Funding Research into Paget's Disease

The Paget's Association funds many aspects of research into Paget's disease.

Here are just a few of the Paget's Research Projects that the Paget's Association has funded. You can download our Research and Educational Funding leaflet here:

DEVELOPING A 3D BONE MODEL

Developing a Fully Human 3D Bone Organ Model of Paget’s Disease

On hearing the news that the Paget's Association had approved funding for their Paget's research Professor Hulley, from the Botnar Research Centre at the University of Oxford, said, “Thank you!! This is very good news. It means a great deal to us to be able to develop our system in this way to be more helpful to patients. We are enormously grateful to the Paget’s Association for their interest and vision!”.

Professor Philippa Hulley and Dr Helen Knowles summarise their fascinating new project below.

"Paget’s disease affects all three specialist bone cells that work together to engineer the mechanical architecture of human bones. These cell types are osteoblasts that build bone, osteoclasts that break it down and osteocytes that form a long‑lived residential network, locally co‑ordinating the work of the other two cells. Paget’s causes focal loss of bone where the osteoclasts become aggressively active and erode bone excessively and the osteoblasts fail to repair these weakened patches properly. This suggests a focal loss of control that is likely to come from the osteocytes because they live the longest of all the bone cells and provide a locally co‑ordinated response to damage or changes in loading. The most common disease‑causing mutation in Paget’s disease is in a gene called SQSTM1 and our goal is to investigate, for the first time, how this mutation affects the regulatory/co‑ordinating role of the osteocytes.

Osteocytes are notoriously difficult to grow in the lab and, since Paget’s is a human disease, mouse models are limited in predicting mechanisms and responses to treatment. However, we recently discovered how to make human osteocytes from donated bone tissue, scraps of “sawdust” leftover from cutting or drilling when knees and hips are replaced. We can grow the bone cells over several months in statically loaded, 3D mini‑bone constructs that move through the adult bone formation process until mature osteocytes emerge. Using this technique, for the first time, we can investigate the effect of Paget’s mutations in human osteocytes and discover what these master cells do in Paget’s disease.

Furthermore, we recently discovered a new way to grow human osteoclasts from donated blood that allows us to handle large quantities of these fragile giant cells. Crucially, we can viably sort them using their cell surface proteins into sub‑groups at different life stages that may be differentially affected by the mutated osteocytes in Paget’s disease.

We now seek to combine both of these new cell systems to fully explore the role of osteocytes in Paget’s disease, modelling standard drug treatments and introducing a common Paget’s mutation into the osteocytes to see for the first time what these osteocytes do in Paget’s disease. This model will then be ready to populate with cells derived from donated blood or tissue from patients with Paget’s disease or other rare bone diseases, providing the first‑in‑kind fully human mini‑bone organ disease model. This will provide a uniquely human drug discovery tool for testing novel therapeutics and achieving personalised medicine with customisable use of individual patient’s cells or mutations."

THE ROLE OF STMP1 IN SUSCEPTIBILITY TO PAGET'S

The Role of STMP1 in Susceptibility to Paget’s Disease of Bone

Investigators: Mr Navnit Makaram, Dr Sachin Wani, Prof Robert Hill and Prof Stuart Ralston from the Centre for Genomic & Experimental Medicine MRC Institute of Genetics & Molecular Medicine, at the University of Edinburgh.

Mr Navnit Makaram explains new genetic research funded by the Paget’s Association -

"Genetic factors play a key role in Paget’s Disease of Bone and previous studies have identified a region on human chromosome 7q33 which is strongly associated with the risk of developing the condition. The region on 7q33 contains four known genes which are called NUP205, STMP1, CNOT4, and SLC13A4. Up until now, it was thought that the gene at this location most likely to cause Paget’s disease was NUP205 because the strongest signal of association was with a variant in the NUP205 gene. However, it has recently become apparent that another gene, situated close to NUP205, which is called STMP1, may instead be responsible for predisposing people to Paget’s. There are two reasons for this. First, a previous research group has shown that the genetic variant that predisposes to the condition is associated with high levels of STMP1. Secondly, initial research, that I have carried out, has identified variations in the STMP1 gene that is likely to play a key role in gene regulation.

Although this all suggests that STMP1 is the culprit, the effects of STMP1 on bone metabolism hasn’t been previously studied. The aim of this study will be to investigate the effects that STMP1 has on bone-resorbing cells (osteoclasts) and bone‑forming cells (osteoblasts) since the activity of both cell types is increased in Paget’s disease. We will also determine if levels of STMP1 are increased in osteoclasts cultured from patients who have Paget’s as compared with unaffected people.

If STMP1 is found to upregulate the activity of bone‑resorbing and bone-forming cells, it could emerge as a new target for the design of drugs to prevent and treat Paget’s disease as well as other bone diseases."

PAIN IN PAGET'S DISEASE

Deciphering the Mechanisms of Pain in Paget’s Disease

Principal Investigator: Professor Stuart Ralston from the Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh.

in 2017, the Paget’s Association awarded a grant to facilitate research into pain as it is the most common symptom in Paget’s Disease of Bone, occurring in about 73% of patients who come to medical attention. In some patients, the pain seems to be due to abnormalities in a process called bone remodelling which is essential for maintaining healthy bones. In Paget’s disease, the bone remodelling process is accelerated greatly and this can sometimes be associated with pain. However, for reasons that are unclear, many patients with Paget’s who have accelerated bone remodelling, don’t experience pain, and others experience pain where the rates of bone remodelling appear to be normal.

The lack of understanding of pain mechanisms is reflected in the fact that pain continues to be a significant issue in Paget’s patients, despite treatment with drugs called bisphosphonates, which are highly effective at correcting abnormalities in bone remodelling. The reasons are unclear but possibilities are that irreparable damage to the bone has already occurred by the time of presentation; that the bone pain is not due to increased renewal and repair of bone, but to other causes such as an alteration in pain thresholds; or that some of the factors that are responsible for stimulating bone renewal and repair in Paget’s disease have direct effects on pain pathways. This study will investigate these possibilities. The team will carefully evaluate a group of 300 patients with Paget’s disease, some of whom have pain and others who do not, with the aim of identifying the clinical and biochemical characteristics of patients who have pain and those who do not. Next, they will focus on patients who do have pain and categorise these individuals into subgroups based on the likely cause of the pain. This information will be used to develop a personalised treatment package for patients with pain. The researchers will then investigate the evolution of Paget’s disease in relation to the development of pain, in participants of a clinical trial (the ZiPP study), which is already in progress. The aim of this will be to identify, at an early stage, whether there are any blood tests or other characteristics that can be used to predict the development of pain and to determine whether early treatment with the bisphosphonate zoledronic acid, influences symptoms of pain.

The outcome of the programme of research will be to gain a much greater understanding of pain mechanisms than we have at present, and to apply this knowledge to improve quality of life for patients already affected with Paget’s disease and their children, who may be at risk of developing Paget’s disease.

2019

MEDIEVAL LIVES: EXPLORING PAGET'S AT NORTON PRIORY

Medieval Lives

Exploring Paget’s Disease of Bone at Norton Priory, North West England

Principal Investigator: Professor Silvia Gonzalez from the School of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool.

A grant was awarded in 2017 for research at Liverpool John Moores University. The project aims to study Paget’s Disease of Bone within the Norton Priory Bone collection, Cheshire. An investigation identified that six male skeletons were severely affected with Paget’s disease, with over 75% of their skeleton affected. Additional analyses from a single tooth from each skeleton have indicated that these skeletons are Medieval in age (1150-1395 AD), that the population had a predominantly marine-based diet, and were originally from the north‑west of England. Since these analyses, new research has continued to explore the remaining Norton bone collection, consisting of a total of 130 individuals. Currently, a further 22 skeletons have been identified presenting skeletal lesions typical of Paget’s disease. This is a remarkably high occurrence of Paget’s (21.5%), compared to any other UK archaeological site. For this new investigation, ten of the 22 skeletons with Paget’s disease have been selected for full osteological examination including radiographic and micro-CT imaging, radiocarbon dating, paleodiet assessment and the determination of geographical origin. This research will also make a comparison of medieval bone affected by Paget’s disease with affected modern bone, to identify any similarities or differences. Overall, the new data will contribute to our understanding of the prevalence and nature of medieval Paget’s disease at Norton Priory and the development of the condition through time.

DOCUMENTARY

Further information including the latest research paper regarding Norton Priory, can be found here and specially produced for Paget's Awareness Day 2020, this exciting Research documentary below explores the latest findings from Norton Priory and interviews the researchers.

2020

EXCESSIVE BONE FORMATION IN PAGET'S DISEASE

Dr Anna Daroszewska, from the University of Liverpool, explains below, new research, funded by the Paget’s Association.

Understanding Excessive Bone Formation in Paget’s Disease

Paget’s Disease of Bone is characterised by focally increased bone remodelling, which is driven by hyperactive bone-dissolving cells, known as osteoclasts. These hyperactive pagetic osteoclasts ‘hijack’ bone-making cells, known as osteoblasts, and force them to produce an excessive amount of bone, which can lead to deformity and pain. Rarely, this excessive bone formation may get out of control and the pagetic bone undergoes transformation into bone cancer (osteosarcoma), which is very difficult to treat, as we do not understand the underlying mechanism causing it.

It is well established that one of the most common genetic causes of Paget’s disease is a mutation in a gene called Sequestosome 1. This is responsible for making a molecule known as p62, which has many important functions within cells. P62 is a scaffolding molecule, which connects other molecules in communication channels (known as signalling pathways) and plays a role in waste disposal and cell ‘cleansing’. The abnormal pagetic p62 causes a sustained increase in signalling in pagetic osteoclasts, hence development of pagetic lesions. On the other hand, p62 is important in cancer cells, although its role is incompletely understood., Reducing the activity of p62, however, has been shown to improve the outcome in some cancers and in theory could be of benefit in Paget’s disease, or other conditions of the ageing skeleton, characterised by high osteoclast activity, such as osteoporosis.

To study whether removing p62 would be beneficial in age-related bone loss, i.e. osteoporosis, in a collaborative project with an Italian group, we set out to analyse the bones in a pre-clinical model lacking p62, however, unexpectedly, found evidence of exacerbated new bone formation, which could be detrimental in Paget’s disease.

In this new research project, funded by the Paget’s Association, we will study in detail the changes in bone cells and tissues, which appear in the absence of p62, so that we gain an understanding of the underlying mechanism driving the excessive bone formation and determine whether it could lead to osteosarcoma. This knowledge is important, as we need to understand the consequences of dampening the activity of p62 in Paget’s disease, should such treatment be offered for another reason (such as adjunctive treatment to chemotherapy for prostate or breast cancer) to individuals affected by Paget’s disease, or carriers of a pagetic mutation.

Sept 2020

GENETIC FACTORS IN PAGET'S DISEASE

Dr Asim Azfer, from the University of Edinburgh, summarises below new genetic research into Paget’s disease, which has been funded by the Paget’s Association.

Genetic Factors of Paget’s Disease

Genetic factors are important in Paget’s disease, but the mechanisms by which genetic variations cause the disease are not fully understood. Previous studies have pinpointed a region on human chromosome 1p13, which is strongly associated with Paget’s disease. This is interesting since the same region contains a gene called CSF1, which codes for a cytokine called Macrophage Colony Stimulating Factor (M-CSF). This is relevant to Paget’s, as M-CSF plays a key role in the development of bone-resorbing cells (osteoclasts). We believe that the genetic variants that predispose to Paget’s disease in this region, might do so by causing increased production of M-CSF, which in turn would be expected to stimulate osteoclast activity and bone resorption, and therefore act as a causal factor for the condition.

The aim of this study is to determine whether the gene variants that are associated with Paget’s disease, are also associated with increased circulating M-CSF levels, and to investigate whether levels of M-CSF are associated with signs or symptoms in people with the disease.

This research will result in improved understanding of what causes Paget’s. We already know that variations in a gene called SQSTM1 predisposes to the disease by increasing activity of osteoclasts, and there is evidence that the same applies for other genes including OPTN and PML. The mechanisms by which other genes predispose to Paget’s disease are unknown.

This study will clarify if genetically mediated elevations in levels of M-CSF (produced by the CSF1 gene) are a risk factor for Paget’s and if levels of M-CSF are associated with signs or symptoms of Paget’s disease. If this theory is correct, it could be relevant clinically, in opening up new avenues for treatment, since monoclonal antibodies and small molecule inhibitors of the receptor for M-CSF, which have already been developed for the treatment of autoimmune cancer, could be repurposed for the treatment of Paget’s disease.

Sept 2020

PAIN IN PAGET'S - MSc project

Deciphering the Mechanisms of Pain in Paget's Disease (PiP) - MSc project (2019)

The Michael Davie Student Research Bursary - Awarded to Kathryn Berg from the University of Edinburgh

Deciphering the Mechanisms of Pain in Paget’s (PiP Study)

Kathryn Berg is a Data Manager, at the Institute of Genetics and Molecular Medicine, within the University of Edinburgh. Kathryn attended our information meeting in Nottingham to discuss her work for a pain study, known as Pain in Paget’s (PiP), which has received funding from the Paget’s Association. We are delighted to say that the Association, in conjunction with the Michael Davie Research Foundation, awarded Kathryn a Student Research Bursary, which will enable her to use her involvement with the PiP research to study towards a master’s degree (MSc).

The PiP project aims to achieve greater understanding of the causes of pain in Paget’s disease. The research team will be looking at the bacterial makeup of the mouth and gut, the markers of disease activity in the blood, and the genetics of volunteers recruited from hospitals across the UK.

Kathryn explained that they are looking for 250 volunteers from across the country to help them with this important project. Patients who volunteer to get involved in the study are required to answer a questionnaire, undergo sensory testing, and provide blood and saliva samples. This takes about an hour and a half. Kathryn demonstrated the simple sensory tests and explained why they might help us to understand pain associated with Paget’s disease.

The recruitment of volunteers has already begun in Edinburgh, with 19 volunteers coming into clinic in just three weeks! The study is soon to begin in Glasgow, Liverpool, London and Newcastle. In the near future, there are also plans to recruit from hospitals in Manchester, Middlesbrough, Norwich, Salford, Sheffield and Cardiff.

Whether you have pain or not, you could be an important part of this study. If you are interested in taking part in this research, you can contact the central study team by emailing Kathryn.Berg@igmm.ed.ac.uk or by phoning 0131 651 8741. They will get in touch with your local research team on your behalf. If you would like to know more, they are happy to send you an information sheet in the post.

STUDYING IMMUNE RESPONSES

Studying Immune Responses

Research Title: Immuno-pathogenesis of Paget’s disease of Bone: a preliminary study

Award date: 2019

Principle investigator: Dr Julie Walker, who is a Consultant Histopathologist at The James Cook University Hospital, Middlesbrough.

Paget’s Disease of Bone is common but becoming rarer. It can be caused by genetic mutations that result in uncontrolled bone cell activity, in particular with the osteoclast cells (the cells which remove old bone). These mutations cause the osteoclast cells to become overactive and result in the unusual bone structure that is characteristic of Paget’ disease.

It is possible that the genetic mutation may also increase our immune responses to infection, giving affected people a survival advantage e.g. in fighting infections like tuberculosis. This may explain why Paget’s disease has persisted since at least Roman times. The infection could activate the immune system but have the unwanted side effect of also activating bone cells, causing Paget’s disease to materialise many years later. There are examples of this type of phenomenon occurring e.g. sickle cell disease is a blood disorder, but it also makes the individual resistant to malaria.

If this theory is correct, studying immune responses in blood from people with Paget’s disease may provide insights into its causes and potential targets for treating and/or preventing it. If the proposed theory is true, then one reason for the fall in incidence of Paget’s in the past 20-30 years may be diminished evolutionary pressure because of reduced exposure to infections, probably through a combination of improved public health, antibiotics and vaccination e.g. against diphtheria and tuberculosis. If this is confirmed by this research then there will be a plausible explanation for the observed changes in epidemiology. If immune responses are altered then exposure to infections, such as mycobacteria, will stimulate both immune and osteoclastic activity. This would bring an explanation for the development of the condition a step nearer and it may be possible to manipulate the immune response to prevent or treat the condition.

This is a small, preliminary study to test this hypothesis by taking blood from 15 men with Paget’s disease and from 15 healthy men without bone problems. Cells from their blood will then be grown in culture and their responses to infectious stimuli tested, including various bacteria and tuberculosis.

IDENTIFICATION OF NOVEL GENETIC MARKERS

Identification of Novel Genetic Markers

Principal Investigator: Dr Omar Albagha from the Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh.

A grant was awarded, in 2017, by the Paget’s Association to fund research which will improve our understanding of the biology of Paget’s disease.
Paget’s Disease of Bone often runs in families and sometimes can be passed on from one generation to the next. Until relatively recently very little was known about the genetic characteristics of patients with Paget’s disease and because of this, it was almost impossible to predict if the disease would be passed on from parent to child. There have been huge advances in understanding exactly which genetic factors are associated with the development of Paget’s disease. Over the past 15 years, however, huge advances have been made in identifying the gene abnormalities, which occur in the condition. So far, about 8 gene variants that predispose to Paget’s disease have been discovered, but research indicates that there are
other variants that remain to be identified.

The aim of this project will be to identify new genetic variants, which predispose to Paget’s disease. We will do this using a technique called, A Genome Wide Association Study. The new study will build upon work that has already been performed, with the aim of providing a comprehensive picture, of which genetic variants predispose to the condition. The value of the project is that it will allow us to develop accurate genetic markers for Paget’s disease that could be offered to people
who have a family history of the disease and provide information whether they are likely to develop it themselves, in future years. People who were found to have markers suggestive of developing Paget’s disease could be entered into a programme of enhanced surveillance so that the disease could be picked up early and they could be offered preventative therapy.

The project will improve our understanding of the biology of the disease and offers the prospect that pain and other complications could be avoided or minimised by early diagnosis and treatment.

BURSARY RESEARCH INTO RARE COMPLICATION

Paget's Bursary Research Helps Scientists Make an Important Discovery

In 2017, Jasmine Sanghera, a biomedicine student at the University of East Anglia (UEA) in Norwich, was awarded the Sir Julian Paget Student Research Bursary by the Paget’s Association, to undertake research into a very rare complication of Paget’s Disease – bone cancer (osteosarcoma). We are delighted to announce that the Sir Julian Paget Student Research Bursary contributed to a paper published on the 13th July 2020.

This work was part of a larger study, which discovered how and why primary bone cancer, which is mostly a childhood cancer, spreads to the lungs. This finding is extremely important as new drugs are now in the pipeline to prevent this spread. One of the adult patient donors in the study had osteosarcoma associated with Paget’s disease and the research proved extremely insightful into comparisons between the childhood form and the Paget’s form of osteosarcoma.

Jasmine will graduate as a Physician Associate in 2021 and said, “This bursary was instrumental in expanding my medical training portfolio, to actually experience scientific research and to take the latest findings with me as I embark on my upcoming medical career. I am so grateful to the Paget’s Association and its supporters for giving me this opportunity”.

Dr Darrell Green, who led the study and who once received a Student Research Bursary from the Paget’s Association himself said, “It was fascinating to see the similarities and differences between childhood and Paget’s osteosarcoma. We now have a far greater understanding of both disease states and that means we can intervene at the clinical level. This discovery would not have happened without funding from the Association, so thank you so much. Jasmine was a fantastic student and I wish her all the best with her medical career. That’s another student entering medicine with the backing of the Paget’s Association, which will also help raise awareness of the condition”.

A Centre of Excellence

The University of East Anglia together with the Norfolk and Norwich University Hospital NHS Foundation Trust, make up the Norwich Paget’s Association Centre of Excellence. Under the leadership of Professor Bill Fraser, the hospital has a well-established metabolic bone disease service. Patients are seen at specialist bone clinics and the centre also hosts a service which provides specialist tests and advice on the interpretation of molecules involved in bone and calcium metabolism to units throughout the UK and for several in Europe (The Supra Regional Assay and Advisory Service).

Sir Henry Paget presented the Student Research Bursary Award to Jasmine in November 2017.

You can read the full story here (pdf).

EXAMINING CHANGES IN BONE GEOMETRY AND BONE STRENGTH

Can Changes in Bone Geometry and Bone Strength be Linked to Fracture Risk in Paget’s Disease of Bone?

Sir Julian Paget Student Research Bursary 2019 - Awarded to Alisha Sharma from the University of Southampton

Research: Assessment of sexually dimorphic bone shape and vascular alterations as indicators of Paget’s disease

Patron, Sir Henry Paget, recently presented the Sir Julian Paget Student Research Bursary to Alisha Sharma, who describes her research project below.

Firstly, I personally would like to take this opportunity to thank the Paget’s Association for awarding me the Sir Julián Paget Student Research Bursary. Currently, I hold a degree in biochemistry and am working towards my PhD in bioengineering at the University of Southampton. My research primarily focuses on Paget’s Disease of Bone, specifically looking at bone shape and strength.

My research aims to answer the question, ‘Can changes in bone geometry and bone strength be linked to fracture risk in Paget’s Disease of Bone?’. Before I could answer this question, a model to study Paget’s disease was required. I used the SQSTM1 gene, a gene many scientists believe to play a key role in the cause of this disease. My collaborator, Professor Stuart Ralston has made artificial changes in the DNA of this gene to use for a model of Paget’s disease. Using this model, I aim to examine bone shape changes and identify whether this links to the strength of bone and ultimately whether this affects fracture occurrence in Paget’s disease. Fracture is a predominant impediment, yet treatment and prevention remain a significant challenge. Simple new methods are urgently required for early diagnosis to prevent bone fractures in Paget’s disease, which are not only debilitating but are linked to increased morbidity. With poor bone quality accounting for several complications of this condition, I aim to identify whether bone shape can be used as an early predictor of Paget’s disease and fracture occurrence.

I will use technology called micro-computed tomography to assess bone structure in both males and females. This involves high energy x-rays, which are used to scan the bones. Using these scans, I can evaluate the shape of the bones without damaging them. As bone shape (such as size) impacts the mechanical competence (strength) of bone, I will do a series of strength tests to determine how geometrical changes in bone affected by Paget’s disease could link to strength and ultimately fracture. Specifically, I have developed a model to assess strength. This model works by applying force to the bone and measuring the amount of force required to break the bone. Further assessment on where the break occurs can then be conducted. Together, these experiments will help assess whether changes in bone geometry can be used to predict fracture risk and location. In addition, with increased blood flow levels reported in case of Paget’s disease, I will also use more powerful micro-computed tomography to visualise some of the internal structures (blood vessels) inside the bone.

Currently, my studies have shown that bone shape and strength can vary depending on gender. Thus, my long-term future research goal is to discover whether development of future treatments should be targeted to gender.

Alisha

THE ROLE OF SQMTM1 AS AN RNA BINDING PROTEIN

Application of iCLIP technology to determine the role of SQMTM1 as an RNA binding protein

The Allan Reid Student Research Bursary awarded to Nicole Ball from the University of East Anglia, in 2019

The Paget’s Association awarded the Allan Reid Student Bursary Award to Nicole Ball from the University of East Anglia. Nicole is a second year PhD student performing research under supervision of Dr Darrell Green, who is a Lecturer in Medicine at Norwich Medical School, and Professor William Fraser, who is the school’s head and a Consultant Metabolic Physician at the Norfolk and Norwich University Hospital. Nicole received the award at the Paget’s Information Day, which was held in Nottingham. Here, they discuss Nicole’s new research project.

Introduction

Paget’s Disease of Bone is the second most common metabolic bone disorder after osteoporosis and affects 1-5% of people with British lineage over the age of 55. In very rare cases (less than one in a thousand cases), there can be transformation into Paget’s associated osteosarcoma, which is a type of bone cancer. This rare complication is thought to initiate due to genetic changes induced by the abnormal turnover of a type of bone cell called an osteoblast, which is responsible for producing new bone. Abnormal turnover of osteoblasts is one of several steps that make up Paget’s disease.

Genes within our DNA provide the instructions for producing proteins. Proteins are complex molecules that are required for the structure and function of cells, hormones, signalling molecules (responsible for transmitting information between cells) and tissues within the body. It is vital that genes for producing proteins are not faulty because incorrect instructions can lead to incorrect construction of proteins. Faulty proteins can cause serious problems within the body. For example, proteins involved in bone turnover (the process of breaking down and producing new bone) could, if faulty, lead to Paget’s disease. There are around 23,000 genes contained within each human cell. Nine genes have been identified as having a likely role in Paget’s if they are abnormal. There are several other genes also being investigated for their role in the condition.

Current Research

Sequestosome 1 (SQSTM1) is a gene that we know has an important role in Paget’s disease. In so called “familial” Paget’s where more than one person in an immediate family has the disease, almost half of cases harbour a faulty SQSTM1 gene. The SQSTM1 gene provides the instructions for the SQSTM1 protein, which has several cellular roles including progression of bone turnover and protecting DNA from damage. In Paget’s disease the abnormal gene, SQSTM1, produces abnormal SQSTM1 protein (figure 1). Most known faults to SQSTM1 lead to a whole section of the SQSTM1 protein being deleted. This particular section of the SQSTM1 protein is usually required for the cell to switch off SQSTM1 when it is not needed. Abnormal SQSTM1 with the missing section cannot be switched off and so accelerates Paget’s disease.

DNA contains the gene SQSTM1. The DNA on the left contains the normal form of SQSTM1 gene that when expressed as RNA (a genetic “middleman”) carries the instructions from DNA before producing a functional SQSTM1 protein.

The DNA on the right contains faulty SQSTM1. Incorrect RNA instructions cause the production of abnormal SQSTM1 protein. Most of the identified faults cause the “tail” end of SQSTM1 to be missing, which is an important part of the protein used to deactivate SQSTM1 later on. As the tail end is missing, SQSTM1 cannot be switched off and is perpetually active.

Interestingly, we recently found that abnormal SQSTM1 may have a protective effect against the development of cancer, specifically, Paget’s associated osteosarcoma. Our research has shown that another molecule called microRNA-16 switches off faulty RNA containing faulty SQSTM1. Whilst this appears to be a protective function against the production of abnormal SQSTM1 protein, it can have the negative effect of switching off SQSTM1 entirely leading to a lack of DNA protection and therefore Paget’s associated osteosarcoma.

Future Research Funded by the Bursary

We speculate that there is a “battle” between SQSTM1 and microRNA-16. Recent experiments have shown that while microRNA-16 is able to switch off production of SQSTM1 RNA, SQSTM1 protein may be able to switch off microRNA-16. The bursary will fund new experiments to develop a new method to characterise the physical interaction between SQSTM1 and microRNA-16 at the molecular level. We hypothesise that if we understand the complexities of this “battle” we can further understand the workings of SQSTM1 and its role in Paget’s disease and Paget’s associated osteosarcoma. In the future, we may be able to interfere with this battle and possibly other battles with SQSTM1 as a new line of treatment.

TARGETING AUTOPHAGY IN PAGET'S DISEASE

Targeting Autophagy in Paget’s Disease

The Michael Davie Student Research Bursary 2017

Recipient: Jack Beard, University of Oxford.

In 2017, thanks to funding from the Michael Davie Research Foundation, (registered charity number: 803202), the Paget’s Association provided a Student Research Bursary Award of £6,000 to Jack Beard. This funded research into the treatment of Paget’s disease, ‘Targeting Autophagy in Paget’s Disease’ and took place at the University of Oxford. The following summarises this student project. It is unsurprising that the accumulation of rubbish leads to all sorts of problems! Interestingly, the cellular environment is not so dissimilar to our city streets, where unwanted or defective products litter the pathways and obstruct normal behaviour. This is certainly true in Paget’s Disease of Bone, where the accumulation of debris within critical cells of bone creates a trash-filled blockage, which impairs their ability to function adequately.

Thanks to the Michael Davie Student Research Bursary, researchers at the University of Oxford have been exploring how changes in waste disposal within the cells of bone might be associated with the development of Paget’s disease and importantly, whether treatment with bisphosphonate drugs might improve the removal and recycling process (autophagy) to restore normal bone cell biology. Paget’s Disease of Bone is primarily driven by defects in bone-resorbing osteoclasts (see page 9 for a detailed explanation of how bone cells function). The dysregulated removal of bone leads to weakened long bone structure, which adopts a characteristic bowed appearance, as is visible on x-ray. In most cases, Paget’s disease can be successfully treated with bisphosphonates, which effectively kill the osteoclasts, reducing the aberrant bone destruction and restoring the delicate cellular balance within the skeleton. In recent years, large scale genomic studies of patients with Paget’s disease have been successful in identifying a small selection of target genes, whose altered function is associated with the development of the disease, and which includes ‘Sequestosome 1’ protein. Interestingly, this gene product helps to regulate the cellular waste removal process of autophagy – necessary for optimal cellular health and ageing.

The work conducted as a result of the Student Bursary Award has revealed a previously unknown mechanism of action of bisphosphonates, in that they might also have the potential to stimulate autophagy. Human cells treated in culture with a panel of bisphosphonate drugs known to possess a diverse range of potencies and activity, showed an increased stimulation of autophagy-related proteins. This finding raises the possibility that treatment with bisphosphonates might also improve Paget’s Disease of Bone by stimulating a more effective removal of waste products within the cells of bone. Interestingly, this work also suggests that bisphosphonates might impact a healthy lifespan through the stimulation of this pro-ageing mechanism. The team in Oxford, who have worked alongside Jack, report that further study is necessary to progress this research further.

EXPLORING GENETIC CONNECTIONS THROUGH TIME

Medieval Paget´s Disease

Research Title: “Contributions of ancient genome DNA, molecular and isotopic studies to aid the understanding of Paget´s disease during the medieval period at Norton Priory.”
Principal investigator: Silvia Gonzalez, who is Professor in Quaternary Geology and Geoarchaeology from the School of Biological and Environmental Sciences, Liverpool John Moores University, Liverpool.

Background to the Study

Since 2015, research exploring Paget’s disease at Medieval Norton Priory in Runcorn, Cheshire, has been a fascinating journey, providing new insights into the development of Paget’s disease in the past.
Originally, only six of the medieval skeletons were recognised to have skeletal signs of Paget’s disease (5%). Further skeletons have been identified during a phase of research completed during the last three years. This has brought the number
of those affected up to 46 out of 130 (35%). This is a remarkable increase and has not been seen before in an archaeological collection.
In collaboration with experts from Liverpool John Moores, Nottingham, East Anglia, Leicester and Liverpool Universities, and with the partnership of Norton Priory Museum, this archaeological collection has been the subject of further detailed evaluation. To date, the original six and an additional twelve skeletons with Paget’s disease have been the subject of detailed analysis. Full macroscopic and x-ray examination has identified that up to 75% of individual skeletons studied are affected by the condition, suggesting an early on‑set in young adulthood.

CT and Micro-CT imaging have complemented the diagnosis of Paget’s in these skeletons. Radiocarbon dating has identified that Paget’s disease has been present at Norton for over 400 years during Medieval times (AD 1020‑1479). By studying their teeth (stable isotope studies) it was identified that these individuals had a mainly marine based diet and were born and lived locally in the North West of England, a recognised hotspot of modern Paget’s disease. Interestingly, molecular research
has identified abnormalities in the SQSTM1 gene or p62 protein in the Norton skeletons, suggesting the presence of an ancient precursor of contemporary Paget’s disease, the first to be reported in an archaeological collection.

In this new research phase (2020 onwards), in collaboration with the Ancient Genomics Laboratory from the Frances Crick Institute in London, the researchers propose to extend their analyses to fourteen new selected skeletons with Paget’s disease from the collection, plus one healthy individual for comparison. The researchers want to characterise, in detail, these medieval individuals and their lifestyles. The study will incorporate the following:

Radiocarbon dating – This is a technique used to learn the age of the skeletons.

Stable isotope studies – Isotopes are present everywhere, but the balance (or ratios) in which different isotopes of the same elements occur, varies between different substances. The isotopes that are in the food we eat and the water we drink are incorporated into all our body tissues, including our skeleton. By measuring the ratios of different isotopes in bones or teeth and using scientific knowledge about how they occur in nature to trace them back to the sources that they came from, scientists can learn many things about an individual, such as what their diet was like and the environment they grew up in.

Paleodiet analysis – This will investigate what type of food was eaten.

Paleoproteomics - A technique which involves protein sequencing using mass spectrometry. This allows analysis of bone samples at the molecular level, by extracting proteins from the ancient bone cells. This offers an insight into the biology of the cell when it was alive many hundreds of years ago.

Exploring aDNA - For the first time the full ancient genome information (aDNA) will be obtained for a medieval population in the UK to explore their genetic connections through time.

Comparing the Ancient with the Modern

Professor Gonzalez remarked, “This research will enhance our understanding of this ancient form of Paget’s disease and enable comparison with modern individuals affected by the condition.”
The Paget’s Association will watch with interest this developing project, which may lead to information crucial to helping doctors understand the fall in incidence of modern‑day Paget’s disease, which has been observed over the past few decades.

2020

APPLICATION OF RNA BIOLOGY

The Allan Reid Student Research Bursary 2016

Recipient: Darrell Green, University of East Anglia.

Research: Application of RNA biology to detect, monitor and treat Paget’s-associated osteosarcoma.

Funding Research into Paget's Disease