|Year : 2015 | Volume
| Issue : 3 | Page : 207-213
Novel mutation detection of fibroblast growth factor receptor 1 (FGFR1) gene, FGFR2IIIa, FGFR2IIIb, FGFR2IIIc, FGFR3, FGFR4 gene for craniosynostosis: A prospective study in Asian Indian patient
Mayadhar Barik, Minu Bajpai, Arun Malhotra, Jyotish Chandra Samantaray, Sadananda Dwivedi, Sambhunath Das
Department of Paediatric Surgery, Nuclear Medicine, Microbiology, Biostatistics and Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||18-Sep-2015|
(Student of: Dr. Minu Bajpai) Department of Paediatric Surgery, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Craniosynostosis (CS) syndrome is an autosomal dominant condition classically combining craniosynostosis and non-syndromic craniosynostosis with digital anomalies of the hands and feet. The majority of cases are caused by heterozygous mutations in the third immunoglobulin-like domain (IgIII) of FGFR2, whilst a larger number of cases can be attributed to mutations outside this region of the protein. Aims: To find out the FGFR1, FGFR2, FGFR3 and FGFR4 gene in craniosynostosis syndrome. Settings and Design: A hospital based prospective study. Materials and Methods: Prospective analysis of clinical records of patients registered in CS clinic from December 2007 to January 2015 was done in patients between 4 months to 13 years of age. We have performed genetic findings in a three generation Indian family with Craniosynostosis syndrome. Results: We report for the first time the clinical and genetic findings in a three generation Indian family with Craniosynostosis syndrome caused by a heterozygous missense mutation, Thr 392 Thr and ser 311 try, located in the IgII domain of FGFR2. FGFR 3 and 4 gene basis syndrome was eponymously named. Genetic analysis demonstrated that 51/56 families to be unrelated. In FGFR3 gene 10/TM location of 1172 the nucleotide changes C>A, Ala 391 Glu 19/56 and Exon-19, 5q35.2 at conserved linker region the changes occurred pro 246 Arg in 25/56 families. Conclusions: Independent genetic origins, but phenotypic similarities in the 51 families add to the evidence supporting the theory of selfish spermatogonial selective advantage for this rare gain-of-function FGFR2 mutation.
Keywords: Craniosynostosis, fibroblast growth factor receptor, genotypic, phenotypic
|How to cite this article:|
Barik M, Bajpai M, Malhotra A, Samantaray JC, Dwivedi S, Das S. Novel mutation detection of fibroblast growth factor receptor 1 (FGFR1) gene, FGFR2IIIa, FGFR2IIIb, FGFR2IIIc, FGFR3, FGFR4 gene for craniosynostosis: A prospective study in Asian Indian patient. J Pediatr Neurosci 2015;10:207-13
|How to cite this URL:|
Barik M, Bajpai M, Malhotra A, Samantaray JC, Dwivedi S, Das S. Novel mutation detection of fibroblast growth factor receptor 1 (FGFR1) gene, FGFR2IIIa, FGFR2IIIb, FGFR2IIIc, FGFR3, FGFR4 gene for craniosynostosis: A prospective study in Asian Indian patient. J Pediatr Neurosci [serial online] 2015 [cited 2022 Jan 22];10:207-13. Available from: https://www.pediatricneurosciences.com/text.asp?2015/10/3/207/165659
| Introduction|| |
Craniosynostosis (CS) is frequently associated with craniofacial disorders. Both syndromic and nonsyndromic group of CS cases were deliberately associated with hereditary, environmental, diet, radiation, heavy metal toxicity, age, sex, occupation, education, ethnicity, and consanguineous marriages.  Overall CS incidence is 1 in 2,500 live births globally but in Indian context it is 1:1000 live births.  CS prevalence rate also varies based on race, region, and ethnicity.  According to our prediction, nonsyndromic CS (NSCS) group is more frequent than the syndromic group in our country.  Authors reported that hotspots mutation in fibroblast growth factor receptor (FGFR) gene, FGFR1, FGFR2, FGFR3, FGFR4, TWIST, EMX, MSX1 and 2 genes detection rate unlikely related to different study population in CS cases both syndromic and nonsyndromic.  Therefore, we straight forward targeted these genes to study in Indian population. The purpose of the study was to know the etiopathogenesis and predisposition of genes with these phenotypes of CS in Indian children in a prospective way.  An Australia and New Zealand cohort of 630 individuals with a diagnosis of CS data was obtained by Sanger sequencing of FGFR1, FGFR2, and FGFR3 hotspot exons and the TWIST1 gene, as well as copy number detection of TWIST1. Of the 630 probands, 231 had one of 80 distinct mutations (36%). Among the 80 mutations, 17 novel sequence variants were detected in three of the four genes screened in Indian samples, we also got the similar results but we got (30%) distinct mutations. In addition to the proband cohort, there were 96 individuals who underwent predictive or prenatal testing as part of family studies.  The dimorphic features were consistent with the known FGFR1-3/TWIST1-associated syndromes. We also show a statistically significant association between splice site mutations in FGFR2 and a clinical diagnosis of Pfeiffer syndrome (PS), more severe clinical phenotypes associated with FGFR2 exon 10 versus exon 8 mutations and more frequent surgical procedures in the presence of a pathogenic mutation. Targeting these gene hot spot areas for mutation analysis is a useful strategy to maximize the success of molecular diagnosis for individuals with CS.  Msx1 and Msx2 were revealed to be candidate genes in craniofacial deformities, such as cleft lip with/without cleft palate (CL/P). In CS, many other genes were demonstrated to have a cross-talk with MSX genes in causing these defects. However, there is no systematic evaluation for these MSX gene-related factors.  In bioinformatic analysis for MSX genes by combining GeneDecks, DAVID, and STRING database, results showed that there were numerous genes related to MSX1, MSX2, M-TWIST, T-TWIST genes, IRF6, TP63, Dlx2, Dlx5, Pax3, Pax9, Bmp4, Tgf-beta2, and Tgf-beta3 that have been demonstrated to be involved in CL/P. FGFR2, FGFR1, FGFR3, and TWIST1 that were involved in CS.  Many of these genes could be enriched into different gene groups involved in different signaling pathways. Hence, it is clear that different craniofacial deformities and different biological process were involved in these syndromes. The function of MSX gene in a gene network, in addition to our findings suggested that Sumo, a novel gene whose polymorphisms were demonstrated to be associated with NSCS.  CL/P by genome-wide association study, has protein-protein interaction with MSX1, an alternative method to perform bioinformatics analysis for genes found by genome-wide association study and can make us predict the disrupted protein function due to the mutation in a gene deoxyribonucleic acid (DNA) sequence. These findings clearly guide us to perform further functional studies in the future treatment.  In our findings, a female patient had an exceedingly rare combination with achondroplasia and multiple-suture CS. Despite these specific features of achondroplasia, synostosis of the metopic, coronal, lambdoid, and squamosal sutures was found.  A series of neurosurgical interventions were carried out. Acrocephaly and posterior plagiocephaly are the most common achondroplasia mutation, a p.Gly380Arg in the FGFR3 genes, was detected in few cases 9/56. Cytogenetic and array CGH analyses, as well as molecular genetic testing of FGFR1, 2, 3, 4 and TWIST1 genes aided to identify an additional genetic alteration. It is suggested that this unusual phenotype is a result of variable expressibility of the common achondroplasia mutation and syndromic and nonsyndromic group of CS. 
| Materials and Methods|| |
Prospective analysis of clinical records of patients registered in CS clinic from December 2007 to January 2015 was done. Ethical clearance was obtained from the Institute's Ethical Committee. Diagnosed cases of syndromic and NSCS patients between 4 months and 13 years of age either preoperative or postoperative were included in the study. Patients with primary microcephaly (secondary CS), postural plagiocephaly, incomplete data, no visual perception, and lost to follow-up were excluded from the study. Diagnostic investigations include clinical examination and plain X-ray skull (anterior-posterior, lateral and Towne's view) and noncontrast computed tomography (NCCT) with three-dimensional (3D) reconstruction if required. Of 63 registered cases, 56 satisfying the inclusion were taken for the study. Blood sample (5 ml) was taken from both the parents along with the child in ethylene-diamine-tetra-acetic acid (vial). For control, 56 healthy children of comparable age group, belonging to the same geographical region were included in this study. Genomic DNA was extracted from peripheral blood lymphocytes by phenol-chloroform extraction method. Primers to diagnose common FGFR1 and FGFR2 mutations in this study were custom-synthesized primers for FGFR1 and FGFR2 gene (Sigma-Aldrich Chemicals Pvt. Ltd., Bengaluru, India). The polymerase chain reaction (PCR) for each sample was performed in 0.2 ml, thin-walled tubes using 20 ng of DNA, 2-5 pmol of each primer, 200 mm dinucleotide triphosphates, 10 × PCR buffer, 1.5 mm MgCl 2 and 0.5 units of DyNAzyme II DNA Polymerase (Thermo Scientific). The PCR reaction was carried out in a T-100 DNA Engine (Bio-Rad, Hercules, CA, USA) Thermal cyclers under the following conditions: 95°C for 3 min, 35 cycles at 95°C for 30 s, annealing temperature as in for 30 s and 72°C for 1 min/kb and a final extension at 75°C for 7 min. Amplicons size were verified by gel electrophoresis by running the PCR product on 2% agarose gel with the 100 bp maker (ladder). After successful amplification, PCR products were digested as per the manufacturer's instructions with the respective restriction endonucleases mentioned in and analyzed on an ethidium bromide-stained 2.0% agarose gel with 50 bp ladder. Finally, PCR purified products were sequenced. 
| Results|| |
There were 58 (69.5%) NSCS cases while 16 (18.6%) were syndromic. 35 (52.4%) were brachycephaly, 19 (23.7%) scaphocephaly, 1 (15.3%) trigonocephaly, 3 (5.8%) plagiocephaly, and 3 (2.9%) oxycephaly. FGFR1 mutation (Pro252Arg) was seen in 51 (2.5%) case of NSCS while the strong association was noted either with FGFR1 or FGFR2 mutation in syndromic and nonsyndromic cases. None of the control group showed any mutation (after verifying control group three times).
Fibroblast growth factor receptor 3 gene-few cases 9/56, and FGFR4 gene mutation detected in this study. PCR sequencing of FGFR1 exon 5 and FGFR2 exons 8, 10, 15, 16, and 17 was performed in all CS patients and revealed 52/86 recurrent mutations in all patients. Most of the mutations clustered in exons 8 and 10 (9/12) accounting for 75% of CS cases (details mentioned in [Table 1]). Here, we have taken cDNA numbering considering the initiator Met codon as nucleotide + 1, FGFR1, 2, 3, 4 gene bank accession number: X52832, and at the same time also checked out from NCBI and Gene Accession Number previously reported in International Standard Literature Gene Accession Number FGFR 1 - BCO18128 (Kallmann), FGFR1 and FGFR3 AF410480, AF360695 (FGFR1 BC015035) FGFR1, 2, 3 Ac009988, Y08089, Y08094 FGFR2 AF410480 as per considering FGFR 2 IIIcNM_023110 (Parallel Germline Mutation) FGFR 3 AY768549 as references in our study group in both the syndrome and nonsyndrome craniosynostosis.
|Table 1: FGFR1, 2, 3,4 gene mutations in Asian and Indian origin children with craniosynostosis|
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| Discussion|| |
Fibroblast growth factors (FGFs) are a family of ligands that bind to four different types of cell surface receptor entitled, FGFR1, FGFR2, FGFR3, and FGFR4. These receptors differ in their ligand-binding affinities and tissue distribution. In these prototypical receptor structure is that of an extracellular region comprising three immunoglobulin (Ig)-like domains. A hydrophobic transmembrane segment and a split intracellular tyrosine kinase domain have an alternative gene splicing affecting the extracellular third Ig loop. It also creates different receptor isoforms entitled FGFRIIIb and FGFRIIIc. Somatic FGFR mutations are implicated in different types of CS and germline FGFR mutations in developmental syndromes particularly those in which CS is a feature. The mutations found in both conditions are often identical. The somatic FGFR mutations in cancer are gain-of-function mutations of established preclinical oncogenic potential. Gene amplification also occurs with 20-25% of squamous cell lung cancers for example having amplification of FGFR1. Ontologic comparators be informative such as an aberrant spermatogenesis being implicated in both spermatocytic seminomas and Apert syndrome. The former arises from somatic FGFR2 mutations, and Apert syndrome arises from germ line FGFR2 mutations. The therapeutics directed at inhibiting the FGF/FGFR interaction is a promising subject for clinical trials.  Five genes implicated in human CS, TWIST1 and FGFRs 1-3 (FGFR1-3) and its isomers, could be the loci of the causative mutation in this unique human model. , Single nucleotide polymorphisms (SNPs) were identified within the TWIST1, FGFR1, and FGFR2 genes. Allelic patterns of these silent mutations were examined in 56 craniosynostotic conditions in our observation in FGFR1 gene (exon-5). SNP analysis of the TWIST1, FGFR1, and FGFR2 genes indicated that none were the locus of origin of the CS phenotype. The structural mutations were identified by direct sequence analysis of FGFR1, FGFR2 with all isomers including TWIST1 and FGFR3 cDNAs.  These data indicate that the causative locus for heritable CS in this animal model is within the TWIST1, FGFR1, and FGFR2 genes. Although a locus in intrinsic or flanking sequences of FGFR3 remains possible, no direct structural mutation was identified for FGFR3.  PS (MIM 101600) is one of the most common syndromic forms of CS. It is characterized by craniosynostosis, midface hypoplasia, broad and medially deviated thumbs, and great toes with partial syndactyly of the digits.  Here, we described clinical and genetic features of 86 unrelated individuals with CS. All 52 patients were sporadic, and advanced paternal age was found in 80% of our earlier cases. PCR sequencing of FGFR1 exon 5 and FGFR2 exons 8, 10, 15, 16, and 17 was performed in all CS patients and revealed 52/86 recurrent mutations in all patients. Most of the mutations clustered in exons 8 and 10 (9/12) accounting for 75% of CS cases [Table 1]. The most frequently detected mutation, p.S351C, was associated with the severe form of CS in the Indian population. Less frequent mutations in exons 16 (p.K641R) and 17 (p.G663E) were also identified. In addition, the p.P252R mutation in FGFR1 was detected in 37 (43.5%) CS patient with unilateral coronal CS expanding the phenotypic spectrum of CS with this particular mutation. Knowing this mutation spectrum of the responsible genes lead to the most effective strategy in identifying mutations causing CS syndrome in the Indian population.  In this FGF, signaling pathway is critically involved in several aspects of craniofacial development including formation of the lip and the palate. FGF receptors are activated by extracellular FGF ligands. In order to regulate cellular processes such as migration and morphogenesis through instruction of specific target and gene expression. A key factor in the development of craniofacial structures is the interaction between mesodermal- and neural crest-derived mesenchyme and ecto- and endodermal-derived epithelium.  FGF signaling occurs in both cell types and promotes epithelial-mesenchymal communication. Region-specific expression of receptor subtypes in FGF ligands and receptors is expressed at specific stages and precise locations. During normal palatogenesis an absolute requirement of some has been demonstrated by their (conditional) inactivation resulting in a cleft palate phenotype. An important signaling pathway involving SHH and SPRY are intricately involved in the interpretation of FGF signaling a cause of human pathology. Functionally validated FGF pathway gene mutations have been exclusively associated with syndromic forms of cleft lip and palate.  CS patients with mutations in FGFR1 and FGFR2 (Kallmann, Pfeiffer, Apert, and Crouzon syndromes) where cleft palate is part of a broad craniofacial phenotype, including CS.  FGF8 mutations have been found in patients with Kallmann-like idiopathic hypogonadotropic hypogonadism, some also with cleft lip and palate. The relevant FGF ligands and receptors important for lip and palate morphogenesis, correlating at their expression patterns with the effects of their perturbation that leads to a clefting pathogenesis.  The FGF and receptor system (FGF/FGFR) mediated cell communication and pattern formation in many tissue types (e.g. osseous, nervous, vascular). In those CS syndromes caused by FGFR1-3 mutations, alteration of signaling in the FGF/FGFR system leads to dysmorphology of the skull, brain, and limbs, among other organs. Since this molecular pathway is widely expressed throughout head development.  Here, we explore and invented whether and how these specific mutations on Fgfr2 causing Apert syndrome in humans affect the pattern and level of integration between the facial skeleton and the neurocranium using inbred syndrome + nonsyndrome CS human subject Fgfr2 (+/S252W) and Fgfr2 (+/P253R) and their nonmutant littermates at P0. Skull morphological integration (MI),  which can reflect developmental interactions among traits. The intensity of statistical associations among them was assessed using data from micro-computed tomography (CT) images of the skull of Apert syndrome and 3D geometric morphometric methods. Our results show that mutant Apert syndrome shares the general pattern of MI with their nonmutant littermates.  But the magnitude of integration between and within the facial skeleton and the neurocranium is increased.  Especially in Fgfr2 (+/S252W), human subject indicated that Fgfr2 mutations disrupt skull MI. FGF/FGFR signaling is a covariance-generating process in skull development, and that acts as a global factor modulating the intensity of MI. Vertebrate evolution, it may have played a significant role in establishing the patterns of skull MI and coordinating proper skull development.  CS is the premature fusion of one or more sutures of the skull, which can be syndromic or isolated. Mutations in FGFR1, FGFR2, or FGFR3, FGFR4 among others are often responsible for these syndromic and nonsyndromic cases. The association of FGFR3 mutations with CS has been restricted to three mutations, the common p.Pro250Arg in Muenke syndrome, p.Ala391Glu in Crouzon syndrome with acanthosis nigricans, and p.Pro250Leu identified in a family with isolated CS. FGFR3 mutations result in varies skeletal dysplasias, achondroplasia, hypochondroplasia, and thanatophoric dysplasia.  Here, we report a novel mutation in exon 8 (IIIc) of FGFR3, p.Ala334Thr, in a young boy with mild CS including his father. The mutation segregated with mild CS in the family and was absent in 120 normal controls. Alanine 334 is evolutionarily conserved pattern in vertebrates and is located at the amino terminus of the βF loop in the FGFR3c isoform. The mutation is predicted to alter the protein tertiary structure which may impair its binding to its ligand, FGF1. The identification of a mutation in these clinically heterogeneous disorders can aid recurrence risk assessments. Although the implementation of a stepwise screening strategy is useful in diagnostics, mutations in unscreened regions of genes associated with CS explain a larger proportion of CS cases.  CS is a condition in which some or all of the sutures in the skull of an infant close prematurely. FGFR2 mutations are a well-known cause of CS. Hence, many syndromes that comprised of CS, such as Apert syndrome, Crouzon syndrome, and PS, and nonsyndrome had one of the phenotypes. In FGFR2 (Exon-B, 1178, T > C (Thr 392 Thr) in 51/56 CS mutant, and in Exon-IIIa, 934, C > G (Ser 311 Try) 51/56 mutant CS in FGFR2 gene and Exon-IIIc has highly conserved protein was observed. In our knowledge, this is the first evidenced base and larger number of sample having novel mutation identified in our study. It's not an 1-day job in our laboratory we have worked hard and faced so many difficult situations still we were unable to find out in control group (healthy control) not possible to get mutation in Indian patients of CS. Mutant patients, FGFRs have been reported in six types (FGFR1-4), and upon binding with FGF ligands. This signal transduction occurred inside of cells. Activated FGFR stimulates an osteogenic master transcription factor. Runx 2, through the MAP kinase and PKC pathways. We obtained a genetic analysis of 56/86. Indian patients who have CS as a phenotype. All of the patients had at least one mutation in the FGFR2 gene; six of those mutations have already been reported elsewhere while three mutation were novel and were hypothesized to lead to syndrome and nonsyndrome CS. In this study, we reported and functionally analyzed a novel mutation of the FGFR2 gene found in a CS patient [Table 2], E731K. The mutation is in the 2 nd tyrosine kinase domain in the C-terminal cytoplasmic region of the molecule. The mutation caused an enhanced phosphorylation of the FGFR2 (E731K) and ERK-MAP kinase. Particularly in this stimulation of the transcriptional activity of Runx 2, and consequently, the enhancement of osteogenic biomarker and gene expression. We conclude that the substitution of E731K in FGFR2 is a novel mutation that resulted in a constitutive activation of the receptor and ultimately resulted in premature suture obliteration. , Apert and PSs are hereditary forms of CS characterized by midfacial hypoplasia and malformations of the limbs and skull. A serious consequence of midfacial hypoplasia in these syndromes is respiratory compromise due to airway obstruction. In this study, we have evaluated FGFR1 (P250R/+) and Fgfr2 (S252W/+) mouse models of these human conditions to study the pathogenesis of midfacial hypoplasia.  Our histologic and micro-CT evaluation revealed premature synostosis of the premaxillary-maxillary, nasal-frontal, and maxillary-palatine sutures of the face and dysplasia of the premaxilla, maxilla, and palatine bones. These midfacial abnormalities were detected in the absence of premature ossification of the cranial base at postnatal day 0. Our results indicate that midfacial hypoplasia is not secondary to premature cranial base ossification but rather primary synostosis of facial sutures presents many challenges in classification and treatment. At least 30% of cases are caused by specific single gene mutations or chromosome abnormalities. This original research article maps out approaches to clinical assessment of a child presenting with an unusual head shape and illustrates how genetic analysis can contribute to diagnosis and management.  Lambdoid synostosis is also a rare form of CS accounting for around 1% of CS patients. It usually occurs in the setting of nonsyndromic multisuture synostosis, although synostosis restricted to this lambdoid suture has been described in rare syndromic associations.  CS patient with an apparently unique combination of bilateral lambdoid synostosis, distinctive craniofacial dysmorphism and normal intelligence. CS patient, the second child of healthy no consanguineous parents with no family history of CS, was delivered at 38 weeks gestation by elective cesarean section following an uneventful pregnancy. Birth weight was 3700 g (90 th centile), length 52 cm (92 th centile), and head circumference 35 cm (10-55 th centile). Severe bilateral lambdoid synostosis was diagnosed at birth resulting in pseudoencephalocele through the posterior fontanelles. Surgical decompression of the posterior fossa and reconstruction of the posterior cranial vault was undertaken at 9 months. An anterior urethral stricture was diagnosed at the time of surgery. Prominent scalp veins, an unusual hair whorl at the apex of the skull, hypertelorism, telecanthus, a short nose with anteverted nostrils, small and low-set ears, microretrognathia, small hands and feet, and horizontal nail ridges were noted [[Figure 1] upper and [Figure 2] lower]. Palate and genitalia were normal. Growth, developmental milestones, hearing, and vision were also normal. We reproduce the clinical photographs of rare cases observed by our pediatric surgical OPD, AIIMS, New Delhi, India.
|Figure 1: Upper - patient at 3 years of age (a) note hypertelorism, telecanthus, short nose and (b) low set ears, unusual hair pattern, pseudoencephalocele (c) having metopic suture (trigonocephally)|
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|Figure 2: Lower - patient at 6 years of age (a) note prominent veins on the scalp, hypertelorism, telecanthus, short nose with anteverted nostrils and (b) an unusual hair whorl at the apex of the skull, and posterior pseudo encephalocele (c) small hands and feet and horizontal nail ridges|
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Cranial magnetic resonance imaging (MRI) showed a structurally normal brain with normal ventricles and normal myelination. The superior sagittal sinus and left distal transverse sinus/proximal sigmoid sinus were reduced in caliber with decreased flow. The scalp vessels from the posterior parietal region forward to the forehead and the central face were markedly prominent, with venous drainage directed anteriorly. DNA was screened using denaturing high-performance liquid chromatography, restriction fragment length polymorphism, PCR, sequencing for mutations in the following exons of the FGFR1-4 and TWIST genes reported to be associated with CS syndromes, and the results were confirmed by DNA sequencing: FGFR1 exon 1; FGFR2 exons 7, 9, 10: FGRG3 exons 7, 10; TWIST exon 1. Molecular karyotyping was undertaken at an inter density of 300 K using the Illumina HumanCytoSNP Array and did not detect any clinically significant copy number changes. Peripheral blood cytogenetic investigation was observed normal with a 46, XY karyotype. This patient presents with a previously undescribed CS syndrome with recognizable craniofacial dysmorphism comprising bilateral lambdoid synostosis, normal intellect, prominent scalp veins, unusual hair whorl, hypertelorism, telecanthus, short nose with anteverted nostrils, small and low-set ears, microretrognathia, and small hands and feet.  This pattern of abnormalities suggested that a genetic etiology and the mode of inheritance can be determined. Other associations with lambdoid synostosis were considered in the differential diagnosis. Moreover, the overall pattern of anomalies found in our case appeared at variance with any known CS disorder. We provide a greater understanding of the phenotype and indicate other diagnostic avenues to explore. CS syndrome is a rare autosomal dominant disorder characterized by coronal CS, brachycephaly, mid-facial hypoplasia, broad and deviated thumbs and great toes. PS occurs in approximately 1:100,000 live births. Clinical manifestations and molecular genetic testing are important to confirm the diagnosis. Mutations of the FGFR1 gene or FGFR2 gene can cause PS. Here, we describe a case of PS with a novel c833_834GC > TG mutation (encoding Cys278 Leu) in the FGFR2 gene associated with a coccygeal anomaly, which is rarest in PS.  NSCS is a very heterogeneous group of disorders. Its etiology and pathophysiology plays an important role in molecular genetics. Chromosomal alterations, mutation, and polymorphism are causative mechanisms of nonsyndromic forms of CS; mutations of several genes are unequivocally associated with nonmendelian principles. Hence, inheritance patterns are strictly different. Genetic tests were done for FGFR1, FGFR2, FGFR2IIIa, FGFR2IIIb, FGFR2IIIc, FGFR3 (FGFR group gene only). We compare with 99mTc ethyl cysteine dimer (ECD) single-photon emission CT (SPECT)/CT, MRI brain, NCCT skull and X-ray skull. 80% of gene in FGFR2 family (FGFR2IIIa, FGFR2IIIb, FGFR2IIIc genes) responsible rather than FGFR1, FGFR3, MSX2, TWIST1, RECQUL4, EFNB1, RAB23, FBN1, POR, TGFBR1 and TGFBR2 in previous. 99mTc ECD SPECT/CT gives clear picture and better correlation with optimum perfusion level in both genotypic as well as phenotypic. Elucidating the genotype-phenotype, genetic pattern, genes, and syndromes of NSCS. FGFR2 IIIa, IIIb, IIIc has given 80% (120). FGFR1, FGFR3 has observed lesser than the correlation with NSCS. In previous scientific literature, study, observation and older hypothesis we first reported and given our results to public health and justified that FGFR2 gene and its isomers FGFR2IIIa, FGFR2IIIb, FGFR2IIIc genes may be reliable for prognostic marker as well as 99mTc ECD brain SPECT before, after the surgery and follow-up of the patients used as diagnostic marker is more helpful for NSCS cases in management, counseling, screening and better treatment for future.  Our study suggests an integrated and holistic approach of medical informatics. It can be highly beneficial for the advanced application of gene therapy (GT) in the years to come. GT has become debatable and often controversial because of tendency to use for manipulating the desirable attributes. Moreover, its rational use is likely to benefit mankind.  This is the first epidemiological study in India that provides evidence that advanced paternal age and higher parental education level might be associated with an increased risk of CS. New mutations were identified in cases of both syndromic and NSCS.  Our study suggests that early surgery and release of CS in patients with preoperative perfusion defects (absent on 99mTh-ECD SPECT study) are beneficial as they lead to improved MPQ after surgery.  Microarray technology and other recent advancement technology like exome-based sequence analysis like next-gen sequence is certainly beneficial for future study and target to drug design and drug delivery system and targeting the therapeutics. 
| Conclusion|| |
Our study established that FGFR1, FGFR2 mutation, which confers predisposition to NSCS and syndrome CS strongly exist in Indian population when compared to the western world. Earlier, we were unable to report because of a smaller number of sample size and very minimal of the results. Our genetic analysis results demonstrated that 51/56 families to be unrelated genotype similarities in phenotypes between the 86 families are discussed. Independent genetic origins, but phenotypic similarities in the 51 families add an evidence supporting that theory of selfish spermatogonial selective advantage for this rare gain-of-function FGFR2 mutation.
| Acknowledgments|| |
We are thankful to Indian Council of Medical Research, India for funding in due time. We thank to Dr. Madavi Tripathy, Dr. S. N. Das, Dr. A. Trika, Dr. Sneh Lata and Dr. Sunil Kumar for their valuable suggestions.
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[Table 1], [Table 2]
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