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Vargel I, Canter HI, Kucukguven A, Aydin A, Ozgur F. ALX-Related Frontonasal Dysplasias: Clinical Characteristics and Surgical Management. Cleft Palate Craniofac J 2021; 59:637-643. [PMID: 34098755 DOI: 10.1177/10556656211019621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM The term frontonasal dysplasia (FND) represents a spectrum of anomalies and its genetics have not been well defined. Recently, the critical role of the aristaless-like homeobox (ALX) gene family on the craniofacial development has been discovered. In the present study, we aimed to propose a systematic surgical treatment plan for the ALX-related FNDs according to the genotypic classification as well as demonstrating their clinical characteristics to help surgeons diagnose the underlying pathology accurately. DESIGN Single-institution retrospective. SETTING Tertiary health care. PATIENTS AND METHODS Eighty-nine FND cases were evaluated. Eight of them had ALX1-related FND3, 3 had ALX3-related FND1, and 2 had ALX4-related FND2. Phenotype characteristics of ALX-related FNDs were evaluated, and relevant surgical interventions were assessed. RESULTS The ALX1-related FND3 phenotype is striking due to the involvement of the eyes in addition to the presence of hypertelorism, facial clefts, and nasal deformities. A widened philtrum and prominent philtral columns are remarkable features of the ALX3-related FND1, whereas the ALX4-related FND2 has more severe deformities: severe hypertelorism, brachycephaly, large parietal bone defects, broad nasal dorsum, and alopecia. Facial bipartition, box osteotomies, eyelid coloboma repair, cleft lip and palate repair, nasal reconstruction, and fronto-orbital advancement can be performed in ALX-related FNDs based on the characteristics of each subtype. CONCLUSIONS This genetic classification system will help surgeon diagnose patients with FND with unique features and draw a roadmap for their treatment with a better surgical perspective.
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Affiliation(s)
- Ibrahim Vargel
- 37515Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - Halil Ibrahim Canter
- 356435Anadolu Medical Center, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey
| | - Arda Kucukguven
- 37515Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
| | - Asim Aydin
- 52994Suleyman Demirel University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Isparta, Turkey
| | - Figen Ozgur
- 37515Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Ankara, Turkey
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2
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Twigg SRF, Ousager LB, Miller KA, Zhou Y, Elalaoui SC, Sefiani A, Bak GS, Hove H, Hansen LK, Fagerberg CR, Tajir M, Wilkie AOM. Acromelic frontonasal dysostosis and ZSWIM6 mutation: phenotypic spectrum and mosaicism. Clin Genet 2016; 90:270-5. [PMID: 26706854 PMCID: PMC5025718 DOI: 10.1111/cge.12721] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 12/22/2015] [Accepted: 12/22/2015] [Indexed: 11/24/2022]
Abstract
Acromelic frontonasal dysostosis (AFND) is a distinctive and rare frontonasal malformation that presents in combination with brain and limb abnormalities. A single recurrent heterozygous missense substitution in ZSWIM6, encoding a protein of unknown function, was previously shown to underlie this disorder in four unrelated cases. Here we describe four additional individuals from three families, comprising two sporadic subjects (one of whom had no limb malformation) and a mildly affected female with a severely affected son. In the latter family we demonstrate parental mosaicism through deep sequencing of DNA isolated from a variety of tissues, which each contain different levels of mutation. This has important implications for genetic counselling.
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Affiliation(s)
- S R F Twigg
- Clinical Genetics Group, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - L B Ousager
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - K A Miller
- Clinical Genetics Group, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Y Zhou
- Clinical Genetics Group, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - S C Elalaoui
- Human Genomics Center, Faculty of Medicine and Pharmacy of Rabat, Rabat, Morocco.,Department of Medical Genetics, National Institute of Health, Rabat, Morocco
| | - A Sefiani
- Human Genomics Center, Faculty of Medicine and Pharmacy of Rabat, Rabat, Morocco.,Department of Medical Genetics, National Institute of Health, Rabat, Morocco
| | - G S Bak
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - H Hove
- Department of Clinical Genetics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - L K Hansen
- Department of Paediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - C R Fagerberg
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - M Tajir
- Human Genomics Center, Faculty of Medicine and Pharmacy of Rabat, Rabat, Morocco.,Department of Medical Genetics, National Institute of Health, Rabat, Morocco
| | - A O M Wilkie
- Clinical Genetics Group, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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3
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Twigg SRF, Wilkie AOM. New insights into craniofacial malformations. Hum Mol Genet 2015; 24:R50-9. [PMID: 26085576 PMCID: PMC4571997 DOI: 10.1093/hmg/ddv228] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/15/2015] [Indexed: 12/13/2022] Open
Abstract
Development of the human skull and face is a highly orchestrated and complex three-dimensional morphogenetic process, involving hundreds of genes controlling the coordinated patterning, proliferation and differentiation of tissues having multiple embryological origins. Craniofacial malformations that occur because of abnormal development (including cleft lip and/or palate, craniosynostosis and facial dysostoses), comprise over one-third of all congenital birth defects. High-throughput sequencing has recently led to the identification of many new causative disease genes and functional studies have clarified their mechanisms of action. We present recent findings in craniofacial genetics and discuss how this information together with developmental studies in animal models is helping to increase understanding of normal craniofacial development.
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Affiliation(s)
- Stephen R F Twigg
- Clinical Genetics Group, Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DS, UK
| | - Andrew O M Wilkie
- Clinical Genetics Group, Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DS, UK
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Smith J, Hing A, Clarke C, Johnson N, Perez F, Park S, Horst J, Mecham B, Maves L, Nickerson D, Cunningham M, Cunningham ML. Exome sequencing identifies a recurrent de novo ZSWIM6 mutation associated with acromelic frontonasal dysostosis. Am J Hum Genet 2014; 95:235-40. [PMID: 25105228 DOI: 10.1016/j.ajhg.2014.07.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022] Open
Abstract
Acromelic frontonasal dysostosis (AFND) is a rare disorder characterized by distinct craniofacial, brain, and limb malformations, including frontonasal dysplasia, interhemispheric lipoma, agenesis of the corpus callosum, tibial hemimelia, preaxial polydactyly of the feet, and intellectual disability. Exome sequencing of one trio and two unrelated probands revealed the same heterozygous variant (c.3487C>T [p. Arg1163Trp]) in a highly conserved protein domain of ZSWIM6; this variant has not been seen in the 1000 Genomes data, dbSNP, or the Exome Sequencing Project. Sanger validation of the three trios confirmed that the variant was de novo and was also present in a fourth isolated proband. In situ hybridization of early zebrafish embryos at 24 hr postfertilization (hpf) demonstrated telencephalic expression of zswim6 and onset of midbrain, hindbrain, and retinal expression at 48 hpf. Immunohistochemistry of later-stage mouse embryos demonstrated tissue-specific expression in the derivatives of all three germ layers. qRT-PCR expression analysis of osteoblast and fibroblast cell lines available from two probands was suggestive of Hedgehog pathway activation, indicating that the ZSWIM6 mutation associated with AFND may lead to the craniofacial, brain and limb malformations through the disruption of Hedgehog signaling.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Michael L Cunningham
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, WA 98101, USA; Department of Pediatrics, University of Washington, Seattle, WA 98195, USA; Craniofacial Center, Seattle Children's Hospital, Seattle, WA 98105, USA.
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5
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Uz E, Alanay Y, Aktas D, Vargel I, Gucer S, Tuncbilek G, von Eggeling F, Yilmaz E, Deren O, Posorski N, Ozdag H, Liehr T, Balci S, Alikasifoglu M, Wollnik B, Akarsu NA. Disruption of ALX1 causes extreme microphthalmia and severe facial clefting: expanding the spectrum of autosomal-recessive ALX-related frontonasal dysplasia. Am J Hum Genet 2010; 86:789-96. [PMID: 20451171 DOI: 10.1016/j.ajhg.2010.04.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 04/05/2010] [Accepted: 04/09/2010] [Indexed: 01/01/2023] Open
Abstract
We present an autosomal-recessive frontonasal dysplasia (FND) characterized by bilateral extreme microphthalmia, bilateral oblique facial cleft, complete cleft palate, hypertelorism, wide nasal bridge with hypoplasia of the ala nasi, and low-set, posteriorly rotated ears in two distinct families. Using Affymetrix 250K SNP array genotyping and homozygosity mapping, we mapped this clinical entity to chromosome 12q21. In one of the families, three siblings were affected, and CNV analysis of the critical region showed a homozygous 3.7 Mb deletion containing the ALX1 (CART1) gene, which encodes the aristaless-like homeobox 1 transcription factor. In the second family we identified a homozygous donor-splice-site mutation (c.531+1G > A) in the ALX1 gene, providing evidence that complete loss of function of ALX1 protein causes severe disruption of early craniofacial development. Unlike loss of its murine ortholog, loss of human ALX1 does not result in neural-tube defects; however, it does severely affect the orchestrated fusion between frontonasal, nasomedial, nasolateral, and maxillary processes during early-stage embryogenesis. This study further expands the spectrum of the recently recognized autosomal-recessive ALX-related FND phenotype in humans.
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Affiliation(s)
- Elif Uz
- Gene Mapping Laboratory, Department of Medical Genetics, Hacettepe University Medical Faculty, Sihhiye, Ankara, Turkey
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6
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Kayserili H, Uz E, Niessen C, Vargel I, Alanay Y, Tuncbilek G, Yigit G, Uyguner O, Candan S, Okur H, Kaygin S, Balci S, Mavili E, Alikasifoglu M, Haase I, Wollnik B, Akarsu NA. ALX4 dysfunction disrupts craniofacial and epidermal development. Hum Mol Genet 2009; 18:4357-66. [PMID: 19692347 DOI: 10.1093/hmg/ddp391] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Genetic control of craniofacial morphogenesis requires a complex interaction of numerous genes encoding factors essential for patterning and differentiation. We present two Turkish families with a new autosomal recessive frontofacial dysostosis syndrome characterized by total alopecia, a large skull defect, coronal craniosynostosis, hypertelorism, severely depressed nasal bridge and ridge, bifid nasal tip, hypogonadism, callosal body agenesis and mental retardation. Using homozygosity mapping, we mapped the entity to chromosome 11p11.2-q12.3 and subsequently identified a homozygous c.793C-->T nonsense mutation in the human ortholog of the mouse aristaless-like homeobox 4 (ALX4) gene. This mutation is predicted to result in a premature stop codon (p.R265X) of ALX4 truncating 146 amino acids of the protein including a part of the highly conserved homeodomain and the C-terminal paired tail domain. Although the RNA is stable and not degraded by nonsense-mediated RNA decay, the mutant protein is likely to be non-functional. In a skin biopsy of an affected individual, we observed a hypomorphic interfollicular epidermis with reduced suprabasal layers associated with impaired interfollicular epidermal differentiation. Hair follicle-like structures were present but showed altered differentiation. Our data indicate that ALX4 plays a critical role both in craniofacial development as in skin and hair follicle development in human.
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Affiliation(s)
- Hulya Kayserili
- Department of Medical Genetics, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Twigg SR, Versnel SL, Nürnberg G, Lees MM, Bhat M, Hammond P, Hennekam RC, Hoogeboom AJM, Hurst JA, Johnson D, Robinson AA, Scambler PJ, Gerrelli D, Nürnberg P, Mathijssen IM, Wilkie AO. Frontorhiny, a distinctive presentation of frontonasal dysplasia caused by recessive mutations in the ALX3 homeobox gene. Am J Hum Genet 2009; 84:698-705. [PMID: 19409524 PMCID: PMC2681074 DOI: 10.1016/j.ajhg.2009.04.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 04/03/2009] [Accepted: 04/14/2009] [Indexed: 01/06/2023] Open
Abstract
We describe a recessively inherited frontonasal malformation characterized by a distinctive facial appearance, with hypertelorism, wide nasal bridge, short nasal ridge, bifid nasal tip, broad columella, widely separated slit-like nares, long philtrum with prominent bilateral swellings, and midline notch in the upper lip and alveolus. Additional recurrent features present in a minority of individuals have been upper eyelid ptosis and midline dermoid cysts of craniofacial structures. Assuming recessive inheritance, we mapped the locus in three families to chromosome 1 and identified mutations in ALX3, which is located at band 1p13.3 and encodes the aristaless-related ALX homeobox 3 transcription factor. In total, we identified seven different homozygous pathogenic mutations in seven families. These mutations comprise missense substitutions at critical positions within the conserved homeodomain as well as nonsense, frameshift, and splice-site mutations, all predicting severe or complete loss of function. Our findings contrast with previous studies of the orthologous murine gene, which showed no phenotype in Alx3(-/-) homozygotes, apparently as a result of functional redundancy with the paralogous Alx4 gene. We conclude that ALX3 is essential for normal facial development in humans and that deficiency causes a clinically recognizable phenotype, which we term frontorhiny.
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Affiliation(s)
- Stephen R.F. Twigg
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Sarah L. Versnel
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, 3000 CB Rotterdam, The Netherlands
| | - Gudrun Nürnberg
- Cologne Center for Genomics and Institute for Genetics, University of Cologne, D-50674 Cologne, Germany
| | - Melissa M. Lees
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- North Thames Cleft Centre, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | | | - Peter Hammond
- Molecular Medicine Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Raoul C.M. Hennekam
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Pediatrics, Academic Medical Centre, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Jane A. Hurst
- Department of Clinical Genetics, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - David Johnson
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Alexis A. Robinson
- Neural Development Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Peter J. Scambler
- Molecular Medicine Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Dianne Gerrelli
- Human Developmental Biology Resource, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Peter Nürnberg
- Cologne Center for Genomics and Institute for Genetics, University of Cologne, D-50674 Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, D-50674 Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, D-50931 Cologne, Germany
| | - Irene M.J. Mathijssen
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, 3000 CB Rotterdam, The Netherlands
| | - Andrew O.M. Wilkie
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford OX3 9DS, UK
- Department of Clinical Genetics, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
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Wu E, Vargevik K, Slavotinek AM. Subtypes of frontonasal dysplasia are useful in determining clinical prognosis. Am J Med Genet A 2008; 143A:3069-78. [PMID: 17955515 DOI: 10.1002/ajmg.a.31963] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Frontonasal dysplasia [FND; OMIM 136760] results from abnormal morphogenesis of the frontonasal process with disruption of the formation of the facial midline. Craniofacial anomalies in FND include anterior cranium bifidum, ocular hypertelorism, orofacial clefting and notching or clefting of the alae nasi. The majority of FND cases are sporadic and discordance has been demonstrated in monozygotic twin pairs, arguing against a strong inherited component in pathogenesis. However, pedigrees with Mendelian inheritance and non-recurrent chromosome aberrations in FND patients demonstrate that gene mutations or cytogenetic imbalance can also be important in the etiology of this phenotype. We classified 101 reported cases of FND from the medical literature and three new cases into seven separate FND phenotypic subtypes in addition to isolated FND. Our aim was to evaluate FND patients for distinct phenotypes within the FND spectrum and to determine the evidence for a genetic etiology in each of the different subtypes. Our analysis showed significant differences in the severity of the accompanying malformations and the rates of learning disabilities in the FND subtypes, although the small patient numbers and method of patient ascertainment may have influenced the data. The results suggest that cases with FND should be evaluated for additional anomalies, as these may help to determine prognosis.
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Affiliation(s)
- E Wu
- Department of Pediatrics, Division of Genetics, University of California, San Francisco, California, USA
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Al-Hassnan ZN, Teebi AS. Craniofacial anomalies, humero-radial synostosis, rhizomelic limb shortness: Previously unrecognized autosomal recessive syndrome. Am J Med Genet A 2007; 143A:521-7. [PMID: 17304553 DOI: 10.1002/ajmg.a.31612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Humero-radial synostosis (HRS) is a rare skeletal anomaly that might be seen in some craniosynostosis syndromes, notably Antley-Bixler syndrome, and in other disorders in association with skeletal anomalies. Here we report on two daughters of first cousin Saudi parents with syndromic HRS. Both patients had distinctive craniofacial features including cranium bifidum occultum, hypertelorism, epicanthus inversus, capillary hemangiomata, and malformed ears. Musculoskeletal examination revealed rhizomelic shortness with normal hands and feet. Skeletal survey showed bilateral HRS with no evidence of craniosynostosis. The craniofacial manifestations in these two patients do not match any of the syndromes known to be associated with HRS. We consider that the constellation is unique and apparently represents a previously unrecognized syndrome.
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Affiliation(s)
- Zuhair N Al-Hassnan
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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