Molecular Diagnosis

In Oncology
&
Genetics
Diagnostic Molecular Pathology

• USE OF:
– Sequence Specific INFORMATION
• in
– MACROMOLECULES
• for
– Risk identfication
– Diagnosis
– Prognosis
– Prediction of response to therapy
– Montoring therapeutic responses
 Macromolecules

• Peptides/proteins
• Polysaccharides
• Polynucleotides/nucleic acids
 “Nucleic Acid Diagnosis”

• Use of specific sequence information

in
• nucleic acids
– DNA and RNA
• for clinical diagnosis
Analysis Of Information In Nucleic Acids

• Sequencing
• Hybridization
• Amplification
– with specific primers
• Restriction enzyme digestion
– Recognize specific sequences
• Electrophoretic mobility
• Translation
 Molecular Oncology

• DIAGNOSITC/PROGNOSTIC INFORMATION
PROVIDED BY:
– Gross alterations in DNA content of tumors
– Cell cycle information
– Molecular Markers of Clonality
– Oncogene/Tumor Suppressor gene mutations
– Tumor Specific Translocations
– “Tissue specific” mRNA in tumor staging
– Minimal residual disease determination
 Identification Of Clonal
Proliferations

• Antigen receptor gene rearrangements.

– Southern Blotting: IgH, TCR; EBV termini.
– PCR: Ig and TCR gene rearrangement.
• X-inactivation.
– Human androgen receptor assay.
• Microsatellite allelotyping.
 11kb
HindIII HindIII

BamHI 18kb
BamHI

L VH1 L VHN JH

18kb
EcoRI EcoRI

Immunoglobulin heavy chain locus - restriction

enzyme digestion sites
Translocations w/o gene
fusion
Activated Mechanism of
Tumor Translocation Gene Activation
B-All/Burkitt t(8;14)(q24;q32) MYC Relocation to
IgH locus
Large Cell t(3;14)(q27;q32) BCL6 Relocation to
Lymphoma IgH locus
Mantle Cell t(11;14)(q13;q32) Cyclin D1 Relocation to
Lymphoma IgH locus
Follicular B- t(14;18)(q32;q21) BCL2 Relocation to
cell lymphoma IgH locus
T-cell ALL t(8;14)(q24;q11) MYC Relocation to
TCR / locus
T-cell ALL t(1;14)(p32;q11) TAL1 Relocation to
TCR / locus
Translocations w/fusion product:
hematologic tumors
TUMOR Translocation Gene fusion

Chronic myelogenous t(9;22) BCR-ABL(p210)

leukemia
Acute promyelocytic t(15;17); PML-RAR
leukemia t(11:17)(q23;q21); PLZF-RAR
t(5;17) (q35;q21); NPM-RAR
t(11;17)(q13;q21) NUMA-RAR
der(17) STAT5b-RAR
AML t(8;21)(q22;q22) AML1-ETO

AML and ALL (esp. 11q23 MLL-(~30 partners)

infants and post-Rx)
Anaplastic large cell t(2;5)(p23;q35) NPM-ALK
lymphoma (pediatric)
ALL t(9;22) BCR-ABL(p190)

MALT lymphoma t(11;18) API2-MLT

 Translocations w/chimeric
products: solid tumors
Tumor Translocation Product

Ewing’s Sarcoma t(11;22); t(21;22); EWS/FLI1; EWS/ERG;

t(7;22); t(12;22) EWS/ETV1;
EWS/ETV4
Alveolar t(1;13); t(2;13) PAX7/FKHR;
Rhabdomyosarc. PAX3/FKHR
Synovial sarcoma t(X;18) SYT/SSX1

DSRCT t(11;22) EWS/WT1

Myxoid/round cell t(12;22) CHOP/FUS
liposarcoma
Clear cell sarcoma t(12;22) EWS.ATF-1
soft parts
Extraskeletal myxoid t(9;22) EWS/TEC
chondrosarc
TRANSLOCATIONS: DETECTION
METHODS
• No fusion product:
– detect at DNA level.
• In situ hybridizaton
• Southern Blotting:
– Probe to translocated sequence hybridizes to
altered band size. (multiple probes)
– Problems: Quantity, quality of DNA, labor intensive.
• PCR
– If recurrent breakpoints in small DNA region
• Available for BCL2 (60% detected); BCL1 (40-
60% detected).
– ? Long-range PCR – need for high quality DNA .
TRANSLOCATIONS: DETECTION
METHODS
• Fusion product:
– Detect at DNA or RNA level.
• DNA level: FISH, Southern blotting.
• RNA detection: RT-PCR
– Highly sensitive.
– Cheaper
– “Real-time” detection.
– Semi-quantitative detection – minimal residual
disease/quantification.
– Chimeric transcript detectable during “complete
remission” : rising titer - impending relapse.
– Need for fresh tissue (in general)
Spectral Karyotyping (SKY)

• FISH w/multiple probes to identify

all chromosomes
– Identify any translocations, markers
etc. w/one test.
– Need for special equipment
– Need for metaphases.
Gene Amplifications & Specific
Mutations
• Amplification
– n-Myc: neuroblastoma.
– Her2/Neu: breast cancer.
• Mutations:
– C-Kit: gastrointestinal stromal tumors.
– EGFR: Lung CA response to Iressa.
– p53: poor prognosis, reduced
chemosensitivity.
 Tumor Suppressor Gene
Mutations
“loss of function mutations”
– many possible mutations
– “hot-spots”
• e.g., p53: Exons 6, 7, 8, 9 > 90% of
mutations
– truncated protein: “protein truncation
test”
– “whole gene sequencing”
• Tumor precentage.
 “Oncogene” Mutations
• :“gain of function mutations.”
– limited number for each gene.
• “regulatory site mutations” - “constitutive
activation.”
• “active site mutations” - “constitutive
activation/altered substrate.
• Often recurrent - test for known
mutations.
• e.g., c-Kit; c-RAS; Ret, EGFR, etc.
 Mutations in GIST

• GIST: CD117/PDGFRA positive GI

stromal tumors.
– c-kit mutations: constitutively activated
KIT tyrosine kinase.
• Juxtamembrane domain (exon11) or
transmembrane domain (exon 9)
– Imatinib (Gleevec) responsive.
• Tyrosine kinase domain mutations:
– Val654Ala, Thr670Ile: Imatinib resistant
 EGFR mutations in Lung
CA
• 10% of patients with Lung CA – rapid
response to Gefitinib (Iressa)
– Non smokers
– Females
– Japanese
– Adenocarcinoma
• Mutations in exons 18, 19, &21
– Kinase catalytic domain
– Increased inhibition by Gefitinib
 Minimal Residual Disease

• Quantitative determination of tumor-

specific fusion transcripts.
• Presence vs quantitation.
• Detection of clone-specific sequences for
T and b-cell neoplasms.
– (Problem: ongoing mutations in antigen
receptor genes).
 Minimal Residual Disease/
Molecular Staging
• Cell-type specific transcript (mRNA):
– PSA (prostate);
– mammaglobin (breast);
– CEA in lymph nodes (adenoCA, e.G., Colon);
– tyrosinase (melanoma);
– thyroglobulin (thyroid).
– Caveat: ? cell-type specificity of low copy-
number transcripts.
 MRD/Molecular Staging
• RT-PCR for mets in histo negative
sentinel nodes.
• Melanoma: Tyrosinase, MART-1,
MAGE, GalNAc-T, PAX3
– Variable results; ? Increased
recurrence in histo-/PCR+, vs.
histo-/PCR-
• Breast: Mammaglobin1,
mammaglobin 2, CEA, CK19, etc.
 Tumor Classification/diagnosis W/
Microarrays

• Label total RNA from a tumor

• hybridize to chip w/  25,0000
cDNAs/oligonucleotides.
– Expression profile unique to tumor type.
– ? Predict behavior
– ? Identify origin of mets
– ? Identify targets for therapy.
 Molecular Genetic Tests
• Genetic test:
– Analyis of human
• DNA
• RNA
• chromosomes
• proteins
• metabolites
– to detect heritable disease-related
• genotype,
• phenotype
• karyotype
– for clinical purposes.
 Genetic Diagnosis
“Purpose”

• Diagnostic Testing
• Screening
• Presymptomatic Testing
• Prenatal testing
• Preimplantation Diagnosis
• Pharmacogenetic testing
• Susceptibility to environmental agents
 Genetic Alterations
• Chromosomal alterations
• “Gene-level” alterations.
 Test Choice
• Cost
• Sample requirements
• Turnaround time
• Sensitivity/Specificity
• Positive/ Negative predictive
value
• Type of mutation detected
• Genotyping vs mutation
scanning
Conventional Cytogenetics
(Karyotyping)
• Detect numerical structural
chromosomal alterations
– trisomy
– monosomy
– duplications
– translocations, etc.
Conventional Cytogenetics
(Karyotyping)
• evaluate all chromosomes
– prior specification of chromosome
unnecessary
– detect unsuspected abnormality
– detect balanced alterations
• (No gain or loss of genetic material)
• FISH may be performed.
– characterize unxpected alterations
Conventional Cytogenetics
(Karyotyping)
• Disadvantages:
– Need for live cells to grow in culture
• (ACMG standards, failure <1%).
– Turnaround time - up to 10 days
• (ACMG standards - 90% of results w/in
14 days)
– Labor Intensive
 FISH
• Use of fluorescently labeled probes
to specifically visualize
– entire chromosomes (chr. paint probes)
– centromeres (centromeric probes)
– specific loci (locus-specific probes)
• Metaphase
– All types of probes
• Interphase
– Centromeric and locus-specific probes
only
 FISH
• Identify:
– translocations
– marker chromosomes
– Small deletions/duplications w/ locus-
sopecific probes
• e.g., DiGeorge’s syndrome.
 Interphase FISH
• rapid (<48 hours) detection of
– Numerical abnormalities
– Duplications/deletions/amplifications
– translocations
– mosaicism
 Interphase FISH
• Prenatal Chr.13, 18, 21, X + Y
– approx. 75-85% of all clinically
relevant abnormalities.
• Dual color FISH w/ subtelomeric
probes:
– Prenatal dx of chromosomal
translocations
 Interphase FISH

• Need for confirmatory conventional

cytogenetic testing.
• Need to specify chromosome
– Information only about specific
chromosome/locus tested.
 Metaphase FISH
• Supplement conventional
cytogenetics
– Identify marker chromosomes
– extra unknown material attached to
chromosome/loss of segment
– detect/identify rearrangements (incl.
cryptic translocations),
– identify/quantify mosaicism
 Metaphase FISH
• Need to specify Chromosome/locus
– Multiple tests to identify marker
chromosome.
– Multiprobe FISH.
 Gene Dosage
Gains/Losses
• Comparative genomic hybridization
(CGH)
– Label normal and test DNA with
separate dyes
– competetively hybridize to
• Metaphase Spread or
• cDNA array.
– Detect Gains and losses.
 Gene Dosage
Gains/Losses
• Classical CGH
– Hybridize to metaphase spread
• Resolution approximately 5Mb
– Information on all chromosomes
– No need for culture.
• can use archival material (e.g., placenta, POC,
tumor etc.)
– Single cell DNA amplification & CHG
• applicable to preimplantation genetic diagnosis
(PGD)
 Gene Dosage
Gains/Losses

• Array-based CGH
– hybridize to BAC-based or cDNA
array.
– Higher resolution (50kb vs 5MB)
 Gene Dosage
Gains/Losses

• PCR-based methods
– Real-time (quantitative) PCR.
– microsatellite PCR.
– Long-range PCR.
– probe amplification techniques.
• Rapid
• For specific loci
– May be “multiplexed” for multiple loci
 Molecular Tests
• Test for:
– karyotpye
– gain or loss of genetic material (“dosage”)
– genetic linkage
– known/recurrent mutations
– variations in lengths of repeat sequences
– alterations in DNA methylation
– unknown mutations in multiple genetic
segments
 Types of mutations-gene
• Point mutations
– Missense (change an amino acid)
– Nonsense (premature termination)
– Silent
• Deletion
– Large variation in size
• Insertion
• Duplication
• Splice site
• Regulatory
• Expanded repeat
gross deletions

complex rearrangements

Gross insertion and duplications

repeat expansions

small ins/del

small insertions

small deletions

regulatory

splicing

Nonsense

Missense

0 2000 4000 6000 8000

 Point Mutations

ATC TTC AGC TGC GAG CTA TAT

Leu Phe Ser Cys Glu Leu Tyr

Missense ATC TTA AGC TGC GAG CTA TAT

Leu Leu Ser Cys Glu Leu Tyr

Nonsense ATC TTC AGC TGA GAG CTA TAT

Leu Phe Ser Stop

ATC TTC AGC TGC GAG CTG TAT

Silent
Leu Phe Ser Cys Glu Leu Tyr
 Missense Mutations
• Change Amino Acid
• Change Protein Structure/function
– Depending upon specific AA change
• Loss of function:
– e.g., Hb S (GAG to GTG – Glu to Val),
Hemochromatosis (C282Y)
• “Gain of Function”:
– e.g., Factor V Leiden
• No functional effect:
– e.g., KVLQT1 P448R
 Missense mutations
• When is a missense mutation
significant?
• known structural and functional domain
• evolutionarily conserved residue
• independent occurrence in unrelated patients
• absent in large control sample
• novel appearance & cosegregation w/disease
phenotype in pedigreee
• In vitro loss of function
• restoration of function by WT protein.
 Nonsense Mutations

• Amino Acid codon to “Stop”

• Three stop codons
– UAA, UAG, UGA
• Truncated protein
– Protein truncation test
• E.g., Betao Thalassemia in Sardinia
– Codon 24, CAG to TAG
Deletions

CATGTAGGCAAT

CATGTAGCAAT
 Deletions
• Complete/partial gene deletion
– Duchenne Muscular Dystrophy
– Alpha thalassemia
• Multiple genes (“contiguous gene
syndromes”
– DiGeorge Syndrome
– TSC2-PKD1
– WAGR syndrome
 Insertions
• Tay Sachs Disease
– 4bp insertion in Ashkenazi Jews
• Hemophilia A
– L1 insertion in FVIII gene (1% of
patients)
 Splice junction mutations
–GT/AG rule
– AAGGTAAGT. .. . .. .. //. .. . YYYYYYYYYYNCAGG

–Loss of splice site

•intron not spliced out
– Creation of novel splice sites
•>100 mutations
– e.g., Hemoglobin E
– Missense mutation and splice site error
– Both normal and new splice site use
• Hemoglobinopathy AND thalassemia features
 Frame-shift Mutations
• Codon = 3 bp
• insertion/deletion not multiple of
3bp
– Change of reading frame - entire
protein altered.
– e.g., Tay Sachs 4 bp insertion, BRCA1
185 delAG, BRCA2 6174delT, etc.
– blood group O (1 bp deletion)
 Other mutations
• Cap-site Mutants
• Mutations in initiation codons
• Creation of a new initiation codon
• Mutations in termination codons
• Polyadenylation/cleavage signal
mutations.
Unstable trinucleotide repeats
• Fragile X Syndrome (CGG)n 5’UT
• Huntington’s syndrome (CAG)n
polyglutamine
• Myotonic dystrophy (CTG)n 3’UT
• SCA type 1 (CAG)n polyglutamine
• Friedrich’s Ataxia (GAA)n intron 1
 Mutation Testing
• Tests for recurrent mutations.
– Limited # of specific mutations.
• significant proportion of cases e.g.,
Factor V Leiden, Hemochromatosis.
• Mutation Scanning Methods.
– Multiple “private” mutations of one or
more genes.
• e.g., BMPR2 mutations in familial PPH,
• Combination.
– e.g., BRCA1/2, CFTR etc.
Recurrent Mutation Tests
• Many rapid methods.
• High sensitivity/specificity.
• Test choice - laboratory preference
– Workflow, equipment, kit availability
– patent issues, etc.
• Detect
– heterozygotes,
– compound heterozygotes
– homozygotes
 Recurrent Mutation Tests
• Choice of mutation tested
– Clinical syndrome
– Family history
– Ethnicity
• Positive results
– Unambiguous
– Technical false positive rare (most
methods)
– Positive predictive value, penetrance,
etc. usu known
 Recurrent Mutation Tests
• Negative predictive value:
– Population screening:
• 1- (ethnic prevalence x [1 - sensitivity for specific
ethnic group])
– Family history (index case w/ unknown
mut)
• 1 - (prior probability x [1- sensitivity for specific
ethnic group])
– Family history (known mutation in index
case)
• 100%
– Affected individual (unknown mutation)
• 0%
 Recurrent Mutations
• Methods
– PCR-RFLP
– Allele-specific probes/primers
– Direct sequencing/“Minisequencing”/
Pyrosequencing.
– Molecular Beacons/TaqMan probes.
– Oligonucleotide ligation assay.
– Mass spectroscopy-based methods.
 PCR-RFLP
• Quick, Robust
• Sources of error:
– Amplification failure of one allele
• linkage disequilibrium with primer site
polymorphism (HFE)
– Failure of restriction enzyme
• Control in same tube
– Different variants with loss of same
restriction site
 Real-Time PCR
• New instruments can monitor PCR
during thermocycling
– intercalating dye:
• non-specific increase in fluorescence with
increased double-stranded DNA
• “Melting curve” analysis - monitor
denaturation of double-stranded DNA
– Probes using Fluorescence Resonance
Energy Transfer (“FRET”)
• Monitor binding of probe to wild-type or
mutatnt allele.
 Repeat Expansions

• Southern Blotting Methods

– Gold Standard
– Labor intensive
– need for high quality DNA
• PCR-based Methods
– Rapid
– Amplification failure with very long repeats.
 Expanded Repeats-Huntington
Disease
(CAG)10-26 (CAG)27-35 (CAG)35-41 (CAG) 42-121

Normal At risk for expansion Variable penetrance Affected

ATCCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGCAGTTC
 Mutation Scanning
Methods
• Test one or more genes for
unknown variation in.
– Exons
– Introns
– splice sites
– Promoters/enhancers
– “locus control region”
 Mutation Scanning
Methods
• Ideal method:
– Screen large DNA sequence
– 100% sensitivity and specificity
– Unambiguously define mutation.
– Minimum # of steps
– High throughput
– No special equipment
– No dangerous reagents
• No such method
– Compromise
 Screening Methods
• physical properties of amplified
gene segments
– denaturation profile, electrophoretic
mobility, etc.
• SSCP
• DGGE
• DHPLC
• Cleavase fragment length polymorphisms
• heteroduplex analysis
• dideoxy fingerprinting.
 Screening methods
– Sensitivity determined by specific
mutation
– Need for multiple conditions
– One datapoint per gene segment
evaluated
– Screen for presence, not identitiy of
mutation.
 Mutation Scanning
Methods
• Direct Sequencing
– Screen presence and identity of mutation
– Bidirectional sequencing
– 2 data-points per base sequenced.
– DNA sequencing
• usu. multiple exons tested.
• splice-site mutations may be missed, especially
mutations deep in large introns.
– RNA sequencing
• need for cells w/c express gene
• “nonsense mediated decay”
• RNA more labile
Direct Sequencing Methods

• Automated fluorescent sequencing

– DNA/cDNA amplification, purification,
and re-amplification with Fluorescent
“Big-Dye” terminators.
– widely available
– need to visually scan electropherograms
• verify “base calling”, heterozygous bases
Direct Sequencing Methods
• Pyrosequencing
– limited to short seqences.
– need to optimize algorithm for each
segment
• Chip-based” sequencing
– rapid
– reduced sensitivity for heterozygous and
frame-shift mutations.
 Interpretation of Variant

• Previously reported variant

– Known to be cause of disorder
– Known to be “neutral variation”
 Interpretation of Variant

• New variant:
– Type likely to be assoc. w/disorder
• frame-shift mutation
• start “ATG” mutation
• “Stop codon”
• splice-junction mutation
• non-conservative missense in active site,
 Interpretation of Variant
• New Variant
– Type likely to be “neutral”
• e.g., no change in amino acid, and not
cryptic splice site
– Type w/c may or may not be assoc.
w/ disorder
• E.g., non-conservative missense
mutation, in region not known to be
active site, etc
 Interpretation of Variant
• Recessive Disorders.
– Test parents to ensure two variants in
trans (separate alleles) not in cis
(same allele).
 Testing Strategies.
• Single gene disease w/ only recurrent
mutations (e.g. Achondroplasia or MEN2)
– Test for recurrent mutation
– Positive result
• penetrance known
– Negative result
• False negative rate known.
– Phenotypic testing, if indicated.
 Testing Strategies.
• Single gene ds w/recurrent and private
mutations (e.g., CFTR, thalassemias).
• test for “ethnic” recurrent mutation(s)
• If positive, singificance known
• If negative, and index case or relative,
perform “mutation scanning” test.
– if positive, probably significant, family testing
may help.
– if negative, significance depends on whether
index case or relative.
 Testing Strategies.
• “Single gene” condition w/ repeat
polymorphisms (Fragile X)
– Test for repeat polymorphisms using
either
• Southern Blotting
• PCR (very large expansions may be missed)
• Clinical sydrome w/ multiple genes
– “recurrent” (SCA)
– Private (Long QT)
Testing Strategies

Cystic Fibrosis
 CFTR Screening
• Carrier frequency in various ethnic
populations
– European Caucasian: 1/25
– Ashkenazi Jewish 1/25
– Hispanic American 1/46
– African American 1/65
– Asian American 1/90
 CFTR Screening
• CFTR Gene:
– 250 kb
– 27 Exons
– 6.5kb mRNA
– In-frame deletion of codon 508 in
70% of cases
(Caucasians/Ashkenazim)
– >1000 mutations reported
 CFTR Screening
• “…recommended that testing for
gene mutations that cause cystic
fibrosis be offered as an option to
all pregnant couples and those
planning pregnancy.”
 CFTR Screening
• ACMG recommendations
– Testing offered to all Caucasians and
Ashkenazim, made available to all
other ethnic groups
– Simultaneous or sequential couple
screening
• Give results to both partners
 CFTR Screening
Universal pan-ethnic core mutation
panel consisting of:
– 25 mutations.
– 3 exonic polymorphisms as reflex
tests.
– 5/7/9T intronic polymorphism as
reflex test only if R117H is positive.
 CFTR Screening
• Extended mutation panels for positive-
negative couples not encouraged
• Reporting of results and residual risks
should be based on model report forms
developed by ACMG committee
• Primary care providers uncomfortable
w/ these complexities should refer pt to
genetic counselor
 CFTR Screening
• 5T/7T/9T intronic polymphorphism
• R117H + 5T in cis - CF
• R117H + 7T in cis - CBAVD
• R117H (etc.) + 5T in trans – CBAVD
• 5T/5T homozygosity - CBAVD
– R117H causes CF only when w/ 5T on same
allele
– 5T with least efficiency of RNA processing
– 5T in 5% of US population
 CFTR Screening
• Limitations
– Inability to detect all CF mutations
– Correct paternity assumed; results
applicable only for current reproductive
partners
– Assumes family history is truly negative
– Poor genotype-phenotype correlation -
prognostic prediction in affected offspring
difficult
 CFTR Screening
• Concurrent testing: Both partners
screened, both informed.
• Advantages:
– Quicker
– Alerts both partners
• w/ current and future partners
– Informs both families of potential risk
• Disadvantage:
– Anxiety
– Cost
 CFTR carrier Screening
• Sequential
• Advantages:
– More efficient when low carrier rate
– Less potential anxiety
• Disadvantages
– Higher residual risk
– No information for family of partner
not tested
 CFTR: INCIDENCE, CARRIER,
MUTATION RATES: BY POPULATION
Carrier % other % group- Sensit
Group Incidence freq. %ΔF508 “common” specific ivity
Caucasian 1:3,300 1/29 70 13 80-
90%
Hispanic 1/8-9000 1/46 46 11 57%

Ashkena 1:3,300 1/29 30 67 97%

zim
Native 1:1500 – 0 25 69 94%
Am. 3970
African 1:15,300 1:60-65 48 4 23 75%
Am.
Asian 1:32,100 1:90 30 0 0 30%
Am.
 Negative results: + family history
• Caucasian Couple
• each w/ sibling with CF.
– (Prior Probability of each parent being a
carrier = 2/3).
• Both test negative for the 25 mutations.
– Probability parent is carrier = (0.67
*(1-.90)) = 0.067.
– Probability both parents carriers = .004489
– Probability of affected child = 1 in 900
Negative Results: + Family History

• Hispanic Couple w/ same history and

results:
– Probability of being carrier = (0.67 *(1-
0.57)) = 0.287;
– probability of an affected child = 1 in 48!
– (versus untested prob.: .67*.67*.25=1/9)

• Asian couple w/ same hx and results:

– probability of affected child 1 in 18!
 Genetic testing additional
considerations:
• Benefits Vs. Risk of Testing:
– Availability of treatment/prevention of
clinical syndrome
– Presence or absence of pre-clinical
manifestations.
– Discrimination:
• Insurance
• Employment
• Confidentiality
 Additional Considerations
• Screening vs testing “index” case.
• Index case.
– Known disease;
– negative result:
• mutation not detected
• carrier testing not possible.
• Locus heterogeniety:
– Long QT; red-cell membrane defects;
phenylketonuria; etc.
• Variable “penetrance”
– variable predictive value of positive results
• Variable expressivity
 Additional Considerations
• Potential interventions:
– Behavioral
• lung cancer-risk - smoking cessation;
• heart disease risk - diet/exercise;
• risk of breast/colon cancer - screening
accepatnce.
– Medical
• e.g., prophylactic mastectomy/thyroidectomy;
• blood-letting/blood donation for HFE;
• anti-arrhythmics for Long QT, etc.
 Additional Considerations
• Pre-morbid/clinical syndrome
– Is there a clinically identifiable syndrome ?
– ? Need for intervention prior to clinical
manifestations
• Technical considerations
– e.g., Fragile X-syndrome.
• Patent issues
– affect availability/cost of testing
 Additional Considerations
• Ethics
– implications for patients and relatives.
• e.g., identical twins; siblings;
• paternity issues -
• Legal issues
– New York State Civil Right Law:
• Need for nformed consent
– Genetic testing only (not phenotypic testing)
– Standards for informed consent in civil rights law,
section 79-l [http://assembly.state.ny.us/leg/?
cl=17&a=12].
 Factors affecting utility of genetic testing

• Increased Utility • Decreased utility

– High morbidity and – Low morbidity and mortality
mortality of the disease of disease
– Effective but imperfect – Highly effective and
treatment acceptable treatment (i.e., no
harm is done by waiting for
– High predictive power of clinical disease to treat
genetic test (high patient)
penetrance)
– Poor predictive power of the
– High cost or onerous nature genetic test (low penetrance)
of screening and – Availability of inexpensive,
surveillance methods acceptable, and effective
– Preventive measures that surveillance methods (or
are expensive or associated need for surveillance whether
with adverse effects or not one has increased
genetic risk)
– Preventive measures that are
Modified from: BMJ: 322: 1054; April inexpensive, efficacious, and
28, 2001. highly acceptable - e.g.,
folate supplementation.
 Ordering Molecular Tests
• Patient preparation: None
– Avoid heparin: interferes with PCR.
• Specimens:
– Fresh whole blood: EDTA/Citrate
– Fresh tissues
– Frozen tissues
– Paraffin embeded tissues
– Slides etc.
Ordering Molecular Tests
• Specimen Handling
• DNA-based tests:
– Room temperature, up to 72 hours
(maybe more with special buffers)
• RNA-based tests:
– Deliver ASAP (4-6 hours)
– Special considerations for proprietary
test.
 Ordering Molecular Tests
• Essential info (Molecular Genetic
Tests):
– Clinical information
– pedigree, if possible
– Race
– reason for testing.
• Informed consent:
– New York State Civil Rights Law.
• Nature of test; availability of genetic
counseling; implications of positive and
negative tests, etc.