MSX2 COPY number increase and craniosynostosis Pelegrino KO et al. 4q22.1 region and craniosynostosis has been described. In addition, no patient with case data reported in DECIPHER who had alterations in 8q24.3 or 9q34.2-34.3 similar to those in our patient exhibited craniosynostosis. In a detailed study that investigated common CNVs in Asian population, it was found that the KLHL8 (4q22.1), VAV2 (9q34.2) and OLFM1 (9q34.3) genes exhibited copy number variations in phenotypically normal subjects (15), indicating that copy number losses in these genes most likely do not contribute to the craniosynostosis phenotype. Corro- borating these findings, a search of the Online Mendelian Inheritance in Man (OMIM) database (16) returned no correlations between the genes KLHL8, VAV2, DRD1, SFXN1, DENND3, SLC45A4 and OLFM1 and clinical pheno- types. The SARDH gene, located in the 9q34.2 region, was shown to be associated with sarcosinemia, which is generally considered a benign condition unrelated to neurologic symptoms or significant clinical problems (17). Among the CNVs found in the present work, the gain in the 5q35.2 chromosome region where the MSX2 gene is located has already been reported to be associated with craniosynos- tosis (8); however, the MSX2 gain was confirmed using molecular techniques in only four cases (8-11). MSX2 is a member of the homeobox MSX family and is related to Drosophila muscle segment homeobox (msh). MSX2 has important roles in tissue and organ development (3) and is also expressed in several regions of the developing skull. In mice, Msx2 is strongly expressed in osteogenic cells from calvarial sutures, and Msx2 activation is thought to initiate the release of factors from the dura mater that affect osteoblastic suture cells (18,19). Consistent with this role of Msx2, transgenic mice that over expressed this gene exhibited premature suture closure and craniofacial abnormalities (5), whereas other evidence suggests that MSX2 haploinsufficiency leads to a delayed or incomplete closure of the opening between the frontal and parietal bones. MSX2 haploinsufficiency has been demon- strated to be responsible for the majority of foramina parietalia permagna (FPP) cases (20-22). There are 39 reported cases of 5q distal trisomy, but craniosynostosis was observed in only ten of these cases. Because most craniosynostosis patients exhibit a distal 5q duplication, it is hypothesized that in patients with larger duplications, MSX2 expression may be inhibited due to extra copies of other genes (8). Additional cases may help to elucidate the validity of this hypothesis. In conclusion, our analysis indicates that an increase in MSX2 copy number is correlated with this disorder, corroborating previous findings that subjects with gains in 5q35.2 in the MSX2 gene region exhibit craniosynostosis. In addition, the aCGH technique was shown to be useful for the detection of CNVs throughout the whole genome. Further studies should now be undertaken to determine which of these CNVs are normal individual variations and which are of clinical relevance, e.g., associated with specific syndromes. ACKNOWLEDGMENTS We would like to thank the patient and her parents for their participation in our research. This study used data generated by the DECIPHER Consortium. A full list of the centers that contributed to the generation of the data is available from http://decipher.sanger.ac.uk and via e-mail from: decipher@sanger.ac.uk. We would specifically like to thank Dr. J. M. Friedman and Dr. McGillivray from the University of British Columbia for 984 CLINICS 2012;67(8):981-985 additional data on Decipher patient 994, Dr. Anne Philippe from Universite´ Rene´ Descartes for data on Decipher patient 753 and Dr. Koen Devriendt for data on patient 249573. This study was supported by Fleury Group. AUTHOR CONTRIBUTIONS Pelegrino KO performed the aCGH experiments, the qPCR assays and the data analysis and interpretation and participated in the preparation and revision of the manuscript. Sugayama S was responsible for the patient examination and clinical description and participated in the preparation of the manuscript. Lezirovitz K performed the DNA extraction and participated in the aCGH experiments. Catelani AL performed the karyotype analysis. Kok F participated in the writing of the discussion section and in the revision of the manuscript. 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