La recerca bàsica i traslacional en malalties rares és fonamental per entendre la fisiologia humana i per desenvolupar teràpies innovadores sovint útils també per malalties molt més prevalents. L’anèmia de Fanconi, caracteritzada per disfunció de la medul·la òssia i predisposició tumoral, n’és un exemple edificant. El primer transplantament de cordó umbilical de la història de la medicina fou en un pacient Fanconi. El primer nen medicament va néixer per curar un pacient Fanconi. El primer cop que s’han generat teixits sans per auto-transplantament curant, desprogramant i re-diferenciant cèl·lules de la pell d’un malalt ha estat en anèmia de Fanconi. I els primers assajos clínics de teràpia gènica s’estan desenvolupat també en malalties de la sang com l’anèmia de Fanconi. Aquests són alguns exemples de com l’estudi de malalties rares por transcendir més enllà del pacient afecte en benefici de tota la societat.

1. Cicle de Conferències en Malalties Rares, VHIR, Barcelona, 16 Des 2014
Rare diseases as platform to develop
novel therapeutic strategies: the
example of Fanconi anemia
Dr. Jordi Surrallés
Catedràtic de Genética
Professor ICREA-Acadèmia
Universitat Autònoma de Barcelona
Genome Instability Group: http://gig.uab.cat

2. Fanconi anemia

3. http://www.malaltiaamagada.com
A tale: Arnau has a hidden disease

4. Garaycoechea and Patel (2014) Blood 123:26-34
Bone marrow failure in Fanconi anemia

5. Disease evolution in Fanconi Anemia
Kutler et al., Blood, 2003

6. Chromosome fragility in Fanconi anemia

7. C. Group Gene Reference
FA-A FANCA Lo Ten Foe et al. Nature Genetics 1996
FABC Consortium. Nature Genetics 1996
FA-B FANCB Meetei et al Nature Genetics 2004
FA-C FANCC Strathdee et al. Nature, 1992
FA-D1 FANCD1/BRCA2 Howlett et al. Science, 2002
FA-D2 FANCD2 Timmers et al. Mol Cell, 2001
FA-E FANCE De Winter et al. Am. J. Hum Genet 2000
FA-F FANCF De Winter et al. Nature Genet. 2000
FA-G FANCG De Winter et al. Nature Genet. 1998
FA-I FANCI Smogorzewska et al. Cell 2007
FA-J FANCJ/BRIP1 Levran et al. Nature Genet. 2005;
Levitus et al. Nature Genet. 2005;
FA-L FANCL Ruhikanta et al. Nature Genet. 2003
FA-M FANCM Meetei et al Nature Genetics 2005
FA-N FANCN/PALB2 Reid et al Nature Genetics 2007
Xia et al Nature Genetics 2007
FA-O FANCO/RAD51C Vaz et al Nature Genetics 2010
FA-P FANCP/SLX4 Stoepker et al Nature Genetics 2011
Kim et al Nature Genetics 2011
15+1 complementation Groups in Fanconi Anemia

8. Interstrand crosslink repair (ICLR)
Fork stalling
Unhooking
Translesion sythesis
Recombination

9. 1 10 100 1000
100
80
60
40
20
0
FANC-C
FANC-G
FANC-F
FANC-A
MMC (nM)
Relativesurvival%
Empty
Retroviral subtyping of FA

10. Genetic subtyping of 143 Spanish FA patients
Callen et al., Blood 2005; Casado et al., J Med Genet 2007; Kalb et al Am J Hum Genet
2007; Castella et al Blood 2011
Unassigned

11. whole exome sequencing
501500
498499
FA 287

12. Mutations in the XPF nuclease lead to three
rare disorders: XP, XFE-progeria and FA
Xeroderma pigmentosum XFE-progeria Fanconi anemia
FANCQ alias for XPF in HUGO
Bogliolo et al., 2013, Am J Hum Genet

13. Interstrand crosslink
repair (ICLR)
Fork stalling
Unhooking
Homologous recombination
Nucleotide excision
repair (NER)
recognition
dual incision
excision
DNA synthesis
ligation
UV

14. NER
ICLR
Xeroderma pigmentosum
NER
ICLR
Xeroderma pigmentosum
NER
ICLR
Fanconi anemia
NER
ICLR
Fanconi anemia
NER ICLR
Progeria
NER ICLR
Progeria
1 gene (XPF), 2 repair pathways, 3 syndromes
Bogliolo et al., Am J Hum Genet (2013)
UV skin sensitivity anemia Anemia + UV skin
sensitivity

15. C. Group Gene Reference
FA-A FANCA Lo Ten Foe et al. Nature Genetics 1996
FABC Consortium. Nature Genetics 1996
FA-B FANCB Meetei et al Nature Genetics 2004
FA-C FANCC Strathdee et al. Nature, 1992
FA-D1 FANCD1/BRCA2 Howlett et al. Science, 2002
FA-D2 FANCD2 Timmers et al. Mol Cell, 2001
FA-E FANCE De Winter et al. Am. J. Hum Genet 2000
FA-F FANCF De Winter et al. Nature Genet. 2000
FA-G FANCG De Winter et al. Nature Genet. 1998
FA-I FANCI Smogorzewska et al. Cell 2007
FA-J FANCJ/BRIP1 Levran et al. Nature Genet. 2005;
Levitus et al. Nature Genet. 2005;
FA-L FANCL Ruhikanta et al. Nature Genet. 2003
FA-M FANCM Meetei et al Nature Genetics 2005
FA-N FANCN/PALB2 Reid et al Nature Genetics 2007
Xia et al Nature Genetics 2007
FA-O FANCO/RAD51C Vaz et al Nature Genetics 2010
FA-P FANCP/SLX4 Stoepker et al Nature Genetics 2011
Kim et al Nature Genetics 2011
FA-Q FANCQ/ERCC4 Bogliolo et al Am J Hum Genet 2013
16 complementation Groups in Fanconi Anemia

17. DNA damage response
Ataxia Telang.
Nijmegen
Fanconi
Bloom
Seckle

18. Breast cancer risk in BRCA1/2 mutation carriers

19. April 2005
Synthetic lethality in cancer therapeutics

20. Synthetic lethality in cancer treatment
Lord and Ashworth BMC Biology 2010 8:38 doi:10.1186/1741-7007-8-38

23. 1 10 100 1000
100
80
60
40
20
0
FA disrupted
tumor cell
Tumor cell
Cisplatin concentration
Relativesurvival%
Chemo-sensitizing tumor cells through
disruption of the FA/BRCA pathway
Lyakhovich and Surralles, 2009

24. From genes to therapy
-Bone marrow or umbilicar cord blood
transplant
-Preimplantational embryo selection
-Gene therapy?
-Stem cell based regenerative medicine???

25. Dr. Eliane Gluckman and Matthew Farrow
1988

26. 1993
Dr. Pablo Rubinstein and Mitch Santa
Leukemia
M
etabolic
syndrom
es

27. Saviour babies to cure FA
Molly Nash

28. Barcelona, August 15th 2006

29. Trujillo and Surralles, in press
Savior babies and Fanconi anemia: low success
rates after 38 trials in 7 families

31. Gene therapy of severe immunodeficiencies

33. Fancostem/Fancolen team
C. Díaz de Heredia
Vall Hebron
J. Surrallés
UAB
J. Bueren
CIEMAT
J. Sevilla
Niño Jesús

34. Phase I/II Gene therapy trial of Fanconi anemia
patients with a new Orphan Drug consisting of a
lentiviral vector carrying the FANCA gene
Coordinator: Juan Bueren (Madrid)
http://www.eurofancolen.eu
EuroFancoLen Project
WP1 WP2 WP3 WP4
J. Surralles A. Thrasher M. CavazzanaA. Galy and F. Mavilio

35. Transduction with therapeutic
lentiviral vectors
blood mobilization
Plerixafor+filgrastim
CD34+ cells
Selection
Infusion of transduced graft
Gene therapy: Genetic Correction of
Hematopoietic Stem Cells (CD34+)

36. cPPT Wpre*
GA
U3 R U5
PGK
SD SA
RRE
y
FANCA
CMV R U5
PGK-FANCA.Wpre* LV
Orphan Medicinal Product Designation: EU 3/10/822
Lentiviral vector containing the Fanconi anemia A (FANCA) gene
Lentiviral vector: better and safer

37. Figure 3
Navarro et al., 2008, Blood; Rio et al., 2009, Blood
It works in mice
Gene therapy of FANCD1 KO mice (BRCA2-/-)

38. “Natural” vs “medical” gene therapy
Mutation Reverse mutation
(mosaics)
After gene therapy

39. Mosaicism often results in fast
clinical improvement
hemoglobin
platelets
Des 2008
T=G
Oct 2013
T>>>G
Feb 2011
T>G
c.3335T>G

40. Future

43. FA fibro
IPS
cytokines Blood
Haematopoietic
progenitors
3-4 transcription
factors* (retro)
*KLF4, cMYC, OCT4, SOX2
FA gene (lenti)
Raya et al. Nature, 2009
Disease-corrected haematopoietic progenitors from
Fanconi anemia induced pluripotent stem (iPS) cells

44. Disease-free cardiomyocytes from Fanconi anemia skin
Nature 460:53-59

45. Making blood cells from IPS cells
Liu et al., Nature Communications, 2014

46. Modeling Fanconi Anemia
therapeutics using patients iPSCs
Liu et al., Nature Communications, 2014

47. DSB
DSB
mutation repair (genome editing or
homologous recombination)
save integration (save harbour)
Nucleases
(ZFN, TALEN, CRISPR)
Fixing rare diseases by genome editing

48. Spanish FANCA mutational spectrum
Point mutation
Splicing mutation
Microdeletion
Microinsertion
Deletion
Callén et al., 2005; Blood; Castella et al., Blood 2011
C>T missense mutation

49. Genome editing to correct a FANCA mutation
by homologous recombination
(helper dependent adenoviral vectors targeting FANCA)
FA Crt FA-CFA Crt FA-C
Liu et al., Nature Communications, 2014

50. Save harbour: the AAVS1 locus and ZFN
Rio et al., EMBO Mol Med, 2014

51. Harvest of
CD34+ cells
Infusion of
genetically-
corrected Cells
PATIENT
Gene therapy in the future
Freezing of
CD34+ cells
Genome
editing

52. Why research on rare genetic diseases?
• First umbilical cord blood transplant
• First savior baby
• Among the first gene therapy trials
• First generated disease-free IPS
• Model to understand fundamental
biological processes (genome stability,
cancer, ageing, pluripotency…)
• Tool to find new cancer drugs and new
cancer genes

53. Surrallés’ lab members, Barcelona
Dr. M. Bogliolo
Dr. L. Mina
Dr. J. Minguillón
Dr. R. Pujol
Dr. MJ Ramírez
Dr. J. Surrallés
Dr. G. Hernández
Dr. M. Aza-Carmona
A. Molina
M. Marin
H. Montanuy
M. Peiró
Genome Instability Group: www.gig.uab.cat