Journal of Genetics (2019) 98:42
© Indian Academy of Sciences https://doi.org/10.1007/s12041-019-1090-5
RESEARCH ARTICLE
Clinical presentation and genetic profiles of Chinese patients with velocardiofacial syndrome in a large referral centre
DANDAN WU1,2, YANG CHEN1,2, QIMING CHEN1,2, GUOMING WANG1,2∗, XIAOFENG XU1,2, A. PENG3, JIN HAO4, JINGUANG HE5∗, LI HUANG6∗ and JIEWEN DAI1,2∗
1Department of Oral and Cranio-maxillofacial Surgery, National Clinical Research Center for Oral Disease, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, People’s Republic of China 2Shanghai Key Laboratory of Stomatology, Shanghai 200011, People’s Republic of China 3State Key Laboratory of Oral Diseases, West China School of Stomatology, Chengdu 610041, People’s Republic of China 4Harvard School of Dental Medicine, Harvard University, Boston 02125, USA 5Department of Plastic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, People’s Republic of China 6Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People’s Republic of China
*For correspondence. E-mail: Jiewen Dai, [email protected]; Guoming Wang, [email protected]; Jinguang He, [email protected]; Li Huang, [email protected].
Received 29 November 2017; revised 8 January 2019; accepted 11 January 2019; published online 4 May 2019 Abstract. Diagnosis and treatment of velocardiofacial syndrome (VCFS) with variable genotypes and phenotypes are considered to be very complicated. Establishing an exact correlation between the phenotypes and genotypes of VCFS is still a challenging. In this paper, 88 Chinese VCFS patients were divided into five groups based on palatal anomalies and one or two of other four common phenotypes, and copy number variations (CNVs) were detected using multiplex ligation-dependent probe amplification (MLPA), array comparative genomic hybridization (aCGH) and quantitative polymerase chain reaction. The findings showed that palatal anomalies and characteristic malformation of face were important indicators for 22q11.2 microdeletion, and there was difference in the phenotypic spectrum between the duplication and deletion of 22q11.2. MLPA was a highly cost-effective, sensitive and preferred method for patients with 22q11.2 deletion or duplication. Our results also firstly reported that all three patients who simultaneously exhibited palatal anomalies and cognitive disorder, without other phenotypes, have Top3b duplication, which strongly suggested that Top3b may be a pathogenic gene for these patients. Further, the findings showed that patients with palatal anomalies and congenital heart disease or immune deficiency, with or without other uncommon phenotypes, exhibited heterogeneity in CNVs, including 4q34.1- qter, 6q25.3, 4q23, Xp11.4, 13q21.1, 17q23.2, 7p21.3, 2p11.2, 11q24.3 and 16q23.3, and some possible pathogenic genes, including
BCOR, PRR20A, TBX2, SMYD1, KLKB1 and TULP4 have been suggested. For these patients, aCGH, whole genomic sequencing,
combined with references and phenomics database to find pathogenic gene, may be choices of priority. Taking these findings together, we offered an alternative method for diagnosis of Chinese VCFS patients based on this phenotypic strategy.
Keywords. diagnosis; Chinese patients; velocardiofacial syndrome patients; phenotypic strategy.
Introduction
Velocardiofacial syndrome (VCFS) (MIM: 192430, also named DiGeorge syndrome, MIM: 188400), affects ∼1
Dandan Wu, Yang Chen and Qiming Chen contributed equally to this work.
Electronic supplementary material: The online version of this article (https://doi.org/10.1007/s12041-019-1090-5) contains supplemen- tary material, which is available to authorized users.
1
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in 2000–7000 individuals (Kobrynski and Sullivan 2007; Materials and methods Wu et al. 2013; Kruszka et al. 2017). Phenotypes in
Patients
every patient with VCFS exhibited great variety, and more than 180 clinical features involving almost all organs and systems have been reported. The five most common symptoms for VCFS patients include palatal anomalies, congenital heart disease (CHD), characteristic malformation of face (CMF), immune deficiency and cognitive or behavioural disorder. However, no single phenotype occurs in all patients, and no patient would exhibit all reported phenotypes (Perez and Sullivan 2002; Kobrynski and Sullivan 2007; Lopez-Rivera et al. 2017).
Eighty-eight patients, diagnosed as VCFS based on clinical and auxiliary examinations, from the Center for Cleft Lip and Palate, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine were enrolled in this study. Some patients’ samples and materials from our previous study also were included in this study (Wu et al. 2013). Patients who exhibited at least two of the five most common phenotypes, including palatal abnormality, CHD, CMF, immune deficiency and cognitive or behavioural disorder were clinically diagnosed as VCFS. Except for these five common phenotypes, all the other phenotypes were defined as uncommon phenotypes. In this study, palatal abnormalities mean patients exhibited submucosal cleft palate, occult submucous cleft palate, complete cleft palate (CCP) or congenital velopharyngeal insufficiency (CVPI). CMF mean patients exhibited all of the following phenotypes: vertically long face, narrow palpebral fissures, fleshy nose with a broad nasal root, flattened malar region and retrognathia. CHD mean patients with one or several conotruncal CHDs, aortic arch anomalies or other phenotypes: tetralogy of fallot, atrial septal defect, interrupted aortic arch, patent ductus arteriosus and ventricular septal defect. Immune deficiency means patients had thymic hypoplasia, T-cell deficiency or history of recurrent infections. Cognitive or behavioural disorders mean mild mental retardation or intellectual disability. Every enrolled patient would receive a general physical examination in detail, and the phenotypes were diagnosed by specialist physicians. The basic information and clinical phenotypes of these patients are listed in table 1 in electronic supplementary material at http://www.ias.ac.in/ jgenet/.
In this study, we tried to classify VCFS patients based on the five most common phenotypes. All enrolled 88 patients in this study were divided into five groups (table 2 in electronic supplementary material): (i) group 1 (patients 1 to 66): patients exhibited palatal anomalies and CMF, with or without other phenotypes; (ii) group 2 (patients 67 to 69): patients exhibited palatal anomalies and cognitive or behavioural disorder, with or without other uncommon phenotypes; (iii) group 3 (patients 70 to 80): patients exhibited palatal anomalies and CHD, with or without other uncommon phenotypes; (iv) group 4 (patients 81 to 86): patients exhibited palatal anomalies and immune defi- ciency, with or without other uncommon phenotypesand (v) group 5 (patients 87 and 88): there were two patients exhibiting palatal anomalies, cognitive or behavioural disorder and immune deficiency, with or without other uncommon phenotypes.
Previous evidence showed that an autosomal dominant microdeletion on the long arm of chromosome 22(22q11.2) was the most common pathogenic factor for VCFS, and the vast majority of individuals with 22q11.2 microdeletion carry a typical 3-Mb deletion. In addition, some patients carry a proximal 1.5-Mb deletion nested to the typically deleted region (TDR), and only a few patients exhibited atypical deletions overlapping or nonoverlapping with the TDR (Perez and Sullivan 2002; Ensenauer et al. 2003; Kobrynski and Sullivan 2007; Panamonta e t a l. 2016a, b). However, exceptfor22q11.2microdeletion, previous findings also showed that some cases exhibited clinical phenotypes similar to those of VCFS having 22q11.2 duplication or copy number variations (CNVs) on other chromosomes. These patients were also clinically diagnosed as VCFS by some geneticists and doctors (Wu
et al. 2013).
Establishing an exact correlation between the phenotypes and genotypes of VCFS is still a challenge. With the development of biotechnology, such as whole-genome sequencing, array comparative genomic hybridization (aCGH) and multiplex ligation-dependent probe amplification (MLPA), detection of genetic variation in patients has become easier (Jalali et al. 2008; Poirsier et al. 2016). However, narrowing the detecting area and focus on some potential target based on the phenotypes may increase the precision of diagnosis and reduce patients’ cost. Humanphenotypeontologyoffersacomputationalbridge between genotypes and phenotypes (Zemojtel et al. 2014; Kohler et al. 2017). Our previous preliminary findings also showed that all VCFS patients with palatal anomalies and CMF would have a 22q11.2 microdeletion (Wu et al. 2013). All of these findings inspired us that VCFS patients may be divided into different groups based on clinical phenotypes, and these different groups may exhibit different genetic variations.
In this paper, 88 Chinese patients with clinical diagnosis of VCFS were divided into five groups based on palatal anomalies and one or two of other four common phenotypes, and these groups exhibited different CNVs. Further, some new possible pathogenic genes also were found based on this strategy, which offered a useful method for classification diagnosis of Chinese VCFS patients based on this phenotypic strategy.
One hundred normal patients were included in this study as a control. The summary of these control patients’ demographic data is listed in tables 3 and 4 in electronic
Clinical and genetic profiles of Chinese VCFS patients
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Figure 1. Algorithm for CNV testing in VCFS patients and controls. All VCFS patients and controls would firstly undergo MLPA analysis, and the patients without 22q11.2 microdeletion, a most common pathogenic factor of VCFS, being detected by MLPA would undergo aCGH analysis. Further, if the internal reference probe sites were similar to the sample’s sites, sample probes array floating and irregular, or there were less sample probes in the aCGH image, the aCGH results should be further evaluated by qPCR. CNVs, copy number variations.
supplementary material. Thirty available parent pairs (60 10–50 ng/μL DNA was prepared for MLPA analysis, parents) of subjects with typical 22q11 deletion were also aCGH or qPCR. included in this study to determine whether 22q11 deletion was inherited or de novo.
MLPA analysis
The VCFS patients, controls and parent pairs would undergo MLPA, aCGH or quantitative polymerase chain reaction (qPCR) analyses following the planed arrangement (figure 1).
The protocols for MLPA analysis is described in detail in the previous literature. Briefly, the SALSA MLPA KIT P250-B1 DiGeorge (MRC-Holland, Amsterdam, the Netherlands) was used for MLPA analysis according to the manufacturer’s instructions. Capillary electrophoresis on an ABI 3130XL Genetic Analyser (Applied Biosystems,
DNA extraction
Whole peripheral blood was collected, and genomic DNA Foster City, USA) was used to detect and quantify the was extracted from the peripheral blood using a Qiagen amplification products, and the files of electropherograms DNA blood kit (Qiagen, Hilden, Germany) following the were analysed using GeneMarker software v1.8 (Softgemanufacturer’s instructions. Then the concentration was netics, State College, USA). Forty-eight probes for 48 detected using a spectrophotometry method (NanoDrop different genes were included in this MLPA kit, and the 1000, Thermo Scientific, USA), and a concentration of detailed information on these probes is described in the
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previous literature (Wu et al. 2013). Each MLPA analysis on the VCFS-related tissues, including cardiovascular
- was carried out in triplicate.
- system, brain, haemolymphoid system, branchial arch and
limb.
Array comparative genomic hybridization (aCGH)
Prediction of CNVs and possible pathogenic genes based on phenomics
The MLPA analysis results showed that there were 16 patients exhibiting no CNVs (patients 70–76, 78–80, 81–86), four patients with atypical 22q11.2 duplication (patients 77, 67–69) and one patient (patient 88) with 4q34 loss of heterozygosity. High-density probe microarray analyses were performed to evaluate the complete genomes of these 21 patients, who had no 22q11.2 microdeletion, to determine the other possible CNVs. Genomic DNA was extracted from whole blood using the QIAamp DNA Blood Maxi kit following the instructions described above. CNVs were analysed using the CytoScan HD array (Affymetrix, Santa Clara, USA) and Affymetrix Chromosome Analysis Suite (Affymetrix) software according to the manufacturer’s instructions. Briefly, the protocols included the following eight procedures before scanning the chip: genomic DNA digestion, Nsp I adapter ligation, fragment amplification by PCR, purifi- cation of PCR product, fragmentation of PCR product, end-labelling, hybridization and washing. The obtained CNVs were compared with the CNVs in the database of genomic variants (DGV).
We used the on-line database, phenolizer (http://phenolyze r.wglab.org/) and phenomizer (http://compbio.charite.de/ phenomizer/), to make a prediction of CNVs or possible pathogenic genes based on the patients’ phenotypes. Whenever there were many genes located in CNVs, the phenolizer database was also used to sort the possible pathogenicity for these genes based on the patients’ phenotypes.
Statistical analysis
The χ2 test was used to compare the CNVs and clinical characteristics among the five groups using SPSS 17.0 software, and P < 0.05 was considered significant.
Ethics statement
The protocols used in this study were carried out according to the principles of the Declaration of Helsinki, and were approved by the Ethics Committee in Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine. Written informed consent was obtained from all participants or from their parents.
CNVs validation by qPCR
If the internal reference probe sites were similar to the sample’s sites, sample probes array floating and irregular or there were less sample probes in the aCGH image, the aCGH results should be further evaluated. In this study, the detected CNVs in patients 70, 71, 75, 79–86 and 88 by aCGH were selected for further validation by qPCR. SYBR Green analysis on an ABI 7900 HT Sequence Detection System (Applied Biosystems) was used to quantify copy numbers. Primer 5.0 was used to design primers to amplify the region of interest, and the sequences of these primers are listed in table 5 in electronic supplementary material. Each qPCR run included amplification of an endogenous control with known copy number (RPP30-71 and RPPH1-63). In total, 10 μL reaction solutions were used with 10 ng DNA according to the manufacturer’s recommended protocols. qPCR was conducted in duplicate. The CNVs were calculated as
Results
CNVs and clinical characteristics of VCFS patients in group 1
The MLPA results showed that all 66 patients (patients 1 to 66) who simultaneously exhibited CMF and palatal anomalies have 22q11.2 heterozygous deletion, of whom 62 (93.93%) exhibited typical 3-Mb deletion, and four (6.07%) displayed proximal 1.5-Mb deletion (table 1 in electronic supplementary material). No case was found with atypical deletion and duplication of 22q11.2.
For common phenotypes, 32 patients (48.48%) exhibited incomplete cleft palate (ICP) or occult submucous cleft palate, whereas 34 patients had CVPI among these 66 patients. Twenty-three patients (34.85%) suffered from CHDs, 50 patients (75.76%) exhibited cognitive or behaviouraldisorderand38patients(57.58%)hadimmune deficiency (table 1 in electronic supplementary material).
For uncommon phenotypes, 33 patients (50%) showed
21−(ꢀC samples−ꢀC internal reference)
.
Expression patterns of possible pathogenic genes
The expression patterns of possible pathogenic genes were other uncommon phenotypes, such as epilepsy, funnel obtained from the database of Mouse Genome Infor- chest and enamel hypomineralization. Among these matics(http://www.informatics.jax.org/), GeneExpression uncommon phenotypes, seven patients (10.61%) exhibited Atlas (http://www.ebi.ac.uk/rdf/services/atlas/) and NCBI epilepsy, and 16 (24.24%) showed growth retardation or (https://www.ncbi.nlm.nih.gov/gene/). We mainly focussed short stature. No patient exhibited CCP or cleft lip in
Clinical and genetic profiles of Chinese VCFS patients
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Figure 2. Images of MLPA analysis using the P250-B1 DiGeorge kit. (a) Patients exhibited normal copy numbers. (b) Patients 67–69 exhibited TOP3B heterozygous duplications within 22q11.2. (c) Patient 77 exhibited LZTR1 heterozygous deletion within 22q11.2. (d) Patient 88 exhibited 4q34 (SLC25A4, KLKB1) heterozygous deletion (red spots).
all these 66 patients (table 1 in electronic supplementary process (figure 3, b–e) (Wamstad and Bardwell 2007).
- material).
- Previous studies showed that Top3b plays a crucial role
No chromosomal abnormalities were detected by using in catalysing RNA transesterification, and works with the the MLPA kit in all 325 controls (figure 2a; tables 3 and fragile X syndrome protein to promote synapse forma4 in electronic supplementary material), which further tion (Stoll et al. 2013; Xu et al. 2013). Knock out of confirmed that nonsyndromic palate anomalies or CHD Top3b in mice would lead to reduced mean lifespan, and would exhibit no 22q11.2 deletion or duplication, and results in inflammation or autoimmunity in many impor-
- most 22q11.2 deletion in patients was de novo.
- tant organs (table 6 in electronic supplementary material)
(Kwan and Wang 2001; Kwan et al. 2003, 2007). Further, previous studies also reported Top3b duplication or deletioninasmallnumberofcaseswhenperformedascreening in a relatively large samples of CHD or schizophrenia patients (table 6 in electronic supplementary material) (Kaufman et al. 2016). In this study, we firstly reported that patients simultaneously having palatal anomalies and mild-cognitive disorder (without other phenotypes) would exhibit a higher ratio with Top3b duplication (3/3, 100%). Further, we also find that patient 67 has 7p21.3 duplication (figure 1 in electronic supplementary material;
CNVs and clinical characteristics of VCFS patients in group 2
The MLPA results showed that all the three patients had 22q11.2 duplication, and this region only includes Top3b (figure 2b; table 1 in electronic supplementary material). The aCGH results further confirmed the findings (figure 3a). The Gene Expression Atlas on-line database showed that Top3b expressed in the brain and branchial arch tissues during the mouse embryonic development
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Figure 3. (a) aCGH detection results showed that one 264 kb copy duplication of 22q11.2 (22,315,092–22,578,983) in patients 67, 68 and 69. (b) Top3b expression patterns in the mouse brain obtained from the Gene Expression Atlas on-line database. (c–e) Top3b expression patterns in the E8.5 (c), E9.5 (d) and E10.5 (e) mouse tissues from first branchial arch obtained from the Gene Expression Atlas on-line database. E, embryonic.
- table 1), which may contribute to growth retardation and
- The MLPA results showed that patient 77 exhibited
morphology anomalies. Previous study reported a case LZTR1 duplication (figure 2c). But aCGH results did not with 7p21.3-p22 duplication exhibiting slow response, detectthisvariation, andexcludedthisfalse-positiveresult. facial anomalies, hypoimmunity and pulmonary hyperten- Although all patients in group 3 exhibited no deletion sion. Although, patient 67 exhibited no such phenotypes or duplication of 22q11.2, the aCGH and qPCR results at the current stage, we should pay attention in future showed that four patients (40.0%) exhibited other CNVs
- follow-up.
- in these patients (table 1).
We firstly showed that patient 70 has a deletion in
4q23 (figure 2a in electronic supplementary material), and only C4orf37 (also named STPG2) located in this region (table 1). Although no STPG2 variation related to human disease has been reported, previous findings showed that SRCAP mutation contributed to FloatingHarbour syndrome and would lead to STPG2 hypermethylate (Hood et al. 2016). Previous records also showed that STPG2 expressed in the cardiovascular system, brain and haemolymphoid system, which implied that STPG2