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Développement D'une Signature Moléculaire Dans La Maladie

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Développement D'une Signature Moléculaire Dans La Maladie Développement d’une signature moléculaire dans la maladie osseuse de Paget Thèse Sabrina Guay-Bélanger Doctorat en médecine moléculaire Philosophiæ doctor (Ph.D.) Québec, Canada © Sabrina Guay-Bélanger, 2015 Résumé La maladie osseuse de Paget (MOP) a changé de visage au cours des dernières années, augmentant le nombre d’individus atteints qui demeurent asymptomatiques. Étant donné le risque élevé de développer un ostéosarcome associé avec la MOP, cette maladie est une contre-indication à la prescription d’agents ostéoformateurs. Avec l’apparition prochaine de nouveaux agents ostéoformateurs pour le traitement de l’ostéoporose, il devient crucial de pouvoir dépister de façon fiable la présence de la MOP. Les objectifs de ce projet étaient (1) de mettre au point un test plus sensible permettant de détecter et d’évaluer la fréquence des mutations post-zygotiques SQSTM1/P392L chez les patients pagétiques, (2) de développer un test génétique de dépistage de la MOP incluant les mutations germinales et post-zygotiques dans SQSTM1, (3) et d’évaluer les performances diagnostiques de ce test intégré avec des marqueurs biochimiques dans une signature moléculaire spécifique à la maladie. Une technique de PCR sensible utilisant un acide nucléique bloqué (LNA) spécifique à la mutation SQSTM1/P392L a été développée, puis la présence de cette mutation a été recherchée dans les cohortes disponibles au laboratoire et dans différents tissus. Ensuite, le développement de la signature moléculaire a utilisé les données génotypiques et biochimiques disponibles dans les cohortes du laboratoire, puis des régressions logistiques ont été effectuées afin de déterminer la combinaison de marqueurs ayant la meilleure capacité à identifier correctement les patients avec la MOP. Des mutations post- zygotiques SQSTM1/P392L étaient présentes chez 4,8% des patients pagétiques, et 1,4% des individus sains dans les populations étudiées, cette mutation post-zygotique étant restreinte à la lignée monocytaire. Deux tests moléculaires sous forme d’algorithme en deux étapes ont ensuite été proposés. D’une part, un algorithme génétique pur pourrait être utilisé : des mutations germinales dans le gène SQSTM1 devraient d’abord être recherchées, et si elles sont absentes, le score génétique basé sur la combinaison de cinq marqueurs génétiques développée dans ce projet devrait être calculé. Cet algorithme génétique avait une sensibilité égale à 83,61% et une spécificité égale à 51,03% dans les cohortes étudiées. D’autre part, un algorithme génétique et biochimique pourrait être proposé: des mutations germinales dans le gène SQSTM1 devraient d’abord être recherchées, et si elles sont absentes, le score combiné basé sur la combinaison des marqueurs génétiques et biochimiques développée dans ce projet devrait être calculé. Dans les populations étudiées, cet algorithme avait une sensibilité égale à 93,88% et une spécificité égale à 54,00%. La découverte des mutations post-zygotiques confirme l’existence d’un spectre mutationnel de SQSTM1 dans la MOP et pourrait expliquer en partie son caractère focal. Ces résultats ont par la suite permis de développer deux tests moléculaires capables de dépister la MOP de façon plus fiable que les biomarqueurs actuellement disponibles en pratique clinique. iii Abstract Paget’s disease of bone (PDB) has changed in recent years, increasing the number of affected individuals who remain asymptomatic. Given the high risk of developing an osteosarcoma associated with PDB, this disease is a contraindication to the prescription of bone anabolic agents. With the incoming introduction of new bone anabolic agents indicated for osteoporosis treatment, it will be crucial to screen accurately for the presence of PDB. The objectives of this project were (1) to develop a more sensitive test to detect and assess the frequency of SQSTM1/P392L post-zygotic mutations in pagetic patients, (2) to develop a genetic test of PDB, including germinal and post-zygotic SQSTM1 mutations, (3) and to assess the diagnostic performance of this test integrated with bone biomarkers in a molecular signature of PDB. A sensitive PCR method using a locked nucleic acid (LNA) specific to the SQSTM1/P392L mutation was developed, and the presence of this mutation was investigated in the cohorts available in the laboratory, and in different tissues. Then, the development of the molecular signature used genotypic and biochemical data available in the laboratory, and logistic regressions were performed to determine the combination of markers with the best ability to correctly identify PDB patients. SQSTM1/P392L post-zygotic mutations were present in 4.8% of pagetic patients, and in 1.4% of healthy individuals in the population studied, this mutation being restricted to the monocytic lineage. Two molecular tests relying on a two steps algorithm were then developed. Firstly, a pure genetic algorithm could be proposed: a screen in the SQSTM1 gene should first be performed to search for disease-causing germinal mutations, and if negative, the genetic score based on a combination of the five SNPs developed in this study should be calculated. In the populations studied, this genetic algorithm had a sensitivity of 83.61% and a specificity of 51.03%. On the other hand, a genetic and biochemical algorithm could be used: a screen in the SQSTM1 gene should first be performed to search for disease-causing germinal mutations, and if negative, the combined score based on a combination integrating both genetic and biochemical markers developed in this study should be calculated. This genetic algorithm had a sensitivity of 83.61% and a specificity of 51.03% in the populations studied. The presence of post-zygotic mutations confirms the existence of a mutational spectrum of SQSTM1 in PDB, and may explain its focal character. These results conducted to the development of two molecular tests which predicted the PDB phenotype better than bone biomarkers already available in clinical practice. v Table des matières Résumé ............................................................................................................................................................. iii Abstract .............................................................................................................................................................. v Table des matières .......................................................................................................................................... vii Liste des tableaux ............................................................................................................................................ xi Liste des figures ............................................................................................................................................. xiii Liste des abréviations..................................................................................................................................... xv Remerciements .............................................................................................................................................. xxi Avant-propos ................................................................................................................................................ xxiii Introduction ....................................................................................................................................................... 1 1. Épidémiologie de la maladie osseuse de Paget ..................................................................................... 1 1.1 Incidence actuelle de la maladie osseuse de Paget ............................................................................. 2 1.2 Prévalence actuelle de la maladie osseuse de Paget .......................................................................... 2 1.3 Rôle des facteurs environnementaux dans la maladie osseuse de Paget ......................................... 11 2. Aspects cliniques de la maladie osseuse de Paget .................................................................................. 13 2.1 Physiopathologie de la maladie osseuse de Paget ............................................................................ 13 2.1.1 Tissu osseux normal ................................................................................................................... 13 2.1.2 Tissu osseux pagétique .............................................................................................................. 16 2.2 Présentation clinique de la maladie osseuse de Paget ...................................................................... 18 2.2.1 Symptômes ................................................................................................................................. 18 2.2.2 Diagnostic ................................................................................................................................... 19 2.2.3 Traitement et suivi ....................................................................................................................... 21 2.2.4 Complications .............................................................................................................................. 23 2.3 Désordres osseux apparentés à la maladie osseuse de Paget .......................................................... 28 2.3.1 Ostéolyse expansive familiale ..................................................................................................... 28 2.3.2
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