Balanced chromosomal rearrangements comprising translocations or inversions with an incidence 0.52% in the general population are structural chromosomal rearrangements without cytogenetically detected imbalances [1]. As conventional karyotyping might not be able to detect the smaller than 5-10 Mb imbalances, some submicroscopic imbalances can be overlooked [2]. These types of rearrangements are called as apparently balanced chromosomal rearrangements (ABCRs) and can be familial or
The application of chromosomal microarray (CMA) has become an essential tool in routine diagnostics to detect the submicroscopic genomic imbalances for genome-wide screening at kilobase (kb) levels. Chromosomal microarray contributes a 15.0-20.0% detection rate of cryptic chromosomal imbalance in selected patients who have multiple congenital anomalies/intellectual disability (MCA/ID) with normal karyotypes [6,7].
We report here the CMA results of the 34 clinically affected patients (13 prenatal, 21 postnatal) carrying
The study contains the cytogenetic and array-comparative genomic hybridization (aCGH) results of 34 affected patients (13 prenatal, 21 postnatal) carrying ABCRs and 76 of family members (including parents and siblings) investigated between the years 2001-2017. All cases were examined, counseled and laboratory work was performed at the Department of Medical Genetics, Istanbul University Faculty of Medicine, Istanbul, Turkey. Fetal ultrasonography (USG) and invasive procedures [one chorionic villus sampling (CVS), four fetal blood sampling (FSB) and eight by amniocentesis (AC)] were performed at the Perinatology Division of the Obstetrics and Gynecology Department, Istanbul University Faculty of Medicine, Istanbul, Turkey.
Lymphocytes cultures of peripheral and cord blood samples, amniotic fluid and chorionic villus samples using short and long-term cell cultures were performed according to traditional techniques. Routine cytogenetic analyses were performed on metaphase chromosomes at 550-600 banding levels using Giemsa-Pancreatin-Leishman’s banding.
The SurePrint G3+SNP (single nucleotide polymorphism) Human CGH Microarray (4 × 180 K) dual-color array containing more than 170,334 distinct biological probes with 13 kb genome-wide median probes spacing was carried out following the protocols provided by the manufacturer (Agilent Technologies Inc., Santa Clara, CA, USA) in parents to detect inheritance and for confirmation of detected CNVs that were larger than 1 Mb in index cases.
Aberration calls using Nexus Copy Number (Bio-Discovery, El Segundo, CA, USA) was implemented following thresholds for copy numbers; 100 kb gains, 50 kb losses across the genome with a minimum of 25 markers to make the call. For regions of known significance, the minimal setting was 25 kb and 25 markers for gains and losses. Detected variations were classified according to the American College of Medical Genetics and Genomics (ACMG) guidelines [8,9]. Only likely pathogenic or pathogenic variations were reported and uncertain CNVs were evaluated by taking into consideration of ACMG classification scores [8,9].
This study was reviewed and approved by the Ethics Committee of the Istanbul Medical Faculty [N. 08/13]. Written informed consent was obtained from all subjects or their legal guardians included in this study.
Clinical findings, karyotype and chromosomal microarray results for the postnatal patients.
# | Sex- Age | Clinical Details | Initial Karyotype | CMA Result (GRCh37/hg19] | Size | Type of Anomaly (gain/loss) | Parental Origin of Imbalance |
---|---|---|---|---|---|---|---|
1a | M-4 | consanguineous marriage; stereotypic hand movements, PSMR; short eye contact duration; pathology in brain MRI; ASD | 46,XY,t(4;10)(q34.2;q26.2) | 10q26.3 (130669231-135534747)x3 | 4.8 Mb | gain | |
2a | M-13 | minimal nonspecific ID; hypo-glycemia; cryptorchidism; facial dysmorphism; short neck; hypo-myelinization and subarachnoid enlargement in cranial CT | 46,XY,t(4;10)(q25;q22.1) | normal | – | – | – |
3a | M-6 | PSMR; anal stenosis; bilateral inguinal hernia; facial dysmorphism; macrocephaly; short fingers and clinodactyly on the fifth finger | 46,XY,t(5;17)(q12.2;q21.33) | normal | – | – | – |
4a | M-4 | PSMR; drug therapy due to convulsion; facial dysmorphism; pes planus | 46,XY,t(2;10)(q33.2;p12.32) | normal | – | – | – |
5a | F-7 | PSMR; hypotonia; central obesity; childhood polyphagia | 46,XX,t(6;9)(q25.1;q32) | normal | – | – | – |
6b | M-11 | consanguineous marriage; ID; hyperactivity; poor eye contact, repetitive speech; family history of MR (paternal side); fragile X test normal | 46,XY,t(9;10)(p22;q24)pat | normal | – | – | |
7b | M-13 | consanguineous marriage; mild ID; brother and maternal aunt’s daughter affected; microphthalmia; severe PSMR; muscle atrophy; microcephaly; bilateral hydronephrosis; facial dysmorphism | 46,XY,t(6;19)(p11;p13.2)mat | normal | – | – | – |
8b | F-9 | consanguineous marriage; microcephaly; facial dysmorphism; clinodactyly; cranial CT consistent with Lissencephaly type 1 | 46,XX,t(3;4)(p22;q26)mat (negative FISH result for Smith- Magenis-Dieker Probe) | normal | – | – | – |
9b | M-1 | consanguineous marriage; facial dysmorphism; CHD; right kidney agenesis, left kidney size increase; undescended testicle; anal atresia | 46,XY,t(8;22)(p11.2;q22)mat | normal | – | – | – |
10a | F-7 | neuromotor retardation; seizures; growth retardation; microcephaly; facial dysmorphism; clinodactyly; pathology in brain MRI | 46,XX,inv(1)(q25.1q32.2) | 1q23.3q24.2(161969134-169579696)x1 | 7.6 Mb | loss | |
11b | M-13 | ID; undescended testicle; advanced bone age; obesity; agitation; fragile X test normal | 46,XY,parinv(12)(p13.3q13.1)pat | normal | – | – | – |
12b | M-3 | consanguineous marriage; PSMR; growth retardation; microcephaly; facial dysmorphism; clinodactyly; joint hypermobility | 46,XY,inv(12)(p11q14)mat | normal | – | – | – |
13b | M-5 | consanguineous marriage; pectus excavates; pulmonary stenosis; cryptorchidism, micropenis; lytic bone lesions; mutation negative in | 46,XY,parinv(12)(q21.2q24.1)mat | normal | – | – | – |
14a | M-4 | PSMR; hypotonia; microcephaly; syndactyly; lack of eye contact | 46,XY,t(8;13)(q24.13;q21.2), ins(2)(p16.2q33.2q22.2) | 2q36.1q36.3(225194399-228263782)x1 | 3.0 Mb | loss | |
15a | M-9 | PSMR; alopecia; hyperpigmentation; facial dysmorphism; bilateral cubitus valgus; accessory nipple on bilateral nipple line; tracheostomy | 46,XY,inv(3)(p13p25)t(11;18) (p13.5;q12.2) | 4q13.3(71013108-72174576)x1 | 1.1 Mb 2.9 Mb | loss loss | |
16a | M-1 | bilateral aniridia; cryptorchidism; micropenis; heart murmur; hypertonia of the lower extremities | 46,XY,t(3;15;21)(p13;q21.1; q22.3),t(4;16)(q31;p31.1) | 11p14.13(30031595-33045209)x1 | 2.5 Mb | loss | |
17a | F-3 | PSMR; microcephaly; dystrophinopathy; myogenic EMG findings; walking difficulties | 46,X,t(X;13;17)(p21;q13;q22) | normal | – | – | – |
18 | M-3 | CHD; negative FISH result for DiGeorge syndrome | 46,XY,der(3)(15qter→15q22.3: :3p11.2→3qter)der(15)(15pter→ 15q22.3::3p26→3p11.2: :3p26→3pter) | normal | – | – | – |
19a | F-13 | mild ID; dystrophinopathy; Gowers’ sign; pektus ekskavatum; minimal facial dysmorphism; normal MLPA result | 46,X,t(X;8;14)(8qter→8q11: :Xp21→Xqter)(Xpter→Xp21: :8p21.1→8q11::14q13) | normal | – | – | – |
20a | M-4 | consanguineous marriage; neuromotor retardation; mild ID; facial dysmorphism; brachycephaly; hypoplastic scrotum | 46,XY,t(1;18)(q32.1;q23),t(5;12) (p14.2;q21.2) | 5q13.3-q14.1(74571645-77654540)x1 | 2.4 Mb 1.6 Mb 1.9 Mb 2.3 Mb | loss loss loss loss | |
21a | F-2 | facial dysmorphism; short neck; soft, dry skin; clinodactyly; bilateral clubfoot, talipes echi- novarus; hypoplastic clitoris; tooth grinding; multiple renal stones; partial ACC; normal MLPA result | 46,XX,t(11;13;18)(13pter→ 13q22::11p13→11pter; 13qter→13q22::11p13→11q24: :18q21→18qter;18pter→18q21: :11q24→11qter) | 11p14.3(22454510-246887178)x1 | 2.2 Mb 10.6 Mb 2.7 Mb | loss loss loss |
#: case number; CMA: chromosomal microarray; PSMR: psychomotor retardation; MRI: magnetic resonance imaging; ASD: atrial septal defect; ID: intellectual disability; CHD: congenital heart defect; FISH: fluorescent
a
b Familial rearrangement.
Ultrasonography findings, karyotype and chromosomal microarray results for the prenatal patients.
# | Weeks’ Gestation/ Invasive Procedure | USG Findings | Initial Karyotype | CMA Result (GRCh37/hg19] | Size | Type of Anomaly (gain/loss) | Parental Origin of Imbalance |
---|---|---|---|---|---|---|---|
22a | 24/CVS | NT (5 mm) | 46,XX,t(2;4)(p23;q31.1) | normal | – | – | – |
23a | 21/AC | abdominal cysts; polyhydramnios | 46,XY,t(10;16)(q23.2;q13) | 10q23.1(86441275-87680071)x1 | 1.2 Mb | loss | |
24a | 24/AC | dilated intestine; EIF | 46,XX,t(7;12)(q36;q15) | normal | – | – | – |
25a | 17/AC | CPCs; fetal intracranial cysts | 46,XY,t(2;3)(q31.2;q27.32) | normal | – | – | – |
26a | 19/AC | CPCs | 46,XX,t(3;16)(p21.3q11) | 16p11.2(28220816-33816801)x3 | 5.5 Mb | gain | maternal |
27a | 23/AC | SUA; HEB; increased cardiothoracic ration | 46,XY,t(5;13)(q15;q22) | normal | – | – | – |
28a | 20/AC | bilateral ventriculomegaly; hydrochephalus | 46,XX,t(8;16)(q24.1;q12.1) | normal | – | – | – |
29b | 24/AC | asymmetric ventriculomegaly | 46,XY,t(15;17)(q24.1;q21.3)pat | normal | – | – | – |
30b | 22/FBS | bilateral pes equinovarus; amniotic band sequence | 46,XY,t(11;15)(q13.3;q25)pat | normal | – | – | – |
31b | 23/FBS | situs inversus totalis, CHD | 46,XY,inv(12)(p11.23q15)mat | normal | – | – | – |
32b | 22/AC | anhydramnios; laryngeal atresia; bilateral renal agenesis; SUA; absence/hypoplasia of lower extremities; ambiguous genitalia | 46,XX,inv(7)(q11.2q32)mat | normal | – | – | – |
33b | 24/FBS | ascites; polyhydramnios; IUMF; increased cardiothoracic ratio; thick placenta | 46,XX,inv(6)(q21.2q26)pat | normal | – | – | – |
34a | 23/FBS | IUGR; ambiguous genitalia; micropenis; hand and foot deformities; ASD | 46,XY,t(1;9;11)(1pter→1q43: :9p22.2→9pter;11pter→ 11p11.22::9p21→9qter) | normal | – | – | – |
USG: ultrasonography; CMA: chromosomal microarray; CVS: chorionic villus sampling; NT: nuchal translucency; AC: amniocentesis; EIF: echogenic intracardiac focus; CPCs: choroid plexus cysts; SUA: single umbilical artery; HEB: hyperechogenic bowel; FBS: fetal blood sampling; CHD: congenital heart failure; IUMF:
a
b Familial rearrangement.
No cryptic genomic imbalance by CMA was observed in familial cases (
Of five
All CCRs (
Molecular karyotyping allowed us to detect genomewide chromosomal imbalances even in size of kbs using DNA copy number and/or SNP variation probes [10]. Recent reports have suggested that ABCRs in patients having abnormal phenotypes can be more complex at the molecular level than suspected by karyotyping. Therefore, ABCRs either
Molecular karyotyping reveals the breakpoints of the rearrangements, especially for inversions and insertions, more precisely than the karyotyping seen in our cases 10, 14, and 21. As CMA is a genome-wide technique, it allowed us to detect the imbalances elsewhere in the genome such as in our cases 15, 16, 20, and 21. Eight CNVs at different locations, apart from the suspected breakpoints, indicates the complexity of the CCRs and effectiveness of CMA [16].
No molecular imbalances were observed in our familial ABCRs (five prenatal, seven postnatal). However, Gijsbers
The rate of
Variations of unknown significance detected in prenatal CMA studies are confusing and genetic counseling is difficult. Therefore, to decrease the VUS possibility, the standards and guidelines of 2013 [9] recommends reporting the variations that are >400 kb for both deletions and duplications in prenatal and postnatal studies by whole genome array platforms. Different countries have their approach for prenatal cases, such as including genes number [>18 genes (Belgium), size of imbalances (>500 kb for deletions and >1.0 Mb for duplications (Canada)], choosing array platforms reducing densities of the probes [23,24, 25]. In this study, we initially used higher CMA resolution (1.4 Mb) for both postnatal and prenatal cases. Detected imbalances in prenatal cases were over 1.0 Mb, which could be confirmed by 180 K resolution. In some cases, a lower resolution can cause difficulties to search the whole genome or the size of the CNV may differ from the actual size due to the limited number of probes [26].
Parental array studies showed that the detected duplication at 16p11 in case 26 was inherited maternally, which, coincidentally, was on one of the ABCR-involved chromosomes. Imbalances (size range 579 kb to 4.6 Mb) including deletions and duplications at 16p11 showing incomplete penetrance/variable expressivity, can be associated with global development delay, behavioral problems, epilepsy, autism [27]. The critical region comprising breakpoints four and five (BP4-BP5) (600 kb, chr16; 29.6-30.2 mb-HG19) called 16p11.2 microdeletion/microduplication syndrome is reported in about three in 10,000 [28]. Most of the 16p11.2 microduplications (70.0%) are familial, and the clinical findings are variable from severe to mild [29]. The size of microduplication in our case was larger than the critical region, the healthy carrier mother decided to continue the pregnancy. Clinical evaluations of the newborn revealed normal results, clinical follow-up controls of the baby were planned. In general, the detection of duplications is troublesome, either cytogenetically or clinically due to the nonspecific and variable phenotypes. Based on these experiences, it was expected that the frequency of the duplications is higher by CMA than in karyotyping in patients with behavioral problems or autism without distinct dysmorphic features [30]. Therefore, genetic counseling for
When the data of published postnatal
Comparison with the previous reports for postnatal
Study | Array Platform | Translocation | Inversion | CCRs | Total | Imbalances at the Breakpoint | Imbalances at Different Breakpoint Regions |
---|---|---|---|---|---|---|---|
[13] | 1 Mb BAC | 5/8 (62.5) | – | 0/2 (0.0) | 5/10 (50.0) | 2/10 (20.0) | 3/10 (30.0) |
[11] | Agilent 44K or 244k | 11/27 (40.0) | – | 12/13 (92.3) | 23/40 (57.5) | 16/40 (40.0) | 7/40 (17.5) |
[37] | Agilent Genomics 244k/2600, BAC, Spectral | 4/9 (44.4) | – | – | 4/9 (44.4) | 1/9 (11.1) | 3/9 (33.3) |
[34]a | Whole Genome Tilepath 30k | 4/11 (36.3) | – | 1/2 (50.0) | 5/13 (38.4) | 4/13 (30.7) | 1/13 (7.7) |
[5] | Cytochip Bluegnome 1 Mb | 2/6 (33.2) | – | – | 2/6 (33.2) | 1/6 (16.6) | 1/6 (16.6) |
[14] | Agilent 44K or 244k | 8/21 (38.1) | 4/7 (57.1) | 4/5 (80.0) | 16/33 (48.5) | 9/33 (27.3) | 7/33 (21.2) |
[16]a | Affymetrix GeneChip 250k | 3/3 (100.0) | 2/2 (100.0) | – | 5/5 (100.0) | 2/5 (40.0) | 3/5 (60.0) |
[12]a | 32250k k BAC, Affymetrix 105k/244k Agilent, | 11/40 (27.5) | 0/6 (0.0) | 7/8 (87.5) | 18/54 (33.3) | 11/54 (20.3) | 7/54 (13.0) |
[15]a | 370k, 370-Duo Illumina | 2/5 (40.0) | 2/4 (50.0) | – | 4/9 (44.4) | 2/9 (22.2) | 2/9 (22.2) |
[17] | 135k NimbleGen CGX-3 | 3/7 (43.0) | 1/4 (25.0) | – | 4/11 (36.4) | 3/11 (27.3) | 1/11 (9.1) |
[38] | SNP 6.0/750k Affymetrix | 1/11 (9.0) | 0/3 (0.0) | 1/1 (100.0) | 3/15 (20.0) | 1/15 (6.7) | 2/15 (13.3) |
This study | 1.4M NimbleGen CGX-3/ 180k Agilent | 1/5 (20.0) | 1/1 (100.0) | 5/8 (62.5) | 7/14 (50.0) | 2/14 (14.3) | 5/14 (35.7) |
Total | 55/153 (35.9) | 10/27 (37.0) | 29/39 (74.4) | 96/219 (43.8) | 54/219 (24.6) | 42/219 (19.2) |
CCRs: complex chromosome rearrangements; BAC: bacterial artificial chromosome.
Manufacturers’ locations. BAC: in-house methods; Agilent Technologies Inc.: Santa Clara, CA, USA; Spectral Genomics Co.: Houston, TX, USA; Whole Genome Tilepath: in-house methods; BlueGnome Ltd.: Cambridge, Cambridgeshire, UK; Affymetrix, Inc.: Santa Clara, CA, USA; Illumina Inc.: San Diego, CA, USA; Roche NimbleGen, Inc.: Madison, WI, USA.
a Unknown parental origins for karyotype result of the reported cases were excluded.
The imbalances at unrelated regions of the break-points/chromosomes observed in five CCR cases (cases 10, 15, 16, 20, 21) demonstrate the advantage of genome-wide array studies. Multiple breaks and consecutive micro-deletions in these cases show the complexity of the CCRs, and support that
Altogether, the imbalance rate of
In conclusion: