Melissa Stosic, Jessica L. Giordano, Brynn Levy, and Ronald Wapner


Chromosomal microarray analysis (CMA) by which chromosomal anomalies beyond the resolution of traditional karyotyping can be identified has become a mainstay of prenatal diagnosis over the past several years. In 2012, a landmark study was published comparing CMA to the previous standard of care, karyotype analysis, which can identify aneuploidy and chromosomal structural changes bigger than 7–10 million base pairs (Mb) (1). It was shown that CMA was able to detect all of the unbalanced changes identified on karyotype as well as additional microdeletions and duplications (copy number changes [CNVs]) in 1.7% of pregnancies without ultrasound anomalies. In pregnancies with a structural anomaly and a normal karyotype, 6% of fetuses had a clinically significant CNV identified by CMA. This incremental yield of CMA over karyotype led the American College of Obstetricians and Gynecologists (ACOG) along with the Society for Maternal-Fetal Medicine (SMFM) to publish guidelines suggesting that microarray be the preferred test for anomalous pregnancies. They also commented that in average-risk pregnancies undergoing invasive testing for indications such as advanced maternal age or abnormal screening, either karyotype or CMA is appropriate (2).

Basics of chromosomal microarray analysis

Standard karyotype is able to detect CNVs that are 7–10 megabases (Mb), or million base pairs in size or greater, such as a monosomy, trisomy, or a large deletion or duplication. Fluorescence in situ hybridization (FISH) can identify smaller copy number changes in specific regions of the genome by utilizing probes specific to that region or chromosome. Comparatively, CMA has the ability to find microdeletions and duplications as small as 10 kilobases (kb) or thousand base pairs, across the entire genome. These small deletions and duplications are missed by standard karyotyping and can cause genetic syndromes with intellectual disabilities and/or structural abnormalities. Table 36.1 lists common microdeletion and microduplication syndromes and the major phenotypic features associated with each condition.

Table 36.1 Common microdeletion and microduplication syndromes

Condition; genomic location


Major phenotypic features

16p11.2 duplication


Normal to DD, ASD, ADHD, microcephaly, psychiatric conditions

16p11.2 deletion


ID/DD, ASD, ADHD, macrocephaly, psychiatric conditions

16p13.11 deletion


ID/DD, seizures, schizophrenia

1q21.1 duplication


Normal to motor skill and articulation difficulty, ID/DD, ASD, ADHD, scoliosis, abnormal gait, scoliosis, macrocephaly, short stature, psychiatric conditions, CHD

22q11.2 deletion syndrome (DiGeorge, VCFS)


CHD (most commonly conotruncal), palate abnormalities, characteristic facies, ID/DD, immune deficiency, hypocalcemia, psychiatric conditions in young adulthood, etc.

22q11.2 duplication


Normal to ID/DD, growth retardation, hypotonia

1p36 deletion syndrome


ID/DD, hypotonia, seizures, structural brain abnormalities, CHD, vision and hearing issues, skeletal anomalies, characteristic facies

Charcot–Marie–Tooth Type 1A; 17p12 duplication


Slowly progressive neuropathy causing distal muscle weakness and atrophy, sensory loss, and slow nerve conduction velocity first noticeable in the first or second decade

X-linked ichthyosis; Xp22.31 deletion


ID/DD, ichthyosis, Kallmann syndrome, short stature, ocular albinism

Williams syndrome; 7q11.23 deletion


ID/DD, cardiovascular disease, characteristic facies, connective tissue abnormalities, specific personality, growth anomalies, endocrine abnormalities

7q11.23 duplication


DD, normal to ID intellectually, speech problems, hypotonia, problems with movement and walking, behavioral abnormalities, seizures, aortic enlargement

Prader–Willi syndrome; 15q11.2 paternal deletion


ID/DD, hypotonia and feeding difficulties in infancy, excessive eating, obesity, behavioral difficulties, hypogonadism, short stature

Angelman syndrome; 15q11.2 maternal deletion


ID/DD, severe speech impairment, gait ataxia, inappropriate happy affect, microcephaly, seizures

17q12 deletion


Kidney/urinary abnormalities, diabetes, ID/DD, ASD, psychiatric conditions

Sotos syndrome; 5q35 deletion


ID/DD, overgrowth, characteristic facies

Smith–Magenis syndrome; 17p11.2 deletion


ID/DD, characteristic facies, sleep disturbances, behavioral issues including self-injury and self-hugging and aggression, characteristic facies, reduced sensitivity to pain and temperature,

Cri-du-chat; 5p15 deletion


High-pitched cry, microcephaly, hypotonia, characteristic facies, ID/DD, CHD

Koolen–de Vries; 17q21 deletion


ID/DD, sociable personality, hypotonia, seizures, distinct facial features, CHD, kidney anomalies, foot deformities

Potocki–Lupski syndrome; 17p11.2 duplication


ID/DD, ASD, hypotonia, CHD

Types of CMA and coverage

CMA is performed by mixing a control normal sample of fragmented DNA with DNA from the sample to be tested. Each sample is attached to a florescent dye of a different color (usually red and green). The mixture is then heated to denature (separate) the double-stranded DNA fragments from the patient and the control into single strands. The mixture is then hybridized to a slide embedded with short probes of known DNA sequences. If an equal number of strands from the control and the patient are present at a location on the chip, this will be represented by an equal amount of red and green fragments. The slide is then read by a laser that evaluates all the locations on the slide and interprets their color. Deletions and duplications will appear as too much or too little of one color since the matching strand is either missing or overrepresented. Oligonucleotide arrays are “comparative” in that they compare the sample to a reference genome and are hence described as comparative genomic hybridization arrays (aCGH). This is illustrated in Figure 36.1.

A second type of array is the SNP microarray that uses high-density oligonucleotide-based arrays in which target probes are chosen from DNA locations known to vary between individuals by a single base pair, i.e., single nucleotide polymorphisms (SNPs). Today, most CMAs utilized for prenatal diagnosis are hybrid arrays that contain both SNP probes and copy number probes. By including SNPs on the array, additional clinically useful information such as uniparental disomy (UPD), zygosity, maternal cell contamination, parent of origin, and consanguinity, may be extracted from the genotype plots generated from the SNPs. Consanguinity and UPD can be responsible for recessive genetic conditions in the SNP regions with long contiguous stretches of homozygosity (LCSH), and UPD can cause disease when it occurs on an imprinted chromosome. Examples of imprinting disorders include Russell–Silver syndrome, which is caused by UPD 7; Prader–Willi syndrome, which results from maternal UPD 15; and Beckwith-Wiedemann syndrome, which occurs from partial UPD 11. In addition, triploidy, which cannot be detected by aCGH, can easily be identified by SNP oligonucleotide microarray analysis (SOMA) by assessing the SNP allele patterns on the array. (The allele plots should show four distinct tracks for every autosome, see Figure 36.2.)



Figure 36.2 CMA findings and corresponding ultrasound anomalies. For the CMA images, a loss is indicated in the software call panel by the presence of a red bar and a gain by the presence of a blue bar. Losses are identified by a decrease in the Log2 ratio from zero as seen in the Log2 Ratio panel while gains are observed as an increase in the Log2 ratio. The gene content within the regions of imbalance can be ascertained using the genome coordinates using Human Genome Build Hg19. The allele difference panel indicates the genotype for each SNP probe. For normal copy number of 2, there are only three possible SNP combinations, AA, AB, and BB, which are plotted on the allele difference graph. When there is a deletion (copy number of 1), the genotype options are either A or B and thus only two distinct tracks are visible on the allele difference graph. When there is a duplication (copy number of 3), the genotype options are AAA, AAB, ABB, and BBB giving rise to four visible tracks on the allele difference graph. The chromosome ideogram in the chromosome panel highlights the position (breakpoints) on the chromosome where copy number imbalances are present. The red bar in the chromosome panel represents a deletion, and a blue bar indicates a duplication. (A-i) A 4.693 Mb terminal deletion of the short arm of chromosome 5 which is associated with a clinical diagnosis of cri du chat microdeletion syndrome. The precise coordinates of the deletion correspond to chr5:113,576–4,806,382. (A-ii) 23-week ultrasound revealing estimated fetal weight less than third percentile and a thickened placenta (arrow). (B-i) A 4.573 Mb interstitial deletion of the long arm of chromosome 14. The precise coordinates of the deletion correspond to chr14:76,837,875–81,411,347. (B-ii) Routine ultrasound scan identifying a small subarachnoid cyst of the brain (arrows). (C-i) A 2.816-Mb deletion of the proximal long arm region of chromosome 22 which is associated with a clinical diagnosis of DiGeorge/velocardiofacial microdeletion syndrome. The precise coordinates of the deletion correspond to chr22:18,649,166–21,465,659. (C-ii) Fetal echocardiogram demonstrating a fetal truncus arteriosis. (D-i) Loss of the entire short arm and gain of the entire long arm of chromosome 18 resulting from the formation of an isochromosome of 18q. Monosomy 18p and trisomy 18q are together associated with severe anomalies such as holoprosencephaly and cloacal dysgenesis. (D-ii) 18-week scan with multiple fetal anomalies. Shown is a single midline monoventricle and fused thalamus consistent with alobar holoprosencephaly.

May 10, 2020 | Posted by in GYNECOLOGY | Comments Off on Microarrays
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