Fanconi Anemia as a Window into Premalignant Field Cancerization of the Oral Mucosa

Head and neck squamous cell carcinoma (HNSCC) evolves through stepwise clonal expansion within genetically altered mucosa fields, yet actionable biomarkers remain undefined. Leveraging Fanconi anemia (FA), a cancer predisposition syndrome with extreme HNSCC risk due to defective DNA interstrand crosslink repair, we profiled premalignant changes in the oral cavity using noninvasive brush biopsies. Consistent with our prior demonstration of genomic instability in FA-associated SCCs, we detected pathogenic TP53 variants in 26% and copy number alterations in 60.5% in clinically normal-appearing oral mucosa of individuals with FA. These subclinical clonal expansions define candidate biomarkers of early clonal evolution amenable to serial sampling for risk stratification and prevention studies. Since FA-associated SCCs share genomic features with sporadic HNSCC, these findings may extend to the broader population. We also identify somatic reversion of a pathogenic FANCB variant, providing evidence of genomic self-correction and suggesting a potential avenue for gene-based cancer prevention in FA.

Oral mucosa of individuals with Fanconi anemia contains frequent abnormal clones creating a premalignant field that increases cancer risk. The noninvasive brush sampling approach allows repeated measurements, ongoing surveillance, and assessment of prophylactic strategies that may be useful in the prevention of cancers in people with FA and in the general population. Somatic reversion of a pathogenic FANC variant may protect the oral mucosa from DNA repair deficiency and premalignant clonal evolution.