Cancer spectrum and frequency among children with Noonan, Costello, and cardio-facio-cutaneous syndromes.

BACKGROUND: Somatic mutations affecting components of the Ras-MAPK pathway are a common feature of cancer, whereas germline Ras pathway mutations cause developmental disorders including Noonan, Costello, and cardio-facio-cutaneous syndromes. These 'RASopathies' also represent cancer-prone syndromes, but the quantitative cancer risks remain unknown. METHODS: We investigated the occurrence of childhood cancer including benign and malignant tumours of the central nervous system in a group of 735 individuals with germline mutations in Ras signalling pathway genes by matching their information with the German Childhood Cancer Registry. RESULTS: We observed 12 cases of cancer in the entire RASopathy cohort vs 1.12 expected (based on German population-based incidence rates). This corresponds to a 10.5-fold increased risk of all childhood cancers combined (standardised incidence ratio (SIR)=10.5, 95% confidence interval=5.4-18.3). The specific cancers included juvenile myelomonocytic leukaemia=4; brain tumour=3; acute lymphoblastic leukaemia=2; rhabdomyosarcoma=2; and neuroblastoma=1. The childhood cancer SIR in Noonan syndrome patients was 8.1, whereas that for Costello syndrome patients was 42.4. CONCLUSIONS: These data comprise the first quantitative evidence documenting that the germline mutations in Ras signalling pathway genes are associated with increased risks of both childhood leukaemia and solid tumours.

[The histological confirmation of diffuse axonal injury in severe brain injury survivors]. / Der histologische Nachweis des diffusen axonalen Hirnschadens bei Überlebenden schwerer Schädel-Hirntraumen.

Diffuse axonal injury (DAI) plays a major role after traumatic brain injury (TBI). Its imaging is based on computed tomography (CT) or magnetic resonance imaging (MRI). However, DAI is a histological diagnosis. Histopathological findings on survival after TBI are very rare. Hence, it is unclear whether the neuroradiological findings are of clinical relevance. Cerebral specimens were taken in 24 patients with TBI requiring surgery. The presence of histopathological evidence for DAI was evaluated. Specimens were taken from an extracranial brain prolapse (n = 2) and from peripheral parts of a brain contusion (n = 22). Histological findings were correlated to the clinical course and the neurological status. A clinical follow-up was carried out 6 months after the surgery using the Glasgow Outcome Score (GOS). The study was approved by the local ethics committee. Specimens taken were temporal (n = 11), frontal (n = 8), parietal (n = 4) and cerebellar (n = 1). The incidence of DAI within these specimens was 30% (7 with DAI, 17 without DAI). DAI was verifiable up to 3 days after trauma. There was no correlation between DAI and Marshall classification in CT. The period of coma was longer in subjects with DAI. There was no difference in GOS in the case of a verified DAI. These results enforce the prognostic and neuroradiologic relevance of DAI. However, it is debatable whether the pathomorphologic findings in CT or MRI represent the histological findings of DAI. We suggest a multicentre study for further clarification.

CHD7 mutations causing CHARGE syndrome are predominantly of paternal origin.

CHARGE (coloboma, heart defects, atresia of the choanae, retarded growth and development, genital hypoplasia, ear anomalies and deafness) syndrome is a congenital malformation syndrome caused by mutations in the CHD7 gene in approximately 2/3 of cases. In the vast majority of cases, CHARGE syndrome is sporadic. There are only a few reports of parent-to-child transmission and somatic or gonadal mosaicism. To determine the parental origin of CHD7 mutations in sporadic CHARGE syndrome, we screened 30 families for informative exonic or intronic polymorphisms located near the detected CHD7 mutation. An informative polymorphism could be identified in 13 out of 30 families. Linkage analysis was performed between the CHD7 mutation and the polymorphism in the child. In 12 out of 13 families, the mutation affected the paternal allele (92.3%). In our cohort, the mean paternal age at birth was 32.92 years. Comparing the age of fathers of an affected CHARGE patient with the paternal age of the German population in general, we could not observe any paternal age effect. Taken together, we show in this study that de novo CHD7 mutations occur predominantly in the male germ line.

Electrostriction at the LaAlO3/SrTiO3 interface.

We present a direct comparison between experimental data and ab initio calculations for the electrostrictive effect in the polar LaAlO(3) layer grown on SrTiO(3) substrates. From the structural data, a complete screening of the LaAlO(3) dipole field is observed for film thicknesses between 6 and 20 uc. For thinner films, an expansion of the c axis of 2% matching the theoretical predictions for an electrostrictive effect is observed experimentally.

Evolution of the interfacial structure of LaAlO3 on SrTiO3.

The evolution of the atomic structure of LaAlO_{3} grown on SrTiO_{3} was investigated using surface x-ray diffraction in conjunction with model-independent, phase-retrieval algorithms between two and five monolayers film thickness. A depolarizing buckling is observed between cation and oxygen positions in response to the electric field of polar LaAlO_{3}, which decreases with increasing film thickness. We explain this in terms of competition between elastic strain energy, electrostatic energy, and electronic reconstructions. Based on these structures, the threshold for formation of a two-dimensional electron system at a film thickness of 4 monolayers is quantitatively explained. The findings are also qualitatively reproduced by density-functional-theory calculations.

Stenosis of a colorectal anastomosis solved by transanal endoscopic microsurgery combined with laparoscopy.

OBJECTIVE: The objective of this case report is to present a minimally invasive technique for solving an anastomotic colorectal stenosis using Transanal Endoscopic Microsurgery (T.E.M.) in combination with laparoscopy. SUMMARY: Often a re-intervention is indicated for the resolution of an anastomotic (sub-) obstruction. This re-intervention is associated with the morbidity and mortality of a laparotomy and a prolonged hospital stay. In the case here presented, a 68-year-old man underwent a laparoscopic rectosigmoid resection for a rectal adenocarcinoma. An end-to-end circular stapled colorectal anastomosis was performed. At first without any postoperative problems, the patient presented with a stenosis of the anastomosis 6 months postoperatively. This stenosis did not result in a total obstruction but was sufficiently advanced to cause faecal impaction and discomfort, which was confirmed using a retrograde gastrografine bowel study. Colonoscopic dilatations were insufficient and after several days the patient experienced a recurrence of the original stenosis. A minimally invasive re-intervention with T.E.M. was performed in combination with laparoscopy to solve the stenosis. To our knowledge, this technique has not yet been described. CONCLUSION: In this paper we describe a possible minimally invasive technique to avoid laparotomy after colorectal or colo-anal anastomotic stenosis. Both the duration of the hospital stay and patient morbidity can be reduced in this way.

Proven germline mosaicism in a father of two children with CHARGE syndrome.

CHARGE syndrome is an autosomal dominant malformation syndrome caused by mutations in the CHD7 gene. The majority of cases are sporadic and only few familial cases have been reported. In these families, mosaicism in one parent, as well as parent- to-child transmission of a CHD7 mutation, has been described. In some further cases, germline mosaicism has been suggested. Here, we report the first case in which germline mosaicism could be demonstrated in a father of two affected children with CHARGE syndrome. The truncating mutation c.7302dupA in exon 34 of the CHD7 gene was found in both affected children but was not detected in parental lymphocytes. However, in DNA extracted from the father's spermatozoa, the c.7302dupA mutation could be identified. Furthermore, mutation analysis of DNA isolated from 59 single spermatozoa revealed that the c.7302dupA mutation occurs in 16 spermatozoa, confirming germline mosaicism in the father of the affected children. This result has a high impact for genetic counselling of the family and for their recurrence risk in further pregnancies.

Rectal cancer surgery : what's in a name?

The field of rectal cancer treatment is a dynamic and changing field, due to better understanding of the pathology and new medical treatment options, but perhaps mostly due to innovations in the surgical approach. Surgery is the cornerstone for rectal cancer treatment. Currently, Total Mesorectal Excision is the gold standard. After evolution towards laparoscopic TME, improving technology has led to the development of platforms that allow transanal TME and robotic TME. In addition, local excision can be performed safer and more accurately by means of Transanal Endoscopic Microsurgery (TEM), TransAnal Minimally Invasive Surgery or Endoscopic Submucosal Dissection (ESD), possibly avoiding TME. The aim of this review is to summarize the different surgical techniques and approaches for rectal cancer in function of tumor stage and describe the specifics of the technique.

Enhanced Population Control in a Synthetic Bacterial Consortium by Interconnected Carbon Cross-Feeding.

Engineered microbial consortia can provide several advantages over monocultures in terms of utilization of mixed substrates, resistance to perturbations, and division of labor in complex tasks. However, maintaining stability, reproducibility, and control over population levels in variable conditions can be challenging in multispecies cultures. In our study, we modeled and constructed a synthetic symbiotic consortium with a genetically encoded carbon cross-feeding system. The system is based on strains of Escherichia coli and Acinetobacter baylyi ADP1, both engineered to be incapable of growing on glucose on their own. In a culture supplemented with glucose as the sole carbon source, growth of the two strains is afforded by the exchange of gluconate and acetate, resulting in inherent control over carbon availability and population balance. We investigated the system robustness in terms of stability and population control under different inoculation ratios, substrate concentrations, and cultivation scales, both experimentally and by modeling. To illustrate how the system might facilitate division of genetic circuits among synthetic microbial consortia, a green fluorescent protein sensitive to pH and a slowly maturing red fluorescent protein were expressed in the consortium as measures of a circuit's susceptibility to external and internal variability, respectively. The symbiotic consortium maintained stable and linear growth and circuit performance regardless of the initial substrate concentration or inoculation ratio. The developed cross-feeding system provides simple and reliable means for population control without expression of non-native elements or external inducer addition, being potentially exploitable in consortia applications involving precisely defined cell tasks or division of labor.

Compound heterozygosity in the SPG4 gene causes hereditary spastic paraplegia.

The SPG4 gene is frequently mutated in autosomal dominant form of hereditary spastic paraplegia (HSP). We report that the compound heterozygous sequence variants S44L, a known polymorphism, and c.1687G>A, a novel mutation in SPG4 cause a severe form of HSP in a patient. The family members carrying solely c.1687G>A mutation are asymptomatic for HSP. The reverse transcriptase-polymerase chain reaction (RT-PCR) analysis revealed that the c.1687G>A mutation is a splice site mutation and causes skipping of the exon 15 of spastin. Furthermore, quantification of RT-PCR products by sequencing and quantification of allele-specific expression by pyrosequencing assay revealed that c.1687G>A is a leaky or hypomorphic splice site mutation. At the protein level, c.1687G>A mutation in SPG4 leads to E563K substitution. In ex vivo study, about 10% of cells expressing E563K mutant spastin showed filamentous expression pattern, suggesting a hypomorphic effect at the protein level. Collectively, our results suggest that S44L in association with c.1687G>A (E563K) drops the functional level of spastin below a threshold limit sufficient to manifest HSP.

Conducting interfaces between polar and non-polar insulating perovskites.

Two-dimensional electron gases in semiconductors have found use in applications such as optoelectronics, high-power radio-frequency and magnetoelectronic devices. The ability to grow heterostructures of oxides exhibiting similar effects is a significant step towards the fabrication of all-oxide devices. Here, we give an overview of recent studies of two-dimensional electron gases formed at the interface between polar and non-polar perovskites. We discuss the proposed explanations of the origin of the conductivity and properties of the ground state.

[Cancer screening for women is less frequently visited in regions with lower household income--analysis of data from health insurances in Bavaria]. / Die Krebsfrüherkennungsuntersuchung für Frauen wird in Regionen mit niedrigerem Haushaltseinkommen seltener in Anspruch genommen--Analyse von Daten der Kassenärztlichen Vereinigung Bayerns.

AIM OF THE STUDY: Differences in health care in Germany have rarely been analysed. Recent research, however, indicates that subjects of the lower social class participate in cancer screening less frequently. METHODS: Participation in screening for cervical cancer among women older than 20 years has been analysed using billing information of the KVB (Kassenärztlichen Vereinigung Bayern) for the period from 2002-2005. Women were assigned to one of the 96 Bavarian districts based on their postal code. The following variables were used: Participation rate in cervical cancer screening; age; average household income; gynaecologists per 10,000 women. Multivariate analyses were based on age-stratified linear regressions. RESULTS: There are considerable regional differences in participation in screening for cancer among older women. Participation rates are lower in districts with lower average household income. The correlation between participation rates and average household income shows an almost linear dependence on the level of districts. This association could not be explained by the variable "gynaecologists per 10,000 women". CONCLUSION: In order to provide social equality in health care, regional differences in cancer screening participation should be targeted. This is especially important in districts with lower average household incomes.

Anastomotic leakage of a colorectal anastomosis treated by transanal endoscopic microsurgery.

OBJECTIVE: To report a minimal invasive technique for repairing an anastomotic leakage with Transanal Endoscopic Microsurgery (T.E.M.) without creating a protective ostomy. SUMMARY: There are a large number of techniques for the management of anastomotic leakage after colorectal surgery. Depending on the size and location of the disruption, a protective ileostomy, a permanent colostomy or even reintervention for drainage or closure of the leak may be indicated. In most cases the patient faces the morbidity associated with a new intervention, a prolonged hospital stay and a future operation for closure of the stoma. In the present case a 56-year-old man underwent a laparoscopic rectosigmoid resection after two episodes of diverticulitis in six months. An end-to-end circular stapled anastomosis was constructed. Unfortunately 8-days postoperatively an anastomotic leak occurred. Attempts to close the tear non-surgically with colonoscopy and clipping failed. A minimally invasive reintervention with transanal endoscopic microsurgery (T.E.M.) was performed without creation of an ileostomy. One week postoperatively a gastrografin bowel study showed no leakage. To our knowledge, this technique has not yet been reported without the simultaneous construction of a stoma. CONCLUSION: We describe a possible minimally invasive technique to avoid laparotomy and/or the creation of a derivative stoma in the management of anastomotic leakage. Hospital stay is not significantly prolonged, future reïntervention for closure of stoma is avoided and sphincter function is preserved.

Positron emission tomographic analysis of central D1 and D2 dopamine receptor occupancy in patients treated with classical neuroleptics and clozapine. Relation to extrapyramidal side effects.

Positron emission tomography and selective radioligands were used to determine D1 and D2 dopamine receptor occupancy induced by neuroleptics in the basal ganglia of drug-treated schizophrenic patients. In 22 patients treated with conventional dosages of classical neuroleptics, the D2 occupancy was 70% to 89%. Patients with acute extrapyramidal syndromes had a higher D2 occupancy than those without side effects. This finding indicates that neuroleptic-induced extrapyramidal syndromes are related to the degree of central D2 occupancy induced in the basal ganglia. In five patients treated with clozapine, the prototype atypical antipsychotic drug, a lower D2 occupancy of 38% to 63% was found. This finding demonstrates that clozapine is also "atypical" with respect to the central D2 occupancy in patients. During treatment with clozapine, there is a low frequency of extrapyramidal syndromes, which accordingly may reflect the comparatively low D2 occupancy induced by clinical doses of clozapine. Classical neuroleptics, like haloperidol or sulpiride, did not cause any evident D1 occupancy, but the thioxanthene flupentixol induced a 36% to 44% occupancy. In four patients treated with clozapine, the D1 occupancy was 38% to 52%. The D1 occupancy induced by clozapine and flupentixol may contribute to the antipsychotic effect of these drugs.

Angiogenesis in multiple myeloma: correlation between in vitro endothelial colonies growth (CFU-En) and clinical-biological features.

Mouse models and studies performed on fixed bone marrow (BM) specimens obtained from patients with multiple myeloma (MM) suggest that plasma cell growth is dependent on endothelial cell (EC) proliferation within the BM microenvironment. In order to assess whether EC overgrowth in MM reflects a spontaneous in vitro angiogenesis, BM mononucleated cells from 13 untreated (UT) MM, 20 treated (11 with melphalan and nine with DAV schedule) MM, eight patients with monoclonal gammopathy of uncertain significance (MGUS) and eight controls were seeded in an unselective medium to assess EC proliferation. Furthermore, the influence of IL6 on the EC growth was investigated. Endothelial colonies (CFU-En) appeared as small clusters, formed by at least 100 slightly elongated and sometimes bi-nucleated cells expressing factor VIII, CD31 and CD105 (endoglin). The CFU-En mean number/10(6) BM mononucleated cells in untreated MM samples (2.07 s.d. +/- 1.3) was significantly higher than in normal BM (0.28 +/- 0.48), while no difference was seen between normal BM and MGUS (0.28 +/- 0.54). Interestingly, the mean number of CFU-En in the DAV group (1.88 +/- 1.6) did not differ from the UT, while it was found to be lower in the melphalan group (0.31 +/- 0.63). The addition of anti-IL6 monoclonal antibody induced a reduction of both the plasma cells in the supernatant and the CFU-En number. This study describes a rapid and feasible assay providing support for the association between EC and plasma cells further suggesting that the in vitro angiogenesis process may parallel that observed in vivo.

Immunohistochemical determination of five somatostatin receptors in meningioma reveals frequent overexpression of somatostatin receptor subtype sst2A.

Meningioma is one of a variety of human tumors that exhibit a very high density of somatostatin receptors and in many cases show a true positive somatostatin receptor scintigraphy. However, the level of expression of individual somatostatin receptor proteins in meningioma has not been investigated. We have recently developed a panel of somatostatin receptor subtype-specific antibodies that effectively stain formalin-fixed, paraffin-embedded tumor tissue (S. Schulz et al., Clin. Cancer Res., 4: 2047-2052, 1998). In the present study, we have used these antibodies to determine the somatostatin receptor status of 40 randomly selected meningiomas. Immunoreactive staining for all somatostatin receptors was clearly located at the plasma membrane of the tumor cells and completely blocked with antigenic peptide. The vast majority of tumors (29 cases; 70%) were positive for sst2A immunoreactivity; among these, 20 (69%) tumors showed high levels of sst2A immunoreactivity. In contrast, all other somatostatin receptors were only detected sporadically, and none of these cases revealed a particularly strong staining. However, it is uncertain to what extent somatostatin receptor-immunoreactive staining intensity may translate into somatostatin receptor protein expression on the tumor cells. Therefore, in a prospective study, 16 surgically removed meningiomas were collected, and the level of sst2A expression was determined using Western blot analysis. Whereas sst2A was readily detectable as a broad band migrating at Mr 70,000 in 12 (75%) of these tumors, 8 tumors (50%) showed particularly high levels of immunoreactive sst2A receptors. There was an excellent correlation (P < 0.001) between the level of sst2A protein expression detected in Western blots and the sst2A- immunoreactive staining seen in tissue sections. Thus, the frequent overexpression of the sst2A receptor may explain the high tracer uptake often observed in meningioma patients during somatostatin receptor scintigraphy. Moreover, this simple immunohistochemical method could prove useful in identifying those cases of recurrent disease that may possibly respond to therapy with sst2-selective agonists.

Induction of topoisomerase II activity after ErbB2 activation is associated with a differential response to breast cancer chemotherapy.

ErbB2 (HER-2) gene amplification and overexpression have been shown to predict a better outcome with doxorubicin-based chemotherapy as opposed to alkylator-based chemotherapy in early stage breast cancer. To understand the mechanism of differential response to these two regimens, we have evaluated the effect of signaling through the ErbB2 receptor on downstream enzymes that may affect drug response, using two different models. The first system employs breast cancer cells that have high levels of endogenous ErbB2 by gene amplification (BT-474 and SKBR3 cells). The second system allows us to isolate the effect of ErbB2 receptor-mediated intracellular signaling using an epidermal growth factor receptor-ErbB2 chimeric receptor activated by epidermal growth factor. Our experiments show that the cytotoxicity of doxorubicin is inhibited in ErbB2+ breast cancer cells by the anti-ErbB2 antibody, Herceptin. This is accompanied by a decrease in topoisomerase (topo) IIalpha protein and activity, suggesting that this is the mechanism of change in doxorubicin response. In addition, a 10-100-fold (1-2 log) decrease in the LD(50) of doxorubicin is seen after ErbB2 activation using the chimeric receptor model. Furthermore, we see a 100-fold decrease in the LD(50) of etoposide, another topo II inhibitor. This increase in doxorubicin sensitivity is associated with a 4.5-fold increase in the amount of topo IIalpha protein and an increase in topo II activity as measured by DNA decatenating and unknotting activities, as well as cleavable complex formation. In contradistinction to doxorubicin, we have observed an increased resistance to cyclophosphamide chemotherapy after chimeric receptor activation. We propose that the differential benefit seen with doxorubicin- versus alkylator-based chemotherapy in ErbB2+ breast cancer is due, in some cases, to ErbB2-mediated topo IIalpha activation. These data also suggest hypotheses for the optimal sequencing of Herceptin and chemotherapy agents in ErbB2+ breast cancer.

Tumors of low malignant potential arising in the fallopian tube: case reports.

BACKGROUND: There is a paucity of information regarding fallopian tube tumors of low malignant potential (LMP) in the literature. CASE: We present two cases representing alternative management options of low LMP of the fallopian tube. CONCLUSION: Although low malignant potential tumors of the ovary are relatively common, there are few reported cases of tumors of LMP originating in the fallopian tube. Treatment has been extrapolated from tumors of LMP of the ovary, and conservative fertility-sparing surgery and complete staging procedure remains controversial. We urge continued reporting of these fallopian tube tumors of LMP to enhance understanding of these rare tumors and to develop a more cohesive treatment plan.

CD34(+) cell subsets and long-term culture colony-forming cells evaluated on both autologous and normal bone marrow stroma predict long-term hematopoietic engraftment in patients undergoing autologous peripheral blood stem cell transplantation.

OBJECTIVE: The aim of this study was to evaluate which CD34(+) cell subset contained in leukapheresis products could be regarded as the most predictive of long-term hematopoietic recovery after autologous peripheral blood stem cell transplantation (auto-PBSCT). MATERIALS AND METHODS: Based on data from 34 patients with hematologic malignancies, doses of CD34(+) cells and CD34(+) cell subsets, defined by the expression of HLA-DR, CD38, CD117 (c-kit/R), CD123 (alpha subunit of IL-3/R), CD133 (AC133), and CD90 (Thy-1) antigens, were correlated with the number of short-term (i.e., colony-forming cells [CFC]) and long-term culture CFC (LTC-CFC) (generated at week 5 of culture) and with the kinetics of hematopoietic engraftment following auto-PBSCT. The capacity of autologous stroma (AS), normal human bone marrow stroma, and M2-10B4 murine cell line to sustain CD34(+) cell growth was comparatively evaluated in the LTC assay. RESULTS: Our data demonstrated that some of the most primitive progenitor subsets (CD34(+)CD117(-)HLA-DR(-), and CD34(+)CD38(+)HLA-DR(-)) showed the strongest correlation with LTC-CFC numbers generated within the AS, whereas no significant correlation was noted using normal bone marrow stroma. Multivariate analysis showed that the only CD34 cell subset independently associated with long-term (3 to 6 months) platelet engraftment after auto-bone marrow transplantation was the CD34(+)CD117(-)HLA-DR(-) phenotype; long-term erythrocyte engraftment was correlated with CD34(+)CD38(+)HLA-DR(-) cell content. The latter further influenced platelet engraftment in the first 3 months after auto-PBSCT. The most predictive parameters for neutrophil engraftment were CD34(+)CD38(+)HLA-DR(-) cell subtype and the total LTC-CFC quantity infused. CONCLUSIONS: These data further support the hypothesis that the type of stromal feeders influences the frequency of LTC-CFC, possibly because they differ in their ability to interact with distinct subsets of hematopoietic stem cells. Furthermore, as the use of AS in LTC assay can mimic in vitro the human bone marrow microenvironment, it can be speculated that this culture system could be a useful means to study the kinetics of recovery of bone marrow stroma following chemotherapy and PBSCT. From these results, it can be concluded that some CD34(+) cell subsets appear to be more reliable predictors of long-term hematopoietic recovery rates than total CD34(+) cell quantity.

Large deletions play a minor but essential role in congenital coagulation factor VII and X deficiencies.

UNLABELLED: Congenital factor VII (FVII) and factor X (FX) deficiencies belong to the group of rare bleeding disorders which may occur in separate or combined forms since both the F7 and F10 genes are located in close proximity on the distal long arm of chromosome 13 (13q34). We here present data of 192 consecutive index cases with FVII and/or FX deficiency. 10 novel and 53 recurrent sequence alterations were identified in the F7 gene and 5 novel as well as 11 recurrent in the F10 gene including one homozygous 4.35 kb deletion within F7 (c.64+430_131-6delinsTCGTAA) and three large heterozygous deletions involving both the F7 and F10 genes. One of the latter proved to be cytogenetically visible as a chromosome 13q34 deletion and associated with agenesis of the corpus callosum and psychomotor retardation. CONCLUSIONS: Large deletions play a minor but essential role in the mutational spectrum of the F7 and F10 genes. Copy number analyses (e. g. MLPA) should be considered if sequencing cannot clarify the underlying reason of an observed coagulopathy. Of note, in cases of combined FVII/FX deficiency, a deletion of the two contiguous genes might be part of a larger chromosomal rearrangement.