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Molecular
Diagnostics
Fundamentals, Methods,
and Clinical Applications
THIRD EDITION
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Thanks and gratitude are extended to all who helped This book was originally envisioned by my co-author
in the completion of the third edition of this work. The for the first edition, Dr. Maribeth Flaws. Thanks to her
useful input provided by reviewers who gave their valu- for initiating this project. Thanks to Dr. Herb Miller and
able time to comment on and improve the writing is the Medical Laboratory Science faculty in the Rush Uni-
gratefully acknowledged. Molecular laboratory science versity College of Health Sciences for the opportunity
is an example of innovative technology applied to the to participate in medical laboratory science education. I
ultimate goal of improved patient care. greatly appreciate the guidance and support of the pub-
I owe thanks to my colleagues at Rush University lication staff at F. A. Davis—Christa Fratantoro, Julie
Medical Center, Dr. Wei-Tong Hsu, Dr. Nick Moore, Chase, Roxanne Klaas, and Katharine Margeson—for
Dr. Mary Hayden, Dr. Sivadasan Kanangat, and Dr. Eliz- the illustration and production of the text.
abeth Berry-Kravis, for help and support in their areas of I would like to acknowledge and thank fellow
expertise. I would also like to acknowledge colleagues members of the Association for Molecular Pathology, a
in the Rush University College of Health Sciences, res- vibrant and resourceful organization dedicated to educa-
idents, fellows, students, and laboratory professionals tion and policy in the practice of molecular diagnostics.
who provided suggestions for the third edition, partic- This organization has provided an outlet for contex-
ularly Alexandra Vardouniotis, Dr. Mezgebe Gebrekiris- tual information, training, and sanction to further this
tos, and Adrian Tira, with whom I work and from whom ever-advancing field of study.
I learn every day.
xi
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To our students committed to
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Preface
Molecular technology continues to grow in importance purpose, principles, and interpretation of the molecular
in the clinical laboratory. Training of health-care pro- diagnostic tests that they will be ordering and assessing
fessionals routinely includes molecular biology, from for their patients.
laboratory techniques to therapeutic decisions. This text- Students who are first learning about molecular-based
book was written to provide fundamental knowledge of assays will find the text useful for explaining the funda-
molecular biology, current methods, and their clinical mental principles. Practitioners who are performing and
applications. interpreting these assays can use this text as a resource
The primary audience for this text is students enrolled for reference and troubleshooting and to drive the imple-
in Clinical/Medical Laboratory Science programs at all mentation of additional molecular-based assays in their
levels. It explains the principles of molecular technol- laboratories.
ogy that are used for diagnostic purposes. Examples of An Instructor ’s Resource package has been devel-
applications of molecular-based assays are included in oped for educators who adopt this text for a course.
the text, along with case studies that illustrate the use These resources, including PowerPoint presentations, a
and interpretation of these assays in patient care. test-item bank, and additional case studies, are available
This text is also appropriate for those in other on DavisPlus at http://davisplus.fadavis.com.
health-related disciplines who need to understand the
Lela Buckingham
vii
Reviewers
Catherine E. Bammert, MS, CT, MB (ASCP)CM Rachel Hulse, MS, MLS (ASCP)CM
Associate Professor Program Director
Program Director, Diagnostic Molecular Science Medical Laboratory Sciences
Clinical Laboratory Sciences Idaho State University
Northern Michigan University Pocatello, Idaho
Marquette, Michigan
Marisa K. James, MA, MLS (ASCP)CM
Katie Bennett, PhD, MB (ASCP), NRCC-CC Program Director
Assistant Professor and Laboratory Director School of Clinical Laboratory Science
Laboratory Sciences and Primary Care North Kansas City Hospital
Texas Tech University Health Sciences Center North Kansas City, Missouri
Lubbock, Texas
Jacqueline Peacock, PhD, MB (ASCP)CM
Tammy Carter, PhD, MT (ASCP), MB (ASCP) Assistant Professor and Program Coordinator
Assistant Professor, CLS Program Director Clinical Laboratory, Respiratory Care, and Health
Laboratory Science and Primary Care Administration Programs
Texas Tech University Health Sciences Center Ferris State University
Lubbock, Texas Grand Rapids, Michigan
ix
x Reviewers
Transfer RNA 33
Section I Other RNAs 35
Fundamentals of Molecular Biology: RNA POLYMERASES 35
OTHER RNA-METABOLIZING ENZYMES 36
An Overview 1
Ribonucleases 36
1 Nucleic Acids and Proteins 2 RNA Helicases 37
PROTEINS AND THE GENETIC CODE 37
DNA 3
Amino Acids 38
DNA STRUCTURE 4
Genes 43
Nucleotides 4
The Genetic Code 43
Nucleic Acid 8
TRANSLATION 46
DNA REPLICATION 9
Amino Acid Charging 46
Polymerases 11
Protein Synthesis 47
ENZYMES THAT METABOLIZE DNA 14
Restriction Enzymes 14 2 Gene Expression and Epigenetics 57
DNA Ligase 17 TRANSCRIPTION 58
Other DNA Metabolizing Enzymes 17 Transcription Initiation 58
RECOMBINATION IN SEXUALLY REPRODUCING ORGANISMS 19 Transcription Elongation 58
RECOMBINATION IN ASEXUAL REPRODUCTION 21 Transcription Termination 59
Conjugation 21 REGULATION OF TRANSCRIPTION 60
Transduction 23 Regulation of Messenger RNA Synthesis at Initiation 60
Transformation 23 Post-Transcriptional Regulation 64
PLASMIDS 25 Post-Translational Regulation 64
RNA 27 EPIGENETICS 65
Transcription 27 Histone Modification 65
Transcription Initiation 28 Nucleic Acid Methylation 66
Transcription Elongation 28 CLASSIFICATION OF EPIGENETIC FACTORS 69
Transcription Termination 29 NONCODING RNAs 69
TYPES/STRUCTURES OF RNA 29 MicroRNAs 70
Ribosomal RNA 29 Small Interfering RNAs 70
Messenger RNA 29 Other Small RNAs 70
Small Nuclear RNA 33 Long Noncoding RNAs 71
xiii
xiv Contents
Kirsten Rat Sarcoma Viral Oncogene Homolog, K-ras (12p12); HLA Test Discrepancies 436
Neuroblastoma ras, N-ras (1p13); and Harvey Rat Sarcoma Coordination of HLA Test Methods 437
Viral Oncogene Homolog, H-ras (11p15) 375 ADDITIONAL RECOGNITION FACTORS 437
Ewing Sarcoma, EWS (22q12) 376 Minor Histocompatibility Antigens 437
Synovial Sarcoma Translocation, Chromosome 18—Synovial Nonconventional MHC Antigens 437
Sarcoma Breakpoint 1 and 2, SYT-SSX1, SYT-SSX2 t(X;18) Killer Cell Immunoglobulin-Like Receptors 437
(p11.2;q11.2) 377 MHC DISEASE ASSOCIATION 438
Paired Box-Forkhead in Rhabdomyosarcoma, PAX3-FKHR, SUMMARY OF LABORATORY TESTING 439
PAX7-FKHR, t(1;13), t(2;13) 378
Tumor Protein 53, TP53 (17p13) 378 15 Quality Assurance and Quality Control
Ataxia Telangiectasia Mutated Gene, ATM (11q22) 379 in the Molecular Laboratory 446
Breast Cancer 1 Gene, BRCA1 (17q21), and Breast Cancer 2 Gene, SPECIMEN HANDLING 447
BRCA2 (13q12) 380 Collection Tubes for Molecular Testing 448
Von Hippel–Lindau Gene, VHL (3p26) 380 Precautions 450
V-myc Avian Myelocytomatosis Viral-Related Oncogene, Holding and Storage Requirements 451
Neuroblastoma-Derived, MYCN or n-myc (2p24) 381 TEST PERFORMANCE 451
V-Ros Avian UR2 Sarcoma Virus Oncogene Homolog 1 (ROS1) Next-Generation Sequencing 456
Proto-Oncogene (6q22.1) and Rearranged During Transfection Calibrators and Method Calibration 456
(RET) Proto-Oncogene (10q11) 381 Controls 457
Anaplastic Lymphoma Receptor Tyrosine Kinase (ALK) QUALITY CONTROL 458
Proto-Oncogene, 2p23.1 382 QUALITY ASSURANCE 458
V-Kit Hardy-Zuckerman 4 Feline Sarcoma Viral Oncogene Homolog, INSTRUMENT MAINTENANCE 459
KIT, c-KIT (4q12) 382 Instrument Calibration 463
Other Molecular Abnormalities 382 REAGENTS 463
Microsatellite Instability 382 Reagent Categories 464
Loss of Heterozygosity 385 Chemical Safety 465
Liquid Biopsy 386 Reagent Storage 466
MOLECULAR ANALYSIS OF LEUKEMIA AND LYMPHOMA 387 Reagent Labeling 466
Gene Rearrangements 387 PROFICIENCY TESTING 468
Mutations in Hematological Malignancies 397 DOCUMENTATION OF TEST RESULTS 468
Mutation Spectra 405 Gene Nomenclature 469
Gene Sequencing Results 469
14 DNA-Based Tissue Typing 417 REPORTING RESULTS 469
THE MHC LOCUS 418
HLA POLYMORPHISMS 420 Appendix A Study Question Answers 473
HLA Nomenclature 420
MOLECULAR ANALYSIS OF THE MHC 425
Appendix B Answers to Case Studies 501
Serological Analysis 427 Glossary 505
DNA-Based Typing 430
Combining Typing Results 436 Index 529
107 copies
106 copies
105 copies
100
104 copies
103 copies
102 copies
101 copies
10
Rn
0.1
1 3 5 7 9 21 23 25 27 29 33 35 37 39 41 43 45 47 49
Cycle
COLOR PLATE 1 A plot of the accumulation of polymerase COLOR PLATE 3 Chromosome painting showing a deriva-
chain reaction (PCR) product over 50 cycles of PCR. In this tive chromosome formed by the movement of a fragment of
sigmoid curve, the generation of fluorescence occurs earlier chromosome 12 (black) to an unidentified chromosome. See
with more starting template (solid lines) than with less (dotted Figure 7.19 in the text.
lines). See Figure 6.13A in the text.
Cell nucleus
Probes
Reciprocal
translocation
Translocated product
chromosome
CCTTTTTGAAATAAAGNCCTGCCCNGTATTGCTTTAAACAAGATTT
10 20 30 40
CCTCTATTGTTGGATCATTCGTCACAAAATGATTCTGAATTAGCGTATCGT
60 70 80 90 100
COLOR PLATE 5 Electropherogram showing a dye blob at the beginning of a sequence (nucleotide positions 9 to 15). The
sequence read around this area is not accurate. See Figure 9.10 in the text.
A
C
G
T
GATTCTGAATTAGCTGTATCG NNTTSTGNMATYNKCTKNATCG
COLOR PLATE 6 Examples of good sequence quality (left) and poor sequence quality (right). Note the clean baseline on the
good sequence; that is, only one color peak is present at each nucleotide position. Automatic sequence-reading software will not
accurately call a poor sequence. Compare the text sequences below the two scans. See Figure 9.11 in the text.
A
C
G
T
COLOR PLATE 7 Sequencing of a heterozygous G to T mutation in exon 12 of the KRAS gene. The normal codon sequence is
GGT (left). The heterozygous mutation (GT; center) is confirmed in the reverse sequence (CA; right). See Figure 9.12 in the text.
A
C
G
T
G T A T G C A G A A A A T C T T A G A G T G T C C C A T C T G G T A A G T C A G C
G T A T G C A G A A A A T C T T A G W G T S T C M Y M T S K K G R W A W S T S M R C
COLOR PLATE 8 The 187 delAG mutation in the BRCA1 gene detected by Sanger sequencing. This heterozygous dinucleotide
deletion is evident in the lower panel where, at the site of the mutation, two sequences are overlaid: the normal sequence and the
normal sequence minus two bases. See Figure 9.13 in the text.
0.08
Fluorescence (FZ/Back–F1)
0.07
BK
0.06
0.05
0.04
JC
0.03
0.02
0.01
0
55 60 65 70 75 80 85
Temperature (°C)
Fluorescence, d(FZ/Back–F1)dt
0.012
0.01
COLOR PLATE 9 Melt-curve analysis of BK and JC viruses. BK BK
JC
and JC are differentiated from one another by differences in the 0.008
Tm* of the probe specific for each viral sequence. Fluorescence 0.006
from double-stranded DNA decreases with increasing temperature 0.004
and DNA denaturation to single strands (top panel). Instrument 0.002
software will present the derivative of the fluorescence (bottom
0
panel) where the melting temperatures (Tm; 67°C to 68°C for BK
–0.002
and 73°C to 74°C for JC) are observed as peaks. See Figure 11.4 60 62 64 66 68 70 72 74 76 78 80
in the text. Temperature (°C)
HAZARDOUS MATERIALS
CLASSIFICATION
2
0 Will not burn
4 May deteriorate
3 Shock and heat
Oxidizer OXY may deteriorate
Acid ACID 2 Violent chemical
Alkali ALK change
Corrosive COR 1 Unstable if
Use No Water W heated
Radiation 0 Stable
RADIATION
COLOR PLATE 13 Rooms, cabinets, and equipment contain-
ing radioactive chemicals are identified with radiation safety
labels. See Figure 15.18 in the text.
Section I
Fundamentals of Molecular
Biology: An Overview
1
Chapter 1
Nucleic Acids and Proteins