Pattern of SQSTM1 Gene Variants in a Hungarian Cohort of Paget’s Disease of Bone

Paget’s disease of bone (PDB) is characterized by focal or multifocal increase in bone turnover. One of the most well-established candidate genes for susceptibility to PDB is Sequestosome 1 (SQSTM1). Mutations in SQSTM1 have been documented among Western-European, British and American patients with PDB. However, there is no information on SQSTM1 mutation status in PDB patients from the Central- and Eastern-European regions. In this study, we conducted a mutation screening for SQSTM1 gene variants in 82 PDB patients and 100 control participants in Hungary. Mutations of SQSTM1 were detected in 18 PDB patients (21.95%); associations between genotype and clinical characteristics were also analyzed. Altogether, six different exonic alterations, including two types of UTR variants in the SQSTM1 gene, were observed in our PDB patients. Similarly, to previous genetic studies on Paget’s disease, our most commonly detected variant was the c.1175C > T (p.Pro392Leu) in nine cases (four in monostotic and five in polyostotic form). We have surveyed the germline SQSTM1 variant distribution among Hungarian patients with PDB. We also highlighted that the pattern of the analyzed disease-associated pathophysiological parameters could partially discriminate PDB patients with normal or mutant SQSTM1 genotype. However, our findings also underline and strengthen that not solely SQSTM1 stands in the background of the complex PDB etiology. Electronic supplementary material The online version of this article (10.1007/s00223-020-00758-4) contains supplementary material, which is available to authorized users.


Introduction
Paget's disease of bone (PDB) is characterized by focal areas of rapid bone remodeling. This remodeling imbalance leads to mechanically weak, disorganized bone structure with irregular collagen fibers [1][2][3]. The pathological changes may result in mild to severe clinical manifestations in that some patients have no symptoms whereas others experience bone pain, deformity, pathological fractures, bone deformity and deafness [4][5][6]. There are marked differences in prevalence in different geographical regions [7,8]. There has been a decline in both prevalence and severity of the disease in many but not all regions in the last twenty years [9,10].
The etiology of the disease is incompletely understood but genetic factors play an important role. The most important susceptibility gene is Sequestosome 1 (SQSTM1) but genome-wide association studies have identified several additional loci that predispose to classical PDB at a genome wide significant level [11][12][13][14][15].
Population-based distribution of alterations is well documented in more details among Western-European, British, American and Australian origins as well [14,16]. However, there are no literature data in relation to the mutational pattern of PDB patients in the Central-and Eastern-European region.
This study describes the SQSTM1 mutations and the clinical parameters of Hungarian PDB patients.

Participants and Routine Methods
The study participants were treated between 2006-2016 at the National Institute of Rheumatology and Physiotherapy, Budapest, Hungary. Clinical diagnosis was made on whole body scan to all PDB patients, radiographs of all bones displaying an uptake in bone scan to perform differential diagnosis to all. The number of bones affected by PDB was established from 99Tc-labelled methylene diphosphate (MDP)-labelled bone scintigraphy. We measured routine laboratory parameters in all patients and in the case of high GGT, abdominal ultrasound was also made [19,20]. Plasma total alkaline phosphatase (ALP) activity was measured using a Dimension Xpand analyzer (Siemens Diagnostics, Germany), with a reference range of 98-280 U/L. ALP at the time of diagnosis was used in the analysis.
The presence of bone deformity was recorded by the attending physicians who were asked to assess whether the patient had clinical evidence of bone deformity or not on physical examination [17,18] We excluded people with rare PDB-like syndromes such as familial expansile osteolysis, expansile skeletal hyperphosphatasia and juvenile Paget's disease of bone. In the study only untreated PDB cases at the time of diagnosis were included. Genetic analysis was performed on 82 Hungarian patients (59% male, 41% female) with Paget's disease of bone. The majority of PDB patients were unrelated (78 of 82), four patients (two pairs of siblings) had family history. Age at recruitment ranged from 45 to 94 years with an average (± SD) of 71.6 ± 8.74 years (Table 1).
We collected 100 control participants from our centre, who were affected by mild degenerative rheumatological conditions as spondylosis, scoliosis or osteoarthritis. The controls came from the same geographic area as the PDB patients. They had the same ethnicity, they were not related, and were not age-matched to the PDB patients. PDB was ruled out in controls by routine laboratory parameters (plasma alkaline phosphatase and GGT level measuring). The control patients did not have evidence of bone pain and their ALP levels were in the normal range, but scintigraphy was not routinely performed in these individuals. The average (± SD) age of the control group was 62.2 ± 11.91 years, with 44% male and 56% female participants.

DNA Isolation and Sequencing
Genomic DNA was isolated from EDTA-anticoagulated peripheral blood samples using QIAamp DNA Blood Mini Kit on automated QIAcube HT System (QIAGEN, Hilden, Germany) according to the manufacturer's instructions. We assessed the quality and concentration of the isolated DNA using NanoDrop spectrophotometer (NanoDrop Technologies, Montchanin, DE, USA) at 260/280 nm.
For variant screening, exons 7 and 8 were targeted, including the intron-exon boundaries. The primer set used was previously designed by Hocking LJ and coworkers [19,20]: For exon 7: forward 5′TTA AAG TCA CGC TGG GAA CCT GCT 3′; reverse-5′AGG GCA GGA TGC TCT AAA  [21]. PDB patients were defined as 'mutant' if any known pathogenic or uncertain variants were detected in the analyzed exonic regions. We utilized a clinically certified annotation platform VarSome to interpret our sequence data and to summarize the possible impact of the described variants [22]. Due to our sequencing design, we could also identify intronic variants in the gene. We have used ESEfinder 2.0 software (https ://krain er01.cshl.edu/tools /ESE2/index .html) to predict in silico whether the intronic variants could show a pathogenic behaviour. This software identifies the intronic binding sites for exonic splicing enhancers (ESE).

Statistical Analysis
Student's t test was used to evaluate differences between patients with and without SQSTM1 mutations for continuous variables and Pearson's chi-square test was used for categorical variables. In cases where chi-square was suspect (20% of the cells had expected count less than 5), Fisher's exact test (two-sided) was also used.

Results
The clinical characteristics of patients are summarized in Table 1. Patients with SQSTM1 mutations differed significantly from those without mutations in terms of family history and bone pain thought to be caused by PDB. No significant differences were detected between genotype groups in term of other parameters Genetic analysis was completed in all the examined 182 patients. Six different exonic alterations including two types of UTR variants in the gene were observed in PDB patients (listed in Table 2). Eighteen out of the 82 PDB-affected participants (21.9%) carried a mutation. Four patients (two pairs of siblings) had family history. One of the two brothers (aged 71) carried the variant c.*174insTG; the other (69) did not show any pathogenic SQSTM1 gene variations. Both, the older (74) female sibling and her younger (70) brother, carried the NM_003900.5:c.1175C > T, p.Pro392Leu mutation. Phenocopy refers to a non-hereditary change, in this case due to the absence of the mutation in one of the siblings. This might be a possible scenario; however, no relevant clinical differences were found.

Discussion
This is the first study about the distribution of germline mutations among Hungarian patients diagnosed with PDB. Population-based screening of variants has not yet been reported from the Central European region and especially in any Hungarian PDB cohort. To map the detailed genetic aspects of a hereditary disease, it is indispensable to have a wide range of genomic DNA data from different nationalities and ethnic groups.
Eighteen out of the 82 PDB-affected participants (23.2%) harbored a mutation in SQSTM1 gene. The incidence of the p.Pro392Leu mutations in PDB varies in different populations worldwide from 2.4-16%. Currently, there are 139 annotated variants from which 34 were classified as pathogenic in the ClinVar database. Based on recent literature about PDB, most of the clinically relevant causal sequence variants are clustered within the ubiquitin-associated (UBA) domain encoded by exon 7-8 [12,14].
The distribution by country are as follows: 2.4-3.7% and 5.4-7.3% in Dutch and Belgian cohort, respectively, 4.8-5.4% in Italian series and 15.6% in Spanish PDB participants as well as 8.6-8.9% in those of British ancestry and 9-16% in the French-Canadian population. [12,14,15,23]. Consistent with other studies, p.Pro392Leu (rs104893941, c.1175C > T) was the most frequently identified pathogenic single-nucleotide variant (SNV) in our patients. The substitution of Pro to Leu disrupts the ubiquitin-binding activity of Sequestosome 1. Nearly, half (47%0.37%) of the detected alterations was this recurrent missense variant as well as 11% (9/82) of our cases carrying the p.Pro392Leu mutation. Among the noticed SNVs, one nonsense NM_003900.5:c.1185dup (p.Glu396Ter) variant-causing premature termination-was revealed in a man, who was diagnosed with monostotic PDB affecting the scapula at age 50 years. This variant effectively removes the large majority of UBA domain in the gene product [24].
Furthermore, we determined two distinct 3′ UTR variants which cause a 2-bp TG insertion (NM_003900.5:c.*174_*175 =) or 3-bp deletion (NM_003900.5:c.*2_*4delCAC) after the stop codon and they were classified as likely benign or VUS (Variant of Uncertain Significance), respectively. In one genetic study of Lucas et al., 3′ UTR polymorphisms have been noted without marked differences in their allele frequencies between British PDB cases and controls [25]. It has been well-documented that microRNAs (miRs) widely modulate gene expression through binding the 3′ untranslated region of target mRNAs [26].
Although not yet proven today, it cannot be ruled out, so the two 3′UTR variants we found may affect miRNA binding sites and regulate SQSTM1 expression.
From our 100 control participants, two showed SQSTM1 variants. One carried a NM_003900.5:c.*83 = (G > A substitution) variant-with clinically uncertain importancein 3′ UTR of exon 8, and one exhibited the pathogenic c.1175C > T (p.Pro392Leu) alteration. According to the original article by Visconti MR et al., the overall frequency of alterations is on average 0.07% among unaffected controls [27] and, consistently, the allele frequency of p.Pro392Leu in the EXaC database has been reported to be 0.10%. In this regard it is interesting to note that some patients with pathogenic variants in SQSTM1 do not develop PDB but instead present with neurological disease such as amyotrophic lateral sclerosis (ALS) as part of multisystem proteinopathy syndromes [28] The reason underlying these different presentations remains incompletely understood but there is evidence that digenic inheritance of more than one variant may play a role [29].
There is compelling evidence that intronic variants have been potentially associated to the pathogenesis of ALS and early-onset Alzheimer dementia, as well [30][31][32]. However, clinical significance of the intronic mutations in PDB has not yet been proven.
To summarize the findings of genetic analysis and the clinical characteristics of Hungarian PDB cohort, we can conclude that the alterations in our PDB patients (21.95%) lay on the higher end of the range (10%-21%) reported in the literature. The recurrent c.1175C > T (p.Pro392Leu) sequence variant incidence has been correlated with the globally available average allele frequency (11% vs. 7.1%) among unrelated PDB cases. Likewise, we have seen some minor variations in the clinical manifestation and disease phenotypes. Family history of PBD and bone pain thought to be caused by PBD occurred significantly higher in case of SQSTM1 mutations. Although SQSTM1 has been associated with severity [27], previous studies have not indicated more prevalence of Pagetic pain. These few differences can be explained by the different demographic features and the relatively low sample size.
We have surveyed the germline variant distribution among Hungarian patients with Paget's disease of bone. We also highlighted that the pattern of the analyzed diseaseassociated pathophysiological parameters could partially discriminate PDB patients with normal or mutant genotype. The suspected patterns need to be verified and tested on a larger sample; the next step of this investigation.
Funding Open access funding provided by National Institute of Rheumatology and Physiotherapy.

Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval
The study was approved by the Regional Committee of Science and Research Ethics (Permission Number: ad.S-64/2009-1 0 18EKU), and all patients gave written informed consent.
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