIATRICS 2022. [DOI: 10.15690/vsp.v21i6s.2482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background. Fibrodysplasia ossificans progressiva (FOP) is a genetic disease of the heterotopic ossification group associated with the mutation in ACVR1/ALK2 gene. FOP is characterized by progressive heterotopic endochondral ossification of connective tissue that occurs in postnatal period. It leads to formation of qualitatively normal bone in extraskeletal areas. Congenital hallux deformity is typical for this disease. The clinical picture is characterized by aggravations that are usually caused by trauma or viral infections. Formation of Heterotopic ossificate formation can be observed during aggravations. There is no etiological treatment for FOP. Systemic glucocorticosteroids, non-steroidal anti-inflammatory drug (NSAIDs), mast cell stabilisers, antileukotriene drugs and bisphosphonates can be used in these patients. Clinical case description. The child was born with congenital hallux deformity typical for FOP. The disease onset was noted at the age of 2 years 8 months with a tumor-like painful mass on the neck. Oncological (lymphoproliferative) disease was suspected but biopsy from the lesion did not confirm its malignant nature. The child was consulted by pediatric rheumatologist who has diagnosed FOP. Etanercept and zoledronic acid were administrated, though etanercept was later discontinued. For now, the child receives zoledronic acid infusions 2 times per year and daily NSAIDs. Conclusion. The difficulties in FOP diagnosing are associated to its sporadic nature and clinical picture similarity to other diseases. Suspected malignancy leads to biopsy that is highly undesirable in FOP patients due to high risk of iatrogenic complications.
Collapse
|
4
|
Elamin M, Almutasim Ibrahim A, Omer A. Fibrodysplasia Ossificans Progressiva: A Report of Four Cases. Cureus 2022; 14:e23392. [PMID: 35475090 PMCID: PMC9022658 DOI: 10.7759/cureus.23392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/03/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare disease with less than a thousand confirmed cases. It is a severely disabling genetic condition that affects soft tissues and is characterized by progressive extraskeletal heterotopic ossification and great toe deformities. The mode of FOP inheritance is autosomal dominant with no association to race, gender, or geographic distribution. While laboratory results and imaging studies support the identification of FOP, the diagnosis of this rare condition is mainly clinical. Recently, FOP has been linked to a mutation of the ACVR1/ALK2 gene that induces osteoblast activation. We are reporting four cases of fibrodysplasia ossificans progressiva over a period of two years (2014-2016). Three out of four cases were treated conservatively. The first case was treated by excision of a bony bar, and the patient developed progressive bony formation and restriction of movement afterwards. Almost always, FOP needs to be treated conservatively with non-steroidal anti-inflammatory drugs (NSAIDs) and gentle physiotherapy. Aside from anesthetic complications, surgical interventions provoke more bone formation, hence the recurrent joint restriction. Therefore, surgery should only be reserved for severely disabling deformities.
Collapse
|
5
|
Sun D, Liu P, Wang Z, Mu J, Cao J. Fibrodysplasia ossificans progressiva: A rare disease with spinal deformity and severe hip dysfunction. Front Pediatr 2022; 10:981372. [PMID: 36186647 PMCID: PMC9520337 DOI: 10.3389/fped.2022.981372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Progressive fibrous dysplasia ossification (FOP) is a rare genetic disease characterized by congenital bone malformations and soft tissue masses that progress to heterotopic ossification. Congenital great toe deformity and progressive heterotopic ossifications with an anatomical and temporal pattern are the two classical clinical characteristics of FOP. We present a unique case of FOP characterized by mandibular angle fascial contracture and back and iliopsoas muscle ossification managed via surgery in a 13 year old girl. CASE PRESENTATION A 13 year old girl with a history of right cervical fascial release surgery and back heterotopic osteotomy presented to our clinic due to recurrence of heterotopic ossification, scoliosis, and progressive joint stiffness. Computed tomography (CT) or magnetic resonance imaging (MRI) examination confirmed heterotopic ossification of the left back and left iliopsoas muscle and spinal scoliosis. Two years after the surgery, the patient presented with recurrence of back heterotopic ossification and rapidly advancing ossification of the left iliopsoas muscle. Six months after surgery, the patient had no disability, pain and clinical recurrence, and the joint function recovered. CONCLUSIONS In patients with multiple-site heterotopic ossification caused by FOP, oral function and hip stiffness improve with detailed facial release surgery and rehabilitation treatment. However, dorsal fascia ossification and spinal scoliosis can recur shortly after resection.
Collapse
Affiliation(s)
- Dong Sun
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Peng Liu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Zhaolin Wang
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jianhu Mu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jian Cao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| |
Collapse
|
6
|
Macrophages in heterotopic ossification: from mechanisms to therapy. NPJ Regen Med 2021; 6:70. [PMID: 34702860 PMCID: PMC8548514 DOI: 10.1038/s41536-021-00178-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 09/30/2021] [Indexed: 01/04/2023] Open
Abstract
Heterotopic ossification (HO) is the formation of extraskeletal bone in non-osseous tissues. It is caused by an injury that stimulates abnormal tissue healing and regeneration, and inflammation is involved in this process. It is worth noting that macrophages are crucial mediators of inflammation. In this regard, abundant macrophages are recruited to the HO site and contribute to HO progression. Macrophages can acquire different functional phenotypes and promote mesenchymal stem cell (MSC) osteogenic differentiation, chondrogenic differentiation, and angiogenesis by expressing cytokines and other factors such as the transforming growth factor-β1 (TGF-β1), bone morphogenetic protein (BMP), activin A (Act A), oncostatin M (OSM), substance P (SP), neurotrophin-3 (NT-3), and vascular endothelial growth factor (VEGF). In addition, macrophages significantly contribute to the hypoxic microenvironment, which primarily drives HO progression. Thus, these have led to an interest in the role of macrophages in HO by exploring whether HO is a "butterfly effect" event. Heterogeneous macrophages are regarded as the "butterflies" that drive a sequence of events and ultimately promote HO. In this review, we discuss how the recruitment of macrophages contributes to HO progression. In particular, we review the molecular mechanisms through which macrophages participate in MSC osteogenic differentiation, angiogenesis, and the hypoxic microenvironment. Understanding the diverse role of macrophages may unveil potential targets for the prevention and treatment of HO.
Collapse
|
7
|
Esposito P, Verzola D, Picciotto D, Cipriani L, Viazzi F, Garibotto G. Myostatin/Activin-A Signaling in the Vessel Wall and Vascular Calcification. Cells 2021; 10:2070. [PMID: 34440838 PMCID: PMC8393536 DOI: 10.3390/cells10082070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023] Open
Abstract
A current hypothesis is that transforming growth factor-β signaling ligands, such as activin-A and myostatin, play a role in vascular damage in atherosclerosis and chronic kidney disease (CKD). Myostatin and activin-A bind with different affinity the activin receptors (type I or II), activating distinct intracellular signaling pathways and finally leading to modulation of gene expression. Myostatin and activin-A are expressed by different cell types and tissues, including muscle, kidney, reproductive system, immune cells, heart, and vessels, where they exert pleiotropic effects. In arterial vessels, experimental evidence indicates that myostatin may mostly promote vascular inflammation and premature aging, while activin-A is involved in the pathogenesis of vascular calcification and CKD-related mineral bone disorders. In this review, we discuss novel insights into the biology and physiology of the role played by myostatin and activin in the vascular wall, focusing on the experimental and clinical data, which suggest the involvement of these molecules in vascular remodeling and calcification processes. Moreover, we describe the strategies that have been used to modulate the activin downward signal. Understanding the role of myostatin/activin signaling in vascular disease and bone metabolism may provide novel therapeutic opportunities to improve the treatment of conditions still associated with high morbidity and mortality.
Collapse
Affiliation(s)
- Pasquale Esposito
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy; (P.E.); (D.V.); (L.C.); (F.V.)
- IRCCS Ospedale Policlinico San Martino, Clinica Nefrologica, Dialisi, Trapianto, 16132 Genova, Italy;
| | - Daniela Verzola
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy; (P.E.); (D.V.); (L.C.); (F.V.)
| | - Daniela Picciotto
- IRCCS Ospedale Policlinico San Martino, Clinica Nefrologica, Dialisi, Trapianto, 16132 Genova, Italy;
| | - Leda Cipriani
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy; (P.E.); (D.V.); (L.C.); (F.V.)
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy; (P.E.); (D.V.); (L.C.); (F.V.)
- IRCCS Ospedale Policlinico San Martino, Clinica Nefrologica, Dialisi, Trapianto, 16132 Genova, Italy;
| | - Giacomo Garibotto
- Department of Internal Medicine, University of Genova, 16132 Genova, Italy; (P.E.); (D.V.); (L.C.); (F.V.)
| |
Collapse
|
8
|
Cappato S, Traberg R, Gintautiene J, Zara F, Bocciardi R. A case of Fibrodysplasia Ossificans Progressiva associated with a novel variant of the ACVR1 gene. Mol Genet Genomic Med 2021; 9:e1774. [PMID: 34347384 PMCID: PMC8580088 DOI: 10.1002/mgg3.1774] [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: 05/19/2021] [Accepted: 07/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Fibrodysplasia Ossificans Progressiva (FOP) is a rare autosomal dominant disease characterized by congenital malformation of the great toes and progressive heterotopic ossification of soft tissues leading to cumulative disability. The genetic cause of FOP are mutations in the ACVR1 gene that encodes a type I receptor of Bone Morphogenetic Proteins. The most recurrent mutation in FOP patients is R206H affecting the Glycine‐Serine rich domain and causing the hyper‐activation of the receptor and the responsivity to the non‐canonical ligand, Activin A. In the present study, we described a 3‐years old child with early and highly suggestive clinical features of FOP who was found negative for the recurrent p.R206H substitution. Methods Molecular screening of the whole ACVR1 coding sequence and functional characterization in transfection‐based assays. Results and Conclusions We identified a novel, de novo variant in the fifth ACVR1 coding exon (NM_001111067.4:c.772A>T; NP_001104537.1:p.(R258W)). This substitution, never reported in association with FOP, affects a conserved arginine residue in the kinase domain of the protein. In silico analysis predicted the pathogenicity of this substitution, demonstrated by in vitro assays showing that the p.R258W ACVR1 mutated receptor acquires the ability to transduce the aberrant Activin A‐mediated signaling, as observed for the gene variants associated with FOP.
Collapse
Affiliation(s)
- Serena Cappato
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Rasa Traberg
- Department of Genetics and Molecular Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jolita Gintautiene
- Department of Paediatric Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Federico Zara
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy.,UOC Genetica Medica, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Renata Bocciardi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Sciences (DINOGMI), University of Genoa, Genoa, Italy.,UOC Genetica Medica, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| |
Collapse
|
9
|
Grgurevic L, Novak R, Hrkac S, Salai G, Grazio S. Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient. Rheumatol Int 2021; 41:1495-1501. [PMID: 34110466 PMCID: PMC8190523 DOI: 10.1007/s00296-021-04911-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022]
Abstract
Fibrodyplasia ossificans progressiva (FOP) is a rare hereditary disease, which has a variable course characterized by occasional flare-ups of heterotopic ossification (HO) in soft tissues that are followed by swelling, stiffness, pain and warmth. Here, we report for the first time a case of a 45-year-old female patient with known FOP recovering from COVID-19 with disease progression potentially linked with the viral illness. In December 2020 the patient contracted a mild form of COVID-19 infection without need for hospital admission. Since January 2021, the patient felt unwell, with occasional abdominal pain which progressively intensified. In March 2021 she presented with new onset of HO, complaining of pain, swelling and thickening sensation in the lower abdomen and left part of the neck. Computerized tomography (CT) and cytokine analysis were performed. CT scan revealed new heterotopic bone formation in multiple soft tissue areas of the neck indicating clear radiological progression. Radiotherapy, which has proven to be an efficient tool to control HO in this patient, was not able to halt HO formation after COVID-19 infection. Cytokine analysis of a plasma sample obtained during a flare-up after COVID-19 infection showed a significantly elevated pro-inflammatory cytokines compared to a flare-up panel prior to infection. Of the 23 analyzed levels of cytokines, a staggering number of 21 were above normal levels. This case is the first confirmation of uncontrolled post-COVID-19 effects in a FOP patient, which manifested with flare-ups followed by progressive HO, possibly caused by a thus far, never described form of post-COVID syndrome.
Collapse
Affiliation(s)
- Lovorka Grgurevic
- Department of Anatomy, School of Medicine, University of Zagreb, Zagreb, Croatia. .,Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia.
| | - Rudjer Novak
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia
| | - Stela Hrkac
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia
| | - Grgur Salai
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia
| | - Simeon Grazio
- Department of Rheumatology, Physical and Rehabilitation, Medicine University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| |
Collapse
|
10
|
Wang Z, Wang X, Liu B, Hou Y. Fibrodysplasia ossificans progressiva in a young adult with genetic mutation: Case report. Medicine (Baltimore) 2021; 100:e24620. [PMID: 33655926 PMCID: PMC7939192 DOI: 10.1097/md.0000000000024620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder characterized by congenital skeletal deformities and soft tissue masses that progress into heterotopic ossification. Deformities of the great toes are distinctive and heterotrophic ossification usually begins in the first decade of the patient's life. Any invasive procedure could potentially trigger a flare and heterotopic calcification. The diagnosis is difficult and there is no effective treatment for FOP and the approximate life expectancy is 4 decades. PATIENT CONCERNS A 22-year-old male patient who had suffered from pain and movement limitations for 14 years. At the early stage of disease, the child underwent an operation on both thighs with a diagnosis of myophagism. He had serious stiffness and multiple bony masses with the characteristic bilateral hallux valgus deformity and microdactyly. DIAGNOSES The patient was diagnosed with FOP by the help of characteristic great toe malformations and widespread heterotopic ossification throughout the body. Deoxyribonucleic acid sequencing demonstrated that the patient had a de novo heterozygous mutation (c.617G>A; p.R206H) in activin A receptor/activin-like kinase 2. INTERVENTIONS We administered a co-therapy of glucocorticoids, NSAIDs to relieve pain, and montelukast for 2 months. Bisphosphonate (5 mg, intravenous) was used once. OUTCOMES At the follow-up 12 months later, the patient still felt low back pain sometimes and need take NSAIDs three times a week. LESSONS Clinicians and radiologists should realize the characteristic features of FOP and early diagnosis can prevent additional invasive harm to the patient.
Collapse
Affiliation(s)
- Zhankui Wang
- Department of Rheumatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
- Shandong Provincial Key Laboratory for Rheumatic Disease and Translational Medicine, Jinan
| | - Xiuhua Wang
- Department of Rheumatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
- Shandong Provincial Key Laboratory for Rheumatic Disease and Translational Medicine, Jinan
| | - Baojin Liu
- Shandong First Medical University, Jinan, Shandong, China
| | - Yanfeng Hou
- Department of Rheumatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
- Shandong Provincial Key Laboratory for Rheumatic Disease and Translational Medicine, Jinan
| |
Collapse
|
11
|
Alexander KA, Tseng HW, Salga M, Genêt F, Levesque JP. When the Nervous System Turns Skeletal Muscles into Bones: How to Solve the Conundrum of Neurogenic Heterotopic Ossification. Curr Osteoporos Rep 2020; 18:666-676. [PMID: 33085000 DOI: 10.1007/s11914-020-00636-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Neurogenic heterotopic ossification (NHO) is the abnormal formation of extra-skeletal bones in periarticular muscles after damage to the central nervous system (CNS) such as spinal cord injury (SCI), traumatic brain injury (TBI), stroke, or cerebral anoxia. The purpose of this review is to summarize recent developments in the understanding of NHO pathophysiology and pathogenesis. Recent animal models of NHO and recent findings investigating the communication between CNS injury, tissue inflammation, and upcoming NHO therapeutics are discussed. RECENT FINDINGS Animal models of NHO following TBI or SCI have shown that NHO requires the combined effects of a severe CNS injury and soft tissue damage, in particular muscular inflammation and the infiltration of macrophages into damaged muscles plays a key role. In the context of a CNS injury, the inflammatory response to soft tissue damage is exaggerated and persistent with excessive signaling via substance P-, oncostatin M-, and TGF-β1-mediated pathways. This review provides an overview of the known animal models and mechanisms of NHO and current therapeutic interventions for NHO patients. While some of the inflammatory mechanisms leading to NHO are common with other forms of traumatic and genetic heterotopic ossifications (HO), NHOs uniquely involve systemic changes in response to CNS injury. Future research into these CNS-mediated mechanisms is likely to reveal new targetable pathways to prevent NHO development in patients.
Collapse
Affiliation(s)
- Kylie A Alexander
- Mater Research Institute, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, Queensland, 4102, Australia
| | - Hsu-Wen Tseng
- Mater Research Institute, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, Queensland, 4102, Australia
| | - Marjorie Salga
- Department of Physical Medicine and Rehabilitation, CIC 1429, Raymond Poincaré Hospital, APHP, Garches, France
- END:ICAP U1179 INSERM, University of Versailles Saint Quentin en Yvelines, UFR Simone Veil-Santé, Montigny le Bretonneux, France
| | - François Genêt
- Department of Physical Medicine and Rehabilitation, CIC 1429, Raymond Poincaré Hospital, APHP, Garches, France
- END:ICAP U1179 INSERM, University of Versailles Saint Quentin en Yvelines, UFR Simone Veil-Santé, Montigny le Bretonneux, France
| | - Jean-Pierre Levesque
- Mater Research Institute, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, Queensland, 4102, Australia.
| |
Collapse
|
12
|
Kaliya-Perumal AK, Carney TJ, Ingham PW. Fibrodysplasia ossificans progressiva: current concepts from bench to bedside. Dis Model Mech 2020; 13:13/9/dmm046441. [PMID: 32988985 PMCID: PMC7522019 DOI: 10.1242/dmm.046441] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Heterotopic ossification (HO) is a disorder characterised by the formation of ectopic bone in soft tissue. Acquired HO typically occurs in response to trauma and is relatively common, yet its aetiology remains poorly understood. Genetic forms, by contrast, are very rare, but provide insights into the mechanisms of HO pathobiology. Fibrodysplasia ossificans progressiva (FOP) is the most debilitating form of HO. All patients reported to date carry heterozygous gain-of-function mutations in the gene encoding activin A receptor type I (ACVR1). These mutations cause dysregulated bone morphogenetic protein (BMP) signalling, leading to HO at extraskeletal sites including, but not limited to, muscles, ligaments, tendons and fascia. Ever since the identification of the causative gene, developing a cure for FOP has been a focus of investigation, and studies have decoded the pathophysiology at the molecular and cellular levels, and explored novel management strategies. Based on the established role of BMP signalling throughout HO in FOP, therapeutic modalities that target multiple levels of the signalling cascade have been designed, and some drugs have entered clinical trials, holding out hope of a cure. A potential role of other signalling pathways that could influence the dysregulated BMP signalling and present alternative therapeutic targets remains a matter of debate. Here, we review the recent FOP literature, including pathophysiology, clinical aspects, animal models and current management strategies. We also consider how this research can inform our understanding of other types of HO and highlight some of the remaining knowledge gaps. Summary: Fibrodysplasia ossificans progressiva is a rare disease characterised by progressive heterotopic bone formation. Here, we present a comprehensive summary of the recent literature on this debilitating condition and discuss approaches to solving this clinical puzzle.
Collapse
Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 59 Nanyang Drive, 636921, Singapore
| | - Tom J Carney
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 59 Nanyang Drive, 636921, Singapore.,Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Proteos 138673, Singapore
| | - Philip W Ingham
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 59 Nanyang Drive, 636921, Singapore .,Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Proteos 138673, Singapore
| |
Collapse
|
13
|
Allen RS, Tajer B, Shore EM, Mullins MC. Fibrodysplasia ossificans progressiva mutant ACVR1 signals by multiple modalities in the developing zebrafish. eLife 2020; 9:53761. [PMID: 32897189 PMCID: PMC7478894 DOI: 10.7554/elife.53761] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 08/12/2020] [Indexed: 12/14/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare human genetic disorder characterized by altered skeletal development and extraskeletal ossification. All cases of FOP are caused by activating mutations in the type I BMP/TGFβ cell surface receptor ACVR1, which over-activates signaling through phospho-Smad1/5 (pSmad1/5). To investigate the mechanism by which FOP-ACVR1 enhances pSmad1/5 activation, we used zebrafish embryonic dorsoventral (DV) patterning as an assay for BMP signaling. We determined that the FOP mutants ACVR1-R206H and -G328R do not require their ligand binding domain to over-activate BMP signaling in DV patterning. However, intact ACVR1-R206H has the ability to respond to both Bmp7 and Activin A ligands. Additionally, BMPR1, a type I BMP receptor normally required for BMP-mediated patterning of the embryo, is dispensable for both ligand-independent signaling pathway activation and ligand-responsive signaling hyperactivation by ACVR1-R206H. These results demonstrate that FOP-ACVR1 is not constrained by the same receptor/ligand partner requirements as WT-ACVR1.
Collapse
Affiliation(s)
- Robyn S Allen
- Department of Cell and Developmental Biology University of Pennsylvania Perelman School of Medicine, Philadelphia, United States.,Departments of Orthopaedic Surgery and Genetics University of Pennsylvania Perelman School of Medicine, Philadelphia, United States
| | - Benjamin Tajer
- Department of Cell and Developmental Biology University of Pennsylvania Perelman School of Medicine, Philadelphia, United States
| | - Eileen M Shore
- Departments of Orthopaedic Surgery and Genetics University of Pennsylvania Perelman School of Medicine, Philadelphia, United States
| | - Mary C Mullins
- Department of Cell and Developmental Biology University of Pennsylvania Perelman School of Medicine, Philadelphia, United States
| |
Collapse
|
14
|
Clinical Aspects and Current Therapeutic Approaches for FOP. Biomedicines 2020; 8:biomedicines8090325. [PMID: 32887348 PMCID: PMC7555688 DOI: 10.3390/biomedicines8090325] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/19/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an extremely rare heritable disorder of connective tissues characterized by progressive heterotopic ossification in various skeletal sites. It is caused by gain-of-function mutations in the gene encoding activin A receptor type I (ACVR1)/activin-like kinase 2 (ALK2), a bone morphogenetic protein (BMP) type I receptor. Heterotopic ossification is usually progressive leading to severe deformities in the trunk and extremities. Early clinical diagnosis is important to prevent unnecessary iatrogenic harm or trauma. Clinicians should become aware of early detectable skeletal malformations, including great toe deformities, shortened thumb, neck stiffness associated with hypertrophy of the posterior elements of the cervical spine, multiple ossification centers in the calcaneus, and osteochondroma-like lesions of the long bones. Although there is presently no definitive medical treatment to prevent, stop or reverse heterotopic ossification in FOP, exciting advances of novel pharmacological drugs focusing on target inhibition of the activated ACVR1 receptor, including palovarotene, REGN 2477, rapamycin, and saracatinib, have developed and are currently in clinical trials.
Collapse
|
15
|
Shi X, Zhou L, Shang J, Wang K, Chu CQ. Fibrodysplasia ossificans progressiva-a rare disease with distinctive features yet still a diagnostic challenge: A case report. Medicine (Baltimore) 2020; 99:e19933. [PMID: 32332674 PMCID: PMC7440274 DOI: 10.1097/md.0000000000019933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Fibrodysplasia ossificans progressiva (FOP) is rare genetic disease featuring progressive heterotopic ossification of soft tissues of the musculoskeletal system which leads to severe disability and premature death. Recognition of this disease is important since invasive diagnostic procedures can promote disease progression. However, despite its distinctive clinical manifestations, diagnosis can be difficult because of its rarity PATIENT CONCERNS:: A 20-year-old woman was referred to rheumatology clinic for management of "ankylosing spondylitis". The patent had begun to have hard subcutaneous nodules when she was 1 year old, and subsequently developed hip joint pain and flexion contractures of knees and hips leading to disability. DIAGNOSES Based on characteristic bilateral great toe deformities and radiographic images of ossification of soft tissues, a clinical diagnosis of FOP was made. This was confirmed by genetic test showing a heterozygous mutation (c.G617A) of the activin receptor 1A gene (ACVR1). INTERVENTIONS The patient was treated symptomatically and with supportive measures, and her condition remained stable. LESSONS Diagnosis of FOP can be difficult, despite its distinctive clinical manifestations, because of its rarity. Recognition of this disease is important to avoid invasive diagnostic procedures which can promote progression.
Collapse
Affiliation(s)
- Xiaofei Shi
- Department of Rheumatology and Immunology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University and VA Portland Health Care System, Portland, OR
| | - Liqing Zhou
- Department of Rheumatology and Immunology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Jingjing Shang
- Department of Rheumatology and Immunology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Ke Wang
- Department of Rheumatology and Immunology, The First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Cong-Qiu Chu
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University and VA Portland Health Care System, Portland, OR
| |
Collapse
|
16
|
Zhang JM, Li CF, Ke SY, Piao YR, Han TX, Kuang WY, Wang J, Deng JH, Tan XH, Li C. Analysis of clinical manifestations and treatment in 26 children with fibrodysplasia ossificans progressiva in China. World J Pediatr 2020; 16:82-88. [PMID: 31529313 DOI: 10.1007/s12519-019-00302-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/01/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is a rare and disabling heritable connective tissue disease that is difficult to treat. This study seeks to explore the clinical characteristics, clinical manifestations, treatment and prognosis of FOP to provide a clinical basis for its early diagnosis and treatment. METHODS Twenty-six children with FOP were retrospectively analyzed in terms of their onset, clinical manifestations, auxiliary examinations and treatment. RESULTS Among the 26 cases, the youngest age of manifestation of mass was 8 days after birth, and the average age was 3 years and 2 months. The peak age was 2-5 years old. Inflammatory mass and toe-finger deformity are the main early clinical manifestations of the disease. These inflammatory masses often lead to hard osteogenic deposits that initially mainly involve the central axis, such as the neck (22/26, 84.6%), back (20/26, 76.9%), and head (13/26, 50%). Toe-finger deformity mainly manifests as symmetrical great toe deformity, or short and deformed thumb and little finger. The diagnosis of FOP requires typical clinical manifestations or ACVR1 gene detection. The main therapeutic drugs for FOP include glucocorticoids and non-steroidal anti-inflammatory drugs. Although not compliant with the recommended medical management of FOP, in our clinical practice children with uncontrollable illness could be treated using a variety of immunosuppressive agents in combination. CONCLUSIONS FOP is a rare autosomal dominant heritable disease. The main clinical manifestations observed in this study were recurrent inflammatory mass and toe-finger deformity. If the diagnosis and treatment are not performed in a timely manner, serious complications are likely to affect the prognosis. Therefore, early diagnosis and active treatment should be performed.
Collapse
Affiliation(s)
- Jun-Mei Zhang
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Cai-Feng Li
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China.
| | - Shuang-Ying Ke
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Yu-Rong Piao
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Tong-Xin Han
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Wei-Ying Kuang
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Jiang Wang
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Jiang-Hong Deng
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Xiao-Hua Tan
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Chao Li
- Department of Rheumatology and Immunology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nan Li Shi Road No. 56, Beijing, 100045, China
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW Fibrodysplasia ossificans progressiva (FOP) is an extremely rare and severely disabling autosomal dominant disease that is yet to be clearly understood. The purpose of this review is to present recent literature on pathophysiology, clinical features, diagnosis and treatment of FOP. RECENT FINDINGS FOP is characterized by congenital great toe deformity and progressive heterotopic ossifications in connective tissue. Heterotopic ossifications occur after painful flare-ups that can arise spontaneously or can be triggered by minor trauma. Each flare-up ultimately causes restriction of related-joint, and along with the others eventually leads to immobility. Death is usually caused by pulmonary complications because of chest wall involvement. The causative gene of FOP is activin A receptor type 1 (ACVR1), a bone morphogenetic protein-signalling component, which normally acts to inhibit osteoblastogenesis. The treatment of FOP is still preventive and supportive. SUMMARY Although there are still gaps in the underlying mechanism of FOP, effective treatment options, such as potential pharmacologic targets and cell-based therapies are promising for the future. Some of these were tested without a clinical trial setting, and are currently in the process of evidence-based research.
Collapse
Affiliation(s)
- Gulseren Akyuz
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine
| | - Kardelen Gencer-Atalay
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine
| | - Pinar Ata
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| |
Collapse
|
19
|
Shi F, Gao J, Zou J, Ying Y, Lin H. Targeting heterotopic ossification by inhibiting activin receptor‑like kinase 2 function (Review). Mol Med Rep 2019; 20:2979-2989. [PMID: 31432174 PMCID: PMC6755183 DOI: 10.3892/mmr.2019.10556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022] Open
Abstract
Heterotopic ossification (HO) refers to the appearance of osteoblasts in soft tissues under pathological conditions, such as trauma or infection. HO arises in an unpredictable way without any recognizable initiation. Activin receptor-like kinase-2 (ALK2) is a type I cell surface receptor for bone morphogenetic proteins (BMPs). The dysregulation of ALK2 signaling is associated with a variety of diseases, including cancer and HO. At present, the prevention and treatment of HO in the clinic predominantly includes nonsteroidal anti-inflammatory drugs (NSAIDs), bisphosphonates and other drug treatments, low-dose local radiation therapy and surgical resection, rehabilitation treatment and physical therapy. However, most of these therapies have adverse effects. These methods do not prevent the occurrence of HO. The pathogenesis of HO is not being specifically targeted; the current treatment strategies target the symptoms, not the disease. These treatments also cannot solve the fundamental problem of the occurrence of HO. Therefore, scholars have been working to develop targeted therapies based on the pathogenesis of HO. The present review focuses on advances in the understanding of the underlying mechanisms of HO, and possible options for the prevention and treatment of HO. In addition, the role of ALK2 in the process of HO is introduced and the progress made towards the targeted inhibition of ALK2 is discussed. The present study aims to offer a platform for further research on possible targets for the prevention and treatment of HO.
Collapse
Affiliation(s)
- Fuli Shi
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Jiayu Gao
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Junrong Zou
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Ying Ying
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Hui Lin
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| |
Collapse
|
20
|
The role of Activin A in fibrodysplasia ossificans progressiva: a prominent mediator. Biosci Rep 2019; 39:BSR20190377. [PMID: 31341010 PMCID: PMC6680371 DOI: 10.1042/bsr20190377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/16/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022] Open
Abstract
Heterotopic ossification (HO) is the aberrant formation of mature, lamellar bone in nonosseous tissue. Fibrodysplasia ossificans progressiva (FOP) is a rare and devastating genetic disorder that causes progressive HO in the ligaments, tendons, and muscles throughout the body. FOP is attributed to an autosomal mutation in activin receptor-like kinase 2 (ALK2), a bone morphogenetic protein (BMP) type I receptor. Initial studies show that mutant ALK2 drives HO by constitutively activating the BMP signaling pathway. Recently, mutant ALK2 has been shown to transduce Smad1/5 signaling and enhance chondrogenesis, calcification in response to Activin A, which normally signals through Smad2/3 and inhibits BMP signaling pathway. Furthermore, Activin A induces heterotopic bone formation via mutant ALK2, while inhibition of Activin A blocks spontaneous and trauma-induced HO. In this manuscript, we describe the molecular mechanism of the causative gene ALK2 in FOP, mainly focusing on the prominent role of Activin A in HO. It reveals a potential strategy for prevention and treatment of FOP by inhibition of Activin A. Further studies are needed to explore the cellular and molecular mechanisms of Activin A in FOP in more detail.
Collapse
|
21
|
Grgurević L, Novak R, Trkulja V, Hamzić LF, Hrkač S, Grazio S, Santini M. Elevated plasma RANTES in fibrodysplasia ossificans progressiva - A novel therapeutic target? Med Hypotheses 2019; 131:109313. [PMID: 31443758 DOI: 10.1016/j.mehy.2019.109313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 12/13/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare hereditary disease caused by a mutation in the intracellular domain of the activin A receptor type I and is characterized by episodes (flare-ups) of progressive heterotopic endochondral ossification (HO) in the soft tissues. The mutation alone is not sufficient for the occurrence of HO since flare-ups are triggered by inflammation and activation of the innate immune system. A number of cellular and humoral mediators have been implicated in animal and in vitro models. Observations in humans support the inflammatory nature of the condition, but data on the involved mediators are variable. We hypothesize that for induction of flare-ups in patients with FOP increase in at least one of the pro-inflammatory cytokines is both essential and sufficient to trigger the entire process of the inflammatory cells influx resulting in the novel ectopic bone formation and we suggest that C-C motif ligand 5 (CCL5), a pro-inflammatory chemokine also known as Regulated on activation, normal T-cell expressed and secreted (RANTES), might be the key candidate. CCL5 is a chemoattractant for all cellular types implicated in HO and is produced by the cells of the tissue microenvironment at the sites of HO as well as by the pro-inflammatory cellular mediators. CCL5 induces ossification in cultured human pluripotent mesenchymal cells (hMSCs) and in the primary culture of monocytes from FOP patients (but not from their healthy relatives), stimulation with lipopolysaccharide induces CCL5 expression. Finally, in a pilot study we used a panel of 23 cytokines and chemokines to screen the plasma samples of three subjects: a female patient with FOP during a flare-up; a female patient with hyperostosis corticalis generalisata (van Buchem disease), another rare disease characterized by excessive bone formation at the sites where it regularly occurs that does not include inflammatory events; and a healthy woman without bone disorders. There appeared a rather clear-cut signal of a 2-fold higher level of CCL5 in the FOP patient vs. the healthy subject and the van Buchem patient. Evaluation of the hypothesis would require an international prospective study, with main motivation being the lack of a conclusive treatment as the major unmet need in FOP. A treatment targeting CCL5 receptor already exists and is used in HIV-infected patients.
Collapse
Affiliation(s)
- Lovorka Grgurević
- Drago Perović Department of Anatomy, School of Medicine, University of Zagreb, Zagreb, Croatia; Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Ruđer Novak
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vladimir Trkulja
- Department of Pharmacology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Lejla Ferhatović Hamzić
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Stela Hrkač
- Drago Perović Department of Anatomy, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Simeon Grazio
- University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Marija Santini
- University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| |
Collapse
|
22
|
Wu J, Ren B, Shi F, Hua P, Lin H. BMP and mTOR signaling in heterotopic ossification: Does their crosstalk provide therapeutic opportunities? J Cell Biochem 2019; 120:12108-12122. [PMID: 30989716 DOI: 10.1002/jcb.28710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/17/2019] [Accepted: 03/22/2019] [Indexed: 12/23/2022]
Abstract
Heterotopic ossification (HO) refers to the pathological formation of ectopic bone in soft tissues, it occurs following severe trauma or in patients with a rare genetic disorder known as fibrodysplasia ossificans progressiva. The pathological process of HO formation is a two-step mechanism: inflammation and destruction of connective tissues, followed by bone formation. The latter is further subdivided into three stages: fibroproliferation/angiogenesis, chondrogenesis, and osteogenesis. Currently, therapeutic options for HO are limited. New potential therapeutics will most likely arise from a more detailed understanding of the signaling pathways implicated in each stage of ectopic bone formation and molecular targets that may be effective at both the early and late stages of HO. Bone morphogenetic protein (BMP) signaling is believed to play a key role in the overall HO process. Recently, the mammalian target of rapamycin (mTOR) signaling pathway has received attention as a critical pathway for chondrogenesis, osteogenesis, and HO. Inhibition of mTOR signaling has been shown to block trauma-induced and genetic HO. Intriguingly, recent studies have revealed crosstalk between mTOR and BMP signaling. Moreover, mTOR has emerged as a factor involved in the early hypoxic and inflammatory stages of HO. We will summarize the current knowledge of the roles of mTOR and BMP signaling in HO, with a particular focus on the crosstalk between mTOR and BMP signaling. We also discuss the activation of AMP activated protein kinase (AMPK) by the most widely used drug for type 2 diabetes, metformin, which exerts a dual negative regulatory effect on mTOR and BMP signaling, suggesting that metformin is a promising drug treatment for HO. The discovery of an mTOR-BMP signaling network may be a potential molecular mechanism of HO and may represent a novel therapeutic target for the pharmacological control of HO.
Collapse
Affiliation(s)
- Jianhui Wu
- Jiangxi Medical School, Nanchang University, Nanchang, Jiangx, China.,Nanchang Joint Programme, Queen Mary University of London, London, UK
| | - Bowen Ren
- Jiangxi Medical School, Nanchang University, Nanchang, Jiangx, China.,Nanchang Joint Programme, Queen Mary University of London, London, UK
| | - Fuli Shi
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology and Department of Pathophysiology, School of Basic Medical Sciences, Nanchang University, Nanchang, Jiangxi, China
| | - Ping Hua
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology and Department of Pathophysiology, School of Basic Medical Sciences, Nanchang University, Nanchang, Jiangxi, China
| | - Hui Lin
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology and Department of Pathophysiology, School of Basic Medical Sciences, Nanchang University, Nanchang, Jiangxi, China
| |
Collapse
|
23
|
Cappato S, Giacopelli F, Tonachini L, Ravazzolo R, Bocciardi R. Identification of reference genes for quantitative PCR during C3H10T1/2 chondrogenic differentiation. Mol Biol Rep 2019; 46:3477-3485. [PMID: 30847849 PMCID: PMC6548758 DOI: 10.1007/s11033-019-04713-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/20/2019] [Indexed: 01/03/2023]
Abstract
C3H10T1/2, a mouse mesenchymal stem cell line, is a well-known in vitro model of chondrogenesis that can be easily employed to recapitulate some of the mechanisms intervening in this process. Moreover, these cells can be used to validate the effect of candidate molecules identified by high throughput screening approaches applied to the development of targeted therapy for human disorders in which chondrogenic differentiation may be involved, as in conditions characterized by heterotopic endochondral bone formation. Chondrogenic differentiation of C3H10T1/2 cells can be monitored by applying quantitative polymerase chain reaction (qPCR), one of the most sensitive methods that allows detection of small dynamic changes in gene expression between samples obtained under different experimental conditions. In this work, we have used qPCR to monitor the expression of specific markers during chondrogenic differentiation of C3H10T1/2 cells in micromass cultures. Then we have applied the geNorm approach to identify the most stable reference genes suitable to get a robust normalization of the obtained expression data. Among 12 candidate reference genes (Ap3d1, Csnk2a2, Cdc40, Fbxw2, Fbxo38, Htatsf1, Mon2, Pak1ip1, Zfp91, 18S, ActB, GAPDH) we identified Mon2 and Ap3d1 as the most stable ones during chondrogenesis. ActB, GAPDH and 18S, the most commonly used in the literature, resulted to have an expression level too high compared to the differentiation markers (Sox9, Collagen type 2a1, Collagen type 10a1 and Collagen type 1a1), therefore are actually less recommended for these experimental conditions. In conclusion, we identified nine reference genes that can be equally used to obtain a robust normalization of the gene expression variation during the C3H10T1/2 chondrogenic differentiation.
Collapse
Affiliation(s)
- Serena Cappato
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, 16132, Genova, Italy
| | - Francesca Giacopelli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, 16132, Genova, Italy
| | - Laura Tonachini
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, 16132, Genova, Italy
| | - Roberto Ravazzolo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, 16132, Genova, Italy.,Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, 16147, Genova, Italy
| | - Renata Bocciardi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, 16132, Genova, Italy. .,Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, 16147, Genova, Italy.
| |
Collapse
|
24
|
Sekimata K, Sato T, Sakai N, Watanabe H, Mishima-Tsumagari C, Taguri T, Matsumoto T, Fujii Y, Handa N, Honma T, Tanaka A, Shirouzu M, Yokoyama S, Miyazono K, Hashizume Y, Koyama H. Bis-Heteroaryl Pyrazoles: Identification of Orally Bioavailable Inhibitors of Activin Receptor-Like Kinase-2 (R206H). Chem Pharm Bull (Tokyo) 2019; 67:224-235. [DOI: 10.1248/cpb.c18-00598] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Katsuhiko Sekimata
- Drug Discovery Chemistry Platform Unit, RIKEN Center for Sustainable Resource Science
| | - Tomohiro Sato
- Drug Discovery Computational Chemistry Platform Unit, RIKEN Center for Biosystems Dynamics Research
| | - Naoki Sakai
- Drug Discovery Structural Biology Platform Unit, RIKEN Biosystems Dynamics Research
| | - Hisami Watanabe
- Drug Discovery Structural Biology Platform Unit, RIKEN Biosystems Dynamics Research
| | | | - Tomonori Taguri
- Drug Discovery Chemistry Platform Unit, RIKEN Center for Sustainable Resource Science
| | - Takehisa Matsumoto
- Drug Discovery Structural Biology Platform Unit, RIKEN Biosystems Dynamics Research
| | - Yoshifumi Fujii
- Crystallographic Drug Discovery Platform Unit, RIKEN Systems and Structural Biology Center
| | - Noriko Handa
- Crystallographic Drug Discovery Platform Unit, RIKEN Systems and Structural Biology Center
| | - Teruki Honma
- Drug Discovery Computational Chemistry Platform Unit, RIKEN Center for Biosystems Dynamics Research
| | - Akiko Tanaka
- Drug Discovery Structural Biology Platform Unit, RIKEN Biosystems Dynamics Research
| | - Mikako Shirouzu
- Drug Discovery Structural Biology Platform Unit, RIKEN Biosystems Dynamics Research
| | - Shigeyuki Yokoyama
- Crystallographic Drug Discovery Platform Unit, RIKEN Systems and Structural Biology Center
| | - Kohei Miyazono
- Department of Molecular Pathology, Graduate School of Medicine, The University of Tokyo
| | | | - Hiroo Koyama
- Drug Discovery Chemistry Platform Unit, RIKEN Center for Sustainable Resource Science
| |
Collapse
|
25
|
Wentworth KL, Masharani U, Hsiao EC. Therapeutic advances for blocking heterotopic ossification in fibrodysplasia ossificans progressiva. Br J Clin Pharmacol 2019; 85:1180-1187. [PMID: 30501012 DOI: 10.1111/bcp.13823] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease in which heterotopic bone forms in muscle and soft tissue, leading to joint dysfunction and significant disability. FOP is progressive and many patients are wheelchair-bound by the 3rd decade of life. FOP is caused by an activating mutation in the ACVR1 gene, which encodes the activin A Type 1 receptor. Aberrant signalling through this receptor leads to abnormal activation of the pSMAD 1/5/8 pathway and triggers the formation of bone outside of the skeleton. There is no curative therapy for FOP; however, exciting advances in novel therapies have developed recently. Here, we review the clinical and translational pharmacology of three drugs that are currently in clinical trials (palovarotene, REGN 2477 and rapamycin) as well as other emerging treatment strategies for FOP.
Collapse
Affiliation(s)
- Kelly L Wentworth
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Umesh Masharani
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
| | - Edward C Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| |
Collapse
|
26
|
Gencer-Atalay K, Ozturk EC, Yagci I, Ata P, Delil K, Ozgen Z, Akyuz G. Challenges in the treatment of fibrodysplasia ossificans progressiva. Rheumatol Int 2018; 39:569-576. [PMID: 30343406 DOI: 10.1007/s00296-018-4179-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 10/15/2018] [Indexed: 01/19/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP), is a rare autosomal dominant connective tissue disease with a prevalence of 1 in 2 million. It is characterized by congenital foot deformities and multiple heterotopic ossifications in fibrous tissue. It usually starts with painful soft tissue swellings occurring with attacks at the ages of three or four. The attacks develop spontaneously or after minor trauma, and gradually turn into heterotopic ossifications that cause joint limitations, growth defects, skeletal deformities and chronic pain. The average life expectancy is forthy, and most of the patients are lost due to pulmonary complications. FOP is often misdiagnosed as fibromatosis, desmoid tumour or cancer, bunion, myositis, arthritis and rheumatic diseases. After clinical suspicion, confirmatory genetic analysis should be used for the diagnosis. The treatment of FOP is currently supportive. An effective, proven method has not yet been established. Herein, we present an 18-year-old female patient with FOP who underwent different treatment modalities in a 5-year period. This case-based review reveals all available treatment approaches with at least 6-month follow-up for FOP in the literature.
Collapse
Affiliation(s)
- Kardelen Gencer-Atalay
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, 34899 Pendik Ust Kaynarca, Istanbul, Turkey
| | - Ekim Can Ozturk
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, 34899 Pendik Ust Kaynarca, Istanbul, Turkey
| | - Ilker Yagci
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, 34899 Pendik Ust Kaynarca, Istanbul, Turkey
| | - Pinar Ata
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Kenan Delil
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Zerrin Ozgen
- Department of Radiation Oncology, Marmara University School of Medicine, Istanbul, Turkey
| | - Gulseren Akyuz
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, 34899 Pendik Ust Kaynarca, Istanbul, Turkey.
| |
Collapse
|
27
|
Tiwari V, Behera P, Sarawagi R, Rafi BM, Sahu S, Raj H, Rajpoot M. Atypical Presentation of Fibrodysplasia Ossificans Progressiva: A Case Report and Review of Literature. Cureus 2018; 10:e2955. [PMID: 30214843 PMCID: PMC6132596 DOI: 10.7759/cureus.2955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease characterized by widespread areas of abnormal bone formation in muscles, ligaments, tendons and joint capsules. Typically, the symptoms begin in the first decade of life with episodes of painful inflammatory soft tissue swellings. Gradually, there occurs restriction of motion at various joints, severely limiting the activities of daily living and the quality of life of such patients by the third decade of life. There is no definite cure available for the disease and the current treatment options target symptomatic and palliative management. We describe the case of a 10-year-old child who presented to our institute with a severe disability of upper limbs due to joint contractures along with several bony masses at various locations of the body but without having any prior complaints of painful soft tissue lesions or the characteristic flare-ups of the disease ever. Identification of typical soft tissue ossified masses in the specific anatomic pattern, along with the presence of short and malformed great toes helped us in reaching the diagnosis. Surgical procedures including biopsies should be strictly avoided in such patients to prevent triggering the development of more lesions, which occurred in our patient after inadvertent removal of the first swelling by an orthopaedic specialist.
Collapse
Affiliation(s)
- Vivek Tiwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Prateek Behera
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Radha Sarawagi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhopal, IND
| | - Babu Mohammed Rafi
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Saurabh Sahu
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Bhopal, IND
| | - Hemanth Raj
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Manish Rajpoot
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| |
Collapse
|