Detecting novel cancer predisposing mutations by utilizing the Finnish Cancer Registry and archival tissue material

Integrative Life Science (ILS) Doctoral Programme

DETECTING NOVEL CANCER PREDISPOSING MUTATIONS BY UTILIZING THE FINNISH CANCER REGISTRY AND ARCHIVAL TISSUE

MATERIAL

Iikki Donner

Department of Medical and Clinical Genetics, Medicum Applied Tumor Genomics Research Program

Faculty of Medicine University of Helsinki, Finland

ACADEMIC DISSERTATION

To be publicly discussed, with the permission of the Faculty of Biological and Environmental Sciences, in Metsätalo, Room 2, Unioninkatu 40, Helsinki, on June

5^th, 2020, at 12 noon.

Helsinki 2020

2

Supervised by Academy Professor Lauri A. Aaltonen, MD,

PhD

Department of Medical and Clinical Genetics, Medicum

Applied Tumor Genomics Research Program

Faculty of Medicine

University of Helsinki, Finland

Docent Auli Karhu, PhD

Department of Medical and Clinical Genetics, Medicum

Applied Tumor Genomics Research Program

Faculty of Medicine

University of Helsinki, Finland

Reviewed by Docent Hellevi Peltoketo, PhD

Biocenter Oulu

Cancer and Translational Medicine Research Unit

Faculty of Medicine University of Oulu, Finland

Docent Katri Pylkäs, PhD Biocenter Oulu

Cancer and Translational Medicine Research Unit

Faculty of Medicine University of Oulu, Finland

Official opponent Docent Jaana Hartikainen, PhD

Faculty of Health Sciences School of Medicine

Institute of Clinical Medicine

Clinical Pathology and Forensic Medicine University of Eastern Finland, Finland

ISBN 978-951-51-6169-7 (paperback) ISBN 978-951-51-6170-3 (PDF)

http://urn.fi/URN:ISBN:978-951-51-6170-3 Unigrafia Oy

Helsinki 2020

3

CONTENTS

ORIGINAL PUBLICATIONS ... 5

ABBREVIATIONS ... 6

‡‡”ƒŽ ... 6

‡‡• ... 7

‹‘ƒ…‹†• ... 10

ABSTRACT ... 11

1 REVIEW OF THE LITERATURE ... 14

ͳǤͳƒ…‡”ƒ•ƒ‹Š‡”‹–‡††‹•‡ƒ•‡ ... 14

ͳǤͳǤͳŠ‡ŠƒŽŽƒ”•‘ˆ…ƒ…‡” ... 14

ͳǤͳǤʹ†‹•‡ƒ•‡‘ˆ–Š‡‰‡‘‡ ... 16

ͳǤͳǤ͵‡‡–‹……ƒ…‡”•—•…‡’–‹„‹Ž‹–› ... 18

ͳǤʹŠ‡ ‹‹•Š’‘’—Žƒ–‹‘Ȃƒ™‡ŽŽǦ•–—†‹‡†‰‡‡–‹…‹•‘Žƒ–‡ ... 20

ͳǤʹǤͳ ‹‹•Š’‘’—Žƒ–‹‘Š‹•–‘”› ... 21

ͳǤʹǤʹŠ‡ ‹‹•Š†‹•‡ƒ•‡Š‡”‹–ƒ‰‡ ... 21

ͳǤʹǤ͵‡…‘”†‹‰’‘’—Žƒ–‹‘ƒ††‹•‡ƒ•‡Š‹•–‘”› ... 21

ͳǤ͵‡š–Ǧ‰‡‡”ƒ–‹‘•‡“—‡…‹‰ ... 22

ͳǤ͵Ǥͳ‡ˆ‡”‡…‡‰‡‘‡•ƒ†’‘’—Žƒ–‹‘…‘–”‘Ž• ... 22

ͳǤ͵Ǥʹƒ’Ž‡’”‡’ƒ”ƒ–‹‘ƒ†–Š‡•‡“—‡…‹‰”‡ƒ…–‹‘ ... 23

ͳǤ͵Ǥ͵ƒ–ƒ’”‘…‡••‹‰ ... 25

ͳǤ͵ǤͶ—””‡–Ž‹‹–ƒ–‹‘•ƒ†…ŠƒŽŽ‡‰‡•‘ˆ ... 26

ͳǤͶƒ…‡”’Š‡‘–›’‡•ƒƒŽ›œ‡†‹–Š‹•–Š‡•‹• ... 27

ͳǤͶǤͳ‡”‡†‹–ƒ”›†‹ˆˆ—•‡‰ƒ•–”‹……ƒ…‡”ȋȌ ... 27

ͳǤͶǤʹ•‘’Šƒ‰‡ƒŽ•“—ƒ‘—•…‡ŽŽ…ƒ”…‹‘ƒȋȌ ... 29

ͳǤͶǤ͵—‰ƒ†‡‘…ƒ”…‹‘ƒȋȌ ... 30

ͳǤͶǤͶ‰‹‘‹—‘„Žƒ•–‹…Ǧ…‡ŽŽŽ›’Š‘ƒȋȌ ... 31

2 AIMS OF THE STUDY ... 33

3 MATERIALS AND METHODS ... 34

͵Ǥͳ–Š‹…•ƒ’’”‘˜ƒŽ ... 34

͵ǤʹŽ—•–‡”‹‰ ... 34

͵Ǥ͵ƒ–‹‡–•ƒ†•ƒ’Ž‡• ... 34

͵Ǥ͵Ǥͳ–—†› ... 34

͵Ǥ͵Ǥʹ–—†› ... 35

4

͵Ǥ͵Ǥ͵–—†› ... 37

͵Ǥ͵ǤͶ–—†› ... 37

͵ǤͶš‘‡•‡“—‡…‹‰ ... 37

͵Ǥͷƒ–ƒƒƒŽ›•‹• ... 38

͵Ǥ͸ƒ‰‡”•‡“—‡…‹‰ ... 40

4 RESULTS ... 42

ͶǤͳ‘••‹„Ž›’ƒ–Š‘‰‡‹…˜ƒ”‹ƒ–•‹INSRǡFBXO24ǡƒ†DOT1L•‡‰”‡‰ƒ–‡‹ CDH1—–ƒ–‹‘‡‰ƒ–‹˜‡ˆƒ‹Ž›ȋȌ ... 42

ͶǤʹƒ†‹†ƒ–‡•—•…‡’–‹„‹Ž‹–›˜ƒ”‹ƒ–•ˆ‘”ȋȌ ... 42

ͶǤʹǤͳ”‹…Š‡–‘ˆ…Ž—•–‡”‡†’ƒ–‹‡–•‹…‡†‡†ƒ”‡Ž‹ƒ ... 42

ͶǤʹǤʹ‘•‡•‡˜ƒ”‹ƒ–‹DNAH9’”‡•‡–‹ͳͷΨ‘ˆ’ƒ–‹‡–• ... 43

ͶǤʹǤ͵EP300‹••‡•‡˜ƒ”‹ƒ–‹…‘ˆ‹”‡†ˆƒ‹Ž› ... 43

ͶǤ͵ƒ†‹†ƒ–‡•—•…‡’–‹„‹Ž‹–›˜ƒ”‹ƒ–•ˆ‘”Ž—‰ƒ†‡‘…ƒ”…‹‘ƒ‹›‘—‰ ‡˜‡”Ǧ•‘‹‰™‘‡ȋȌ ... 45

ͶǤ͵Ǥͳ‡”Ž‹‡—–ƒ–‹‘•‹™‡ŽŽǦ‡•–ƒ„Ž‹•Š‡†…ƒ…‡”’”‡†‹•’‘•‹–‹‘ ‰‡‡• ... 45

ͶǤ͵Ǥʹ ‹˜‡’‘••‹„Ž›’ƒ–Š‘‰‡‹…˜ƒ”‹ƒ–•‹COL6A1 ... 45

ͶǤ͵Ǥ͵ ƒ‹Ž›Š‹•–‘”›‘ˆŽ—‰ƒ†‡‘…ƒ”…‹‘ƒƒ†‹†‹‘’ƒ–Š‹…’—Ž‘ƒ”› ˆ‹„”‘•‹• ... 49

ͶǤͶ‘•‡•‡˜ƒ”‹ƒ–‹POLKƒ†‹••‡•‡˜ƒ”‹ƒ–‹PRKCB•‹‰‹ˆ‹…ƒ–Ž› ‡”‹…Š‡†‹’ƒ–‹‡–‰‡”Ž‹‡•ƒ’Ž‡•‡–ȋȌ ... 49

5 DISCUSSION ... 51

ͷǤͳ Ǧ†‡”‹˜‡†ƒ† ... 51

ͷǤʹ †ƒ–ƒ…Ž—•–‡”‹‰ȋȌ ... 53

ͷǤ͵‘’…ƒ†‹†ƒ–‡•—•…‡’–‹„‹Ž‹–›‰‡‡•ˆ‘”–Š‡†‹ˆˆ‡”‡–’Š‡‘–›’‡• ... 53

ͷǤ͵ǤͳINSRǡFBXO24ǡƒ†DOT1L˜ƒ”‹ƒ–•‹ˆƒ‹Ž›ȋȌ ... 54

ͷǤ͵ǤʹDNAH9ƒ†EP300˜ƒ”‹ƒ–•‹ȋȌ ... 55

ͷǤ͵Ǥ͵TP53ǡBRCA1ǡƒ†BRCA2—–ƒ–‡†‹–Š‡‰‡”Ž‹‡‘ˆ›‘—‰™‘‡ ™‹–ŠȋȌ ... 56

ͷǤ͵ǤͶSCN7A—–ƒ–‡†‹–™‘’ƒ–‹‡–•ƒ† ƒˆˆŽ‹…–‡†”‡Žƒ–‹˜‡ȋȌ . 59 ͷǤ͵ǤͷPOLKƒ†PRKCB˜ƒ”‹ƒ–•†‡–‡…–‡†‹’ƒ–‹‡–•‡”‹‡•ȋȌ ... 60

ͷǤͶ‹‹–ƒ–‹‘•‘ˆ–Š‡•–—†‹‡• ... 61

CONCLUDING REMARKS AND FUTURE PROSPECTS ... 62

ACKNOWLEDGEMENTS ... 63

REFERENCES ... 65

5

ORIGINAL PUBLICATIONS

Š‹•†‘…–‘”ƒŽ–Š‡•‹•‹•„ƒ•‡†‘–Š‡ˆ‘ŽŽ‘™‹‰’—„Ž‹…ƒ–‹‘•ǣ

I Donner Iǡ ‹˜‹Ž—‘–‘ ǡ ‹•–‹¡‹ ǡ ƒŽ–‘‡ ǡ ƒŠ–‡”‹•–‘ Ǥ š‘‡

•‡“—‡…‹‰”‡˜‡ƒŽ•–Š”‡‡‘˜‡Ž…ƒ†‹†ƒ–‡’”‡†‹•’‘•‹–‹‘‰‡‡•ˆ‘”†‹ˆˆ—•‡

‰ƒ•–”‹……ƒ…‡”ǤFamilial CancerǡʹͲͳͷǤ

II Donner Iǡ ƒ–ƒ‹‡ ǡ ƒ•ƒ‡ ǡ ƒƒ•‹‡ ǡ ƒ˜‹‘ ǡ ˜ƒ•ƒ ǡ

”–ƒƒǡ—ƒŽƒǡƒŽ–‘‡Ǥƒ†‹†ƒ–‡•—•…‡’–‹„‹Ž‹–›˜ƒ”‹ƒ–•ˆ‘”

‡•‘’Šƒ‰‡ƒŽ•“—ƒ‘—•…‡ŽŽ…ƒ”…‹‘ƒǤGenes Chromosomes CancerǡʹͲͳ͹Ǥ III Donner Iǡ ƒ–ƒ‹‡ ǡ ‹’‹Ž¡ ǡ ƒ˜‹‘ ǡ —ƒŽƒ ǡ ƒŽ–‘‡ Ǥ

‡”Ž‹‡ —–ƒ–‹‘• ‹ ›‘—‰ ‘Ǧ•‘‹‰ ™‘‡ ™‹–Š Ž—‰

ƒ†‡‘…ƒ”…‹‘ƒǤLung Cancer, ʹͲͳͺǤ

IV Donner Iǡ ƒ–ƒ‹‡ ǡ ƒƒ•‹‡ ǡ ƒ˜‹‘ ǡ ‹’‹Ž¡ ǡ —ƒŽƒ ǡ

ƒŽ–‘‡Ǥƒ†‹†ƒ–‡•—•…‡’–‹„‹Ž‹–›˜ƒ”‹ƒ–•‹ƒ‰‹‘‹—‘„Žƒ•–‹…Ǧ …‡ŽŽŽ›’Š‘ƒǤFamilial CancerǡʹͲͳͻǤ

Š‡ ’—„Ž‹…ƒ–‹‘• ƒ”‡ ”‡ˆ‡””‡† –‘ ‹ –Š‡ –‡š– „› –Š‡‹” ‘ƒ —‡”ƒŽ• ƒ†

”‡’”‘†—…‡† ™‹–Š –Š‡ ’‡”‹••‹‘ ‘ˆ –Š‡ …‘’›”‹‰Š– Š‘Ž†‡”•Ǥ —„Ž‹…ƒ–‹‘ ‹•

‹…Ž—†‡† ‹ –Š‡ †‘…–‘”ƒŽ –Š‡•‹• Dz Ǧdz„›‹—ƒ–ƒ‹‡ȋ‡Ž•‹‹ǡʹͲʹͲȌǤ

6

ABBREVIATIONS

General

AITL ƒ‰‹‘‹—‘„Žƒ•–‹…Ǧ…‡ŽŽŽ›’Š‘ƒ

BAM ‹ƒ”›Ž‹‰‡–ƒ’

CGC ƒ…‡”‡‡‡•—•

COSMIC ƒ–ƒŽ‘‰—‡‘ˆ‘ƒ–‹…—–ƒ–‹‘•‹ƒ…‡”

E ‡š’‡…–‡†

EBV ’•–‡‹Ǧƒ””˜‹”—•

ESCC ‡•‘’Šƒ‰‡ƒŽ•“—ƒ‘—•…‡ŽŽ…ƒ”…‹‘ƒ

FCR ‹‹•Šƒ…‡”‡‰‹•–”›

FF ˆ”‡•ŠǦˆ”‘œ‡

FFPE ˆ‘”ƒŽ‹Ǧˆ‹š‡†ǡ’ƒ”ƒˆˆ‹Ǧ‡„‡††‡†

FIMM •–‹–—–‡ˆ‘”‘Ž‡…—Žƒ”‡†‹…‹‡ ‹Žƒ†

FUSION ‹Žƒ†Ǧ‹–‡†–ƒ–‡•˜‡•–‹‰ƒ–‹‘‘ˆ‡‡–‹…• gnomAD ‡‘‡‰‰”‡‰ƒ–‹‘ƒ–ƒ„ƒ•‡

GWAS ‰‡‘‡™‹†‡ƒ••‘…‹ƒ–‹‘•–—†›

HDGC Š‡”‡†‹–ƒ”›†‹ˆˆ—•‡‰ƒ•–”‹……ƒ…‡”

HDR Š‘‘Ž‘‰›†‹”‡…–‡†”‡’ƒ‹”

GATK ‡‘‡ƒŽ›•‹•‘‘Ž‹–

IGCLC –‡”ƒ–‹‘ƒŽƒ•–”‹…ƒ…‡”‹ƒ‰‡‘•‘”–‹—

INDEL •‡“—‡…‡‹•‡”–‹‘‘”†‡Ž‡–‹‘

IPF ‹†‹‘’ƒ–Š‹…’—Ž‘ƒ”›ˆ‹„”‘•‹•

LFS ‹Ǧ ”ƒ—‡‹•›†”‘‡

LOH Ž‘••‘ˆŠ‡–‡”‘œ›‰‘•‹–›

LUAD Ž—‰ƒ†‡‘…ƒ”…‹‘ƒ

MAF ‹‘”ƒŽŽ‡Ž‡ˆ”‡“—‡…›

MN …ƒ…‡”…Ž—•–‡”…‘•‹•–‹‰‘ˆ’ƒ–‹‡–•™‹–Š•Šƒ”‡†—‹…‹’ƒŽ‹–›ƒ†

ˆƒ‹Ž›ƒ‡ƒ–„‹”–Š

NGS ‡š–Ǧ‰‡‡”ƒ–‹‘•‡“—‡…‹‰

NSCLC ‘Ǧ•ƒŽŽ…‡ŽŽŽ—‰…ƒ…‡”

O ‘„•‡”˜‡†

O/E ‘„•‡”˜‡†Ȁ‡š’‡…–‡†

PARP ’‘Ž›”‹„‘•‡’‘Ž›‡”ƒ•‡

PCR ’‘Ž›‡”ƒ•‡…Šƒ‹”‡ƒ…–‹‘

PIS ‘’—Žƒ–‹‘ˆ‘”ƒ–‹‘›•–‡

PTCL ’‡”‹’Š‡”ƒŽǦ…‡ŽŽŽ›’Š‘ƒ

SCLC •ƒŽŽ…‡ŽŽŽ—‰…ƒ…‡”

SEM1 ͳʹ͸’”‘–‡ƒ•‘‡…‘’Ž‡š•—„—‹–

SISu ‡“—‡…‹‰‹–‹ƒ–‹˜‡—‘‹

7 SNP •‹‰Ž‡—…Ž‡‘–‹†‡’‘Ž›‘”’Š‹•

SNV •‹‰Ž‡—…Ž‡‘–‹†‡˜ƒ”‹ƒ–

TFH ˆ‘ŽŽ‹…—Žƒ”Š‡Ž’‡”

TSG –—‘”•—’’”‡••‘”‰‡‡

UIP —•—ƒŽ‹–‡”•–‹–‹ƒŽ’‡—‘‹ƒ

VCF ˜ƒ”‹ƒ–…ƒŽŽˆ‘”ƒ–

WT ™‹Ž†–›’‡

Genes

ABCC10 „‹†‹‰…ƒ••‡––‡•—„ˆƒ‹Ž›‡„‡”ͳͲ ADH1B ƒŽ…‘Š‘Ž†‡Š›†”‘‰‡ƒ•‡ͳȋ…Žƒ••Ȍǡ„‡–ƒ’‘Ž›’‡’–‹†‡

ALDH2 ƒŽ†‡Š›†‡†‡Š›†”‘‰‡ƒ•‡ʹˆƒ‹Ž›‡„‡”

ALK ƒƒ’Žƒ•–‹…Ž›’Š‘ƒ”‡…‡’–‘”–›”‘•‹‡‹ƒ•‡

ANK2 ƒ›”‹ʹ

ATM •‡”‹‡Ȁ–Š”‡‘‹‡‹ƒ•‡

ATP7B ƒ•‡…‘’’‡”–”ƒ•’‘”–‹‰„‡–ƒ

BAG1 ʹƒ••‘…‹ƒ–‡†ƒ–Šƒ‘‰‡‡ͳ BAP1 ͳƒ••‘…‹ƒ–‡†’”‘–‡‹ͳ BRCA1 ͳ”‡’ƒ‹”ƒ••‘…‹ƒ–‡†

BRCA2 ʹ”‡’ƒ‹”ƒ••‘…‹ƒ–‡†

CABIN1 …ƒŽ…‹‡—”‹„‹†‹‰’”‘–‡‹ͳ

CACNA1S …ƒŽ…‹—˜‘Ž–ƒ‰‡Ǧ‰ƒ–‡†…Šƒ‡Ž•—„—‹–ƒŽ’Šƒͳ CD28 ʹͺ‘Ž‡…—Ž‡

CDH1 …ƒ†Š‡”‹ͳ

CDKN1B …›…Ž‹†‡’‡†‡–‹ƒ•‡‹Š‹„‹–‘”ͳ CDKN2A …›…Ž‹†‡’‡†‡–‹ƒ•‡‹Š‹„‹–‘”ʹ CFTR –”ƒ•‡„”ƒ‡…‘†—…–ƒ…‡”‡‰—Žƒ–‘”

CHEK2 …Š‡…’‘‹–‹ƒ•‡ʹ

CHRNA3 …Š‘Ž‹‡”‰‹…”‡…‡’–‘”‹…‘–‹‹…ƒŽ’Šƒ͵•—„—‹–

CHRNA5 …Š‘Ž‹‡”‰‹…”‡…‡’–‘”‹…‘–‹‹…ƒŽ’Šƒͷ•—„—‹–

CHRNB4 …Š‘Ž‹‡”‰‹…”‡…‡’–‘”‹…‘–‹‹…„‡–ƒͶ•—„—‹–

CLIP4 ǦŽ›†‘ƒ‹…‘–ƒ‹‹‰Ž‹‡”’”‘–‡‹ˆƒ‹Ž›‡„‡”Ͷ CLPTM1L …Ž‡ˆ–Ž‹’ƒ†’ƒŽƒ–‡–”ƒ•‡„”ƒ‡’”‘–‡‹ͳǦŽ‹‡’”‘–‡‹

CREBBP „‹†‹‰’”‘–‡‹

COL6A1 …‘ŽŽƒ‰‡–›’‡ƒŽ’Šƒͳ…Šƒ‹

COL6A6 …‘ŽŽƒ‰‡–›’‡ƒŽ’Šƒ͸…Šƒ‹

CTNNA1 …ƒ–‡‹ƒŽ’Šƒͳ CTNNB1 …ƒ–‡‹„‡–ƒͳ

CYP1A1 …›–‘…Š”‘‡ͶͷͲˆƒ‹Ž›ͳ•—„ˆƒ‹Ž›‡„‡”ͳ CYP21A2 …›–‘…Š”‘‡ͶͷͲˆƒ‹Ž›ʹͳ•—„ˆƒ‹Ž›‡„‡”ʹ

8 DCDC2B †‘—„Ž‡…‘”–‹†‘ƒ‹…‘–ƒ‹‹‰ʹ

DDOST †‘Ž‹…Š›ŽǦ†‹’Š‘•’Š‘‘Ž‹‰‘•ƒ……Šƒ”‹†‡Ǧ’”‘–‡‹‰Ž›…‘•›Ž–”ƒ•ˆ‡”ƒ•‡

‘Ǧ…ƒ–ƒŽ›–‹…•—„—‹–

DICER1 †‹…‡”ͳǡ”‹„‘—…Ž‡ƒ•‡

DNAH9 †›‡‹ƒš‘‡ƒŽŠ‡ƒ˜›…Šƒ‹ͻ DNMT3A ‡–Š›Ž–”ƒ•ˆ‡”ƒ•‡͵ƒŽ’Šƒ

DOT1L ͳŽ‹‡Š‹•–‘‡Ž›•‹‡‡–Š›Ž–”ƒ•ˆ‡”ƒ•‡

EGF ‡’‹†‡”ƒŽ‰”‘™–Šˆƒ…–‘”

EGFR ‡’‹†‡”ƒŽ‰”‘™–Šˆƒ…–‘””‡…‡’–‘”

EML4 ‡…Š‹‘†‡”‹…”‘–—„—Ž‡Ǧƒ••‘…‹ƒ–‡†’”‘–‡‹ǦŽ‹‡Ͷ EP300 ͳ„‹†‹‰’”‘–‡‹’͵ͲͲ

ER ‡•–”‘‰‡”‡…‡’–‘”

ERBB2 ‡”„Ǧ„ʹ”‡…‡’–‘”–›”‘•‹‡‹ƒ•‡ʹ

ERCC4 ‡š…‹•‹‘”‡’ƒ‹”Ͷǡ‡†‘—…Ž‡ƒ•‡…ƒ–ƒŽ›–‹…•—„—‹–

EXT1 ‡š‘•–‘•‹‰Ž›…‘•›Ž–”ƒ•ˆ‡”ƒ•‡ͳ FANCA …‘’Ž‡‡–ƒ–‹‘‰”‘—’

FANCD2 …‘’Ž‡‡–ƒ–‹‘‰”‘—’ʹ FANCE …‘’Ž‡‡–ƒ–‹‘‰”‘—’

FANCL …‘’Ž‡‡–ƒ–‹‘‰”‘—’

FAT1 ƒ–›’‹…ƒŽ…ƒ†Š‡”‹ͳ FBXO24 Ǧ„‘š’”‘–‡‹ʹͶ

FBXW7 Ǧ‘šƒ†”‡’‡ƒ–†‘ƒ‹…‘–ƒ‹‹‰͹

FCSK ˆ—…‘•‡‹ƒ•‡

FGFR1 ˆ‹„”‘„Žƒ•–‰”‘™–Šˆƒ…–‘””‡…‡’–‘”ͳ

FYN ’”‘–‘Ǧ‘…‘‰‡‡ǡ”…ˆƒ‹Ž›–›”‘•‹‡‹ƒ•‡

GCN1 ͳƒ…–‹˜ƒ–‘”‘ˆ ʹͶ GJB6 ‰ƒ’Œ—…–‹‘’”‘–‡‹„‡–ƒ͸

GKAP1 ‹ƒ•‡ƒ…Š‘”‹‰’”‘–‡‹ͳ GNL3L ’”‘–‡‹—…Ž‡‘Žƒ”͵Ž‹‡

GTF2I ‰‡‡”ƒŽ–”ƒ•…”‹’–‹‘ˆƒ…–‘”‹

HEATR3 ‡’‡ƒ–‘–ƒ‹‹‰͵

HOTAIR –”ƒ•…”‹’–ƒ–‹•‡•‡

HNF1A ͳŠ‘‡‘„‘š

IDH2 ‹•‘…‹–”ƒ–‡†‡Š›†”‘‰‡ƒ•‡ȋȋΪȌȌʹǡ‹–‘…Š‘†”‹ƒŽ

INSR ‹•—Ž‹”‡…‡’–‘”

KDM6A Ž›•‹‡†‡‡–Š›Žƒ•‡͸

KMT2A Ž›•‹‡‡–Š›Ž–”ƒ•ˆ‡”ƒ•‡ʹ KMT2D Ž›•‹‡‡–Š›Ž–”ƒ•ˆ‡”ƒ•‡ʹ MMP2 ƒ–”‹š‡–ƒŽŽ‘’‡’–‹†ƒ•‡ʹ NFE2L2 —…Ž‡ƒ”ˆƒ…–‘”ǡ‡”›–Š”‘‹†ʹŽ‹‡ʹ

NFX1 —…Ž‡ƒ”–”ƒ•…”‹’–‹‘ˆƒ…–‘”ǡǦ„‘š„‹†‹‰ͳ NOTCH1 ‘–…Š”‡…‡’–‘”ͳ

9

OSGEPL1 Ǧ•‹ƒŽ‘‰Ž›…‘’”‘–‡‹‡†‘’‡’–‹†ƒ•‡Ž‹‡ͳ OTOG ‘–‘‰‡Ž‹

PCDHGB6 ’”‘–‘…ƒ†Š‡”‹‰ƒƒ•—„ˆƒ‹Ž›ǡ͸

PDE4D ’Š‘•’Š‘†‹‡•–‡”ƒ•‡Ͷ

PIK3CA ’Š‘•’Šƒ–‹†›Ž‹‘•‹–‘ŽǦͶǡͷǦ„‹•’Š‘•’Šƒ–‡͵Ǧ‹ƒ•‡…ƒ–ƒŽ›–‹…•—„—‹–

ƒŽ’Šƒ

PLCE1 ’Š‘•’Š‘Ž‹’ƒ•‡‡’•‹Ž‘ͳ PLCG1 ’Š‘•’Š‘Ž‹’ƒ•‡‰ƒƒͳ POLK ’‘Ž›‡”ƒ•‡ƒ’’ƒ

PRKCB ’”‘–‡‹‹ƒ•‡„‡–ƒ

PRKN ’ƒ”‹͵—„‹“—‹–‹’”‘–‡‹Ž‹‰ƒ•‡

PRRC2B ’”‘Ž‹‡”‹…Š…‘‹Ž‡†Ǧ…‘‹Žʹ PTCH1 ’ƒ–…Š‡†ͳ

RASSF9 ƒ•ƒ••‘…‹ƒ–‹‘†‘ƒ‹ˆƒ‹Ž›‡„‡”ͻ RB1 –”ƒ•…”‹’–‹‘ƒŽ…‘”‡’”‡••‘”ͳ

RGS17 ”‡‰—Žƒ–‘”‘ˆ’”‘–‡‹•‹‰ƒŽ‹‰ͳ͹

RHBDF2 ”Š‘„‘‹†ͷŠ‘‘Ž‘‰ʹ RHOA ”ƒ•Š‘‘Ž‘‰ˆƒ‹Ž›‡„‡”

RUNX1 ƒ‹Ž›”ƒ•…”‹’–‹‘ ƒ…–‘”ͳ RYR1 ”›ƒ‘†‹‡”‡…‡’–‘”ͳ

SCN7A •‘†‹—˜‘Ž–ƒ‰‡Ǧ‰ƒ–‡†…Šƒ‡ŽƒŽ’Šƒ•—„—‹–͹

SEC24A ʹͶŠ‘‘Ž‘‰ǡ…‘ƒ–…‘’Ž‡š…‘’‘‡–

SMARCB1 Ȁ ”‡Žƒ–‡†ǡƒ–”‹šƒ••‘…‹ƒ–‡†ǡƒ…–‹†‡’‡†‡–”‡‰—Žƒ–‘”‘ˆ

…Š”‘ƒ–‹ǡ•—„ˆƒ‹Ž›„ǡ‡„‡”ͳ SP100 ͳͲͲ—…Ž‡ƒ”ƒ–‹‰‡

ST6GAL1 „‡–ƒǦ‰ƒŽƒ…–‘•‹†‡ƒŽ’ŠƒǦʹǡ͸Ǧ•‹ƒŽ›Ž–”ƒ•ˆ‡”ƒ•‡ͳ TERT –‡Ž‘‡”ƒ•‡”‡˜‡”•‡–”ƒ•…”‹’–ƒ•‡

TET2 –‡–‡–Š›Ž…›–‘•‹‡†‹‘š›‰‡ƒ•‡ʹ TP53 –—‘”’”‘–‡‹’ͷ͵

TTC36 –‡–”ƒ–”‹…‘’‡’–‹†‡”‡’‡ƒ–†‘ƒ‹͵͸

TTN –‹–‹

USH2A —•Š‡”‹

XBP1 Ǧ„‘š„‹†‹‰’”‘–‡‹ͳ ZNF676 œ‹…ˆ‹‰‡”’”‘–‡‹͸͹͸

ZNHIT3 œ‹…ˆ‹‰‡”Ǧ–›’‡…‘–ƒ‹‹‰͵

10

Amino acids

11

ABSTRACT

Ž–Š‘—‰Š‘•–…ƒ…‡”•ƒ”‡•’‘”ƒ†‹…ǡƒ…‘•‹†‡”ƒ„Ž‡’”‘’‘”–‹‘‹•†—‡–‘‰‡‡–‹…

•—•…‡’–‹„‹Ž‹–›Ǥ ƒ› …ƒ…‡” –›’‡• †‹•’Žƒ› ‘†‡”ƒ–‡ –‘ Š‹‰Š Š‡”‹–ƒ„‹Ž‹–›ǡ „—–

’”‡†‹•’‘•‹–‹‘‰‡‡•Šƒ˜‡„‡‡‡•–ƒ„Ž‹•Š‡†ˆ‘”‘Ž›ƒˆ‡™Ǥ–Š‹•–Š‡•‹•’”‘Œ‡…–ǡ

™‡Šƒ˜‡—–‹Ž‹œ‡†–Š‡†ƒ–ƒ‹–Š‡ ‹‹•Šƒ…‡”‡‰‹•–”›ȋ Ȍƒ†–Š‡‘’—Žƒ–‹‘

ˆ‘”ƒ–‹‘›•–‡ȋȌ†ƒ–ƒ„ƒ•‡•–‘‹†‡–‹ˆ›…ƒ…‡”’ƒ–‹‡–•™‹–Šƒ’‘–‡–‹ƒŽ

‰‡‡–‹… ’”‡†‹•’‘•‹–‹‘Ǥ ‘” ‘•– ‘ˆ –Š‡ ’ƒ–‹‡–• ‹ –Š‡ ƒ”…Š‹˜ƒŽ –‹••—‡

ƒ–‡”‹ƒŽ ‹ –Š‡ ˆ‘” ‘ˆ ’ƒ”ƒˆˆ‹Ǧ‡„‡††‡† ˆ‘”ƒŽ‹Ǧˆ‹š‡† ȋ Ȍ „Ž‘…• ‹•

ƒ˜ƒ‹Žƒ„Ž‡ ‹ –Š‡ ’ƒ–Š‘Ž‘‰‹…ƒŽ †‡’ƒ”–‡– ‘ˆ –Š‡‹” Ž‘…ƒŽ Š‘•’‹–ƒŽǡ ™Š‹…Š ƒ‡•

‰‡‡–‹…•–—†‹‡•‘•‡Ž‡…–‡†…ƒ•‡•’‘••‹„Ž‡ǤŠ‡ ‹‹•Š’‘’—Žƒ–‹‘‹•†—‡–‘‹–•

†‡‘‰”ƒ’Š‹… Š‹•–‘”› ‘”‡ Š‘‘‰‡‡‘—• –Šƒ ‘•– ’‘’—Žƒ–‹‘•ǡ ƒ† –Š—•

‘’–‹ƒŽˆ‘”•–—†‹‡•‘‰‡”Ž‹‡’”‡†‹•’‘•‹–‹‘–‘†‹•‡ƒ•‡Ǥ

Š‹• –Š‡•‹• ‹…Ž—†‡• •–—†‹‡• ‘ –™‘ …ƒ…‡” –›’‡• …—””‡–Ž› Žƒ…‹‰ ™‡ŽŽǦ

‡•–ƒ„Ž‹•Š‡† •—•…‡’–‹„‹Ž‹–› ‰‡‡•ǣ Ž—‰ ƒ†‡‘…ƒ”…‹‘ƒ ȋȌǡ ƒ†

ƒ‰‹‘‹—‘„Žƒ•–‹… Ǧ…‡ŽŽ Ž›’Š‘ƒ ȋȌǤ  ƒ††‹–‹‘ǡ › –Š‡•‹• ™‘”

‡šƒ‹‡•‡•‘’Šƒ‰‡ƒŽ •“—ƒ‘—• …‡ŽŽ …ƒ”…‹‘ƒ ȋȌ ƒ† Š‡”‡†‹–ƒ”› †‹ˆˆ—•‡

‰ƒ•–”‹……ƒ…‡”ȋȌ•—•…‡’–‹„‹Ž‹–›Ǥˆ”ƒ…–‹‘‘ˆ–Š‡•‡…ƒ…‡”•…ƒ„‡ƒ––”‹„—–‡†

–‘ ‰‡”Ž‹‡ —–ƒ–‹‘• ‹RHBDF2 ƒ†CDH1ǡ ”‡•’‡…–‹˜‡Ž›Ǥ ‡ —–‹Ž‹œ‡† ‡š‘‡

•‡“—‡…‹‰‹ƒŽŽ•–—†‹‡•™‹–Š–Š‡ƒ‹–‘†‹•…‘˜‡”‘˜‡Ž•—•…‡’–‹„‹Ž‹–›‰‡‡•ˆ‘”

–Š‡†‹ˆˆ‡”‡–’Š‡‘–›’‡•Ǥ

ƒ•–”‹… …ƒ…‡” ‹• –Š‡ •‡…‘† Ž‡ƒ†‹‰ …ƒ—•‡ ‘ˆ …ƒ…‡” ‘”–ƒŽ‹–›Ǥ Š”‡‡ †‹•–‹…–

Š‡”‡†‹–ƒ”› ‰ƒ•–”‹… …ƒ…‡” •›†”‘‡• ƒ”‡ ”‡…‘‰‹œ‡†ǣ ǡ ˆƒ‹Ž‹ƒŽ ‹–‡•–‹ƒŽ

‰ƒ•–”‹… …ƒ…‡”ǡ ƒ† ‰ƒ•–”‹… ƒ†‡‘…ƒ”…‹‘ƒ ƒ† ’”‘š‹ƒŽ ’‘Ž›’‘•‹• ‘ˆ –Š‡

•–‘ƒ…ŠǤ’–‘‘‡–Š‹”†‘ˆˆƒ‹Ž‹‡•Šƒ˜‡Š‡–‡”‘œ›‰‘—•‰‡”Ž‹‡—–ƒ–‹‘•

‹CDH1ǡ™Š‹…Š‡…‘†‡•Ǧ…ƒ†Š‡”‹Ǥ‘•–…ƒ•‡••Š‘™‹‰ˆƒ‹Ž‹ƒŽƒ‰‰”‡‰ƒ–‹‘†‘

‘–ǡŠ‘™‡˜‡”ǡŠƒ˜‡ƒ‘™‰‡‡–‹…„ƒ•‹•ǤŠ‡ƒ‹‘ˆ–Š‡ˆ‹”•–•–—†›™ƒ•–‘ˆ‹†

–Š‡ ’—–ƒ–‹˜‡ …ƒ…‡”Ǧ’”‡†‹•’‘•‹‰ ‰‡‡ †‡ˆ‡…– ‹ ƒ ˆƒ‹Ž› –Šƒ– Šƒ†

’”‡˜‹‘—•Ž› „‡‡ –‡•–‡† ‡‰ƒ–‹˜‡ ˆ‘” CDH1 —–ƒ–‹‘•Ǥ ‡ ‹†‡–‹ˆ‹‡† –Š”‡‡

…ƒ†‹†ƒ–‡ ˜ƒ”‹ƒ–•ǣ ’ǤŽ—ͳ͵ͳ͵›• ‹ ǡ ’Ǥ”‰ͺͳ”‘ ‹ ʹͶ ƒ†

’Ǥ”‘ͳͳͶ͸‡—‹ͳǤINSR‹•‘ˆ•’‡…‹ƒŽ‹–‡”‡•–ƒ•‹•—Ž‹•‹‰ƒŽ‹‰Šƒ•„‡‡

•Š‘™–‘‘†—Žƒ–‡Ǧ…ƒ†Š‡”‹‰Ž›…‘•›Žƒ–‹‘ƒ†•–ƒ„‹Ž‹–›Ǥ

”‡’”‡•‡–•–Š‡‘•–…‘‘•—„–›’‡‘ˆ‡•‘’Šƒ‰‡ƒŽ…ƒ…‡”ǡƒ…‘‘ƒ†

‘ˆ–‡ˆƒ–ƒŽƒŽ‹‰ƒ…›ǤŽ–Š‘—‰Š•Š‘™•ˆƒ‹Ž‹ƒŽ…Ž—•–‡”‹‰ƒ†‘†‡”ƒ–‡–‘

Š‹‰Š Š‡”‹–ƒ„‹Ž‹–›ǡ ˆ‡™ •–—†‹‡• ‘ ‘†‡”ƒ–‡ –‘ Š‹‰Š ’‡‡–”ƒ…‡ ’”‡†‹•’‘•‹–‹‘

‡š‹•–Ǥ‡Šƒ˜‡’”‡˜‹‘—•Ž›ˆ‘—†ˆƒ‹Ž‹ƒŽƒ‰‰”‡‰ƒ–‹‘‘ˆ…Žƒ••‹…ƒ’‘•‹•ƒ”…‘ƒ

„›’‡”ˆ‘”‹‰ˆƒ‹Ž›ƒ‡ƒ–„‹”–Šƒ†—‹…‹’ƒŽ‹–›ƒ–„‹”–Š„ƒ•‡†…Ž—•–‡”‹‰‘ˆ

ƒŽŽ…ƒ…‡”…ƒ•‡•‹–Š‡ Ǥ•–—†›ǡ™‡—•‡†–Š‡•ƒ‡…Ž—•–‡”‹‰ƒŽ‰‘”‹–Š–‘

ˆ‹† ’‘–‡–‹ƒŽ ˆƒ‹Ž‹ƒŽ …ƒ•‡• ‘ˆ Ǥ ‡ ƒƒ‰‡† –‘ ˆ‹† ƒ ‰‡‘‰”ƒ’Š‹…ƒŽ

’‘’—Žƒ–‹‘ •—„•‡– –Šƒ– •Š‘™‡† ‡”‹…Š‡– ‘ˆ …Ž—•–‡”‡† ’ƒ–‹‡–•Ǥ Š‡

12

ˆ‹†‹‰ƒ›‹†‹…ƒ–‡–Šƒ–ƒ•—•…‡’–‹„‹Ž‹–›˜ƒ”‹ƒ–‹•‡”‹…Š‡†‹–Š‹•’‘’—Žƒ–‹‘

•—„•‡–Ǥ ‡ …‘ŽŽ‡…–‡† –‹••—‡ ƒ–‡”‹ƒŽ ƒ† ‡š‘‡ •‡“—‡…‡† ƒ –‘–ƒŽ ‘ˆ ͵Ͳ …ƒ•‡•Ǥ‹š˜ƒ”‹ƒ–•’ƒ••‡†ˆ‹Ž–‡”‹‰ƒ†ƒƒŽ›•‹•…”‹–‡”‹ƒǡ–Š‡‘•–ˆ”‡“—‡–

„‡‹‰ƒ‘•‡•‡—–ƒ–‹‘‹DNAH9†‡–‡…–‡†‹ˆ‘—”—”‡Žƒ–‡†’ƒ–‹‡–•Ǥ‡

’ƒ–‹‡–̵•–—‘”•Š‘™‡†Ž‘••‘ˆ–Š‡™‹Ž†–›’‡ƒŽŽ‡Ž‡‘ˆDNAH9ǡ•—‰‰‡•–‹‰ƒ–—‘”Ǧ

•—’’”‡••‹˜‡ˆ—…–‹‘ǤŠ‡‘–Š‡”…ƒ†‹†ƒ–‡‰‡‡•GKAP1ǡBAG1ǡNFX1ǡFCSKǡƒ†

DDOST Šƒ”„‘”‡† ‹••‡•‡ ˜ƒ”‹ƒ–•Ǥ ”ƒ”‡ ˜ƒ”‹ƒ– ‹EP300ǡ ƒ ‰‡‡ –Šƒ– Šƒ•

’”‡˜‹‘—•Ž›„‡‡‹’Ž‹…ƒ–‡†‹…ƒ”…‹‘‰‡‡•‹•ǡ™ƒ•†‹•…‘˜‡”‡†–‘•‡‰”‡‰ƒ–‡

‹–Š”‡‡ƒˆˆ‡…–‡†‹†‹˜‹†—ƒŽ•‹ƒ•‹‰Ž‡ˆƒ‹Ž›Ǥ

—‰…ƒ…‡”‹•–Š‡‘•–…‘‘…ƒ…‡”‹–Š‡™‘”Ž†ƒ†–Š‡Ž‡ƒ†‹‰…ƒ—•‡‘ˆ

…ƒ…‡” †‡ƒ–Š ‹ „‘–Š ‡ ƒ† ™‘‡Ǥ – ‹• ™‡ŽŽ ‡•–ƒ„Ž‹•Š‡† –Šƒ– –Š‡ ’”‹ƒ”›

…ƒ—•‡‘ˆ–Š‡ƒŽ‹‰ƒ…›‹•…‹‰ƒ”‡––‡•‘‡ǡŠ‘™‡˜‡”ǡ‘–Š‡”ˆƒ…–‘”•ƒ”‡‹˜‘Ž˜‡†

ƒ•‘Ž›ƒ’’”‘š‹ƒ–‡Ž›ͳͷΨ‘ˆ•‘‡”•†‡˜‡Ž‘’Ž—‰…ƒ…‡”ƒ†ƒ‡•–‹ƒ–‡†ͳͲǦ ʹͷΨ‘ˆƒŽŽŽ—‰…ƒ…‡”•‘……—”‹‡˜‡”•‘‡”•Ǥ‡†‡”‹ˆŽ—‡…‡•–Š‡”‹•‘ˆŽ—‰

…ƒ…‡”ƒ†™‘‡ƒ”‡‘˜‡””‡’”‡•‡–‡†ƒ‘‰‡˜‡”•‘‡”•™‹–Š–Š‡†‹•‡ƒ•‡Ǥ

‡…ƒ—•‡‘ˆƒ’‘••‹„Ž‡†‹ˆˆ‡”‡…‡‹–Š‡‘Ž‡…—Žƒ”„ƒ•‹•ǡ™‡…Š‘•‡–‘•–—†›‡˜‡”Ǧ

•‘‡”™‘‡™‹–Š‹•–—†›Ǥ‡•‡Ž‡…–‡†–Š‡›‘—‰‡•–’ƒ–‹‡–•Ž‹•–‡†

‹–Š‡ ǡ™Š‘ƒ”‡‘”‡Ž‹‡Ž›–‘Šƒ”„‘”ƒ’”‡†‹•’‘•‹‰‰‡”Ž‹‡—–ƒ–‹‘Ǥ‡

ƒƒ‰‡†–‘…‘ŽŽ‡…–‘”ƒŽ –‹••—‡ƒ–‡”‹ƒŽˆ”‘ʹͳ‡˜‡”Ǧ•‘‡”™‘‡

™Š‘Šƒ†„‡‡†‹ƒ‰‘•‡†™‹–ŠŽ—‰ƒ†‡‘…ƒ”…‹‘ƒ„‡ˆ‘”‡–Š‡ƒ‰‡‘ˆͶͷǤ

‘–‡–‹ƒŽŽ›’ƒ–Š‘‰‡‹…˜ƒ”‹ƒ–•™‡”‡ˆ‘—†‹‡‹‰Š–ƒ…‡”‡‡‡•—•‰‡”Ž‹‡

‰‡‡•ǣBRCA1ǡBRCA2ǡERCC4ǡEXT1ǡHNF1 AǡPTCH1ǡSMARCB1ǡ ƒ†TP53Ǥ Š‡

˜ƒ”‹ƒ–•‹TP53ǡBRCA1ǡƒ†BRCA2ƒ”‡˜‡”›Ž‹‡Ž›–‘Šƒ˜‡…‘–”‹„—–‡†–‘–Š‡

‡ƒ”Ž›Ǧ‘•‡– Ž—‰ …ƒ…‡” ‹ –Š‡ ”‡•’‡…–‹˜‡’ƒ–‹‡–•Ǥ Š‹• •—’’‘”–• –Š‡‹†‡ƒ –Šƒ–

Ž—‰ ƒ†‡‘…ƒ”…‹‘ƒ …ƒ „‡ ƒ …‘’‘‡– ‘ˆ …‡”–ƒ‹ …ƒ…‡” ’”‡†‹•’‘•‹–‹‘

•›†”‘‡•Ǥƒ††‹–‹‘ǡˆ‹ˆ–‡‡‰‡‡•†‹•’Žƒ›‡†’‘–‡–‹ƒŽŽ›’ƒ–Š‘‰‡‹…—–ƒ–‹‘•

‹ƒ–Ž‡ƒ•––™‘’ƒ–‹‡–•ǣABCC10ǡATP7BǡCACNA1Sǡ CFTRǡCLIP4ǡCOL6A1ǡCOL6A6ǡ GCN1ǡGJB6ǡRYR1ǡSCN7AǡSEC24AǡSP100ǡTTNǡ ƒ†USH2AǤ ‘‡ ‘ˆ –Š‡•‡

…ƒ†‹†ƒ–‡‰‡‡•ƒ›‡š’Žƒ‹ƒ•—„•‡–‘ˆˆ‡ƒŽ‡Ž—‰ƒ†‡‘…ƒ”…‹‘ƒǤ

‹•ƒ•—„–›’‡‘ˆ’‡”‹’Š‡”ƒŽǦ…‡ŽŽŽ›’Š‘ƒ™‹–Šƒ„Ž‡ƒ’”‘‰‘•‹•Ǥ‘ƒ–‹…

†”‹˜‡”—–ƒ–‹‘•Šƒ˜‡„‡‡ˆ‘—†‹TET2ǡIDH2ǡDNMT3AǡRHOAǡFYNǡPLCG1ǡ

ƒ†CD28ǡ ™Š‡”‡ƒ• ‰‡”Ž‹‡ •—•…‡’–‹„‹Ž‹–› –‘ Šƒ• –‘ ‘—” ‘™Ž‡†‰‡ ‘–

„‡‡•–—†‹‡†Ǥ•–—†›™‡’‡”ˆ‘”‡†ƒ‡š‘‡Ǧ™‹†‡”ƒ”‡˜ƒ”‹ƒ–ƒƒŽ›•‹•‹

ʹ͵ ’ƒ–‹‡–•Ǥ ‘ ‰‡”Ž‹‡ —–ƒ–‹‘• ™‡”‡ ˆ‘—† ‹ –Š‡ †”‹˜‡” ‰‡‡•ǡ

‹†‹…ƒ–‹‰–Šƒ––Š‡›ƒ”‡‘–ˆ”‡“—‡–Ž›‹˜‘Ž˜‡†‹‰‡‡–‹…’”‡†‹•’‘•‹–‹‘Ǥ

‘–‡–‹ƒŽŽ› ’ƒ–Š‘‰‡‹… ˜ƒ”‹ƒ–• ’”‡•‡– ‹ ƒ– Ž‡ƒ•– –™‘ ’ƒ–‹‡–• ƒ† •Š‘™‹‰

•‹‰‹ˆ‹…ƒ–‡”‹…Š‡–‹‘—”•ƒ’Ž‡•‡–™‡”‡ˆ‘—†‹–‡‰‡‡•ǣPOLKǡPRKCBǡ ZNF676ǡPRRC2BǡPCDHGB6ǡGNL3LǡTTC36ǡOTOGǡOSGEPL1ǡ ƒ†RASSF9Ǥ Š‡

‘•–•‹‰‹ˆ‹…ƒ–Ž›‡”‹…Š‡†˜ƒ”‹ƒ–•™‡”‡’Ǥ›•Ͷ͸ͻ‡”‹ƒ•’Ž‹…‡˜ƒ”‹ƒ–‘ˆ

ƒ†’Ǥ”‘ͷͺͺ‹•‹ǤŠ‡•‡–™‘ƒ”‡‹–”‹‰—‹‰…ƒ†‹†ƒ–‡•ǡƒ•Polk†‡ˆ‹…‹‡–

13

‹…‡ †‹•’Žƒ› ƒ •’‘–ƒ‡‘—• —–ƒ–‘” ’Š‡‘–›’‡ ƒ†PRKCB Šƒ• „‡‡ ˆ‘—†

•‘ƒ–‹…ƒŽŽ›—–ƒ–‡†‹͵͵Ψ‹ƒ†—Ž–Ǧ…‡ŽŽŽ›’Š‘ƒǡƒ‘–Š‡”ˆ‘”‘ˆ’‡”‹’Š‡”ƒŽ

Ǧ…‡ŽŽŽ›’Š‘ƒǤ

Š‡•‡•–—†‹‡••Š‘™–Šƒ–”ƒ”‡Ž›’‡”ˆ‘”‡†‡š–Ǧ‰‡‡”ƒ–‹‘•‡“—‡…‹‰‘ˆ

‡š–”ƒ…–‡† ˆ”‘ –‹••—‡ •ƒ’Ž‡• ‹• ™‡ŽŽ •—‹–‡† ˆ‘” ”‡•‡ƒ”…Š ƒ† •Š‘—Ž† „‡

—–‹Ž‹œ‡† –‘ ƒ ‰”‡ƒ–‡” ‡š–‡–Ǥ ‡ ˆ‘—† ’Žƒ—•‹„Ž‡ …ƒ†‹†ƒ–‡ ‰‡‡• ˆ‘” –Š‡

’Š‡‘–›’‡• —†‡” •–—†›Ǥ ‘™‡˜‡”ǡ †—‡ –‘ ”‡Žƒ–‹˜‡Ž› •ƒŽŽ •ƒ’Ž‡ •‡–•ǡ ‘—”

ˆ‹†‹‰• ‡‡† –‘ „‡ ‰‡‡–‹…ƒŽŽ› ˜ƒŽ‹†ƒ–‡† ‹ ‹†‡’‡†‡– •ƒ’Ž‡ •‡”‹‡• ƒ†

–Š”‘—‰Šˆ—…–‹‘ƒŽ•–—†‹‡•–‘’”‘˜‡…ƒ—•ƒŽ‹–›Ǥ

14

1 REVIEW OF THE LITERATURE

1.1 Cancer as an inherited disease

‘•– …ƒ•‡• ‘ˆ …ƒ…‡” ƒ”‡ •’‘”ƒ†‹…Ǥ Š‡› ƒ”‹•‡ „‡…ƒ—•‡ ‘ˆ ‡˜‹”‘‡–ƒŽ

‡š’‘•—”‡•ǡ Ž‹ˆ‡•–›Ž‡ ˆƒ…–‘”•ǡ ƒ† …Šƒ…‡ ȋƒƒ‡‹ ‡– ƒŽǤǡ ʹͲͲͷǢ ‘ƒ•‡––‹ Ƭ

‘‰‡Ž•–‡‹ǡ ʹͲͳͷȌǤ Š‡ ”‹• ‘ˆ †‡˜‡Ž‘’‹‰ …ƒ…‡” ‹• ˆ—”–Š‡” ‹ˆŽ—‡…‡† „› –Š‡

‹Š‡”‹–‡† ‰‡‡–‹… ƒ‡—’ ‘ˆ ‡ƒ…Š ‹†‹˜‹†—ƒŽǤ Ž–Š‘—‰Š –Š‹• Š‡”‡†‹–ƒ”›

…‘’‘‡–‹•’”‡•‡–‹‘•–…ƒ…‡”…ƒ•‡•ǡŠ‡”‡†‹–ƒ”›…ƒ…‡”‹•‘”‡•–”‹‰‡–Ž›

†‡ˆ‹‡† ƒ• ƒ …ƒ…‡” –Šƒ– ‹• –”‹‰‰‡”‡† „› ƒ ”ƒ”‡ Š‹‰ŠǦ”‹• ‰‡”Ž‹‡ —–ƒ–‹‘

ȋƒŠƒǡʹͲͳͶȌǤŠ‹•‹Š‡”‹–‡†•—•…‡’–‹„‹Ž‹–›‹…”‡ƒ•‡•–Š‡”‹•‘ˆƒ‹†‹˜‹†—ƒŽ

–‘†‡˜‡Ž‘’…ƒ…‡”ƒ”‡†Ž›ǤCDH1—–ƒ–‹‘…ƒ””‹‡”•ǡˆ‘”‡šƒ’Ž‡ǡŠƒ˜‡ƒͶʹΨ ȋ‡Ȍ ‘” ͵͵Ψ ȋ™‘‡Ȍ …Šƒ…‡ ‘ˆ †‡˜‡Ž‘’‹‰ ‰ƒ•–”‹… …ƒ…‡” „› –Š‡ ƒ‰‡ ‘ˆ ͺͲ ȋ‘„‡”–•‡–ƒŽǤǡʹͲͳͻȌǡ™Š‡”‡ƒ•–Š‡”‹•‘ˆ†‡˜‡Ž‘’‹‰‰ƒ•–”‹……ƒ…‡”‹–Š‡‰‡‡”ƒŽ

’‘’—Žƒ–‹‘‹•ͳǤͺ͹؈‘”‡ƒ†ͲǤ͹ͻ؈‘”™‘‡ȋ”ƒ›‡–ƒŽǤǡʹͲͳͺȌǤ‡”‡†‹–ƒ”›

…ƒ…‡”•…Ž—•–‡”‹ˆƒ‹Ž‹‡•ƒ†–›’‹…ƒŽŽ›Šƒ˜‡ƒ›‘—‰ƒ‰‡ƒ–‘•‡–Ǥ‡•–‹ƒ–‡†

ˆ‹˜‡–‘–‡’‡”…‡–‘ˆƒŽŽ…ƒ…‡”•„‡Ž‘‰–‘–Š‹•‰”‘—’ȋƒ‰›‡–ƒŽǤǡʹͲͲͶȌǤ

Š‡ˆ‹”•–…ƒ—•ƒ–‹˜‡—–ƒ–‹‘ˆ‘”Š‡”‡†‹–ƒ”›…ƒ…‡”•—•…‡’–‹„‹Ž‹–›™ƒ•†‹•…‘˜‡”‡†

‹ͳͻͺ͹ǡ™Š‡–Š‡RB1‰‡‡™ƒ••Š‘™–‘„‡—–ƒ–‡†‹”‡–‹‘„Žƒ•–‘ƒȋ —‰

‡–ƒŽǤǡͳͻͺ͹ȌǤŠ‹•ˆ‘ŽŽ‘™‡†–Š‡ƒ–Š‡ƒ–‹…ƒŽ‘†‡ŽŽ‹‰‘ˆ‹–•‡’‹†‡‹‘Ž‘‰›„›

—†•‘ȋ—†•‘ǡͳͻ͹ͳȌǤ•—†•‘Šƒ†’”‡†‹…–‡†ǡ„‘–ŠƒŽŽ‡Ž‡•‘ˆRB1‡‡†‡†

–‘„‡‹ƒ…–‹˜ƒ–‡†ˆ‘””‡–‹‘„Žƒ•–‘ƒ–‘‘……—”Ǥ‡”‡†‹–ƒ”›…ƒ•‡•…ƒ””‹‡†ƒ‰‡”Ž‹‡

ȋ…‘•–‹–—–‹‘ƒŽȌ—–ƒ–‹‘‹‘‡ƒŽŽ‡Ž‡ǡ”‡“—‹”‹‰‘Ž›‘‡‹ƒ…–‹˜ƒ–‹‰•‘ƒ–‹…

ȋƒ…“—‹”‡†ȌŠ‹–ȋFigure 1ȌǤ

Š‡Ž‘…—•‘ˆ–Š‡™‡ŽŽǦ‘™Š‡”‡†‹–ƒ”›„”‡ƒ•–ƒ†‘˜ƒ”‹ƒ…ƒ…‡”‰‡‡BRCA1

™ƒ•†‹•…‘˜‡”‡†‹ͳͻͻͲǡƒ†–Š‡‰‡‡‹–•‡Žˆ™ƒ•…Ž‘‡†ˆ‘—”›‡ƒ”•Žƒ–‡”ȋƒŽŽ‡–

ƒŽǤǡͳͻͻͲǢ‹‹‡–ƒŽǤǡͳͻͻͶȌǤƒ…‡”’”‡†‹•’‘•‹–‹‘‰‡‡•…ƒ„‡†‡ˆ‹‡†ƒ•‰‡‡•

‹™Š‹…Š…‡”–ƒ‹”ƒ”‡—–ƒ–‹‘•…ƒ—•‡ƒ‘†‡”ƒ–‡–‘Š‹‰Š‹…”‡ƒ•‡‹…ƒ…‡””‹•

ȋƒŠƒǡ ʹͲͳͶȌǤ Š‡ †ƒ–ƒ„ƒ•‡ ƒ–ƒŽ‘‰—‡ ‘ˆ ‘ƒ–‹… —–ƒ–‹‘• ‹ ƒ…‡”

ȋȌ Ž‹•–• ͹ʹ͵ ‰‡‡• –Šƒ– ƒ”‡ …ƒ—•ƒŽŽ› ‹’Ž‹…ƒ–‡† ‹ …ƒ…‡”ǡ –Š‡ •‘Ǧ…ƒŽŽ‡†

ƒ…‡”‡‡‡•—•ȋȌȋ‘†ƒ‡–ƒŽǤǡʹͲͳͺǢƒ–‡‡–ƒŽǤǡʹͲͳͻȌǤˆ–Š‡•‡ǡͳͲ͵

ƒ”‡’”‘„ƒ„Ž‡–ƒ”‰‡–•‘ˆ…ƒ…‡”’”‡†‹•’‘•‹‰—–ƒ–‹‘•Ǥ

1.1.1 The hallmarks of cancer

ƒ…‡” ‹• …Šƒ”ƒ…–‡”‹œ‡† „› –Š‡ ‰”‘™‹‰ —„‡” ‘ˆ ƒ„‘”ƒŽ …‡ŽŽ• –Šƒ– †‘ ‘–

ˆ‘ŽŽ‘™–Š‡‘”ƒŽ–‹‰Š–Ž›…‘–”‘ŽŽ‡†Ž‹ˆ‡…›…Ž‡ ‘ˆ–Š‡…‡ŽŽ–›’‡‹“—‡•–‹‘ǤŠ‡

ƒŽ‹‰ƒ–…‡ŽŽ•…ƒˆ‘”ƒ••‡•ȋ•‘Ž‹†–—‘”•Ȍ‘”„‡†‹•’‡”•‡†ƒ•‹•–Š‡…ƒ•‡™‹–Š

…ƒ…‡”• ‘ˆ –Š‡ Š‡ƒ–‘’‘‹‡–‹… ƒ† Ž›’Š‘‹† –‹••—‡•Ǥ Šƒ– †‹ˆˆ‡”‡–‹ƒ–‡• ƒ

15

ƒŽ‹‰ƒ–Ž‡•‹‘ˆ”‘ƒ„‡‹‰‘‡‹•‹–•ƒ„‹Ž‹–›–‘‹˜ƒ†‡•—””‘—†‹‰–‹••—‡•

ƒ†‡–ƒ•–ƒ•‹œ‡ǤʹͲͲͲƒƒŠƒƒ†‡‹„‡”‰’—„Ž‹•Š‡†–Š‡‹”•‡‹ƒŽƒ”–‹…Ž‡

DzŠ‡ ƒŽŽƒ”• ‘ˆ ƒ…‡”dz ‹ ™Š‹…Š –Š‡› ƒ”‰—‡ –Šƒ– –Š‡ †‹ˆˆ‡”‡…‡ „‡–™‡‡

‘”ƒŽ …‡ŽŽ• ƒ† …ƒ…‡” …‡ŽŽ• …ƒ „‡ ‡š’Žƒ‹‡† „› •‹š —†‡”Ž›‹‰ ’”‹…‹’Ž‡•

ȋƒƒŠƒƬ‡‹„‡”‰ǡʹͲͲͲȌǤ ‘—”‘”‡’”‹…‹’Ž‡•‘”–”ƒ‹–•™‡”‡ƒ††‡†–‘–Š‹•

Ž‹•–‹ʹͲͳͳȋƒƒŠƒƬ‡‹„‡”‰ǡʹͲͳͳȌǤŠ‡–‡ŠƒŽŽƒ”•‘ˆ…ƒ…‡”ƒ”‡Ž‹•–‡†

‹Box 1Ǥ

Š‡•‡ ŠƒŽŽƒ”• Šƒ˜‡ „‡‡ ™‹†‡Ž› ƒ……‡’–‡† „› –Š‡ •…‹‡–‹ˆ‹… …‘—‹–›ǡ

Š‘™‡˜‡”ǡƒ‡Ž›‘–‘ƒ†‘‡•…Š‡‹Šƒ˜‡…”‹–‹…‹œ‡†–Š‹•…‡ŽŽǦ„ƒ•‡†Dz•‘ƒ–‹…

—–ƒ–‹‘ –Š‡‘”›dzǡ …Žƒ‹‹‰ ‹•–‡ƒ† –Šƒ– …ƒ…‡” ‹• ƒ –‹••—‡Ǧ„ƒ•‡† †‹•‡ƒ•‡

ȋ‘‡•…Š‡‹ Ƭ ‘–‘ǡ ʹͲͳͺǢ ‘–‘ Ƭ ‘‡•…Š‡‹ǡ ʹͲͳͳȌǤ Š‡‹” ƒŽ–‡”ƒ–‹˜‡

Dz–‹••—‡‘”‰ƒ‹œƒ–‹‘ˆ‹‡Ž†–Š‡‘”›dz‹•„ƒ•‡†‘–Š‡’”‡‹•‡–Šƒ–’”‘Ž‹ˆ‡”ƒ–‹‘ƒ†

Figure 1. Somatic versus germline mutations. Somatic mutations occur after conception throughout an individual’s lifetime. The progenitors of the affected cell all carry the mutation. By definition, a somatic mutation does not affect the germ cells, and is thus not passed onto the offspring. Germline mutations occur in the germ cells, which develop into sperm and ova. If one of these germ cells forms a zygote, the mutation will be present in every cell of the developing offspring, since they are all progenitors of the mutated germ cell. Adapted from Dizon and Monk 2017.

16

‘–‹Ž‹–› ƒ”‡ –Š‡ †‡ˆƒ—Ž– •–ƒ–‡ ‘ˆ ƒŽŽ …‡ŽŽ•ǡ ƒ† –Šƒ– …ƒ”…‹‘‰‡‡•‹• ‹• †—‡ –‘

ƒŽ–‡”ƒ–‹‘•‹–Š‡‹–‡”ƒ…–‹‘„‡–™‡‡…‡ŽŽ•ƒ†–Š‡‹”‹…”‘‡˜‹”‘‡–Ǥ

1.1.2 A disease of the genome

ƒ…‡”‹•ƒ‰‡‡–‹…†‹•‡ƒ•‡ƒ†

•–‡• ˆ”‘ –Š‡ •‘ƒ–‹…

ƒ……——Žƒ–‹‘ ‘ˆ ‰‡‡–‹…

ƒŽ–‡”ƒ–‹‘•‹•‘…ƒŽŽ‡††”‹˜‡”

‰‡‡• ƒ† –Š‡‹” ”‡‰—Žƒ–‘”›

”‡‰‹‘• ȋ‘‰‡Ž•–‡‹ ‡– ƒŽǤǡ ʹͲͳ͵ȌǤ —Ž–‹’Ž‡ ƒŽ–‡”ƒ–‹‘• ‹

–Š‡•‡ƒ”‡—•—ƒŽŽ›”‡“—‹”‡†ˆ‘”

…ƒ…‡” –‘ ‡‡”‰‡ǣ ƒ –›’‹…ƒŽ

–—‘” …‘–ƒ‹• –™‘ –‘ ‡‹‰Š–

†”‹˜‡”—–ƒ–‹‘•–Šƒ–†‡˜‡Ž‘’

‘˜‡” –Š‡ …‘—”•‡ ‘ˆ ʹͲ –‘ ͵Ͳ

›‡ƒ”•ǡƒ……‘”†‹‰–‘‘‰‡Ž•–‡‹

ƒ† …‘™‘”‡”•Ǥ —‘”• ƒŽ•‘

…‘–ƒ‹ ’ƒ••‡‰‡” —–ƒ–‹‘•

–Šƒ– Šƒ˜‡ ‘ ‡ˆˆ‡…– ‘ –Š‡

‡‘’Žƒ•–‹…’”‘…‡••ǡ•‘–Šƒ–ƒƒ˜‡”ƒ‰‡‘ˆ͵͵Ǧ͸͸‰‡‡•ƒ”‡ƒŽ–‡”‡†‹ƒ™ƒ›–Šƒ–

ƒˆˆ‡…–• –Š‡‹” ’”‘–‡‹ ’”‘†—…–Ǥ ‘™‡˜‡”ǡ –Š‡ —–ƒ–‹‘ ˆ”‡“—‡…› ˜ƒ”‹‡• ‰”‡ƒ–Ž›

„‡–™‡‡…ƒ…‡”–›’‡•ƒ†‹†‹˜‹†—ƒŽ•ȋƒ™”‡…‡‡–ƒŽǤǡʹͲͳ͵ȌǤ‡†‹ƒ–”‹……ƒ…‡”•

–‡† –‘ Šƒ˜‡ Ž‘™ —–ƒ–‹‘ ˆ”‡“—‡…‹‡• ȋ„‡Ž‘™ ͲǤͳȀ‡‰ƒ„ƒ•‡Ȍǡ ™Š‡”‡ƒ• –Š‡

—–ƒ–‹‘ƒŽŽ‘ƒ†•‘ˆ‡Žƒ‘ƒƒ†Ž—‰…ƒ…‡”ƒ”‡ƒ‘‰–Š‡Š‹‰Š‡•–ȋ‘”‡–Šƒ

ͳͲͲȀ‡‰ƒ„ƒ•‡Ȍǡ”‡ˆŽ‡…–‹‰–Š‡‹˜‘Ž˜‡‡–‘ˆ—–ƒ‰‡•ȋ…‹‰ƒ”‡––‡•‘‡‹Ž—‰

…ƒ…‡”‘”—Ž–”ƒ˜‹‘Ž‡–Ž‹‰Š–‹‡Žƒ‘ƒȌǤ‹‰Š—–ƒ–‹‘ˆ”‡“—‡…‹‡•…ƒƒŽ•‘„‡

ˆ‘—†‹–—‘”•™‹–Š†‡ˆ‡…–‹˜‡”‡’ƒ‹”‘””‡’Ž‹…ƒ–‹‘‡…Šƒ‹••ǡ‡Ǥ‰Ǥ›…Š

•›†”‘‡ –—‘”• •Š‘™ ‹•–ƒ„‹Ž‹–› ‘ˆ •Š‘”– –ƒ†‡ ”‡’‡ƒ– •‡“—‡…‡•

ȋ‹…”‘•ƒ–‡ŽŽ‹–‡•Ȍ †—‡ –‘ †ƒƒ‰‹‰ ˜ƒ”‹ƒ–• ‹ –Š‡ ‹•ƒ–…Š ”‡’ƒ‹” ‰‡‡•

ȋƒŽ–‘‡Ƭ‡Ž–‘¡‹ǡͳͻͻͶȌǤ ‹ƒŽŽ›ǡ†—‡–‘ƒŽƒ”‰‡”ƒ‘—–‘ˆ”‡’Ž‹…ƒ–‹‘

‡˜‡–•ǡ …‡ŽŽ –›’‡• ™‹–Š Š‹‰Š –—”‘˜‡” ”ƒ–‡• ƒ……——Žƒ–‡ —–ƒ–‹‘• ˆƒ•–‡” –Šƒ

•Ž‘™‡” †‹˜‹†‹‰ …‡ŽŽ•ǡ ƒ• –Š‡ ‡†‘‰‡‘—• —–ƒ–‹‘ ”ƒ–‡ ‘ˆ †‹ˆˆ‡”‡– …‡ŽŽ –›’‡•

•‡‡••–ƒ„Ž‡ȋ›…ŠǡʹͲͳͲȌǤ……‘”†‹‰Ž›ǡ–Š‡Ž‹ˆ‡–‹‡”‹•‘ˆ…ƒ…‡”‘ˆƒ•’‡…‹ˆ‹…

–‹••—‡ ‹• …‘””‡Žƒ–‡† ™‹–Š –Š‡ ”ƒ–‡ ‘ˆ •–‡ …‡ŽŽ †‹˜‹•‹‘• ‘ˆ –Šƒ– –‹••—‡ –›’‡

ȋ‘ƒ•‡––‹Ƭ‘‰‡Ž•–‡‹ǡʹͲͳͷȌǤ

”‹˜‡”‰‡‡•…ƒ„‡…Žƒ••‹ˆ‹‡†ƒ•’”‘–‘Ǧ‘…‘‰‡‡•ƒ†–—‘”Ǧ•—’’”‡••‘”•Ǥ”‘–‘Ǧ

‘…‘‰‡‡•ƒ”‡‰‡‡•–Šƒ–™Š‡—–ƒ–‡†…‘ˆ‡”ƒ‰”‘™–Šƒ†˜ƒ–ƒ‰‡–‘–Š‡…‡ŽŽ„›

•–‹—Žƒ–‹‰ …‡ŽŽ ’”‘Ž‹ˆ‡”ƒ–‹‘ ‘” ’”‡˜‡–‹‰ ƒ’‘’–‘•‹• ȋ‘‰‡Ž•–‡‹ Ƭ ‹œŽ‡”ǡ Box 1. The ten hallmarks of cancer

ƒ Sustaining proliferative signaling

ƒ Evading growth suppressors

ƒ Resisting cell death

ƒ Enabling replicative immortality

ƒ Inducing angiogenesis

ƒ Reprogramming cellular metabolism

ƒ Avoiding immune destruction

ƒ Activating invasion and metastasis

ƒ Genomic instability and mutation

ƒ Tumor promoting inflammation

17

ʹͲͲͶȌǤ ’”‘–‘Ǧ‘…‘‰‡‡ ƒ› ™Š‡ —–ƒ–‡† „‡…‘‡ ƒ ‘…‘‰‡‡Ǥ —–ƒ–‹‘•

–Šƒ–…”‡ƒ–‡‘…‘‰‡‡•ƒ”‡ƒ…–‹˜ƒ–‹‰—–ƒ–‹‘•–Šƒ–Šƒ˜‡ƒ‰ƒ‹Ǧ‘ˆǦˆ—…–‹‘‡ˆˆ‡…–

‘”…ƒ—•‡–Š‡’”‘–‡‹–‘„‡‘˜‡”‡š’”‡••‡†ǤŠ‡›ƒ”‡—•—ƒŽŽ›†‘‹ƒ–‹–Š‡•‡•‡

–Šƒ–‘Ž›‘‡ƒŽŽ‡Ž‡‡‡†•–‘„‡ƒŽ–‡”‡†ˆ‘”ƒ‡ˆˆ‡…–Ǥ–—‘”Ǧ•—’’”‡••‘”‰‡‡

ȋȌǡ ‘ –Š‡ ‘–Š‡” Šƒ†ǡ Šƒ• ƒ ‰”‘™–Š ‹Š‹„‹–‘”› ‘” …‡ŽŽ †‡ƒ–Š ’”‘‘–‹‰

ˆ—…–‹‘Ǥ”‹˜‡”—–ƒ–‹‘•‹•ƒ”‡‹ƒ…–‹˜ƒ–‹‰ƒ†–Š‡‡ˆˆ‡…–‘ˆ–‡”‡…‡••‹˜‡ǡ

‹‘–Š‡”™‘”†•ǡ„‘–ŠƒŽŽ‡Ž‡•‡‡†–‘„‡‹ƒ…–‹˜ƒ–‡†ǤŠ‡”‡ƒ”‡‡š…‡’–‹‘•–‘–Š‹•ǡ

Š‘™‡˜‡”ǤTP53—–ƒ–‹‘•ˆ‘”‡šƒ’Ž‡…ƒ„‡†‘‹ƒ–‡‰ƒ–‹˜‡ǡ‹™Š‹…Š…ƒ•‡

–Š‡’”‘–‡‹’”‘†—…–‘ˆ–Š‡—–ƒ–‡†ƒŽŽ‡Ž‡‹Š‹„‹–•–Š‡ˆ—…–‹‘‘ˆ–Š‡™‹Ž†Ǧ–›’‡

’”‘–‡‹ȋ‹Ž‡”Ƭ‡†…ƒŽˆǡͳͻͻͳȌǤŽ•‘ǡ•‘‡ˆ—…–‹‘•ƒ”‡•‡•‹–‹˜‡–‘‰‡‡

†‘•ƒ‰‡ǡ ƒ† CDKN1B ™ƒ• –Š‡ ˆ‹”•– –—‘”Ǧ•—’’”‡••‘” •Š‘™ –‘ „‡

Šƒ’Ž‘‹•—ˆˆ‹…‹‡–ȋ ‡”‘‡–ƒŽǤǡͳͻͻͺȌǤŠ‡ˆ—…–‹‘•‘ˆ•ˆƒŽŽ‹–‘ƒ™‹†‡”ƒ‰‡

‘ˆ …ƒ–‡‰‘”‹‡•ǡ ƒ† –Š‡› ƒ”‡ ˆ—”–Š‡” …Žƒ••‹ˆ‹‡† ‹–‘ ‰ƒ–‡‡‡’‡”•ǡ …ƒ”‡–ƒ‡”• ƒ†

Žƒ†•…ƒ’‡”• ȋ‹œŽ‡” Ƭ ‘‰‡Ž•–‡‹ǡ ͳͻͻ͹Ǣ ‹œŽ‡” Ƭ ‘‰‡Ž•–‡‹ǡ ͳͻͻͺȌǤ

ƒ–‡‡‡’‡”• ƒ”‡ †‹”‡…–Ž› ‰”‘™–Š ‹Š‹„‹–‘”› ‘” ƒ’‘’–‘•‹• ‹†—…‹‰ǡ ™Š‹Ž‡

…ƒ”‡–ƒ‡”• ƒ”‡ ‡••‡–‹ƒŽ ‹ ƒ‹–ƒ‹‹‰ ‰‡‘‹… •–ƒ„‹Ž‹–›Ǥ  ‡šƒ’Ž‡ ‘ˆ

…ƒ”‡–ƒ‡”• ƒ”‡ –Š‡ ”‡’ƒ‹” ‰‡‡•Ǥ ‘’”‘‹•‡† ”‡’ƒ‹” Ž‡ƒ†• –‘

ƒ……——Žƒ–‹‘‘ˆ—–ƒ–‹‘•Ǥ‘‡‘ˆ–Š‡•‡™‹ŽŽ„›…Šƒ…‡‘……—”‹‘–Š‡”‹†•‘ˆ

• ƒ• ™‡ŽŽ ƒ• ’”‘–‘Ǧ‘…‘‰‡‡•ǡ –Š—• ’”‘‘–‹‰ –—‘”‹‰‡‡•‹•Ǥ ƒ†•…ƒ’‡”•

ˆƒ…‹Ž‹–ƒ–‡ –Š‡ ‰”‘™–Š ‘ˆ ‡‘’Žƒ•• „› ‡•–ƒ„Ž‹•Š‹‰ ƒ ‹…”‘‡˜‹”‘‡– –Šƒ–

ˆƒ˜‘”•—”‡‰—Žƒ–‡†…‡ŽŽ’”‘Ž‹ˆ‡”ƒ–‹‘Ǥ

‹ˆˆ‡”‡–‹†•‘ˆ—–ƒ–‹‘•ƒ”‡–›’‹…ƒŽˆ‘”†”‹˜‡”‰‡‡•†‡’‡†‹‰‘‹ˆ–Š‡›ƒ”‡

’”‘–‘Ǧ‘…‘‰‡‡•‘”•Ǥ—–ƒ–‹‘•–Šƒ–…”‡ƒ–‡‘…‘‰‡‡•ƒ”‡—•—ƒŽŽ›Ž‘…ƒŽ‹œ‡†

‹••‡•‡—–ƒ–‹‘•‹•‘…ƒŽŽ‡†Š‘–Ǧ•’‘–•‹…ƒ–ƒŽ›–‹…†‘ƒ‹•ǡ…Šƒ‰‡•‹–Š‡

…‘’›—„‡”‘ˆ–Š‡‰‡‡ǡ‘””‡ƒ””ƒ‰‡‡–•™Š‡”‡–Š‡’”‘–‘Ǧ‘…‘‰‡‡‹•’—–

—†‡”–Š‡…‘–”‘Ž‘ˆƒ‘”‡ƒ…–‹˜‡’”‘‘–‡”ȋ”‘…‡ǡʹͲͲͺȌǤ••‡‡†–‘„‡

‹ƒ…–‹˜ƒ–‡†ǡ –Š‡› ƒ”‡ ‘”‡ …‘‘Ž› –”—…ƒ–‡† „› ƒ ‘•‡•‡ ‘” ˆ”ƒ‡•Š‹ˆ–

—–ƒ–‹‘ǡƒ†Ž‡••ˆ”‡“—‡–Ž›Šƒ˜‡Š‘–Ǧ•’‘–•ȋ‹—‡–ƒŽǤǡʹͲͳͳȌǤƒ”‰‡†‡Ž‡–‹‘•

‡…‘’ƒ••‹‰–Š‡™Š‘Ž‡‰‡‡‘”’ƒ”–•‘ˆ‹–ƒ”‡ƒŽ•‘…‘‘ǡƒ†‘ˆ–‡…‘•–‹–—–‡

–Š‡•‡…‘†Š‹–ǡƒ’Š‡‘‡‘…ƒŽŽ‡†Ž‘••‘ˆŠ‡–‡”‘œ›‰‘•‹–›ȋȌǤ•…ƒƒŽ•‘

„‡ •‹Ž‡…‡† „› ‡’‹‰‡‡–‹… ‡…Šƒ‹•• •—…Š ƒ• ’ ‹•Žƒ† ’”‘‘–‡”

Š›’‡”‡–Š›Žƒ–‹‘ȋƒ›Ž‹Ƭ‘‡•ǡʹͲͳ͸ȌǤ”‘‘–‡”•‘ˆ–Š‹•‹†ƒ”‡—•—ƒŽŽ›‘–

‡–Š›Žƒ–‡†‹ …‘–”ƒ•– –‘ ͺͲΨ ‘ˆ’ •‹–‡• ‡Ž•‡™Š‡”‡ ‹ –Š‡ ‰‡‘‡Ǥ  …ƒ…‡”ǡ –Š‡ ƒ˜‡”ƒ‰‡ ’ ‡–Š›Žƒ–‹‘ Ž‡˜‡Ž• ƒ…–—ƒŽŽ› •‹ –‘ ͶͲΨȂ͸ͲΨǤ Š‹•

‰‡‡”ƒŽ Š›’‘‡–Š›Žƒ–‹‘ ƒ› …‘–”‹„—–‡ –‘ ‰‡‘‹… ‹•–ƒ„‹Ž‹–› ƒ†

‘˜‡”‡š’”‡••‹‘‘ˆ’”‘–‘Ǧ‘…‘‰‡‡•ȋƒ›Ž‹Ƭ‘‡•ǡʹͲͳ͸Ǣ†‡‡–ƒŽǤǡʹͲͲ͵ȌǤ

‘‡ —–ƒ–‹‘• ƒ”‡ —’”‘˜‘‡† ‡””‘”• ‘ˆ ”‡’Ž‹…ƒ–‹‘ǡ ƒ† †‘ ‘– ‡…‡••ƒ”‹Ž›

‡‡† ƒ –”‹‰‰‡”ǡ ƒ• ”‡’Ž‹…ƒ–‹‘ ‹• ’”‘‡ –‘ ‡””‘”• ƒ† –Š‡ ”‡’Ž‹…ƒ–‹‘

ƒ…Š‹‡”› ‡˜‡ ™Š‡ ˆ—ŽŽ› ˆ—…–‹‘ƒŽ ‹• ‹’‡”ˆ‡…– ȋ‘ƒ•‡––‹ Ƭ ‘‰‡Ž•–‡‹ǡ ʹͲͳͷȌǤ ‘™‡˜‡”ǡ •‡˜‡”ƒŽ ƒ–—”ƒŽǡ ’Š›•‹…ƒŽǡ ƒ† …Š‡‹…ƒŽ ƒ‰‡–•ǡ ‡Ǥ‰Ǥ ˜‹”ƒŽ

‹ˆ‡…–‹‘•ǡ—Ž–”ƒ˜‹‘Ž‡–Ž‹‰Š–ǡ‘”…‹‰ƒ”‡––‡•‘‡ǡŠƒ˜‡„‡‡•Š‘™–‘„‡—–ƒ‰‡‹…

18

‘” …ƒ”…‹‘‰‡‹… ƒ† –Š—• …‘•–‹–—–‡ ƒ ”‹• ˆƒ…–‘” ˆ‘” …ƒ…‡”Ǥ ƒ› ‘™

…ƒ”…‹‘‰‡• Šƒ˜‡ ƒ •’‡…‹ˆ‹… •‘ƒ–‹… —–ƒ–‹‘ ’ƒ––‡”ǡ ƒ —–ƒ–‹‘ƒŽ •‹‰ƒ–—”‡ǡ

”‡ˆŽ‡…–‹‰ –Š‡ ‘Ž‡…—Žƒ” ‡…Šƒ‹• „› ™Š‹…Š –Š‡ ƒ‰‡– …ƒ—•‡• †ƒƒ‰‡

ȋŽ‡šƒ†”‘˜‡–ƒŽǤǡʹͲͳ͵Ǣ‡”†—…ƒ‡–ƒŽǤǡʹͲͳͺǢƒ‘‡…‡–ƒŽǤǡʹͲͳͻȌǤ’‡…‹ˆ‹…

•‹‰ƒ–—”‡•…ƒƒŽ•‘„‡ˆ‘—†ˆ‘”—–ƒ–‡†‰‡‡•‹˜‘Ž˜‡†‹ƒ‹–‡ƒ…‡ ȋƒ••‡–ƒŽǤǡʹͲͳ͸ȌǤ

1.1.3 Genetic cancer susceptibility

 ‹†‹˜‹†—ƒŽ …ƒ ‹Š‡”‹– ƒ —–ƒ–‡† ‰‡‡ǡ ™Š‹…Š ‹…”‡ƒ•‡• Š‹• ‘” Š‡” ”‹• ˆ‘”

…ƒ…‡”ǤŽƒ••‹…Š‡”‡†‹–ƒ”›…ƒ…‡”•ƒ”‡—•—ƒŽŽ›‘‘‰‡‹…†‹•‡ƒ•‡•…ƒ—•‡†„›”ƒ”‡

Š‹‰ŠǦ”‹• —–ƒ–‹‘•ǡ ƒ† –Š—• ˆ‘ŽŽ‘™ •‹’Ž‡ ‡†‡Ž‹ƒ ‹Š‡”‹–ƒ…‡ ’ƒ––‡”•

ȋƒ‰›‡–ƒŽǤǡʹͲͲͶȌǤ”‡†‹•’‘•‹‰—–ƒ–‹‘•ƒ”‡‘ˆ–‡ˆ‘—†‹•–Šƒ–”‡“—‹”‡

ƒDz•‡…‘†Š‹–dzȋ—†•‘ǡͳͻ͹ͳȌǤ•‘‡Šƒ”ˆ—Ž—–ƒ–‹‘‹•ƒŽ”‡ƒ†›’”‡•‡–‹

‡˜‡”›…‡ŽŽ‘ˆ–Š‡„‘†›ǡ–Š‡–Š”‡•Š‘Ž†‘ˆƒ…“—‹”‹‰…ƒ…‡”‹••‹‰‹ˆ‹…ƒ–Ž›Ž‘™‡”‡†Ǥ

ŽŽ•—•…‡’–‹„‹Ž‹–›‰‡‡•ƒ”‡‘–ǡŠ‘™‡˜‡”ǡ…Žƒ••‹…•ǡ‘”†‘ƒŽŽ‹’‘•‡ƒ•–”‘‰

‡ˆˆ‡…–ǣ ˆƒ‹Ž‹ƒŽ …Ž—•–‡”‹‰ ‘ˆ …ƒ…‡” ‹• …‘‘ǡ ƒ† …ƒ „‡ ‡š’Žƒ‹‡† „› ƒ …‘„‹ƒ–‹‘‘ˆŽ‘™–‘‘†‡”ƒ–‡”‹•—–ƒ–‹‘•ȋ–Šƒ–ƒ›„—–‡‡†‘–„‡ˆ‘—†

‹…Žƒ••‹…†”‹˜‡”‰‡‡•Ȍ…‘„‹‡†™‹–ŠŽ‹ˆ‡•–›Ž‡ˆƒ…–‘”•ƒ†‡š’‘•—”‡•ȋƒ‰›‡–

ƒŽǤǡʹͲͲͶǢ‘Ž†‰ƒ”‡–ƒŽǤǡͳͻͻͶȌǤ

‡”Ž‹‡—–ƒ–‹‘•ƒ”‡ƒŽ•‘…ƒŽŽ‡†˜ƒ”‹ƒ–•ƒ†’‘Ž›‘”’Š‹••Ǥ—””‡–—ƒ

‡‘‡ƒ”‹ƒ–‹‘‘…‹‡–›ȋ‘”Ȍ”‡…‘‡†ƒ–‹‘•ƒ”‡–Šƒ––Š‡–‡”˜ƒ”‹ƒ–

„‡ —•‡†ǡ ‘– —–ƒ–‹‘ ‘” ’‘Ž›‘”’Š‹•ǡ ƒ• –Š‡ –™‘ Žƒ––‡” „‘–Š Šƒ˜‡ ˜ƒ”›‹‰

†‡ˆ‹‹–‹‘•ȋ†‡—‡‡–ƒŽǤǡʹͲͳ͸ȌǤŠ‹•‹•„‡…ƒ—•‡‹•‘‡…ƒ•‡•ǡDz—–ƒ–‹‘dz

”‡ˆ‡”•–‘”ƒ”‹–›ǡ™Š‡”‡ƒ•‹•‘‡…ƒ•‡•‹–‹•‡“—‹˜ƒŽ‡––‘ƒ’ƒ–Š‘‰‡‹…˜ƒ”‹ƒ–Ǥ

ƒ•‹‹Žƒ”ƒ‡”Dz’‘Ž›‘”’Š‹•dz—•—ƒŽŽ›”‡ˆ‡”•–‘ƒ‘”‡…‘‘˜ƒ”‹ƒ–ǡ„—–

‹•‘‡…ƒ•‡•Šƒ•–Š‡‡ƒ‹‰‘ˆƒ‘Ǧ’ƒ–Š‘‰‡‹…˜ƒ”‹ƒ–Ǥ–‹•–”—‡Š‘™‡˜‡”ǡ

–Šƒ– †—‡–‘ ƒ–—”ƒŽ •‡Ž‡…–‹‘ ƒ›†‹•‡ƒ•‡Ǧ…ƒ—•‹‰ ˜ƒ”‹ƒ–• ƒ”‡ ”ƒ”‡ǡ™Š‡”‡ƒ•

…‘‘˜ƒ”‹ƒ–•”ƒ”‡Ž›Šƒ˜‡ƒ•–”‘‰’ƒ–Š‘‰‡‹…‡ˆˆ‡…–ȋƒ‘Ž‹‘‡–ƒŽǤǡʹͲͲͻȌǤ

Š‡”‡Žƒ–‹‘•Š‹’„‡–™‡‡‡ˆˆ‡…–•‹œ‡ƒ†ƒŽŽ‡Ž‡ˆ”‡“—‡…›‘ˆ’ƒ–Š‘‰‡‹…˜ƒ”‹ƒ–•

‹•‹ŽŽ—•–”ƒ–‡†‹Figure 2Ǥ

19

‡”‹–ƒ„‹Ž‹–›”‡ˆ‡”•–‘–Š‡”‡Žƒ–‹˜‡…‘–”‹„—–‹‘‘ˆ‰‡‡–‹…˜ƒ”‹ƒ–‹‘–‘‘„•‡”˜‡†

†‹ˆˆ‡”‡…‡•‹ƒ’Š‡‘–›’‹…–”ƒ‹–ǡ‡Ǥ‰Ǥ†‹•‡ƒ•‡”‹•ǡƒ†…ƒ„‡ˆ—”–Š‡”†‡ˆ‹‡†ƒ•

‡‹–Š‡” „”‘ƒ† •‡•‡ ‘” ƒ””‘™ •‡•‡ ȋ‹••…Š‡” ‡– ƒŽǤǡ ʹͲͲͺȌǤ ”‘ƒ† •‡•‡

Š‡”‹–ƒ„‹Ž‹–› ‹• –Š‡ ”ƒ–‹‘ ‘ˆ ƒ††‹–‹˜‡ ‰‡‡–‹… ˜ƒ”‹ƒ…‡ ƒ† ‘Ǧƒ††‹–‹˜‡ ‰‡‡–‹…

‹ˆŽ—‡…‡•ȋ•—…Šƒ•†‘‹ƒ…‡ƒ†‡’‹•–ƒ•‹•Ȍ†‹˜‹†‡†„›–Š‡‘˜‡”ƒŽŽ’Š‡‘–›’‹…

˜ƒ”‹ƒ…‡ǡƒ””‘™•‡•‡”‡ˆ‡”•‘Ž›–‘–Š‡ƒ††‹–‹˜‡‰‡‡–‹…˜ƒ”‹ƒ…‡Ǥ ‘”–”ƒ‹–•–Šƒ–

ƒ”‡‘–…‘–‹—‘—•„—–†‹…Š‘–‘‘—•ȋDz‘Ȁ‘ˆˆdzȌ•—…Šƒ•ƒ›†‹•‡ƒ•‡•ǡƒŽ‹ƒ„‹Ž‹–›

–Š”‡•Š‘Ž† ‘†‡Ž ‹• ‡’Ž‘›‡† ȋ‹––‡ ‡– ƒŽǤǡ ʹͲͳͶȌǤ ƒ› …ƒ…‡”• Šƒ˜‡ Š‹‰Š

Š‡”‹–ƒ„‹Ž‹–›‡•–‹ƒ–‡•ȋ—……‹‡–ƒŽǤǡʹͲͳ͸ȌǤ

™‹ǡ ƒ†‘’–‹‘ǡ ƒ† ˆƒ‹Ž› •–—†‹‡• Šƒ˜‡ –”ƒ†‹–‹‘ƒŽŽ› „‡‡ —•‡† –‘ ’ƒ”–‹–‹‘

‰‡‡–‹…ƒ†‡˜‹”‘‡–ƒŽ‡ˆˆ‡…–•ǡ™Š‡”‡ƒ•–Š‡ˆ‘…—•Šƒ•‘™•Š‹ˆ–‡†–‘‰‡‘‡Ǧ

™‹†‡ƒ••‘…‹ƒ–‹‘•–—†‹‡•ȋȌƒ†ƒ••‘…‹ƒ–‡†˜ƒ”‹ƒ–•ȋƒ’•‘‡–ƒŽǤǡʹͲͳͷȌǤ

 ǡ –Š‡ ‰‡‘–›’‡• ȋ”‡‰ƒ”†‹‰ …‘‘ •‹‰Ž‡ —…Ž‡‘–‹†‡ ˜ƒ”‹ƒ–‹‘Ȍ ‘ˆ

’‡‘’Ž‡™‹–Šƒ…‡”–ƒ‹–”ƒ‹–ƒ”‡…‘’ƒ”‡†–‘’‡‘’Ž‡™‹–Š‘—–‹–ǡƒ†–Š‡”‡•—Ž–‹•

—•—ƒŽŽ›‘‡‘”ƒ›ƒ••‘…‹ƒ–‹‘•‹‰ƒŽ•ˆ‘”™Š‹…Š‡ˆˆ‡…–•‹œ‡•ƒ†•‹‰‹ˆ‹…ƒ…‡ …ƒ„‡…ƒŽ…—Žƒ–‡†ȋƒ‡–ƒŽǤǡʹͲͳͻȌǤ

Figure 2. The relationship between effect size and allele frequency of pathogenic variants. The genetic basis of Mendelian syndromes occupying the upper left corner of the diagram have been fairly well uncovered by linkage studies, and lately there has been success in discovering common variants of low effect by GWAS (lower right). Common variants of high effect are usually removed from the gene pool by natural selection, whereas rare variants of low effect are currently extremely hard to detect. Low frequency variants of intermediate effect are not well studied and may explain a part of missing heritability. Adapted from Manolio et al., 2009.

20

‘‘…ƒ…‡”•Šƒ˜‡„‡‡‡š–‡•‹˜‡Ž›•–—†‹‡†„›ȋ—†‡–ƒŽǤǡʹͲͳ͹Ǣƒ

‡– ƒŽǤǡ ʹͲͳͻȌǤ Š‡ Žƒ”‰‡” –Š‡ •ƒ’Ž‡ •‹œ‡• ‹ –Š‡•‡ •–—†‹‡• „‡…‘‡ǡ –Š‡ ‘”‡

‰‡‡–‹… ˜ƒ”‹ƒ–• –Šƒ– ƒ”‡ •‘‡Š‘™ ƒ••‘…‹ƒ–‡† ™‹–Š –Š‡ ƒŽ‹‰ƒ…› –—” —’ǡ

Š‘™‡˜‡”ǡ–Š‡‡ˆˆ‡…–‘ˆƒ•‹‰Ž‡—…Ž‡‘–‹†‡’‘Ž›‘”’Š‹•ȋȌ‹•—•—ƒŽŽ›‹‹ƒŽ

ȋ‘›Ž‡‡–ƒŽǤǡʹͲͳ͹ȌǤ‘›Ž‡ƒ†…‘™‘”‡”•’”‘’‘•‡–Šƒ–†—‡–‘–Š‡…‘’Ž‡š‹–›‘ˆ

„‹‘…Š‡‹…ƒŽ‡–™‘”•ǡ‹–‹‰Š–‡˜‡„‡’‘••‹„Ž‡–Šƒ–‡˜‡”›”‡‰‹‘‘ˆ–Šƒ–‹•

ƒ…–‹˜‡‹ƒ•’‡…‹ˆ‹…–‹••—‡‹••‘‡Š‘™Ž‹‡†–‘‹–•ƒŽˆ—…–‹‘ǤŠ‹–•ƒ”‡

‘ˆ–‡ˆ‘—†‹‘Ǧ…‘†‹‰”‡‰‹‘•ǡƒ†–Š‡ƒ—–Š‘”•…‘–‹—‡–Šƒ–‘•–‘ˆ–Š‡•‡

’”‘’ƒ„Ž›Šƒ˜‡‘†‹”‡…–”‡Ž‡˜ƒ…‡–‘–Š‡†‹•‡ƒ•‡—†‡”•–—†›„—–ƒ”‡‘”‡Ž‹‡Ž›

‹˜‘Ž˜‡†‹–Š‡”‡‰—Žƒ–‹‘‘ˆƒ—…Š•ƒŽŽ‡”—„‡”‘ˆ…‘”‡‰‡‡•™‹–Š†‹”‡…–

”‡Ž‡˜ƒ…‡Ǥ

—‡–‘ƒ–—”ƒŽ•‡Ž‡…–‹‘ǡ˜ƒ”‹ƒ–•‹…‘”‡‰‡‡•–Šƒ–†‹”‡…–Ž›…ƒ—•‡†‹•‘”†‡”•ƒ”‡

—•—ƒŽŽ› ”‡Žƒ–‹˜‡Ž› ”ƒ”‡ǡ ƒ† Šƒ• –”ƒ†‹–‹‘ƒŽŽ› …‘˜‡”‡† ‘Ž› …‘‘

˜ƒ”‹ƒ–•ȋ‘›Ž‡‡–ƒŽǤǡʹͲͳ͹ȌǤ……‘”†‹‰Ž›ǡ–Š‡‰‡‡–‹…˜ƒ”‹ƒ…‡‹…ƒ…‡””‹•–Šƒ–

…ƒ„‡‡š’Žƒ‹‡†„›‹•…—””‡–Ž›•ƒŽŽ‡”–Šƒ–Š‡‡•–‹ƒ–‡•†‡”‹˜‡†ˆ”‘

…Žƒ••‹…•–—†‹‡•ǡƒ†‹•…”‡’ƒ…›”‡ˆ‡””‡†–‘ƒ•‹••‹‰Š‡”‹–ƒ„‹Ž‹–›ȋƒ‘Ž‹‘‡–ƒŽǤǡ ʹͲͲͻȌǤ–Š‡”ˆƒ…–‘”•”‡•’‘•‹„Ž‡ˆ‘”–Š‹•‰ƒ’ƒ›‹˜‘Ž˜‡•–”—…–—”ƒŽ˜ƒ”‹ƒ–•–Šƒ–

ȋ™‹–Š –Š‡ ‡š…‡’–‹‘ ‘ˆ ƒŽŽ‡Ž‹… ‹„ƒŽƒ…‡Ȍ ƒ”‡ ’‘‘”Ž› †‡–‡…–‡† „› ƒ˜ƒ‹Žƒ„Ž‡

‰‡‘–›’‹‰ ƒ””ƒ›•ǡ †‘‹ƒ…‡ǡ ‡’‹•–ƒ•‹•ǡ ‰‡‘–›’‡Ǧ‡˜‹”‘‡– ‹–‡”ƒ…–‹‘•ǡ

ƒ† ‹ƒ†‡“—ƒ–‡ ƒ……‘—–‹‰ˆ‘”•Šƒ”‡†‡˜‹”‘‡– ƒ‘‰”‡Žƒ–‹˜‡•ȋ‡ƒ‹‰

–Šƒ–•‘‡‘ˆ–Š‡‘”‹‰‹ƒŽ‡•–‹ƒ–‡•…‘—Ž†„‡‡šƒ‰‰‡”ƒ–‡†Ȍȋג‡œǦ‘”–‡‰ƒ‘Ƭ

ƒ„ƒŽŽ‡”‘ǡʹͲͳͻȌǤ

1.2 The Finnish population – a well-studied genetic isolate ’‘’—Žƒ–‹‘ …ƒ „‡…‘‡ ‹•‘Žƒ–‡† ˆ‘” ˜ƒ”‹‘—• ”‡ƒ•‘•Ǥ Š‡•‡ ƒ”‡ ‘•– ‘ˆ–‡

‰‡‘‰”ƒ’Š‹…ƒŽǡ„—–…—Ž–—”ƒŽǡ”‡Ž‹‰‹‘—•ƒ†Ž‹‰—‹•–‹…†‹ˆˆ‡”‡…‡•Šƒ˜‡ƒŽ•‘’Žƒ›‡†ƒ

„‹‰’ƒ”–‹ƒ› …ƒ•‡•ȋ”…‘•Ǧ—”‰‘•Ƭ—‡‡ǡʹͲͲʹǢ‡Ž–‘‡‡–ƒŽǤǡͳͻͻͷȌǤ

‡‡–‹…ƒŽŽ›ǡ’‘’—Žƒ–‹‘‹•‘Žƒ–‡•ƒ”‡…Šƒ”ƒ…–‡”‹œ‡†„›”‡†—…‡†Š‡–‡”‘‰‡‡‹–›ƒ†

‡”‹…Š‡– ‘ˆ ‘–Š‡”™‹•‡ ”ƒ”‡ ˜ƒ”‹ƒ–‹‘ ȋ”…‘•Ǧ—”‰‘• Ƭ —‡‡ ʹͲͲʹǢ ƒ”ƒ

ʹͲͳͷȌǤŠ‹•‹•Žƒ”‰‡Ž›„‡…ƒ—•‡‹•‘Žƒ–‡•ƒ”‡•—„Œ‡…––‘–Š‡ˆ‘—†‡”‡ˆˆ‡…–ǡ™Š‹…Š

‘……—”•™Š‡ƒ•ƒŽŽ—„‡”‘ˆ‹†‹˜‹†—ƒŽ•ˆ”‘ƒŽƒ”‰‡”’‘’—Žƒ–‹‘‡•–ƒ„Ž‹•Š‡•

ƒ ‡™ ’‘’—Žƒ–‹‘ǣ ƒ …‘•‹†‡”ƒ„Ž‡ ’”‘’‘”–‹‘ ‘ˆ –Š‡ ‰‡‡–‹… †‹˜‡”•‹–› ‘ˆ –Š‡

‘”‹‰‹ƒŽ’‘’—Žƒ–‹‘™‹ŽŽ„‡Ž‘•–ǡƒ††—‡–‘”ƒ†‘•ƒ’Ž‹‰ǡƒ‰‡‘–›’‡–Šƒ–™ƒ•

‘–‹–Š‡ƒŒ‘”‹–›‹–Š‡‘”‹‰‹ƒŽ’‘’—Žƒ–‹‘‹‰Š–†‘‹ƒ–‡‹–Š‡‡™‘‡Ǥ

•ƒŽŽ’‘’—Žƒ–‹‘‹•ƒŽ•‘‘”‡‡š’‘•‡†–‘‰‡‡–‹…†”‹ˆ–ȋƒƒ”Ƭ†ƒ‹ʹͲͳ͹Ȍǡƒ†

‘”‡ Ž‹‡Ž› …‘•ƒ‰—‹‡‘—• ȋ”…‘•Ǧ—”‰‘• ƒ† —‡‡ ʹͲͲʹǢ ƒ”ƒ ʹͲͳͷȌǤ

‘’—Žƒ–‹‘„‘––Ž‡‡…•ǡ†—‡–‘•‘‡†‡‘‰”ƒ’Š‹……”‹•‹•ǡŠƒ˜‡–Š‡•ƒ‡‡ˆˆ‡…–‘

ƒ’‘’—Žƒ–‹‘ (‡Ž–‘‡‡–ƒŽǤǡͳͻͻͷǢƒ”ƒʹͲͳͷȌǤ

21 1.2.2 The Finnish disease heritage

Š‡’‘’—Žƒ–‹‘Š‹•–‘”›‘ˆ ‹Žƒ†Šƒ•Ž‡†–‘ƒ†‡…”‡ƒ•‡‹–Š‡‰‡‡–‹…†‹˜‡”•‹–›‘ˆ

–Š‡ ’‘’—Žƒ–‹‘ ƒ† ƒ†‡ ‹– ‘”‡ Š‘‘‰‡‘—• –Šƒ ‘•– ‘–Š‡” ’‘’—Žƒ–‹‘•ǡ

™Š‹…ŠŠƒ•…ƒ—•‡†ƒ‡”‹…Š‡–‹•‘‡Š‡”‹–ƒ„Ž‡†‹•‡ƒ•‡•ȋ¡¡”‹¡‹‡‡–ƒŽǤǡ ʹͲͳ͹ȌǤ  –Š‡ ‘–Š‡” Šƒ†ǡ •‘‡ ”ƒ”‡ †‹•‡ƒ•‡• ’”‡•‡– ™‘”Ž†™‹†‡ ȋ‡Ǥ‰Ǥ

’Š‡›Ž‡–‘—”‹ƒǡ ‰ƒŽƒ…–‘•‡‹ƒǡ ƒ’Ž‡ •›”—’ †‹•‡ƒ•‡ǡ ƒ† …›•–‹… ˆ‹„”‘•‹•Ȍ ƒ”‡

’”ƒ…–‹…ƒŽŽ› ‘‡š‹•–‡– ‹ ‹Žƒ† (†‡ Žƒ Šƒ’‡ŽŽ‡ǡ ͳͻͻ͵ȌǤ Š‡ ‹‹•Š †‹•‡ƒ•‡

Š‡”‹–ƒ‰‡ ”‡ˆ‡”• –‘ •‡˜‡”ƒŽ ”ƒ”‡ ‘‘‰‡‹… †‹•‡ƒ•‡•–Šƒ– ƒ”‡ ‘”‡ ’”‡˜ƒŽ‡– ‹

‹Žƒ†–Šƒ‹–Š‡”‡•–‘ˆ–Š‡™‘”Ž†ȋ‘”‹‘‡–ƒŽǤǡͳͻ͹͵ȌǤ—””‡–Ž›ǡ‹–…‘’”‹•‡•

͵͸†‹•‡ƒ•‡•ȋ¡¡”‹¡‹‡‡–ƒŽǤǡʹͲͳ͹Ǣ‘Ž˜‹‡–ƒŽǤǡʹͲͳ͵ȌǤŠ‡Š‘‘‰‡‡‘—•‰‡‡

’‘‘Ž–Šƒ–Šƒ•Ž‡†–‘–Š‡‡”‹…Š‡–‘ˆ–Š‡•‡†‹•‡ƒ•‡•Šƒ•ƒŽ•‘‡ƒ•‡†–Š‡†‹•…‘˜‡”›

‘ˆ †‹•‡ƒ•‡Ǧ…ƒ—•‹‰ ‰‡‡• ȋ‘•–Ž› –Š”‘—‰Š ’‘•‹–‹‘ƒŽ …Ž‘‹‰ ƒ† Ž‹ƒ‰‡

ƒƒŽ›•‹•Ȍǡƒ†–Š‡‘Ž‡…—Žƒ”„ƒ…‰”‘—†‘ˆ–Š‡•‡Šƒ•„‡‡‡ˆˆ‹…‹‡–Ž›•–—†‹‡†Ǥ

ˆƒ…–ǡ –Š‡ •–—†› ‘ˆ –Š‡ ‹‹•Š †‹•‡ƒ•‡ Š‡”‹–ƒ‰‡ ”‡’”‡•‡–• ‘‡ ‘ˆ –Š‡ ‘•–

•—……‡••ˆ—Ž ‡ˆˆ‘”–• ‹ ƒ’’‹‰ ‰‡‡–‹… †‹•‘”†‡”• ‹ ƒ ’‘’—Žƒ–‹‘ ‹•‘Žƒ–‡

ȋ”‹•–‹ƒ••‘‡–ƒŽǤǡʹͲͲͺȌǤ ‘”‘•–‘ˆ–Š‡†‹•‡ƒ•‡•–Š‡”‡‹•‘Ž›‘‡…ƒ—•ƒ–‹˜‡

ˆ‘—†‡”˜ƒ”‹ƒ–ǡ–‡”‡† ‹ƒŒ‘”ǡ™Š‹…Šƒ……‘—–•ˆ‘”‡ƒ”Ž›ƒŽŽ…ƒ•‡•Ȅ‹ˆƒ•‡…‘†

ˆ‘—†‡”—–ƒ–‹‘‹•’”‡•‡–‹–Š‡’‘’—Žƒ–‹‘ǡ‹–‹•”‡ˆ‡””‡†–‘ƒ• ‹‹‘”ȋ‘Ž˜‹

‡–ƒŽǤǡʹͲͳ͵ȌǤ–Ž‡ƒ•–‘‡…ƒ—•ƒ–‹˜‡—–ƒ–‹‘Šƒ•„‡‡ˆ‘—†ˆ‘”ƒŽŽ†‹•‡ƒ•‡•‘ˆ

–Š‡ ‹‹•Š †‹•‡ƒ•‡ Š‡”‹–ƒ‰‡ǡ–Š‡ Žƒ–‡•– †‹•…‘˜‡”›„‡‹‰ ƒ —–ƒ–‹‘ ‹ZNHIT3ǡ …ƒ—•‹‰ ’”‘‰”‡••‹˜‡ ‡…‡’ŠƒŽ‘’ƒ–Š› ™‹–Š ‡†‡ƒǡ Š›’•ƒ””Š›–Š‹ƒ ƒ† ‘’–‹…

ƒ–”‘’Š›ȋȌ•›†”‘‡ȋ––‘‡‡–ƒŽǤǡʹͲͳ͹ȌǤ

1.2.1 Finnish population history

”…Šƒ‡‘Ž‘‰‹…ƒŽ ‡˜‹†‡…‡ ‹†‹…ƒ–‡• Š—ƒ ’”‡•‡…‡ ‹ ‹Žƒ† •‹…‡ ͻͲͲͲ ȋƒ‹†‹•‡–ƒŽǤǡʹͲͳͺȌǤŠ‡ƒŒ‘”‹–›‘ˆ’”‡•‡–†ƒ› ‹•™‡”‡‘”‹‰‹ƒŽŽ›–Š‘—‰Š–

–‘‘”‹‰‹ƒ–‡ˆ”‘•ƒŽŽˆ‘—†‡”’‘’—Žƒ–‹‘•–Šƒ–‹‰”ƒ–‡†•‘‡ʹͲͲͲ›‡ƒ”•ƒ‰‘

ˆ”‘ƒƒ”‡ƒ‹–Š‡•‘—–Š–Šƒ–‹…Ž—†‡•’”‡•‡–†ƒ›•–‘‹ƒȋ†‡ŽƒŠƒ’‡ŽŽ‡ǡͳͻͻ͵ȌǤ

‘™‡˜‡”ǡ–Š‹•‘†‡Žˆ‹–•’‘‘”Ž›–Š‡†‹•–‹…–‰‡‡–‹…•–”—…–—”‡‘ˆ‘†‡” ‹•ǡ

™Š‘ ‡Ǥ‰Ǥ •Š‘™ ‹…”‡ƒ•‡† ƒŽŽ‡Ž‡ •Šƒ”‹‰ ™‹–Š ‘†‡” ƒ•– •‹ƒ ’‘’—Žƒ–‹‘•

ȋƒœƒ”‹†‹•‡–ƒŽǤǡʹͲͳͶȌǤŠ‡†—ƒŽ–Š‡‘”›‘ˆ–Š‡‹Šƒ„‹–ƒ–‹‘‘ˆ ‹Žƒ†ǡ•—’’‘”–‡†

„› ƒƒŽ›•‹• ‘ˆ …Š”‘‘•‘‡ Šƒ’Ž‘–›’‡•ǡ •—‰‰‡•–• ƒ‘–Š‡” ‡ƒ”Ž‹‡” ‹‰”ƒ–‘”›

™ƒ˜‡ ˆ”‘ –Š‡ ’”‘š‹‹–› ‘ˆ ƒ†‘‰ƒ ƒ‡ ƒ„‘—– ͶͲͲͲ ›‡ƒ”• ƒ‰‘ ȋ‹––Ž‡• ‡– ƒŽǤǡ ͳͻͻͺȌǤ‘†‡” ‹•Šƒ˜‡ƒ‹„‡”‹ƒ‰‡‡–‹……‘’‘‡–ǡ–Šƒ–„ƒ•‡†‘•–—†‹‡•

‘ƒ…‹‡–‰‡‘‡•ƒ””‹˜‡†‹–Š‡”‡‰‹‘ƒ–Ž‡ƒ•–͵ͷͲͲȋƒ‹†‹•‡–ƒŽǤǡʹͲͳͺȌǤ

‡•’‹–‡ ”‡’‡ƒ–‡† •ƒŽŽ ƒ††‹–‹‘•–‘ –Š‡ ‰‡‡ ’‘‘Žǡ –Š‡ ‹‹•Š ’‘’—Žƒ–‹‘ Šƒ•

‰”‘™Žƒ”‰‡Ž›‹‹•‘Žƒ–‹‘†—‡–‘‰‡‘‰”ƒ’Š‹…ƒŽƒ†‰‡‘’‘Ž‹–‹…ƒŽ”‡ƒ•‘•ǡƒ†–Š‹•

‹•‘Žƒ–‹‘™ƒ•ˆ—”–Š‡”‹–‡•‹ˆ‹‡†„›ƒ†‹•–‹…–Žƒ‰—ƒ‰‡ƒ†…—Ž–—”‡ȋ‡Ž–‘‡‡–

ƒŽǤǡ ͳͻͻͷȌǤ Š‡ ’‘’—Žƒ–‹‘ ˆŽ—…–—ƒ–‡†ǣ ˆƒ‹‡•ǡ ‡’‹†‡‹…•ǡ ƒ† ™ƒ”• …”‡ƒ–‡†

22

‰‡‡–‹…„‘––Ž‡‡…•ȋ¡¡”‹¡‹‡‡–ƒŽǤǡʹͲͳ͹ȌǤŠ‡‘•–‘–ƒ„Ž‡‘ˆ–Š‡•‡‘……—””‡†

†—”‹‰–Š‡‰”‡ƒ–ˆƒ‹‡‹ͳ͸ͻ͸Ǧͳ͸ͻͺȄ–Š‡ˆƒ‹‡ƒ†•—„•‡“—‡–‡’‹†‡‹…•

ƒ”‡‡•–‹ƒ–‡†–‘Šƒ˜‡‹ŽŽ‡†—’–‘‘‡–Š‹”†‘ˆ–Š‡ ‹‹•Š’‘’—Žƒ–‹‘ǡ–Š‡ƒ†‡

—’ ‘ˆ ƒ’’”‘š‹ƒ–‡Ž› ͶͲͲͲͲͲ ‹†‹˜‹†—ƒŽ• ȋ‡Ž–‘‡ ‡– ƒŽǤǡ ͳͻͻͻȌǤ ……‘”†‹‰ –‘

‡Ž–‘‡ǡ–Š‡’‘’—Žƒ–‹‘™ƒ•–Š—•ƒ‡•–‹ƒ–‡†ʹͷͲͲͲͲ‹–Š‡„‡‰‹‹‰‘ˆ–Š‡

ͳͺ^–Š…‡–—”›ǡƒˆ–‡”™Š‹…Š‹–‰”‡™”ƒ’‹†Ž›–‘‹–•…—””‡–ͷǤͷ‹ŽŽ‹‘Ǥ

–ˆ‹”•–ǡŠƒ„‹–ƒ–‹‘™ƒ•…‘…‡–”ƒ–‡†–‘–Š‡…‘ƒ•–ƒŽƒ”‡ƒ•ȋ‡Ž–‘‡‡–ƒŽǤǡͳͻͻͷȌǤ

‹–‡”ƒŽ‹‰”ƒ–‹‘‘˜‡‡–„‡‰ƒ‹–Š‡ͳ͸^–Š…‡–—”›ǡ•‡–‹‘–‹‘„›–Š‡

‡‡† –‘ …—Ž–‹˜ƒ–‡ ‘”‡ Žƒ†ǡ „—– ƒŽ•‘ ƒ ƒ––‡’– –‘ ƒ˜‘‹† –Š‡ –ƒšƒ–‹‘ ‘ˆ –Š‡

™‡†‹•Š ”‘™ ȋ‡Ž–‘‡ ‡– ƒŽǤǡ ͳͻͻͻȌǤ ‡Ž–‘‡ ƒ† …‘ŽŽ‡ƒ‰—‡• ƒ†† –Šƒ– –Š‹•

‹‰”ƒ–‹‘ •–ƒ”–‡† ˆ”‘ ƒ •ƒŽŽ •‘—–Š‡ƒ•–‡” ƒ”‡ƒ ‘ˆ –Š‡ …‘—–”› ƒ† …”‡ƒ–‡†

”‡‰‹‘ƒŽ•—„‹•‘Žƒ–‡•ˆ‹”•–‹–Š‡‹††Ž‡ƒ†™‡•–‡”’ƒ”–•ǡƒ†Žƒ–‡”‹–Š‡‡ƒ•–‡”

ƒ†‘”–Š‡”’ƒ”–•‘ˆ–Š‡…‘—–”›ǡ‰‹˜‹‰”‹•‡–‘Ž‘…ƒŽˆ‘—†‡”‡ˆˆ‡…–•Ǥ

1.3 Next-generation sequencing

Š‡ˆ‹”•–…‘‡”…‹ƒŽŽ›•—……‡••ˆ—Ž•›•–‡ˆ‘”ƒ••‹˜‡Ž›’ƒ”ƒŽŽ‡Ž•‡“—‡…‹‰ǡ‘”

‡š–Ǧ‰‡‡”ƒ–‹‘ •‡“—‡…‹‰ ȋȌǡ ‘” •‡…‘† ‰‡‡”ƒ–‹‘ •‡“—‡…‹‰ǡ ™ƒ•

†‡˜‡Ž‘’‡†„›ͶͷͶ‹ˆ‡…‹‡…‡•‹ʹͲͲͷȋƒ”‰—Ž‹‡•‡–ƒŽǤǡʹͲͲͷȌǤŠ‡‹’ƒ…–

Šƒ•Šƒ†‘‰‡‡–‹…”‡•‡ƒ”…Š‹•‹‡•‡ǤŠ‡‹–…‘‡•–‘‹Š‡”‹–‡††‹•‘”†‡”•ǡ

–Š‡•‡ ™‡”‡ –”ƒ†‹–‹‘ƒŽŽ› •–—†‹‡† —•‹‰ …ƒ†‹†ƒ–‡ ‰‡‡ ƒ’’”‘ƒ…Š‡• ‘” Ž‹ƒ‰‡

ƒƒŽ›•‹•…‘„‹‡†™‹–Š’‘•‹–‹‘ƒŽ…Ž‘‹‰ȋƒ„„ƒ‹‡–ƒŽǤǡʹͲͳʹȌǤŽ–Š‘—‰Šƒ›

•–—†‹‡•‘ˆ–Š‹•‡”ƒ™‡”‡•—……‡••ˆ—Žǡƒ„„ƒ‹ƒ†…‘™‘”‡”•‡’Šƒ•‹œ‡–Šƒ––Š‡

‡–Š‘†•™‡”‡Žƒ„‘”‹‘—•ƒ†•ƒŽŽ‹†”‡†•‹œ‡•ƒ†‰‡‡–‹…Š‡–‡”‘‰‡‡‹–›™‡”‡

ƒ•‡”‹‘—•Ž‹‹–ƒ–‹‘ǤŠƒ•ƒ†‡‹–’‘••‹„Ž‡–‘‘˜‡”…‘‡–Š‡•‡‘„•–ƒ…Ž‡•Ǥ

‘•– •–—†‹‡• ‘ ‹Š‡”‹–‡† †‹•‡ƒ•‡• Šƒ˜‡ —–‹Ž‹œ‡† ‡š‘‡ ‹•–‡ƒ† ‘ˆ ‰‡‘‡

•‡“—‡…‹‰ǣ ‡š‘‡ •‡“—‡…‹‰ ‹• ‘”‡ …‘•–Ǧ ƒ† –‹‡Ǧ‡ˆˆ‡…–‹˜‡ǡ ƒ• –Š‡ ‡š‘‡

…‘•–‹–—–‡•‘Ž›ͳΨ‘ˆ–Š‡‰‡‘‡ǡ™Š‹Ž‡…‘•‹†‡”‡†–‘„‡‘”‡Ž‹‡Ž›–‘Šƒ˜‡

ˆ—…–‹‘ƒŽ…‘•‡“—‡…‡•‹ˆ—–ƒ–‡†ȋŠ‘‹‡–ƒŽǤǡʹͲͲͻǢƒ„„ƒ‹‡–ƒŽǤǡʹͲͳʹȌǤ•

–Š‡ƒ†˜‡–‘ˆ‰ƒ˜‡”‹•‡–‘ƒ•‹’Ž‡ƒ†‡ˆˆ‹…‹‡–™ƒ›‘ˆ†‹•…‘˜‡”‹‰‘˜‡Ž

†‹•‡ƒ•‡Ǧƒ••‘…‹ƒ–‡†‰‡‡•ǡ–Š‡—„‡”‘ˆ‰‡‡•ƒ••‘…‹ƒ–‡†™‹–Šƒ”ƒ”‡†‹•‡ƒ•‡Šƒ•

‰”‘™ƒ–ƒ‹’”‡••‹˜‡”ƒ–‡ȋƒ„„ƒ‹‡–ƒŽǤǡʹͲͳʹȌǤ

1.3.1 Reference genomes and population controls

‘”†‡”–‘„‡ƒ„Ž‡–‘ƒƒŽ›œ‡†ƒ–ƒǡƒ”‡ˆ‡”‡…‡‰‡‘‡‹•”‡“—‹”‡†ǤŠ‡ˆ‹”•–

Š—ƒ ”‡ˆ‡”‡…‡ ‰‡‘‡ „› –Š‡ –‡”ƒ–‹‘ƒŽ —ƒ ‡‘‡ ‡“—‡…‹‰

‘•‘”–‹— ™ƒ• ’—„Ž‹•Š‡† ʹͲͲ͵ ȋ–‡”ƒ–‹‘ƒŽ —ƒ ‡‘‡ ‡“—‡…‹‰

‘•‘”–‹—ǡʹͲͲͶȌǤ‘–‘Ž›‹•ƒ”‡ˆ‡”‡…‡‡‡†‡†–‘ƒŽ‹‰–Š‡”‡ƒ†•…”‡ƒ–‡†„›

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•Š‘”–Ǧ”‡ƒ†•‡“—‡…‹‰ȋ–Š‡‘”‹‰‹ƒŽƒ†…—””‡–Ž›‘•–—•‡†‡–Š‘†Ȍǡ„—–ƒŽ•‘–‘

„‡ƒ„Ž‡–‘…ƒŽŽ–Š‡„ƒ•‡•–Šƒ–†‹ˆˆ‡”ˆ”‘–Š‹•”‡ˆ‡”‡…‡Ǥ•—…Š‘ˆ”ƒ”‡†‹•‡ƒ•‡

”‡•‡ƒ”…Š”‡Ž‹‡•‘ˆ‹†‹‰˜ƒ”‹ƒ–•–Šƒ–ƒ”‡”ƒ”‡ǡƒ††‹–‹‘ƒŽ”‡ˆ‡”‡…‡•ƒ”‡‡‡†‡†

–‘†‡–‡”‹‡‹ˆƒ•’‡…‹ˆ‹…˜ƒ”‹ƒ–‹•‹ˆƒ…–”ƒ”‡‹–Š‡’‘’—Žƒ–‹‘Ǥ‡…ƒ—•‡‘ˆǡ

–Š‡ ƒ‘—– ‘ˆ ’‘’—Žƒ–‹‘ •’‡…‹ˆ‹… …‘–”‘Ž• Šƒ• ‡š’Ž‘†‡†Ǥ Š‡ ‡‘‡

‰‰”‡‰ƒ–‹‘ƒ–ƒ„ƒ•‡ǡ‘”‰‘ǡ–Š‡Žƒ”‰‡•–’—„Ž‹…Ž›ƒ˜ƒ‹Žƒ„Ž‡‡š‘‡Ȁ‰‡‘‡

†ƒ–ƒ„ƒ•‡ǡ‹•ƒ…‘ƒŽ‹–‹‘•‡‡‹‰–‘ƒ‰‰”‡‰ƒ–‡‡š‘‡ƒ†‰‡‘‡•‡“—‡…‹‰†ƒ–ƒ

ˆ”‘ ƒ ˜ƒ”‹‡–› ‘ˆ Žƒ”‰‡Ǧ•…ƒŽ‡ •‡“—‡…‹‰ ’”‘Œ‡…–• ȋƒ”…œ‡™•‹ ‡– ƒŽǤǡ ʹͲͳͻȌǤ – …—””‡–Ž›Š‘Ž†•–Š‡˜ƒ”‹ƒ–…ƒŽŽ•ˆ”‘ͳʹͷǡ͹Ͷͺ‡š‘‡•ƒ†ͳͷǡ͹Ͳͺ‰‡‘‡•‘ˆ

—”‡Žƒ–‡†‹†‹˜‹†—ƒŽ•ˆ”‘†‹ˆˆ‡”‡–’ƒ”–•‘ˆ–Š‡™‘”Ž†–Šƒ–Šƒ˜‡„‡‡•‡“—‡…‡†

ƒ• ’ƒ”– ‘ˆ ˜ƒ”‹‘—• †‹•‡ƒ•‡Ǧ•’‡…‹ˆ‹… ƒ† ’‘’—Žƒ–‹‘ ‰‡‡–‹… •–—†‹‡•

ȋŠ––’•ǣȀȀ‰‘ƒ†Ǥ„”‘ƒ†‹•–‹–—–‡Ǥ‘”‰ȀȌǤ Š‡’”‡†‡…‡••‘” ‘ˆ ‰‘ǡ ™Š‹…Š …‘–ƒ‹‡† ‡š…Ž—•‹˜‡Ž› ‡š‘‡ †ƒ–ƒǡ ™ƒ• ‘™ ƒ• –Š‡ š‘‡ ‰‰”‡‰ƒ–‹‘

‘•‘”–‹— ȋšȌǤ Š‡ ‡“—‡…‹‰ ‹–‹ƒ–‹˜‡ —‘‹ ’”‘Œ‡…– ȋ—Ȍ ‹• ƒ

‹–‡”ƒ–‹‘ƒŽ…‘ŽŽƒ„‘”ƒ–‹‘…‘‘”†‹ƒ–‡†„›–Š‡•–‹–—–‡ˆ‘”‘Ž‡…—Žƒ”‡†‹…‹‡

‹Žƒ† ȋ Ȍ ƒ– –Š‡ ‹˜‡”•‹–› ‘ˆ ‡Ž•‹‹ ȋ‹ ‡– ƒŽǤǡ ʹͲͳͶȌǤ – Š‘Ž†• –Š‡

‡š‘‡•‘ˆͳͲǡͶͻͲ‹†‹˜‹†—ƒŽ•ˆ”‘ ‹Žƒ†ȋŠ––’ǣȀȀ™™™Ǥ•‹•—’”‘Œ‡…–Ǥˆ‹ȀȌǤ

1.2.3 Recording population and disease history

—”‹‰–Š‡‹††Ž‡ƒ‰‡•ǡ–Š‡™‡†‹•Š‡’‹”‡‡š’ƒ†‡†ƒ†–‘‘…‘–”‘Ž‘˜‡”–Š‡

ƒŒ‘”‹–›‘ˆ–Š‡ƒ”‡ƒ–Šƒ–‘™…‘•–‹–—–‡• ‹Žƒ†ȋ‡Ž–‘‡‡–ƒŽǤǡͳͻͻͻȌǤ ‹Žƒ†

”‡ƒ‹‡† —†‡” ™‡†‹•Š ”—Ž‡ —–‹Ž ͳͺͲͻǡ ™Š‡ ‹– ™ƒ• …‡†‡† –‘ —••‹ƒ ƒ• ƒ …‘•‡“—‡…‡ ‘ˆ –Š‡ ‹‹•Š ƒ” ȋ‡•–‡”Š‘Žǡ ʹͲͲʹȌǤ —”‹‰ –Š‡ ”‡‰‹‡ ‘ˆ

™‡†‹•Š ‹‰ —•–ƒ˜—• ‘ˆ ƒ•ƒ ͳͷʹ͵Ǧͳͷ͸Ͳǡ …Š—”…Š ƒ† Žƒ† ”‡…‘”†• ™‡”‡

…”‡ƒ–‡†ȄŽƒ–‡” ‹ ͳ͸ͺ͸ǡ –Š‡ ™‡†‹•Š Š—”…Š ƒ™ ™ƒ• ƒ†‘’–‡†Ǥ ‘‰ ‘–Š‡”

”‡ˆ‘”•ǡ –Š‹• Žƒ™ •–ƒ–‡† –Šƒ– ƒŽŽ’ƒ”‹•Š ˜‹…ƒ”• ™‡”‡ ‘„Ž‹‰ƒ–‡† –‘‡‡’ ƒ ’ƒ”‹•Š

”‡‰‹•–‡”ƒ†‘–‡‡˜‡”›„‹”–Šǡ„ƒ’–‹•ƒŽƒ††‡ƒ–Š‹–Š‡’ƒ”‹•ŠȋŠ––’•ǣȀȀ†˜˜Ǥˆ‹ȀȌǤ

Š‡’ƒ”‹•Š”‡…‘”†•ƒŽ•‘…‘–ƒ‹‹ˆ‘”ƒ–‹‘‘‡Ǥ‰Ǥƒ””‹ƒ‰‡•ǡ…ƒ—•‡•‘ˆ†‡ƒ–Šǡ

ƒ†ˆƒ‹Ž›”‡Ž‘…ƒ–‹‘•ǤŠ‡•‡…‘’”‡Š‡•‹˜‡”‡…‘”†•Šƒ˜‡„‡‡‘ˆ‰”‡ƒ–˜ƒŽ—‡

ˆ‘”Žƒ–‡”‰‡‡–‹…•–—†‹‡•Ǥ

‘†ƒ›ǡ’‘’—Žƒ–‹‘‹ˆ‘”ƒ–‹‘‹••–‘”‡†‹–Š‡ ‹‹•Š‘’—Žƒ–‹‘ˆ‘”ƒ–‹‘

›•–‡ȋȌǡƒƒ–‹‘ƒŽ”‡‰‹•–‡”•‡–—’‹ͳͻ͸ͻƒ†ƒ‹–ƒ‹‡†„›–Š‡‘’—Žƒ–‹‘

‡‰‹•–‡”‡–”‡ƒ†Ž‘…ƒŽ”‡‰‹•–‡”‘ˆˆ‹…‡•ȋŠ––’•ǣȀȀ†˜˜Ǥˆ‹ȀȌǤ–…‘–ƒ‹•„ƒ•‹…†ƒ–ƒ

”‡Žƒ–‡† –‘ –Š‡ ‹†‡–‹ˆ‹…ƒ–‹‘ ‘ˆ ‹‹•Š …‹–‹œ‡• ƒ† ˆ‘”‡‹‰ …‹–‹œ‡• ”‡•‹†‹‰

’‡”ƒ‡–Ž›‹ ‹Žƒ†ǤŠ‡’‡”•‘ƒŽ‹ˆ‘”ƒ–‹‘‘ˆ‡˜‡”›‘‡”‡…‘”†‡†‹–Š‡

•›•–‡ ‹…Ž—†‡ ƒ‡ǡ ’‡”•‘ƒŽ ‹†‡–‹–› …‘†‡ǡ ƒ††”‡••ǡ …‹–‹œ‡•Š‹’ǡ ƒ–‹˜‡

Žƒ‰—ƒ‰‡ǡˆƒ‹Ž›”‡Žƒ–‹‘•ǡ†ƒ–‡‘ˆ„‹”–Šǡƒ††ƒ–‡‘ˆ†‡ƒ–Šǡ‹ˆƒ’’Ž‹…ƒ„Ž‡Ǥ

Š‡ ‹‹•Š ƒ…‡” ‡‰‹•–”› ȋ Ȍ ™ƒ• ˆ‘—†‡† ‹ ͳͻͷʹǡ ‡˜‡ „‡ˆ‘”‡ –Š‡

ȋŠ––’•ǣȀȀ…ƒ…‡””‡‰‹•–”›Ǥˆ‹ȀȌǤ ƒ–‹‘™‹†‡”‡‰‹•–”ƒ–‹‘‘ˆ…ƒ…‡”•„‡‰ƒ‹ͳͻͷ͵ǡ