VILLOCENTESI O AMNIOCENTESI? Vantaggi e svantaggi da una esperienza di 115 000 analisi cromosomiche prenatali Prof. Giuseppe SIMONI TOMA, Advanced Biomedical Assays, S.p.A. Controversie e nuove tecnologie nella diagnosi prenatale del primo trimestre: dal laboratorio alle procedure strumentali Bologna, 5 Aprile 2008
1994- January 15th 2008: 115 576 AF AND CVS FREQUENCIES OF UNBALANCED FETAL KARYOTYPES AT AMNIOCENTESIS AND CVS AF N CASES UNBALANCED ABNORMALITIES* % INDICATION Maternal age 70,860 976 1.38% Previous child/fetus with chr abnorm. 742 7 0.94% Balanced chr abnorm. In parents 252 16 6.35% Increased risk at screening test 8,042 195 2.42% Other 4,951 418 8.44% TOTAL 84,847 1612 (1.9%) CVS N CASES UNBALANCED ABNORMALITIES* % INDICATION Maternal age 25997 582 2.24% Previous child/fetus with chr abnorm. 972 20 2.06% Balanced chr abnorm. In parents 209 21 10.05% Increased risk at screening test 445 27 6.07% Other 3106 660 21.25% TOTAL 30729 1310 (4.25%) *UN B A L.A B N OR M. T R IS 21 T R IS 18 T R IS 13 SEX C H R.A N EUP L. M OSA IC S SUP ER N.M A R KER S D E N OVO R EA R R. D EL/ D UP OT H ER
TYPES OF UNBALANCED ABNORMALITIES FOUND AT AMNIOCENTESIS N CASES TRIS 21 697 TRIS 18 174 TRIS 13 72 SEX CHR.ANEUPL. 218 45,X 53 OT H ER SEX C H R A B N 165 MOSAICS 219 SUPERN.MARKERS 47 TRIPLOIDS 27 OTHERS 158 TOTAL 1612 REL. PROPORTION (%) 43.24% 10.79% 4.47% 13.52% 13.59% 2.92% 1.67% 9.80% 3.29% 10.24% FREQUENCIES OF UNBALANCED FETAL KARYOTYPES AT AMNIOCENTESIS ACCORDING TO MATERNAL AGE N OF CASES N OF UNBALANCED ABNORMALITIES % AGE 35 years 48446 801 1.65% < 35 years 22414 175 0.78%
FREQUENCIES OF THE DIFFERENT TYPES OF UNBALANCED FETAL KARYOTYPES AT AMNIOCENTESIS ACCORDING TO MATERNAL AGE TRIS 21 TRIS 18 TRIS 13 SEX CHR.ANEUPL. 45,X OT H ER SEX C H R MOSAICS SUPERN.MARKERS TRIPLOIDS OTHERS SUBTOTAL TOTAL < 35Y N CASE (%) 35Y N CASE (%) 51 (29,1) 398 (49,7) 5 (2,9) 73 (9,1) 5 (2,9) 27 (3,4) 40 (22,9) 109 (13,6) 32 (18,3) 106 (13,2) 5 (2,9) 25 (3,1) 0 7 (4,0) 33 (18,9) 37 (21,1) 60 (7,5) 175 (17.9) 801 (82.1) 976 3 (0,4) 8 (1,0) 101 (12,6)
TYPES OF UNBALANCED ABNORMALITIES FOUND AT CVS N CASES TRIS 21 623 TRIS 18 230 TRIS 13 84 SEX CHR.ANEUPL. 176 45,X 102 OT H ER SEX C H R A B N 74 MOSAICS confirmed at AF 88 SUPERN.MARKERS 16 TRIPLOIDS 40 OTHERS 53 TOTAL 1310 REL. PROPORTION (%) 47.56% 17.56% 6.41% 13.44% 6.72% 1.22% 3.05% 4.05% 7.79% 5.65% FREQUENCIES OF UNBALANCED FETAL KARYOTYPES AT CHORIONIC VILLI SAMPLING ACCORDING TO MATERNAL AGE N OF CASES N OF UNBALANCED ABNORMALITIES % AGE 35 years 20,596 513 2.49% < 35 years 5,401 69 1.28%
FREQUENCIES OF THE DIFFERENT TYPES OF UNBALANCED FETAL KARYOTYPES AT CVS ACCORDING TO MATERNAL AGE TRIS 21 TRIS 18 TRIS 13 SEX CHR.ANEUPL. 45,X OT H ER SEX C H R A B N MOSAICS SUPERN.MARKERS TRIPLOIDS OTHERS SUBTOTAL TOTAL < 35Y N CASE (%) 35Y N CASE (%) 20 (29,0) 276 (53,8) 5 (7,2) 69 (13,5) 5 (7,2) 24 (4,7) 13 (18,8) 64 (12,5) 8 (11,6) 16 (23,2) 39 (7,6) 1 (1,4) 12 (2,3) 2 (2,9) 11 (2,1) 7 (10,1) 20 (3,9) 69 (11.9) 5 (7,2) 582 513 (88.1) 9 (1,8) 55 (10,7)
SUMMARY OF PRENATAL DIAGNOSIS OF MOSAICISM AT AMNIOCENTESES TYPE OF MOSAICISM Autosomes Sex chromosome Marker chromosome TOTAL N CASES 63 117 39 219 % on total cases 219/84847=0,26%* *Frequencies of True Fetal Mosaicisms at CVS: 10,53% X 2.05% /100= 0.23%
VANTAGGI DELL ANALISI CITOGENETICA SUI VILLI CORIALI MARGINI DI TEMPO SUFFICIENTI PER INDAGINI SUPPLEMENTARI (FISH, ANALISI MOLECOLARI, MLPA ) IDENTIFICAZIONE DI MOSAICISMO SU VILLI CORIALI CONFERMA DEL MOSAICO NEGLI AMNIOCITI (TFM) ESCLUSIONE DI UPD FETALE NEI CASI DI CPM ASSOCIAZIONE DEL RITARDO DI CRESCITA FETALE IDIOPATICO CON CPM
Confined placental mosaicisms Kalousek D., 1984
TIPO I TIPO II TIPO III
MOSAICISM IN CHORIONIC VILLI CONFIRMATORY AMNIOCENTESIS MOSAICISM IN AMNIOCYTES CONFIRMATORY FETAL BLOOD SAMPLING
RISULTATI Frequenze dei differenti tipi di mosaico 24237 mosaicismo CV: 498 (2,05%) 380 AF Table 1: Incidences of the different types of mosaicisms (CPM and TFM) found after chrionic villous and amniocytes karyotyping TYPE NATURE TROPHOBLAST MESENCHYME (direct) (culture) AMNIOCYTES RELATIVE FREQUENCIES I CPM Abnormal Normal Normal 36,58% (139/380) II CPM Normal Abnormal Normal 44,7% (170/380) III CPM Abnormal Abnormal Normal 8,1% (31/380) IV TFM Abnormal Normal Abnormal 1,58% (6/380) V TFM Normal Abnormal Abnormal 4.7% (18/380) VI TFM Abnormal Abnormal Abnormal 4,2% (16/380) *Summary of prenatal diagnosis of Mosaicisms at amniocentesis: 219/84847= 0.26% 10.53%* (40/380) (40/380) = 0.23% CVS = 0.23% CVS SAMPLES SAMPLES
RISULTATI Probabilità di conferma nel feto Table 2: Probabilities of confirmation on amniocytes of Mosaic or Non Mosaic abnormal cell line considering the different combinations of the affected placental tissues TROPHOBLAST MESENCHYME (direct) (culture) CONFIRMATION A N 4,14% (6/145) MA N Type IV/Type I+IV=3/112+3= 2,6% NMA N 3/27+3= 10% N A 9,6% (18/188) N MA Type V/Type II+V= 6/150+6= 3,8% N NMA 12/20+12= 37,5% A A 34% (16/47) MA MA Type VI/Type III+VI= 9/19+9= 28,5% NMA MA 3/9+3= 25% MA NMA 4/0+4= 100% NMA* NMA* 0/3+0= 0% A=Abnormal; N=Normal; MA=Mosaic Abn; NMA=Non Mosaic Abn;*exhotic chr
203 TOTAL CASES OF WHICH 51 INVOLVED AN IMPRINTED CHROMOSOME
VANTAGGI DELL ANALISI CITOGENETICA SU AMNIOCITI CELLULE DERIVATE DA DIVERSI TESSUTI E PARTI FETALE MIGLIORE RISOLUZIONE DEL BANDEGGIO CROMOSOMICO
REPORTED DETECTION RATES (d.r( d.r.).)
REPORTED DETECTION RATES Detection Rates SURUSS (U.K.) (n=47'507) FASTER (U.S.A.) (n=38'033) I TRIMESTER (9-13wg) MESUREMENTS (+MAT. AGE) TRIS 21* TRIS 21* TRIS 18 & OTHER Combined-1 NT+f-β-hCG 65% / / Combined-2 Combined-1+PAPP-A 83% 85% 78% Combined-3 Combined-2+AFP 84% / / Combined-4 Combined-3+uE3 86% / / *False Positive Rate: 5% False Positive Rate: 6% Detection Rates SURUSS (U.K.) (n=47'507) FASTER (U.S.A.) (n=36'171) II TRIMESTER (14-22wg) MESUREMENTS (+MAT. AGE) TRIS 21* TRIS 21* TRIS 18 & OTHER DOUBLE AFP+f-β-hCG 71% / / TRIPLE DOUBLE+uE3 77% 70% / QUADRUPLE TRIPLE+inhA 83% 81% 69% *False Positive Rate: 5% False Positive Rate: 8,9% Detection Rates SURUSS (U.K.) (n=47'507) FASTER (U.S.A.) (n=36'171) I+II TRIMESTER MESUREMENTS (+MAT. AGE) TRIS 21* TRIS 21* TRIS 18 & OTHER Integrated (NT+PAPP-A) + QUADRUPLE 93% 86% / *False Positive Rate: 5%
RELATIVE INCIDENCE OF +21,+18,+13,X0,TRIPLOIDS ON THE TOTAL FETAL CHROMOSOMOPATHY IN OUR SURVEY CV (582 cases with a significant chromosomopathy: Chr. Abnormality N Cases Relative % XXX and XYY excluded) <35 (69 abn. cases) 35 (513 abn. cases) TRIS 21 20 29% TRIS 18 5 7.2% TRIS 13 5 7.2% X0 5 7.2% TRIPLOIDY 2 2.9% 37/69 53.6% TRIS 21 276 53.8% TRIS 18 69 13.5% TRIS 13 24 4.7% X0 9 1.8% TRIPLOIDY 11 2.1% 389/513 75.8% AF (976 cases with a significant chromosomopathy: XXX and XYY excluded) <35 (175 abn. cases) 35 (801 abn. cases) Chr. Abnormality N Cases Relative % TRIS 21 51 29.1% TRIS 18 5 2.9% TRIS 13 5 2.9% X0 7 4.0% TRIPLOIDY 0-68/175 38.9% TRIS 21 398 49.7% TRIS 18 73 9.1% TRIS 13 27 3.4% X0 8 1.0% TRIPLOIDY 3 0.4% 509/801 63.5%
PERCENTAGES OF CHROMOSOMAL ABNORMALITIES ACTUALLY DETECTED BY PRENATAL SCREENING ON THE TOTAL FETAL CHROMOSOMOPATY (1) 1 TRIMESTER TRISOMY 21 +18,+13,X0,TRIPLOIDS 1 TRIMESTER age OBSERVED % a d.r. b DETECTABLE % a % c OBSERVED % a d.r. b DETECTABLE % a % c COMBINED-2 <35 29.0% 35 53.8% 85% 24.6% -4.4% 45.7% -8.1% 24.6% (17/69) 22.0% (113/513) 78% 19.2% -5.5% 17.2% -4.8% 1 TRIMESTER age Σ% OBSERVED Σ% DETECTABLE % d COMBINED-2 <35 35 53.6% 75.8% 43.8% 62.9% -9.80% -12.90% a ON TOTAL FETAL CHROMOSOMOPATHY b Best Reported Detection Rate c partial (DETECTABLE%-OBSERVED%) d total (DETECTABLE%-OBSERVED%)
PERCENTAGES OF CHROMOSOMAL ABNORMALITIES ACTUALLY DETECTED BY PRENATAL SCREENING ON THE TOTAL FETAL CHROMOSOMOPATY (2) 1I TRIMESTER TRISOMY 21 +18,+13,X0,TRIPLOIDS 2 TRIMESTER age OBSERVED % a d.r. b DETECTABLE % a % c OBSERVED % a d.r. b DETECTABLE % a % c DOUBLE TRIPLE QUADRUPLE DOUBLE TRIPLE QUADRUPLE <35 29.1% 35 49.7% 71% 20.7% -8.4% 77% 22.4% -6.7% 83% 24.2% -4.9% 71% 35.3% -14.4% 77% 38.3% -11.4% 83% 41.2% -4.5% 9.7% (17/175) 13.9% (111/801) N.R. / / N.R. / / 69% 6.7% -3.0% N.R. / / N.R. / / 69% 9.6% -4.3% 2 TRIMESTER age Σ% OBSERVED Σ% DETECTABLE % d DOUBLE TRIPLE QUADRUPLE DOUBLE TRIPLE QUADRUPLE <35 35 38.90% 63.50% / / 30.9% / / 50.8% -8.00% -12.70% a ON TOTAL FETAL CHROMOSOMOPATHY b Best Reported Detection Rate c partial (DETECTABLE%-OBSERVED%) d total (DETECTABLE%-OBSERVED%)
IN SUMMARY 100% TOTAL FETAL CHROMOSOMOPATHY 50% 43.8% 56% 62.9% 37% 30.9% 69% 50.8% 49% 0% DETECTABLE NOT DETECTED <35 35 <35 35 1st TRIM-COMBINED 2nd TRIM-QUADRUPLE