Niedersachsenprofessur für Molekulare Hämatopoese

Transcription

Kinderheilkunde und Jugendmedizin
Niedersachsenprofessur für Molekulare Hämatopoese

Direktor: Prof. Dr. Karl H. Welte
Tel.: 0511-532-6710 • E-Mail: [email protected] • intranet.mh-hannover.de/12105.html

Keywords: Schwere kongenitale Neutropenie, Myelopoese, Granulopoese, Leukämogenese
Forschungsprofil
Das Forschungsprofil der Abteilung Molekulare Hämatopoese wird maßgeblich durch die klinische Forschung und
Grundlagenforschung auf dem Gebiet der angeborenen Erkrankungen der Blutbildung und Leukämogenese bestimmt.
Mitglieder der Abteilung haben auf diesem Gebiet international beachtete Pionierarbeit geleistet. Beispielsweise wurden
neue Genmutationen identifiziert, die in der Entwicklung von Leukämien beteiligt sind (siehe ausführlicher Bericht).
Weiter wurden mehrere neue und wichtige Signalwege in der Entwicklung myeloider Zellen und in der Leukämogenese
identifiziert. Die Ergebnisse konnten in den letzten Jahren in den hoch renommierten Journalen "Nature Medicine"
und "Blood" veröffentlicht werden. Darüber hinaus ist die Europazentrale des Internationalen Registers für schwere
chronische Neutropenie hier angesiedelt. Die Mitglieder der Abteilung sind und waren in mehreren Forschungsnetzwerken federführend beteiligt, dem Bundesministerium für Bildung und Forschung (German Network on Congenital
Bone Marrow Failure Syndromes) und der BMBF-geforderten Initiative für seltene Erkrankungen (E-Rare) der EU-Staaten.
Forschungsprojekte
Outcome and Management of Pregnancies in Severe Chronic Neutropenia Patients by the European
Branch of the Severe Chronic Neutropenia International Registry
Severe chronic neutropenia is a heterogeneous group of inherited and acquired rare disorders with a common hematological and clinical phenotype. It is characterized by peripheral blood absolute neutrophil counts below 0.5´109/L
and early onset of bacterial infections.
Prior to the availability of recombinant human Granulocyte-Colony Stimulating Factor (G-CSF), patients with severe
chronic neutropenia experienced frequent bacterial infections and required multiple antibiotic courses.
Data from the Severe Chronic Neutropenia International Registry (SCNIR) have demonstrated that more than
90 percent of all treated patients respond well to granulocyte-colony stimulating factor with a sustained increase
of absolute neutrophil counts. Thus, patients are significantly less prone to bacterial infections. As a consequence,
life expectancy is prolonged and our first patients have reached adulthood with the desire for parenthood being an
emerging issue.1-3 Patients and physicians often ask about benefits and safety of G-CSF treatment during pregnancy
which led us to initiate this survey.
So far, there is only limited data on the risk of developing severe bacterial infections during pregnancy for women
suffering from severe chronic neutropenia with or without G-CSF treatment.
Current data on the molecular causes indicate that congenital neutropenia is a genetic disorder with more than
10 underlying gene mutations described to date. However, in approximately 30 percent of patients the genetic basis of
congenital neutropenia is still unknown. Gene mutations responsible for congenital neutropenia follow an autosomal
dominant, autosomal recessive or X-linked pattern of inheritance depending on the type of mutation. Genetic analyses
in autosomal dominant and sporadic cases of congenital neutropenia indicate that the majority of these cases are
attributable to mutations in the elastase 2 (ELANE) gene encoding neutrophil elastase. Thirty-two percent of congenital
(CN) and 80 percent of cyclic neutropenia (CyN) patients harbour ELANE mutations (ELANE-CN vs. ELANE-CyN) as
180
Forschungsbericht 2014
reported by the European branch of the Severe Chronic Neutropenia International Registry. Although some mutations
are related to both, congenital and cyclic neutropenia, the clinical phenotype and course of disease differ significantly:
ELANE-CN patients have severe chronic neutropenia with a substantial risk of life-threatening infections and a high risk
for secondary leukemias. They require higher G-CSF doses and may develop G-CSF receptor (CSF3R/colony stimulating
factor 3 receptor) mutations during life. In contrast ELANE-CyN patients respond to lower G-CSF doses and show the
typical cycling of neutrophil counts throughout their life without malignant transformation. Recessive inheritance of
congenital neutropenia is related to HAX1 gene mutations (Kostmann syndrome patients) and a number of other rare
mutations which are mainly associated with multi-organ involvement for instance SBDS, G6PT (SLC37A4), G6PC3 and
p14 (LAMTOR2, MAPBPIP). In X-linked subtypes mutations in TAZ or WAS may be detected.4-11 The clinical status in
newborns of mothers and fathers with different genetic subtypes of congenital neutropenia has not yet been reported.
In this study, we assessed the outcome of pregnancies reported to the SCNIR in Europe since 1994 with regard to:
1) Use of G-CSF and dosing during pregnancy
2) The impact of G-CSF treatment on pregnancy outcome, maternal and newborn complications (e. g. infections
during pregnancy and fetal teratogenicity) in all neutropenia subtypes
3) The transmission of inherited neutropenia to newborns of mothers and fathers with different genetic neutropenia
subtypes
Ad 1: Use of G-CSF and dosing during pregnancy
Data on the use of G-CSF were available in 35 of the 38 pregnancies. In the majority of documented pregnancies,
women received G-CSF for a minimum of one trimester. Reflecting the severity of the underlying neutropenia subtype,
81 percent of congenital compared to 50 percent of cyclic and 25 percent of idiopathic neutropenia patients were
treated. Fortunately, none of our patients experienced severe bacterial infections. The high proportion of treated women
with the most severe clinical phenotype (congenital neutropenia) corresponds to the well reported high susceptibility
of bacterial infections and the documented risk of death from sepsis in these patients.
Fig. 1: G-CSF Treatment of mothers during pregnancy by neutropenia subtype. The pie charts show the maternal G-CSF exposure
(G-CSF exposure, no G-CSF, unknown exposure) by neutropenia subtype for each pregnancy: congenital neutropenia in purple,
cyclic neutropenia in blue and idiopathic neutropenia in green.
181
Figure 2 shows the G-CSF doses during pregnancy for each trimester.
Fig. 2: Median G-CSF dose prior and during pregnancy by neutropenia subtype. In the figure the median G-CSF doses (μg/kg/d)
for each neutropenia subtype (congenital neutropenia in purple; cyclic neutropenia in blue and idiopathic neutropenia in green)
prior to pregnancy (first column) are compared to the median G-CSF dose during pregnancy divided into the three trimesters (2-4
columns of each color).
Ad 2: The impact of G-CSF treatment on pregnancy outcome, maternal and newborn complications (e. g. infections
during pregnancy and fetal teratogenicity) in all neutropenia subtypes
Our evaluation demonstrates that G-CSF treatment resulted in a significantly higher mean absolute neutrophil
count in treated compared to untreated women indicating a better ability to fight against bacterial infections.
Thirty-one of the total 38 pregnancies resulted in life births (82 percent). Our analysis showed a minor difference
between the proportion of miscarriages and septic abortions in treated versus untreated mothers (two versus three).
Two stillbirths were reported in one untreated mother and one mother with unknown G-CSF exposure, both suffering
from idiopathic neutropenia. A significantly higher rate of spontaneous miscarriages in untreated pregnant women
with severe chronic neutropenia was previously reported by Boxer et al., but could not be confirmed in our study, where
the difference of miscarriages was not significant.
In our cohort we documented five preterm deliveries in three different women corresponding to an incidence of
13,2 percent. This incidence is significantly higher compared to the overall incidence of premature newborns in Europe
(2010: 6,2 percent for European countries). Advanced age as an additional risk factor for premature delivery could
be excluded in our cohort. The median age of the mothers at birth was 29 years (maximum 35 years). A significantly
increased risk of premature delivery has been reported for women from age 35-40 and even higher in women over
age 40. In the majority of pregnancies resulting in preterm delivery no G-CSF was given. One preterm delivery was
related to preeclampsia in a woman with Shwachman-Diamond syndrome.
Ad 3: The transmission of inherited neutropenia to newborns of mothers and fathers with different genetic neutropenia subtypes
Transmission of neutropenia was evaluated in newborns of nine mothers and seven fathers with known neutropenia causing dominant ELANE mutation (congenital and cyclic neutropenia) and in newborns of mothers and fathers
with unclassified congenital or cyclic neutropenia (six women, one man) In seven of 12 newborns neutropenia was
passed on from the mother (58 percent). In eight of 13 newborns the neutropenia was passed on from the fathers (62
percent). One woman suffered from Shwachman-Diamond Syndrome characterized by compound heterozygous SBDS
mutations without transmission to her baby, as expected.
182
In summary, our evaluation demonstrates that the use of G-CSF throughout pregnancy is safe and well tolerated.
No noticeable side effects were reported. Our data support the recommendation to continue G-CSF treatment women
with different types of severe chronic neutropenia throughout pregnancy to prevent major infections and newborn
complications. The recommendation is based on the reported high risk for bacterial infections and septic death in severe
congenital neutropenia. The risk may be lower for patients suffering from cyclic or idiopathic neutropenia. However,
since there is no better predictor for this risk than the absolute neutrophil count, we would recommend offering G-CSF
treatment to all patients with absolute neutrophil counts below 0,5x109/L.

Projektleitung: Dr. med. Cornelia Zeidler, Severe Chronic Neutropenia International Registry (SCNIR);
Kooperationspartner: Ulrike A. H. Grote,1 Anna Nickel,1 Beate Brand,1 Göran Carlsson,2 Emília Cortesão,3 Carlo
Dufour,4 Caroline Duhem,5 Gundula Notheis,6 Helen A. Papadaki,7 Hannah Tamary,8 Geir E. Tjønnfjord,9 Fabio
Tucci,10 Jan Van Droogenbroeck,11 Christiane Vermylen,12 Jaroslava Voglova,13 Blanca Xicoy14 and Karl Welte1 1
European Branch of the Severe Chronic Neutropenia International Registry (SCNIR), Dept. of Molecular Hematopoiesis,
Hannover Medical School, Hanover, Germany ; 2 Childhood Cancer Research Unit, Dept. of Women’s and Children’s
Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; 3 Dept. of Hematology, Hospitais
da Universidade de Coimbra, Coimbra, Portugal; 4 Hematology Unit, G. Gaslini Children's Institute, Genova, Italy; 5
Dept. of Hematology-Oncology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg; 6 Dept. for Pediatric
Hematology/Oncology and Infection/Immunity, Dr. von Haunersches Kinderspital, Ludwig-Maximilians-University,
Munich, Germany; 7 Dept. of Hematology, University Hospital of Heraklion, Heraklion, Greece; 8 Pediatric Hematology
Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel ; 9 Dept. of Haematology, Oslo University
Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway; 10 Dept. of Pediatric Onco-Hematology,
AOU Meyer, Florence, Italy; 11 Dept. of Hematology, A.Z. Sint-Jan, Brugge, Belgium; 12 Dept. of Pediatric Hematology,
Université Catholique de Louvain, Cliniques universitaires Saint Luc, Brussels, Belgium ; 13 4th Department of Internal
Medicine - Haematology, University Hospital, Hradec Králové, Czech Republic; 14 Dept. of Hematology, Germans Trias
i Pujol Hospital, Badalona, Spain; Förderung: ***
Weitere Forschungsprojekte
E-Rare-Verbund: Angeborene Neutropenien mit Mutationen im ELA2-GEN: Klinische Genotyp-Phänotyp
Analyse

Projektleitung: Zeidler, Cornelia (Dr. med.); Förderung: BMBF, Projektträger im DLR
E-Rare-Verbund: Angeborene Neutropenien mit Mutationen im ELA2-GEN: Epigenetische
Veränderungen zusätzlich zu ELANE-Mutationen

Projektleitung: Welte, Karl (Prof. Dr. med.); Förderung: BMBF, Projektträger im DLR
Die Analyse der Ursachen der Leukämieentstehung bei Patienten mit schwerer angeborener
Neutropenie und de novo AML`s

Projektleitung: Skokowa, Julia (Prof. Dr. med. PhD); Förderung: Madeleine Schickedanz Kinderkrebsstiftung
Severe Chronic Neutropenia International Registry

Projektleitung: Zeidler, Cornelia (Dr. med.), Welte, Karl (Prof. Dr. med.); Kooperationspartner: Dale, David, University
of Washington, Seattle, USA; Förderung: National Institute of Health (NIH), USA
183
Mechanismen der STAT5-Hyperphosphorylisierung, des darauffolgenden Abbaus des LEF-1 Proteins und
deren Rolle für die leukämische Transformation bei Patienten mit schwerer angeborener Neutropenie
und de novo AML

Projektleitung: Skokowa, Julia (Prof. Dr. med., PhD), Welte, Karl (Prof. Dr. med.); Förderung: Deutsche Krebshilfe
Comparison of the hematopoietic differentiation of iPS cells generated from CN and CyN patients
carrying same ELANE mutations

Projektleitung: Skokowa, Julia (Prof. Dr. med., PhD), Welte, Karl (Prof. Dr. med.); Förderung: Exzellenzcluster REBIRTH
The role of LEF-1 transcription factor and its interaction partner HCLS1 in the inhibition of cellular
senescence of leukemic cells

Projektleitung: Skokowa, Julia (Prof. Dr. med., PhD), Welte, Karl (Prof. Dr. med.); Förderung: Deutsche José Carreras
Leukämie-Stiftung e.V.
Zuteilung von Rechenkontingent am HLRN: Sequence Search in Human Pedigrees with Familial Cancer
Syndromes on Whole- and Exome Genome Scale

Projektleitung: Welte, Karl (Prof. Dr. med.), Ünalan, Murat (Dr. med., PhD); Förderung: HLRN - Norddeutscher
Verbund zur Förderung des Hoch- und Höchstleistungsrechnens
Anschaffung von Chips für die Sequenzierung des menschlichen Genoms

Projektleitung: Skokowa, Julia (Prof. Dr. med., PhD); Förderung: Benekids e.V.
CHIP Sequenzierungsanalyse Genom-weiter genregulatorischer Effekte durch leukemogene
Genmutationen bei Patienten mit schwerer angeborener Neutropenie

Projektleitung: Ünalan, Murat (Dr. med.); Förderung: Dieter Schlag Stiftung
Deutsches Netzwerk und Beratungszentrum für Patienten mit dem Risiko für sekundäre Leukämien
bei schweren angeborenen Neutropenien

Projektleitung: Zeidler, Cornelia (Dr. med.); Förderung: Deutsche José Carreras Leukämie-Stiftung e.V.
Mechanisms of myeloid differentiation and leukemogenesis

Projektleitung: Skokowa, Julia (Prof. Dr. med., PhD); Förderung: Exzellenzcluster REBIRTH
The role NAMPT-triggered deacetylation of LEF-1 and C/EBPa in myelopoiesis and leukemogenesis

Projektleitung: Skokowa, Julia (Prof. Dr. med., PhD); Förderung: DFG
Originalpublikationen
Boztug K., Järvinen P. M., Salzer E., Racek T., Mönch S., Garncarz W.,
Gertz E. M., Schäffer A. A., Antonopoulos A., Haslam S. M., Schieck L.,
Puchalka J., Diestelhorst J., Appaswamy G., Lescoeur B., Giambruno
R., Bigenzahn J. W., Elling U., Pfeifer D., Conde C. D., Albert M. H.,
Welte K., Brandes G., Sherkat R., van der Werff Ten Bosch J., Rezaei
N., Etzioni A., Bellanne-Chantelot C., Superti-Furga G., Penninger J.
M., Bennett K. L., von Blume J., Dell A., Donadieu J., Klein C. JAGN1
deficiency causes aberrant myeloid cell homeostasis and congenital
neutropenia. Nat.Genet. 2014;46(9):1021-1027
Skokowa J., Steinemann D., Katsman-Kuipers J. E., Zeidler C., Klimenkova O., Klimiankou M., Unalan M., Kandabarau S., Makaryan
V., Beekman R., Behrens K., Stocking C., Obenauer J., Schnittger S.,
Kohlmann A., Valkhof M. G., Hoogenboezem R., Göhring G., Reinhardt D., Schlegelberger B., Stanulla M., Vandenberghe P., Donadieu
J., Zwaan C. M., Touw I. P., van den Heuvel-Eibrink M. M., Dale D.
C., Welte K. Cooperativity of RUNX1 and CSF3R mutations in severe
congenital neutropenia: a unique pathway in myeloid leukemogenesis.
Blood 2014;123(14):2229-2237
Makaryan V., Rosenthal E. A., Bolyard A. A., Kelley M. L., Below J. E.,
Bamshad M. J., Bofferding K. M., Smith J. D., Buckingham K., Boxer
L. A., Skokowa J., Welte K., Nickerson D. A., Jarvik G. P., Dale D. C.,
UW Center for Mendelian Genomics. TCIRG1-associated congenital
neutropenia. Hum.Mutat. 2014;35(7):824-827
Thakur B. K., Zhang H., Becker A., Matei I., Huang Y., Costa-Silva B.,
Zheng Y., Hoshino A., Brazier H., Xiang J., Williams C., RodriguezBarrueco R., Silva J. M., Zhang W., Hearn S., Elemento O., Paknejad
N., Manova-Todorova K., Welte K., Bromberg J., Peinado H., Lyden
D. Double-stranded DNA in exosomes: a novel biomarker in cancer
184
detection. Cell Res. 2014;24(6):766-769
Auszeichnungen
Welte K. G-CSF: filgrastim, lenograstim and biosimilars. Expert
Opin.Biol.Ther. 2014;14(7):983-993
Julia Skokowa (Prof. Dr. med., PhD): wurde auf die W3 Professur
“Translationale Onkologie” der Universität Tübingen berufen und
hat den Ruf angenommen
Zeidler C., Grote U. A., Nickel A., Brand B., Carlsson G., Cortesao
E., Dufour C., Duhem C., Notheis G., Papadaki H. A., Tamary
H., Tjonnfjord G. E., Tucci F., Van Droogenbroeck J., Vermylen
C., Voglova J., Xicoy B., Welte K. Outcome and management of
pregnancies in severe chronic neutropenia patients by the European
Branch of the Severe Chronic Neutropenia International Registry.
Haematologica 2014;99(8):1395-1402
Abstracts
Weitere Tätigkeiten in der Forschung
Welte, Karl (Prof. Dr. med.): Mitglied des Hochschulrates der MHH;
Vorsitzender des wissenschaftlichen Beirates der Deutschen Jose
Carreras Leukamie Stiftung; Mitglied der Deutschen Akademie der
Naturforscher Leopolodina.
Skokowa, Julia (Prof. Dr. med., PhD): Editorial Board Mitglied von
Blood Journal; Reviewer Nature Medicine und Blood.
2014 wurden 15 Abstracts publiziert.
Promotionen
Klimenkova, Olga (PhD M.Sc. Immunology): Mechanisms of disturbed G-CSF-triggered granulopoiesis in CN patients downstream of
ELANE and HAX1 mutations.
185