Dyskeratosis Congenita 101

Sharon A. Savage, M.D. Chief, Clinical Genetics Branch Clinical Director, Division of Epidemiology & Genetics

Camp Sunshine September 2018 2012

2016 Dyskeratosis Congenita – early descriptions

Year Author(s) Reference

Atrophia Cutis Reticularis cum Pigmentatione, Dystrophia 1906 Zinsser, F Unguium et oris, Ikonogr Derm (Kioto), p 219

A Unique Case of Reticular Pigmentation of the Skin with 1910 Engman, MF, Sr Atrophy, Society Transactions, Arch Derm Syph 13:685

Cole, HN, Dyskeratosis Congenita with Pigmentation, Dystrophia 1930 Rauschkolb JE, Unguis, and Leukokeratosis Oris, Arch Derm Syph 21:71 and Toomey J Archives of Dermatology Vol 88, Sept. 1963 People with biology disorders may face multiple medical problems and always

Remember: Ø Everyone is different Ø These problems don’t happen to everyone Ø Things change with age Ø We learn more everyday Diagnostic Triad 1. Dysplastic Nails Diagnostic Triad 2. Skin pigmentation Diagnostic Triad 3. Oral leukoplakia Hematopoietic (blood) system

Bone marrow failure Failure to produce enough blood cells

Myelodysplastic syndrome Abnormal looking blood cells associated with low numbers and leukemia risk

Leukemia Cancer of the blood forming cells Respiratory system Head and neck squamous cell cancer

Pulmonary fibrosis

Pulmonary arterio- venous malformations (AVMs) Abnormal blood vessel formation in lungs Gastrointestinal (GI) system

Esophageal stenosis Liver disease Narrowing of the esophagus Fibrosis and/or abnormal blood vessel connections between liver, spleen, and/or lungs Bleeding in stomach or intestines Poor absorption of food malabsorption

Ano-genital cancer Genitourinary system

Narrowing of the urethra Urethral stenosis Small head Nervous system microcephaly

Developmental delay Small cerebellum Balance problems Psychiatric illnesses

Stay tuned for more information in Sonia Bhala’s presentation Skeletal system

Avascular necrosis of Low density shoulders or hips Osteopenia or osteoporosis

Fractures Eye-related complications

Abnormal eyelash growth Tear duct narrowing

Abnormal blood vessels in retina

Tsilou et al, Ophthalmology 2010;117(3):615-22 What’s in a name?

• Zinsser – Cole – Engman syndrome • Dyskeratosis Congenita • Hoyeraal Hreidarsson syndrome • Telomere Biology Disorder • Coats plus • Aplastic • Familial pulmonary fibrosis • Familial liver fibrosis How are these disorders connected?

Traditional DC diagnosis: Diagnostic Triad or 1 of the triad, + BMF + 2 other findings, Vulliamy et al, Blood, 2006, 107(7):2680-5 A Classic DC Family

Dysplastic nails at 15 BMF at 17 Died at 32 of BMF

Dysplastic nails, abnormal skin pigmentation, oral leukoplakia, mild BMF at 13, microcephaly Mild BMF at 2, microcephaly Severe BMF at 4 Abnormal skin & nails, oral leukoplakia, cerebellar hypoplasia

BMF, failure Dyskeratosis Congenita – connecting telomere biology with human disease

• Germline in (DKC1) found in X-linked recessive DC • Heiss et al, Nature Genet 1998 • Dyskerin (DKC1) associates with H/ACA small nucleolar RNAs and hTr (human RNA, TERC) • DKC1 mutant patient-derived cells have low telomerase, very short • Mitchell and Collins, Nature 1999 • Accounted for ~20% of DC at the time DKC1 What are telomeres?

• Barbara McClintock: • Maize chromosomes stuck together after exposure to X-rays

• Something normally protects chromosome ends from this fate

• Hermann Muller: • Greek: “telos” = end “meros” = part

Reviewed in de Aguiar-Perecin et al., Genet Mol Biol 2000 Telomeres are in algae, humans, and everything in between

Photo: Dr. Peter Lansdorp Molecular structure of telomeres

• Repeats of DNA bases (TTAGGG)n form single-strand overhang • Single-strand region gets folded over and tucked in

Telomere

TTAGGGTTAGGG(TTAGGG)nTTAGGG-3’ AATCCC-5’ Telomeres are protected/regulated by a complex network of

PCNA PARN Histones XRCC6

BRCA1 SIRT1

EXO1 TERRA

ATM/ATR CHK1/CHK2 p53 p21 Why do we need telomeres? DNA damage is a constant threat. Telomeres help keep chromosome ends stable

cellular replication ultra-violet light chemicals metabolism Why do we need telomeres? Repair of a DNA break

Repair • Two types of DNA ends: • DNA breaks • Normal ends of chromosome

• What happens if the cell can’t tell the difference? “Repair” of a normal end:

Repair Telomeres protect DNA ends from being recognized as DNA damage, and “repaired”

Repair of a DNA break: NO “repair” of a normal end:

Repair

Repair Why do we need telomeres?

They give a limit to the number of times cells can divide, which can limit accumulation of DNA damage

Senescence (cells with short telomeres stop dividing) Telomere length

# Cell divisions Telomeres get shorter as we age Normal Lymphocytes

14.0 1%ile 12.0 10%ile 50%ile 10.0 90%ile 99%ile 8.0

6.0

4.0 Telomere Length, kb Length, Telomere 2.0

0.0 0 20 40 60 80 100 Age , ye ars

Baerlocher and Lansdorp, Methods Cell Biol 2004 Alter et al, Blood 2007 Why do telomeres shorten?

• End Replication Problem* - DNA replication machinery can’t fully copy the ends of DNA

• Susceptibility to DNA damage

Shoelace image: Elizabeth Blackburn, PhD, Nobel Lecture 2009

*Watson, 1972; Olovnikov, 1973 Without functional telomeres, chromosome ends can fuse. This causes massive genetic instability

Normal telomeres in mouse cells Telomeres missing a critical component (TRF2)

Okamoto et al., Nature 2013 Telomeres: Dual Roles in Cancer Development

lengthening Longer telomeres permit more cell divisions and accumulation of somatic mutations shortening

Cell division Telomere shortening

Continued cell division with chromosomal abnormalities and genomic instability 31 Development of the Diagnostic Test for DC White blood cell flow-FISH Telomere Length Lymphocytes LymphocytesLymphocytes

14.014.014 DCDC HH Lymphocyte 12.012.012 HH RSRS st SilentSilent telomeres <1 %ile 10.010 10.0 DCDC Rels Rels for age are 8.08.08 >95% sensitive and 6.06.06 99th %ile specific 90th %ile 4.04.04 50th %ile Telomere Length, kb Length, Telomere Telomere Length, kb Length, Telomere Lymphocytes kb Length, Telomere 10th %ile 2.02.02 1st %ile 14.0 DC 0.00.00 0 2020 4040 6060 8080 100100 12.0 HH RS AgeAge,Age , , ye yearsye ars ars Silent 10.0 DC Rels Alter et al, Haematologica 2012;97(3):353-9 8.0 Alter et al. Blood 2007;110(5):1439-1447

6.0

4.0 Telomere Length, kb Length, Telomere 2.0

0.0 0 20 40 60 80 100 Age , ye ars DC-related Telomere Biology Disorders: Earlier onset, distinct complications

• Hoyeraal Hreidarsson (HH) Syndrome • Cerebellar hypoplasia • IUGR • Immune Deficiency

• Revesz Syndrome • Bilateral exudative retinopathy • Intracranial calcifications • IUGR DC-related Telomere Biology Disorders: Earlier onset, distinct complications

• Coats Plus/CRMCC • Retinal telangiectasias • Exudative retinopathy • Intracranial calcifications and/or cysts • Leukodystrophy • GI vascular ectasias • Osteopenia, fractures, poor bone healing

Anderson et al, Nature Genetics 2012 DC-related Telomere Biology Disorders: Later onset, fewer complications

• Apparently isolated disease

Leukemia, 60 , • Pulmonary fibrosis cirrhosis, 38 Gray hair, 23 SAA, 33 • Aplastic Anemia (bone marrow failure) Died at 47, HSCT complications

SAA, 12 carrier • Liver disease dystrophy, gray hair, teens • Head and neck squamous cell carcinoma Normal Lymphocytes

14.0 1%ile 12.0 10%ile • Classic features of DC may not be 50%ile 10.0 90%ile 99%ile present 8.0 6.0

4.0 Telomere Length, kb Length, Telomere • Family history may not be present proband maternal 2.0 grandmother

0.0 0 20 40 60 80 100 Age , ye ars

35 What causes telomere biology disorders? • Genetic changes in critical in telomere biology • 14 genes associated with TBDs, to date, account for ~75% of patients • Different genes are associated with certain complications

RTEL1 NHP2 DKC1 NAF1 TPP1 NOP10 TIN2 TERT POT1

TCAB1

TERC

PARN STN1 CTC1 Details coming up next in Ann Carr’s talk Acknowledgements

NCI’s IBMFS and Telomere Molecular Epidemiology teams Team Telomere Blanche Alter, MD, MPH Neelam Giri, MD Lisa Leathwood, RN Clinical Care Consortium of Functional Studies Ann Carr, CGC Telomere-Associated Ailments S. Artandi: Stanford University S. Agarwal, Harvard Lisa Mirabello, PhD A. Bertuch: Baylor College of Medicine Shahinaz Gadalla MD, PhD A. Bertuch, Baylor J. Tolar, Univ Minnesota T. de Lange: Rockefeller University Payal Khincha, MD Y. Liu: NIA F. Boulad, MSKCC Lisa McReynolds, MD, PhD C. Keegan: University of Michigan K. Myers, Cincinnati Sonia Bhala P. Lansdorp: University of British Columbia Ashley Thompson J.K. Nadakumar: University of Michigan Epidemiology J. Petrini, Memorial Sloan Kettering NCI Cancer Genomics Telomere Length Flow-FISH I. De Vivo: Harvard S. Smith: New York University Research Laboratory P. Lansdorp, Univ R. Hayes: NYU J. Wong: University of British Columbia British Columbia M. Alavanja: NCI And many more… G. Baerlocher, University Bern L. Hou: Northwestern A. Aviv: UMDNJ www.marrowfailure.cancer.gov