EPIDEMIOLOGY OF CORNELIA DE LANGE SYNDROME Introduction Cornelia de Lange Syndrome (CdLS, OMIM 122470) is a multiple congenital anomaly/mental retardation

(MCA/MR) syndrome consisting of characteristic dysmorphic features, microcephaly, hypertrichosis, upper limb defects, growth retardation, developmental delay and a variety of associated major malformations (Brachmann, 1916; de Lange, 1933). Facial appearance is quite characteristic from birth and includes arched eyebrows, synophris, long eyelashes, a small nose with anteverted nostrils, long philtrum, a thin upper lip, downturned corners of mouth and micrognathia (Jackson et al., 1993; Ireland et al., 1993). CdLS has been subject to numerous studies. These studies have increased our understanding of many clinical aspects of the condition, pointing out the variability of the overall clinical presentation. The clinical features seen in individuals with the classic form are quite striking and easily recognisable, which makes the classical phenotype well delineated (Preus and Rex, 1983; Ireland et al., 1993; Van Alen et al., 1993). In mildly affected patients the diagnosis is often problematic as there is no consensus about the minimal diagnostic criteria for this subgroup of patients (Saul et al., 1993; Van Allen et al., 1993; Baraitser and Papavasiliou, 1993). The majority of cases are sporadic, although familial cases have been described, mostly compatible with the autosomal dominant type of inheritance (de Die-Smulders et al., 1992; Russell et al., 2001; McConnell et al., 2003). Recently mutations in the NIPBL gene have been identified in about half the individuals affected with CdLS (Kranz et al., 2004; Gillis et al., 2004; Borck et al., 2004; Miyake et al., 2005; Bhuiyan et al., 2005) Patients harbouring NIPBL gene mutations show variable clinical phenotype indicating the possible influence of other modifying genes (Gillis et al., 2004). Rare forms of CDL have been associated with apparently balanced chromosomal aberrations suggesting the potential existence of a second CdLS disease locus (Ireland et al., 1991; Hulinsky et al., 2005, Price et al., 2005; De Scipio et al., 2005; Egeman et al., 2005.) Based on two surveys of mentally retarded children in Australia and Denmark the estimated prevalence of CdLS is 0.5 -1 /100,000 (Pearce and Pitt, 1967; Beck et al., 1976; Beck and Fenger, 1985). Opitz (1985) suggested that these studies underestimated 75% of cases and based on his personal experience, estimated the total prevalence of both severe and mild cases to be as high as 1/10,000. This figure is usually quoted in published papers dealing with CdLS. However, there is lack of population-based studies that provide reliable epidemiologic data on the prevalence of CdLS that could confirm his assumption. In a more recent study Martinez-Frias et al., (1998) found the prevalence for the severe form of the syndrome in the Spanish population to be 0.97 per 100000 live births, e.g. ten times less that expected. A description of the epidemiologic characteristics of CdLS is important for an improved understanding of the condition and for clarifying findings from studies of hospital-based series or studies based on the observation of subjects from the support groups. In this report, we used the EUROCAT database, a large European network of birth defect registries with multiple sources of active case ascertainment, to conduct a population-based study of the epidemiologic and clinical aspects of the classical form of CdLS. In this report we describe our findings regarding the population-based prevalence (including stillbirths, fetal deaths and termination of pregnancy), prenatal diagnosis, associated congenital malformations and descriptive epidemiology (type of birth, sex, gestational age at discovery, gestational age at birth, birth

weight, survival in the first week of life, maternal age, maternal reproductive history, karyotype, consanguinity, family history), of CdL syndrome. Methods The data were provided by 33 registries from 16 European countries that register congenital malformations in live births, stillbirths and terminations of pregnancy covering approximately 25% of annual births in the countries included in the EUROCAT network. Registries participating in the study use the same EUROCAT programme and the same epidemiological methodologies (www.eurocat.ulster.ac.uk). All registries are population-based, with the exception of Campania (Italy) and ISMAC (Italy), which are hospital-based. A physician, usually a neonatologist, collects obstetrical data and interviews the mothers of cases to obtain prenatal and family histories. The cases are notified from multiple sources (clinicians at hospitals, birth and death certificates, cytogenetic reports and post mortem examinations) to ensure complete and accurate information. The staff of the registry, usually including clinical geneticists, carefully analyse this information in an attempt to identify specific diagnoses. The goal of the process is to ascertain all major birth defects among stillborn infants, terminated pregnancies and live-born children ideally up to 1 year of age. Stillbirth definition for each registry can be found elsewhere (www.eurocat.ulster.ac.uk). Termination of pregnancy after prenatal diagnosis is allowed in the second trimester of pregnancy in all registry areas (22nd-24th week of gestation), with the exception of Ireland and Malta. France, Germany and United Kingdom have no upper gestational age limit for seriously handicapping conditions. Registries differ in the maximum age of follow-up of the registered cases. Table 1 presents the number of births in registries during the period of the data collection, local policy on prenatal diagnosis, follow-up of registered cases, and the involvement of clinical geneticists in the diagnosis and coding of multiple malformation and syndrome cases. Clinical geneticists make diagnoses in most multiply malformed and syndrome cases in 19/29 registries (65.5 %). In 7/29 registries (24.1%) (Odense, Saxony-Anhalt, North East Italy, Tuscany, North Netherlands, Barcelona, Basque Country), geneticists are involved in the diagnostic process of some cases. Only in 3/29 registries (10.3%) (Dublin, Cork and Kerry and Styria), geneticists do not contribute to the diagnosis. The registration forms are completed by members of the medical staff, and contain information regarding the foetus/infant (sex, number of babies delivered, type of birth, birth weight, gestation length, survival beyond one week of age), malformations, prenatal diagnosis, mother and father. The coding system used for diagnosis by all participating registries are the ICD9/BPA or ICD10/BPA (British Paediatrics Association Classification of Diseases) and McKusick. All the data are collected in the common Central Registry database. Confidentiality is assured at all levels of data collection. Detailed descriptions of EUROCAT methods have been published elsewhere (www.eurocat.ulster.ac.uk). The data were extracted from the central database on the bases of the ICD codes for the confirmed Cornelia de Lange cases (759821, Q8712), unconfirmed cases (75982) and McKusick code (12247(0)). Medical geneticist reviewed all the cases and contacted the local registries for the confirmation and text information, if missing in the central database. In the analysis of the associated anomalies present in the Cornelia de Lange cases, minor anomalies were not included. The malformations were classified according to the EUROCAT subgroups of congenital anomalies (www.eurocat.ulster.ac.uk).

Descriptive data in this paper are presented as percentages. Comparisons have been performed using 95% confidence intervals, the Chi-square test and t test. Results Between January 1980 and December 2002, we monitored a total population of 8,604049 births, and identified 106 cases with CdL syndrome. This corresponds to a prevalence of 1.23 per 100,000 births, or 1:81,301 births. Of those, 97/106 (91.5%) were live born, 3/106 (2.8 %) stillborn, and 6/106 (5.7%) were pregnancy terminations (Table 2). Of 85 cases with a known time of diagnosis, 20 (23.5%) cases were diagnosed prenatally, 38 cases (44.7%) were diagnosed at birth, 18 (21.2%) in the first week of life, and 9 (10.6 %) were diagnosed within one year of life (Figure 1). All prenatally diagnosed cases were diagnosed by ultrasound. Mean gestational age at discovery was 22,54,4 gestational weeks. Of 20 prenatally diagnosed cases, 11 were live born, 3 stillborn, and 6 pregnancies were terminated. Karyotype was performed in 63 cases (59.4%). Three karyotypes were abnormal. The results were available for two patients: 46,XY,del(3)(q12q21),inv(5)(p13q13) and 46,XX, t(X;22)(p11;qter). The frequencies of major associated congenital anomalies in 93 cases with available information on malformations are presented in table 3 and figure 2. Of 79 cases in which the survival data were available, 6 (7.6%) were terminated, 3 (3.8%) were stillbirths, 6 (7.6%) died during the first week and 64 (81%) survived one week. Descriptive epidemiologic data on the live born children with CdLS are given in Table 4 There were 55 females and 50 cases were males, the sex of one case was unknown. The f/m ratio was 1.1. The proportion of Cornelia de Lange cases by maternal and paternal age is also presented in Table 4. Comparing the maternal age distribution with the distribution in the EUROCAT population, no significant difference was found (p=0.27). The mean maternal age was 28.7 4.7 years and the mean paternal age was 31 5.1 years. The mean birth weight in live births was 2,021 645 g for males and 2,153 597 g for females. The birth weight distribution is presented in Table 4. Of 64 cases born after 37 weeks of gestation, 44 (68.8%) weighed less than 2,500g. Sex distribution, maternal and paternal age according to the birth weight are given in Table 5. The number of cases with limb anomalies was more frequent in the group weighting 2,500 g (p=0,0022). There were no sex or maternal age differences between two birth weight groups (p=0.27 and p=0.39 respectively). No sibs or relatives with CdLS were recorded. Among 52 cases for which parental consanguinity data were known, no consanguinity was found. We found 15 reports of various illnesses of mothers before or during pregnancy, but all were different and unspecific (hypertension, thyrotoxicosis, obesity, etc). There was no evidence of exposures to consistent teratogenic agents.

Comments We have described here the prevalence, epidemiologic and clinical characteristics of CdLS and examined potential risk factors associated with several routinely collected infant and parental data. The data have been drawn from a total of 8,604,049 births, registered in the period from 1980-2002 as born to women resident in the European regions covered by congenital malformation registries participating in the EUROCAT programme. Prevalence There are only a few studies providing epidemiologic data on the prevalence of CdLS. The prevalence of 0.5-1/100,000 in studies by Beck et al., (1976) and Pearce and Pitt. (1967) based on the screening of institutionalised mentally retarded patients had the possibility of including some mildly affected patients diagnosed later in childhood, but missed cases of stillbirths, foetal deaths, and terminations of pregnancy. Martinez-Frias et al., (1998) reported the prevalence of 0.97/100,000 live births in the Spanish Collaborative Study of Congenital Malformations (ECEMC) Registry. Cases were limited to diagnoses made in the first three days of life. The prevalence of 1.23/100,000 births in the EUROCAT registry represents a minimum figure as only patients with the classical form of the syndrome detected prenatally or during the first weeks of life are recorded. As no set of criteria exist for the diagnosis of mild cases, there is no absolute diagnostic certainty in the diagnosis of cases at the mild end of the CdLS spectrum. The craniofacial features in mild CdLS may be present at birth, but they may also become obvious as late as 2-4 years (Allanson et al., 1997). This subset of patients is missed in our data. The proportion of patients with a mild phenotype is estimated to be 30 - 75% of the total number of cases of CdLS (Opitz, 1985; Allanson et al., 1997). Based on this estimate, the overall prevalence for mild and classical cases would be 1.6 2.2 per 100,000 or 1:62,000 1: 45,000. This agrees with the estimated prevalence of 1: 40,000 by Ireland et al., (1996) and is significantly lower than the usually cited prevalence figure of 1:10,000 births (Opitz, 1985). Prenatal diagnosis Almost a quarter of registered cases were detected prenatally, as early as 15 weeks of gestation. The diagnosis was made following ultrasound detection of limb defects, abnormal facial profile, intrauterine growth retardation or major malformation. The prenatal diagnosis of Cornelia de Lange syndrome was most efficient in Wessex and Northern Netherlands with a rate of 100% and 80% respectively. So far only single case reports on prenatal diagnosis of CdLS have been reported (Kliewer et al., 1993; Boog et al., 1999; Sekimoto et al., 2000; Urban and Hartung, 2001; Le Vaillant et al., 2004). This study is the first one to give population - based data on prenatal diagnosis of CdLS indicating the impact of prenatal ultrasound on the birth prevalence data. It seems that the second-trimester maternal serum pregnancy associated plasma protein-A measurements may be an useful adjunct to ultrasonography in the prenatal diagnosis of Cornelia de Lange syndrome (Aitken et al., 1999). Karyotype Abnormal karyotypes may be responsible for the Cornelia de Lange phenotype by disruption of the gene/genes responsible for the CdLS phenotype, but may also be a coincidental finding (DeScipio et al., 2005). Three abnormal karyotypes were found among 63 cytogenetic investigations performed. In the first case 46, XY del(3)(q12q21),inv(5)(p13q13), the aberration affects the region 5p13, where NIPBL gene is located (Krantz et al., 2004; Tonkin et al., 2004).

Mutations of the NIPBL gene were found in approximately 50% of the Cornelia de Lange cases (Gillis et al., 2004; Bhuiyan et al., 2005). The other abnormal karyotype was 46,XX t(X;22)(p11;qter). A case of de novo t(X;8)(p11.2;q24.3) demonstrating Cornelia de Lange syndrome has recently been described, (Egleman et al., 2005), indicating Xp11 as the genomic region within which the other gene responsible for CdLS phenotype may lie. Associated malformations Our study confirmed many of the findings previously documented in CdLS. The data on rates of associated malformations in different studies are not really comparable, because different case definitions and diverse case ascertainment methods were used. The most frequent group of anomalies in our study were limb defects (73.1%), including micromelia, phocomelia, olygodactyly and syndactyly. In previous studies the association with limb malformations was differently reported depending of the type of the anomalies included. In series where minor anomalies (clinodactily, webbing of 2-3 toes etc.) were recorded, limb defects are found in 93% - 100 % of cases (Jackson et al., 1993; Martinez-Frias et al. 1998). Congenital heart malformations were present in 45.2 % of cases. Rates of CHD associated with CdLS reported in literature range from 13-70% (Greenwood et al., 1977; Jackson et al., 1993; Mehta and Ambalavanan, 1997; Tsukahara et al., 1998; Martinez-Frias et al., 1998). Genitourinary defects were detected in 15.1% of cases. In their cohort of patients from the support group Jackson et al., (1993) found that 12% had genitourinary problems (including vesicoureteral reflux). This is comparable with our data, but significantly less in comparison with 41% reported by Selicorni et al., (2005) after either ultrasound or voiding cystourethrography were performed. The high rate of eye anomalies in Cornelia de Lange cases reported by Wygnanski-Jaffe et al., (2005) and Levin et al., (1990) is not comparable with our finding of 8.6%, since we registered only major eye malformations. Survival There is almost no population-based information on survival of infants with CdLS. The detection of severe cases during pregnancy has led to the elective termination of a proportion of serious cases. We found that, overall, infants with CdLS had a high first week survival rate, as only 7.6% of cases died during the first week of life. Further studies are needed to determine whether infants with CdLS will experience a significant increase in mortality rate beyond the first week of life. This type of data is available for only a limited number of EUROCAT registries. Descriptive epidemiologic data and exposure The average birth weight in the series of patients by Jackson et al., (1993) was 2,221 g for males and 2,145 g for females (range 540-4,120g). Kline et al., (1993) gave the birth weight distribution for 277 patients. The mean birth weight of his cases was 2,280 g for males and 2,270 g for females. Mean birth weight in live births in our series of cases was 2,021 645 g for males and 2,153597 g for females. The birth weight distribution and mean birth weight in our series are comparable with the birth weight data for the patients in both studies (p=0.13; p>0.05). Almost 80% of our cases, born after the 37th week of gestation, weighed less than 2500 g, Hawley et al., (1985) suggested that low birth weight correlates with a more severe phenotype, including severe limb anomalies. They also noted an excess of females, and older maternal age in the low birth weight group. In our series, the number of cases with limb anomalies was also

significantly more frequent in the group weighting 2,500 g. On the other hand we did not observed sex or maternal age differences between the two birth weight groups. Parental age Based on our data, the increased or low maternal/paternal does not age seem not to be the risk factor for CdLS. Martinez Frias et al., (1998) observed that parental ages tend to be relatively young. On the other hand, Jackson et al., (1993) found that mean maternal age was 28 years and paternal age 31 at the childs birth, which is consistent with reported norms and our results. In his series 4 fathers were over 45 at the birth of their CdLS child. An excess of older fathers was not observed among our cases. Risk factors Suggested non-genetic risk factors for CdLS include alcohol, valproic acid and dilantin (Neri et al., 1991; Van Allen et al., 1993). Most of these suggested risk factors were identified anecdotally in case reports, or small unselected case series, without confirmation by systematically conducted studies. Among CdLS patients registered in the EUROCAT network there was no evidence of exposure to consistent teratogenes. Recurrence Although a recurrence risk of 2-5% has been reported, with occasional case reports of concordance between monzygotic twins, in the series reported here no recurrences or familial cases have been found. Recurrence in sibs is best explained by germ cell mosaicism (de DieSmulders et al., 1992; Ireland et al, 1993; Jackson et al., 1993; Gillis et al., 2004). The lack of affected relatives and consanguinity in our patients is in accordance with observations in previous reports that the vast majority of cases are sporadic events, presumably due to the new dominant mutations (Russel et al., 2001). Conclusions Based on the 20-years epidemiologic monitoring of birth defects in Europe we found that: - the prevalence of classical Cornelia de Lange syndrome is 1.23/ 100,000 births. - the overall prevalence for classical and mild cases is estimated to be 1.6 2.2 /100,000 births - the most frequent major congenital malformations associated with CdLS are limb defects (73.1%), congenital heart defects (45.6%), central nervous system malformations (40.2%) and cleft palate (21.7%) - prenatal diagnosis by ultrasound examination accounts for almost a quarter of diagnosed cases - infants with CdLS have a high first week survival rate - in the majority of cases the karyotype is normal. Identified abnormal karyotypes may be responsible for the Cornelia de Lange syndrome by disruption of the gene/genes responsible for the CdLS phenotype - maternal age and paternal age do not seem to be a risk factors for CdLS - almost 80% of cases, born after the 37th week of gestation, weighed less than 2,500 g; low birth weight correlates with a more severe phenotype, including severe limb anomalies. - all cases were sporadic and there was no evidence of exposure to consistent teratogenic agents.

References 1. Aitken DA. Ireland M. Berry E. Crossley JA. Macri JN. Burn J. Connor JM. Secondtrimester pregnancy associated plasma protein-A levels are reduced in Cornelia de Lange syndrome pregnancies. Prenatal Diagnosis 1999;19(8):706-10 2. Allanson JE, Hennekam RCM, Ireland M. De Lange syndrome: subjective and objective comparison of the classical and mild phenotypes. J Med Genet 1997;34:645-650. 3. Beck B. Epidemiology of Cornelia de Langes syndrome. Acta Paediatr Scand 1976;65(5):631-8. 4. Beck B, Fenger K. Mortality, pathological findings and causes of death in the de Lange syndrome. Acta Paediatr Scand 1985;74:765-69 5. Baraitser M, Papavasiliou AS. Mild de Lange syndrome does it exist? Clin Dysmorph 1993;2:147-150. 6. Bhuiyan Z, Klein M, Hammond P, Mannens MM, Van Haeringen A, Van Berckelaer-Onnes I, Hennekam RC. Genotype-Phenotype correlations of 39 patients with Cornelia de Lange syndrome:the Dutch experience. J Med Genet. 2005; [Epub ahead of print] 7. Boog G, Sagot F, Winer N, David A, Nomballais MF. Branchmann-de Lange syndrome: a cause of early symmetric foetal growth delay. Obstet & Gynecol 1999;85:173-77. 8. Borck G, Redon R, Sanlaville D, Rio M, Prieur M, Lyonnet S, Vekemans M, Carter NP, Munnich A, Colleaux L, Cormier-Daire V. NIPBL mutations and genetic heterogeneity in Cornelia de Lange syndrome. J Med Genet. 2004;41(12):e128. 9. Brachmann W. En Fall von symmetrischer Monodaktylie durch Ulnadefekt, mit symmetrischer Flughautbildung in den Ellenbogen sowie anderen Abnormalitten. J B Kinderheilk Phys Erzieh 1916;84225.-235 10. de Die-Smulders C, Theunissen P, Schrander-Stumpel C. On the variable expression of the Brachmann-de Lange syndrome. Clin Genet 1002;41:42-5. 11. De Lange C. Sur un type nouveau dgneration (typus Amstelodamensis). Arch Med Enfant 1933;36:713-19. 12. DeScipio C, Kaur M, Yaeger D, Innis JW, Spinner NB, Jackson LG, Krantz ID. Chromosome rearrangements in Cornelia de Lange syndrome (CdLS): report of a der(3)t(3;12)(p25.3;p13.3) in two half sibs with features of CdLS and review of reported CdLS cases with chromosome rearrangements. Am J Med Genet A 2005;137(3):276-82. 13. Egemen A, Ulger Z, Ozkinay F, Gulen F, Cogulu O. A de novo t (X;8)(p11.2;q24.3) demonstrating Cornelia de Lange syndrome phenotype. Genet Couns. 2005;16(1):27-30. 14. Gillis LA, McCallum J, Kaur M, Descipio C, Yaeger D, Mariani A, Kline AD, Li HH, Devoto M, Jackson LG, Krantz ID. NIPBL mutational analysis in 120 individuals with Cornelia de Lange syndrome and evaluation of genotype-phenotype correlations. Am J Hum Genet 2004;75(4):610-23. 15. Greenwood RD, Sommer A, Craenen J, Waldman JD, Rosenthal A. Congenital heart disease in de Langes syndrome. South Med J 1977;70(1):80-1. 16. Hawley PP, Jackson LG, Kurnit DM. Sixty-four patients with Brachmann-de Lange syndrome: a survey. Am J Med Genet 1985;20(3):453-9. 17. Hulinsky R, Byrne JL, Lowichik A, Viskochil DH. Fetus with interstitial del(5)(p13.1p14.2) diagnosed postnatally with Cornelia de Lange syndrome. Am J Med Genet A. 2005 Sep 1;137(3):336-8.

18. Ireland M, English C, Cross I, Houlsby WT, Burn J. A de novo translocation t(3;17)(q26.3;q23.1) in a child with Cornelia de Lange syndrome. J Med Genet 1991;28(9):639-40. 19. Ireland M. Cornelia de Lange syndrome: clinical features, common complications and longterm prognosis. Curr Pediatr 1996;6:69-73 20. Ireland M, Donnai D, Burn J. Brachman-de Lange syndrome. Delineation of the clinical phenotype. Am J Med Genet 1993;47(7):959-64. 21. Jackson L, Kline AD, Barr MA, Koch S. De Lange syndrome: a clinical review of 310 individuals. Am J Med Genet 1993;47(7):940-6. 22. Kline AD, Barr M, Jackson LG. Growth manifestations in the Brachmann-de Lange syndrome. Am J Med Genet 1993;47(7):1042-9. 23. Kliewer MA, Kahler SG, Hertzberg BS, Bowie JD. Fetal biometry in the Brachmann-de Lange syndrome. Am J Med Genet 1993; 47(7):1035-41. 24. Krantz ID, McCallum J, DeScipio C, Kaur M, Gillis LA, Yaeger D, Jukofsky L, Wasserman N, Bottani A, Morris CA, Nowaczyk MJ, Toriello H, Bamshad MJ, Carey JC, Rappaport E, Kawauchi S, Lander AD, Calof AL, Li HH, Devoto M, Jackson LG. Cornelia de Lange syndrome is caused by mutations in NIPBL, the human homolog of Drosophila melanogaster Nipped-B. Nat Genet 2004;36(6):631-5. 25. Le Vaillant C. Quere MP. David A. Berlivet M. Boog G. Prenatal diagnosis of a 'minor' form of Brachmann-de Lange syndrome by three-dimensional sonography and three-dimensional computed tomography. Fetal Diagn & Ther 2004;19(2):155-9. 26. Levin AV, Seidman DJ, Nelson LB, Jackson LG. Ophthalmologic findings in the Cornelia de Lange syndrome. J Pediatr Ophthalmol Strabismus 1990;27(2)-94-102. 27. Martinez-Frias ML, Bermejo E, Felix V, Jimenez N, Gomez-Ullate J, Lopez JA, Aparicio P, Ayala A, Gairi JM, Galan E, Suarez ME, Penas A, de Tapia JM, Neito C, de la Serna E. Sndrome de Brachmann de Lange en nuestro medio: caractersticas clnicas y epidemiolgicas. An Esp Pediatr 1998;48(3):293-8. 28. McConnell V, Brown T, Morrison PJ. An Irish three-generation family of Cornelia de Lange syndrome displaying autosomal dominant inheritance. Clin Dysmorphol. 2003;12(4):241-4. 29. Mehta AV, Ambalavanan SK. Occurrence of congenital heart disease in children with Brachmann-de Lange syndrome. Am J Med Genet 1997;71(4):434-5. 30. Miyake N, Visser R, Kinoshita A, Yoshiura K, Niikawa N, Kondoh T, Matsumoto N, Harada N, Okamoto N, Sonoda T, Naritomi K, Kaname T, Chinen Y, Tonoki H, Kurosawa K. Four novel NIPBL mutations in Japanese patients with Cornelia de Lange syndrome. Am J Med Genet A. 2005;135(1):103-5. 31. Neri G, Scarano G, Selicorni A. Etiological heterogeneity of the Brachmann-de Lange phenotype. Proceedings of the DW Smith Workshop on Malformations and Morphogenesis 32. Opitz JM. The Brachmann-de Lange syndrome. Am J med Genet 1985;22(1):89-102. 33. Pearce PM, Pitt DB. Six cases of de Langes syndrome; parental consanguinity in two. Med J Aust 1967;1(10):502-6. 34. Preus M, Rex AP. Definition and diagnosis of the Brachman-De Lange Syndrome. Am J Med Genet 1983;16:301-312. 35. Price N, Bahra M, Griffin D, Hanna G, Stock A. Cornelia de Lange Syndrome in association with a balanced reciprocal translocation involving chromosomes 3 and 5. Prenat Diag 2005;25(7):602-3.

36. Russell KL, Ming JE, Patel K, Jukofsky L, Magnusson M, Krantz ID. Dominant paternal transmission of Cornelia de Lange syndrome: a new case and review of 25 previously reported familial recurrences. Am J Med Genet 2001;104:267-76. 37. Sekimoto H, Osada H, Kimura H, Kamiyama M, Arai K, Sekiya S. Prenatal findings in Brachmann-de Lange syndrome. Arch Gynecol & Obstet 2000;263(4):182-4, 38. Selicorni A, Sforzini C, Milani D, Cagnoli G, Fossali E, Bianchetti MG. Anomalies of the kidney and urinary tract are common in de Lange syndrome. Am J Med Genet A 2005;132(4):395-7. 39. Saul RA, Regers RC, Phelan MC, Stevenson RE. Brachmann-de Lange syndrome: diagnostic difficulties posed by the mild phenotype. Am J Med Genet 1993;47:999-1002. 40. Tonkin ET, Wang TJ, Lisgo S, Bamshad MJ, Strachan T. NIPBL, encoding a homolog of fungal Scc2-type sister chromatid cohesion proteins and fly Nipped-B, is mutated in Cornelia de Lange syndrome. Nat Genet 2004;36(6):636-41. 41. Tsukahara M, Okamoto N, Ohashi H, Kuwajima K, Kondo I, Sugie H, Nagai T, Naritomi K, Hasegawa T, Fukushima Y, Masuno M, Kuroki Y. Brachamann-de Lange syndrome and congenital heart disease. Am J Med Genet 1998;75(4):441-2. 42. Urban M. Hartung J. Ultrasonographic and clinical appearance of a 22-week-old fetus with Brachmann-de Lange syndrome. Am J Med Genet 2001;102(1):73-5. 43. Van Allen MI, Filippi G, Siegel-Bartelt J, Yong SL, McGillivray B, Zuker RM, Smith CR, Magee JF, Ritchie S, Toi A, Reynolds JF. Clinical variability within Brachmann-de Lange syndrome: a proposed classification system. Am J Med Genet 1993;47(7):947-58. 44. Wygnanski-Jaffe T, Shin J, Perruzza E, Abdolell M, Jackson LG, Levin AV. Ophthalmologic findings in the Cornelia de Lange Syndrome. J AAPOS 2005;9(5):407-15. 45. www.eurocat.ulster.ac.uk

Table 1. List of European registries contributing to the study: years of data, total number of births, prenatal diagnosis policy, followup of cases and involvement of clinical geneticist in diagnosis and coding of multiple congenital anomaly and/or syndrome cases
Upper gestational age limit for TOP Routine US (n) (weeks) 2 3 3 32 0 3 3 3 3 3 1 1 3 3 3 3 3 no data 0 3 3 3 3 3 3 2 1 1 1 1 1 1 1 22-24 no upper limit 22-24 22-24 no upper limit no upper limit no upper limit no upper limit no upper limit not legal 22-24 22-24 22-24 22-24 not legal Involvement of clinical geneticist diagnosis STYRIA ANTWERPEN HAINAUT ZAGREB ODENSE AUVERGNE PARIS STRASBOURG MAINZ SAXONY-ANHALT CORK AND KERRY DUBLIN CAMPANIA EMILIA ROMAGNA ISMAC NORTH EAST ITALY TUSCANY MALTA NORTH NETHERLANDS POLAND WIELKOPOLSKA SOUTH PORTUGAL ASTURIAS BARCELONA BASQUE COUNTRY VAUD CARIS WALES GLASGOW NORTH THAMES NORTHERN REGION OXFORD TRENT WESSEX AUSTRIA BELGIUM BELGIUM CROATIA DENMARK FRANCE FRANCE FRANCE GERMANY GERMANY IRELAND IRELAND ITALY ITALY ITALY ITALY ITALY MALTA NETHERLANDS POLAND POLAND PORTUGAL SPAIN SPAIN SPAIN SWITZERLAND UK UK UK UK UK UK UK 1985-2001 1990-2002 1980-2002 1983-2002 1980-2002 2002 1991-2002 1982-2001 1990-2002 1987-2002 1996-2001 1980-2002 1996-2002 1981-2002 1991-2002 1981-2002 1980-2002 1986-2002 1981-2002 1999-2002 1999-2002 1990-2002 1990-2002 1992-2002 1990-2002 1989-2002 1998-2002 1980-2000 1991-2002 2000-2002 1991-2002 1998-2002 1994-2002 213117 161446 251670 120345 122463 13397 450499 267848 46872 211486 46073 486550 358674 524358 216605 1056672 386107 83335 349484 702046 139123 169161 89290 137615 214511 106180 158475 253316 563393 118667 70721 281391 233159 1 year 1 year 1 week 5 years no data 1 week 2 to 5 years 10 years 1 year no routine follow up 1 year 1 week - 1 year adulthood 1 year 1 year no most cases most cases most cases some cases no data most cases most cases most cases some cases some cases no most cases most cases all cases most cases some cases most cases some cases most cases most cases no data most cases some cases rare defects all cases no data no data most cases most cases most cases most cases most cases no upper limit until the diagnosis is complete coding no some cases most cases all cases some cases no data no most cases no no no no most cases all cases all cases all cases some cases no most cases all cases all cases no data no no no all cases no data no data some cases some cases most cases most cases most cases

Registry

Country

Years of data Total births (n)

Follow up of cases

not legal until the diagnosis is complete

22-24 until the diagnosis is complete

22-24 until the diagnosis is complete 22-24 until the diagnosis is complete 22-24 until the diagnosis is complete 22-24 22-24 22-24 22-24 no upper limit no upper limit no upper limit no upper limit no upper limit no data 5 years 3 days 1 year no data no data no data 1 year 1 month

no upper limit until the diagnosis is complete

no upper limit until the diagnosis is complete no upper limit until the diagnosis is complete

10

TOTAL

1980-2002

8604049

11

Table 2. Prevalence and outcome of pregnancies of Cornelia de Lange syndrome in the EUROCAT birth defect registries, for period 1980-2002

Monitored period

Total births

Total No of cases

LB

SB

TOP

Birth prevalence per 100000

Eurocat Registries

1980-2002

8,604,049

106

97

1.23

Figure 1. Time of diganosis of classical form of Cornelia de Lange syndrome, EUROCAT, 1980-2002 n=85
50 40 total cases (%) 30 23,5 20 10,6 10 0 PND at birth 1st week 1st year 21,2 44,7

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Table 3. Major anomalies associated with CdLS

TYPE OF ANOMALY NERVOUS SYSTEM Microcephaly Holoprosencephaly Other EYE EAR NECK Short neck CONGENITAL HEART DISEASE Transposition of the great vessels Ventricular septal defect Atrial septal defect Atrioventricular canal defect Fallot's tetralogy Pulmonary valve stenosis Aortic valve stenosis Coarctation of aorta Other RESPIRATORY SYSTEM Choanal atresia Lung lobar anomaly ORO-FACIAL CLEFTS Cleft palate DIGESTIVE SYSTEM Duodenal stenosis Stenosis of other parts of small intestine Diaphragmatic hernia Other ABDOMINAL WALL DEFECTS Omphalocele GENITOURINARY SYSTEM Cystic kidney disease Congenital hydronephrosis Hypospadia Indeterminate sex Other LIMB NO OF CASES 37 31 1 6 8 3 3 3 42 2 13 10 2 2 9 2 2 11 3 2 1 21 20 12 1 1 4 6 1 1 14 1 1 6 1 8 68 % 39.8 33.3 1.1 6.5 8.6 3.2 3.2 3.2 45.2 2.2 14.0 10.8 2.2 2.2 9.7 2.2 2.2 11.8 3.2 2.2 1.1 22.6 21.5 12.9 1.1 1.1 4.3 6.5 1.1 1.1 15.1 1.1 1.1 6.5 1.1 8.6 73.1

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Limb reduction Upper limb reduction Lower limb reduction Unspecified limb reduction Complete absence of the upper limb Club foot - talipes equinovarus Hip dislocation and/or dysplasia Polydactyly Syndactyly Other MUSCULO-SKELETAL SYSTEM OTHER TOTAL

45 33 8 11 1 1 1 1 16 17 5 6 93

48.4 35.5 8.6 11.8 1.1 1.1 1.1 1.1 17.2 18.3 5.4 6.5 100.0

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Figure 2. Malformations in Cornelia de Lange syndrome (n=93)

80,0 73,1

60,0

45,2 39,8 40,0

22,6 20,0 15,1 12,9 8,6 5,4 3,2 0,0 3,2 1,1 6,5

NERVOUS SYSTEM HEART DEFECTS DIGESTIVE SYSTEM LIMB DEFECTS

EYE RESPIRATORY SYSTEM ABDOMINAL WALL DEFECTS MUSCULO-SKELETAL SYSTEM

EAR CLEFT PALATE GENITO-URINARY SYSTEM OTHER

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Table 4. Descriptive epidemiologic data on children with CdLS

Variable Sex M F Maternal age, y < 20 20-24 25-29 30-34 35-39 40 + Unknown Paternal age, y < 20 20-24 25-29 30-34 35-39 40 + Unknown Birth weight under 1500 1500-1999 2.000-2499 2500-2999 > 3000 unknown Gestational age, wk < 37 37-41 42 unknown No of cases 50 55 n=106 4 (3.8%) 13 (12.3%) 38 (35.9%) 34 (32.1%) 12 (11.3%) 0 (0.0%) 5 (4.7 %) n=106 1 (0.9%) 5 (4.7%) 18(17%) 21 (19.8%) 11 (10.4%) 4 (3.8%) 46 (43.4%) n=97 (liveborn) 14 (14.4%) 26 (26.8%) 32 (33%) 17 (17. 6%) 4 (4.1%) 4(4.1%) n= 97 (liveborn) 30 (30,9%) 61 (62.9%) 1 (1%) 5 (5.2%)

Table 5. Sex distribution, maternal and paternal age according to the birth weight in live birth children with CdLS
Birth weight 2,500 g M:F maternal age paternal age limb anomalies 0.98 (39/40) 29.1 4.7 31.3 4.9 No of cases = 47/61 (77.1%) >2,500 g 0.54 (7/13) 27.8 4.84 29.8 5.7 No of cases = 7/18 (38.9%) Total 0.87 28.8 4.7 31 4.9

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