MUTYH c.1585C>A, p.(Leu529Met)

Reasoning

No usable population-specific BS1 rule is provided by the MUTYH InSiGHT specification, whose retrieved rule payload is empty, so the supplied generic SVI BS1 default of allele frequency >=0.01 applies. The variant reaches AF 0.0241255554 in the gnomAD v2.1 non-cancer Admixed American subgroup and grpmax FAF 0.0228593, exceeding 0.01; the overall non-cancer exome AF is 0.0036336473. The elevated ancestry-specific frequency is relevant for this autosomal-recessive condition and is sufficient for generic BS1, although it should not be mistaken for BA1.

Rule

Generic BS1: allele frequency >=0.01, with per-gene derivation preferred; a governing VCEP-specific rule would take precedence, but none was populated in the retrieved MUTYH specification.

Evidence considered

• The retrieved MUTYH InSiGHT specification provides no populated criterion-specific population thresholds, so the supplied generic SVI BS1 default applies.
• gnomAD v2.1 non-cancer exomes report Admixed American AF 0.0241255554 (847/35108 alleles), exome grpmax FAF 0.0228593, and overall non-cancer exome AF 0.0036336473.
• The supplied generic SVI BS1 default is allele frequency >=0.01; per-gene derivation is preferred (Whiffin et al., 2017; PMID:28518168).
• The gnomAD v4.1 query failed and therefore contributes no additional frequency estimate.

Still missing

• The MUTYH InSiGHT specification was retrieved, but its population rule payload is empty; no MUTYH-specific BS1 threshold was available.
• The highest frequency is ancestry-specific, so ancestry representation and disease-prevalence calibration should be confirmed if a gene-specific threshold becomes available.

Sources

Reasoning

The applicable MUTYH InSiGHT specification is present but contains no criterion-specific functional rules, so generic ACMG/AMP functional interpretation is used. Komine et al. evaluated the exact p.Leu529Met substitution in a MutY-deficient E. coli complementation assay with wild-type comparison and a predefined quantitative functional-retention threshold. p.Leu529Met was among the variants classified as functionally retained, with retention defined as a rifampicin-resistance mutation rate less than 1.7-fold above wild type. This is a direct, quantitative assay relevant to MUTYH base-excision-repair activity and supports BS3 at supporting strength. A single bacterial complementation system does not warrant escalation beyond supporting without independent orthogonal validation or a VCEP-specific calibration.

Evidence considered

• The MUTYH InSiGHT specification is applicable but provides no criterion-specific functional rule payload, so generic ACMG/AMP functional interpretation was required.
• The exact p.Leu529Met substitution was tested in a MutY-deficient E. coli complementation assay measuring rifampicin-resistant mutation rates against wild-type MUTYH.
• The study classified p.Leu529Met as functionally retained, with retention defined as a mutation rate less than 1.7-fold above wild type.
• The assay is biologically relevant to MUTYH DNA base-excision repair and quantitatively controlled, but a single bacterial system without independent orthogonal validation supports only supporting-strength BS3.

Still missing

• No independent orthogonal mammalian or human-cell functional assay for p.Leu529Met was identified.
• The MUTYH VCEP material supplies no functional-strength calibration for escalation beyond supporting.

Sources

Reasoning

NM_001128425.2:c.1585C>A is a missense variant, p.(Leu529Met), so BP4 must be adjudicated using REVEL only. The REVEL score is 0.237, meeting the generic ClinGen SVI supporting BP4 threshold of <=0.29 (Pejaver et al. 2022, PMID:36413997), but not the moderate threshold of <=0.183 or strong threshold of <=0.016. Therefore BP4 is met at supporting strength. The SpliceAI max delta of 0.005 is not considered because splice predictions cannot provide BP4 evidence for a missense consequence. The MUTYH InSiGHT framework is present but supplies no applicable PP3/BP4 rule payload, so the supplied generic calibration applies.

Rule

missense: REVEL only; BP4 supporting <=0.29, moderate <=0.183, strong <=0.016

Evidence considered

• Variant consequence: missense, NM_001128425.2:c.1585C>A, p.(Leu529Met).
• REVEL score is 0.237; the supplied ClinGen SVI calibration assigns BP4 supporting at <=0.29, moderate at <=0.183, and strong at <=0.016 (Pejaver et al. 2022, PMID:36413997).
• Path selection: missense variants use REVEL only; the SpliceAI max delta of 0.005 is not used for BP4.
• The MUTYH InSiGHT framework is applicable but contains no PP3/BP4-specific rule payload, so the supplied generic calibration is used.

Sources

Reasoning

PS1 is not met. The variant is NP_001121897.1:p.(Leu529Met), and the reviewed functional paper reports this same p.L529M variant as functionally retained in a MutY-deficient E. coli complementation assay; this is evidence about the index variant itself, not an independently observed pathogenic variant producing the same amino-acid change. No independent same-amino-acid-change comparator was identified.

Rule

PS1 requires a well-established pathogenic variant resulting in the same amino-acid change as the variant under review.

Evidence considered

• Komine et al. tested p.L529M directly in a MutY-deficient E. coli complementation assay and categorized it as functionally retained; this cannot serve as PS1 because PS1 requires an independent variant with the same amino-acid change.
• The normalized variant is NP_001121897.1:p.(Leu529Met).

Still missing

• No independent pathogenic variant producing the same amino-acid change was identified.

Sources

Reasoning

The applicable MUTYH InSiGHT specification is present but contains no criterion-specific functional rules, so generic ACMG/AMP functional interpretation is used. Komine et al. directly tested the exact p.Leu529Met substitution (NM_001128425.2:c.1585C>A) in a MutY-deficient E. coli complementation assay measuring rifampicin-resistance mutation rates. The assay categorized p.Leu529Met as functionally retained, using a predefined functional-retention threshold of less than 1.7-fold above wild-type mutation rate. This result does not demonstrate abnormal or reduced protein function and therefore does not support PS3 at any strength.

Evidence considered

• The MUTYH InSiGHT specification is applicable but provides no criterion-specific functional rule payload, so generic ACMG/AMP functional interpretation was required.
• Komine et al. tested the exact p.Leu529Met substitution in a MutY-deficient E. coli complementation assay measuring rifampicin-resistant mutation rates.
• The study categorized p.Leu529Met as functionally retained; functional retention was defined as a mutation rate less than 1.7-fold higher than wild type, which is evidence against the functional impairment required for PS3.

Sources

Reasoning

No usable population-specific PM2 rule is provided by the MUTYH InSiGHT specification, whose retrieved rule payload is empty, so the supplied generic SVI PM2 supporting threshold of allele frequency <=0.0001 applies. The variant is present at AF 0.0036336473 in gnomAD v2.1 non-cancer exomes, with 16 homozygotes, and at AF 0.0015545372 in gnomAD v3.1 non-cancer genomes, with 2 homozygotes. These frequencies are above 0.0001 and the variant is not absent, so PM2 is not met. The gnomAD v4.1 query failure is missing data and cannot be used to alter this conclusion.

Rule

Generic PM2 Supporting: allele frequency <=0.0001; a governing VCEP-specific rule would take precedence, but none was populated in the retrieved MUTYH specification.

Evidence considered

• gnomAD v2.1 non-cancer exomes report AF 0.0036336473 from 861/236952 alleles and 16 homozygotes.
• gnomAD v3.1 non-cancer genomes report AF 0.0015545372 from 230/147954 alleles and 2 homozygotes; v3 has no exome cohort.
• The supplied generic SVI PM2 supporting threshold is allele frequency <=0.0001 (ClinGen SVI recommendation; PMID:25741868).
• The gnomAD v4.1 query failed; missing data cannot support PM2 or any frequency-based criterion.

Still missing

• The MUTYH InSiGHT specification was retrieved, but its population rule payload is empty; no MUTYH-specific PM2 threshold was available.

Sources

Reasoning

PP2 is not met. MUTYH is not established here as a gene in which missense variation is both a predominant disease mechanism and benign missense variation is uncommon: the available MUTYH functional literature describes numerous missense variants and established recurrent missense variants, including p.Y179C and p.G396D. The applicable MUTYH specification supplies no PP2 rule that would override this generic assessment.

Rule

PP2 is supporting evidence only when missense variation is a common pathogenic mechanism for the gene and benign missense variation is uncommon.

Evidence considered

• The MUTYH functional-assay paper states that more than 200 missense variants have been detected and identifies recurrent missense variants p.Y179C and p.G396D, inconsistent with a truncating-only disease mechanism or uniformly uncommon benign missense variation.
• The applicable MUTYH specification contains no retrieved PP2-specific rule.

Sources

Reasoning

NM_001128425.2:c.1585C>A is a missense variant, p.(Leu529Met), so PP3 must be adjudicated using REVEL only. The REVEL score is 0.237, below the generic ClinGen SVI supporting PP3 threshold of >=0.644 (Pejaver et al. 2022, PMID:36413997), and therefore does not support PP3 at any strength. The SpliceAI max delta of 0.005 is not considered because splice predictions cannot provide PP3 evidence for a missense consequence. The MUTYH InSiGHT framework is present but supplies no applicable PP3/BP4 rule payload, so the supplied generic calibration applies.

Rule

missense: REVEL only; PP3 supporting >=0.644, moderate >=0.773, strong >=0.932

Evidence considered

• Variant consequence: missense, NM_001128425.2:c.1585C>A, p.(Leu529Met).
• REVEL score is 0.237; the supplied ClinGen SVI calibration assigns PP3 supporting at >=0.644, moderate at >=0.773, and strong at >=0.932 (Pejaver et al. 2022, PMID:36413997).
• Path selection: missense variants use REVEL only; the SpliceAI max delta of 0.005 is not used for PP3.
• The MUTYH InSiGHT framework is applicable but contains no PP3/BP4-specific rule payload, so the supplied generic calibration is used.

Sources

Reasoning

PP5 is restricted here to an exact-variant ClinVar expert-panel classification of Pathogenic or Likely pathogenic. ClinVar reports Benign/Likely benign submissions for the exact matched variant, but the submission audit identifies 0 expert-panel submissions. Ordinary laboratory submissions, aggregate labels, and non-expert assertions cannot trigger PP5.

Rule

Apply PP5 only for an exact-variant ClinVar expert-panel classification of Pathogenic or Likely pathogenic; laboratory submissions and aggregate ClinVar labels are excluded.

Evidence considered

• The exact-match ClinVar submission audit reports 0 expert-panel submissions.
• The exact-variant ClinVar submission summary is Benign (11 laboratories) and Likely benign (6 laboratories), not Pathogenic or Likely pathogenic.

Sources

Reasoning

No usable population-specific BA1 rule is provided by the MUTYH InSiGHT specification, whose retrieved rule payload is empty, so the supplied generic ACMG/AMP BA1 threshold of allele frequency >=0.05 applies. The highest observed frequency is 0.0241255554 in the gnomAD v2.1 non-cancer Admixed American subgroup, with overall non-cancer exome AF 0.0036336473; both are below 0.05. The gnomAD v4.1 all-comers query failed and cannot be treated as absence or used to establish BA1.

Rule

Generic BA1: allele frequency >=0.05; a governing VCEP-specific rule would take precedence, but none was populated in the retrieved MUTYH specification.

Evidence considered

• The retrieved MUTYH InSiGHT specification identifies autosomal-recessive familial adenomatous polyposis 2 but provides no populated criterion-specific population thresholds, so the supplied generic ACMG/AMP threshold applies.
• gnomAD v2.1 non-cancer exomes report overall AF 0.0036336473 (861/236952 alleles) and the highest subgroup AF 0.0241255554 in Admixed American individuals (847/35108 alleles).
• The supplied generic ACMG/AMP BA1 threshold is allele frequency >=0.05 (Richards et al., 2015; PMID:25741868).
• The gnomAD v4.1 query failed; this missing result is not evidence of absence or a qualifying frequency.

Still missing

• The MUTYH InSiGHT specification was retrieved, but its population rule payload is empty; no MUTYH-specific BA1 threshold was available.

Sources

Reasoning

BP1 is not met. BP1 applies when a gene's disease mechanism is well established to be exclusively or almost exclusively truncating; MUTYH has documented missense variation relevant to disease interpretation, including recurrent missense variants p.Y179C and p.G396D. The applicable MUTYH specification provides no gene-specific BP1 rule establishing a truncating-only mechanism.

Rule

BP1 is supporting benign evidence for a missense variant in a gene where disease is established to be caused almost exclusively by truncating or loss-of-function variants.

Evidence considered

• The MUTYH functional-assay paper describes recurrent missense variants p.Y179C and p.G396D and evaluates many additional missense variants, arguing against a truncating-only disease mechanism.
• The applicable MUTYH specification contains no retrieved BP1-specific rule establishing that only truncating variants cause disease.

Sources

Reasoning

BP6 is restricted here to an exact-variant ClinVar expert-panel classification of Benign or Likely benign. Although the exact-match ClinVar record contains Benign/Likely benign laboratory submissions, the submission audit identifies 0 expert-panel submissions; therefore the aggregate and non-expert classifications cannot trigger BP6.

Rule

Apply BP6 only for an exact-variant ClinVar expert-panel classification of Benign or Likely benign; ordinary laboratory submissions and aggregate labels are excluded.

Evidence considered

• The exact-match ClinVar submission audit reports 0 expert-panel submissions.
• ClinVar reports Benign and Likely benign classifications from laboratory submissions, which are explicitly excluded from BP6 under the adjudication rule.

Sources

Reasoning

PS2 cannot be assessed: the available case evidence contains no proband-level parental testing demonstrating that NM_001128425.2:c.1585C>A (p.Leu529Met) is absent from both parents, and provides no confirmed de novo observation or maternity/paternity information. The MUTYH InSiGHT framework was reviewed but contains no criterion-specific PS2 rule or case data to resolve this gap.

Evidence considered

• The reviewed case evidence contains no proband-level parental testing, de novo statement, or maternity/paternity confirmation for NM_001128425.2:c.1585C>A (p.Leu529Met).
• The ClinGen InSiGHT MUTYH specification is present, but its retrieved ruleset is incomplete and contains no PS2-specific rule payload or variant-level segregation data.

Still missing

• Documented parental genotypes for both biological parents
• Confirmation of maternity and paternity if applying de novo evidence
• A proband-level clinical report establishing a de novo occurrence

Sources

Reasoning

The MUTYH InSiGHT specification was retrieved, but its rule payload is unstructured and supplies no PS4 threshold. The reviewed exact-variant literature does not mention NM_001128425.2:c.1585C>A (NP_001121897.1:p.(Leu529Met)); the available papers therefore provide no affected-case count, control comparison, odds ratio, likelihood ratio, or other case-control enrichment measurement for this variant. PS4 cannot be adjudicated without variant-specific phenotype prevalence or statistically quantified enrichment evidence.

Rule

PS4 requires statistically significant enrichment of the exact variant in affected individuals compared with controls; no applicable MUTYH-specific threshold was retrieved.

Evidence considered

• The retrieved ClinGen InSiGHT MUTYH specification is the governing framework, but it contains no structured PS4 rule or threshold.
• PMID:22703879 reports other MUTYH variants in 572 ClinSeq participants and explicitly does not mention c.1585C>A or p.(L529M).
• PMID:24728327 reports variation in a healthy cohort and explicitly does not mention c.1585C>A or p.(L529M); it provides no exact-variant case-control enrichment statistic.

Still missing

• Variant-specific affected-case and control counts or a published case-control enrichment statistic are unavailable.
• No governing MUTYH PS4 threshold is available in the retrieved specification.

Sources

Reasoning

PM1 could not be assessed to a defensible positive or negative conclusion. The governing InSiGHT MUTYH specification is applicable, but its retrieved ruleset is unstructured and provides no domain-table entry or authoritative critical-domain boundaries. Therefore residue 529 cannot be checked against a complete approved domain list, and no independent validated critical-domain source was supplied.

Rule

PM1 requires location in a mutational hot spot and/or critical functional domain without benign variation; a governing VCEP domain table takes precedence when available.

Evidence considered

• The applicable ClinGen InSiGHT MUTYH specification identifies the gene and transcript but has an incomplete unstructured ruleset with no extracted PM1 domain table.
• Because no authoritative complete domain list is available, residue 529 was not treated as being in or outside an approved critical functional domain.

Still missing

• An authoritative MUTYH critical-domain list or validated domain boundaries covering residue 529 are unavailable.

Sources

Reasoning

The MUTYH ClinGen InSiGHT framework establishes autosomal-recessive inheritance, but the available case evidence contains no affected proband with this variant, no second pathogenic or likely pathogenic MUTYH variant, and no validated evidence that this variant is in trans with another disease-causing allele. Population homozygote observations do not establish affected status, pathogenicity of the other allele, or phase. Therefore PM3 cannot be assessed.

Evidence considered

• The governing ClinGen InSiGHT MUTYH specification identifies familial adenomatous polyposis 2 as autosomal recessive, but its retrieved criterion rules are unstructured and provide no case-specific PM3 observation for this variant.
• The extracted PMID:25820570 finding concerns an E. coli complementation assay for p.Leu529Met and explicitly reports no case observations or segregation data; it therefore does not establish PM3.
• The extracted PMID:22703879 finding describes other MUTYH variants and notes that none were biallelic, but it does not mention c.1585C>A and cannot supply affected-proband or trans-phase evidence for this variant.

Still missing

• Affected-proband data for NM_001128425.2:c.1585C>A are unavailable.
• A second pathogenic or likely pathogenic MUTYH variant and confirmed trans phase are unavailable.
• No segregation or family-phasing evidence is available.

Sources

Reasoning

PM5 could not be assessed because no independently observed pathogenic or likely pathogenic missense comparator at MUTYH residue 529 was identified. The available report of p.L529M is the index variant itself, and the harvested PM5 candidate record contains no same-residue candidates.

Rule

PM5 requires a novel missense change at a residue where a different missense change is established as pathogenic or likely pathogenic; the comparator must be independent of the index variant.

Evidence considered

• The functional study lists p.L529M itself and classifies it as functionally retained; it does not provide an independent pathogenic comparator at residue 529.
• No same-residue comparator variant with a reliable pathogenic or likely pathogenic classification was identified.

Still missing

• Independent same-residue comparator variants with reliable pathogenic classifications are unavailable.

Sources

Reasoning

PM6 cannot be assessed: the available case evidence contains no report of NM_001128425.2:c.1585C>A (p.Leu529Met) as apparently de novo without parental testing, and no phenotype-linked proband report or family context is supplied to support such an inference. The MUTYH InSiGHT framework was reviewed but contains no criterion-specific PM6 rule or case data to resolve this gap.

Evidence considered

• The reviewed case evidence contains no apparently de novo observation, affected-proband report, parental-testing limitation, or phenotype-linked family history for NM_001128425.2:c.1585C>A (p.Leu529Met).
• The ClinGen InSiGHT MUTYH specification is present, but its retrieved ruleset is incomplete and contains no PM6-specific rule payload or variant-level evidence.

Still missing

• A published or clinical report identifying the variant in an affected proband
• Evidence that the variant was apparently de novo despite unavailable parental testing
• Phenotype and family context supporting the observation

Sources

Reasoning

PP1 cannot be assessed: no affected relatives, unaffected relatives, informative meioses, variant-positive or variant-negative family members, or phenotype-consistent segregation data are documented for NM_001128425.2:c.1585C>A (p.Leu529Met). The MUTYH InSiGHT framework was reviewed but contains no criterion-specific PP1 rule or case data to establish a strength.

Evidence considered

• The reviewed case evidence contains no pedigree, family genotypes, affected-relative observations, unaffected-relative observations, informative meioses, or phenotype-consistent segregation data for NM_001128425.2:c.1585C>A (p.Leu529Met).
• The ClinGen InSiGHT MUTYH specification is present, but its retrieved ruleset is incomplete and contains no PP1-specific rule payload or variant-level segregation data.

Still missing

• Number and clinical status of informative relatives
• Genotypes of affected and unaffected relatives
• Pedigree structure and number of informative meioses
• Phenotype consistency and penetrance context

Sources

Reasoning

No patient-level phenotype, clinical presentation, or phenotype-specific diagnostic context for the exact variant is provided in the available evidence. Gene-level statements that MUTYH is associated with colorectal cancer or familial adenomatous polyposis are not sufficiently specific to establish PP4 for this variant. The retrieved MUTYH specification supplies no usable structured PP4 rule.

Rule

PP4 requires a highly specific phenotype or family history for the disease associated with the gene; general gene-disease association alone is insufficient.

Evidence considered

• The retrieved ClinGen InSiGHT MUTYH specification contains no structured PP4 rule payload.
• Available evidence contains only gene-level disease context, not a specific phenotype in an individual carrying this exact variant.

Still missing

• Patient-level phenotype and diagnostic context for the exact variant are unavailable.
• No usable structured MUTYH-specific PP4 rule was retrieved.

Sources

Reasoning

The population data report homozygotes, including 16 homozygotes in gnomAD v2.1 non-cancer exomes and 2 homozygotes in gnomAD v3.1 non-cancer genomes, which is potentially relevant to recessive MUTYH-associated disease. However, gnomAD non-cancer status does not document age, clinical examination, adenomatous polyposis status, cancer status beyond cohort labeling, or penetrance, and the available evidence cannot establish that these individuals were healthy adults unaffected by a variably penetrant, adult-onset condition. BS2 therefore cannot be applied without phenotyped observations or a validated MUTYH-specific rule allowing these population counts.

Rule

Generic BS2 requires observation in healthy adults or an otherwise clinically appropriate unaffected context; population homozygote counts alone are not sufficient here without documented age and phenotype for this variably penetrant, adult-onset recessive disorder.

Evidence considered

• gnomAD v2.1 non-cancer exomes report 16 homozygotes among 861 alternate alleles, and gnomAD v3.1 non-cancer genomes report 2 homozygotes among 230 alternate alleles.
• The population records provide cohort labels and allele counts but do not provide individual ages, examination findings, adenomatous polyposis status, or sufficiently characterized unaffected status.
• The retrieved MUTYH InSiGHT specification has no populated BS2 rule; the gnomAD v4.1 query failed and cannot resolve the phenotypic gap.

Still missing

• No phenotyped homozygous individuals with documented age, clinical examination, polyposis status, and cancer history were identified.
• No populated MUTYH-specific BS2 rule was available to define whether these gnomAD homozygotes qualify despite uncertain penetrance and age of onset.

Sources

Reasoning

BS4 cannot be assessed: the available case evidence contains no documented non-segregation, including no affected relatives shown to lack NM_001128425.2:c.1585C>A (p.Leu529Met), and no family phenotype/genotype data from which an expected segregation pattern could be evaluated. The MUTYH InSiGHT framework was reviewed but contains no criterion-specific BS4 rule or case data to resolve this gap.

Evidence considered

• The reviewed case evidence contains no affected-relative testing, negative familial genotypes, pedigree, or other documented non-segregation observation for NM_001128425.2:c.1585C>A (p.Leu529Met).
• The ClinGen InSiGHT MUTYH specification is present, but its retrieved ruleset is incomplete and contains no BS4-specific rule payload or variant-level evidence.

Still missing

• Genotypes and phenotypes of affected relatives
• Documented affected relatives who tested negative for the variant
• Pedigree and penetrance information sufficient to judge expected segregation

Sources

Reasoning

BP2 requires documented occurrence of the variant in trans with a pathogenic or likely pathogenic variant, or in cis with a pathogenic variant, in a relevant individual or dataset. The available evidence contains no validated phase information, no pathogenic MUTYH co-allele for this variant, and no cis configuration. The gnomAD homozygote observations do not establish a pathogenic co-allele or phase. Therefore BP2 cannot be assessed.

Evidence considered

• The governing ClinGen InSiGHT MUTYH specification establishes the autosomal-recessive disease context but supplies no variant-specific phase or co-occurrence rule application for c.1585C>A.
• gnomAD v2.1 reports 16 homozygotes among 893 observed alleles, but population homozygosity alone does not identify a pathogenic co-allele, establish cis/trans phase, or satisfy BP2.
• The extracted PMID:22703879 finding reports other MUTYH variants as monoallelic and does not mention c.1585C>A; it provides no BP2 co-occurrence evidence for this variant.

Still missing

• No individual-level co-occurrence data with a pathogenic or likely pathogenic allele are available.
• No cis/trans phasing information is available.
• No family or tumor-normal data establish the required allelic configuration.

Sources

Reasoning

No affected individual with an established alternate molecular explanation for the phenotype is documented for this exact variant. The available literature and ClinVar records do not provide a qualifying BP5 co-occurrence observation with a confirmed alternative pathogenic cause, so BP5 cannot be adjudicated from the supplied evidence.

Rule

BP5 requires an alternate molecular basis explaining the affected individual's phenotype; absence of such case-level evidence is insufficient for application.

Evidence considered

• The reviewed exact-variant sources contain no documented affected individual with a confirmed alternative molecular cause of the relevant phenotype.

Still missing

• No qualifying affected-individual co-occurrence and confirmed alternative molecular diagnosis are available.