www.jped.com.br
ORIGINAL
ARTICLE
Diagnostic
implications
of
associated
defects
in
patients
with
typical
orofacial
clefts
夽
,
夽夽
Isabella
L.
Monlleó
a,∗,
Amanda
G.R.
de
Barros
b,
Marshall
I.B.
Fontes
c,
Ana
K.M.
de
Andrade
b,
Gisele
de
M.
Brito
b,
Diogo
L.L.
do
Nascimento
d,
Vera
L.
Gil-da-Silva-Lopes
eaSchoolofMedicine,ClinicalGeneticsService,HospitalUniversitárioProf.AlbertoAntunes,UniversidadeFederaldeAlagoas
(UFAL),Maceió,AL,Brazil
bSchoolofMedicine,UniversidadeFederaldeAlagoas(UFAL),Maceió,AL,Brazil
cMaternal-ChildandAdolescentHealthDepartment,UniversidadeEstadualdeCiênciasdaSaúdedeAlagoas(UNCISAL),Maceió,
AL,Brazil
dLaboratoryofHumanCytogenetics(LCH),UniversidadeEstadualdeCiênciasdaSaúdedeAlagoas(UNCISAL),Maceió,AL,Brazil eDepartmentofMedicalGenetics,FaculdadedeCiênciasMédicas(FCM),UniversidadeEstadualdeCampinas(UNICAMP),
Campinas,SP,Brazil
Received10October2014;accepted16December2014 Availableonline4June2015
KEYWORDS
Cleftlip; Cleftpalate; Congenital abnormalities; Phenotype
Abstract
Objectives: Todescribeprevalenceofassociateddefectsandclinical---geneticcharacteristics
ofpatientswithtypicalorofacialcleftsseenatareferencegeneticservice.
Methods: Descriptive study conducted between Septemberof 2009 and July of 2014. Two
experienceddysmorphologistspersonallycollectedandcodedclinicaldatausingavalidated, standardmulticenterprotocol.Syndromiccasesweredefinedbythepresenceoffourormore minordefects,oneormoremajordefects,orrecognitionofaspecificsyndrome.Fisher’sexact andKruskal---Wallistestswereusedforstatistics.
Results: Among 141 subjects, associated defects were found in 133 (93%), and84 (59.5%)
were assigned as syndromic. Cleft palate was statistically associated with a greater num-berofminordefects(p<0.0012)andsyndromicassignment(p<0.001).Syndromicgroupwas associated withlowbirthweight(p<0.04)andlessaccesstosurgicaltreatment(p<0.002). There wasnostatistical differencebetween syndromicandnon-syndromicgroups regarding gender(p<0.55),maternalageof35yearsandabove(p<0.50),alcohol(p<0.50)andtobacco consumption(p<0.11),consanguinity(p<0.59),recurrence(p<0.08),averagenumberof preg-nancies(p<0.32),andoffspring(p<0.35).
夽 Pleasecitethisarticleas:MonlleóIL,deBarrosAG,FontesMI,deAndradeAK,BritoGM,doNascimentoDL,etal.Diagnosticimplications
ofassociateddefectsinpatientswithtypicalorofacialclefts.JPediatr(RioJ).2015;91:485---92.
夽夽StudyconductedattheSchoolofMedicine,ClinicalGeneticsService,HospitalUniversitárioProf.AlbertoAntunes,UniversidadeFederal
deAlagoas(UFAL),Maceió,AL,Brazil.
∗Correspondingauthor.
E-mail:[email protected](I.L.Monlleó).
http://dx.doi.org/10.1016/j.jped.2014.12.001
Conclusions: Thereisalackofinformationonsyndromicclefts.Theclassificationsystemfor phenotype assignment adopted inthis study hasfacilitated recognition ofhigh prevalence ofassociated defectsandsyndromiccases. Thissystem may beauseful strategy togather homogeneoussamples,toelectappropriatetechnologiesforetiologicandgenotype---phenotype approaches,andtoassistwithmultiprofessionalcareandgeneticcounseling.
©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE
Fendadelábio; Fendadepalato; Anomalias Congênitas; Fenótipo
Implicac¸õesdiagnósticasdedefeitosassociadosempacientescomfendasorofaciais típicas
Resumo
Objetivos: descreveraprevalênciadedefeitosassociadoseascaracterísticasgenético-clínicas
depacientescomfendasorofaciaistípicas(FOT)emumservic¸odereferênciaemgenética.
Métodos: Estudodescritivorealizadoentresetembro/2009ajulho/2014.Osdadosforam
col-hidosecodificadospordoisobservadoresclínicoscomexperiênciaemdismorfologia,utilizando protocolovalidadoemestudomulticêntrico.Presenc¸ade4oumaisdefeitosminor,umoumais defeitosmajorediagnósticodesíndromereconhecidaforamcritériosutilizadosparaclassificar ocasocomosindrômico.Utilizou-seTesteExatodeFisherparaanálisedevariáveiscategóricas eKruskal-Wallisparaigualdadedemédias.
Resultados: Entre141sujeitos,133(93%)apresentavamaomenosumdefeitominoroumajor
associado, sendo84 (59,5%) classificadoscomo sindrômicos.Asfendas de palato estiveram associadascommaiornúmerodedefeitosminor(p<0,0012)ecomaclassificac¸ãosindrômica (p<0,01).Ogruposindrômicoapresentoumaiortaxadebaixopeso(p<0,04)emenoracesso a tratamento cirúrgico (p<0,02). Não houve diferenc¸as entre os grupos quanto ao gênero (p<0,55), idade materna ≥ 35 anos (p<0,50), ingestão de álcool (p<0,50) e tabagismo (p<0,11), consanguinidade (p<0,59), recorrência familial (p<0,08) e média de gestac¸ões (p<0,32)edefilhosnascidosvivos(p<0,35).
Conclusões: Existe escassez de informac¸ões sobre fendas sindrômicas. O método de
classificac¸ãofenotípicautilizadopossibilitouaidentificac¸ãode altaprevalênciade defeitos associados e de casos sindrômicos. Este método seria uma alternativa para homogeneizar amostras, determinar tecnologias visando investigac¸ão etiológica e estudos de correlac¸ão genótipo-fenótipo, além de colaborar para intervenc¸ão multiprofissional e aconselhamento genético.
©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Thescientificinterestinthetypicalorofacialclefts(OFCs), representedbyparamedianfissuresaffectingthelip,palate orboth, datesbacktothe mid-eighteenthcentury.1,2 The
developmentoftechnologicaltoolsinthegenomicerahas allowedtheexpansionofknowledgeontheiretiology, nat-uralhistory, andrisk factors. However,the understanding ofoverlapping gene---gene andgene---environment associa-tionsandtheireffectsonphenotyperemainsanimportant challenge.Thisknowledgeformsthetheoreticalbasisupon which cost-effective treatment and prevention proposals shouldbebuilt.1---4
TypicalOFCsarecongenitalmalformationswithlarge epi-demiological,social, psychological, andeconomic impact. The prevalence ranges fromone case toevery 500---2500 births.This variation reflects the interference of genetic and environmental factors related to ethnic background, geographicregion,andnutritionalandhealthstatusofthe population.2---5
InBrazil,thereareproblemsregardingthe epidemiolog-icalregistryofbirthdefects.Inspiteofthatfact,arecently publishedestimatepredicted thebirth of2900---4000 chil-dren with OFCs in the country in 2011.6 Considering the
maintenance of the birth rate in the country and taking intoaccountthatthetreatmentofanindividualwithOFCs extendsintoadulthood,thisestimateofnewcases/yearhas animportanteconomicimpactonthehealthcaresystem.
Surgical repair of thecleft is usually perceived by the familyastheonlytreatment required.However,apatient withatypicalOFCrequirescontinuedspeechtherapy, den-tal, otorhinolaryngological,and psychologicalsupportinto adulthood, and usually requires more than one surgical intervention.1---4
individualswithOFCs,consideringspecifictreatment, con-trol,andpreventionofcomorbidities.2,3,5
The prevalence of the association of OFCs with other birthdefectsis acontroversial areain theliterature.The fact is that, in the presence of associated defects, the OFCisnolongerconsideredanisolatedmalformation (non-syndromic OFC) with multifactorial etiology, and is then classifiedassyndromic.Itisestimatedthatitoccursin30% ofcases withcleftlip withorwithout cleft palate(CL/P) andin50%ofcasesofcleftpalate(CP).2,3,5,7
SyndromicOFCsmaypresentaknownetiology,classified as a monogenic, chromosomal, or teratogenic syndrome, or may present an unknown etiology, constituting cases withmultiplemalformation,oftencalledmultiple congeni-taldefects(MCDs).2,3,5,7,8
The classification of OFCs as syndromic and non-syndromic and the recognition of associated defects and theunderlyingetiologyareimportanttoestablishthe diag-nosis,estimateprognosis,anddefinetherapeuticplanning andgeneticcounseling,allwithprimaryimpactonthe indi-vidual’shealth.Thisknowledgeisalsoimportanttoobtain epidemiological informationandtoincrease the powerof thegenotype---phenotypecorrelationstudies.2,3,5
The objective of this study was to describe the prevalenceofassociateddefectsandgenetic---clinical char-acteristicsofacohortofpatientswithtypicalOFCstreated atareferralserviceofclinicalgenetics.
Materials
and
methods
Thiswasacross-sectionalstudyofsubjectswithtypicalOFCs ofanyage,treatedattheServiceofClinicalGeneticsof Hos-pitalUniversitárioProfessorAlbertoAntunesofUniversidade FederaldeAlagoas(SGC/HUPAA-UFAL),betweenSeptember of 2009 and July of 2014. Cases of medial, oblique, and submucosalOFCs,aswellasbifiduvulawereexcluded.
Datacollectionwascarriedoutusingtheclinicalprotocol oftheBrazilianDatabaseofClinicalandFamilialData.9The
basiccomplementaryassessmentincludedperipheralblood karyotype withGTG banding and resolution of 400 bands forallpatients,performedattheHumanCytogenetics Lab-oratoryof UniversidadeEstadual deCiênciasda Saúdede Alagoas.
Malformationscreeningwasperformed inspecificcases throughimagingexamsandadditionalgeneticanalysis tech-niques were applied (fluorescence in situ hybridization [FISH], multiplex ligation-dependent probe amplification [MLPA], andarray-based genomic hybridization [aGH]),at theLaboratoryofCytogeneticsandHumanCytogenomicsof theMedicalGeneticsDepartmentofUniversidadeEstadual deCampinas.
The classification and codification of OFCs and associ-ateddefectswereperformedbytwogeneticistsexperienced indysmorphology,usingthemethodsdescribedbyMonlleó etal.9Thefollowingdefinitionswereused7,8,10---13:
- Minor defect: morphological abnormalities that do not implyinsignificantestheticorfunctionalimpairment. - Syndrome: clinical picture consisting of OFCs
associ-ated with minor and/or major defects with previously demonstrated single etiology factor (e.g. chromosomal
abnormality)orstronglysuspectedbasedontheir recur-renceinanumberofcases.
- MCDs:anycombination ofOFCswithoneor moremajor defectsforwhichnoetiologicalfactorhasbeen demon-stratedorsuspected.
Theoutcomevariable,dependent,wasthepresenceof morphologicalabnormalitiesassociatedwithOFCs,withthe samplebeingregroupedaccordingtothephenotypic classi-ficationofcasesofnon-syndromicOFCs(presenceofupto threeminordefects)andcasesofsyndromicOFCs(presence offouror moreminordefects, diagnosisofthesyndrome, andof MCDs). Independentvariables and their respective categorieswere:
Demographiccharacteristics:age,gender.
Maternal, newborn,andfamilycharacteristics:maternal ageatconception,maternallevelofeducation,alcoholor tobacco consumption duringpregnancy, number of preg-nanciesandlivebirthsofthemother,birthweight(<2500g and≥2500g),consanguinity,andfamilyhistoryofOFCs. Clinical characteristics: type of OFCs, severity of cleft lip, typeofassociateddefect,anatomicaldistributionof majordefectsandidentifiedsyndromes,accesstoprimary surgeryforOFCs.
Data were tabulated and analyzed usingthe programs MicrosoftExcel (Microsoft,2003, ComputerSoftware,WA, USA) and Epi InfoTM version 3.5.2. (Epi InfoTM, GA, USA). Descriptive analysiswas performed with frequency distri-bution,centraltendency,anddispersionmeasures.Fisher’s exact test wasused for the analysis of categorical varia-blesandtheKruskal---Wallistestforequalityofmeans.The significancelevelwassetat5%(p<0.05).
The research had the following ethical approvals:
00907/2009-66 (CEP/UFAL), 0009838/2009-56
(CEP/UNCISAL),059/2008(CEP/UNICAMP),14733(CONEP), andCAAE35316314.9.1001.5404.
Results
Between September of 2009 and July of 2014, a total of 146patients with OFCswere treated. Of this total,after applyingthe inclusioncriteria, the sample comprised 141 cases.
Age ranged from 0 to 37 years (mean 5±8.48), with 94(67%)individualsfrom0to10years,34(24%)between 11and 20 years,and 13 (9%)older than 20 yearsof age. Seventy-two (51%) patients were males. Maternal age at conception ranged from15 to 47 years(mean 24±6.92). Eighteen(15.7%)motherswereadolescentsatthetimeof thepregnancyand13(11.3%)wereolderthan35years.In 81(58.7%)cases,themotherhadnotcompletedelementary school.
Table1 Distributionofclinicalcharacteristicsofthesubjectsaccordingtothetypeoftypicalorofacialcleft.
CL/CL/P(113) CP(28) p
Gender
Male 65(57.5) 7(25) 0.0018a
Female 48(42.5) 21(75)
Associateddefects
Nodefects 8(7)
---Onlyminordefects 82(73) 18(64) 0.10a
Minor+majordefects 23(20) 10(36)
Onlymajordefects ---
---Minordefect
1---3 48(46) 7(25) 0.037a
≥4 57(54) 21(75)
Mean 4.2(±2.8) 6.5(±3.3) 0.0012b
Majordefect
1---3 21(91) 9(90) 0.51a
≥4 2(9) 1(10)
Mean 1.6(±0.9) 1.8(±0.9) 0.44b
Phenotypicclassification
Non-syndromictypicalOFCs 51(45) 6(21) 0.01a
SyndromicOFCs 62(55) 22(79)
CL/CL/P,cleftliporcleftlipandpalate;CP,cleftpalate;OFCs,orofacialclefts. aFisher’sexacttest.
b Kruskal---Wallistest.
Associated defects of any kind (minor or major) were observedin 105 (93%)cases of CL/P and28 (100%) ofCP. Therewerenostatisticallysignificant differencesbetween theCL/P and CPgroups in relation tothetype of associ-ateddefect(p<0.10);however,thepresenceoffourormore minordefectswashigherintheCPgroup(p<0.0012).The anatomicallocation,type,andnumberofindividuals with specificmajordefectsareshowninTable2.Thecraniofacial region,thecardiovascularsystem,andthemusculoskeletal systemwerethemostfrequentlyaffectedsites.
Regarding the phenotypic classification, 84 (59.6%) patients were classified as syndromic OCP, which was moreprevalentin theCPgroup(p<0.01)(Table1).There were no statistically significant differences between the syndromic and non-syndromic OFC groups regarding the
distributionbygender(p<0.55),maternalageriskfor chro-mosomal abnormalities (p<0.50),maternal alcohol intake (p<0.50),maternalsmoking(p<0.11),parental consanguin-ity(p<0.59), familialrecurrence(p<0.08), meannumber of pregnancies (p<0.32), and meannumber of livebirths (p<0.35). However,thesyndromic OFC groupshowed the highestrateoflowbirthweight(p<0.04)andlessaccessto surgicaltreatment(p<0.02)(Table3).
Ofthe84patientsclassifiedassyndromicOFC,44(52%) hadfourormoreminordefects,18(22%)hadoneormore majordefectsconstitutingcasesofMCDs,and22(26%)had knownsyndromes.
Conventionalperipheralbloodkaryotypewasperformed in115individuals(81.5%),whichidentifiedabnormalitiesin sevencases.Ofthese,fourbelongedtothesyndromicOFC
Table2 Anatomicallocation,type,andnumberofsubjectswithmajordefects.
Anatomicalsite Typeofdefects
Skullandface Microcephaly(12),anophthalmia/bilateralmicrophthalmia,retinalcoloboma,bifidnoseapex, rudimentaryshapedears(2),irisandcornealhypoplasia,agenesisofteeth,lachrymalduct agenesis,hemifacialmicrosomia
Cardiovascularsystem Atrialseptaldefect(7),ventricularseptaldefect
Musculoskeletalsystem Dwarfismwithshortlimbs,arthrogryposis(3),partialabsenceoflowerlimb,fusedribs, vertebralsegmentationdefect
Genitourinarytract Hypospadias,genitalambiguity,renalagenesis,micropenis(2),bilateralcryptorchidism Handsandfeet Syndactylyinhands,hypoplasticdistalphalangesofthehandsandfeet,post-axial
polydactyly,terminaltransversedefects Skinandannexes Pterygium(3)
Table3 Distributionofclinicalcharacteristicsofthesubjectsaccordingtothetypeoftypicalorofacialcleft.
SyndromicOFCs (84)
Non-syndromicOFCs (57)
p
Gender
Male 43(51) 29(51) 0.55a
Female 41(49) 28(49)
Birthweight
<2500g 19(31) 4(13) 0.04
≥2500g 43(69) 27(87)
Maternalage≥35years 9(12) 4(10) 0.50
Maternalalcoholconsumption 22(26.5) 14(25) 0.50
Maternalsmoking 16(19.5) 17(29.8) 0.11
Parentalconsanguinity 9(10.8) 6(10.5) 0.59
Familialrecurrence 18(21.7) 19(34) 0.08
Accesstosurgicaltreatment 46(54.8) 41(71.9) 0.02
Totalnumberofpregnancies
1 13(15.7) 11(19.3)
2---4 51(61.4) 25(43.9)
≥5 19(22.9) 21(36.8)
Mean 3.5(±2.5) 4.3(±3.2) 0.32b
Numberoflivebirthsborntothemother
1 15(18) 10(17.5)
2---4 55(66.3) 28(49.1)
≥5 13(15.7) 19(33.4)
Mean 3.1(±2.2) 4(±3.1) 0.35b
OFCs,orofacialclefts. a Fisher’sexacttest. b Kruskal---Wallistest.
group and had an unbalanced chromosomal abnormality, whereasthreehadchromosomalpolymorphism(pericentric inversionofchromosome9).Twoofthelattermetthe crite-riaforthenon-syndromicOFCgroupandonehadfourminor defects(elbowhyperextensibility,scoliosis,cubitusvalgus, genuvalgum,andrecurvatum),withnonosologicaldiagnosis established.
Seven cases of syndromic OFCs (MCDs) were included in aspecific investigation protocolwithaGH. Onepatient showedduplicationof9.2Mbintheregion16p13.2-16p13.3 (46,XX.ishins(22;16)(q13;p13.2p13.3)),relatedtothe phe-notype.Twopatientsdidnothaveacopynumbervariation (CNV)andfourshoweddeletionsorduplicationsinregions without known causativegenes. Table 4 shows the listof syndromes and laboratory resources used asevidence for diagnosis.
Discussion
Itisafactthatsurgicaltreatmentisacrucialstageforthe onsetofrehabilitationofindividualswithOFCs.Inthis con-text,itispossiblethatthegeneticevaluationisnotseenas necessaryatfirst.However,theidentificationofassociated defectsandtheetiologyhasanimpactondecision-making regardingboththetreatmentplanandfamilygenetic coun-seling.
TheWorldHealthOrganization(WHO)recommends mul-tidisciplinarycare,whichincludesgeneticevaluation.This
isbasedontheperformanceofadetailedphysical examina-tionthattakesintoaccounttheidentificationandanalysis ofdysmorphicsigns, allowingthe differentiation between syndromicandnon-syndromicOFCs.14
Despitethe highprevalence, the supplyof health care servicesin theOFC areais stillinsufficient in many parts of the world. In the period of 1993---2003, there was a significant advance in this area in the Brazilian Unified Health System (SUS). Currently, Brazil has a network of multidisciplinary services accredited by the Ministry of Health for medical-surgical rehabilitation; however, few of them include medical geneticists. Theiraccess is reg-ulated through the National Center of High Complexity Regulation.15
ThestateofAlagoashasnomultidisciplinaryservicesfor individualswithOFCs.Theprimaryattentionand medium-complexity care in this area also lack infrastructure. As a consequence, many patients have access only to surgi-caltreatment offered by non-governmental organizations (NGOs),whichalthoughmaybringindividualbenefits,donot constituteahealthpolicycapableofmodifyingthescenario ofinequityandfragmentationofcare.16
As for the diagnostic evaluation and genetic counsel-ing,the SGC/HUPAA-UFAL is the only institution available to meet the SUS demand in the state. The service has maintainedaspecificoutpatientclinicforpatientsand fam-ilies with OFCs since 2009.16 The genetic---clinical profile
Table4 Identifiedsyndromesandrespectivediagnosticevidence.
Identifiedsyndrome n TypeofOFCs Diagnosticevidence
Chromosome15ringsyndrome46,XY,r(15)20 1 CL/P GbandKTP
Greigsyndrome 1 CP Clinical
Del22q11syndrome:[46,XY.ishdel(22)(q11.2q11.2)(TUPLEI-)], 1 CL/P FISHandMLPA
Oculofaciocardiodentalsyndrome 1 CL/P Clinical
CHARGEsyndrome 1 CL/P Clinical
VATERassociation 1 CL/P Clinical
Spondyloepiphysealdysplasia 1 CP Radiological
Waardenburgsyndrome 1 CL/P Clinical
Escobarsyndrome 1 CP Clinical
Acrofrontofacionasaldysostosis 1 CL/P Clinical
Emanuelsyndrome:47,XX,+der(22)t(11;22)(q23;q11)mat20 1 CP GbandKTP
16p13.3microduplicationsyndrome:46,XX.ishins(22;16)(q13;p13.2p13.3) 1 CP FISHandaGH
Saethre---Chotzensyndrome 2 CL/P(2) Clinical
Robertssyndrome 1 CL/P Clinical
Goldenharsyndrome 2 CPandCL/P Clinical
Ectodermaldysplasiaectrodactyly 1 CL/P Clinical
Amnioticbandsyndrome 1 CL/P Clinical
Moebiussyndrome 1 CP Clinical
Kallmannsyndrome 1 CL/P Clinical
MosaicEdwardssyndrome:(46,XX/47,XX+18) 1 CL/P GbandKTP
KTP, karyotype; FISH, fluorescence in situ hybridization; MLPA, multiplex ligation-dependent probe amplification; aCGH, array-comparativegenomichybridization;CHARGEsyndrome,Colobomaoftheeye,Heartdefects,Atresiaofthechoanae,Retardationof growthand/ordevelopment,Genitaland/orurinaryabnormalities,andEarabnormalitiesanddeafness;VATERassociation,vertebral defects,analatresia,tracheoesophagealfistulawithesophagealatresia,andradialorrenaldysplasia;OFCs,orofacialclefts.
Demographicandmaternalcharacteristicsshowaslight predominanceofmales,broadagerangeofpatientsatthe timeoftheinitialtreatmentandmothersatconception,and lowmaternallevelofschooling.
Onlyone-fourthof theindividualswereyoungerthan1 yearofageatthefirstconsultation.Consideringthe dysmor-phicfacialaspectoftypicalOFCcases,itwouldbeexpected thatmostwouldhavebeen referredfor earlyassessment. The little knowledge of the genetic nature of the OFCs andlimited accessto geneticservices generallyobserved inBrazil17maybefactorsinvolved.
Almostone-thirdofthemotherswereintheagegroupof risk(≤18or≥35years)atthetimeofconception.Teenage pregnancyinvolves risksrelatedtoproblemsinlabor, pre-maturity, low birth weight, and hypoxia, mainly due to reproductive system immaturity, poor maternal nutrition, and frequent use of legal or illegal drugs.18 Conversely,
anomalies caused by numerical chromosomal aberrations significantlyincreasewithadvancingageatthetimeof preg-nancyafter35years.19,20 Lowmaternallevelof schooling,
found in most cases of this sample, is another risk fac-torassociatedwithincreasedincidenceofprematurity,low birthweight,andbirthdefectsintheoffspring.18
The predominanceof CL/P overCP,of unilateral clefts over bilateral ones, the left side involvement over the right,andthestatisticalassociationbetweenCL/Pandmale gender and CP and female gender corroborate the clas-siccharacteristicsofOFCs.2---4Smallvariationsinfrequency
betweensubgroupscanbejustifiedbythesamplesize. The association of OFCs withother malformations has beenthesubjectofseveralstudiesworldwide.21---27
Differ-ences in the examiner’s experience, patient age, clinical
expressionvariability,availabilityoftechnologicalresources (especially imaging exams), inclusion/exclusion criteria, andtypeofclassificationused,amongothers,are respon-siblefor theobserveddivergent rates,rangingfrom3%to 63%.2---4,7,28
The inclusionof minordefects, the size,and the sam-ple source (Service of Genetics), as well as the clinical assessmentbyphysiciansexperiencedindysmorphology,can explainthehighfrequency ofassociateddefectsobserved inthissample.
Several authors recommend the exclusion of minor defects, considering them an important source of het-erogeneity for epidemiological studies. In additionto the acknowledgment that these defects do not imply signifi-cantimpairment,otherreasonsforexcludingthemarethe low concordance rates represented by recordsperformed bydifferentprofessionalsandthevariabilityrelatedtosex, ethnicity,andageofonset.10---13
Nonetheless,thepredictivevalue of minordefectshas been established,both for the screening of major abnor-malities and the diagnostic definition of syndromes more easily recognizedby analyzing the setof dysmorphic fea-tures, instead of the placing excessive importance onan isolatedclinicalsign.10---13
Despite the methodological differences between the studies,itisassumedthat,in20%ofinfants withthreeor moreminorsigns,amajorsignisdetected.10,12Considering
cases (ILM andMIBF), reinforcingthe homogeneity of the morphologicalevaluation.
A high frequency of major and minor defects was observed in the sample, with no preferential association withtheOFCtype.However,theCPgroupshowedahigher numberofassociateddefects.Thisresultcorroboratesthose foundintheliterature,asCPhasbeenmostoftenassociated withsyndromicconditions.2---4
Itisnoteworthythatallpatientswithmajordefectsalso hadminordefects.Inthese,themostaffectedanatomical sitesweresimilartothosedescribedintheliterature,whose frequencyisvariable,onceagainduetotheuseofdifferent sampleselectionmethods.21---24,27
Considering the phenotypic classification, it was observedthatthesyndromicOFCgrouppredominatedover the non-syndromic group and was statistically associated withCP.ThefrequencyofsyndromicOFCcaseswashigher thanthatreportedintheliteraturebothintheCL/PandCP groups.2---4 These resultsmust berelatedtothe expansion
ofsyndromiccasedefinitioncriteriausedinthisstudy. The absenceofdifferencesbetweenthesyndromicand non-syndromic OFC groups regarding the maternal and familialvariables probablyreflects theetiological hetero-geneityof the syndromic group andthe sample size. The highfrequencyofalcoholandtobaccouseduringpregnancy is alarming and requires health education interventions. Consanguinity and familial recurrence, also important in thissample,areriskfactorsthatshouldreceivethe atten-tionof health professionals for an appropriatepreventive approach.29,30TheassociationbetweensyndromicOFCsand
lowbirthweightisexpected,consideringthehigherclinical severityobservedinthesecases.1,2,4,5
The absenceofdifferencesbetweenthesyndromicand non-syndromicOFCgroupsregardingthenumberof pregnan-ciesmayreflectthelackof informationbythepopulation about the hereditary natureof OFCs and the difficultyin accessingageneticsservicefordiagnosisandgenetic coun-seling. The lack of diagnosis, anticipatory conduct, and therapeuticplanningprovidedbythegeneticevaluation,as wellasthemoresevereclinicalcourse,maybepartofthe reasonsthatjustifythesignificantlyloweraccesstosurgical treatmentinthesyndromicOFCgroup.
Chromosomal aberrations are traditionally associ-ated with OFCs.2,3,5,7 In this sample, the karyotype
clarified the etiology in three cases (46,XY,r(15), 47,XX,+der(22)t(11;22)(q23;q11)mat, and 46,XX/47,+18), and was indicative of the etiology in one [46,XX,add(22) (q13)].Inthelatter,the16p13.3microduplicationsyndrome was identified,whose clinical and geneticdetails will be theobjectofaspecificpublication.
In a patient with normal karyotype, the MLPA tech-niqueidentifiedthe22q11.2[46,XY.ishdel(22)(q11.2q11.2)] deletion,consistentwiththeclinicalsuspicion,aresult con-firmedbyFISH.ThecasesofMCDswithnormalkaryotype, butthat remainedwithout anappropriatediagnosis, rein-forcetheimportanceoffollow-upandtheuseoflaboratory resourcesofgreatertechnologicalsophisticationinselected situations.Itisnoteworthythatamongthecasesdefinedas syndromic,mostwerediagnosedbasedonclinicalcriteria, reinforcingtheimportanceofgeneticevaluation.
By considering associated defects (minor and major), this study provides a new approach and easy practical
applicationfor thecodification andclassificationof OFCs. Theproposalextendstheconceptandestablishesthe lim-itsbetweensyndromicandnon-syndromicOFCswithclinical bases.
In addition to the possibility of planning the clinical-surgicalrehabilitationinlinewiththespecifichealthneeds ofeachindividual,theuseofthisproposalcouldcontribute tohomogenizethesampleselectionandestablishtheuseof newtechnologiesfor etiological andgenotype---phenotype correlationstudiesinOFCs.Itisexpectedthatthisapproach willbereplicatedinstudieswithlargersamplesinorderto gatherinformationtoassessitslimitationsandpotential.
Funding
Fundac¸ão de Amparo à Pesquisa do Estado de Alagoas (FAPEAL),ConselhoNacionaldeDesenvolvimentoCientífico e Tecnológico --- Programa Interinstitucional de Bolsas de Iniciac¸ãoCientífica(CNPq/PIBIC),andFundac¸ãodeAmparo àPesquisadoEstadodeSãoPaulo(FAPESP).
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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