“SMRTer Confirmation”: Scalable clinical read-through variant confirmation using the Pacific Biosciences SMRT Sequencing platform
Next-generation sequencing (NGS) has significantly improved the cost and turnaround time for diagnostic genetic tests. ACMG recommends variant confirmation by an orthogonal method, unless sufficiently high sensitivity and specificity can be demonstrated using NGS alone. Most NGS laboratories make extensive use of Sanger sequencing for secondary confirmation of single nucleotide variants (SNVs) and indels, representing a large fraction of the cost and time required to deliver high quality genetic testing data to clinicians and patients. Despite its established data quality, Sanger is not a high-throughput method by today’s standards from either an assay or analysis standpoint as it can involve manual review of Sanger traces and is not amenable to multiplexing. Toward a scalable solution for confirmation, Invitae has developed a fully automated and LIMS-tracked assay and informatics pipeline that utilizes the Pacific Biosciences SMRT sequencing platform. Invitae’s pipeline generates PCR amplicons that encompass the variant(s) of interest, which are converted to closed DNA structures (SMRTbells) and sequenced in pools of 96 per SMRTcell. Each amplicon is appended with a 16nt barcode that encodes the patient and variant IDs. Per-sample de-multiplexing, alignment, variant calling, and confirmation resolution are handled via an automated pipeline. The confirmation process was validated by analyzing 243 clinical SNVs and indels in parallel with the gold standard Sanger sequencing method. Amplicons were sequenced and analyzed in technical replicates to demonstrate reproducibility. In this study, the PacBio-based confirmation pipeline demonstrated high reproducibility (97.5%), and outperformed Sanger in the fraction of primary NGS variants confirmed (PacBio = 93.4% and 94.7% confirmed across two replicates, Sanger = 84.8%) while having 100% concordance of confirmation status among overlapping confirmation calls.