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Lounev V, Groppe JC, Brewer N, Wentworth KL, Smith V, Xu M, Schomburg L, Bhargava P, Al Mukaddam M, Hsiao EC, Shore EM, Pignolo RJ, Kaplan FS. Matrix metalloproteinase-9 deficiency confers resilience in fibrodysplasia ossificans progressiva in a man and mice. J Bone Miner Res 2024; 39:382-398. [PMID: 38477818 DOI: 10.1093/jbmr/zjae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Single case studies of extraordinary disease resilience may provide therapeutic insight into conditions for which no definitive treatments exist. An otherwise healthy 35-year-old man (patient-R) with the canonical pathogenic ACVR1R206H variant and the classic congenital great toe malformation of fibrodysplasia ossificans progressiva (FOP) had extreme paucity of post-natal heterotopic ossification (HO) and nearly normal mobility. We hypothesized that patient-R lacked a sufficient post-natal inflammatory trigger for HO. A plasma biomarker survey revealed a reduction in total matrix metalloproteinase-9 (MMP-9) compared to healthy controls and individuals with quiescent FOP. Whole exome sequencing identified compound heterozygous variants in MMP-9 (c.59C > T, p.A20V and c.493G > A, p.D165N). Structural analysis of the D165N variant predicted both decreased MMP-9 secretion and activity that were confirmed by enzyme-linked immunosorbent assay and gelatin zymography. Further, human proinflammatory M1-like macrophages expressing either MMP-9 variant produced significantly less Activin A, an obligate ligand for HO in FOP, compared to wildtype controls. Importantly, MMP-9 inhibition by genetic, biologic, or pharmacologic means in multiple FOP mouse models abrogated trauma-induced HO, sequestered Activin A in the extracellular matrix (ECM), and induced regeneration of injured skeletal muscle. Our data suggest that MMP-9 is a druggable node linking inflammation to HO, orchestrates an existential role in the pathogenesis of FOP, and illustrates that a single patient's clinical phenotype can reveal critical molecular mechanisms of disease that unveil novel treatment strategies.
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Affiliation(s)
- Vitali Lounev
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Jay C Groppe
- Department of Biomedical Sciences, Texas A & M University College of Dentistry, Dallas, TX 75246-2013, United States
| | - Niambi Brewer
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Kelly L Wentworth
- Department of Medicine, Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA 94143-0794, United States
- Department of Medicine, University of California, San Francisco, CA 94143-0794, United States
| | | | - Meiqi Xu
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charite University Hospital, D-10115 Berlin, Germany
| | | | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Edward C Hsiao
- Department of Medicine, University of California, San Francisco, CA 94143-0794, United States
- Division of Endocrinology and Metabolism, The Institute for Human Genetics, the Program in Craniofacial Biology, University of California, San Francisco, CA 94143-0794, United States
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Genetics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
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Pignolo RJ, Kaplan FS, Wang H. Cell Senescence in Heterotopic Ossification. Biomolecules 2024; 14:485. [PMID: 38672501 PMCID: PMC11047966 DOI: 10.3390/biom14040485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
The formation of bone outside the normal skeleton, or heterotopic ossification (HO), occurs through genetic and acquired mechanisms. Fibrodysplasia ossificans progressiva (FOP), the most devastating genetic condition of HO, is due to mutations in the ACVR1/ALK2 gene and is relentlessly progressive. Acquired HO is mostly precipitated by injury or orthopedic surgical procedures but can also be associated with certain conditions related to aging. Cellular senescence is a hallmark of aging and thought to be a tumor-suppressive mechanism with characteristic features such as irreversible growth arrest, apoptosis resistance, and an inflammatory senescence-associated secretory phenotype (SASP). Here, we review possible roles for cellular senescence in HO and how targeting senescent cells may provide new therapeutic approaches to both FOP and acquired forms of HO.
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Affiliation(s)
- Robert J. Pignolo
- Department of Medicine, Section of Geriatric Medicine & Gerontology, Mayo Clinic, Rochester, MN 55905, USA
- Divisions of Endocrinology and Hospital Internal Medicine, Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN 55905, USA;
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA;
- Department of Medicine, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
- The Center for Research in FOP and Related Disorders, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Haitao Wang
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
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Wang H, Kaplan FS, Pignolo RJ. The HIF-1α and mTOR Pathways Amplify Heterotopic Ossification. Biomolecules 2024; 14:147. [PMID: 38397384 PMCID: PMC10887042 DOI: 10.3390/biom14020147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP; MIM# 135100) is an ultra-rare congenital disorder caused by gain-of-function point mutations in the Activin receptor A type I (ACVR1, also known as ALK2) gene. FOP is characterized by episodic heterotopic ossification (HO) in skeletal muscles, tendons, ligaments, or other soft tissues that progressively causes irreversible loss of mobility. FOP mutations cause mild ligand-independent constitutive activation as well as ligand-dependent bone morphogenetic protein (BMP) pathway hypersensitivity of mutant ACVR1. BMP signaling is also a key pathway for mediating acquired HO. However, HO is a highly complex biological process involving multiple interacting signaling pathways. Among them, the hypoxia-inducible factor (HIF) and mechanistic target of rapamycin (mTOR) pathways are intimately involved in both genetic and acquired HO formation. HIF-1α inhibition or mTOR inhibition reduces HO formation in mouse models of FOP or acquired HO in part by de-amplifying the BMP pathway signaling. Here, we review the recent progress on the mechanisms of the HIF-1α and mTOR pathways in the amplification of HO lesions and discuss the future directions and strategies to translate the targeting of HIF-1α and the mTOR pathways into clinical interventions for FOP and other forms of HO.
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Affiliation(s)
- Haitao Wang
- Department of Medicine, Geriatric Medicine & Gerontology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Medicine, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
- The Center for Research in FOP and Related Disorders, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Robert J. Pignolo
- Department of Medicine, Geriatric Medicine & Gerontology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine, Divisions of Endocrinology, Hospital Internal Medicine, Rochester, MN 55905, USA
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Lindborg CM, Al Mukaddam M, Baujat G, Cho TJ, De Cunto CL, Delai PLR, Eekhoff EMW, Haga N, Hsiao EC, Morhart R, de Ruiter R, Scott C, Seemann P, Szczepanek M, Tabarkiewicz J, Pignolo RJ, Kaplan FS. Most Fractures Treated Nonoperatively in Individuals With Fibrodysplasia Ossificans Progressiva Heal With a Paucity of Flareups, Heterotopic Ossification, and Loss of Mobility. Clin Orthop Relat Res 2023; 481:2447-2458. [PMID: 37156007 PMCID: PMC10642855 DOI: 10.1097/corr.0000000000002672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/05/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultrarare genetic disorder with episodic and progressive heterotopic ossification. Tissue trauma is a major risk factor for flareups, heterotopic ossification (HO), and loss of mobility in patients with FOP. The International Clinical Council on FOP generally recommends avoiding surgery in patients with FOP unless the situation is life-threatening, because soft tissue injury can trigger an FOP flareup. Surprisingly little is known about flareups, HO formation, and loss of mobility after fractures of the normotopic (occurring in the normal place, distinct from heterotopic) skeleton when treated nonoperatively in patients with FOP. QUESTIONS/PURPOSES (1) What proportion of fractures had radiographic evidence of union (defined as radiographic evidence of healing at 6 weeks) or nonunion (defined as the radiographic absence of a bridging callus at 3 years after the fracture)? (2) What proportion of patients had clinical symptoms of an FOP flareup because of the fracture (defined by increased pain or swelling at the fracture site within several days after closed immobilization)? (3) What proportion of patients with fractures had radiographic evidence of HO? (4) What proportion of patients lost movement after a fracture? METHODS We retrospectively identified 36 patients with FOP from five continents who sustained 48 fractures of the normotopic skeleton from January 2001 to February 2021, who were treated nonoperatively, and who were followed for a minimum of 18 months after the fracture and for as long as 20 years, depending on when they sustained their fracture during the study period. Five patients (seven fractures) were excluded from the analysis to minimize cotreatment bias because these patients were enrolled in palovarotene clinical trials (NCT02190747 and NCT03312634) at the time of their fractures. Thus, we analyzed 31 patients (13 male, 18 female, median age 22 years, range 5 to 57 years) who sustained 41 fractures of the normotopic skeleton that were treated nonoperatively. Patients were analyzed at a median follow-up of 6 years (range 18 months to 20 years), and none was lost to follow-up. Clinical records for each patient were reviewed by the referring physician-author and the following data for each fracture were recorded: biological sex, ACVR1 gene pathogenic variant, age at the time of fracture, fracture mechanism, fracture location, initial treatment modality, prednisone use at the time of the fracture as indicated in the FOP Treatment Guidelines for flare prevention (2 mg/kg once daily for 4 days), patient-reported flareups (episodic inflammatory lesions of muscle and deep soft connective tissue characterized variably by swelling, escalating pain, stiffness, and immobility) after the fracture, follow-up radiographs of the fracture if available, HO formation (yes or no) as a result of the fracture determined at a minimum of 6 weeks after the fracture, and patient-reported loss of motion at least 6 months after and as long as 20 years after the fracture. Postfracture radiographs were available in 76% (31 of 41) of fractures in 25 patients and were independently reviewed by the referring physician-author and senior author for radiographic criteria of fracture healing and HO. RESULTS Radiographic healing was noted in 97% (30 of 31) of fractures at 6 weeks after the incident fracture. Painless nonunion was noted in one patient who sustained a displaced patellar fracture and HO. In seven percent (three of 41) of fractures, patients reported increased pain or swelling at or near the fracture site within several days after fracture immobilization that likely indicated a site-specific FOP flareup. The same three patients reported a residual loss of motion 1 year after the fracture compared with their prefracture status. HO developed in 10% (three of 31) of the fractures for which follow-up radiographs were available. Patient-reported loss of motion occurred in 10% (four of 41) of fractures. Two of the four patients reported noticeable loss of motion and the other two patients reported that the joint was completely immobile (ankylosis). CONCLUSION Most fractures treated nonoperatively in individuals with FOP healed with few flareups, little or no HO, and preservation of mobility, suggesting an uncoupling of fracture repair and HO, which are two inflammation-induced processes of endochondral ossification. These findings underscore the importance of considering nonoperative treatment for fractures in individuals with FOP. Physicians who treat fractures in patients with FOP should consult with a member of the International Clinical Council listed in the FOP Treatment Guidelines ( https://www.iccfop.org ). LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Carter M. Lindborg
- Department of Orthopaedic Surgery, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Genevieve Baujat
- Département de Genetique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Carmen L. De Cunto
- Department of Pediatrics, Pediatric Rheumatology Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Patricia L. R. Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo, Brazil
| | - Elisabeth M. W. Eekhoff
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Nobuhiko Haga
- Rehabilitation Services Bureau, National Rehabilitation Center for Persons with Disabilities, Tokorozawa City, Japan
| | - Edward C. Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, the Institute for Human Genetics, the Ely and Edythe Broad Institute for Regeneration Medicine, the Program in Craniofacial Biology and the Department of Medicine, University of California, San Francisco, CA, USA
| | - Rolf Morhart
- Department of Pediatrics, Klinikum Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
| | - Ruben de Ruiter
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Christiaan Scott
- Department of Orthopaedic Surgery, the University of Cape Town, Cape Town, South Africa and Department of Rheumatology, Red Cross Children’s Hospital, Cape Town, South Africa
| | - Petra Seemann
- Institute for Experimental Endocrinology, Charite University Hospital, Berlin, Germany
| | - Małgorzata Szczepanek
- Department of Pediatrics, Institute of Medical Sciences, Medical College of Rzeszow University, University of Rzeszow, Rzeszow, Poland
| | - Jacek Tabarkiewicz
- Department of Human Immunology, Institute of Medical Sciences, Medical College of Rzeszow University, University of Rzeszow, Rzeszow, Poland
| | - Robert J. Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
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Pignolo RJ, Al Mukaddam M, Baujat G, Brown MA, De Cunto C, Hsiao EC, Keen R, Le Quan Sang KH, Grogan DR, Marino R, Strahs AR, Kaplan FS. Study methodology and insights from the palovarotene clinical development program in fibrodysplasia ossificans progressiva. BMC Med Res Methodol 2023; 23:269. [PMID: 37957586 PMCID: PMC10642058 DOI: 10.1186/s12874-023-02080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The design of clinical trials in rare diseases is often complicated by a lack of real-world translational knowledge. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder characterized by skeletal malformations and progressive heterotopic ossification (HO). Palovarotene is a selective retinoic acid receptor gamma agonist. Here, we describe the methodology of three studies in the palovarotene clinical development program in FOP and discuss insights that could inform future research, including endpoint suitability and the impact of trial design. METHODS PVO-1A-001 (NCT02322255) was a prospective, protocol-specified, longitudinal FOP natural history study (NHS). PVO-1A-201 (NCT02190747) was a randomized, double-blind, placebo-controlled phase II trial; PVO-1A-202 (NCT02279095) was its open-label extension. Trial designs, including treatment regimens and imaging assessments, were refined between PVO-1A-201 and PVO-1A-202, and within PVO-1A-202, based on emerging data as the studies progressed. Palovarotene doses were administered using a flare-up treatment regimen (higher dose for 2/4 weeks, followed by lower dose for 4/≥8 weeks; from flare-up onset), with or without accompanying chronic (daily) treatment. Flare-up and disease progression outcomes were assessed, including incidence and volume of new HO during flare-ups and/or annually, as well as other clinical, patient-reported, and exploratory outcomes. Safety was monitored throughout all studies. RESULTS Overall, 114 and 58 individuals with FOP were enrolled in the NHS and phase II trials, respectively. Results of the NHS and PVO-1A-201 were published in 2022; complete results of PVO-1A-202 will be publicly available in due course. Together the studies yielded important information on endpoint suitability, including that low-dose whole-body computed tomography was the optimum imaging modality for assessing HO progression annually and that long study durations are needed to detect substantial changes in functional and patient-reported outcomes. CONCLUSIONS A flexible clinical development program is necessary for underexplored rare diseases to overcome the many challenges faced. Here, the NHS provided a longitudinal evaluation of FOP progression and interventional trials were based on emerging data. The studies described informed the design and endpoints implemented in the phase III MOVE trial (NCT03312634) and provide a foundation for future clinical trial development. TRIAL REGISTRATION NCT02322255 (registered 23/12/2014); NCT02190747 (registered 15/07/2014); NCT02279095 (registered 30/10/2014).
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Affiliation(s)
| | - Mona Al Mukaddam
- Departments of Orthopedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Geneviève Baujat
- Département de Génétique, Institut Imagine, Hôpital Universitaire Necker-Enfants Malades, Université Paris Cité, Paris, France
| | - Matthew A Brown
- Faculty of Life Sciences and Medicine, King's College London, and Genomics England Ltd, London, UK
| | - 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 Edythe 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, US
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Institut Imagine, Hôpital Universitaire Necker-Enfants Malades, Université Paris Cité, Paris, France
| | | | | | | | - Frederick S Kaplan
- Departments of Orthopedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
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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: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Yang YS, Lin C, Ma H, Xie J, Kaplan FS, Gao G, Shim JH. AAV-Mediated Targeting of the Activin A-ACVR1 R206H Signaling in Fibrodysplasia Ossificans Progressiva. Biomolecules 2023; 13:1364. [PMID: 37759764 PMCID: PMC10526456 DOI: 10.3390/biom13091364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder characterized by progressive disabling heterotopic ossification (HO) at extra-skeletal sites. Here, we developed adeno-associated virus (AAV)-based gene therapy that suppresses trauma-induced HO in FOP mice harboring a heterozygous allele of human ACVR1R206H (Acvr1R206H/+) while limiting the expression in non-skeletal organs such as the brain, heart, lung, liver, and kidney. AAV gene therapy carrying the combination of codon-optimized human ACVR1 (ACVR1opt) and artificial miRNAs targeting Activin A and its receptor ACVR1R206H ablated the aberrant activation of BMP-Smad1/5 signaling and the osteogenic differentiation of Acvr1R206H/+ skeletal progenitors. The local delivery of AAV gene therapy to HO-causing cells in the skeletal muscle resulted in a significant decrease in endochondral bone formation in Acvr1R206H/+ mice. These mice showed little to no expression in a major AAV-targeted organ, the liver, due to liver-abundant miR-122-mediated repression. Thus, AAV gene therapy is a promising therapeutic strategy to explore in suppressing HO in FOP.
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Affiliation(s)
- Yeon-Suk Yang
- Department of Medicine, Division of Rheumatology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (Y.-S.Y.); (C.L.)
| | - Chujiao Lin
- Department of Medicine, Division of Rheumatology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (Y.-S.Y.); (C.L.)
| | - Hong Ma
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (H.M.); (J.X.)
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Viral Vector Core, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Jun Xie
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (H.M.); (J.X.)
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Viral Vector Core, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA;
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Guangping Gao
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (H.M.); (J.X.)
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Viral Vector Core, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Jae-Hyuck Shim
- Department of Medicine, Division of Rheumatology, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (Y.-S.Y.); (C.L.)
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (H.M.); (J.X.)
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
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8
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Groppe JC, Lu G, Tandang-Silvas MR, Pathi A, Konda S, Wu J, Le VQ, Culbert AL, Shore EM, Wharton KA, Kaplan FS. Polypeptide Substrate Accessibility Hypothesis: Gain-of-Function R206H Mutation Allosterically Affects Activin Receptor-like Protein Kinase Activity. Biomolecules 2023; 13:1129. [PMID: 37509165 PMCID: PMC10376983 DOI: 10.3390/biom13071129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Although structurally similar to type II counterparts, type I or activin receptor-like kinases (ALKs) are set apart by a metastable helix-loop-helix (HLH) element preceding the protein kinase domain that, according to a longstanding paradigm, serves passive albeit critical roles as an inhibitor-to-substrate-binding switch. A single recurrent mutation in the codon of the penultimate residue, directly adjacent the position of a constitutively activating substitution, causes milder activation of ACVR1/ALK2 leading to sporadic heterotopic bone deposition in patients presenting with fibrodysplasia ossificans progressiva, or FOP. To determine the protein structural-functional basis for the gain of function, R206H mutant, Q207D (aspartate-substituted caALK2) and HLH subdomain-truncated (208 Ntrunc) forms were compared to one another and the wild-type enzyme through in vitro kinase and protein-protein interaction analyses that were complemented by signaling read-out (p-Smad) in primary mouse embryonic fibroblasts and Drosophila S2 cells. Contrary to the paradigm, the HLH subdomain actively suppressed the phosphotransferase activity of the enzyme, even in the absence of FKBP12. Unexpectedly, perturbation of the HLH subdomain elevated kinase activity at a distance, i.e., allosterically, at the ATP-binding and polypeptide-interacting active site cleft. Accessibility to polypeptide substrate (BMP Smad C-terminal tails) due to allosterically altered conformations of type I active sites within heterohexameric cytoplasmic signaling complexes-assembled noncanonically by activin-type II receptors extracellularly-is hypothesized to produce a gain of function of the R206H mutant protein responsible for episodic heterotopic ossification in FOP.
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Affiliation(s)
- Jay C Groppe
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246, USA
| | - Guorong Lu
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246, USA
| | - Mary R Tandang-Silvas
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246, USA
| | - Anupama Pathi
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246, USA
| | - Shruti Konda
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246, USA
| | - Jingfeng Wu
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246, USA
| | - Viet Q Le
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02912, USA
- Program in Molecular Medicine, Boston Children's Hospital, Boston, MA 02115, USA
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA 02115, USA
| | - Andria L Culbert
- Department of Orthopaedics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Eileen M Shore
- Department of Orthopaedics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Kristi A Wharton
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02912, USA
| | - Frederick S Kaplan
- Department of Orthopaedics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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9
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Sangadala S, Shore EM, Xu M, Bergwitz C, Lozano-Calderon SA, Lin AE, Boden SD, Kaplan FS. Multifocal heterotopic ossification in a man with germline variants of LIM Mineralization Protein-1 (LMP-1). Am J Med Genet A 2023. [PMID: 37218523 DOI: 10.1002/ajmg.a.63304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 04/26/2023] [Accepted: 05/10/2023] [Indexed: 05/24/2023]
Abstract
A 54-year-old man with a history of unimelic, post-traumatic multifocal heterotopic ossification (HO) and normal genetic analysis of ACVR1 and GNAS had variants of unknown significance (VUS) in PDLIM-7 (PDZ and LIM Domain Protein 7), the gene encoding LMP-1 (LIM Mineralization Protein-1), an intracellular protein involved in the bone morphogenetic protein (BMP) pathway signaling and ossification. In order to determine if the LMP-1 variants were plausibly responsible for the phenotype observed, a series of in vitro experiments were conducted. C2C12 cells were co-transfected with a BMP-responsive reporter as well as the LMP-1 wildtype (wt) construct or the LMP-1T161I or the LMP-1D181G constructs (herein designated as LMP-161 or LMP-181) corresponding to the coding variants detected in the patient. A significantly increased BMP-reporter activity was observed in LMP-161 or LMP-181 transfected cells compared to the wt cells. The LMP-181 variant exhibited BMP-reporter activity with a four-fold increase over the LMP-1 wt protein. Similarly, mouse pre-osteoblastic MC3T3 cells transfected with the patient's LMP-1 variants expressed higher levels of osteoblast markers both at mRNA and protein levels and preferentially mineralized when stimulated with recombinant BMP-2 compared to control cells. Presently, there are no pathogenic variants of LMP-1 known to induce HO in humans. Our findings suggest that the germline variants in LMP-1 detected in our patient are plausibly related to his multifocal HO (LMP1-related multifocal HO). Further observations will be required to firmly establish this gene-disease relationship.
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Affiliation(s)
- Sreedhara Sangadala
- The Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eileen M Shore
- The Departments of Orthopaedic Surgery and Genetics, and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meiqi Xu
- The Department of Orthopaedic Surgery and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clemens Bergwitz
- Section of Endocrinology and Metabolism, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Santiago A Lozano-Calderon
- The Department of Orthopaedics, Massachusetts General Hospital and Harvard University School of Medicine, Boston, Massachusetts, USA
| | - Angela E Lin
- Department of Pediatrics, Medical Genetics Unit, Mass General for Children and Harvard University School of Medicine, Boston, Massachusetts, USA
| | - Scott D Boden
- The Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Frederick S Kaplan
- The Departments of Orthopaedic Surgery and Medicine, and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pignolo RJ, Kimel M, Whalen J, Kawata AK, Artyomenko A, Kaplan FS. The Fibrodysplasia Ossificans Progressiva Physical Function Questionnaire (FOP-PFQ): A patient-reported, disease-specific measure. Bone 2023; 168:116642. [PMID: 36526263 DOI: 10.1016/j.bone.2022.116642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/24/2022] [Accepted: 12/03/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To assess the reliability and validity of age-specific versions of the Fibrodysplasia Ossificans Progressiva Physical Function Questionnaire (FOP-PFQ), developed to measure the impact of FOP on physical function and activities of daily living. METHODS FOP-PFQ development included a literature review, two iterative phases of qualitative work involving individuals with FOP, and clinical expert review. The analysis used pooled FOP-PFQ data from an FOP natural history study (NCT02322255), a patient registry (NCT02745158), and phase II trials (NCT02190747; NCT02279095; NCT02979769). Item-level and factor analysis informed item retention and determined factor structure. Reliability was evaluated using Cronbach's alpha and intraclass correlation coefficients. Convergent validity was assessed by comparing scores with age, the Cumulative Analogue Joint Involvement Scale (CAJIS), the Patient-Reported Outcomes Measurement Information System Global Health Scale (PROMIS), and heterotopic ossification (HO) volume. Known-groups validity assessment used age, CAJIS, and HO volume. RESULTS Factor analysis confirmed a two-factor solution: Mobility and Upper Extremity. Results reflected high internal consistency and were supportive of test-retest reliability; correlation coefficients >0.90 demonstrated FOP-PFQ scores were stable over a one- to three-week period. The majority of scores were moderately (r = 0.30-0.50) to highly (r ≥ 0.50) correlated with CAJIS and HO volume, supporting convergent validity. With the exception of some age-based and functional groups, FOP-PFQ scores were significantly worse in groups with more severe disease, demonstrating known-groups validity. CONCLUSION The FOP-PFQ was demonstrated to be a reliable, valid measure that may be responsive to change in individuals with FOP, although some results were inconclusive for pediatric versions.
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Affiliation(s)
| | | | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Pignolo RJ, Hsiao EC, Al Mukaddam M, Baujat G, Berglund SK, Brown MA, Cheung AM, De Cunto C, Delai P, Haga N, Kannu P, Keen R, Le Quan Sang KH, Mancilla EE, Marino R, Strahs A, Kaplan FS. Reduction of New Heterotopic Ossification (HO) in the Open-Label, Phase 3 MOVE Trial of Palovarotene for Fibrodysplasia Ossificans Progressiva (FOP). J Bone Miner Res 2023; 38:381-394. [PMID: 36583535 DOI: 10.1002/jbmr.4762] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, severely disabling genetic disorder of progressive heterotopic ossification (HO). The single-arm, open-label, phase 3 MOVE trial (NCT03312634) assessed efficacy and safety of palovarotene, a selective retinoic acid receptor gamma agonist, in patients with FOP. Findings were compared with FOP natural history study (NHS; NCT02322255) participants untreated beyond standard of care. Patients aged ≥4 years received palovarotene once daily (chronic: 5 mg; flare-up: 20 mg for 4 weeks, then 10 mg for ≥8 weeks; weight-adjusted if skeletally immature). The primary endpoint was annualized change in new HO volume versus NHS participants (by low-dose whole-body computed tomography [WBCT]), analyzed using a Bayesian compound Poisson model (BcPM) with square-root transformation. Twelve-month interim analyses met futility criteria; dosing was paused. An independent Data Monitoring Committee recommended trial continuation. Post hoc 18-month interim analyses utilized BcPM with square-root transformation and HO data collapsed to equalize MOVE and NHS visit schedules, BcPM without transformation, and weighted linear mixed-effects (wLME) models, alongside prespecified analysis. Safety was assessed throughout. Eighteen-month interim analyses included 97 MOVE and 101 NHS individuals with post-baseline WBCT. BcPM analyses without transformation showed 99.4% probability of any reduction in new HO with palovarotene versus NHS participants (with transformation: 65.4%). Mean annualized new HO volume was 60% lower in MOVE versus the NHS. wLME results were similar (54% reduction fitted; nominal p = 0.039). All palovarotene-treated patients reported ≥1 adverse event (AE); 97.0% reported ≥1 retinoid-associated AE; 29.3% reported ≥1 serious AE, including premature physeal closure (PPC)/epiphyseal disorder in 21/57 (36.8%) patients aged <14 years. Post hoc computational analyses using WBCT showed decreased vertebral bone mineral density, content, and strength, and increased vertebral fracture risk in palovarotene-treated patients. Thus, post hoc analyses showed evidence for efficacy of palovarotene in reducing new HO in FOP, but high risk of PPC in skeletally immature patients. © 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)
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edythe 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, USA
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geneviève Baujat
- Département de Génétique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Staffan K Berglund
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Matthew A Brown
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Genomics England Ltd, London, UK
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Delai
- Centro de Pesquisa Clinica, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Peter Kannu
- Hospital for Sick Children, Toronto, ON, Canada
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Edna E Mancilla
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 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
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wentworth KL, Lalonde RL, Groppe JC, Brewer N, Moody T, Hansberry S, Taylor KE, Shore EM, Kaplan FS, Pignolo RJ, Yelick PC, Hsiao EC. Functional Testing of Bone Morphogenetic Protein (BMP) Pathway Variants Identified on Whole-Exome Sequencing in a Patient with Delayed-Onset Fibrodysplasia Ossificans Progressiva (FOP) Using ACVR1 R206H -Specific Human Cellular and Zebrafish Models. J Bone Miner Res 2022; 37:2058-2076. [PMID: 36153796 PMCID: PMC9950781 DOI: 10.1002/jbmr.4711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/28/2022] [Accepted: 08/07/2022] [Indexed: 11/06/2022]
Abstract
Bone morphogenetic protein (BMP) signaling is critical in skeletal development. Overactivation can trigger heterotopic ossification (HO) as in fibrodysplasia ossificans progressiva (FOP), a rare, progressive disease of massive HO formation. A small subset of FOP patients harboring the causative ACVR1R206H mutation show strikingly mild or delayed-onset HO, suggesting that genetic variants in the BMP pathway could act as disease modifiers. Whole-exome sequencing of one such patient identified BMPR1AR443C and ACVR2AV173I as candidate modifiers. Molecular modeling predicted significant structural perturbations. Neither variant decreased BMP signaling in ACVR1R206H HEK 293T cells at baseline or after stimulation with BMP4 or activin A (AA), ligands that activate ACVR1R206H signaling. Overexpression of BMPR1AR443C in a Tg(ACVR1-R206Ha) embryonic zebrafish model, in which overactive BMP signaling yields ventralized embryos, did not alter ventralization severity, while ACVR2AV173I exacerbated ventralization. Co-expression of both variants did not affect dorsoventral patterning. In contrast, BMPR1A knockdown in ACVR1R206H HEK cells decreased ligand-stimulated BMP signaling but did not affect dorsoventral patterning in Tg(ACVR1-R206Ha) zebrafish. ACVR2A knockdown decreased only AA-stimulated signaling in ACVR1R206H HEK cells and had no effect in Tg(ACVR1-R206Ha) zebrafish. Co-knockdown in ACVR1R206H HEK cells decreased basal and ligand-stimulated signaling, and co-knockdown/knockout (bmpr1aa/ab; acvr2aa/ab) decreased Tg(ACVR1-R206Ha) zebrafish ventralization phenotypes. Our functional studies showed that knockdown of wild-type BMPR1A and ACVR2A could attenuate ACVR1R206H signaling, particularly in response to AA, and that ACVR2AV173I unexpectedly increased ACVR1R206H -mediated signaling in zebrafish. These studies describe a useful strategy and platform for functionally interrogating potential genes and genetic variants that may impact the BMP signaling pathway. © 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)
- Kelly L Wentworth
- Department of Medicine, Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Robert L Lalonde
- Tufts University School of Dental Medicine, Division of Craniofacial and Molecular Genetics, Boston, MA, USA
| | - Jay C Groppe
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, Dallas, TX, USA
| | - Niambi Brewer
- Department of Orthopedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tania Moody
- Institute for Human Genetics, the Program in Craniofacial Biology, the UCSF Eli and Edythe Broad Institute for Regeneration Medicine, and the Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Steven Hansberry
- San Francisco State University, California Institute of Regenerative Medicine Bridges to Stem Cell Research Program, San Francisco, CA, USA
| | - Kimberly E Taylor
- Russell/Engleman Rheumatology Research Center, University of California, San Francisco, CA, USA
| | - Eileen M Shore
- Department of Orthopedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frederick S Kaplan
- Department of Orthopedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Pamela C Yelick
- Tufts University School of Dental Medicine, Division of Craniofacial and Molecular Genetics, Boston, MA, USA
| | - Edward C Hsiao
- Institute for Human Genetics, the Program in Craniofacial Biology, the UCSF Eli and Edythe Broad Institute for Regeneration Medicine, and the Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
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14
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Böing EA, Mukaddam MA, Toder KS, Davis M, Croskery K, Grandoulier AS, Kaplan FS. RF18 | PSAT149 Joint Function and Quality of Life in Fibrodysplasia Ossificans Progressiva: Results from an International Burden of Illness Survey of Patients and Family Members. J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Introduction
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder of progressive heterotopic ossification, resulting in cumulative loss of joint function and severe disability. We present results from an international, cross-sectional FOP Burden of Illness Survey (NCT04665323) demonstrating the impact of loss of joint function on quality of life (QoL) for patients and their family members.
Methods
Individuals with FOP (survey proxy-completed for patients aged <13 years), their primary caregivers, and other family members (aged ≥18 years) were eligible to participate. Family members who acted as a proxy could also participate themselves, as a family member. The survey was available online from 18Jan21–30Apr21 in 15 countries and 11 languages. The Patient-Reported Mobility Assessment (PRMA) evaluated range of motion across 12 joints and 3 body regions (total scores range from 0–30; higher scores reflect more severe limitations). PRMA total scores were categorized into four Levels: Level 1, 0–6; Level 2, 7–12; Level 3, 13–18; Level 4, ≥19. To assess the impact of FOP on QoL, patients ≥13 years and their family members completed the EuroQoL health-related QoL questionnaire (EQ-5D-5L; index ranges from <0 [worst health] to 1 [full health]). Descriptive analyses of EQ-5D-5L index scores were performed for each population and by patients’ PRMA Level. Linear regression analyses (adjusted for geographic region) were used to evaluate the relationship between patients’ degree of joint impairment (PRMA total score) and patient or family member EQ-5D-5L index score.
Results
463 survey responses were received from 405 individuals: patient/proxy population, n=219 (patients ≥13 years, n=161; proxies for patients <13 years, n=58); family member population, n=244, of whom 163 identified as primary caregivers. Mean (standard deviation [SD]) EQ-5D-5L index score was 0.24 (0.36) for patients ≥13 years, 0.83 (0.22) for primary caregivers, and 0.85 (0.21) across all family members. For the patient population, mean (SD) EQ-5D-5L index score decreased as PRMA Level increased: Level 1, 0.61 (0.26); Level 2, 0.46 (0.34); Level 3, 0.21 (0.30); Level 4, 0.05 (0.26). There was a significant negative association between PRMA total score and EQ-5D-5L index score for patients, such that for every 1-unit increase in the PRMA total score of the patient, there was a mean (standard error [SE]) decrease of 0.029 (0.003; p<0.0001) in EQ-5D-5L adjusted for geographic region. For all family members, there was no significant association between EQ-5D-5L and the PRMA total score of the patient (p=0.6737).
Conclusion
Loss of joint function (as represented by PRMA Level) has a significant, detrimental impact on QoL for patients with FOP. These findings increase understanding of the impact of FOP on patients and their family members, and may help to improve quality of care and access to support for the FOP community. Funding: Sponsored by Ipsen.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:48 p.m. - 12:53 p.m.
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15
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Yang YS, Kim JM, Xie J, Chaugule S, Lin C, Ma H, Hsiao E, Hong J, Chun H, Shore EM, Kaplan FS, Gao G, Shim JH. Suppression of heterotopic ossification in fibrodysplasia ossificans progressiva using AAV gene delivery. Nat Commun 2022; 13:6175. [PMID: 36258013 PMCID: PMC9579182 DOI: 10.1038/s41467-022-33956-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/04/2022] [Indexed: 12/24/2022] Open
Abstract
Heterotopic ossification is the most disabling feature of fibrodysplasia ossificans progressiva, an ultra-rare genetic disorder for which there is currently no prevention or treatment. Most patients with this disease harbor a heterozygous activating mutation (c.617 G > A;p.R206H) in ACVR1. Here, we identify recombinant AAV9 as the most effective serotype for transduction of the major cells-of-origin of heterotopic ossification. We use AAV9 delivery for gene replacement by expression of codon-optimized human ACVR1, ACVR1R206H allele-specific silencing by AAV-compatible artificial miRNA and a combination of gene replacement and silencing. In mouse skeletal cells harboring a conditional knock-in allele of human mutant ACVR1 and in patient-derived induced pluripotent stem cells, AAV gene therapy ablated aberrant Activin A signaling and chondrogenic and osteogenic differentiation. In Acvr1(R206H) knock-in mice treated locally in early adulthood or systemically at birth, trauma-induced endochondral bone formation was markedly reduced, while inflammation and fibroproliferative responses remained largely intact in the injured muscle. Remarkably, spontaneous heterotopic ossification also substantially decreased in in Acvr1(R206H) knock-in mice treated systemically at birth or in early adulthood. Collectively, we develop promising gene therapeutics that can prevent disabling heterotopic ossification in mice, supporting clinical translation to patients with fibrodysplasia ossificans progressiva.
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Affiliation(s)
- Yeon-Suk Yang
- Department of Medicine/Division of Rheumatology, UMass Chan Medical School, Worcester, MA, USA
| | - Jung-Min Kim
- Department of Medicine/Division of Rheumatology, UMass Chan Medical School, Worcester, MA, USA
| | - Jun Xie
- Horae Gene Therapy Center, UMass Chan Medical School, Worcester, MA, USA
- Department of Microbiology and Physiological Systems, UMass Chan Medical School, Worcester, MA, USA
- Viral Vector Core, UMass Chan Medical School, Worcester, MA, USA
| | - Sachin Chaugule
- Department of Medicine/Division of Rheumatology, UMass Chan Medical School, Worcester, MA, USA
| | - Chujiao Lin
- Department of Medicine/Division of Rheumatology, UMass Chan Medical School, Worcester, MA, USA
| | - Hong Ma
- Horae Gene Therapy Center, UMass Chan Medical School, Worcester, MA, USA
- Department of Microbiology and Physiological Systems, UMass Chan Medical School, Worcester, MA, USA
- Viral Vector Core, UMass Chan Medical School, Worcester, MA, USA
| | - Edward Hsiao
- Division of Endocrinology and Metabolism, Department of Medicine; the Institute for Human Genetics; the Program in Craniofacial Biology; and the Eli and Edyth Broad Institute of Regeneration Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Jaehyoung Hong
- Department of Mathematical Sciences, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Hyonho Chun
- Department of Mathematical Sciences, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Guangping Gao
- Horae Gene Therapy Center, UMass Chan Medical School, Worcester, MA, USA.
- Department of Microbiology and Physiological Systems, UMass Chan Medical School, Worcester, MA, USA.
- Viral Vector Core, UMass Chan Medical School, Worcester, MA, USA.
- Li Weibo Institute for Rare Diseases Research, UMass Chan Medical School, Worcester, MA, USA.
| | - Jae-Hyuck Shim
- Department of Medicine/Division of Rheumatology, UMass Chan Medical School, Worcester, MA, USA.
- Horae Gene Therapy Center, UMass Chan Medical School, Worcester, MA, USA.
- Li Weibo Institute for Rare Diseases Research, UMass Chan Medical School, Worcester, MA, USA.
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Al Mukaddam M, Toder KS, Davis M, Cali A, Liljesthröm M, Hollywood S, Croskery K, Grandoulier AS, Böing EA, Whalen JD, Kaplan FS. The impact of fibrodysplasia ossificans progressiva (FOP) on patients and their family members: results from an international burden of illness survey. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1199-1213. [PMID: 36017643 DOI: 10.1080/14737167.2022.2115360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, genetic disorder of heterotopic ossification, which transforms soft, connective tissues into bone, resulting in limited joint function and severe disability. We present results from an international burden of illness survey (NCT04665323) assessing physical, quality of life (QoL), and economic impacts of FOP on patients and family members. METHODS Patient associations in 15 countries invited their members to participate; individuals with FOP and their family members were eligible. The survey was available online, in 11 languages, from January 18-April 30, 2021. Participants responded to assessments measuring joint function, QoL, healthcare service and living adaptation utilization, out-of-pocket costs, employment, and travel. RESULTS The survey received 463 responses (patients, n=219; family members, n=244). For patients, decreased joint function was associated with reduced QoL and greater reliance on living adaptations. Nearly half of primary caregivers experienced a mild to moderate impact on their health/psychological wellbeing. Most primary caregivers and patients (≥18 years) reported that FOP impacted their career decisions. CONCLUSIONS Data from this survey will improve understanding of the impact of FOP on patients and family members, which is important for identifying unmet needs, optimizing care, and improving support for the FOP community.
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Affiliation(s)
- Mona Al Mukaddam
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine S Toder
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Amanda Cali
- The Radiant Hope Foundation, Mountain Lakes, NJ, USA.,The Ian Cali FOP Research Fund, PENN Medicine, The Center for Research in FOP and Related Disorders, Philadelphia, PA, USA.,Tin Soldiers: Global Patient Identification Program, Johannesburg, South Africa
| | - Moira Liljesthröm
- Fundación FOP, Buenos Aires, Argentina.,Argentine Representative to the International President's Council of the International FOP Association, Buenos Aires, Argentina
| | | | | | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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18
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Pignolo RJ, McCarrick-Walmsley R, Wang H, Qiu S, Hunter J, Barr S, He K, Zhang H, Kaplan FS. Plasma-Soluble Biomarkers for Fibrodysplasia Ossificans Progressiva (FOP) Reflect Acute and Chronic Inflammatory States. J Bone Miner Res 2022; 37:475-483. [PMID: 34954853 DOI: 10.1002/jbmr.4492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/07/2021] [Accepted: 12/21/2021] [Indexed: 11/07/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a progressive, debilitating genetic disease in which skeletal muscle and connective tissue is episodically replaced by heterotopic bone. Discovery of surrogate biomarkers of disease (genotype)-related and flare-up-associated activity of FOP in a readily accessible matrix, such as plasma, would facilitate an understanding of the complex pathophysiology of FOP, aid patient care, and provide a valuable tool for the development and monitoring of potential therapeutics. In a case-control study, using a carefully collected and curated set of plasma samples from 40 FOP patients with the classic ACVR1R206H mutation and 40 age- and sex-matched controls, we report the identification of disease-related and flare-up-associated biomarkers of FOP using a multiplex analysis of 113 plasma-soluble analytes. Adiponectin (implicated in hypoxia, inflammation, and heterotopic ossification) as well as tenascin-C (an endogenous activator of innate immune signaling through the TLR4 pathway and a substrate for kallikrein-7) were highly correlated with FOP genotype, while kallikrein-7 was highly correlated with acute flare-up status. Plasma-soluble biomarkers for FOP support a flare-up-related acute inflammatory phase of disease activity superimposed on a genotypic background of chronic inflammation. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Robert J Pignolo
- Departments of Medicine and Physiology/Biomedical Engineering, Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ruth McCarrick-Walmsley
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Haitao Wang
- Departments of Medicine and Physiology/Biomedical Engineering, Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Kevin He
- Blueprint Medicines, Cambridge, MA, USA
| | - Hui Zhang
- Blueprint Medicines, Cambridge, MA, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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19
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Wang H, Zhang Q, Kaplan FS, Pignolo RJ. Clearance of Senescent Cells From Injured Muscle Abrogates Heterotopic Ossification in Mouse Models of Fibrodysplasia Ossificans Progressiva. J Bone Miner Res 2022; 37:95-107. [PMID: 34633114 PMCID: PMC8770661 DOI: 10.1002/jbmr.4458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/19/2021] [Accepted: 10/02/2021] [Indexed: 11/10/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease caused by mutations in activin A receptor type I/activin-like kinase 2 (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor, resulting in the formation of extraskeletal or heterotopic ossification (HO) and other features consistent with premature aging. During the first decade of life, episodic bouts of inflammatory swellings (flare-ups) occur, which are typically triggered by soft tissue trauma. Through an endochondral process, these exacerbations ultimately result in skeletal muscles, tendons, ligaments, fascia, and aponeuroses transforming into ectopic bone, rendering movement impossible. We have previously shown that soft tissue injury causes early FOP lesions characterized by cellular hypoxia, cellular damage, and local inflammation. Here we show that muscle injury in FOP also results in senescent cell accumulation, and that senescence promotes tissue reprogramming toward a chondrogenic fate in FOP muscle but not wild-type (WT) muscle. Using a combination of senolytic drugs we show that senescent cell clearance and reduction in the senescence associated secretory phenotype (SASP) ameliorate HO in mouse models of FOP. We conclude that injury-induced senescent cell burden and the SASP contribute to FOP lesion formation and that tissue reprogramming in FOP is mediated by cellular senescence, altering myogenic cell fate toward a chondrogenic cell fate. Furthermore, pharmacological removal of senescent cells abrogates tissue reprogramming and HO formation. Here we provide proof-of-principle evidence for senolytic drugs as a future therapeutic strategy in FOP. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Haitao Wang
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Qiang Zhang
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Pignolo
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
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20
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Kaplan FS, Groppe JC, Xu M, Towler OW, Grunvald E, Kalunian K, Kallish S, Al Mukaddam M, Pignolo RJ, Shore EM. An ACVR1 R375P pathogenic variant in two families with mild fibrodysplasia ossificans progressiva. Am J Med Genet A 2021; 188:806-817. [PMID: 34854557 DOI: 10.1002/ajmg.a.62585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/06/2021] [Accepted: 11/02/2021] [Indexed: 11/11/2022]
Abstract
Genetic variants are vital in informing clinical phenotypes, aiding physical diagnosis, guiding genetic counseling, understanding the molecular basis of disease, and potentially stimulating drug development. Here we describe two families with an ultrarare ACVR1 gain-of-function pathogenic variant (codon 375, Arginine > Proline; ACVR1R375P ) responsible for a mild nonclassic fibrodysplasia ossificans progressiva (FOP) phenotype. Both families include people with the ultrarare ACVR1R375P variant who exhibit features of FOP while other individuals currently do not express any clinical signs of FOP. Thus, the mild ACVR1R375P variant greatly expands the scope and understanding of this rare disorder.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay C Groppe
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, Dallas, Texas, USA
| | - Meiqi Xu
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - O Will Towler
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eduardo Grunvald
- Division of General Internal Medicine, The Department of Medicine, The University of California San Diego, San Diego, California, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, The Department of Medicine, UC San Diego School of Medicine, La Jolla, California, USA
| | - Staci Kallish
- The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Translational Medicine and Human Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert J Pignolo
- The Department of Medicine, The Mayo Clinic, Rochester, Minnesota, USA
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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22
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Scott C, Kaplan FS, Friedman C, Delai P, Al Mukaddam M, Cali A, Harries V, Ezra N, Schwegler O. P068 Abstract tin soldiers Global FOP patient search. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab722.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
While looking for one, you may find another: Tin Soldiers and the search for undiagnosed individuals with Fibrodysplasia Ossificans Progressiva (FOP)
Background
FOP is an ultra-rare condition where heterozygous, gain-of-function missense mutations in the ACVR1 gene result in progressive heterotopic bone formation in ligaments, tendons and muscles and result in severe disability.1 FOP has an estimated incidence of 0.6–1.3 per million individuals 2,3 suggesting that currently there are ∼8000 patients living with FOP worldwide, however only about 900 patients are currently diagnosed worldwide The diagnosis is made clinically by identification of typical malformations of the great toes as well as inflammatory swellings (flare-ups) that result in progressive and episodic ossification of soft connective tissues, often triggered by trauma.4 Muscle biopsies, though contraindicated, are frequently performed mistakenly during the course of diagnosis, as FOP is not a well-known condition. There is an urgent need to identify individuals with FOP across the globe in order to avoid harmful biopsies and to provide a pathway to care for patients with FOP.
Tin Soldiers is a global FOP patient search program utilizing multimedia campaigns aimed at educating and bringing attention to FOP, to find individuals across the globe and to connect them to pathways of care. The mission is to identify every person with FOP who is currently undiagnosed, as well as to deliver education and support to those living with a diagnosis, but not connected to support networks. Once found, all people living with FOP are connected to pathways to care. The aim is to describe the Tin Soldiers global FOP patient search program approach and report early results of the program.
Methods
Tin Soldiers creates multimedia campaigns to create awareness and to educate medical professionals, healthcare workers, general public and local communities on FOP. At the heart of the communication program is story-telling of people living with FOP, from a feature-length documentary to public service announcements, animated short films and an 8-part Global Master Series—all designed to bring attention to FOP in order to find patients and provide a pathway to diagnosis and care. Importantly diagnosis is not the end of the journey, it’s just the beginning.
Results
Since official operations commenced in March 2020, Tin Soldiers has trained 535 medical professionals; established an African Clinicians Council of 10 doctors with the intention of mentoring others across the continent; increased the number of African patients with a diagnosis from 25 patients in December 2020–32 in April 2021. Connected previously diagnosed (but not connected) patients to a robust support network and held the first African FOP Family Gathering with clinicians from both South Africa and Nigeria.
On the journey, patients with other conditions have been discovered including Juvenile Idiopathic Arthritis (JIA), Progressive Osseus Heteroplasia (POH) and Multiple Osteochondromas (MO). These patients have been diagnosed and connected to both medical care and patient support. Another important outcome is the continued education of doctors globally with the uptake of the CME Master Series in Russia and planned rollouts in Algeria, Nigeria, Kenya, Namibia, Sweden (in partnership with the national patient organization) and Brazil (under the First Lady’s patronage).
Conclusion
Tin Soldiers offers an innovative model of patient identification, diagnosis, support and education at all levels of care, using the power of story-telling and multi-media marketing. Such a model could be considered for raising the profile of other musculoskeletal or rare conditions and connecting patients to a functioning pathway to care.
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Affiliation(s)
- Christiaan Scott
- Paediatric Rheumatology, Red Cross Children's Hospital, University of Cape Town
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania
| | - Clive Friedman
- Schulich School of Medicine and Dentistry Pediatric Oral Health and Dentistry
| | - Patricia Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery & Medicine and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania
| | - Amanda Cali
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
| | - Vanda Harries
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
| | - Nicola Ezra
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
| | - Odette Schwegler
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
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23
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Kaplan FS, Teachey DT, Andolina JR, Siegel DM, Mancilla EE, Hsiao EC, Al Mukaddam M, Rocke DM, Pignolo RJ. Off-on-off-on use of imatinib in three children with fibrodysplasia ossificans progressiva. Bone 2021; 150:116016. [PMID: 34022457 DOI: 10.1016/j.bone.2021.116016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/05/2021] [Accepted: 05/15/2021] [Indexed: 11/21/2022]
Abstract
The compassionate use of available medications with unproven efficacy is often in conflict with their clinical evaluation in placebo-controlled clinical trials. For ultra-rare diseases where no approved treatments exist, such as fibrodysplasia ossificans progressiva (FOP), routine clinical trial enrollment for available medications may be difficult to achieve. Therefore adaptive methods of evaluation are often desirable. Off-on-off-on (O4) approaches offer an opportunity to rapidly assess the potential symptomatic efficacy and tolerability of a medication with a limited number of patients and may aid in the design of more focused clinical trials that are amenable to enrollment. Here we report three children with classic FOP who had recalcitrant flare-ups of the back and who had been treated with an O4 regimen of imatinib. In all three children, fewer flare-ups, decreased swelling and improved function with activities of daily living were reported by the parents and treating physician when the children were "on" imatinib than when they were "off" imatinib. The median time to improvement on imatinib was 2-3 weeks. The anecdotal O4 experience with imatinib reported here in three children with FOP who had recalcitrant flare-ups of the back supports the design of a brief placebo controlled trial to assess the potential efficacy of imatinib in reducing the symptoms in children with refractory flare-ups of FOP. A tool to prospectively measure and quantitate flare-up symptoms is presently being developed and validated and will be used for such a study.
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Affiliation(s)
- Frederick S Kaplan
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America.
| | - David T Teachey
- The Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America.
| | - Jeffrey R Andolina
- The Department of Pediatrics, Division of Hematology-Oncology, University of Rochester School of Medicine, Rochester, NY 14642, United States of America.
| | - David M Siegel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY 14642, United States of America.
| | - Edna E Mancilla
- The Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
| | - Edward C Hsiao
- The Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Institute for Human Genetics, University of California- San Francisco, San Francisco, CA, United States of America.
| | - Mona Al Mukaddam
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America.
| | - David M Rocke
- The Division of Biostatistics, Department of Biomedical Engineering, University of California - Davis, Davis, CA, United States of America.
| | - Robert J Pignolo
- The Department of Medicine, The Mayo Clinic, Rochester, MN 55905, United States of America.
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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25
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Wang H, De Cunto CL, Pignolo RJ, Kaplan FS. Spatial patterns of heterotopic ossification in fibrodysplasia ossificans progressiva correlate with anatomic temperature gradients. Bone 2021; 149:115978. [PMID: 33915334 DOI: 10.1016/j.bone.2021.115978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/23/2021] [Accepted: 04/21/2021] [Indexed: 09/30/2022]
Abstract
Progressive heterotopic ossification (HO) is a hallmark of fibrodysplasia ossificans progressiva (FOP); however, this tissue transformation is not random. Rather, we noticed that HO in FOP progresses in well-defined but inexplicable spatial and temporal patterns that correlate precisely with infrared thermographs of the human body. FOP is caused by gain-of-function mutations in Activin A receptor type I (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor kinase. As with all enzymes, the activity of ACVR1 is temperature-dependent. We hypothesized that connective tissue progenitor cells that express the common heterozygous ACVR1R206H mutation (FOP CTPCs) exhibit a dysregulated temperature response compared to control CTPCs and that the temperature of FOP CTPCs that initiate and sustain HO at various anatomic sites determines, in part, the anatomic distribution of HO in FOP. We compared BMP pathway signaling at a range of physiologic temperatures in primary CTPCs isolated from FOP patients (n = 3) and unaffected controls (n = 3) and found that BMP pathway signaling and resultant chondrogenesis were amplified in FOP CTPCs compared to control CTPCs (p < 0.05). We conclude that the anatomic distribution of HO in FOP may be due, in part, to a dyregulated temperature response in FOP CTPCs that reflect anatomic location. While the association of temperature gradients with spatial patterns of HO in FOP does not demonstrate causality, our findings provide a paradigm for the physiologic basis of the anatomic distribution of HO in FOP and unveil a novel therapeutic target that might be exploited for this disabling condition.
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Affiliation(s)
- Haitao Wang
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carmen L De Cunto
- Department of Pediatrics, Pediatric Rheumatology Section, Hospital Italiano de Buenos Aires, Gascón 450, 1181 Ciudad Autónoma de Buenos Aires, Argentina
| | - Robert J Pignolo
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of the Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
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26
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Ho M, Park BY, Rosenblum NG, Al Mukaddam M, Kaplan FS, Kucherov V, Hubosky SG, Kane G, Desai V, Kramer MR, Ku BS, Schwenk ES, Baratta JL, Harshavardhana D, Grunwald Z. Surgical and Radiological Management of Complicated Uterine Leiomyoma Aided by 3D Models in a Patient with Fibrodysplasia Ossificans Progressiva. Am J Case Rep 2021; 22:e931614. [PMID: 34108438 PMCID: PMC8207543 DOI: 10.12659/ajcr.931614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 27-year-old Final Diagnosis: Fibrodysplasia ossificans progressiva Symptoms: Fever Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic • Obstetrics and Gynecology
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Affiliation(s)
- Michelle Ho
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.,Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
| | - Beau Y Park
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Norman G Rosenblum
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopedic Surgery, Center for Research in FOP and Related Disorders, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frederick S Kaplan
- Departments of Medicine and Orthopedic Surgery, Center for Research in FOP and Related Disorders, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Kucherov
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott G Hubosky
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Kane
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vishal Desai
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael R Kramer
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bon S Ku
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Deepti Harshavardhana
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Zvi Grunwald
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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27
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Martín-García D, Towler OW, Xu M, Alfonso-Hernández O, Oliveira PR, Alonso-Clavo M, Shore EM, Kaplan FS. Nonclassic fibrodysplasia ossificans progressiva: A child from Angola with an ACVR1 G328E variant. Am J Med Genet A 2021; 185:2572-2575. [PMID: 33973349 DOI: 10.1002/ajmg.a.62253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/03/2021] [Accepted: 04/24/2021] [Indexed: 11/09/2022]
Abstract
Little is known about FOP in Africa and few cases of nonclassic fibrodysplasia ossificans progressiva (FOP) have been reported on the continent. Here we report a three-year-old girl from Angola with a nonclassic FOP clinical presentation that is characterized by complex malformations of the toes and fingers, reduction defects of the digits, absence of nails, progressive heterotopic ossification, and a confirmed heterozygous ACVR1 variant at c.983G > A. Emerging knowledge of FOP can serve as a catalyst for increasing awareness of FOP in under-represented medical communities by achieving a correct FOP diagnosis, improving access of individuals with FOP to clinical trial recruitment, and enhancing the ability of affected individuals to be part of and interact with the international FOP community.
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Affiliation(s)
| | - O Will Towler
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meiqi Xu
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Osmany Alfonso-Hernández
- Faculty of Medicine, Katyavala Bwila University, Benguela, Angola.,Division of Orthopedics, Benguela's General Hospital, Benguela, Angola
| | - Paula R Oliveira
- Faculty of Medicine, Katyavala Bwila University, Benguela, Angola
| | - Marleny Alonso-Clavo
- Faculty of Medicine, Katyavala Bwila University, Benguela, Angola.,Division of Pediatrics, Benguela's General Hospital, Benguela, Angola
| | - Eileen M Shore
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Genetics, The Perelman School of Medicine at the University of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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28
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Dahir KM, Mcginniss J, Mellis S, Sanchez RJ, Rocco MD, Keen R, Orcel P, Funck-Brentano T, Roux C, Kolta S, Madeo A, Bubbear JS, Tabarkiewicz J, Szczepanek M, Bachiller-Corral J, Cheung AM, Botman E, Mukaddam MA, Tile L, Portal-Celhay C, Sarkar N, Hou P, Forleo-Neto E, Rankin AJ, Economides AN, Trotter DG, Eekhoff EMW, Kaplan FS, Pignolo RJ. Garetosmab Reduces Flare-ups in Patients With Fibrodysplasia Ossificans Progressiva. J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, autosomal dominant disorder driven by mutations in ACVR1 that render it responsive to Activin A. FOP is characterized by progressive heterotopic ossification (HO) and distressing inflammatory events called “flare-ups.” Flare-ups can precede new HO; however, limited prospective data exists on this phenomenon. Garetosmab (GAR), an investigational human monoclonal antibody against Activin A, blocks formation of new HO in FOP. Methods: This is a post-hoc analysis of LUMINA-1 (NCT03188666) a phase 2, randomized, double-blind, placebo-controlled study, which evaluated the safety and efficacy of GAR (10 mg/kg/week IV) versus placebo (PBO) in adult patients with FOP over 28 weeks. Patient-reported flare-ups were collected via a patient diary and severity level was reported as mild, moderate or severe. Clinician-reported flare-ups were collected as adverse events in the trial. HO lesions were imaged by 18F-NaF positron emission tomography (PET) and whole-body low-dose X-ray computed tomography (CT). Results: There was a two-fold higher proportion of patients who reported one or more flare-ups on PBO 17/24 (71%) compared with GAR 7/20 (35%). Clinicians reported a four-fold higher proportion of patients experiencing one or more flare-ups on PBO 10/24 (42%) compared with GAR 2/20 (10%). Overall rates of flare-up events were two-fold higher on PBO vs. GAR (1.4 vs. 0.65 events/patient/28 weeks) for patient-reported events and eight-fold higher on PBO vs. GAR by clinician report (0.83 vs. 0.10 events/patient/28 weeks). Most flare-ups occurred on the extremities and back; pain was the most commonly reported symptom. Patient-reported flare-ups on PBO were more frequently reported as severe (29.4%) compared with GAR (7.7%). Among subjects with at least 12 weeks of follow-up from start of patient-reported flare-up, development of new HO near the site was 5/27 (18.5%) on PBO and (0%) on GAR. Of all new HO lesions, 41% on PBO and 0% on GAR occurred with spatial and temporal relation to flare-up. Conclusions: Approximately two-thirds of patients on PBO reported flare-ups over 28 weeks. GAR was associated with reductions in frequency and severity of flare-ups. Fewer than 20% of patient-reported flare-ups were associated with new HO, indicating frequent discordance of these phenomena, and compatible with previous reports. GAR’s ability to reduce patient- and clinician-reported flare-ups, as well as new HO lesions may provide an important therapeutic option.
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Affiliation(s)
| | | | | | | | | | - Richard Keen
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
| | - Philippe Orcel
- AP-HP.Nord - Université de Paris and INSERM U1132 Bioscar, Paris, France, Paris, France
| | - Thomas Funck-Brentano
- AP-HP.Nord - Université de Paris and INSERM U1132 Bioscar, Paris, France, Paris, France
| | - Christian Roux
- Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sami Kolta
- Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | | | - Judith S Bubbear
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
| | | | | | | | | | - Esmée Botman
- Amsterdam UMC, Vrije Universiteit, Amsterdam Bone Center, Amsterdam, 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
| | | | | | | | | | | | | | | | | | - E Marelise W Eekhoff
- Amsterdam UMC, Vrije Universiteit, Amsterdam Bone Center, Amsterdam, 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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29
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de Ruiter RD, Smilde BJ, Pals G, Bravenboer N, Knaus P, Schoenmaker T, Botman E, Sánchez-Duffhues G, Pacifici M, Pignolo RJ, Shore EM, van Egmond M, Van Oosterwyck H, Kaplan FS, Hsiao EC, Yu PB, Bocciardi R, De Cunto CL, Longo Ribeiro Delai P, de Vries TJ, Hilderbrandt S, Jaspers RT, Keen R, Koolwijk P, Morhart R, Netelenbos JC, Rustemeyer T, Scott C, Stockklausner C, ten Dijke P, Triffit J, Ventura F, Ravazzolo R, Micha D, Eekhoff EMW. Fibrodysplasia Ossificans Progressiva: What Have We Achieved and Where Are We Now? Follow-up to the 2015 Lorentz Workshop. Front Endocrinol (Lausanne) 2021; 12:732728. [PMID: 34858325 PMCID: PMC8631510 DOI: 10.3389/fendo.2021.732728] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare progressive genetic disease effecting one in a million individuals. During their life, patients with FOP progressively develop bone in the soft tissues resulting in increasing immobility and early death. A mutation in the ACVR1 gene was identified as the causative mutation of FOP in 2006. After this, the pathophysiology of FOP has been further elucidated through the efforts of research groups worldwide. In 2015, a workshop was held to gather these groups and discuss the new challenges in FOP research. Here we present an overview and update on these topics.
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Affiliation(s)
- Ruben D. de Ruiter
- Department of Internal Medicine, Section Endocrinology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
- *Correspondence: Ruben D. de Ruiter, ; Elisabeth M. W. Eekhoff,
| | - Bernard J. Smilde
- Department of Internal Medicine, Section Endocrinology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Gerard Pals
- Department of Clinical Genetics and Bone Histomorphology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Nathalie Bravenboer
- Department of Clinical Chemistry, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Petra Knaus
- Freie Universität Berlin, Institute for Chemistry and Biochemistry, Berlin, Germany
| | - Ton Schoenmaker
- Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit, Amsterdam, Netherlands
| | - Esmée Botman
- Department of Internal Medicine, Section Endocrinology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | | | - Maurizio Pacifici
- Translational Research Program in Pediatric Orthopaedics, Abramson Research Center, Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Eileen M. Shore
- Department of Orthopaedic Surgery and Genetics, and the Center for Research in FOP and Related Disorders, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Marjolein van Egmond
- Department of Molecular Cell Biology and Immunology, Cancer Center Amsterdam, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Hans Van Oosterwyck
- Division of Biomechanics, Department of Mechanical Engineering, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- Prometheus division of skeletal tissue engineering, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Edward C. Hsiao
- Department of Endocrinology and Metabolism, and the Institute for Human Genetics, Department of Medicine, University of California, San Francisco, CA, United States
| | - Paul B. Yu
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Renata Bocciardi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Carmen Laura De Cunto
- Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Teun J. de Vries
- Department of Periodontology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit, Amsterdam, Netherlands
| | - Susanne Hilderbrandt
- Freie Universität Berlin, Institute for Chemistry and Biochemistry, Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies, Charité Medical University of Berlin, Berlin, Germany
| | - Richard T. Jaspers
- Laboratory for Myology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Peter Koolwijk
- Department of Physiology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rolf Morhart
- Department of Pediatrics, Garmisch-Partenkichen Medical Center, Garmisch-Partenkirchen, Germany
| | - Jan C. Netelenbos
- Department of Internal Medicine, Section Endocrinology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Thomas Rustemeyer
- Department of Dermatology, Amsterdam University Medical Center (AmsterdamUMC), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Christiaan Scott
- Division of Paediatric Rheumatology, Departmet of Paediatrics and Child Heath, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
| | - Clemens Stockklausner
- Laboratory for Myology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
| | - Peter ten Dijke
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, Netherlands
| | - James Triffit
- Botnar Research Centre, University of Oxford, Oxford, United Kingdom
| | - Francesc Ventura
- Departamento de Cièncias Fisiológicas, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain
| | - Roberto Ravazzolo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Università degli Studi di Genova, Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Dimitra Micha
- Department of Clinical Genetics and Bone Histomorphology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Elisabeth M. W. Eekhoff
- Department of Internal Medicine, Section Endocrinology, Amsterdam University Medical Center (Amsterdam UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, Netherlands
- *Correspondence: Ruben D. de Ruiter, ; Elisabeth M. W. Eekhoff,
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Towler OW, Kaplan FS, Shore EM. The Developmental Phenotype of the Great Toe in Fibrodysplasia Ossificans Progressiva. Front Cell Dev Biol 2020; 8:612853. [PMID: 33364240 PMCID: PMC7753048 DOI: 10.3389/fcell.2020.612853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/16/2020] [Indexed: 12/30/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder in which extensive heterotopic ossification (HO) begins to form during early childhood and progresses throughout life. Although HO does not occur during embryonic development, children who carry the ACVR1R206H mutation that causes most cases of FOP characteristically exhibit malformation of their great toes at birth, indicating that the mutation acts during embryonic development to alter skeletal formation. Despite the high prevalence of the great toe malformation in the FOP population, it has received relatively little attention due to its clinically benign nature. In this study, we examined radiographs from a cohort of 41 FOP patients ranging from 2 months to 48 years of age to provide a detailed analysis of the developmental features, progression, and variability of the great toe malformation of FOP, which include absent skeletal structures, malformed epiphyses, ectopic ossification centers, malformed first metatarsals and phalangeal fusion.
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Affiliation(s)
- O Will Towler
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States.,The Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States.,The Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Eileen M Shore
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States.,The Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States.,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Towler OW, Peck SH, Kaplan FS, Shore EM. Dysregulated BMP signaling through ACVR1 impairs digit joint development in fibrodysplasia ossificans progressiva (FOP). Dev Biol 2020; 470:136-146. [PMID: 33217406 DOI: 10.1016/j.ydbio.2020.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/01/2020] [Accepted: 11/10/2020] [Indexed: 12/30/2022]
Abstract
The development of joints in the mammalian skeleton depends on the precise regulation of multiple interacting signaling pathways including the bone morphogenetic protein (BMP) pathway, a key regulator of joint development, digit patterning, skeletal growth, and chondrogenesis. Mutations in the BMP receptor ACVR1 cause the rare genetic disease fibrodysplasia ossificans progressiva (FOP) in which extensive and progressive extra-skeletal bone forms in soft connective tissues after birth. These mutations, which enhance BMP-pSmad1/5 pathway activity to induce ectopic bone, also affect skeletal development. FOP can be diagnosed at birth by symmetric, characteristic malformations of the great toes (first digits) that are associated with decreased joint mobility, shortened digit length, and absent, fused, and/or malformed phalanges. To elucidate the role of ACVR1-mediated BMP signaling in digit skeletal development, we used an Acvr1R206H/+;Prrx1-Cre knock-in mouse model that mimics the first digit phenotype of human FOP. We have determined that the effects of increased Acvr1-mediated signaling by the Acvr1R206H mutation are not limited to the first digit but alter BMP signaling, Gdf5+ joint progenitor cell localization, and joint development in a manner that differently affects individual digits during embryogenesis. The Acvr1R206H mutation leads to delayed and disrupted joint specification and cleavage in the digits and alters the development of cartilage and endochondral ossification at sites of joint morphogenesis. These findings demonstrate an important role for ACVR1-mediated BMP signaling in the regulation of joint and skeletal formation, show a direct link between failure to restrict BMP signaling in the digit joint interzone and failure of joint cleavage at the presumptive interzone, and implicate impaired, digit-specific joint development as the proximal cause of digit malformation in FOP.
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Affiliation(s)
- O Will Towler
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States
| | - Sun H Peck
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Perelman Center for Advanced Medicine, Philadelphia, PA 19104, United States; Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States
| | - Eileen M Shore
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Department of Genetics, Perelman School of Medicine, University of Pennsylvania, 415 Curie Boulevard, Clinical Research Building, Philadelphia, PA 19104, United States; Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States.
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Kaplan FS, Al Mukaddam M, Stanley A, Towler OW, Shore EM. Fibrodysplasia ossificans progressiva (FOP): A disorder of osteochondrogenesis. Bone 2020; 140:115539. [PMID: 32730934 PMCID: PMC7502483 DOI: 10.1016/j.bone.2020.115539] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder of extraskeletal bone formation, but could appropriately be viewed as a seminal disorder of osteochondrogenesis. Many, if not most, of the musculoskeletal features of FOP are related to dysregulated chondrogenesis including abnormal articular cartilage formation, abnormal diarthrodial joint specification, growth plate dysplasia, osteochondroma formation, heterotopic endochondral ossification (HEO), and precocious arthropathy. In FOP, causative activating mutations of Activin receptor A type I (ACVR1), a bone morphogenetic protein (BMP) type I receptor, are responsible for the osteochondrodysplasia that impacts developmental phenotypes as well as postnatal features of this illustrative disorder. Here, we highlight the myriad developmental and postnatal effects on osteochondrogenesis that emanate directly from mutant ACVR1 and dysregulated bone morphogenetic protein (BMP) signaling in FOP.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Alexandra Stanley
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - O Will Towler
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Genetics, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Sang KHLQ, Strahs A, Marino R, Kaplan FS. A natural history study of fibrodysplasia ossificans progressiva (FOP): 12-month outcome results. Bone Rep 2020. [DOI: 10.1016/j.bonr.2020.100607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Strahs A, Grogan DR, Marino R, Kaplan FS. Measuring outcomes in ultra-rare bone diseases: Methodology of the palovarotene fibrodysplasia ossificans progressiva clinical development programme. Bone Rep 2020. [DOI: 10.1016/j.bonr.2020.100609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kou S, De Cunto C, Baujat G, Wentworth KL, Grogan DR, Brown MA, Di Rocco M, Keen R, Al Mukaddam M, le Quan Sang KH, Masharani U, Kaplan FS, Pignolo RJ, Hsiao EC. Patients with ACVR1 R206H mutations have an increased prevalence of cardiac conduction abnormalities on electrocardiogram in a natural history study of Fibrodysplasia Ossificans Progressiva. Orphanet J Rare Dis 2020; 15:193. [PMID: 32727600 PMCID: PMC7389682 DOI: 10.1186/s13023-020-01465-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background Genetic contributors to cardiac arrhythmias are often found in cardiovascular conduction pathways and ion channel proteins. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare disease of massive heterotopic ossification caused by a highly recurrent R206H mutation in ACVR1/ALK2. This mutation causes abnormal activation of the bone morphogenetic protein (BMP) pathway in response to Activin A. Prior studies suggested increased risks of cardiopulmonary complications in FOP. We examined participants in a Natural History Study (NHS) of FOP (ClinicalTrials.gov #NCT02322255) to better understand their cardiovascular status. Methods The NHS is an ongoing 3 year international multi-center longitudinal study of 114 patients (ages 4–56 years) with genetically confirmed ACVR1/ALK2R206H FOP. Patients were clinically assessed at baseline and 12 months. Electrocardiograms (ECGs) were reviewed in a central ECG laboratory. Conduction abnormalities were compared against clinical data collected in the NHS, and echocardiograms collected from NHS and non-NHS patients. Results Conduction abnormalities were present in 45.3% of baseline ECGs, with the majority of abnormalities classified as nonspecific intraventricular conduction delay (37.7%). More specifically, 22.2% of patients > 18 years old had conduction abnormalities, which was significantly higher than a prior published study of a healthy population (5.9%; n = 3978) (p < 0.00001). Patients with FOP < 18 years old also had a high prevalence of conduction abnormalities (62.3%). The 12-month follow up data was similar to baseline results. Conduction abnormalities did not correlate with chest wall deformities, scoliosis, pulmonary function test results, or increased Cumulative Analog Joint Involvement Scale scores. Echocardiograms from 22 patients with FOP revealed 8 with structural cardiac abnormalities, only 1 of which correlated with a conduction abnormality. Conclusions We found that patients with FOP may have subclinical conduction abnormalities manifesting on ECG, independent of heterotopic ossification. Although clinically significant heart disease is not typically associated with FOP, and the clinical implications for cardiovascular risk remain unclear, knowledge about ECG and echocardiogram changes is important for clinical care and research trials in patients with FOP. Further studies on how ACVR1/ALK2R206H affects cardiac health will help elucidate the underlying mechanism.
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Affiliation(s)
- Samuel Kou
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Geneviève Baujat
- Department de Genetique Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Kelly L Wentworth
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA.,Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Donna R Grogan
- Clementia Pharmaceuticals, an Ipsen Company, Montreal, Canada
| | - Matthew A Brown
- Guy's & St. Thomas' NHS Foundation Trust and King's College London NIHR Biomedical Research Centre, London, England
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh le Quan Sang
- Department de Genetique Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Umesh Masharani
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA
| | - Frederick S Kaplan
- Department of Medicine, Perelman School Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA. .,The Institute for Human Genetics and the Program in Craniofacial Biology, University of California, San Francisco, CA, USA.
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Kou S, DeCunto C, Baujat G, Wentworth KL, Grogan D, Brown MA, Rocco MD, Keen R, Mukaddam MA, Kaplan FS, Pignolo RJ, Hsiao EC. SUN-344 Patients with Fibrodysplasia Ossificans Progressiva Have an Increased Prevalence of Cardiac Conduction Abnormalities. J Endocr Soc 2020. [PMCID: PMC7209090 DOI: 10.1210/jendso/bvaa046.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Genetic contributors to cardiac arrhythmias often found in cardiovascular conduction pathway and channel proteins. However, genes outside of these categories can contribute to cardiovascular conduction abnormalities. Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease characterized by large volumes heterotopic ossification caused by a highly recurrent R206H mutation in the ACVR1/Alk2 gene. This mutation produces an abnormal activation of the bone morphogenetic pathway (BMP) pathway in response to Activin A. Prior studies suggested an increased risk of cardiopulmonary complications in FOP1. We examined patients in a Natural History Study (NHS) of FOP (NCT02322255) to better understand their cardiovascular risk. Methods The NHS is an ongoing 3 year international multi-center cross-sectional study of 114 patients with FOP (ages 4–56 years) genetically verified to have the AVCR1 R206H mutation. Patients at baseline and 12 months were assessed by electrocardiogram (ECG). Abnormal lead placements were excluded. ECG readings were assessed in a central ECG laboratory. Results At baseline, 45.3% (48/106) of ECGs showed conduction abnormalities. The majority of these abnormalities were classified as nonspecific intraventricular conduction delay (37.7% of all ECGs). For patients > 18 years old, 22.7% (10/44) had conduction abnormalities, which was significantly higher than previously reported in the healthy population (5.9%; n=3978)2 (proportional t-test; p<0.00001). FOP patients < 18 years of age also had an extremely high prevalence of conduction abnormalities (60.3%, 38/61). The NHS 12-month follow up data showed similar prevalence. The high frequency of conduction abnormalities did not correlate with the presence of chest wall deformities or scoliosis, abnormal pulmonary function test results, increased cumulative analog joint involvement scale (CAJIS) scores, or abnormal echocardiograms. Conclusions Our results show that some patients with FOP may have subclinical conduction abnormalities. These ECG changes appear to be independent of chest wall deformities or scoliosis, although ectopic bone may make ECG measurement in FOP patients challenging. Though there is no reported association of FOP with clinically significant heart block to date and clinical implications for cardiovascular risk remain unclear, knowledge about these ECG changes may be important for planning clinical care and clinical trials of investigational agents in patients with FOP. Further studies of how the AVCR1 R206H activating mutation and BMP signaling changes cardiac conduction are needed to better understand the mechanistic link. References (1)Hingorani et al. Indian J Med Res. 2012; 135:322–330 (2)Kussmaul et al. Clinical Orthopaedic Related Research. 1998; 346:104–109
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Affiliation(s)
- Samuel Kou
- University of California, San Francisco, San Francisco, CA, USA
| | - Carmen DeCunto
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Geneviève Baujat
- Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | | | | | - Matthew A Brown
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London NIHR Biomedical Research Centre, London, United Kingdom
| | | | - Richard Keen
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom
| | | | | | | | - Edward Chiaming Hsiao
- University of California (San Francisco) Endocrine Fellowship Program, San Francisco, CA, USA
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Mukaddam MA, Pignolo RJ, Baujat G, Brown MA, De Cunto C, Rocco MD, Hsiao EC, Keen RW, Sang KHLQ, Strahs A, Marino R, Kaplan FS. OR29-05 A Natural History Study of Fibrodysplasia Ossificans Progressiva (FOP): 12-Month Outcomes. J Endocr Soc 2020. [PMCID: PMC7208621 DOI: 10.1210/jendso/bvaa046.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: FOP is an ultra-rare, severely disabling genetic disorder characterized by episodic flare-ups and heterotopic ossification (HO) leading to restricted movement, physical disability, and early death. FOP may initially be misdiagnosed in ~90% of individuals leading to unnecessary and often harmful interventions. Patients with FOP are diagnosed and managed by multiple specialties, including endocrinologists. Data from an ongoing, prospective, longitudinal, global, natural history study (NCT02322255) were used to investigate the progression of FOP, HO formation, and impact on physical functioning over time. We present results from the first 12 months of the 3-year study. Methods: Males and females with FOP and a documented ACVR1 R206H mutation participated. HO volume was assessed by low-dose whole body computed tomography (WBCT) scan, excluding the head. All imaging was interpreted at a blinded, central laboratory using pre-specified procedures. Functional outcomes were evaluated using the Cumulative Analogue Joint Involvement Scale (CAJIS; for each joint: score=0 represents <10% involvement, score=1 represents 10–90% involvement, and score=2 represents >90% ankylosed across 15 major joints; total score range 0 to 30 [higher scores indicate more severe mobility limitations]) and the FOP Physical Function Questionnaire (FOP-PFQ; percent total score). Changes from Baseline at Month 12 were evaluated for new HO volume, CAJIS, and FOP-PFQ. Results: Of 114 participants (pts) with Baseline data, 99 (4 to 56 years at enrollment; mean 17 years of age; 56% male) also had a Month 12 assessment. A total of 93 pts had evaluable WBCT scans at Baseline and Month 12 and were included in the HO analysis. In total, 40% (37/93) of pts had new HO over 12 months; the mean volume of new HO in these pts was 57,706 mm3 (SD=100,079 mm3; median=20,753 mm3; range: 522 to 438,826 mm3). Of the pts with new HO, 65% (24/37) reported at least one flare-up (mean rate of 2.3 flare-ups/year). Over 12 months, 60% (56/93) of pts did not have new HO; 43% (24/56) of them reported at least one flare-up (mean rate of 1.8 flare-ups/year). Mean changes from Baseline in CAJIS and FOP-PFQ were minimal: CAJIS: 0.6 (SD=2.4; median=1.0; n=99) and FOP-PFQ: 4.4% (SD=11.2; median=3.7%; n=90); and were similar across pts with or without new HO. Conclusions: In participants with FOP, although deterioration of physical function is expected over a patient’s lifetime, CAJIS and FOP-PFQ scores did not worsen significantly in the relative short-term of this study. However, HO volume, quantified by WBCT, increased over the course of 12 months. These results show that measuring HO may be a viable way to monitor changes in FOP over short periods of time.
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Affiliation(s)
- Mona Al Mukaddam
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Geneviève Baujat
- Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Matthew A Brown
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London NIHR Biomedical Research Centre, London, United Kingdom
| | | | - Maja Di Rocco
- Department of Pediatrics, Giannina Gaslini Institute, Genova, Italy
| | - Edward C Hsiao
- UCSF Metabolic Bone Clinic, the Institute of Human Genetics, and the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Richard W Keen
- Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | | | | | - Rose Marino
- Clementia Pharmaceuticals Inc., Newton, MA, USA
| | - Frederick S Kaplan
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Affiliation(s)
- Robert J. Pignolo
- Departments of Medicine, Physiology & Biomedical Engineering, and the Robert and Arlene Kogod Center on Aging, Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederick S. Kaplan
- Departments of Orthopaedic Surgery, Medicine, and the Center for Research in FOP & Related Disorders, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Towler OW, Shore EM, Kaplan FS. Skeletal malformations and developmental arthropathy in individuals who have fibrodysplasia ossificans progressiva. Bone 2020; 130:115116. [PMID: 31655222 DOI: 10.1016/j.bone.2019.115116] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE Fibrodysplasia ossificans progressiva (FOP) is primarily a disease of progressive heterotopic ossification (HO) leading to impaired mobility throughout life. An additional diagnostic feature is a characteristic malformation of the great toes. The culpable gene for FOP,ACVR1 (activin A receptor type 1) has a clear effect on the induction of extra-skeletal bone formation. However, this bone morphogenetic protein (BMP) pathway receptor is expressed widely throughout skeletal development and has a seminal role in axial and appendicular chondrogenesis, prompting suspicion of widespread bone and joint defects in those with ACVR1 mutations. MATERIALS AND METHODS We analyzed baseline whole body (minus skull) computed tomographic (CT) scans of 113 individuals with classic clinical features of FOP and the ACVR1 (R206H) mutation who were enrolled in a non-interventional natural history study ((NCT02322255)) for skeletal malformations, atypical morphology, intra-articular synovial osteochondromatosis, developmental arthropathy, and associated degenerative joint phenotypes. Individuals were evaluated in three age groups: 4-13; 14-25; and 25-56 years old, based on historical models of FOP disease progression. RESULTS We found widespread evidence of developmental arthropathy throughout the axial and appendicular skeleton in all age groups (61M, 52F; ages: 4-56 years). Asymmetric narrowing and subchondral sclerosis were present throughout the joints of the normotopic skeleton and osteophytes were common in the hips and knees of individuals who have FOP in all age groups. The costovertebral joints, intervertebral facet joints, and proximal tibio-fibular joints frequently showed partial or total intra-articular ankylosis, particularly after age 13. The hips of FOP subjects are frequently malformed and dysplastic. We also found evidence of degenerative joint phenotypes after age 13, particularly in the spine, sacro-iliac joints, and lower limbs. CONCLUSIONS The effects of ACVR1 mutation on the normotopic skeletons of individuals who have FOP extend beyond malformation of the great toes and include both morphological defects and developmental arthropathy. Associated degenerative joint disease occurring at multiple sites starts in adolescence and progresses throughout life. These phenotypes appear to be uncoupled from heterotopic bone formation, indicating a potential role for ACVR1 in the development and progression of degenerative joint disease. SIGNIFICANCE FOP is a disease of not only progressive heterotopic ossification, but also widespread and extensive developmental arthropathy and associated degenerative joint disease. These findings have relevance for understanding the natural history of FOP and for designing and evaluating clinical trials with emerging therapeutics.
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Affiliation(s)
- O Will Towler
- Departments of Orthopaedic Surgery, The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Departments of The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States
| | - Eileen M Shore
- Departments of Orthopaedic Surgery, The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Departments of Genetics, The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Departments of The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery, The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Departments of Medicine, The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States; Departments of The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at The University of Pennsylvania, 3450 Hamilton Walk, 309A Stemmler Hall, Philadelphia, PA 19104, United States.
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Gucev Z, Tasic V, Plaseska-Karanfilska D, Dimishkovska M, Laban N, Bozinovski Z, Kostovski M, Saveski A, Polenakovic M, Towler OW, Shore EM, Kaplan FS. Cover Image, Volume 179A, Number 7, July 2019. Am J Med Genet A 2019. [DOI: 10.1002/ajmg.a.61212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Zoran Gucev
- Medical Faculty - Skopje; University Ss Cyril and Methodius of Skopje; Skopje Republic of North Macedonia
| | - Velibor Tasic
- Medical Faculty - Skopje; University Ss Cyril and Methodius of Skopje; Skopje Republic of North Macedonia
| | - Dijana Plaseska-Karanfilska
- Research Centre for Genetic Engineering and Biotechnology “Georgi D. Efremov”, Macedonian Academy of Sciences and Arts; Skopje Republic of North Macedonia
| | - Marija Dimishkovska
- Research Centre for Genetic Engineering and Biotechnology “Georgi D. Efremov”, Macedonian Academy of Sciences and Arts; Skopje Republic of North Macedonia
| | - Nevenka Laban
- Medical Faculty - Skopje; University Ss Cyril and Methodius of Skopje; Skopje Republic of North Macedonia
| | - Zoran Bozinovski
- Medical Faculty - Skopje; University Ss Cyril and Methodius of Skopje; Skopje Republic of North Macedonia
| | - Marko Kostovski
- Medical Faculty - Skopje; University Ss Cyril and Methodius of Skopje; Skopje Republic of North Macedonia
| | - Alek Saveski
- Medical Faculty - Skopje; University Ss Cyril and Methodius of Skopje; Skopje Republic of North Macedonia
| | - Momir Polenakovic
- Research Centre for Genetic Engineering and Biotechnology “Georgi D. Efremov”, Macedonian Academy of Sciences and Arts; Skopje Republic of North Macedonia
| | - O. Will Towler
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders; Perelman School of Medicine, The University of Pennsylvania; Philadelphia Pennsylvania
| | - Eileen M. Shore
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders; Perelman School of Medicine, The University of Pennsylvania; Philadelphia Pennsylvania
- Department of Genetics, Perelman School of Medicine; The University of Pennsylvania; Philadelphia Pennsylvania
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders; Perelman School of Medicine, The University of Pennsylvania; Philadelphia Pennsylvania
- Department of Medicine; Perelman School of Medicine, The University of Pennsylvania; Philadelphia Pennsylvania
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Sang KHLQ, Wilson A, White B, Grogan DR, Kaplan FS. Correction to: Natural history of fibrodysplasia ossificans progressiva: cross-sectional analysis of annotated baseline phenotypes. Orphanet J Rare Dis 2019; 14:113. [PMID: 31122250 PMCID: PMC6532205 DOI: 10.1186/s13023-019-1096-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Geneviève Baujat
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation (IHBI), Translational Research Institute, Princess Alexandra Hospital, Queensland University of Technology (QUT), Queensland, Australia
| | - 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
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, The Institute of Human Genetics, and the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh Le Quan Sang
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Amy Wilson
- Clementia Pharmaceuticals Inc, Newton, 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.
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Sang KHLQ, Wilson A, White B, Grogan DR, Kaplan FS. Natural history of fibrodysplasia ossificans progressiva: cross-sectional analysis of annotated baseline phenotypes. Orphanet J Rare Dis 2019; 14:98. [PMID: 31053156 PMCID: PMC6499994 DOI: 10.1186/s13023-019-1068-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/17/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Fibrodysplasia Ossificans Progressiva (FOP; OMIM#135100) is an ultra-rare, severely disabling genetic disease characterized by congenital malformation of the great toes and progressive heterotopic ossification (HO) in muscles, tendons, ligaments, fascia, and aponeuroses often preceded by painful, recurrent soft tissue swelling (flare-ups). The formation of HO leads to progressive disability, severe functional limitations in joint mobility, and to a shortened life-span. In this prospective natural history study, we describe the baseline, cross-sectional disease phenotype of 114 individuals with FOP. METHODS All subjects underwent protocol-specified baseline assessments to determine their disease status. Cross-sectional analyses were performed using linear regression in which functional evaluations (Cumulative Analogue Joint Involvement Scale [CAJIS] and the FOP-Physical Function Questionnaire [FOP-PFQ]) and the burden of HO as measured by low-dose whole body CT (volume of HO and number of body regions with HO) were assessed. RESULTS Findings from 114 subjects (age range 4 to 56 years) were evaluated. While subject age was significantly (p < 0.0001) correlated with increased CAJIS (r = 0.66) and FOP-PFQ scores (r = 0.41), the estimated mean increases per year (based on cross-sectional average changes over time) were small (0.47 units and 1.2%, respectively). There was also a significant (p < 0.0001) correlation between baseline age and HO volume (r = 0.56), with an estimated mean increase of 25,574 mm3/year. There were significant (p < 0.0001) correlations between the objective assessment of HO volume and clinical assessments of CAJIS (r = 0.57) and FOP-PFQ (r = 0.52). CONCLUSIONS Based on the cross-sectional analysis of the baseline data, functional and physical disability as assessed by CAJIS and the FOP-PFQ increased over time. Although longitudinal data are not yet available, the cross-sectional analyses suggest that CAJIS and FOP-PFQ are not sensitive to detect substantial progression over a 1- to 2-year period. Future evaluation of longitudinal data will test this hypothesis. The statistically significant correlations between HO volume and the functional endpoints, and the estimated average annual increase in total HO volume, suggest that the formation of new HO will be measurable over the relative short-term course of a clinical trial, and represents an endpoint that is clinically meaningful to patients. TRIAL REGISTRATION This study ( NCT02322255 ) was first posted on 23 December, 2014.
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Affiliation(s)
| | - Geneviève Baujat
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation (IHBI), Translational Research Institute, Princess Alexandra Hospital, Queensland University of Technology (QUT), Queensland, Australia
| | - 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
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Institute of Human Genetics, and the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh Le Quan Sang
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Amy Wilson
- Clementia Pharmaceuticals Inc, Newton, 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.
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Gucev Z, Tasic V, Plaseska-Karanfilska D, Dimishkovska M, Laban N, Bozinovski Z, Kostovski M, Saveski A, Polenakovic M, Towler OW, Shore EM, Kaplan FS. Severe digital malformations in a rare variant of fibrodysplasia ossificans progressiva. Am J Med Genet A 2019; 179:1310-1314. [PMID: 31012264 DOI: 10.1002/ajmg.a.61153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/23/2019] [Accepted: 04/01/2019] [Indexed: 11/06/2022]
Abstract
A 16-year-old girl with a history of nontraumatic swelling of both forearms, osteochondromas of the knees, heterotopic ossification of the neck and back, severe malformations of all digits with hypoplastic or absent nails, alopecia partialis of the scalp, and moderate cognitive impairment was seen for diagnostic evaluation. Whole exome sequencing identified an activating mutation of ACVR1 (c.983G > A; p.Gly328Glu) which confirmed a suspected FOP variant. The delayed diagnosis of an FOP variant in this patient could have been avoided if the significance of severe digital malformations had been recognized, especially in the setting of progressive heterotopic ossification.
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Affiliation(s)
- Zoran Gucev
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Velibor Tasic
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Dijana Plaseska-Karanfilska
- Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov", Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - Marija Dimishkovska
- Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov", Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - Nevenka Laban
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Zoran Bozinovski
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Marko Kostovski
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Alek Saveski
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Momir Polenakovic
- Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov", Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - O Will Towler
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eileen M Shore
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Genetics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Segmental progeroid syndromes are commonly represented by genetic conditions which recapitulate aspects of physiological aging by similar, disparate, or unknown mechanisms. Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease caused by mutations in the gene for ACVR1/ALK2 encoding Activin A receptor type I/Activin-like kinase 2, a bone morphogenetic protein (BMP) type I receptor, and results in the formation of extra-skeletal ossification and a constellation of others features, many of which resemble accelerated aging. The median estimated lifespan of individuals with FOP is approximately 56 years of age. Characteristics of precocious aging in FOP include both those that are related to dysregulated BMP signaling as well as those secondary to early immobilization. Progeroid features that may primarily be associated with mutations in ACVR1 include osteoarthritis, hearing loss, alopecia, subcutaneous lipodystrophy, myelination defects, heightened inflammation, menstrual abnormalities, and perhaps nephrolithiasis. Progeroid features that may secondarily be related to immobilization from progressive heterotopic ossification include decreased vital capacity, osteoporosis, fractures, sarcopenia, and predisposition to respiratory infections. Some manifestations of precocious aging may be attributed to both primary and secondary effects of FOP. At the level of lesion formation in FOP, soft tissue injury resulting in hypoxia, cell damage, and inflammation may lead to the accumulation of senescent cells as in aged tissue. Production of Activin A, platelet-derived growth factor, metalloproteinases, interleukin 6, and other inflammatory cytokines as part of the senescence-associated secretory phenotype could conceivably mediate the initial signaling cascade that results in the intense fibroproliferative response as well as the tissue-resident stem cell reprogramming leading up to ectopic endochondral bone formation. Consideration of FOP as a segmental progeroid syndrome offers a unique perspective into potential mechanisms of normal aging and may also provide insight for identification of new targets for therapeutic interventions in FOP.
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Affiliation(s)
- Robert J. Pignolo
- Department of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Department of Physiology-Biomedical Engineering, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Kogod Center on Aging, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- *Correspondence: Robert J. Pignolo
| | - Haitao Wang
- Department of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Department of Physiology-Biomedical Engineering, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Kogod Center on Aging, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Center for Research in FOP and Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Wang H, Shore EM, Pignolo RJ, Kaplan FS. Activin A amplifies dysregulated BMP signaling and induces chondro-osseous differentiation of primary connective tissue progenitor cells in patients with fibrodysplasia ossificans progressiva (FOP). Bone 2018; 109:218-224. [PMID: 29170109 DOI: 10.1016/j.bone.2017.11.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP), is caused by mutations in the type I BMP receptor ACVR1 that lead to increased activation of the BMP-pSmad1/5/8 signaling pathway. Recent findings suggest that Activin A (Act A) promiscuously stimulates the bone morphogenetic protein (BMP) signaling pathway in vitro and mediates heterotopic ossification (HO) in mouse models of FOP, but primary data from FOP patient cells are lacking. OBJECTIVE To examine BMP-pSmad1/5/8 pathway signaling and chondro-osseous differentiation in response to endogenous and exogenous Act A in primary connective tissue progenitor cells [CTPCs; also known as stem cells from human exfoliated deciduous teeth (SHED) cells] from patients with FOP. These cells express the common FOP mutation, ACVR1 (R206H). RESULTS We found that Act A amplifies dysregulated BMP pathway signaling in human FOP primary CTPCs cells through the Smad1/5/8 pathway and induces chondro-osseous differentiation. Amplification of BMP-pSmad1/5/8 signaling was inhibited by Follistatin and by a neutralizing antibody to Activin A. The increased basal pSmad1/5/8 activity, as well as the hypoxia-induced stimulation of FOP CTPCs cells, were BMP4 and Act A independent. Importantly, either BMP4 or Act A stimulated pSmad1/5/8 pathway signaling but BMP4 signaling was not dependent on Activin A and vice versa. Circulating plasma levels of Act A or BMP4 are similar in controls compared to FOP patients, and suggest the potential for an autocrine or paracrine route for pathological signaling. CONCLUSIONS The mutated FOP receptor [ACVR1 (R206H)] is hypersensitive to BMP4 and uniquely sensitive (compared to the wild type receptor) to Act A. Both canonical and non-canonical ligands have a synergistic effect on BMP-pSmad1/5/8 signaling in FOP CTPCs and may cooperate to alter the threshold for HO in FOP. Our findings in primary human FOP CTPCs have important implications for the design of clinical trials to inhibit dysregulated BMP pathway signaling in humans who have FOP.
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Affiliation(s)
- Haitao Wang
- Department of Physiology and Biomedical Engineering, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Eileen M Shore
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
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Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) causes progressive disability due to heterotopic ossification from episodic flare-ups. Using data from 500 FOP patients (representing 63% of all known patients world-wide), age- and joint-specific risks of new joint involvement were estimated using parametric and nonparametric statistical methods. RESULTS Compared to data from a 1994 survey of 44 individuals with FOP, our current estimates of age- and joint-specific risks of new joint involvement are more accurate (narrower confidence limits), based on a wider range of ages, and have less bias due to its greater comprehensiveness (captures over three-fifths of the known FOP patients worldwide). For the neck, chest, abdomen, and upper back, the estimated hazard decreases over time. For the jaw, lower back, shoulder, elbow, wrist, fingers, hip, knee, ankle, and foot, the estimated hazard increases initially then either plateaus or decreases. At any given time and for any anatomic site, the data indicate which joints are at risk. CONCLUSIONS This study of approximately 63% of the world's known population of FOP patients provides a refined estimate of risk for new involvement at any joint at any age, as well as the proportion of patients with uninvolved joints at any age. Importantly, these joint-specific survival curves can be used to facilitate clinical trial design and to determine if potential treatments can modify the predicted trajectory of progressive joint dysfunction.
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Affiliation(s)
- Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Blythe P Durbin-Johnson
- Department of Public Health Sciences, School of Medicine, Department of Biomedical Engineering, University of California, Davis, CA, United States.
| | - David M Rocke
- Department of Public Health Sciences, School of Medicine, Department of Biomedical Engineering, University of California, Davis, CA, United States.
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
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Kaplan FS, Andolina JR, Adamson PC, Teachey DT, Finklestein JZ, Ebb DH, Whitehead B, Jacobs B, Siegel DM, Keen R, Hsiao E, Pignolo RJ. Early clinical observations on the use of imatinib mesylate in FOP: A report of seven cases. Bone 2018; 109:276-280. [PMID: 28736245 DOI: 10.1016/j.bone.2017.07.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/15/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultrarare genetic disorder of progressive, disabling heterotopic ossification (HO) for which there is presently no definitive treatment. Research studies have identified multiple potential targets for therapy in FOP, and novel drug candidates are being developed for testing in clinical trials. A complementary approach seeks to identify approved drugs that could be re-purposed for off-label use against defined targets in FOP. One such drug is imatinib mesylate, a tyrosine kinase inhibitor originally developed for use in patients with chronic myeloid leukemia (CML). Imatinib has the desirable effect of attacking multiple targets involved in the early hypoxic and inflammatory stages of FOP flare-ups, including HIF1-α, PDGFRα, c-KIT, and multiple MAP kinases. RESULTS Based on compelling biologic rationale, strong preclinical data, and a favorable safety profile, imatinib has been prescribed on an off-label basis in a non-trial setting in seven children with continuous FOP flare-ups, predominantly in the axial regions, and which were not responsive to standard-of-care regimens. Anecdotal reports in these seven isolated cases document that the medication was well-tolerated with a ubiquitous reported decrease in the intensity of flare-ups in the six children who took the medication. CONCLUSIONS These early clinical observations support the implementation of clinical trials in children with uncontrolled FOP flare-ups to determine if imatinib may ameliorate symptoms or alter the natural history of this debilitating and life-threatening disease.
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Affiliation(s)
- Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Jeffrey R Andolina
- Department of Pediatrics, Division of Hematology-Oncology, University of Rochester School of Medicine, Rochester, NY 14642, United States.
| | - Peter C Adamson
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States.
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States.
| | - Jerry Z Finklestein
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Jonathan Jacques Children's Cancer Center, Long Beach, CA 90806, United States
| | - David H Ebb
- Department of Pediatrics, Division of Hematology-Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, United States.
| | - Benjamin Whitehead
- Lady Cilento Children's Hospital, Rheumatology Department, South Brisbane 4101, Australia.
| | - Benjamin Jacobs
- Department of Paediatrics, the Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, United Kingdom.
| | - David M Siegel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY 14642, United States.
| | - Richard Keen
- Department of Rheumatology, the Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, United Kingdom.
| | - Edward Hsiao
- Division of Endocrinology and Metabolism, Department of Medicine, Institute for Human Genetics, University of California-San Francisco School of Medicine, San Francisco, CA 94143, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, United States.
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Kaplan FS, Pignolo RJ, Shore EM. Heterotopic Ossification: The Keys to the Kingdom. Bone 2018; 109:1-2. [PMID: 29567209 DOI: 10.1016/j.bone.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104; Department of The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104.
| | | | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104; Department of Genetics, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104; Department of The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104.
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Al Mukaddam M, Rajapakse CS, Pignolo RJ, Kaplan FS, Smith SE. Imaging assessment of fibrodysplasia ossificans progressiva: Qualitative, quantitative and questionable. Bone 2018; 109:147-152. [PMID: 28822792 DOI: 10.1016/j.bone.2017.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 10/19/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare autosomal dominant genetic disorder of heterotopic ossification (HO) characterized by skeletal anomalies and episodic soft tissue swelling (flare-ups) that can transform into heterotopic bone. The progressive development of heterotopic bone and progressive arthropathy leads to significant limitation of mobility. This paper will review various imaging modalities used in evaluating episodic soft tissue swelling (flare-ups), heterotopic bone and skeletal anomalies. Different imaging modalities are required at different stages of the disease. Ultrasound and MRI can be useful for evaluating edema in early stages of a flare-up; MRI being superior to ultrasonography. Plain radiographs and computed tomography (CT) can evaluate heterotopic bone in later stages of HO, but CT scan is better at evaluating presence and the volume of heterotopic bone. Functional imaging demonstrates increased activity at sites of flare-ups, their utility in determining disease progression need to be further evaluated. Cost, radiation exposure, availability of various imaging modalities and the ability of FOP patients to fit in the scanner are all considerations when requesting radiographic tests in a patient with FOP. Future studies are required to determine if early radiographic findings can determine disease progression and response to treatment in this disorder.
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Affiliation(s)
- Mona Al Mukaddam
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Chamith S Rajapakse
- Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Orthopedics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Robert J Pignolo
- Department of Medicine, The Mayo Clinic, Rochester, MN 55905, United States
| | - Frederick S Kaplan
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Orthopedics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Stacy E Smith
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States.
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Lindborg CM, Brennan TA, Wang H, Kaplan FS, Pignolo RJ. Cartilage-derived retinoic acid-sensitive protein (CD-RAP): A stage-specific biomarker of heterotopic endochondral ossification (HEO) in fibrodysplasia ossificans progressiva (FOP). Bone 2018; 109:153-157. [PMID: 28963080 PMCID: PMC7680581 DOI: 10.1016/j.bone.2017.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Genesis of a cartilaginous scaffold is an obligate precursor to bone formation in heterotopic endochondral ossification (HEO). We tested the hypothesis that cartilage-derived retinoic acid-sensitive protein (CD-RAP) can serve as a plasma biomarker for the pre-osseous cartilaginous stage of HEO. Palovarotene, a retinoic acid receptor-gamma (RARγ) agonist, has been proposed as a possible treatment for fibrodysplasia ossificans progressiva (FOP) and is a potent inhibitor of HEO in mouse models. Current drug development for FOP mandates the identification of stage-specific biomarkers to facilitate the evaluation of clinical trial endpoints. RESULTS Here we show in an injury-induced, constitutively-active transgenic mouse model of FOP that CD-RAP levels peaked between day-7 and day-10 during the zenith of histologically-identified chondrogenesis, preceded radiographically apparent HEO, and were diminished by palovarotene. Cross-sectional analysis of CD-RAP levels in plasma samples from FOP patients demonstrated a statistically non-significant trend toward higher levels in the recent flare-up period (three weeks to three months within onset of symptoms). However, in a longitudinal subgroup analysis of patients followed for at least six months after resolution of flare-up symptoms, there was a statistically significant decrease of CD-RAP when compared to levels in the same patients at the time of active or recent exacerbations. CONCLUSIONS These data support the further exploration of CD-RAP as a stage-specific biomarker of HEO in FOP.
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Affiliation(s)
- Carter M Lindborg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Tracy A Brennan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Haitao Wang
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Frederick S Kaplan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
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