POLD1 c.961G>A, p.(Gly321Ser)

Reasoning

The variant is p.Gly321Ser in POLD1's exonuclease domain. Weren et al. explicitly describe POLD1 c.961G>A (p.Gly321Ser) as affecting the exonuclease domain, and Elsayed et al. studied this variant within POLD1 exonuclease-domain exons and describe Gly321 as highly conserved. POLD1 exonuclease-domain missense variation is the established disease-relevant functional region for proofreading-related predisposition. No gene-specific VCEP specification or domain_tables entry was available, so the generic ACMG PM1 rule applies. The available evidence supports a well-established critical functional domain, but does not support a stronger than moderate assignment.

Rule

PM1 (moderate): variant located in a mutational hotspot and/or critical, well-established functional domain without benign variation; use a gene-specific specification when available, otherwise generic ACMG/AMP.

Evidence considered

• Weren et al. report POLD1 c.961G>A, p.Gly321Ser as affecting the exonuclease domain.
• Elsayed et al. evaluated POLD1 exonuclease-domain exons, report the target Gly321Ser variant, and describe Gly321 as highly conserved.
• No POLD1-specific VCEP framework or authoritative domain table was available; therefore the generic ACMG/AMP PM1 rule was used.

Sources

Reasoning

PMID:30827058 provides variant-specific non-segregation: in the family where segregation was evaluated, both sisters with endometrial cancer did not carry POLD1 c.961G>A (p.Gly321Ser), and the authors state that co-segregation was not supportive. This is evidence against segregation in affected relatives and supports BS4 at supporting strength, although the relationship of endometrial cancer to the relevant POLD1 phenotype and the completeness of family testing require clinical review.

Rule

Generic ACMG/AMP BS4 supports a benign interpretation when an apparently affected family member does not carry the variant; apply at supporting strength here because the report documents non-segregation in two affected relatives but leaves phenotype and family-structure details incomplete.

Evidence considered

• PMID:30827058 explicitly states that segregation was not supportive in one family and that the patient's two sisters with endometrial cancer did not carry the variant.

Still missing

• The clinical relevance of endometrial cancer to the POLD1-related phenotype is not fully established in the report.
• The number of tested relatives and assay details are incompletely reported.

Sources

Reasoning

No POLD1-specific VCEP or ClinGen specification was available, so generic ACMG/AMP PS4 applies: significantly increased prevalence in affected individuals versus controls is required. The exact variant was reported in a small number of colorectal polyposis/cancer cases, including two patients in a 332-patient multiple-polyp cohort, but no case-control comparison, odds ratio, likelihood ratio, or statistical enrichment estimate was reported. Case occurrence alone does not establish PS4.

Rule

Generic ACMG/AMP PS4: significantly increased prevalence of the variant in affected individuals compared with controls; case reports without quantified enrichment are insufficient.

Evidence considered

• PMID:25938944 reported POLD1 c.961G>A (p.Gly321Ser) in one individual identified during screening of 51 people from 48 families with multiple colonic adenomas, without a control comparison or variant-specific enrichment estimate.
• PMID:30827058 reported the exact variant in two patients among 332 patients with multiple colorectal polyps; the study did not provide a variant-specific case-control odds ratio or likelihood ratio.
• PMID:33193653 listed the exact variant in one familial colorectal-cancer case as a VUS, without variant-specific prevalence statistics.

Still missing

• No variant-specific case-control dataset or statistically quantified enrichment was available.

Sources

Reasoning

No governing POLD1-specific VCEP specification was identified, so the supplied generic PM2 threshold of allele frequency <=0.0001 was used. The specified non-cancer sources report AF 0.000359621 in gnomAD v2.1 non-cancer exomes and 0.000250030 in gnomAD v3.1 non-cancer genomes; default all-comers sources report AF 0.000348225 in gnomAD v2.1 and 0.000437925 in gnomAD v4.1. All exceed 0.0001, so PM2 is not met.

Rule

Generic PM2: allele frequency <=0.0001; use non-cancer or exome-only data only when required by an applicable VCEP, which is absent here.

Evidence considered

• The case has no applicable POLD1-specific VCEP framework; the supplied generic PM2 threshold is allele frequency <=0.0001 (ClinGen SVI recommendation, PMID:25741868).
• Because no governing VCEP specifies otherwise, the available non-cancer cohorts were checked: gnomAD v2.1 non-cancer exomes AF 0.000359621 and gnomAD v3.1 non-cancer genomes AF 0.000250030.
• The default all-comers sources also exceed the threshold: gnomAD v2.1 AF 0.000348225 and gnomAD v4.1 AF 0.000437925.
• The variant is therefore not sufficiently rare for generic PM2.

Sources

Reasoning

The available family data do not demonstrate supportive co-segregation. In PMID:30827058, segregation was not feasible in one family and was explicitly non-supportive in the other; two sisters with endometrial cancer did not carry the variant. PMID:33193653 reports the variant in family 344 but supplies no segregation results. Because one report lacks usable family testing and the other is non-supportive, PP1 is not met.

Rule

Generic ACMG/AMP PP1 requires co-segregation with disease in multiple affected family members; unavailable or non-supportive segregation does not satisfy PP1.

Evidence considered

• PMID:30827058 states that co-segregation analysis was not feasible in one family and was not supportive in the other; the two sisters with endometrial cancer did not carry POLD1 c.961G>A.
• PMID:33193653 reports the variant in family 344 but does not provide variant-specific segregation data.

Still missing

• The relationship, phenotype relevance, and testing details for the non-carrier sisters are not fully characterized.
• No additional informative meioses or affected relatives with documented genotypes are reported.

Sources

Reasoning

The variant is a missense substitution, NM_002691.4:c.961G>A (p.Gly321Ser), so PP3/BP4 must be adjudicated from the REVEL path only. REVEL is 0.363, which is below the generic ClinGen SVI PP3 supporting threshold of >=0.644; therefore PP3 is not met. SpliceAI is not used for this missense computational assessment. The applicable calibration thresholds are from the ClinGen SVI REVEL calibration by Pejaver et al. 2022 (PMID:36413997).

Rule

Missense variant: apply REVEL only; PP3 supporting requires REVEL >=0.644 (Pejaver et al. 2022, PMID:36413997).

Evidence considered

• The variant is a missense substitution, NM_002691.4:c.961G>A (p.Gly321Ser), so REVEL is the sole applicable PP3/BP4 predictor path.
• REVEL score is 0.363, below the PP3 supporting threshold of >=0.644 from the ClinGen SVI REVEL calibration by Pejaver et al. 2022 (PMID:36413997).
• SpliceAI was not used because splice predictions cannot provide PP3 support for a missense variant.

Sources

Reasoning

No POLD1-specific framework was available, so generic PP4 applies: the patient's phenotype must be highly specific for a disease with a single-gene etiology. The reported observations are colorectal polyposis and colorectal cancer, which are heterogeneous and not sufficiently specific for POLD1-related disease; one report described a coexisting MUTYH variant and another described MSI-H/MMR-deficient cancer with MLH1 promoter hypermethylation. The reports also describe the variant as a VUS and do not establish a characteristic POLD1 phenotype.

Rule

Generic ACMG/AMP PP4: the patient's phenotype or family history is highly specific for a disease with a single-gene etiology; nonspecific colorectal cancer/polyposis is insufficient.

Evidence considered

• PMID:25938944 identified the variant in an individual with multiple colonic adenomas but did not establish a phenotype uniquely specific to POLD1-related disease.
• PMID:30827058 reported two carriers with colorectal polyps/cancer, including one with a heterozygous MUTYH p.(Tyr179Cys) variant and another with MSI-H/MMR-deficient cancer and MLH1 promoter hypermethylation; the authors classified Gly321Ser as a VUS.
• PMID:33193653 listed the variant in a familial colorectal-cancer cohort as a selected VUS without additional characteristic clinical findings.

Still missing

• No highly specific, independently established POLD1 phenotype was documented for this variant.

Sources

Reasoning

PP5 is restricted here to an exact-variant ClinVar expert-panel classification of Pathogenic or Likely pathogenic. ClinVar variation 221136 exactly matches NM_002691.4:c.961G>A, but the record reports no expert-panel submissions and shows only single-submitter laboratory assertions, with aggregate classifications of uncertain significance and likely benign. Therefore PP5 cannot be applied.

Rule

PP5: apply only when an exact-variant ClinVar expert panel classifies the variant as Pathogenic or Likely pathogenic; ordinary submissions and aggregate labels are excluded.

Evidence considered

• ClinVar variation 221136 exactly matches NM_002691.4(POLD1):c.961G>A (p.Gly321Ser), but its expert_panels field is empty; the record contains single-submitter laboratory assertions and conflicting aggregate classifications rather than an expert-panel Pathogenic or Likely pathogenic assertion.

Still missing

• No exact-variant ClinVar expert-panel Pathogenic or Likely pathogenic assertion was identified.

Sources

Reasoning

No governing POLD1-specific VCEP specification was identified, so the supplied generic ACMG/AMP stand-alone BA1 threshold of allele frequency >=0.05 was used. The highest observed frequency is 0.000648145 in the gnomAD v2.1 non-cancer exome NFE subgroup; the gnomAD v2.1, gnomAD v3.1 non-cancer genome, and gnomAD v4.1 frequencies are all far below 0.05. Therefore BA1 is not met.

Rule

Generic ACMG/AMP BA1: allele frequency >=0.05; no applicable POLD1-specific VCEP specification.

Evidence considered

• The case has no applicable POLD1-specific VCEP framework; the supplied generic ACMG/AMP BA1 threshold is allele frequency >=0.05 (ACMG/AMP 2015, PMID:25741868).
• gnomAD v2.1 non-cancer exomes report AF 0.000359621 overall and 0.000648145 in the highest-frequency NFE subgroup; gnomAD v3.1 non-cancer genomes report AF 0.000250030 overall; gnomAD v4.1 reports AF 0.000437925 overall and 0.000549337 in NFE.
• The observed frequencies are orders of magnitude below 0.05, so population frequency does not support BA1.

Sources

Reasoning

No governing POLD1-specific VCEP specification was identified, so the supplied generic BS1 threshold of allele frequency >=0.01 was used. The highest observed frequency is 0.000648145 in the gnomAD v2.1 non-cancer exome NFE subgroup, with gnomAD v4.1 NFE at 0.000549337 and all-comers AF 0.000437925. These values are below 0.01, so BS1 is not met.

Rule

Generic BS1: allele frequency >=0.01; no applicable POLD1-specific VCEP specification.

Evidence considered

• The case has no applicable POLD1-specific VCEP framework; the supplied generic BS1 threshold is allele frequency >=0.01, with per-gene derivation preferred (Whiffin et al. 2017, PMID:28518168).
• gnomAD v2.1 non-cancer exomes report the highest subgroup AF as 0.000648145; gnomAD v3.1 non-cancer genomes report AF 0.000250030 overall; gnomAD v4.1 reports AF 0.000437925 overall and 0.000549337 in NFE.
• No observed population frequency reaches 0.01, so BS1 is not met.

Sources

Reasoning

BP1 is intended for a missense variant in a gene where disease is known to be caused primarily by truncating variants. The available POLD1-specific evidence instead identifies disease-relevant missense variation in the exonuclease domain, including the target p.Gly321Ser, and does not support a truncating-predominant disease mechanism. Therefore BP1 is not met.

Rule

Apply BP1 only to a missense variant in a gene where the established disease mechanism is primarily truncating variation.

Evidence considered

• Weren et al. report the target POLD1 missense variant in the exonuclease domain.
• Elsayed et al. describe POLD1 exonuclease-domain missense variants as the relevant variant class in their cohort and specifically evaluate Gly321Ser.

Sources

Reasoning

The variant is a missense substitution, NM_002691.4:c.961G>A (p.Gly321Ser), so PP3/BP4 must be adjudicated from the REVEL path only. REVEL is 0.363, which exceeds the generic ClinGen SVI BP4 supporting threshold of <=0.29; therefore BP4 is not met. SpliceAI is not used for this missense computational assessment. The applicable calibration thresholds are from the ClinGen SVI REVEL calibration by Pejaver et al. 2022 (PMID:36413997).

Rule

Missense variant: apply REVEL only; BP4 supporting requires REVEL <=0.29 (Pejaver et al. 2022, PMID:36413997).

Evidence considered

• The variant is a missense substitution, NM_002691.4:c.961G>A (p.Gly321Ser), so REVEL is the sole applicable PP3/BP4 predictor path.
• REVEL score is 0.363, above the BP4 supporting threshold of <=0.29 from the ClinGen SVI REVEL calibration by Pejaver et al. 2022 (PMID:36413997).
• SpliceAI was not used because a missense variant's splice prediction cannot provide BP4 support.

Sources

Reasoning

Under generic ACMG/AMP BP5, the affected phenotype must be explained by a pathogenic variant in another gene. One reported patient carrying the exact POLD1 variant also carried MUTYH p.(Tyr179Cys), and another had MSI-H/MMR-deficient cancer with MLH1 promoter hypermethylation, but the available evidence does not establish either as a confirmed pathogenic alternative explanation for the patient's full phenotype. BP5 is therefore not met; the alternative findings warrant human review rather than automatic application.

Rule

Generic ACMG/AMP BP5: a pathogenic variant in another gene explains the patient's phenotype; an unconfirmed coexisting finding or tumor-level abnormality is insufficient.

Evidence considered

• PMID:30827058 reported one carrier with a heterozygous MUTYH p.(Tyr179Cys) variant and another with MSI-H/MMR-deficient cancer plus MLH1 promoter hypermethylation, but did not establish these findings as confirmed pathogenic explanations for the full phenotype or as sufficient to classify POLD1 Gly321Ser benign.

Still missing

• The pathogenicity and phenotype-explanatory role of the reported MUTYH finding were not established in the extracted evidence.
• MLH1 promoter hypermethylation was tumor-level evidence rather than a confirmed alternative germline diagnosis.

Sources

Reasoning

BP6 is restricted here to an exact-variant ClinVar expert-panel classification of Benign or Likely benign. ClinVar variation 221136 exactly matches NM_002691.4:c.961G>A, but no expert-panel submissions are present; the likely-benign entries are ordinary single-submitter laboratory assertions. Those assertions cannot trigger BP6 under the specified rule.

Rule

BP6: apply only when an exact-variant ClinVar expert panel classifies the variant as Benign or Likely benign; ordinary submissions and aggregate labels are excluded.

Evidence considered

• ClinVar variation 221136 exactly matches the variant and includes Likely benign single-submitter laboratory assertions, but its expert_panels field is empty; these ordinary submissions are explicitly insufficient for BP6.

Still missing

• No exact-variant ClinVar expert-panel Benign or Likely benign assertion was identified.

Sources

Reasoning

PS1 requires a pathogenic or likely pathogenic missense change producing the same amino-acid substitution. The available evidence identifies POLD1 p.Gly321Ser but does not provide a validated same-amino-acid comparator with a pathogenic or likely pathogenic classification. ClinVar submissions for the target variant are conflicting and cannot substitute for a comparator.

Rule

Apply PS1 only when an established pathogenic or likely pathogenic missense variant causes the same amino-acid change as the variant under review.

Evidence considered

• The exact target variant is POLD1 NM_002691.4:c.961G>A, p.(Gly321Ser).
• ClinVar reports conflicting submissions, including uncertain significance and likely benign, with no expert-panel submission; these classifications do not establish PS1.

Still missing

• A validated pathogenic or likely pathogenic same-amino-acid comparator is needed.

Sources

Reasoning

No documented parental testing or confirmed de novo event is available for NM_002691.4:c.961G>A (p.Gly321Ser). The available case reports identify the variant in affected individuals but do not establish that both parents were tested and negative, so PS2 cannot be applied.

Rule

Generic ACMG/AMP PS2 requires confirmed de novo occurrence in a patient with confirmed maternity and paternity; absent documented parental testing, PS2 is not assessed.

Evidence considered

• PMID:30827058 reports the variant in two patients but provides no evidence that either patient's parents were tested or that the variant was de novo.
• PMID:33193653 lists the variant in family 344 but does not provide parental-origin or de novo data.

Still missing

• Parental genotypes and testing methodology are not documented.
• A confirmed de novo occurrence in a proband is not reported.

Sources

Reasoning

No applicable POLD1 VCEP specification was identified, so generic ACMG/AMP functional-evidence principles apply. The exact variant NM_002691.4:c.961G>A (p.Gly321Ser) is reported in the literature, but the available reports provide no validated experimental assay measuring POLD1 function. PMID:30827058 explicitly states that no functional assay was performed and that the available evidence was insufficient to evaluate the protein effect; PMID:25938944 reports the variant from cohort screening without functional results. Therefore, PS3 cannot be assessed rather than inferred from exonuclease-domain location, clinical observations, or in-silico predictions.

Evidence considered

• PMID:30827058 reports the exact heterozygous POLD1 c.961G>A (p.Gly321Ser) variant in two patients, but explicitly states that no functional assay was performed and that available evidence was insufficient to evaluate its effect on protein function.
• PMID:25938944 reports the exact POLD1 c.961G>A (p.Gly321Ser) variant during cohort screening, without reporting a functional assay, assay controls, or measured protein activity.
• The variant is a missense change in the POLD1 exonuclease domain, but domain location and computational predictions are not direct functional assay evidence for PS3.

Still missing

• A validated functional assay measuring POLD1 Gly321Ser activity, proofreading, or another biologically relevant endpoint is unavailable.
• Assay controls, replicate data, and an established normal-versus-abnormal calibration are unavailable.

Sources

Reasoning

No applicable POLD1-specific VCEP framework was retrieved, so generic ACMG/AMP criteria were considered. The available case literature reports POLD1 c.961G>A only as a heterozygous variant in affected-proband or cohort observations. No affected proband is documented with this variant and a second pathogenic or likely pathogenic POLD1 variant in trans, no confirmed POLD1 compound-heterozygous or homozygous observation is reported, and no phase-resolved allelic observation establishes recessive inheritance. Therefore, PM3 cannot be assessed from the available evidence rather than being inferred from the reported phenotype.

Rule

Generic PM3: evidence that the variant is observed in trans with a pathogenic or likely pathogenic variant in an affected individual, with strength determined by the number and quality of confirmed phase-resolved observations; no qualifying observation is available here.

Evidence considered

• PMID:30827058 reports POLD1 c.961G>A, p.(Gly321Ser) as a heterozygous germline variant in patients P1 and P2; it does not report a second POLD1 pathogenic variant, biallelic status, or phase.
• PMID:25938944 reports POLD1 c.961G>A, p.Gly321Ser in individual P17 during screening of individuals with multiple adenomas, without a second POLD1 allele or phase information.

Still missing

• Phase-resolved testing for a second POLD1 variant in affected individuals is unavailable.
• No confirmed biallelic or compound-heterozygous POLD1 observation is documented.

Sources

Reasoning

PM5 requires a different missense change at the same residue that is established as pathogenic or likely pathogenic. The available comparator search artifact contains no same-residue candidates, and the reviewed papers do not establish a pathogenic or likely pathogenic alternate substitution at POLD1 residue 321.

Rule

Apply PM5 only when a different missense change at the same residue is established as pathogenic or likely pathogenic; do not infer PM5 from the target variant's own classification.

Evidence considered

• The target residue is POLD1 Gly321.
• The comparator candidate artifact reports zero same-residue candidates and does not establish classic PM5 eligibility.

Still missing

• A validated pathogenic or likely pathogenic alternate missense substitution at residue 321 is needed.

Sources

Reasoning

No report documents a presumed de novo occurrence of NM_002691.4:c.961G>A without parental testing. The variant was observed in two patients and in a separate familial-colorectal-cancer cohort, but those reports do not describe an apparently de novo origin.

Rule

Generic ACMG/AMP PM6 concerns a presumed de novo occurrence when parental testing is unavailable; a presumed de novo designation must still be documented or supported by the clinical report, which is absent here.

Evidence considered

• PMID:30827058 describes two affected patients carrying the variant but does not report presumed de novo origin.
• PMID:33193653 reports the variant in family 344 without parental-origin information.

Still missing

• No documented clinical report identifies this variant as presumed de novo.
• Parental testing status is not provided.

Sources

Reasoning

PP2 requires evidence that the gene has a low rate of benign missense variation and a high prevalence of disease-causing missense variants. The case evidence documents that POLD1 exonuclease-domain missense variants are disease-relevant, but it does not provide the gene-level benign-missense rate, a calibrated missense/pathogenic variant prevalence, or a governing POLD1 specification defining PP2. The available population frequency of the target variant does not establish PP2.

Rule

Apply PP2 only when the gene is established to have a low rate of benign missense variation and a high prevalence of disease-causing missense variants.

Evidence considered

• The literature supports a disease-relevant POLD1 exonuclease-domain missense mechanism but does not quantify the gene-wide benign missense rate or the proportion of disease-causing missense variants required for PP2.
• The target variant's gnomAD frequency is population evidence and cannot by itself establish the gene-level PP2 premise.

Still missing

• A validated gene-level missense constraint and disease-causing missense prevalence assessment is needed.
• A POLD1-specific PP2 rule or published calibration is unavailable.

Sources

Reasoning

The population data show no homozygotes in gnomAD v2.1, gnomAD v2.1 non-cancer exomes, or gnomAD v3.1 non-cancer genomes, but gnomAD v4.1 reports one homozygote. BS2 requires evidence that the variant occurs in an appropriately healthy individual or individuals in a phenotype-relevant context; the available gnomAD record does not provide individual phenotype, age, penetrance, or disease-status information. The single homozygote therefore cannot be adjudicated as BS2 evidence without phenotype review.

Rule

Generic ACMG/AMP BS2 requires observation in healthy individuals appropriate to the disease model; aggregate gnomAD data without individual phenotype are insufficient.

Evidence considered

• gnomAD v4.1 reports one homozygote among 1,591,596 alleles; the gnomAD v4.1 NFE subgroup also reports one homozygote.
• gnomAD v2.1, gnomAD v2.1 non-cancer exomes, and gnomAD v3.1 non-cancer genomes report zero homozygotes.
• The supplied ACMG/AMP framework requires healthy-individual context for BS2; aggregate gnomAD frequency data alone do not establish the carrier's phenotype, age, penetrance, or disease status.

Still missing

• Individual-level phenotype, age, and disease-status information for the gnomAD v4.1 homozygous carrier is unavailable.
• The relevance of a homozygous observation to the applicable POLD1 disease model and penetrance has not been established.

Sources

Reasoning

No applicable POLD1 VCEP specification was identified, so generic ACMG/AMP functional-evidence principles apply. The exact variant NM_002691.4:c.961G>A (p.Gly321Ser) has no reported validated assay demonstrating normal POLD1 function. PMID:30827058 explicitly states that no functional assay was performed and that the effect on protein function could not be evaluated; PMID:25938944 reports the variant without functional testing. Clinical observations, population frequency, absence of segregation, and in-silico predictions cannot establish BS3 without a well-controlled assay showing preserved function.

Evidence considered

• PMID:30827058 reports the exact variant but states that no functional assay was performed, so it provides neither normal-function evidence nor a BS3 calibration.
• PMID:25938944 identifies the exact variant in a clinical cohort but reports no functional experiment or normal-function result.
• The available clinical, segregation, population, and computational information does not substitute for a controlled assay demonstrating normal protein function under BS3.

Still missing

• A validated assay showing preserved POLD1 function for Gly321Ser is unavailable.
• Appropriate wild-type, loss-of-function, and assay-performance controls with quantitative normal-function thresholds are unavailable.

Sources

Reasoning

No applicable POLD1-specific VCEP framework was retrieved, so generic ACMG/AMP criteria were considered. The available literature does not document POLD1 c.961G>A in confirmed trans or cis phase with a qualifying pathogenic POLD1 variant in a manner that meets BP2. PMID:30827058 notes that patient P1 also carried heterozygous MUTYH p.(Tyr179Cys), but does not establish phase and does not provide a qualifying POLD1 allelic co-occurrence; in patient P2, the two sisters with endometrial cancer did not carry the variant, which is not BP2 evidence. Thus BP2 cannot be assessed from the available allelic data.

Rule

Generic BP2: the variant is observed in cis or trans with a pathogenic variant in a configuration relevant to the gene's inheritance model; phase and a qualifying co-occurring POLD1 pathogenic variant are not established here.

Evidence considered

• PMID:30827058 reports that patient P1 carried heterozygous MUTYH p.(Tyr179Cys) alongside heterozygous POLD1 c.961G>A, but provides no phase information and does not document a qualifying pathogenic POLD1 co-occurrence.
• PMID:30827058 reports that P2's two sisters with endometrial cancer did not carry POLD1 c.961G>A; this is not evidence satisfying BP2.
• PMID:25938944 reports a POLD1 c.961G>A observation without a documented qualifying POLD1 co-occurring allele or phase.

Still missing

• Phase information for the reported MUTYH p.(Tyr179Cys) co-occurrence is unavailable.
• No confirmed qualifying pathogenic POLD1 variant co-occurring with c.961G>A is documented.

Sources