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Lagan N, Huggard D, Mc Grane F, Leahy TR, Franklin O, Roche E, Webb D, O’ Marcaigh A, Cox D, El-Khuffash A, Greally P, Balfe J, Molloy EJ. Multiorgan involvement and management in children with Down syndrome. Acta Paediatr 2020; 109:1096-1111. [PMID: 31899550 DOI: 10.1111/apa.15153] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/19/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023]
Abstract
AIM To review multiorgan involvement and management in children with Down syndrome (DS). METHODS A literature review of articles from 1980 to 2019 using the MEDLINE interface of PubMed was performed using the following search terms- [Down syndrome] or [Trisomy 21] AND [Cardiology] or [Respiratory] or [neurodevelopment] or [epilepsy] or [musculoskeletal] or [immune system] or [haematological] or [endocrine] or [gastrointestinal] or [ophthalmological] or [Ear Nose Throat] or [dermatology] or [renal]. RESULTS Congenital heart disease particularly septal defects occur in over 60% of infants with DS and 5%-34% of infants develop persistent pulmonary hypertension of the newborn irrespective of a diagnosis of congenital heart disease. Early recognition and management of aspiration, obstructive sleep apnoea and recurrent lower respiratory tract infections (LRTI) could reduce risk of developing pulmonary hypertension in later childhood. Children with DS have an increased risk of autistic spectrum disorder, attention deficit disorder and epilepsy particularly infantile spasms, which are associated with poor neurodevelopmental outcomes. Congenital anomalies of the gastrointestinal and renal system as well as autoimmune diseases, coeliac disease, arthropathy, thyroid dysfunction fold diabetes mellitus and dermatological conditions are more common. Hearing and visual anomalies are also well recognised association with DS (Table 1). CONCLUSION Children with DS are at an increased risk of multiorgan comorbidities. Organ-specific health surveillance may provide holistic care for the children and families with DS throughout childhood.
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Affiliation(s)
- Niamh Lagan
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Department of Neurodisability and Developmental Paediatrics Children’s Health Ireland at Tallaght Dublin Ireland
| | - Dean Huggard
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
| | - Fiona Mc Grane
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Department of Neurodisability and Developmental Paediatrics Children’s Health Ireland at Tallaght Dublin Ireland
| | | | - Orla Franklin
- Cardiology Children’s Health Ireland at Crumlin Dublin Ireland
| | - Edna Roche
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Paediatric Endocrinology Tallaght University Hospital Dublin Ireland
| | - David Webb
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Department of Neurology Children’s Health Ireland at Crumlin Dublin Ireland
| | - Aengus O’ Marcaigh
- Department of Haematology & Oncology Children’s Health Ireland at Crumlin Dublin Ireland
| | - Des Cox
- Department of Respiratory Children’s Health Ireland at Crumlin Dublin Ireland
| | | | - Peter Greally
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Department of Paediatric Respiratory Medicine Children’s Health Ireland at Tallaght Dublin Ireland
| | - Joanne Balfe
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Department of Neurodisability and Developmental Paediatrics Children’s Health Ireland at Tallaght Dublin Ireland
| | - Eleanor J. Molloy
- Paediatrics Academic Centre Tallaght Hospital Trinity College The University of Dublin Ireland
- Department of Neurodisability and Developmental Paediatrics Children’s Health Ireland at Tallaght Dublin Ireland
- NeonatologyCHI at Crumlin Dublin Ireland
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RUNX family: Oncogenes or tumor suppressors (Review). Oncol Rep 2019; 42:3-19. [PMID: 31059069 PMCID: PMC6549079 DOI: 10.3892/or.2019.7149] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 04/11/2019] [Indexed: 02/07/2023] Open
Abstract
Runt-related transcription factor (RUNX) proteins belong to a transcription factors family known as master regulators of important embryonic developmental programs. In the last decade, the whole family has been implicated in the regulation of different oncogenic processes and signaling pathways associated with cancer. Furthermore, a suppressor tumor function has been also reported, suggesting the RUNX family serves key role in all different types of cancer. In this review, the known biological characteristics, specific regulatory abilities and experimental evidence of RUNX proteins will be analyzed to demonstrate their oncogenic potential and tumor suppressor abilities during oncogenic processes, suggesting their importance as biomarkers of cancer. Additionally, the importance of continuing with the molecular studies of RUNX proteins' and its dual functions in cancer will be underlined in order to apply it in the future development of specific diagnostic methods and therapies against different types of cancer.
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Lum SH, Choong SS, Krishnan S, Mohamed Z, Ariffin H. GATA1 mutations in a cohort of Malaysian children with Down syndrome-associated myeloid disorder. Singapore Med J 2017; 57:320-4. [PMID: 27353457 DOI: 10.11622/smedj.2016106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Children with Down syndrome (DS) are at increased risk of developing distinctive clonal myeloid disorders, including transient abnormal myelopoiesis (TAM) and myeloid leukaemia of DS (ML-DS). TAM connotes a spontaneously resolving congenital myeloproliferative state observed in 10%-20% of DS newborns. Following varying intervals of apparent remission, a proportion of children with TAM progress to develop ML-DS in early childhood. Therefore, TAM and ML-DS represent a biological continuum. Both disorders are characterised by recurring truncating somatic mutations of the GATA1 gene, which are considered key pathogenetic events. METHODS We herein report, to our knowledge, the first observation on the frequency and nature of GATA1 gene mutations in a cohort of Malaysian children with DS-associated TAM (n = 9) and ML-DS (n = 24) encountered successively over a period of five years at a national referral centre. RESULTS Of the 29 patients who underwent GATA1 analysis, GATA1 mutations were observed in 15 (51.7%) patients, including 6 (75.0%) out of 8 patients with TAM, and 9 (42.9%) of 21 patients with ML-DS. All identified mutations were located in exon 2 and the majority were sequence-terminating insertions or deletions (66.7%), including several hitherto unreported mutations (12 out of 15). CONCLUSION The low frequency of GATA1 mutations in ML-DS patients is unusual and potentially indicates distinctive genomic events in our patient cohort.
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Affiliation(s)
- Su Han Lum
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Soo Sin Choong
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Shekhar Krishnan
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia.,University Malaya Cancer Research Institute, Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Zulqarnain Mohamed
- Unit of Genetics and Molecular Biology, Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia
| | - Hany Ariffin
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia.,University Malaya Cancer Research Institute, Faculty of Medicine, Kuala Lumpur, Malaysia
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Jackson RA, Nguyen ML, Barrett AN, Tan YY, Choolani MA, Chen ES. Synthetic combinations of missense polymorphic genetic changes underlying Down syndrome susceptibility. Cell Mol Life Sci 2016; 73:4001-17. [PMID: 27245382 PMCID: PMC11108497 DOI: 10.1007/s00018-016-2276-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 02/08/2023]
Abstract
Single nucleotide polymorphisms (SNPs) are important biomolecular markers in health and disease. Down syndrome, or Trisomy 21, is the most frequently occurring chromosomal abnormality in live-born children. Here, we highlight associations between SNPs in several important enzymes involved in the one-carbon folate metabolic pathway and the elevated maternal risk of having a child with Down syndrome. Our survey highlights that the combination of SNPs may be a more reliable predictor of the Down syndrome phenotype than single SNPs alone. We also describe recent links between SNPs in p53 and its related pathway proteins and Down syndrome, as well as highlight several proteins that help to associate apoptosis and p53 signaling with the Down syndrome phenotype. In addition to a comprehensive review of the literature, we also demonstrate that several SNPs reside within the same regions as these Down syndrome-linked SNPs, and propose that these closely located nucleotide changes may provide new candidates for future exploration.
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Affiliation(s)
- Rebecca A Jackson
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, #05-05, MD7, 8 Medical Drive, Singapore, 117597, Singapore
| | - Mai Linh Nguyen
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, #05-05, MD7, 8 Medical Drive, Singapore, 117597, Singapore
| | - Angela N Barrett
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, #05-05, MD7, 8 Medical Drive, Singapore, 117597, Singapore
| | - Yuan Yee Tan
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, #05-05, MD7, 8 Medical Drive, Singapore, 117597, Singapore
| | - Mahesh A Choolani
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, #05-05, MD7, 8 Medical Drive, Singapore, 117597, Singapore.
- National University Health System, Singapore, Singapore.
| | - Ee Sin Chen
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, #05-05, MD7, 8 Medical Drive, Singapore, 117597, Singapore.
- National University Health System, Singapore, Singapore.
- NUS Graduate School of Science and Engineering, National University of Singapore, Singapore, Singapore.
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Park Y, Lim J, Ko YH, Kim J, Kwon GC, Koo SH. A case of pentasomy 21 with two isochromosome 21s in acute megakaryoblastic leukemia associated with Down syndrome. Ann Lab Med 2015; 35:373-5. [PMID: 25932450 PMCID: PMC4390710 DOI: 10.3343/alm.2015.35.3.373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/07/2014] [Accepted: 02/07/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
- Yeongchun Park
- Department of Laboratory Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jinsook Lim
- Department of Laboratory Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Yong Hyun Ko
- Department of Laboratory Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jimyung Kim
- Department of Laboratory Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Gye Cheol Kwon
- Department of Laboratory Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Sun Hoe Koo
- Department of Laboratory Medicine, Chungnam National University Hospital, Daejeon, Korea
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Abstract
The acquisition of de novo somatic mutations accounts for approximately 90% of all new cancer diagnoses, while the remaining 10% is due to inherited genetic traits. In this latter category, individuals harbouring germline mutations show a higher likelihood of developing potentially life-threatening cancers, often at a very young age. The study of cancer genetics has profoundly helped our understanding of cancer biology, leading to better characterised malignancies, tailored targeted therapies and the identification of individuals at high risk of cancer diagnosis. This review will discuss examples of cancer syndromes in children, adolescents and young adults, the main underlying gene mutations, and the use of genetic testing to identify gene mutation carriers. Finally, we will describe how gene mutation detection is employed for the life-long management of patients with high susceptibility to cancer, including genetic counselling, increased surveillance, early intervention and use of targeted therapies.
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Affiliation(s)
- Federica Saletta
- 1 Children's Cancer Research Unit, Kids Research Institute, 2 Oncology Department, 3 The University of Sydney Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia
| | - Luciano Dalla Pozza
- 1 Children's Cancer Research Unit, Kids Research Institute, 2 Oncology Department, 3 The University of Sydney Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia
| | - Jennifer A Byrne
- 1 Children's Cancer Research Unit, Kids Research Institute, 2 Oncology Department, 3 The University of Sydney Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia
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Zhang Z, Zou J, Li Y, Liu Z, Xu R, Tian W, Zhao Z, Sun H, Han J, Wang J, Zhang B, Ju Y. Clinical characteristics and laboratory analyses of acute myeloid leukemia with t(16;21)(p11;q22). Oncol Lett 2015; 9:2244-2248. [PMID: 26137050 DOI: 10.3892/ol.2015.3051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 02/05/2015] [Indexed: 12/29/2022] Open
Abstract
The present study reviewed three patients with acute myeloid leukemia (AML) who had the specific genetic abnormality t(16;21)(p11;q22). To investigate the clinical and laboratory characteristics of AML with t(16;21)(p11;q22) translocation, the similarities and differences of clinical characteristics and laboratory examinations were compared, and a literature review was conducted. According to the French-American-British classification system, patient 1 was M4, patient 2 was M1 and patient 3 was M2. The cytogenetic aberrations were 46, XY, t(16;21)(p11;q22)/47, idem, +21 for patient 1 and 46, XX, t(16;21)(p11;q22) for patients 2 and 3. Cytophagocytosis and cluster of differentiation 56 antigen expression were found in all three cases. The prognosis was poor in all the cases. AML with t(16;21)(p11;q22) is a specific subtype of AML that exhibits unique characteristics of morphology, immunology, cytogenetics and clinical features, as well as a poor prognosis. Stem cell transplantation may be the first and only choice for treatment.
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Affiliation(s)
- Zhifen Zhang
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Jianwen Zou
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Yuantang Li
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Zhanfeng Liu
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Rui Xu
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Wenjun Tian
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Zongchen Zhao
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Hui Sun
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Jingying Han
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Jia Wang
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Bingchang Zhang
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Ying Ju
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
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Chatterjee A, Dutta S, Mukherjee S, Mukherjee N, Dutta A, Mukherjee A, Sinha S, Panda CK, Chaudhuri K, Roy AL, Mukhopadhyay K. Potential contribution of SIM2 and ETS2 functional polymorphisms in Down syndrome associated malignancies. BMC MEDICAL GENETICS 2013; 14:12. [PMID: 23343470 PMCID: PMC3563522 DOI: 10.1186/1471-2350-14-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 01/18/2013] [Indexed: 01/04/2023]
Abstract
Background Proper expression and functioning of transcription factors (TFs) are essential for regulation of different traits and thus could be crucial for the development of complex diseases. Subjects with Down syndrome (DS) have a higher incidence of acute lymphoblastic leukemia (ALL) while solid tumors, like breast cancer (BC) and oral cancer (OC), show rare incidences. Triplication of the human chromosome 21 in DS is associated with altered genetic dosage of different TFs. V-ets erythroblastosis virus E26 oncogene homolog 2 (ETS2) and Single Minded 2 (SIM2) are two such TFs that regulate several downstream genes involved in developmental and neurological pathways. Here we studied functional genetic polymorphisms (fSNP) in ETS2 and SIM2 encoding genes in a group of patients and control subjects to better understand association of these variants with DS phenotypes. Methods We employed an in silico approach to identify potential target pathways of ETS2 and SIM2. fSNPs in genes encoding for these two TFs were identified using available databases. Selected sites were genotyped in individuals with DS, their parents, ALL, BC, OC as well as ethnically matched control individuals. We further analyzed these data by population-based statistical methods. Results Allelic/genotypic association analysis showed significant (P < 0.03) differences of rs2070530, rs1051476, rs11254, rs711 for DS subjects compared to control. rs711 also exhibited significantly different genotypic distribution pattern in parents of DS probands (P < 0.02) and BC patients (P < 0.02). Interaction analysis revealed independent main effect of rs711 in all the groups, while rs11254 exhibited independent main effect in DS subjects only. High entropy values were noticed for rs461155 in the solid tumor groups. Significant interactive effects of rs2070531 with rs1051475, rs1051476, rs11254 were observed in all the groups except DS. Conclusions We infer from the present investigation that the difference in frequencies of fSNPs and their independent as well as interactive effects may be the cause for altered expression of SIM2 and ETS2 in DS and malignant groups, which affects different downstream biological pathways. Thus, altered expression of SIM2 and ETS2 could be one of the reasons for variable occurrence of different malignant conditions in DS.
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Affiliation(s)
- Arpita Chatterjee
- Manovikas Biomedical Research and Diagnostic Centre, MRIH, Kolkata, India
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Lockrow JP, Fortress AM, Granholm ACE. Age-related neurodegeneration and memory loss in down syndrome. Curr Gerontol Geriatr Res 2012; 2012:463909. [PMID: 22545043 PMCID: PMC3318235 DOI: 10.1155/2012/463909] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 11/21/2011] [Indexed: 01/10/2023] Open
Abstract
Down syndrome (DS) is a condition where a complete or segmental chromosome 21 trisomy causes variable intellectual disability, and progressive memory loss and neurodegeneration with age. Many research groups have examined development of the brain in DS individuals, but studies on age-related changes should also be considered, with the increased lifespan observed in DS. DS leads to pathological hallmarks of Alzheimer's disease (AD) by 40 or 50 years of age. Progressive age-related memory deficits occurring in both AD and in DS have been connected to degeneration of several neuronal populations, but mechanisms are not fully elucidated. Inflammation and oxidative stress are early events in DS pathology, and focusing on these pathways may lead to development of successful intervention strategies for AD associated with DS. Here we discuss recent findings and potential treatment avenues regarding development of AD neuropathology and memory loss in DS.
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Affiliation(s)
- Jason P. Lockrow
- Department of Neurosciences, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, USA
| | - Ashley M. Fortress
- Department of Neurosciences, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, USA
| | - Ann-Charlotte E. Granholm
- Department of Neurosciences, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, USA
- Center on Aging, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, USA
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Hultén MA, Jonasson J, Nordgren A, Iwarsson E. Germinal and Somatic Trisomy 21 Mosaicism: How Common is it, What are the Implications for Individual Carriers and How Does it Come About? Curr Genomics 2011; 11:409-19. [PMID: 21358985 PMCID: PMC3018721 DOI: 10.2174/138920210793176056] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 05/19/2010] [Accepted: 05/24/2010] [Indexed: 12/18/2022] Open
Abstract
It is well known that varying degrees of mosaicism for Trisomy 21, primarily a combination of normal and Trisomy 21 cells within individual tissues, may exist in the human population. This involves both Trisomy 21 mosaicism occurring in the germ line and Trisomy 21 mosaicism documented in different somatic tissues, or indeed a combination of both in the same subjects. Information on the incidence of Trisomy 21 mosaicism in different tissue samples from people with clinical features of Down syndrome as well as in the general population is, however, still limited. One of the main reasons for this lack of detailed knowledge is the technological problem of its identification, where in particular low grade/cryptic Trisomy 21 mosaicism, i.e. occurring in less than 3-5% of the respective tissues, can only be ascertained by fluorescence in situ hybridization (FISH) methods on large cell populations from the different tissue samples.In this review we summarize current knowledge in this field with special reference to the question on the likely incidence of germinal and somatic Trisomy 21 mosaicism in the general population and its mechanisms of origin. We also highlight the reproductive and clinical implications of this type of aneuploidy mosaicism for individual carriers. We conclude that the risk of begetting a child with Trisomy 21 Down syndrome most likely is related to the incidence of Trisomy 21 cells in the germ line of any carrier parent. The clinical implications for individual carriers may likewise be dependent on the incidence of Trisomy 21 in the relevant somatic tissues. Remarkably, for example, there are indications that Trisomy 21 mosaicism will predispose carriers to conditions such as childhood leukemia and Alzheimer's Disease but there is on the other hand a possibility that the risk of solid cancers may be substantially reduced.
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Affiliation(s)
- Maj A Hultén
- Warwick Medical School, University of Warwick, UK
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