To characterize clinically measurable endophenotypes, implicating the TBX6 compound inheritance model.
Patients with congenital scoliosis (CS) from China(N = 345, cohort 1), Japan (N = 142, cohort 2), and the United States (N = 10, cohort 3) were studied. Clinically measurable endophenotypes were compared according to the TBX6 genotypes. A mouse model for Tbx6 compound inheritance (N = 52) was investigated by micro computed tomography (micro-CT). A clinical diagnostic algorithm (TACScore) was developed to assist in clinical recognition of TBX6-associated CS (TACS).
In cohort 1, TACS patients (N = 33) were significantly younger at onset than the remaining CS patients (P = 0.02), presented with one or more hemivertebrae/butterfly vertebrae (P = 4.9 × 10‒8), and exhibited vertebral malformations involving the lower part of the spine (T8–S5, P = 4.4 × 10‒3); observations were confirmed in two replication cohorts. Simple rib anomalies were prevalent in TACS patients (P = 3.1 × 10‒7), while intraspinal anomalies were uncommon (P = 7.0 × 10‒7). A clinically usable TACScore was developed with an area under the curve (AUC) of 0.9 (P = 1.6 × 10‒15). A Tbx6-/mh (mild-hypomorphic) mouse model supported that a gene dosage effect underlies the TACS phenotype.
TACS is a clinically distinguishable entity with consistent clinically measurable endophenotypes. The type and distribution of vertebral column abnormalities in TBX6/Tbx6 compound inheritance implicate subtle perturbations in gene dosage as a cause of spine developmental birth defects responsible for about 10% of CS.
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Manolio TA, Fowler DM, Starita LM, et al. Bedside back to bench: building bridges between basic and clinical genomic research. Cell. 2017;169:6–12.
Yang Y, Muzny DM, Xia F, et al. Molecular findings among patients referred for clinical whole-exome sequencing. JAMA. 2014;312:1870–1879.
Maver A, Lovrecic L, Volk M, et al. Phenotype-driven gene target definition in clinical genome-wide sequencing data interpretation. Genet Med. 2016;18:1102–1110.
Karaca E, Posey JE, Coban Akdemir Z, et al. Phenotypic expansion illuminates multilocus pathogenic variation. Genet Med. 2018 Apr 26; https://doi.org/10.1038/gim.2018.33 [Epub ahead of print].
Wu N, Ming X, Xiao J, et al. TBX6 null variants and a common hypomorphic allele in congenital scoliosis. N Engl J Med. 2015;372:341–350.
Hedequist D, Emans J. Congenital scoliosis. J Am Acad Orthop Surg. 2004;12:266–275.
Sparrow DB, Chapman G, Smith AJ, et al. A mechanism for gene-environment interaction in the etiology of congenital scoliosis. Cell. 2012;149:295–306.
Shen J, Wang Z, Liu J, Xue X, Qiu G. Abnormalities associated with congenital scoliosis: a retrospective study of 226 Chinese surgical cases. Spine (Phila Pa 1976). 2013;38:814–818.
Lefebvre M, Duffourd Y, Jouan T, et al. Autosomal recessive variations of TBX6, from congenital scoliosis to spondylocostal dysostosis. Clin Genet. 2017;91:908–912.
Takeda K, Kou I, Kawakami N, et al. Compound heterozygosity for null mutations and a common hypomorphic risk haplotype in TBX6 causes congenital scoliosis. Hum Mutat. 2017;38:317–323.
Shen Y, Chen X, Wang L, et al. Intra-family phenotypic heterogeneity of 16p11.2 deletion carriers in a three-generation Chinese family. Am J Med Genet B Neuropsychiatr Genet. 2011;156:225–232.
Al-Kateb H, Khanna G, Filges I, et al. Scoliosis and vertebral anomalies: additional abnormal phenotypes associated with chromosome 16p11.2 rearrangement. Am J Med Genet A. 2014;164A:1118–1126.
Sparrow DB, McInerney-Leo A, Gucev ZS, et al. Autosomal dominant spondylocostal dysostosis is caused by mutation in TBX6. Hum Mol Genet. 2013;22:1625–1631.
Shen Y, Irons M, Miller DT, et al. Development of a focused oligonucleotide-array comparative genomic hybridization chip for clinical diagnosis of genomic imbalance. Clin Chem. 2007;53:2051–2059.
Shinawi M, Liu P, Kang SH, et al. Recurrent reciprocal 16p11.2 rearrangements associated with global developmental delay, behavioural problems, dysmorphism, epilepsy, and abnormal head size. J Med Genet. 2010;47:332–341.
McMaster MJ, Ohtsuka K. The natural history of congenital scoliosis. A study of two hundred and fifty-one patients. J Bone Joint Surg Am. 1982;64:1128–1147.
Tsirikos AI, McMaster MJ. Congenital anomalies of the ribs and chest wall associated with congenital deformities of the spine. J Bone Joint Surg Am. 2005;87:2523–2536.
Platt RJ, Chen S, Zhou Y, et al. CRISPR-Cas9 knockin mice for genome editing and cancer modeling. Cell. 2014;159:440–455.
Yang N, Wu N, Zhang L, et al. TBX6 compound inheritance leads to congenital vertebral malformations in humans and mice. Hum Mol Genet. 2018 Oct 10; https://doi:10.1093/hmg/ddy358 [Epub ahead of print].
Sullivan LM, Massaro JM, D'Agostino RB Sr. Presentation of multivariate data for clinical use: the Framingham Study risk score functions. Stat Med. 2004;23:1631–1660.
Reiser B. Measuring the effectiveness of diagnostic markers in the presence of measurement error through the use of ROC curves. Stat Med. 2000;19:2115–2129.
Liu J, Zhou Y, Liu S, et al. The coexistence of copy number variations (CNVs) and single nucleotide polymorphisms (SNPs) at a locus can result in distorted calculations of the significance in associating SNPs to disease. Hum Genet. 2018;137:553–567.
Chapman DL, Papaioannou VE. Three neural tubes in mouse embryos with mutations in the T-box gene. Tbx6 Nat. 1998;391:695–697.
Papapetrou C, Putt W, Fox M, Edwards YH. The human TBX6 gene: cloning and assignment to chromosome 16p11.2. Genomics. 1999;55:238–241.
White PH, Farkas DR, McFadden EE, Chapman DL. Defective somite patterning in mouse embryos with reduced levels of Tbx6. Development. 2003;130:1681–1690.
Chapman DL, Agulnik I, Hancock S, Silver LM, Papaioannou VE. Tbx6, a mouse T-Box gene implicated in paraxial mesoderm formation at gastrulation. Dev Biol. 1996;180:534–542.
Zhao W, Ajima R, Ninomiya Y, Saga Y. Segmental border is defined by Ripply2-mediated Tbx6 repression independent of Mesp2. Dev Biol. 2015;400:105–117.
Dahmann C, Oates AC, Brand M. Boundary formation and maintenance in tissue development. Nat Rev Genet. 2011;12:43–55.
Copp AJ, Greene ND, Murdoch JN. The genetic basis of mammalian neurulation. Nat Rev Genet. 2003;4:784–793.
Nikaido M, Kawakami A, Sawada A, Furutani-Seiki M, Takeda H, Araki K. Tbx24, encoding a T-box protein, is mutated in the zebrafish somite-segmentation mutant fused somites. Nat Genet. 2002;31:195–199.
The 1000 Genomes Project Consortium, Abecasis GR, Auton A, et al. An integrated map of genetic variation from 1,092 human genomes. Nature. 2012;491:56–65.
Lupski JR. Structural variation mutagenesis of the human genome: impact on disease and evolution. Environ Mol Mutagen. 2015;56:419–436.
Lupski JR. Genomic rearrangements and sporadic disease. Nat Genet. 2007;39 7 suppl:S43–47.
Sandbacka M, Laivuori H, Freitas E, et al. TBX6, LHX1 and copy number variations in the complex genetics of Mullerian aplasia. Orphanet J Rare Dis. 2013;8:125.
Bachmann-Gagescu R, Mefford HC, Cowan C, et al. Recurrent 200-kb deletions of 16p11.2 that include the SH2B1 gene are associated with developmental delay and obesity. Genet Med. 2010;12:641–647.
Weiss LA, Shen Y, Korn JM, et al. Association between microdeletion and microduplication at 16p11.2 and autism. N Engl J Med. 2008;358:667–675.
Verbitsky M, Westland R, Perez A, et al. The copy number variation landscape of congenital anomalies of the kidney and urinary tract. Nat Genet. (in press).
Guo J, Zhang J, Wang S, et al. Surgical outcomes and complications of posterior hemivertebra resection in children younger than 5 years old. J Orthop Surg Res. 2016;11:48.
Yang Y, Muzny DM, Reid JG, et al. Clinical whole-exome sequencing for the diagnosis of Mendelian disorders. N Engl J Med. 2013;369:1502–1511.
We thank all the individuals, families, and physicians involved in the study for their participation. We thank the nurses from the Department of Orthopedic Surgery at Peking Union Medical College Hospital for assistance with patient enrollment. We thank the members of Japan Early Onset Scoliosis Research Group: Noriaki Kawakami, Toshiaki Kotani, Hideki Sudo, Ikuho Yonezawa, Koki Uno, Hiroshi Taneichi, Kei Watanabe, Shohei Minami, Hideki Shigematsu, Ryo Sugawara, Yuki Taniguchi, and Nao Ootomo. We thank Sally Dunwoodie and Gavin Chapman from Victor Chang Cardiac Research Institute for their collaborations. We appreciate the support of Ellen Wald at the University of Wisconsin–Madison. This research was funded in part by the National Natural Science Foundation of China (81822030 and 81501852 to N.W., 81472045 and 81772301 to G.Q., 31625015, 31571297 and 31771396 to F.Z., 81472046 and 81772299 to Z.W., 31521003 to L.J., 81672123 to J.Z., 7162029 to X.C.), Beijing Natural Science Foundation (7172175 to N.W., 7162029 to X.C.), Beijing Nova Program (Z161100004916123 to N.W.), Beijing Nova Program Interdisciplinary Collaborative Project (xxjc201717 to N.W.), 2016 Milstein Medical Asian American Partnership Foundation Fellowship Award in Translational Medicine (to N.W.), the Central Level Public Interest Program for Scientific Research Institute (2016ZX310177 to N.W.), PUMC Youth Fund & the Fundamental Research Funds for the Central Universities (3332016006 to N.W.), Chinese Academy of Medical Sciences (CAMS) Initiative Fund for Medical Sciences (2016-I2M-3-003 to G.Q. and N.W., 2016-I2M-2-006 and 2017-I2M-2-001 to Z.W.), the Distinguished Youth Foundation of Peking Union Medical College Hospital (JQ201506 to N.W.), the 2016 PUMCH Science Fund for Junior Faculty (PUMCH-2016-1.1 to N.W.), and the National Key Research and Development Program of China (no. 2016YFC0901501 to S.Z.). This work was also supported by the Japan Agency for Medical Research and Development (AMED, number 17ek0109280h0001 and 17824969 to S.I.) and Japan Orthopedics and Traumatology Research Foundation (number 358 to K.T.), and the US National Institutes of Health, National Institute of Neurological Disorders and Stroke (NINDS R01 NS058529 and R35 NS105078 to J.R.L.), National Human Genome Research Institute/National Heart, Lung, and Blood Institute (NHGRI/NHLBI UM1 HG006542 to D.V. and J.R.L.), and the National Human Genome Research Institute (NHGRI K08 HG008986 to J.E.P.).
J.R.L. has stock ownership in 23andMe, is a paid consultant for Regeneron Pharmaceuticals, and is a coinventor on multiple US and European patents related to molecular diagnostics for inherited neuropathies, eye diseases, and bacterial genomic fingerprinting. The Department of Molecular and Human Genetics at Baylor College of Medicine derives revenue from the chromosomal microarray analysis and clinical exome sequencing offered in the Baylor Genetics Laboratory (http://bmgl.com). The other authors declare no conflicts of interest.
These authors share senior authorship: Zhihong Wu, Shiro Ikegawa, James R. Lupski, Feng Zhang, Guixing Qiu.
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