Opportunities and challenges associated with clinical diagnostic genome sequencing: a report of the Association for Molecular Pathology

Multiplex target capture with double-stranded DNA probes

Target enrichment technologies utilize single-stranded oligonucleotide probes to capture candidate genomic regions from a DNA sample before sequencing. We describe target capture using double-stranded probes, which consist of single-stranded, complementary long padlock probes (cLPPs), each selectively capturing one strand of a genomic target through circularization. Using two probes per target increases sensitivity for variant detection and cLPPs are easily produced by PCR at low cost. Additionally, we introduce an approach for generating capture libraries with uniformly randomized template orientations. This facilitates bidirectional sequencing of both the sense and antisense template strands during one paired-end read, which maximizes target coverage.

The current and future role of sequence-based analysis in prostate cancer treatment

Prostate cancer is the most commonly diagnosed, nondermatologic malignancy in US men. Localized disease can be managed through active surveillance or curative, locally directed therapies, but 30% of men treated with surgery or radiation will need additional (often systemic) treatment for relapsed disease. While spectacular advances in medical treatment of advanced prostate cancer have improved the quality and duration of patients' lives, metastatic prostate cancer remains an incurable, lethal disease that requires additional therapies and better treatment strategies. The advent of ultra-high-throughput sequencing technology provides an opportunity to comprehensively assess the constellation of genetic and molecular events underlying each patient's tumor, and promises to enhance our ability to deliver specifically tailored personalized treatment to men with prostate cancer. The known biological and clinical heterogeneity of prostate cancer presents both opportunities and challenges to the application and utilization of sequence-based analysis to guide prostate cancer treatment.

Existing and emerging technologies for tumor genomic profiling

Ongoing global genome characterization efforts are revolutionizing our knowledge of cancer genomics and tumor biology. In parallel, information gleaned from these studies on driver cancer gene alterations--mutations, copy number alterations, translocations, and/or chromosomal rearrangements--an be leveraged, in principle, to develop a cohesive framework for individualized cancer treatment. These possibilities have been enabled, to a large degree, by revolutionary advances in genomic technologies that facilitate systematic profiling for hallmark cancer genetic alterations at increasingly fine resolutions. Ongoing innovations in existing genomics technologies, as well as the many emerging technologies, will likely continue to advance translational cancer genomics and precision cancer medicine.

Challenges of bringing next generation sequencing technologies to clinical molecular diagnostic laboratories

Molecular diagnosis of complex dual genome mitochondrial disorders is a challenge. It requires the identification of deleterious mutations in one of the ~1,500 nuclear genes and the mitochondrial genome. If the molecular defect is in the mitochondrial genome, quantification of degree of mutation load (heteroplasmy) in affected tissues is important. Due to the extreme clinical and genetic heterogeneity, conventional sequence analysis of the candidate genes one-by-one is impractical, if not impossible. The newly developed massively parallel next generation sequencing (NGS) technique, that allows simultaneous sequence analysis of multiple target genes, when appropriately validated with deep coverage and proper quality controls, can be used as an effective comprehensive diagnostic approach in CLIA certified clinical laboratories.

Diagnosis of silent pheochromocytoma and paraganglioma

Pheochromocytomas or functioning paragangliomas can present in a dramatic manner with headache, palpitations and sometimes shock, but many occur with few symptoms despite at times markedly elevated catecholamine levels. Hypertension is not invariable, and may be paroxysmal. Increased diligence in the diagnosis of presymptomatic pheochromocytoma/paraganglioma is warranted from autopsy studies, suggesting that many of these tumors may be fatal at first presentation. Fortunately, an increasing number of pheochromocytomas/paragangliomas are now diagnosed before the advent of symptoms, either as an incidental finding on abdominal imaging or by targeted surveillance in subjects with known genetic susceptibility. The challenges and pitfalls associated with diagnosis of these silent pheochromocytoma/paragangliomas are reviewed in this article.