Fanconi Anemia Farid Boulad MD February 18 2020

Fanconi Anemia Farid Boulad, MD February 18, 2020

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HEMATOPOIESIS

Fanconi Anemia Case Study • 10 year old male • History Prior Medical History unremarkable Except birth history: small for gestational age • Review of Systems Pallor and easy bruising • Physical Examination Flat thenar eminence – Abnl thumbs • Laboratory • CBC: WBC 1. 0, ANC 0. 4 - Hgb 7. 8 - Plts 20, 000 • BM aspiration: • • • No blasts, no evidence of leukemia Decrease in cellularity Mild non specific dysmorphology Decrease in myeloid, erythroid and megakaryocytic elements Cytogenetics: Normal

Fanconi Anemia Aplastic Anemia • Aplastic “anemia” misnomer (Anemia refers to Red Cell Lineage) Pancytopenia with hypoplastic / aplastic bone marrow. = Bone Marrow Failure + • Definition: 1. CBC with Two of Three Criteria that include: AA SAA - ANC < 1, 500 < 500 - Abs Retic < 60, 000 < 20, 000 - Plts < 50, 000 < 20, 000 2. Bone marrow biopsy with cellularity < 25%

Fanconi Anemia Parenthesis: (Bone Marrow Evaluation) • Aspiration • • • Morphology Lineage maturation Blasts Flow Cytometry Cytogenetics Molecular Genetics • Biopsy • Cellularity

BONE MARROW Aplastic Anemia or Bone Marrow Failure Normal Bone Marrow

Fanconi Anemia Aplastic Anemia - Differential Diagnosis 1. Acquired Severe Aplastic Anemia • Idiopathic • Secondary [Medications – Infections] 2. Paroxysmal Nocturnal Hemoglobinuria 3. Myelodysplastic Syndrome (Hypoplastic MDS) 4. Inherited Bone Marrow Failure Syndromes

Fanconi Anemia Aplastic Anemia / Bone Marrow Failure PNH MDS SAA IBMFS OTHER (RUNX-1, GATA-2 …) SAA: 600 new patients /year in the US MDS: 10, 000 -15, 000 new patients/year in the US PNH: 1, 000 -2, 000 patients in the US (total) IBMFS: 6, 000 - 10, 000 patients in the world (total)

BONE MARROW FAILURE SYNDROMES The Usual Suspects Fanconi Anemia Dyskeratosis Congenita Shwachman Diamond Syndrome Diamond Blackfan Anemia Severe Congenital Neutropenia Amegakaryocytic Thrombocytopenia ~N Cases 4, 000 400 500 800 400 100 Male: Female 1. 2: 1 4: 1 1. 5: 1 1. 1: 1 1. 2 0. 8: 1 Age at diagnosis median (range) 6. 6 (0– 49) 15 (0– 75) 1 (0– 41) 0. 25 (0–? ) 3 (0–? ) 0. 1 (0– 11) Physical findings Yes Yes No No Primary Hematologic Lesion WBC RBC PLTS RBC WBC ANC PLTS Aplastic anemia Yes Yes Rare No Yes Leukemia MDS Yes Yes Yes Feature B. Alter, Blood 2007

Fanconi Anemia What is Fanconi Anemia • Inherited Bone Marrow Failure Syndrome • Genomic Instability → DNA fragility - Chromosomal Breakage Disorder • Rare - Number of patients ~ 5, 000 – Most frequent of the IBMFS • Mostly autosomal recessive disease (rarely X-linked) • Genetically and phenotypically heterogeneous disease • Clinical characteristics 1. Multiple constitutional abnormalities 2. Endocrinopathies 3. Bone marrow failure – Hematologic Cancer susceptibility 4. Epithelial Cancer susceptibility / predisposition

Fanconi Anemia G. Fanconi. Familiäre, infantile perniciosähnliche Anämie (perniziöses Blutbild und Konstitution). Jahrbuch für Kinderheilkunde und physische Erziehung, Wien, 1927, 117: 257 -280.

Fanconi Anemia 1940’s – 1970’s CASE REPORTS

Fanconi Anemia Genetics • Fanconi anemia (FA) is caused by defects in at least 22 distinct genes: FANC A, C, G - D 1, D 2, …V (Majority: 85% of patients A, C, G – Severe phenotype: D 1) • The FA proteins constitute a Nuclear Protein Complex. The FA pathway coordinates a complex mechanism that enlists DNA repair pathways in response to genotoxic insults.

FANCONI ANEMIA Repair of Interstrand Cross. Links (ICL) – The FA pathway Wang et al. Cell 2015

Fanconi Anemia Physical Abnormalities (N= 955) Blanche Alter

FANCONI ANEMIA Physical Abnormalities • FA can also present as the VACTERL syndrome • VACTERL association features • V – vertebral anomalies • A – anal atresia • C – cardiac malformation • T – tracheo-esophageal fistula • E – esophageal atresia • R – renal anomalies • L - limb defects

Fanconi Anemia Cancer Predisposition Cancer type Relative Risk (fold increase) MDS 6000 Acute leukemia 500 -700 All solid tumors 38 HNSCC 600 Vulvar SCC 3000 Alter BP. Best Pract Res Clin Haematol 2014 Alter BP et al. BJH 2010 BMF

FANCONI ANEMIA CLINICAL COURSE Aplastic Anemia 73% MDS AML 27% Median Age At Diagnosis 0 7 AA 98% 10 20 Solid tumors 20 -30% MDS/AML 35 -50% 30 40…. . Age

Fanconi Anemia So what it Fanconi Anemia? - It is a genetic disorder - Its primary “lesion” is DNA fragility - It can present/be diagnosed as - Constitutional abnormalities – short stature – microcephaly/microphthalmia – abnormal thumbs … - Aplastic anemia / Bone marrow failure - MDS - AML - Squamous cell carcinoma / young adults

Fanconi Anemia How is Fanconi Anemia diagnosed? - Functional testing: Di-epoxy butane (DEB) or Mitomycin C testing - Both agents are carcinogenic – They both induce DNA cross-linking DNA breakage - It is a blood test – lymphocytes are isolated – Stimulated – Mixed with DEB or MMC - Quantitation of breakage of chromosomes (compared to normal control) - Genetic testing - Mutation analysis by sequencing - Complementation test

Fanconi Anemia GENETIC TESTING FOR INHERITED BONE MARROW FAILURE SYNDROMES Next Generation Sequencing Testing of established mutations of the different IBMFS disorders Different Labs have different panels EX: 116 Gene panel ~ Cincinnati Childrens’ Hospital

FANCONI ANEMIA FOLLOW-UP and MANAGEMENT Once the diagnosis of FA is made, patients should be followed in a comprehensive manner with attention to all the elements of the disease, including: - Hematology - Genetics - Endocrinology - Head and neck - Gynecologic - Orthopedics Blood counts – Bone marrow Family screening Thyroid – Glucose - Growth cancer screening limb abnormalities - Other systems: Cardiac – Renal – GI – Dermatology - Immune

Fanconi Anemia FA Hematologic Stages

FANCONI ANEMIA How is Fanconi Anemia classified?

ALLOGENEIC HSCT FOR FANCONI ANEMIA Aplastic Anemia AML MDS

FANCONI ANEMIA

FANCONI ANEMIA Fanconi anemia – Timing of HSCT – – Normal counts Mild - moderate isolated cytopenias or AA and Transfusion Independence Low risk MDS (<5% blasts and low risk cytogenetic abnormalities) NO Severe Single Lineage Cytopenia +/- prior trial of Androgens – Severe AA and Transfusion Dependence +/- prior trial of Androgens – High Risk MDS - AML (>5% blasts and/or high risk cytogenetic abnormalities) YES – – Maybe YES

ALLOGENEIC HSCT FOR FANCONI ANEMIA 1980 Eliane Gluckman in France publishes the results of one of the first series of HSCT for Fanconi anemia Description of increased toxicity and increased GVHD One of the 5 patients survived 1983 Dr Gluckman (again) describes the first regimen adapted to Fanconi anemia

ALLOGENEIC HSCT FOR FANCONI ANEMIA Low dose TBI/TAI – Low dose Cy Matched Related & Unrelated donors CIBMTR Gluckman et al. Blood 1995 EBMT 1990’s R. Peffault de Latour, 2013

ALLOGENEIC HSCT FOR FANCONI ANEMIA 1990’s HSCT from Unrelated Donors NMDP – N=58 Overall Survival 1995– 2003 The ability to perform SCT for the treatment of patients with FA, using alternative donors with cytoreductive regimens standardly used for FA had been limited by increased risks of: - Graft rejection / failure - Acute and chronic Gv. HD - Peri-transplant toxicity - Infections DFS: Gluckman et al. Biol Blood Marrow Transpl. 17 -35% > 50% 10 -20% ~ 30%

ALLOGENEIC HSCT FOR FANCONI ANEMIA Gv. HD in the Fanconi anemia host is associated with a very significant increased risk of secondary cancers Development of SCC. Two factors were significantly associated with the hazard of development of SCC. Severe AGVHD was associated with a 33 -fold increase in the hazard of SCC (95% CI 2. 7 -392, adjusted P. 026). Chronic graft-versus-host disease, extensive versus limited or none (CGVHD), also was significantly associated with SCC (adjusted P. 03); all 11 patients with SCC had previously developed CGVHD. Severe AGVHD remained a significant risk factor for SCC in a proportional hazards model restricted to the 41 patients with CGVHD (P. 002). Among 41 patients with CGVHD, 8 patients had severe AGVHD, 2 of whom developed SCC. Rosenberg et al. Blood 2005 T-cell depletion is the most efficient method for Gv. HD prophylaxis

ALLOGENEIC HSCT FOR FANCONI ANEMIA Post Fludarabine Era 2000 New use of Fludarabine in HSCT regimen. PRO Immunosuppression NO toxicity Used at same dose than non. FA patients without needing to adjust 2007

ALLOGENEIC HSCT FOR FANCONI ANEMIA 2000 EBMT R Peffault de Latour, et al. - Blood 2013

ALLOGENEIC HSCT FOR FANCONI ANEMIA INITIAL REGIMEN – TBI DONOR G-CSF 10 mcg/Kg/dose Daily SC PBSC Collection CD 34+ selection/T cell depletion PATIENT Single Dose Flu Flu TBI CY CY -5 -4 -3 -2 ATG ATG -6 CD 34+ PBSCT -1 Start CSA 0

ALLOGENEIC HSCT FOR FANCONI ANEMIA 2007

ALLOGENEIC HSCT FOR FANCONI ANEMIA SECOND REGIMEN – Busulfan DONOR G-CSF 10 mcg/Kg/dose Daily SC PBSC Collection CD 34+ selection/T cell depletion PATIENT BU PK studies BU -8 -7 Flu Flu BU CY CY -6 -5 -4 -3 -2 ATG ATG CD 34+ PBSCT -1 0 X Start CSA

ALLOGENEIC HSCT FOR FANCONI ANEMIA Over the last 2 decades, there has been a difference in the approach of allogeneic HSCT for Fanconi anemia. USA led by U Minnesota, Cincinnati Children’s and MSK Kids, pioneered the use of T-CELL DEPLETION for HSCT for FA, therefore reducing the risk of GVHD. Europe continued with the use of UNMODIFIED BMT for the transplantation of FA patients, Incidence of Acute and Chronic GVHD Gv. HD 9. 6% 2017

ALLOGENEIC HSCT FOR FANCONI ANEMIA Over the last 20 years, we were able to improve overall survival of patients with Fanconi anemia receiving allogeneic SCT from alternative donors. We used a step-wise approach including: Cytoreduction Backbone Immune Suppression Cytoreduction Myeloablation Anti-leukemia Gv. HD Prophylaxis Additional Gv. HD Prophylaxis cy – ATG + FLU TBI 450 c. Gy T-cell depletion Tacro - Steroids cy – ATG + FLU TBI 450 c. Gy T-cell depletion Tacro cy – ATG + FLU BU high dose T-cell depletion CSA cy – ATG + FLU BU adjusted dose T-cell depletion - - - We were able to perform SCT from alternative donors with minimal risks of graft failure and Gv. HD and now without radiation.

ALLOGENEIC HSCT FOR FANCONI ANEMIA T-cell depleted HSCT – αβ T-cell + CD 19 B-cell depletion Bertaina A – Locatelli F, et al. Blood 2014

ALLOGENEIC HSCT FOR FANCONI ANEMIA HLA Matched Sibs Unrelated Donors Mismatched Related Donors Low dose CY Low dose TBI/TAI HLA Matched Sibs Unrelated Donors Mismatched Related Donors + Fludarabine αβ T-cell depletion Post Transplant CY

FANCONI ANEMIA Therapeutic Options Androgens Eltrombopag Quercetin Metformin Aldehyde Dehydrogenase Activator N acetyl cysteine TGF-β Inhibition Allogeneic HSC T – Matched Related Donors – Unrelated Donors – Mismatched Related Donors Non Genotoxic Cytoreduction (anti-c-kit) for HSCT Gene Therapy – FANC A

FANCONI ANEMIA SUMMARY 1. Fanconi anemia is a genetic disorder 2. It is associated with DNA fragility 3. It can present as (1) constitutional abnormalities, (2) AA, (3) MDS/AML or (4) solid tumors 4. Its primary problem is the hematologic complications of AA and MDS/AML 5. Those can be successfully cured with Allogeneic HSCT 6. There has been major progress in allogeneic HSCT for FA with good DFS and minimal Gv. H 7. Other new agents or therapies are being developed for the treatment of FA

Aplastic Anemia or Isolated Severe Single Lineage Cytopenia BM aspiration PNH Flow Cytometry DEB testing Telomere testing Positive testing Treat accordingly Negative testing No constitutional Abnormalities Treat accordingly ANC: SCN Hgb: DBA Plts: CAT IBMFS gene panel Whole exome sequencing

Fanconi Anemia Case Study • 10 year old male • History Prior Medical History unremarkable Except birth history: small for gestational age • Review of Systems Pallor and easy bruising • Physical Examination Flat thenar eminence – Abnl thumbs • Laboratory • CBC: WBC 1. 0, ANC 0. 4 - Hgb 7. 8 - Plts 20, 000 • BM aspiration: • • • No blasts, no evidence of leukemia Decrease in cellularity Mild non specific dysmorphology Decrease in myeloid, erythroid and megakaryocytic elements Cytogenetics: Normal DEB testing IBMFS gene panel Status F/U HSCT Positive FANC A Aplastic anemia Based on counts Based on donors If needs TX

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