Clinical and genetic features of amyotrophic lateral sclerosis patients with C9orf72 mutations

An expansion of the GGGGCC hexanucleotide in the non-coding region of C9orf72 represents the most common cause of familial amyotrophic lateral sclerosis. The objective was to describe and analyse the clinical and genetic features of amyotrophic lateral sclerosis patients with C9orf72 mutations in a large population. Between November 2011 and December 2020, clinical and genetic characteristics of n = 248 patients with amyotrophic lateral sclerosis carrying C9orf72 mutations were collected from the clinical and scientific network of German motoneuron disease centres. Clinical parameters included age of onset, diagnostic delay, family history, neuropsychological examination, progression rate, phosphorylated neurofilament heavy chain levels in CSF and survival. The number of repeats was correlated with the clinical phenotype. The clinical phenotype was compared to n = 84 patients with SOD1 mutations and n = 2178 sporadic patients without any known disease-related mutations. Patients with C9orf72 featured an almost balanced sex ratio with 48.4% (n = 120) women and 51.6% (n = 128) men. The rate of 33.9% patients (n = 63) with bulbar onset was significantly higher compared to sporadic (23.4%, P = 0.002) and SOD1 patients (3.1%, P < 0.001). Of note, 56.3% (n = 138) of C9orf72, but only 16.1% of SOD1 patients reported a negative family history (P < 0.001). The GGGGCC hexanucleotide repeat length did not influence the clinical phenotypes. Age of onset (58.0, interquartile range 52.0-63.8) was later compared to SOD1 (50.0, interquartile range 41.0-58.0;P < 0.001), but earlier compared to sporadic patients (61.0, interquartile range 52.0-69.0;P = 0.01). Median survival was shorter (38.0 months) compared to SOD1 (198.0 months, hazard ratio 1.97, 95% confidence interval 1.34-2.88;P < 0.001) and sporadic patients (76.0 months, hazard ratio 2.34, 95% confidence interval 1.64-3.34;P < 0.001). Phosphorylated neurofilament heavy chain levels in CSF (2880, interquartile range 1632-4638 pg/ml) were higher compared to sporadic patients (1382, interquartile range 458-2839 pg/ml;P < 0.001). In neuropsychological screening, C9orf72 patients displayed abnormal results in memory, verbal fluency and executive functions, showing generally worse performances compared to SOD1 and sporadic patients and a higher share with suspected frontotemporal dementia. In summary, clinical features of patients with C9orf72 mutations differ significantly from SOD1 and sporadic patients. Specifically, they feature a more frequent bulbar onset, a higher share of female patients and shorter survival. Interestingly, we found a high proportion of patients with negative family history and no evidence of a relationship between repeat lengths and disease severity. Wiesenfarth et al. report that amyotrophic lateral sclerosis patients with C9orf72 mutations differ significantly from sporadic patients and SOD1 gene carriers, including a higher share of bulbar onset, female patients, more severe neuropsychological deficits and shorter survival. No evidence of a relationship between repeat lengths and disease severity was found

RAS-pathway mutation patterns define epigenetic subclasses in juvenile myelomonocytic leukemia

Juvenile myelomonocytic leukemia (JMML) is an aggressive myeloproliferative disorder of early childhood characterized by mutations activating RAS signaling. Established clinical and genetic markers fail to fully recapitulate the clinical and biological heterogeneity of this disease. Here we report DNA methylome analysis and mutation profiling of 167 JMML samples. We identify three JMML subgroups with unique molecular and clinical characteristics. The high methylation group (HM) is characterized by somatic PTPN11 mutations and poor clinical outcome. The low methylation group is enriched for somatic NRAS and CBL mutations, as well as for Noonan patients, and has a good prognosis. The intermediate methylation group (IM) shows enrichment for monosomy 7 and somatic KRAS mutations. Hypermethylation is associated with repressed chromatin, genes regulated by RAS signaling, frequent co-occurrence of RAS pathway mutations and upregulation of DNMT1 and DNMT3B, suggesting a link between activation of the DNA methylation machinery and mutational patterns in JMML

Tauroursodeoxycholic acid in patients with amyotrophic lateral sclerosis

Background: Amyotrophic lateral sclerosis (ALS) is a chronic neurodegenerative rare disease that affects motor neurons in the brain, brainstem, and spinal cord, resulting in progressive weakness and atrophy of voluntary skeletal muscles. Although much has been achieved in understanding the disease pathogenesis, treatment options are limited, and in Europe, riluzole is the only approved drug. Recently, some other drugs showed minor effects. Methods: The TUDCA-ALS trial is a phase III, multicenter, randomized, double-blind, placebo-controlled, parallel-group clinical trial. The study aims to enroll 320 patients in 25 centers across seven countries in Europe. Enrolled patients are randomized to one of two treatment arms: TUDCA or identical placebo by oral route. The study measures disease progression during the treatment period and compares it to natural progression during a no-treatment run-in phase. Clinical data and specific biomarkers are measured during the trial. The study is coordinated by a consortium composed of leading European ALS centers. Conclusion: This trial is aimed to determine whether TUDCA has a disease-modifying activity in ALS. Demonstration of TUDCA efficacy, combined with the validation of new biomarkers, could advance ALS patient care. Clinical trial registration: ClinicalTrials.gov, identifier: NCT03800524

Knochendichteanalyse im Becken, Hüfte und der Wirbelsäule mittels der quantitativen Computertomographie (QCT)

Die osteoporotische Beckenfraktur stellt eine stark zunehmende Gesundheitsgefährdung mit schwerwiegenden individuellen, gesellschaftlichen und ökonomischen Folgen dar. In dieser Arbeit sollte die Knochendichte (BMD) im Becken an den frakturrelevanten Lokalisationen im Alter untersucht werden mit dem Ziel, wichtige Informationen über die strukturellen Besonderheiten der Frakturprädilektionsstellen zu gewinnen. Diese Erkenntnisse können als Grundlage für folgende Studien zur Optimierung der Therapie fungieren. Die BMD-Bestimmung in der Multidetektorcomputertomografie (MDCT) und Einführung einer asynchronen Messmethodik im Becken sollen eine Möglichkeit der zeit- und kosten-sparenden Erfassung von Risikopatienten und der präoperativen BMD-Messung aufzeigen. Im µCT wurden die BMD und weitere strukturelle Parameter an Biopsien aus acht Lokalisationen der fünf untersuchten Beckenringe und am Lendenwirbelkörper 5 (LWK 5) erfasst und auf bestehende Korrelationen geprüft, um Hinweise auf die optimale Positionierung und Verankerung eines zu entwickelnden Implantates zu erhalten. Die Bestimmung der Korrelation der BMD zwischen Becken, LWS und Hüfte in der quantitativen Computertomografie (QCT) und MDCT erfolgten an 22 weiblichen und 26 männlichen prospektiv untersuchten Patienten mit einem Durchschnittsalter von 64 Jahren anhand diagnostischer CT-Abdomenuntersuchungen mit untergelegtem Knochendichtephantom. Neben der LWS in der QCT-Auswertungskonsole wurde die BMD in Hüfte, LWS und Becken in der MDCT mittels einer Konversionsgleichung zwischen den HU-Werten des diagnostischen CT-Abdomen und den Messwerten aus dem QCT nach Eliminierung des Kontrastmitteleffektes ermittelt. Diese Methode soll eine Bestimmung der BMD im Becken bereits aus dem im höheren Lebensalter häufig durchgeführten CT-Abdomen ermöglichen. Eine asynchrone, phantomlose Erhebung der BMD aus dem MDCT an 40 Patienten ließ den Vergleich der BMD der früheren und der heutigen älteren Hauptrisikogruppe für Beckenfrakturen in verschiedenen Lokalisationen des Beckens zu. Die Korrelation zwischen der BMD-Messung aus der QCT und der MDCT beträgt r = 0,99 für die weiblichen und r = 0,96 für die männlichen Patienten. Eine Übereinstimmung der beiden Messverfahren wurde anhand eines Bland-Altman-Plots geprüft, der für die weibliche und männliche Patientengruppe ein vergleichbares Bias zeigt. Die höchste BMD am Becken wurde erwartungsgemäß am hinteren Beckenring im sakralen Wirbelkörper 1 (SWK 1) gemessen. Die niedrigsten absoluten BMD-Werte fanden sich an den häufigsten Frakturstellen des vorderen und hinteren Beckenringes, dem Schambein und dem sakralen Flügel. Im Becken liegen die BMD-Werte, mit Ausnahme von SWK 1, bereits in der Gruppe der 25- bis 35-jährigen unter der Osteopenieschwelle von 120 mg/cm³. Sehr hohe Korrelationen der BMD von r ≥ 0,9 gelang es zwischen den LWK 1-3 ebenso wie hohe Korrelationen in nahezu allen Messlokalisationen von 0,7 < r ≤ 0,9 zwischen der LWS und dem Becken zu erfassen. So betragen diese bei höchster Signifikanz (p < 0,001) r ≥ 0,8 zum SWK 1, r = 0,72 - 0,9 zum Schambein, r = 0,67 - 0,77 zum sakralen Flügel und r = 0,72-0,75 zum Beckenkamm. Fielen die Korrelationen des Beckens zum Schenkelhals geringer aus, konnten innerhalb des Beckens zwischen den Frakturstellen am sakralen Flügel und Schambein mit r = 0,75-0,81 hohe Korrelationskoeffizienten errechnet werden. In vitro stellten sich die Korrelationen des LWK 5 bei absolut höheren BMD-Werten zum SWK 1, dem sakralen Flügel und dem ventralen Os Ilium am höchsten dar. Die in der MDCT bzw. der QCT aufgezeigten Korrelationen der BMD konnten für nahezu alle Lokalisationen, Geschlechts- und Altersgruppen die in der Literatur angegebenen Werte im axialen Knochen erreichen oder übertreffen. Die zielgenaue Erfassung des trabekulären Knochens im MDCT mag eine Reduktion des Einflusses der Kortikalis und der anatomischen Komplexität des Beckenrings auf die gemessene BMD zur Folge haben. Im Gegensatz zur Dual-Röntgen-Absorptiometrie (DXA) sind die Messungen dieser Studie weniger von degenerativen Veränderungen, der körperlichen Konstitution der Patienten und dem Knochenvolumen abhängig. Höhere absolute BMD-Werte in vitro können in einer möglichen Beeinträchtigung der Struktur der Knochenprobe durch die Entnahmetechnik und die lokale anatomische Beschaffenheit der Kortikalis begründet sein. Eine Abschätzung der BMD des Beckens aus Biopsien des LWK 5 und somit die Verteilung der Beckenringe auf die Gruppen zur Implantattestung scheint bei den bestehenden Korrelationen möglich. Es konnte gezeigt werden, dass eine hohe Korrelation der BMD im Becken zur LWS in vivo in allen Altersgruppen, bei im Vergleich zur Hüfte und LWS jedoch deutlich niedrigeren, an vielen Lokalisationen bereits beim jungen Patienten osteopenischen BMD-Werten, im MDCT erfasst werden kann. Eine belastungsarme, zeit- und kostensparende präoperative Abschätzung der BMD des Beckens im MDCT, die eine frühzeitige Erfassung von Risikopatienten und Optimierung der Therapie bedeuten kann, ist anhand der Ergebnisse dieser Studie möglich. Die Anwendbarkeit in der klinischen Praxis muss in weiteren prospektiven klinischen Studien geprüft werden

Structural and microstructural neuroimaging signature of C9orf72-associated ALS: A multiparametric MRI study

Background: ALS patients with hexanucleotide expansion in C9orf72 are characterized by a specific clinical phenotype, including more aggressive disease course and cognitive decline. Computerized multiparametric MRI with gray matter volumetry and diffusion tensor imaging (DTI) to analyze white matter structural connectivity is a potential in vivo biomarker. Objective: The objective of this study was to develop a multiparametric MRI signature in a large cohort of ALS patients with C9orf72 mutations. The aim was to investigate how morphological features of C9orf72-associated ALS differ in structural MRI and DTI compared to healthy controls and ALS patients without C9orf72 mutations. Methods: Atlas-based volumetry (ABV) and whole brain-based DTI-based analyses were performed in a cohort of n = 51 ALS patients with C9orf72 mutations and compared with both n = 51 matched healthy controls and n = 51 C9orf72 negative ALS patients, respectively. Subsequently, Spearman correlation analysis of C9orf72 ALS patients‘ data with clinical parameters (age of onset, sex, ALS-FRS-R, progression rate, survival) as well as ECAS and p-NfH in CSF was performed. Results: The whole brain voxel-by-voxel comparison of fractional anisotropy (FA) maps between C9orf72 ALS patients and controls showed significant bilateral alterations in axonal structures of the white matter at group level, primarily along the corticospinal tracts and in fibers projecting to the frontal lobes. For the frontal lobes, these alterations were also significant between C9orf72 positive and C9orf72 negative ALS patients. In ABV, patients with C9orf72 mutations showed lower volumes of the frontal, temporal, and parietal lobe, with the lowest values in the gray matter of the superior frontal and the precentral gyrus, but also in hippocampi and amygdala. Compared to C9orf72 negative ALS, the differences were shown to be significant for cerebral gray matter (p = 0.04), especially in the frontal (p = 0.01) and parietal lobe (p = 0.01), and in the thalamus (p = 0.004). A correlation analysis between ECAS and averaged regional FA values revealed significant correlations between cognitive performance in ECAS and frontal association fibers. Lower FA values in the frontal lobes were associated with worse performance in all cognitive domains measured (language, verbal fluency, executive functions, memory and spatial perception). In addition, there were significant negative correlations between age of onset and atlas-based volumetry results for gray matter. Conclusions: This study demonstrates a distinct pattern of DTI alterations of the white matter and ubiquitous volume reductions of the gray matter early in the disease course of C9orf72-associated ALS. Alterations were closely linked to a more aggressive cognitive phenotype. These results are in line with an expected pTDP43 propagation pattern of cortical affection and thus strengthen the hypothesis that an underlying developmental disorder is present in ALS with C9orf72 expansions. Thus, multiparametric MRI could contribute to the assessment of the disease as an in vivo biomarker even in the early phase of the disease

RAS-pathway mutation patterns define epigenetic subclasses in juvenile myelomonocytic leukemia

Juvenile myelomonocytic leukemia (JMML) is an aggressive myeloproliferative disorder of early childhood characterized by mutations activating RAS signaling. Established clinical and genetic markers fail to fully recapitulate the clinical and biological heterogeneity of this disease. Here we report DNA methylome analysis and mutation profiling of 167 JMML samples. We identify three JMML subgroups with unique molecular and clinical characteristics. The high methylation group (HM) is characterized by somatic PTPN11 mutations and poor clinical outcome. The low methylation group is enriched for somatic NRAS and CBL mutations, as well as for Noonan patients, and has a good prognosis. The intermediate methylation group (IM) shows enrichment for monosomy 7 and somatic KRAS mutations. Hypermethylation is associated with repressed chromatin, genes regulated by RAS signaling, frequent co-occurrence of RAS pathway mutations and upregulation of DNMT1 and DNMT3B, suggesting a link between activation of the DNA methylation machinery and mutational patterns in JMML

Metabolic alterations precede neurofilament changes in presymptomatic ALS gene carriersResearch in context

Summary: Background: The emergence of potentially effective new therapies for genetic forms of amyotrophic lateral sclerosis (ALS) necessitates the identification of biomarkers to facilitate early treatment, prior to the onset of motor symptoms. Here, we sought to investigate whether metabolic alterations are detectable in presymptomatic ALS gene mutation carriers, and whether such alterations precede neurofilament light chain (NfL) changes in serum. Methods: Between 02/2014 and 11/2021, we prospectively studied 60 presymptomatic ALS gene mutation carriers (40% male, age 48.7 ± 14.9; 28 C9orf72, 22 SOD1, 10 other) compared to 73 individuals from the same families (47% male, age 47.4 ± 12.9) without pathogenic mutations as controls. Bioimpedance analysis (BIA) and indirect calorimetry were performed, and Body Mass Index (BMI), Fat Mass (FM), Body Fat Percentage, Body Water (BW), Lean Body Mass (LBM), Extracellular Mass (ECM), Body Cell Mass (BCM), ECM/BCM ratio, Cells Percentage, Phase Angle, Resting Metabolic Rate (RMR), Metabolic Ratio (MR), and NfL were measured. Participants and evaluators were blinded regarding gene carrier status. Findings: Presymptomatic ALS gene carriers showed reduced LBM (p = 0.02), BCM (p = 0.004), Cells Percentage (p = 0.04), BW (p = 0.02), Phase Angle (p = 0.04), and increased ECM/BCM ratio (p = 0.04), consistently indicating a loss of metabolically active body cells. While in C9orf72 mutation carriers all tissue masses were reduced, only metabolically active tissue was affected in SOD1 mutation carriers. Unexpectedly, RMR (p = 0.009) and MR (p = 0.01) were lower in presymptomatic ALS gene carriers compared to non-carriers. NfL serum levels were similar in mutation carriers and non-carriers (p = 0.60). Interpretation: The observed metabolic phenomena might reflect reduced physical activity and/or preemptive, insufficient compensatory mechanisms to prepare for the later hypermetabolic state. As pre-symptomatic biomarkers we propose ECM/BCM ratio and Phase Angle for SOD1, and a 4-compartment affection in BIA for C9orf72 mutation carriers. Funding: This work was an investigator-initiated trial. On the German side, there was no institutional or industrial funding. On the Swedish side, this work was supported by grants from the Swedish Brain Foundation (grants nr. 2013-0279, 2016-0303, 2018-0310, 2020-0353), the Swedish Research Council (grants nr. 2012-3167, 2017-03100), the Knut and Alice Wallenberg Foundation (grants nr. 2012.0091, 2014.0305, 2020.0232), the Ulla-Carin Lindquist Foundation, Umeå University (223-2808-12, 223-1881-13, 2.1.12-1605-14) and the Västerbotten County Council (grants nr 56103-7002829), King Gustaf V:s and Queen Victoria's Freemason's Foundation

Effects of tofersen treatment in patients with SOD1-ALS in a “real-world” setting – a 12-month multicenter cohort study from the German early access programResearch in context

Summary: Background: In April 2023, the antisense oligonucleotide tofersen was approved by the U.S. Food and Drug Administration (FDA) for treatment of SOD1-amyotrophic lateral sclerosis (ALS), after a decrease of neurofilament light chain (NfL) levels had been demonstrated. Methods: Between 03/2022 and 04/2023, 24 patients with SOD1-ALS from ten German ALS reference centers were followed-up until the cut-off date for ALS functional rating scale revised (ALSFRS-R), progression rate (loss of ALSFRS-R/month), NfL, phosphorylated neurofilament heavy chain (pNfH) in cerebrospinal fluid (CSF), and adverse events. Findings: During the observation period, median ALSFRS-R decreased from 38.0 (IQR 32.0–42.0) to 35.0 (IQR 29.0–42.0), corresponding to a median progression rate of 0.11 (IQR −0.09 to 0.32) points of ALSFRS-R lost per month. Median serum NfL declined from 78.0 pg/ml (IQR 37.0–147.0 pg/ml; n = 23) to 36.0 pg/ml (IQR 22.0–65.0 pg/ml; n = 23; p = 0.02), median pNfH in CSF from 2226 pg/ml (IQR 1061–6138 pg/ml; n = 18) to 1151 pg/ml (IQR 521–2360 pg/ml; n = 18; p = 0.02). In the CSF, we detected a pleocytosis in 73% of patients (11 of 15) and an intrathecal immunoglobulin synthesis (IgG, IgM, or IgA) in 9 out of 10 patients. Two drug-related serious adverse events were reported. Interpretation: Consistent with the VALOR study and its Open Label Extension (OLE), our results confirm a reduction of NfL serum levels, and moreover show a reduction of pNfH in CSF. The therapy was safe, as no persistent symptoms were observed. Pleocytosis and Ig synthesis in CSF with clinical symptoms related to myeloradiculitis in two patients, indicate the potential of an autoimmune reaction. Funding: No funding was received towards this study

Tauroursodeoxycholic acid in patients with amyotrophic lateral sclerosis: The TUDCA-ALS trial protocol

Background: Amyotrophic lateral sclerosis (ALS) is a chronic neurodegenerative rare disease that affects motor neurons in the brain, brainstem, and spinal cord, resulting in progressive weakness and atrophy of voluntary skeletal muscles. Although much has been achieved in understanding the disease pathogenesis, treatment options are limited, and in Europe, riluzole is the only approved drug. Recently, some other drugs showed minor effects. Methods: The TUDCA-ALS trial is a phase III, multicenter, randomized, double-blind, placebo-controlled, parallel-group clinical trial. The study aims to enroll 320 patients in 25 centers across seven countries in Europe. Enrolled patients are randomized to one of two treatment arms: TUDCA or identical placebo by oral route. The study measures disease progression during the treatment period and compares it to natural progression during a no-treatment run-in phase. Clinical data and specific biomarkers are measured during the trial. The study is coordinated by a consortium composed of leading European ALS centers. Conclusion: This trial is aimed to determine whether TUDCA has a disease-modifying activity in ALS. Demonstration of TUDCA efficacy, combined with the validation of new biomarkers, could advance ALS patient care