Genetic testing basis of

genetic diagnosis, Pre

symptomatic and
predisposition testing

Definition of Genetic
Testing:
The analysis of human DNA
in any of its forms or related
products (chromosomes,
RNA, proteins)

Genetic Testing
involves the direct examination
of the DNA molecule itself. A
scientist scans a patient's DNA
sample for mutated sequences.
Genetic testing is done for a
particular condition where an
individual is suspected of being at
increased risk due to their family or

Genetic Testing
Getting an informed consent
Genetic tests are performed on the
sample of blood, skin , hair, amniotic
fluid, chorionic villus sampling, or
other tissue.
Should be accompanied by genetic
counselling.

More definitions

Genotype vs. Phenotype

The genetic make-up, as distinguished
from the physical appearance

Mutation
A genetic change, usually one that is
associated with a disease

Karyotype
A visual presentation of
chromosomes

Indications
Maternal risk factors
- Advanced maternal age,>35 yrs
- F/H of previous baby with NTD/
chromosomal anomaly.
- Maternal diabetes, epilepsy, alcoholism
- H/o recurrent miscarriage
- Abnormal maternal serum triple marker
screening test / abnormal serum AFP
- Exposure to medications during pregnancy

-Oligohydramnios or polyhydramnios
-Rubella/ cytomegalovirus infection

Pediatric risk factors

-positive neonatal screening test
-Known chromosomal abnormality
-Delay in growth and development
-Mental retardation

When testing the DNA, it is extracted from the tissue, cut into pieces
by chemical scissors and then the pieces are separated on a gel.
The piece of DNA of interest that contains a particular gene can be
selected from the20,000 or so genes in an individuals DNA using a

Uses of Genetic Testing

Uses of Genetic Testing:

To detect disease-related genotypes, mutations,
phenotypes, or karyotypes for clinical purposes
Helps people to make informed decisions about
managing their health care.
Help couples to decide whether to continue or
terminate the pregnancy.
Neonatal screening helps to identify genetic
disorders so that early treatment can be started to
prevent the harmful irreversible effects.
Early detection of cancer genes enable the carriers
to take necessary preventive measures and regular

Parental testing is the use of genetic

fingerprinting to determine whether two
individuals have a biological parentchild
relationship

 Diagnosis- A direct gene test can be used to

diagnose a genetic condition. This can be very
useful when the clinical picture is not clear.

The two fragments of DNA represent the

faulty gene copy and the working gene
copy. The bands are heavier from
persons A and C as there are two copies
of the same gene at each band. Person A
has two copies of the faulty gene; person
B has one faulty copy and one working
copy (ie. a carrier of the faulty gene) and
person C has two copies of the working

Types of genetic
tests

Genetic Carrier Screening

The term genetic carrier screening
is used to describe direct gene
testing applied to a whole population
or to a defined group.
For example, genetic carrier
screening may be available for
people in the population who have no
personal or family history of a
condition but who have a greater
than average chance of carrying a

Newborn Screening
The blood sample is taken by a heelprick before the baby leaves hospital,
or for home births, on about day 4,
and is sent to a special laboratory.

Presymptomatic Genetic
Testing

The detection of a faulty gene in a person

with a
family history of a particular
condition, but who currently has no
symptoms of that condition, means that that
person will certainly develop the condition in
later life.

Predictive Genetic
Testing
Sometimes the detection of the
faulty gene provides the person
with an increased risk estimate,
rather than certainty, that they will
develop a particular condition later
in life.
Predictive testing for some families
is available for inherited conditions
such as an inherited predisposition
to haemochromatosis or breast

Prenatal testing This is done to detect any genetic abnormality in

the fetus. This type of tests is suggested to
couples who are known carriers or have a
previous baby with genetic or chromosomal
disorder.
Forensic testing
This uses DNA finger printing technique to
identify criminals or catastrophe victims, or
establish biological relationships in case of a
disputed parentage.
Research testing
This is done to find unknown genes, to learn how
genes work and to advance our understanding of

Two Main Types of Genetic Tests

Constitutional
Tests for mutations that affect ALL
CELLS in the body, and have been there
since conception

Acquired
Tests for changes that affect only certain
cells or cell types in the body, and that
occurred later in life

Genetic Tests for Constitutional

Mutations

Molecular Tests
Cytogenetic Tests
Biochemical Tests

Molecular Test: Example

Analysis of DNA
sequence in patient
with a rare inherited
disease
Muscular Dystrophy
Gene: DMD
Clinical Picture
1 in 3500 male births
progressive muscle
weakness starting in early
childhood
wheelchair by age 12
death in 20s

Molecular Test: Muscular

Dystrophy
Obtain blood sample from child
Read the DNA sequence of the DMD
gene
Identify the mutation that caused the
disease

How is this information

useful?
To test Mom Is she an unaffected
carrier of the mutation? Is she at risk
to have more children with this
disease?
to test siblings of affected child
to offer prenatal diagnosis in Moms
next pregnancy OR
to offer pre-implantation genetic
diagnosis
to provide information about
prognosis

Cytogenetic Test: Example

Karyotype to examine the
chromosomal complement of an
individual including number, form,
and size of the chromosomes.
Frequently used for children who
present with multiple anomalies,
developmental delay, autism

Cytogenetic Test: Child with MCA

and autism
Obtain a
blood
sample from
baby
Look at
chromosom
es

How is this information

useful?
To determine exactly which genes
are involved
to test parents and siblings of
affected child to see if they carry the
abnormality
To offer prenatal diagnosis in next
pregnancy OR
to offer pre-implantation genetic
diagnosis
to provide information about
prognosis

Biochemical Test
Analyzes the quantity of a
downstream product of a gene (e.g.
not looking directly at the gene, or
the chromosome).
Example: Newborn Screening
Mandated in all 50 states
Twenty primary targets that all states
do.
Over 4 million newborns tested each
year

Biochemical Test: PKU

Phenylketonuria
Inherited metabolic disorder
If untreated, leads to mental retardation, seizures
Affects 1 in 20,000 newborns

Missing enzyme:
Phenylalanine Hydroxylase
Measure amount of
Phenylalanine in babys
blood

How is this information

useful?
To diagnose the baby in
time, to treat and avoid all
clinical consequences of the
disease
Treatment: Restrict
phenylalanine in the diet

to test siblings of affected

child, to see if they are
carriers for the disease (1 in
70 in the general population
are carriers)

Genetic Tests for Acquired Mutations

Molecular Tests
Cytogenetic Tests
Tests for changes that affect only certain
cells
or cell types in the body, and that occurred
later in life

Molecular Test for Acquired

Disease
KRAS gene test on tumor tissue from
patients with colorectal cancer
Obtain tumor from patient
Extract DNA; treat with enzyme that
allows visualization of the mutation

How is this information

useful?
Patients whos colon tumors do not
have a KRAS mutation are much
more likely to respond to Cetuximab
therapy
Identifies patients most likely to
benefit from specific therapies
Allows choice of alternative therapies
(and saves time and money) for
patients unlikely to respond

Cytogenetic Test for Acquired

Disease: Example
Her-2/neu gene amplification in
Breast Cancer
Occurs early in oncogenesis
Seen in up to 1/3 of breast cancers
Associated with poor prognosis
Responds to Herceptin (trastuzumab)
treatment
Does not respond to Tamoxifen
treatment

Cytogenetic Test for Acquired

Disease
FISH (Fluorescent In Situ Hybridization)
for HER-2/neu is a gene-based test that
allows one to count the number of HER2 genes in a cell.

How is this information

useful?
Assists in selection of patients for
chemotherapy, and which therapy to
use
Predicts response to adjuvant
therapy
Increases survival
Allows choice of alternative therapies
(and saves time and money)
for patients unlikely to
respond

Interpreting results of genetic tests

-A positive test may confirm a diagnosis or
suggest a need for further testing. It may have
implications for certain blood relatives of the person
undergoing testing and may require their screening
for the same genetic condition.
-A negative result can indicate that a person is
not affected by a particular disorder, is not a carrier
of the abnormal gene or does not have the
increased risk of developing the disease.

Predictive genetic testing

Conventional medical diagnostic test
Individual patient
Current status

Predictive genetic test

Direct implications for family members
Future condition (that may or may not develop)
??whether ??when ??how severe ?? Benefits
of intervention

Usually not determinative

Predictive genetic testing for

presymptomatic /predisposed individuals
MEN2
Full penetrance, thyroid Ca

Colorectal cancer
Colonoscopy surveillance

Breast cancer
?? Penetrance
?? Treatment options

Hemochromatosis
Low penetrance
Modifiers: sex, diet, alcohol
Phenotypic screening

Hereditary Hemochromatosis
Common 2-5/1000
iron overload
Clinically serious
liver cirrhosis and
1o hepatic carcinoma
diabetes mellitus
cardiomyopathy
endocrinopathy
arthropathy

Treatable: phlebotomy

Hereditary
Hemochromatosis-2
Modifiers of Phenotype
Sex (protective effect of menses,
pregnancy)
Dietary iron vs blood loss
Alcohol intake
Mendelian disease that
behaves like a common complex disease

Hereditary
Hemochromatosis-3
Why not screen everyone ?
Gene test available: HFE on
chromosome 6
C282Y high penetrance
H63D
low penetrance, common

Phenotypic screening available

Iron, TIBC ,ferritin

What does a positive test mean ?

Family screening vs Population
screening

Utility of testing

Evans et al. BMJ 322:1052-56

(2001)

Presymptomatic Diagnosis
Definition (P.Harper, 1997) = situations
where an abnormal result indicates that the
disease will almost develop at some point in
life.
New Genetic Medicine:
- High risk asymptomatic persons (~ 50%)
for genetic disease
- Late-onset disorders
- Monogenic mendelian disorders

Presymptomatic Diagnosis
Knowledge of genetic status of
asymptomatic individuals at risk for
developing an identified genetic disorder
Concerned persons :
- at risk
- adults
- asymptomatic (absent features)
- Voluntary consent

Presymptomatic Diagnosis
Key notion of medical benefit
2 different situations :
- Possible preventive/curative treatment
(ex: cancer predisposition)
No preventive/curative treatment available
(ex: neurodegenerative disorders)
Model = Huntington disease

Presymptomatic Diagnosis
France (Dcret 2000-570) :
conditions of prescription of genetic
testing
Multidisciplinary teams (Ministry of
Health)
HD: geneticist, neurologist,
psychologist
Care and testing (4-6 months)

Presymptomatic Diagnosis
Justifications
To relieve uncertainly about genetic
status 54 %
To plan a family
14 %
To plan for the future
13 %
To inform the children

Presymptomatic Diagnosis
Remarkable events

Pregnancy
20 %
(50 % PND; 50 % MA)
Serious adverse events:
- Psychological distress and
depression 9 %
- Psychiatric hospitalization

Presymptomatic Diagnosis
Conclusions
New concept
Molecular genetic advances :
2 care levels:
- Severe diseases :
SCA, hereditary dementia/Alzheimer
- Mild diseases :
CMT, FSH myotonic dystrophy

Genetic Testing in Children

Information, free choice, consent : not possible in

children, choice of the parents
Possible in symptomatic children (CF, DMD ..)
Possible: medical benefit in asymptomatic child:
- curative/preventive treatment: cancer
predisposition syndromes (APC, Gorlin )
- screening/follow-up (Steinert, glaucoma )
- professional/social orientation ( CMT )

Genetic Testing in Children

Genetic tests forbidden in asymptomatic
child :
Severe late-onset genetic disorders
- Hereditary cancer predisposition (BRCA1,
BRCA2, HNPCC )
- Neurodegerative late-onset diseases (HD,
SCA, CADASIL )
Recessive heterozygous status
Multigenic/polyfactorial heredity

Genetic Testing in Children

Personal benefit for the child
Preventive/curative treatment for the
family
Deprivation of the right of notknowing
Breakdown in the child-parents
relationship
Disease anticipation

Approach to genetic testing in

children
According to the American Society of Human
Genetics, the following categories of genetic
testing is being followed.
Category I- Disorders requiring immediate
treatment/ prevention/ surveillance
Category II- Testing Asymptomatic carrier to
define reproductive risks
Category III- Testing healthy young person with
predisposition to develop disease
Category IV- Testing healthy young person who
will develop disease

 Category I- Disorders requiring

immediate treatment/ prevention/
surveillance
Eg. PKU,MEN,FAP,XSCID,
hyperlipidemias etc.,
Category II- Testing Asymptomatic
carrier to define reproductive risks
Eg. Xlinked disorders ( hemophilia,
muscular dystrophy,XSCID),
autosomal disorders (cystsics fibrosis,
sickle cell disease, Tay-sachs disease)

 Category III- Testing healthy young

person with predisposition to
develop disease
Eg. Familial breast
cancer(BRCA1,BRCA2) and HNPCC.
Category IV- Testing healthy young
person who will develop disease
Eg. Huntingtons disease, some forms
of Parkinsons disease and PKD

Summary
Constitutional genetic tests impact
patients with inherited disorders and their
families, by providing information about
diagnosis, prognosis, treatment, and
informing reproductive decisions
Genetic tests for acquired diseases impact
patients with diseases like cancer, provide
information about diagnosis and
prognosis, and inform treatment decisions
Genetics and genetic testing impacts
many phases of our lives, and will do so
even more in the future

Thanks