To the Editor: To date, epilepsy is one of the most common neurological disorders
globally, affecting more than 50 million people worldwide. It is debilitating and
represents a large health-care and economic burden, especially when treatment may
often be expensive and not necessarily effective. It has been suggested that the burden
of lifetime epilepsy has been significantly increasing in China in recent decades.[1]
The International League Against Epilepsy has defined epilepsy in 2014 as a neurological
disorder with at least two unprovoked seizures occurring more than 24 h apart, one
unprovoked seizure and a high probability of further seizures, or diagnosis of an
epilepsy syndrome. Although the condition could also be caused by structural, infectious,
metabolic, and/or immune etiologies, it has recently been estimated that a genetic
etiology could be established in up to 40% of such patients.[2] Molecular testing
with a genomic approach would allow delineation of the precise genetic cause, treatment
stratification, as well as further detection of pharmacogenetic variants to avoid
severe adverse drug reactions toward antiepileptic drugs, which is of particular clinical
importance in Asian populations. A precise genetic diagnosis of the patient would
also guide genetic counseling on the prognosis. The numerous genes associated with
epilepsy and the significant genetic heterogeneity necessitated a high-throughput
technique for clinical laboratories in the genomic era. Here, we reported a case of
SCN2A-related seizure disorder, in which the likely pathogenic variant was only possible
to be detected with the use of targeted gene panel with next-generation sequencing.
This exemplary case demonstrated the value of genetic testing with a genomic approach
in this group of genetically heterogeneous disorder.
Our patient was a male born full-term as the first child to nonconsanguineous Chinese
parents. There was uneventful antenatal history and no remarkable family history.
At 24 months of age, he first presented with recurrent afebrile convulsions, which
were apparently more severe during episodes of febrile illness. Semiology ranged from
generalized tonic-clonic convulsions to myoclonic jerks. He was also noted to have
autistic features with severe language delay and depressed social interaction. Physical
examination showed no focal neurological deficit or dysmorphic feature. Electroencephalography
at 25 months once captured a clinical attack with ictal discharges beginning at bilateral
anterior regions and evolving to generalized epileptiform discharges followed by generalized
suppression of activities. Biochemical investigations, including urine organic acids,
plasma and cerebrospinal fluid amino acid profiling, cerebrospinal fluid neurotransmitters,
plasma and urine creatine, and guanidinoacetate, were all unrevealing. Previous genetic
testing for common mitochondrial DNA point mutations was negative.
Approval for the study was obtained from the Kowloon West Cluster Clinical Research
Ethics Committee, Hospital Authority (No. KW-EX-09-155), and written informed consent
was obtained from the family. Next-generation sequencing was performed with targeted
gene capture using TruSight One Sequencing Panel (Illumina; San Diego, CA, USA), which
covers more than 4800 genes associated with specific clinical phenotypes, on a MiSeq
Sequencing System (Illumina; San Diego, CA, USA). Target regions of interest were
restricted to the coding regions and the 10-bp flanking regions of the selected genes.
The sequencing data were aligned to GRCh37/hg19, and variants were identified within
74 selected genes associated with genetic epilepsies using NextGENe sequencing analysis
software (version 2.4.1; State College, PA, USA). Variants identified were annotated
with VariantStudio software (version 2.2.1; Illumina; San Diego, CA, USA) and filtered
with Excel spreadsheet (2010; Microsoft, Richmond, VA, USA). Pathogenic and likely
pathogenic variants were subsequently confirmed by Sanger sequencing in the proband
and in the mother. Since the parents were divorced, no sample could be collected from
the father.
The coding exons and flanking regions (10-bp) of the 74 selected genes were sequenced
with a mean depth of coverage of 93.8 reads, and 93.9% of the targeted bases were
covered by at least 20 reads. The patient was found to harbor a heterozygous insertion-deletion
NM_021007.2:c.2350_2365delinsTGTACTATCCAACAGATACT (NP_066287.2:p.(Thr784Cysfs*45))
in the SCN2A gene, which was confirmed by Sanger sequencing [Figure 1]. The variant
was not detected in the mother, who did not have a history of convulsion or autism.
This variant was not previously reported as disease-causing and not listed in the
Human Gene Mutation Database (Professional 2018.1) and ClinVar at the time of reporting.
This likely pathogenic variant was predicted to cause a frameshift and premature termination
of the protein. At the time of reporting, the variant was absent from controls in
the Exome Sequencing Project, 1000 Genomes Project, and Genome Aggregation Database.
Although the variant was not reported and functional study data were not yet available,
other frameshift and null variants in SCN2A were described previously in patients
with seizures and considered disease-causing.[3] This variant was not found in the
proband's mother. Unfortunately, genotyping of the father was not performed due to
unavailability. The variant was thus considered likely pathogenic according to the
standard variant interpretation guidelines.
Figure 1
The variant is visualized in Integrative Genomics Viewer (Version 2.3.68; Broad Institute).
Due to limitation of the software, the heterozygous indel variant (c.2350_2365delinsTGTACTATCCAACAGATACT)
is detected as a combination of insertions and substitutions. The electrophoretogram
showing confirmation of the variant c.2350_2365delinsTGTACTATCCAACAGATACT by Sanger
sequencing. Note the insertion of TGTACTATCCAACAGATACT (20 nt) in place of ACGGAGCAGTTCAGCA
(16 nt) on the variant allele.
SCN2A encodes the alpha subunit of voltage-gated sodium channel Nav1.2, which is predominantly
expressed in the brain. SCN2A-related disorders are inherited in an autosomal dominant
manner with incomplete penetrance and variable expressivity, while de novo variants
are not uncommon.[3] Pathogenic variants in SCN2A have been associated with a phenotypic
spectrum that includes benign neonatal/infantile seizures, Ohtahara syndrome, epilepsy
of infancy with migrating focal seizures, West syndrome, Lennox-Gastaut syndrome,
myoclonic-atonic epilepsy, electrical status epilepticus during sleep, and intellectual
disability and/or autism without epilepsy.[3] The diagnosis of a SCN2A-related disorder
in this patient could explain his epilepsy as well as his autism and developmental
delay. Sodium channel blockers, for example, phenytoin, carbamazepine, and lamotrigine
usually represent the first-line treatment for SCN2A-related epileptic disorder, although
recently it has been suggested that null variants in SCN2A might be associated epilepsies
with a later onset and treatment resistance to sodium channel blockers.[3] This molecular-level
diagnosis also facilitates appropriate genetic counseling, screening of at-risk family
members, and prenatal diagnosis for future pregnancies in the family.
The Department of Pathology, Princess Margaret Hospital, has been providing clinical
molecular testing service for more than 20 years. Our laboratory was among the first
clinical laboratory to provide targeted gene panel next-generation sequencing since
June 2016 within the Hospital Authority of Hong Kong, China, which serves the public
sector and around 90% of patients in Hong Kong. Referrals for both inpatients and
outpatients are accepted from clinicians or pathologists in Hong Kong with appropriate
informed consent. Targeted genes are selected for each of the individual disease panels
by chemical pathologists with on-going discussion with clinicians and continuous review
of the current literature, with the aim to fill in the gaps within the existing diagnostic
algorithms for the various clinical conditions. Costs of both the instrument and the
consumables for next-generation sequencing have been drastically dropping and will
continue to decrease in the near future.[4] Genomic testing approaches are recently
believed to end diagnostic odysseys early, thus potentially be cost-saving; appropriate
treatment might yield better control of the disorders, improve quality of life, and
reduce health-care expenditure related to hospitalization.[5] The sequencing costs
for each case were estimated to be around US 1000 dollars (or RMB 7000 Yuan), where
minimal set-up costs and preparatory investments were involved. We routinely utilize
commercial software for data analysis, which costs around US 3000 dollars (or RMB
21000 Yuan) per year, and is also backed up with an in-house Linux pipeline consisting
of Burrows-Wheeler Aligner and Genome Analysis Toolkit. The advantages of utilizing
commercial software include user-friendly interface and higher acceptability by technical
staff and pathologists, as well as a large number of users with shared experiences
worldwide, while the analysis could be performed on an average 64-bit personal computer
costing less than US 1000 dollars (or RMB 7000 Yuan) without the need of a dedicated
bioinformatician. Validation is nevertheless necessary and our laboratory has joined
the external quality assessment scheme for next-generation sequencing by the European
Molecular Genetics Quality Network and achieved satisfactory scores since 2014.
A “clinical exome” targeted capture kit is used for the various panels, so that sequencing
is performed for all the 4811 genes associated with clinical phenotypes, where the
uniform workflow aids easier quality assurance. Compared with whole exome sequencing,
the tedious work of interpreting variants and secondary or incidental findings could
be avoided by the tactfully designed workflow and submission of data only to the clinically
relevant genes. A significantly shorter turn-around time that would suit routine clinical
need could also be achieved. At the same time, existing data could be easily reanalyzed
without additional costs when new clinical information becomes available from the
patient, or when genes have been newly associated with the phenotype. The use of the
commercial clinical exome kit is not without limitation: it generates more data than
custom-designed targeted panels and analyses with a lower coverage with the same sequencing
capacity. The genes included in the commercial kit are designed by the vendor, which
might lack flexibility for customization, and supplementary techniques may be required
if the region of interest is not covered by the panel.
In the era of genomic testing, it is of utmost importance to select suitable genes
for testing to achieve optimal diagnostic sensitivity and specificity. Gene panels
are designed in a way not only to address the clinical question but also to streamline
with other investigation modalities that are locally available, which would aid to
limit the size of individual panels. For example, genes associated with common inborn
errors of metabolism that are routinely detected by metabolic screening in our laboratory
are not included in the current epilepsy panel. This could ensure a shorter turn-around
time, as well as avoid reporting variants of uncertain significance unnecessarily
and causing confusion for clinicians, patients, and their families. The gene panels
could also be further updated when local diagnostic pathways are modified.
The panel testing could be initiated as a referral by the case clinician or as part
of investigations by pathologists. The chemical pathologists endorse or choose the
panel based on clinical details provided by the clinician, as well as information
accessible on electronic patient records, including results of biochemical tests,
histopathology, electrophysiology investigations, and/or radiological imaging, as
well as clinical response toward specific medications. Additional testing or reanalysis
could be performed if deemed relevant before the panel testing.
Library preparation, sequencing on instrument, and postsequencing data analysis take
2.0 days, 1.5 days, and 0.5 day, respectively; thus, a list of annotated variants
could become available for interpretation by chemical pathologist around 4.0 days
after receiving the sample. When variants of uncertain significance are detected,
further confirmatory tests could be promptly added, for example, further review of
histological slides or blood films, or additional immunohistochemistry, with collaboration
with other pathology specialties, so that reclassification of the variants is possible
before reporting. Interpretative comments with clinical correlation could be included
in the reports, for example, treatment strategies or suitability of reproductive options
for the patient. Reflex testing of other panels could be initiated by the chemical
pathologist if deemed appropriate, for example, when the first panel turns out unrevealing
or when new clinical information becomes available. Cascade testing and genetic counseling
could also be arranged, which may provide co-segregation data. Successful implementation
of genomic testing in regional hospitals requires clinicians and various pathology
specialties to work closely as a team.
In conclusion, we have successfully implemented targeted panel genomic testing by
next-generation sequencing in clinical diagnostic service in a regional hospital in
Hong Kong (China) with the use of commercially available clinical exome capture kit
and bioinformatics software. This combination provides flexibility and could be exemplary
for implementation of genomic testing in small-to-medium-scaled clinical diagnostic
laboratory service.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.