Fanconi Anemia 101. Blanche P Alter, MD, MPH, FAAP Clinical Genetics Branch Division of Cancer Epidemiology and Genetics Bethesda, MD

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1 Fanconi Anemia 101 Blanche P Alter, MD, MPH, FAAP Clinical Genetics Branch Division of Cancer Epidemiology and Genetics Bethesda, MD FA Camp, August 10, 2012

2 When You Hear., Think., Or. Horses Zebras Unicorns

3 Some Things are Clear; Some are Not

4 Koalas The opposite of FA!

5 Open Minds I ve never seen this before. should be I ve never recognized this before.

6 Questions 1. How many are new to FA Camp? 2. How many have been here before? 3. How many have FA and are 18 years of age or older? 4. How many think that the diagnosis of FA was initially missed by one or more physicians?

7 History: Guido Fanconi Fanconi Anemia (Fanconi pancytopenia syndrome): 1927, 3 brothers with pancytopenia and physical abnormalities, perniziosiforme Fanconi Syndrome (renal Fanconi syndrome): 1936, proteinuria, glucosuria, phosphaturia, aminoaciduria, citraturia, and proximal renal tubular acidosis

8 FA Literature, Case Reports ~2200 Male:female = 1.3:1 Abnormal physical findings 66% Died 684 (32%) Alive, median age 11 yrs (0-56) Died, median age 11 yrs (0-51) Biased by under-reporting, over-reporting, and missing data

9 Fanconi Anemia: Children Photos with permission

10 Fanconi Anemia: Adults Absent radius, 0 Aplastic anemia, 5?, 6 Aplastic anemia, 16 Cancer, 30 BMT donor, 50s

11 0 Frequency FA Literature: Age at Diagnosis yr Age, Years

12 FA Literature: Physical Findings, 66% Gonads female Brain/pituitary Legs, hips, feet Gastrointestinal tract Cardiopulmonary Radii Ears, deaf Developmental delay Skin café au lait Eyes Renal Head, face Gonads male Skin hyperpigmented Thumbs Short Any PE M:F 1.3:1 0% 10% 20% 30% 40% 50% 60% 70%

13 Characteristics of Persons with FA Physical findings described in the literature may not be found in all persons with FA 11% had short stature and skin findings only At least 25% of those reported had no physical findings Some persons without physical findings may be diagnosed at a later age

14 FA: Laboratory Findings Low blood counts (pancytopenia) Large red cells (macrocytosis) Increased fetal hemoglobin (Hb F) Chromosome breakage in lymphocytes or fibroblasts cultured with a DNA crosslinker, e.g. diepoxybutane (DEB) or mitomycin C (MMC)

15 FA: Carrier Frequency 1:300 in New York State in 1971 (Swift, 1971) ~1:100 in Ashkenazi Jews, Afrikaners, Spanish Gypsies, black sub-saharan Africans 1:181 in US in :93 in Israel in 2008 (Rosenberg et al, 2010)

16 FA: Hands Right Left

17 Hb g/dl MCV, fl WBC/ul Plat/ul FA: CBCs - Hand Surgery Hb and MCV WBC and Platelets Age, yrs Age, yrs 0 Hb, g/dl MCV, fl WBC/ul Plat/ul Alter, J Hand Surg, 1992

18 FA: Surgery Recommendations to surgeons and anesthesiologists: Hb, platelets MCV - increased early in marrow failure Trends may precede abnormal values

19 Fanconi Anemia: Definition Autosomal recessive 1 X-linked recessive gene Physical findings Aplastic anemia Leukemia Solid tumors Chromosome instability DNA repair defect >15 genes

20 FA Inheritance Persons with FA: Unaffected parents carry one FA gene and one normal gene (carriers) Affected offspring get one FA gene from each parent Children of persons with FA: Each child will have one FA gene (carriers)

21 Autosomal Recessive Inheritance Affected Carriers Normal

22 Autosomal Recessive Inheritance Child of affected and unaffected

23 Disease-Associated Mutations A mutation is a change in the normal base pair sequence Commonly used to define DNA sequence changes that alter protein function ASCO modified 2/02

24 Thirteen Fanconi Anemia Subtypes 15 FA Genes (?) O P Data from Leiden Open Variation Database,

25 FA: Complementation Groups/Genes Group Locus cdna Exons AA % A 16q ~70 B Xp Rare C 9q ~10 D1/BRCA2* 13q Rare D2 3p Rare E 6p ~5 F 11p Rare G/XRCC9 9p ~10 I/KIAA q Rare J/BACH1/BRIP1* 17q Rare L/PHF9/POG 2p Rare M/Hef 14q Rare N/PALB2* 16p Rare O/RAD51C* 17q Rare P/SLX4* 16p Rare *Breast cancer genes in carriers

26 FA/BRCA DNA Repair Pathway Courtesy of Akiko Shimamura, 2012

27 Who Should be Tested for FA? Characteristic birth defects (eg thumbs, kidneys, poor growth, etc) Aplastic Anemia (AA) Myelodysplastic Syndrome (MDS) Acute Myeloid Leukemia (AML) Decreased fertility Early characteristic cancer Siblings of persons with FA

28 What are the FA Tests? Chromosome breakage, DEB or MMC D2 ubiquitination (Western blot) BRCA2 (Western blot) Complementation with cell lines Complementation with retroviruses Sequencing of candidate genes (eg FANCC IVS4+4 A->T) Sequencing of all cloned genes Blood lymphocytes, skin fibroblasts

29 Chromosome Breakage

30 FA: D2 Ubiquitination Shimamura et al, Blood, 2002 Green and Kupfer, HemOnc Clin NA, 2009

31 Complementation Analysis, Cloned FANC Genes FA cells are sensitive to DEB or MMC Introduce specific cloned FA genes Cells no longer sensitive Normal gene complemented patient cells, defining the complementation group Cells still sensitive Normal gene not identified for patient cells

32 cells alive [%] Retrovirus-mediated Correction of FA Cells Retrovirus-mediated Correction of TA 0252's T-cells analyzed by flow cytometry after five days of MMC-Incubation 100 FANCA S11EG 80 SFA S11FCIEG 60 S11FEIEG2 S11FFIEG 40 S11FG c (MMC) [nm]

33 Blood Production (Hematopoiesis) Myeloid Stem Cell Pluripotent Stem Cell Lymphoid Stem Cell T B Red Cells Platelets Lymphocytes

34 Bone Marrow Biopsy Normal Aplastic

35 Proof of Mosaicism in FA Peripheral blood lymphocyte chromosome breakage test normal Skin fibroblast chromosome breakage test abnormal

36 Mosaicism from Recombination A a A a A a a A a A a A

37 Gastroenterology Anatomical Esophageal atresia, tracheoesophageal fistula, duodenal atresia, imperforate anus GI Symptoms Reflux, gastric emptying delay, poor appetite Liver disease Androgens: abnormal liver function, peliosis, adenomas, hepatomas, Transfusions: iron overload Nutrition Enteral supplements via NG or NJ tubes or gastrostomies

38 FA Literature, Endocrine % Any Osteopenia/porosis, % of adults Puberty abnormal 37 Abnormal lipids Short +/- GHD Glucose/insulin Hypothyroid Obese Metabolic syndrome Midline brain

39 Complications Aplastic Anemia Acute Leukemia Myelodysplastic Syndrome Solid Tumors Liver Tumors

40 Definitions Aplastic Anemia (AA) Pancytopenia Hypocellular bone marrow Acute Leukemia (AL) Malignant proliferation of immature cells Myelodysplastic Syndrome (MDS) Cytopenias with hypercellular bone marrow

41 Aplastic Anemia: Signs and Symptoms Thrombocytopenia bruises, petechiae Anemia fatigue, lassitude, dyspnea Neutropenia infections

42 FA: When to Treat Bone Marrow Cytopenias Hb <8 g/dl or symptoms Platelets <30,000/mm 3 WBC <500/mm 3 Leukemia Blasts in blood >20% blasts in marrow MDS Morphologic + cytopenias Not for clone alone

43 FA: Treatment for Bone Marrow Transplant Androgen Hematopoietic growth factors Gene therapy?

44 FA: Treatment with Transplant Bone marrow, cord blood, or peripheral blood stem cells HLA-related donor when meet any treatment criteria Alternate donor (mismatched unrelated [MUD], partial match family member) Leukemia or clinical MDS (not clone alone) Refractory aplastic anemia

45 FA: Medical Treatment Oxymetholone 2-5 mg/kg/day oral Danazol ~ mg/day oral Folic acid 1 mg/day oral

46 FA: Treatment with G-CSF 5 mg/kg/day subcutaneous Decrease dose and/or give on alternate days Keep absolute neutrophil count >1000/mm 3

47 FA: Supportive Care RBCs - for Hb <8 g/dl or symptoms Platelets - for platelets <10,000/mm 3 or symptoms Blood products no family member donors Leukopoor, possibly irradiated Antibiotics as needed for infections

48 FA Literature: Cancer Types % 3.2% 2.1% 2.1% 0.5% 84.0% AML 158 AL 15 ALL 6 CMML 4 AML P BMT 4 ALL P BMT 1 2.4% 2.1%1.4% 1.0% HNSCC 70 HNSCC P BMT % BRAIN % LIVER CARCINOMA % GYN, VULVA ETC 22 LIVER ADENOMA 20 RENAL, WILMS % ESOPH 17 NEUROBLASTOMA 8 BREAST 7 CERVIX 6 LUNG 4 7.0% STOMACH 3 LYMPHOMA % DERMATOFIBROMA 2 7.7% RETINOBLASTOMA 1 OSTEOSARCOMA 1 BLADDER 1 9.1% HEPATOBLASTOMA 1 9.8% COLON leukemias and 286 solid tumors in 413/2190 patients; 47 had 2-4 cancers.

49 FA Risk of Adverse Events Annual Risk ST Cumulative Incidence BMF BMF AML ST AML Alter et al, BJH, 2010

50 Log Observed/Expected Relative Risk of Cancer in FA All Solid HNSCC Vulvar AML MDS Data from North American Survey, Germany, Israel, and NCI

51 FA: Adult Females Late onset of menses (14-16) Heavy periods if platelets low Early onset of menopause (30s) Decreased fertility Increased need for Caesarean sections Worsening bone marrow function during pregnancy Osteoporosis Cancer AML HNSCC Vulva, vagina, cervix HPV Vaccine

52 FA: Adult Males Short stature Infertility Endocrine problems: cholesterol, thyroid, growth hormone, metabolic syndrome, small pituitary, osteopenia Cancer AML HNSCC HPV vaccine

53 FA Surveillance Every 4-6 months (or more as needed): CBC Annual: BM aspirate/biopsy/chromosomes Liver enzymes, chemistries, lipids, thyroid Liver ultrasound Dental Head and neck with laryngoscopy Gyn exam Skin exam Consider esophageal endoscopy? HPV vaccine

54 Probability FA Survival before and after 2000 Overall Survival p<0.001 ~80% survival >age Age in Years

55 Field Trip Even the car rental companies want to be helpful for FA research

56 Clinical Genetics Branch: Neelam Giri, Sharon Savage Westat: Lisa Leathwood, Maureen Risch, Ann Carr