The authors have no acknowledgements.

Ethics Statement: All testing of human samples was performed after obtaining Institutional Review Board (IRB) approval.
1. DNA Extraction from FFPE Tissue, Peripheral Blood, and Bone Marrow Aspirate
<ol>
	<li>For bone marrow FFPE tissue with DNA FFPE extraction kit
	<ol>
		<li>Begin with FFPE tissue from unstained slides (5 - 10 sections at 5 - 10 &#181;m thickness). 
		NOTE: If beginning with tissue shavings, use 3 - 6 sections at 5 - 10 &#181;m thickness and skip to step 1.1.6.</li>
		<li>Place slides in a slide basket and prepare four wash reservoirs (two for Xylene and two for 100% Alcohol). Add a minimum volume of 600 mL of solution to each basket.</li>
		<li>Deparaffinize the slides by doing a 5 min xylene wash in the first tray. Transfer the slides to the second xylene wash reservoir for an additional 5 min.</li>
		<li>After deparaffinization, wash the slides with 100% alcohol for 5 min. Transfer the slides to the second alcohol wash reservoir for an additional 5 min.</li>
		<li>Allow the slides to dry completely under a hood before scraping them with a razor blade into a microcentrifuge tube. 
		NOTE: If an H&#38;E slide with tumor region indicated is available, align the slides and scrape only the tumor region.</li>
		<li>Proceed with instructions from manufacturer handout included in kit.</li>
	</ol>
	</li>
	<li>For BM aspirate and Peripheral Blood
	<ol>
		<li>Extract according to the manufacturer&#39;s instructions handout with these specifications. 
		NOTE: There are numerous commercially available kits and methods for DNA extraction from FFPE tissues and cells. Practically, all can be used. Use a method that is established in the laboratory.
		<ol>
			<li>Use 200 &#181;L peripheral blood (PB) or 100 &#181;L BM + 100 &#181;L PBS.</li>
			<li>Use 4 &#181;L RNase A stock solution.</li>
			<li>Elute with 100 &#181;L elution buffer.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>DNA Quantification
	<ol>
		<li>Measure DNA concentrations using a spectrophotometer ensuring a 260 nm/280 nm ratio of approximately 1.8 (for pure DNA). If the ratio is appreciably lower, it may indicate the presence of protein, phenol, or other contaminants that may interfere with downstream applications.</li>
		<li>Adjust DNA concentrations to approximately 50 - 100 ng/&#181;L with appropriate elution buffer.</li>
	</ol>
	</li>
</ol>
2. Wild-Type Blocking PCR
<ol>
	<li>Primer Design
	<ol>
		<li>Design and obtain primers for genes of interest according to previously described general guidelines of PCR primer design13. Include M13-forward and reverse universal sequencing primers in PCR primers. 
		NOTE: The MYD88 assay was developed to amplify exon 5 of MYD88 (G259 - N291) and 110 nucleotides located in the 5&#39; intronic region to cover the splice site and part of intron 4. The forward and reverse primers were designed with a 5&#39;-M13 sequence (M13-forward: tgt aaa acg acg gcc agt; M13-reverse: cag gaa aca gct atg acc) to allow for annealing of complementary sequencing primers (see Materials Table).</li>
	</ol>
	</li>
	<li>Locked Nucleic Acid Oligonucleotide Design
	<ol>
		<li>Design the blocking oligonucleotide to be approximately 10 - 15 bases in length and complementary to the WT template where mutant enrichment is desired. 
		NOTE: A shorter oligo will improve mismatch discrimination. To achieve high target specificity, it is important not to use too much blocking nucleotides since this can result in a very &#34;sticky&#34; oligonucleotide. The content and the length and blocking nucleotide should to be optimize according to the specific nucleotide that need to be blocked. It is important to achieve high binding specificity without compromising secondary structure and risking self-complementarity.</li>
		<li>Design the blocking oligo to have a Tm 10 - 15 &#176;C above the extension temperature during thermocycling. Adjust the Tm by adding or removing blocking bases or by substituting blocking bases for DNA while avoiding long stretches (3 - 4 bases) of blocking G or C bases.
		<ol>
			<li>Navigate to the oligo tools website (see Table of Materials) and select the &#34;blocking Oligo Tm Prediction&#34; tool.</li>
			<li>Paste the sequence of the WT template that is desired to be blocked into the &#34;Oligo Sequence&#34; box. Add &#34;+&#34; in front of bases to indicate blocker bases.</li>
			<li>Select the &#34;Calculate&#34; button to determine the approximate Tm of the DNA-Blocker hybrid.</li>
		</ol>
		</li>
		<li>Design the blocking oligo to avoid secondary structure formation or self-dimers.
		<ol>
			<li>Navigate to the oligo tools website (see Table of Materials) and select the &#34;blocking Oligo Optimizer&#34; tool.</li>
			<li>Paste the sequence of the WT template that is desired to be blocked into the box. Add &#34;+&#34; in front of bases to indicate blocking bases.</li>
			<li>Select the two boxes for &#34;Secondary Structure&#34; and &#34;Self Only&#34;. Press the Analyze button to review the oligo for potentially troublesome secondary structures or self-dimers. 
			NOTE: The scores represent very rough estimates of the Tm&#39;s of the secondary structures and self-dimers. Lower scores are therefore optimal and can be achieved by limiting blocker-blocker pairing. The blocking oligonucleotide for MYD88 [MYD88blocker (TCAGA+AG+C+G+A+C+T+G+A+T+CC/invdT/)] was designed to cover amino acids Q262-I266 and features a 3&#39;-inverted dT to inhibit both extension by DNA polymerase and degradation by 3&#39;-exonuclease. This specific blocking oligo is a 17mer with 10 blocking bases which are denoted as &#34;+N&#34;. The remaining 7 bases are ordinary DNA nucleotides.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>WTB-PCR Setup and Thermocycling
	<ol>
		<li>Prepare a WTB-PCR master mix (MMX) using 2.5 &#181;L PCR reaction buffer 10x w/ 20 mM MgCl2, 250 &#181;M dNTPs, 0.2 &#181;M forward and reverse primer, 1.2 &#181;M MYD88blocker, and DNAse, RNAse-free, ultra-pure H2O to create a final solution volume of 21.75 &#181;L per reaction. 
		NOTE: Working concentrations are for the final reaction volume of 25 &#181;L (after addition of DNA template and polymerase). Conventional PCR MMX is prepared by simply omitting the addition of blocker. All protocol steps remain identical for both WTB and conventional PCR. This can be used in validation and determining enrichment achieved by addition of blocker.
		<ol>
			<li>When calculating the amount of MMX to prepare make sure to account for 3 additional reactions (positive and negative controls and a non-template control to check for contamination) and at least 1 additional reaction for pipetting error.</li>
		</ol>
		</li>
		<li>Vortex MMX thoroughly. The MMX can be stored at -80 &#176;C for up to a year.</li>
		<li>Add 0.25 &#181;L Taq DNA polymerase per reaction to the MMX and invert to mix. Once the polymerase has been added to the MMX, keep it on ice.</li>
		<li>Put a new 96 well PCR plate on a cold plate and pipette 22 &#181;L of MMX with polymerase to each reaction well.</li>
		<li>Add 3 &#181;L genomic DNA (50 - 100 ng/&#181;L to each of the wells containing the MMX with polymerase.</li>
		<li>Seal the plate and centrifuge briefly to ensure the solution reaches the bottom of each well.</li>
		<li>Load the PCR plate on a thermocycler.
		<ol>
			<li>Set the thermocycling conditions for the WTB-PCR reaction as follows: initial denaturation at 95 &#176;C for 6 min; 40 cycles of denaturation at 95 &#176;C for 30 s, primer annealing at 56 &#176;C for 30 s, and extension at 72 &#176;C for 1 min 20 s; final extension at 72 &#176;C for 10 min. 
			NOTE: Best practice involves completing the remainder of the protocol in a physically separate area to avoid amplicon contamination in future setups.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Perform gel electrophoresis according to previously described protocols14 in order to determine if WTB-PCR was successful and to confirm a lack of amplification in the non-template control.</li>
	<li>Purification of PCR Product by magnetic beads
	<ol>
		<li>Remove magnetic beads from 4 &#176;C and bring to room temperature.</li>
		<li>Transfer 10 &#181;L PCR product to a new PCR plate.</li>
		<li>Vortex the magnetic beads vigorously to fully resuspend the magnetic particles.</li>
		<li>Add 18 &#181;L magnetic beads to each well on the new plate. Pipette mix 10 times.</li>
		<li>Incubate at room temperature for 5 min.</li>
		<li>Place the PCR plate onto the side-skirted magnet plate for 2 min to separate beads from solution.</li>
		<li>Aspirate the supernatant with a multichannel pipette, avoiding the bead pellet.</li>
		<li>Dispense 150 &#181;L 70% ethanol into each well and incubate at room temperature for at least 30 s. Aspirate the ethanol with a multichannel pipette and discard tips. Repeat this wash procedure once more.</li>
		<li>Using a 20 &#181;L multichannel pipette aspirate the remaining ethanol from each well and discard tips.</li>
		<li>Once wells are dry (~ 10 min), remove from magnet plate and add 40 &#181;L nuclease free water to each well and pipette mix 15 times or vortex gently.</li>
		<li>Incubate at room temperature for 2 min.</li>
		<li>Place the PCR plate onto magnet plate for 1 min to separate beads from solution.</li>
		<li>Transfer 35 &#181;L of purified product to a new PCR plate. This is purified PCR product is now ready to proceed with bi-directional sequencing or can be stored at -20 &#176;C until needed. 
		NOTE: When developing a new assay, quantification of purified PCR product may be required. 1 - 3 ng/&#181;L amplicon DNA is optimal for bi-directional sequencing. If concentration is consistently low, increase PCR product and magnetic beads proportionally (1:1.8). If concentration is consistently high, elute with a greater volume of water.</li>
	</ol>
	</li>
</ol>
3. Sequencing of WTB-PCR Product
<ol>
	<li>Bi-Directional Sequencing 
	NOTE: The following protocol is a modified form of the manufacturer&#39;s instructions that has been optimized to use fewer reagents.
	<ol>
		<li>Prepare forward and reverse sequencing reaction mixes with 0.25 &#181;L Ready Reaction mix, 1.88 &#181;L Sequencing Buffer, 1.78 &#181;M M13-F or M13-R sequencing primers and add and DNAse, RNAse-free, ultra-pure H2O to create a final solution volume of 9 &#181;L per reaction. This sequencing reaction mix can be stored at -20 &#176;C for up to a year.</li>
		<li>Pipette 9 &#181;L of the forward sequencing reaction mix into each well of a new 96 well PCR plate for the forward sequencing reaction. Repeat on a separate plate for the reverse sequencing reaction.</li>
		<li>Add 1 &#181;L of the purified WTB-PCR product to each well on both the forward and reverse plates.</li>
		<li>Seal the plate and centrifuge briefly to ensure the solution reaches the bottom of each well.</li>
		<li>Load the PCR plate on a thermocycler.
		<ol>
			<li>Set the thermocycling conditions for the sequencing reaction as follows: 96 &#176;C for 1 min; 30 cycles of 96 &#176;C for 10 s, 50 &#176;C for 5 s, 60 &#176;C for 4 min; hold at 4 &#176;C until ready for purification.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Purify Sequencing Products
	<ol>
		<li>Prepare a fresh 1:25 solution of 3 M sodium acetate (pH 5.2) and 100% ethanol.</li>
		<li>Prepare a fresh 70% ethanol solution.</li>
		<li>Add 30 &#181;L of sodium acetate/100% ethanol solution to each well of both the forward and reverse sequencing plates and pipette mix 5 times.</li>
		<li>Reseal the plate and incubate in the dark at room temperature for 20 min.</li>
		<li>Centrifuge the plate at 2,250 x g for 15 min.</li>
		<li>Remove the plate sealer and invert over a waste container. 
		NOTE: Invert only once or the pellet may loosen from the well bottoms.</li>
		<li>Place the inverted plate on a clean paper towel and centrifuge at 150 x g for 1 min.</li>
		<li>Add 150 &#181;L 70% ethanol to each well.</li>
		<li>Reseal the plate and spin at 2,250 x g for 5 min.</li>
		<li>Repeat steps 3.2.6 and 3.2.7.</li>
		<li>If the wells are not completely dry, allow them to air dry at room temperature. Make sure the samples are protected from light while drying.</li>
		<li>Add 10 &#181;L Formamide to each well and pipette mix 10 times. Reseal the plate.</li>
		<li>Denature on thermocycler at 95 &#176;C for 3 min followed by 4 &#176;C for 5 min.</li>
		<li>After denaturing, replace the plate sealer with a septa and sequence on sequencing platform according to manufacturer&#39;s instructions15.</li>
	</ol>
	</li>
</ol>
4. Analysis of Sequencing Results
<ol>
	<li>Visualize sequencing traces using a sequencing data analysis software according to manufacturer&#39;s instructions16 and align to the respective reference sequences. Align MYD88 to NCBI reference sequence &#34;NM_002468&#34;.</li>
</ol>

<ol>
	<li>Vogelstein, B., Kinzler, K. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Digital+PCR.">Digital PCR.</a> Proc Natl Acad of Sci U S A. 96 (16), 9236-9241 (1999).</li><li>Milbury, C. A., Li, J., Makrigiorgos, G. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=PCR-based+methods+for+the+enrichment+of+minority+alleles+and+mutations.">PCR-based methods for the enrichment of minority alleles and mutations.</a> Clin Chem. 55 (4), 632-640 (2009).</li><li>Albitar, A., Ma, W., DeDios, I., Estella, J., Agersborg, S., Albitar, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Positive+selection+and+high+sensitivity+test+for+MYD88+mutations+using+locked+nucleic+acid.">Positive selection and high sensitivity test for MYD88 mutations using locked nucleic acid.</a> Int J Lab Hematol. 38 (2), 133-140 (2016).</li><li>Dominguez, P. L., Kolodney, M. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Wild-type+blocking+polymerase+chain+reaction+for+detection+of+single+nucleotide+minority+mutations+from+clinical+specimens.">Wild-type blocking polymerase chain reaction for detection of single nucleotide minority mutations from clinical specimens.</a> Oncogene. 24 (45), 6830-6834 (2005).</li><li>Gray, P. N., Dunlop, C. L. M., Elliott, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Not+All+Next+Generation+Sequencing+Diagnostics+are+Created+Equal:+Understanding+the+Nuances+of+Solid+Tumor+Assay+Design+for+Somatic+Mutation+Detection.">Not All Next Generation Sequencing Diagnostics are Created Equal: Understanding the Nuances of Solid Tumor Assay Design for Somatic Mutation Detection.</a> Cancers. 7 (3), 1313-1332 (2015).</li><li>Smith, E. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biased+estimates+of+clonal+evolution+and+subclonal+heterogeneity+can+arise+from+PCR+duplicates+in+deep+sequencing+experiments.">Biased estimates of clonal evolution and subclonal heterogeneity can arise from PCR duplicates in deep sequencing experiments.</a> Genome Biol. 15 (8), 420 (2014).</li><li>Varettoni, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+and+clinical+significance+of+the+MYD88+(L265P)+somatic+mutation+in+Waldenstr&#246;m's+macroglobulinemia+and+related+lymphoid+neoplasms.">Prevalence and clinical significance of the MYD88 (L265P) somatic mutation in Waldenstr&#246;m's macroglobulinemia and related lymphoid neoplasms.</a> Blood. 121 (13), 2522-2528 (2013).</li><li>Xu, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=MYD88+L265P+in+Waldenstr&#246;m+macroglobulinemia,+immunoglobulin+M+monoclonal+gammopathy,+and+other+B-cell+lymphoproliferative+disorders+using+conventional+and+quantitative+allele-specific+polymerase+chain+reaction.">MYD88 L265P in Waldenstr&#246;m macroglobulinemia, immunoglobulin M monoclonal gammopathy, and other B-cell lymphoproliferative disorders using conventional and quantitative allele-specific polymerase chain reaction.</a> Blood. 121 (11), 2051-2058 (2013).</li><li>Gertz, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Waldenstr&#246;m+macroglobulinemia:+2012+update+on+diagnosis,+risk+stratification,+and+management.">Waldenstr&#246;m macroglobulinemia: 2012 update on diagnosis, risk stratification, and management.</a> Amer J Hematol. 87 (5), 503-510 (2012).</li><li>Salar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=MYD88+(L265P)+Mutation+Confers+Very+Poor+Response+and+Outcome+after+Second-Line+Therapy+in+Patients+with+Diffuse+Large+B-Cell+Lymphoma+(DLBCL).">MYD88 (L265P) Mutation Confers Very Poor Response and Outcome after Second-Line Therapy in Patients with Diffuse Large B-Cell Lymphoma (DLBCL).</a> Blood. 124 (21), 1690-1690 (2014).</li><li>Ngo, V. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Oncogenically+active+MYD88+mutations+in+human+lymphoma.">Oncogenically active MYD88 mutations in human lymphoma.</a> Nature. 470 (7332), 115-119 (2011).</li><li>Pasqualucci, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Analysis+of+the+coding+genome+of+diffuse+large+B-cell+lymphoma.">Analysis of the coding genome of diffuse large B-cell lymphoma.</a> Nat Genet. 43 (9), 830-837 (2011).</li><li>Dieffenbach, C., Lowe, T., Dveksler, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=General+concepts+for+PCR+primer+design.">General concepts for PCR primer design.</a> PCR Methods Appl. 3 (3), S30-S37 (1993).</li><li>Lee, P. Y., Costumbrado, J., Hsu, C. Y., Kim, Y. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Agarose+Gel+Electrophoresis+for+the+Separation+of+DNA+Fragments.">Agarose Gel Electrophoresis for the Separation of DNA Fragments.</a> J Vis Exp. (62), e3923 (2012).</li><li>Applied Biosystems. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> User Guide for Applied Biosystems 3730/3730xl DNA Analyzer. , (2014).</li><li>Applied Biosystems. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> User Guide for SeqScape Software 3. , (2012).</li><li>Mouritzen, P., Nielsen, A. T., Pfundheller, H. M., Choleva, Y., Kongsbak, L., M&#248;ller, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single+nucleotide+polymorphism+genotyping+using+locked+nucleic+acid+(LNA).">Single nucleotide polymorphism genotyping using locked nucleic acid (LNA).</a> Expert Rev Mol Diagn. 3 (1), 27-38 (2003).</li><li>Quach, N., Goodman, M. F., Shibata, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In+vitro+mutation+artifacts+after+formalin+fixation+and+error+prone+translesion+synthesis+during+PCR.">In vitro mutation artifacts after formalin fixation and error prone translesion synthesis during PCR.</a> BMC Clin Pathol. 4 (1), (2004).</li><li>Gallegos Ruiz, M. I., Floor, K., Rijmen, F., Gr&#252;nberg, K., Rodriguez, J. A., Giaccone, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=EGFR+and+K-ras+mutation+analysis+in+non-small+cell+lung+cancer:+comparison+of+paraffin+embedded+versus+frozen+specimens.">EGFR and K-ras mutation analysis in non-small cell lung cancer: comparison of paraffin embedded versus frozen specimens.</a> Anal Cell Pathol. 29 (3), 257-264 (2007).</li><li>Solassol, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=KRAS+mutation+detection+in+paired+frozen+and+formalin-fixed+paraffin-embedded+(FFPE)+colorectal+cancer+tissues.">KRAS mutation detection in paired frozen and formalin-fixed paraffin-embedded (FFPE) colorectal cancer tissues.</a> Int J Mol Sci. 12 (5), 3191-3204 (2011).</li><li>Yost, S. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Identification+of+high-confidence+somatic+mutations+in+whole+genome+sequence+of+formalin-fixed+breast+cancer+specimens.">Identification of high-confidence somatic mutations in whole genome sequence of formalin-fixed breast cancer specimens.</a> Nucleic Acids Res. 40 (14), e107-e107 (2012).</li><li>Do, H., Wong, S. Q., Li, J., Dobrovic, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reducing+sequence+artifacts+in+amplicon-based+massively+parallel+sequencing+of+formalin-fixed+paraffin-embedded+DNA+by+enzymatic+depletion+of+uracil-containing+templates.">Reducing sequence artifacts in amplicon-based massively parallel sequencing of formalin-fixed paraffin-embedded DNA by enzymatic depletion of uracil-containing templates.</a> Clin Chem. 59 (9), 1376-1383 (2013).</li><li>Oldenburg, R. P., Liu, M. S., Kolodney, M. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selective+amplification+of+rare+mutations+using+locked+nucleic+acid+oligonucleotides+that+competitively+inhibit+primer+binding+to+wild-type+DNA.">Selective amplification of rare mutations using locked nucleic acid oligonucleotides that competitively inhibit primer binding to wild-type DNA.</a> J Invest Dermatol. 128 (2), 398-402 (2008).</li><li>Mancini, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two+novel+methods+for+rapid+detection+and+quantification+of+DNMT3A+R882+mutations+in+acute+myeloid+leukemia.">Two novel methods for rapid detection and quantification of DNMT3A R882 mutations in acute myeloid leukemia.</a> J Mol Diagn. 17 (2), 179-184 (2015).</li><li>Parsons, B. L., Heflich, R. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Genotypic+selection+methods+for+the+direct+analysis+of+point+mutations.">Genotypic selection methods for the direct analysis of point mutations.</a> Mutat Res Rev Muta Res. 387 (2), 97-121 (1997).</li><li>Liu, Q., Swiderski, P., Sommer, S. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Truncated+amplification:+a+method+for+high-fidelity+template-driven+nucleic+acid+amplification.">Truncated amplification: a method for high-fidelity template-driven nucleic acid amplification.</a> BioTechniques. 33 (1), 129-139 (2002).</li><li>Kaur, M., Zhang, Y., Liu, W. H., Tetradis, S., Price, B. D., Makrigiorgos, G. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ligation+of+a+primer+at+a+mutation:+a+method+to+detect+low+level+mutations+in+DNA.">Ligation of a primer at a mutation: a method to detect low level mutations in DNA.</a> Mutagenesis. 17 (5), 365-374 (2002).</li><li>Albitar, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=High+Sensitivity+Testing+Shows+Multiclonal+Mutations+in+Patients+with+CLL+Treated+with+BTK+Inhibitor+and+Lack+of+Mutations+in+Ibrutinib-Naive+Patients.">High Sensitivity Testing Shows Multiclonal Mutations in Patients with CLL Treated with BTK Inhibitor and Lack of Mutations in Ibrutinib-Naive Patients.</a> Blood. 126 (23), 716 (2015).</li></ol>

The authors have nothing to disclose.

The WTB-PCR assay described here uses a generic set of primers with a blocking oligo designed to block amplification of WT DNA during extension (Figure 1). The WTB-PCR product is then sequenced for mutational analysis. The utility of WTB-PCR/Sanger lies in its simplicity, high-sensitivity, and high-throughput. Using the guidelines described here, most existing Sanger based assays can be simply modified via the addition of a blocking oligonucleotide to greatly increase sensitivity. In the example assay presented here the addition of a single blocking oligonucleotide to PCR increased the limit of detection from approximately 16% mutant allele in a background of WT for the conventional assay to &#62;0.5% in the WTB-PCR assay3. The effect of which is a 64% reduction in false negatives seen in clinical testing3. Confirming the presence of mutations in MYD88 has significant diagnostic and prognostic implications; falsely reporting a case as negative may have serious consequences on overall therapy and patient management. Testing with WTB-PCR is therefore of great importance, particularly in patients with relatively low abnormal cellularity.
WTB-PCR techniques vary considerably and are sometimes referred to interchangeably with LNA, BNA, or PNA-mediated PCR clamping or PCR-clamp-probe assays2,4,23,24. Some variations utilizing WTB-PCR involve a qPCR assay which necessitates designing an additional fluorescent probe for each specific mutation. A significant challenge associated with this technique includes the need to develop competitively binding probes that accurately discriminate between WT and mutant alleles. Furthermore, because a mutation specific probe is required, the qPCR approach lacks the ability to detect unknown mutations. Another variation of WTB-PCR blocks WT amplification in an allele-specific manner. Instead of using mutation-specific primers however, a blocking probe specific for the WT allele inhibits complete primer binding. While this approach does not require a mutation-specific probe like qPCR, it fails to discriminate between mutations and polymerase induced errors can lead to increased false positives. Exponential amplification of those polymerase induced errors through PCR may obscure the detection of rare mutational events. Any approach that uses PCR amplification to enrich for mutations has its accuracy limited by the frequency of PCR errors25,26,27. A fundamental advantage of WTB-PCR/Sanger over many other high-sensitivity methodologies is that it prevents amplification of both WT template and mutant template whose mutations occur outside the gene region targeted by the blocking oligonucleotide. Therefore, PCR errors introduced by polymerases are effectively filtered out along with WT DNA. Contrary to AS-PCR or qPCR however, enrichment is retained for unknown mutations that occur within the region covered by the blocking oligo. In the case of MYD88, WTB-PCR allowed the detection of both L265P and R264* mutations3. Others have similarly reported the detection of multiple, low-frequency mutations with the use of WTB-PCR4,28. This makes WTB-PCR ideal for both research and clinical purposes.
Along with high sensitivity and inherent internal controls for eliminating false positives, WTB-PCR&#39;s flexibility for adapting an existing sequencing assay with very few additional steps with blocker design make it attractive option for many labs with established assays. The same set of PCR primers used in a conventional assay can typically be used in the WTB-PCR variation. Other protocol changes that are highly recommended for WTB-PCR-including UDG treatment of FFPE tissue and appropriate post-PCR purification methodologies-are equally transferrable. Blocker design, therefore is the critical element in implementing a WTB-PCR assay. Though the guidelines presented in this protocol represent the most relevant factors in that design, various blocking oligonucleotides should be tested to find one that blocks WT amplification efficiently without secondary effects to PCR. This includes adding or removing blocker bases to adjust Tm, shifting the position of the blocking oligo relative to the WT template, and changing the overall length of the oligo. Blocker titration experiments should also be employed to establish a balance between acceptable occurrences of sequencing artifacts and limit of detection.
Selecting an appropriate methodology for detecting mutations that are present in minute cell fractions depends greatly on the application and disease/mutation types. If mutant quantification is desired, qPCR or digital PCR may offer more viable solutions than WTB-PCR/Sanger. Though WTB-PCR is primarily a qualitative assay, it is possible to determine a rough estimate of the mutant allele frequency by testing a sample with conventional and WTB-PCR in parallel. Because the limit of detection for the conventional assay is ~ 10 - 20% mutant allele in a background of WT, it is appropriate to conclude that mutations detected by the WTB-PCR assay but not the conventional are present at a concentration less than the limit of detection for the conventional assay. Few assays offer the versatility, simplicity, and robustness of WTB-PCR. The low cost and short turnaround time makes it ideal for assessing residual disease after therapy or monitoring emerging resistance mutations during therapy. Additionally, the ability to detect previously undescribed mutations make WTB-PCR ideal for research purposes.

Sanger sequencing has traditionally been the gold standard in testing for both known and unknown somatic mutations. One of the limitations of Sanger sequencing is its limit of detection (~ 10 - 20% mutant allele in a background of WT)1. This level of sensitivity is inappropriate for detecting low level somatic mutations that may be present in samples from premalignant tissues or patients with few circulating tumor cells, or when bone marrow (BM) is patchy. This also makes assessing residual disease after therapy or detecting emerging resistance mutations during therapy difficult by conventional sequencing alone2. By replacing conventional PCR with locked nucleic acid (LNA)-mediated wild-type blocking PCR (WTB-PCR) in Sanger sequencing, sensitivities of up to 0.1% mutant allele in a background of WT can be achieved2,3,4. In WTB-PCR, enrichment for mutant alleles is achieved via the addition of a short (~ 10 - 14 NT) blocking (LNA) oligonucleotide that binds preferentially to WT DNA thereby preventing amplification of WT DNA. The mutant enriched WTB-PCR product can then be sequenced. By blocking WT DNA rather than selecting for specific mutations WTB-PCR allows for enrichment of both known and unknown mutations present in minute cell fractions.
Multiple methods are currently used for detecting mutations in small cells fractions. This includes allele-specific PCR, amplification-refractory mutation system (ARMS), denaturing high performance liquid chromatography (DHPLC), beads, emulsions, amplification, and magnetics (BEAMing), electric field-induced release and measurement (EFIRM), high resolution melting point and others. However, most of these methods are limited by false-positives and the ability to only detect one mutation that the assay was designed for4. WTB-PCR, however, allows the user to visualize sequencing traces which enables the detection of multiple mutation types and can aid in ruling out false positives due to artifacts or deamination events. Next-generation sequencing (NGS) may offer a suitable alternative to conventional sequencing, however, substantially greater costs, complexity, and longer assay time render it an unnecessary option for many disease types with few distinct molecular markers or for monitoring patients on therapy for emerging resistance mutations. Furthermore, high false positive rates when detecting variants with mutant allele frequencies of less than 5% can pose a problem for amplicon-based NGS5,6.
Here we demonstrate the increase in sensitivity achieved by WTB-PCR in screening for mutations in the myeloid differentiation factor 88 gene as described by Albitar et al.3 MYD88 mutations are important diagnostic and prognostic factors in Waldenstr&#246;m&#39;s Macroglobulinemia (WM), IgM monoclonal gammopathy of unknown significance (IgM-MGUS), splenic marginal zone lymphoma (SMZL), and diffuse large B-cell lymphoma (DLBCL). MYD88 mutations are found in almost all cases of WM and approximately 50% of patients with Immunoglobulin M (IgM)-secreting MGUS. Contrastingly, MYD88 mutations are found in only 0-6% of patients with SMZL and are absent in multiple myeloma7,8. Because overlapping morphologic, immunophenotypic, cytogenetic, and clinical characteristics between WM and SMZL or IgM-multiple myeloma can often complicate differential diagnoses, the presence of a MYD88 mutation may serve as a useful identifying factor9. MYD88 mutations have also been associated with greater disease burden in patients with DLBCL and poor overall survival following therapy7,10. Additionally, because MYD88 mutations are more frequently found in activated B-cell-like (ABC) DLBCL than germinal center B-cell-like (GCB) DLBCL or primary mediastinal B-cell lymphoma (PMBL), MYD88 mutation status may serve as a surrogate marker for the ABC subtype11,12.
The detailed protocol provided here serves as a template from which new assays can be developed or most existing sequencing assays can be easily adapted to accurately detect low frequency mutations in various sample types. The approach can also be used for monitoring and detecting resistant mutations that may develop in tumors or even bacteria that may develop while patients are being treated with targeted therapy or antibiotics. Furthermore, it addresses and remedies many of the issues associated with mutation enrichment, particularly in formalin-fixed paraffin-embedded (FFPE) tissue.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>1.5 or 2 ml Safe-Lock microcentrifuge tubes</td>
			<td>Eppendorf</td>
			<td>05-402-25</td>
			<td></td>
		</tr>
		<tr>
			<td>100% alcohol</td>
			<td>VWR</td>
			<td>89370-084</td>
			<td>Histology grade; 91.5% Ethanol, 5% Isopropyl alcohol, 4.5% Methyl alcohol</td>
		</tr>
		<tr>
			<td>3730XL sequencer</td>
			<td>ABI</td>
			<td></td>
			<td>or equivalent</td>
		</tr>
		<tr>
			<td>Agencourt AMPure XP</td>
			<td>Beckman Coulter</td>
			<td>A63881</td>
			<td>For magnetic bead PCR purification</td>
		</tr>
		<tr>
			<td>Aluminum sealing foils</td>
			<td>GeneMate</td>
			<td>T-2451-1</td>
			<td>For PCR and cold storage</td>
		</tr>
		<tr>
			<td>BigDye Terminator v3.1 Cycle sequencing kit</td>
			<td>Life Technologies</td>
			<td>4337455</td>
			<td>For bi-directional sequencing. With 5X Sequencing Buffer</td>
		</tr>
		<tr>
			<td>Centrifuge 5804 Series</td>
			<td>Eppendorf</td>
			<td></td>
			<td>A-2-DWP rotor (for PCR plate)</td>
		</tr>
		<tr>
			<td>Cold plate for 96 well plates</td>
			<td>Eppendorf</td>
			<td>Z606634</td>
			<td></td>
		</tr>
		<tr>
			<td>DNAse, RNAse-free, ultra-pure water</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>dNTPs (100mM)</td>
			<td>Invitrogen</td>
			<td>10297-117</td>
			<td></td>
		</tr>
		<tr>
			<td>DynaMag-96 Side-Skirted Magnet</td>
			<td>Thermo Fisher Scientific</td>
			<td>12027</td>
			<td>For use in PCR Purification.</td>
		</tr>
		<tr>
			<td>Ethanol Absolute&#160;</td>
			<td>Sigma</td>
			<td>E7023</td>
			<td>200 proof, for molecular biology</td>
		</tr>
		<tr>
			<td>Exiqon website Oligo Tools</td>
			<td></td>
			<td></td>
			<td><a href="http://www.exiqon.com/oligo-tools">www.exiqon.com/oligo-tools</a></td>
		</tr>
		<tr>
			<td>FastStart Taq DNA polymerase (5 U/ul)</td>
			<td>Roche</td>
			<td>12032937001</td>
			<td>With10X concentrated PCR reaction buffer, with 20 mM MgCl2&#160;</td>
		</tr>
		<tr>
			<td>Gel electrophoresis apparatus</td>
			<td></td>
			<td></td>
			<td>2% agarose gel</td>
		</tr>
		<tr>
			<td>GeneRead DNA FFPE extraction Kit&#160;</td>
			<td>Qiagen</td>
			<td>180134</td>
			<td>Contains uracil DNA glycosylase necessary for reducing sequencing artifacts</td>
		</tr>
		<tr>
			<td>Hi-Di Formamide</td>
			<td>ABI</td>
			<td>4311320</td>
			<td>For sequencing.</td>
		</tr>
		<tr>
			<td>LNA oligonucleotide</td>
			<td>Exiqon</td>
			<td>500100</td>
			<td>5&#39;-TCAGA+AG+C+G+A+C+T+G+A+T+CC/invdT/ (+N = LNA bases)</td>
		</tr>
		<tr>
			<td>M13-F Sequencing Primer</td>
			<td>ABI</td>
			<td></td>
			<td>5&#39;-tgt aaa acg acg gcc agt</td>
		</tr>
		<tr>
			<td>M13-R Sequencing Primer</td>
			<td>ABI</td>
			<td></td>
			<td>5&#39;-cag gaa aca gct atg acc</td>
		</tr>
		<tr>
			<td>Mastercycler Pro S Thermocycler</td>
			<td>Eppendorf</td>
			<td>E950030020</td>
			<td></td>
		</tr>
		<tr>
			<td>Microcentrifuge Model 5430</td>
			<td>Eppendorf</td>
			<td></td>
			<td>FA-45-30-11 rotor (for 1.5/2 ml microcentrifuge tubes)</td>
		</tr>
		<tr>
			<td>NanoDrop 2000 Spectrophotometer</td>
			<td>Thermo Fisher Scientific</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>PCR forward primer</td>
			<td>IDT</td>
			<td></td>
			<td>5&#39;-tgt aaa acg acg gcc agt TGC CAG GGG TAC TTA GAT GG</td>
		</tr>
		<tr>
			<td>PCR reverse primer</td>
			<td>IDT</td>
			<td></td>
			<td>5&#39;-cag gaa aca gct atg acc GGT TGG TGT AGT CGC AGA CA</td>
		</tr>
		<tr>
			<td>PCR plates</td>
			<td>GeneMate</td>
			<td>T-3107-1</td>
			<td></td>
		</tr>
		<tr>
			<td>Pipettors</td>
			<td></td>
			<td></td>
			<td>20, 200, 1000 &#181;l</td>
		</tr>
		<tr>
			<td>Plate septa, 96 well</td>
			<td>ABI</td>
			<td>4315933</td>
			<td></td>
		</tr>
		<tr>
			<td>QIAamp DNA Mini Kit</td>
			<td>Qiagen</td>
			<td>51304</td>
			<td>For BM aspirate and peripheral blood</td>
		</tr>
		<tr>
			<td>SeqScape Sortware v3.0</td>
			<td>ABI</td>
			<td>4474978</td>
			<td>For sequencing analysis</td>
		</tr>
		<tr>
			<td>Slide basket</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sodium Acetate (3M, pH 5.2)&#160;</td>
			<td>Sigma</td>
			<td>S7899</td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile filtered pipette tips&#160;</td>
			<td></td>
			<td></td>
			<td>20, 200, 1000 &#181;l</td>
		</tr>
		<tr>
			<td>Thermomixer C&#160;</td>
			<td>Eppendorf</td>
			<td>5382000023</td>
			<td></td>
		</tr>
		<tr>
			<td>Vortex genie</td>
			<td>Scientific Industries</td>
			<td>SI-0236</td>
			<td></td>
		</tr>
		<tr>
			<td>Wash reservoir</td>
			<td></td>
			<td></td>
			<td>~1000 ml</td>
		</tr>
		<tr>
			<td>Xylene</td>
			<td>VWR</td>
			<td>89370-088</td>
			<td>Histology grade</td>
		</tr>
	</tbody>
</table>

wild-type blocking pcr combined with direct sequencing as a highly sensitive method for detection of low-frequency somatic mutations

Accurate detection and identification of low frequency mutations can be problematic when assessing residual disease after therapy, screening for emerging resistance mutations during therapy, or when patients have few circulating tumor cells. Wild-type blocking PCR followed by sequencing analysis offers high sensitivity, flexibility, and simplicity as a methodology for detecting these low frequency mutations. By adding a custom designed locked nucleic acid oligonucleotide to a new or previously established conventional PCR based sequencing assay, sensitivities of approximately 1 mutant allele in a background of 1,000 WT alleles can be achieved (1:1,000). Sequencing artifacts associated with deamination events commonly found in formalin fixed paraffin embedded tissues can be partially remedied by the use of uracil DNA glycosylase during extraction steps. The optimized protocol here is specific for detecting MYD88 mutation, but can serve as a template to design any WTB-PCR assay. Advantages of the WTB-PCR assay over other commonly utilized assays for the detection of low frequency mutations including allele specific PCR and real-time quantitative PCR include fewer occurrences of false positives, greater flexibility and ease of implementation, and the ability to detect both known and unknown mutations.

A conceptual overview of WTB-PCR during extension is presented in Figure 1. Because a single nucleotide mismatch in the blocker-DNA hybrid greatly decreases its melting temperature (&#916;Tm=20 - 30 &#176;C), amplification of the WT allele is blocked while mutant template DNA is free to complete extension17. In this manner, mutant DNA is amplified exponentially while WT DNA is amplified linearly.
A demonstration of the mutant enrichment achieved by WTB-PCR is presented in Figure 2. Genomic DNA from patients with and without mutations were tested by both conventional and WTB-PCR and then sequenced to demonstrate the typical enrichment achievable by WTB-PCR and a lack of false positives in WT DNA. The working concentration of blocker used in WTB-PCR MMX should be determined by titration experiments and should achieve the desired level of mutant enrichment while not resulting in false positives or blocking amplification of WT DNA entirely. Sequencing analysis of WTB-PCR product demonstrates enrichment for the mutant allele and a limit of detection in excess of 0.5% mutant allele in a background of WT compared with 16% in conventional PCR3.
The effects of this increase in sensitivity in clinical testing may vary depending on the relative quantity of neoplastic cells in the samples tested. In a methods comparison study, the WTB-PCR assay described here has demonstrated that 64% of MYD88 mutations would be missed by conventional testing of patients with WM or MGUS3.
A characteristic drop-off in signal intensity (Figure 3) is often seen if too high a concentration of blocker is used or if post-PCR purification failed to remove blocker prior to bi-directional sequencing. The latter is demonstrated when magnetic bead purification is substituted for enzymatic purification. Though enzymatic purification is an attractive option when working with greater sample numbers, it is inappropriate for application with WTB-PCR as it fails to remove blocker from solution prior to sequencing.
An example of sequence artifacts frequently found in FFPE-derived DNA as a result of cytosine deamination (C:G&#62;T:A) are presented in Figure 43,18,19,20. Though the actual causes of cytosine deamination are poorly understood, any PCR based assay that enriches for mutant alleles will detect these low frequency artifacts21,22. False positives due to deamination are best avoided by starting with high quality template material; in the many cases where this is not possible, treatment with uracil DNA glycosylase (UDG) during extraction can aid in limiting the frequency and intensity of deamination artifacts. UDG treatment of FFPE tissue during extraction (as part of the DNA FFPE kit) excises deaminated cytosine residues thereby preventing artificially induced C:G&#62;T:A mutations. However, 5-methylcytosine residues that frequently occur at CpG dinucleotides are deaminated to thymine, which cannot be excised by UDG. The resulting sequencing artifacts are fairly recognizable and often appear as tandem mutations as seen in Figure 4. If samples have already been extracted, UDG treatment can be implemented in a secondary extraction with relatively low DNA loss.
<img alt="Figure 1" src="/files/ftp_upload/55130/55130fig1.jpg" /> 
Figure 1: Conceptual Overview of WTB-PCR. A single nucleotide mismatch in the Blocker-DNA hybrid decreases Tm by up to 30 &#176;C. By designing the blocking oligonucleotide to have a Tm of 10 - 15 &#176;C above the temperature during extension, amplification of WT DNA is blocked while allowing amplification of mutant DNA. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55130/55130fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" src="/files/ftp_upload/55130/55130fig2.jpg" /> 
Figure 2: Genomic DNA from patients with and without mutations were tested by both conventional and WTB-PCR and then sequenced to demonstrate the typical enrichment achievable by WTB-PCR. The final concentration of blocker used to achieve WTB-PCR was selected to achieve maximum mutant enrichment while not causing false positives in WT DNA or blocking amplification of WT DNA entirely. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55130/55130fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" src="/files/ftp_upload/55130/55130fig3.jpg" /> 
Figure 3: Characteristic drop-off in signal intensity seen when enzymatic PCR purification is used instead of magnetic beads. This is likely because enzymatic purification fails to remove blocker prior to bi-directional sequencing. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55130/55130fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" src="/files/ftp_upload/55130/55130fig4.jpg" /> 
Figure 4: C:G&#62;T:A sequencing artifacts arise in FFPE tissue when cytosine or methylated cytosine are deaminated via formalin fixation to uracil or thymine, respectively. Uracil DNA glycosylase (UDG) can excise uracil prior to WTB-PCR helping to reduce sequencing artifacts. However, thymine resulting from deaminated 5-methylcytosine, which frequently occurs at CpG islands, cannot be excised by UDG. Decreasing the concentration of blocker used in WTB-PCR may help to reduce the occurrence of sequencing artifacts that are not remedied by UDG treatment. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55130/55130fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Wild-type Blocking PCR Combined with Direct Sequencing as a Highly Sensitive Method for Detection of Low-Frequency Somatic Mutations at JoVE.com

Wild-type Blocking PCR Combined with Direct Sequencing as a Highly Sensitive Method for Detection of Low-Frequency Somatic Mutations

Wild-type blocking PCR followed by direct sequencing offers a highly sensitive method of detection for low frequency somatic mutations in a variety of sample types.

Accurate detection and identification of low frequency mutations can be problematic when assessing residual disease after therapy, screening for emerging ...

wild-type-blocking-pcr-combined-with-direct-sequencing-as-highly

Nanyang Technological University

Research

JoVE Journal

Genetics

11.6K Views.  NeoGenomics Laboratories. Wild-type blocking PCR followed by direct sequencing offers a highly sensitive method of detection for low frequency somatic mutations in a variety of sample types.

Video: Wild-type Blocking PCR Combined with Direct Sequencing as a Highly Sensitive Method for Detection of Low-Frequency Somatic Mutations

Detection of Copy Number Alterations Using Single Cell Sequencing

Detection of genomic changes at single cell resolution is important for characterizing genetic heterogeneity and evolution in normal tissues, cancers, and microbial populations. Traditional methods for assessing genetic heterogeneity have been limited by low resolution, low sensitivity, and/or low specificity. Single cell sequencing has emerged as a powerful tool for detecting genetic heterogeneity with high resolution, high sensitivity and, when appropriately analyzed, high specificity. Here we provide a protocol for the isolation, whole genome amplification, sequencing, and analysis of single cells. Our approach allows for the reliable identification of megabase-scale copy number variants in single cells. However, aspects of this protocol can also be applied to investigate other types of genetic alterations in single cells.

Single cell sequencing is an increasingly popular and accessible tool for addressing genomic changes at high resolution. We provide a protocol that uses single cell sequencing to identify copy number alterations in single cells.

Detection of genomic changes at single cell resolution is important for characterizing genetic heterogeneity and evolution in normal tissues, cancers, and ...

Detection of microRNA Expression in Peritoneal Membrane of Rats Using Quantitative Real-time PCR

MicroRNAs (miRNAs) are small noncoding RNAs that regulate messenger RNA expression post-transcriptionally. The miRNA expression profile has been investigated in various organs and tissues in rat. However, standard methods for the purification of miRNAs and detection of their expression in rat peritoneal membrane have not been well established. We have developed an effective and reliable method to purify and quantify miRNAs using quantitative real-time reverse-transcription polymerase chain reaction (qRT-PCR) in rat peritoneal membrane. This protocol consists of four steps: 1) purification of peritoneal membrane sample; 2) purification of total RNA including miRNA from peritoneal membrane sample; 3) reverse transcription of miRNA to produce cDNA; and 4) qRT-PCR to detect miRNA expression. Using this protocol, we successfully determined that the expression of six miRNAs (miRNA-142-3p, miRNA-21-5p, miRNA-221-3p, miRNA-223-3p, miRNA-327, and miRNA-34a-5p) increased significantly in the peritoneal membrane of a rat peritoneal fibrosis model compared with those in control groups. This protocol can be used to study the profile of miRNA expression in the peritoneal membrane of rats in many pathological conditions.

Here we present a protocol for the detection of microRNA expression in rat peritoneal membrane using quantitative real-time reverse-transcription polymerase chain reaction. This method is suitable for studying the microRNA expression profile in rat peritoneal membrane in several pathological conditions.

MicroRNAs (miRNAs) are small noncoding RNAs that regulate messenger RNA expression post-transcriptionally. The miRNA expression profile has been ...

Robust DNA Isolation and High-throughput Sequencing Library Construction for Herbarium Specimens

Herbaria are an invaluable source of plant material that can be used in a variety of biological studies. The use of herbarium specimens is associated with a number of challenges including sample preservation quality, degraded DNA, and destructive sampling of rare specimens. In order to more effectively use herbarium material in large sequencing projects, a dependable and scalable method of DNA isolation and library preparation is needed. This paper demonstrates a robust, beginning-to-end protocol for DNA isolation and high-throughput library construction from herbarium specimens that does not require modification for individual samples. This protocol is tailored for low quality dried plant material and takes advantage of existing methods by optimizing tissue grinding, modifying library size selection, and introducing an optional reamplification step for low yield libraries. Reamplification of low yield DNA libraries can rescue samples derived from irreplaceable and potentially valuable herbarium specimens, negating the need for additional destructive sampling and without introducing discernible sequencing bias for common phylogenetic applications. The protocol has been tested on hundreds of grass species, but is expected to be adaptable for use in other plant lineages after verification. This protocol can be limited by extremely degraded DNA, where fragments do not exist in the desired size range, and by secondary metabolites present in some plant material that inhibit clean DNA isolation. Overall, this protocol introduces a fast and comprehensive method that allows for DNA isolation and library preparation of 24 samples in less than 13 h, with only 8 h of active hands-on time with minimal modifications.

This article demonstrates a detailed protocol for DNA isolation and high-throughput sequencing library construction from herbarium material including rescue of exceptionally poor-quality DNA.

Herbaria are an invaluable source of plant material that can be used in a variety of biological studies. The use of herbarium specimens is associated with ...

Rare Event Detection Using Error-corrected DNA and RNA Sequencing

Conventional next-generation sequencing techniques (NGS) have allowed for immense genomic characterization for over a decade. Specifically, NGS has been used to analyze the spectrum of clonal mutations in malignancy. Though far more efficient than traditional Sanger methods, NGS struggles with identifying rare clonal and subclonal mutations due to its high error rate of ~0.5&#8211;2.0%. Thus, standard NGS has a limit of detection for mutations that are &#62;0.02 variant allele fraction (VAF). While the clinical significance for mutations this rare in patients without known disease remains unclear, patients treated for leukemia have significantly improved outcomes when residual disease is &#60;0.0001 by flow cytometry. In order to mitigate this artefactual background of NGS, numerous methods have been developed. Here we describe a method for Error-corrected DNA and RNA Sequencing (ECS), which involves tagging individual molecules with both a 16 bp random index for error-correction and an 8 bp patient-specific index for multiplexing. Our method can detect and track clonal mutations at variant allele fractions (VAFs) two orders of magnitude lower than the detection limit of NGS and as rare as 0.0001 VAF.

Next-generation sequencing (NGS) is a powerful tool for genomic characterization that is limited by the high error rate of the platform (~0.5&#8211;2.0%). We describe our methods of error-corrected sequencing that allow us to obviate the NGS error rate and detect mutations at variant allele fractions as rare as 0.0001.

Conventional next-generation sequencing techniques (NGS) have allowed for immense genomic characterization for over a decade. Specifically, NGS has been ...

Lentiviral Mediated Production of Transgenic Mice: A Simple and Highly Efficient Method for Direct Study of Founders

For almost 40 years, pronuclear DNA injection represents the standard method to generate transgenic mice with random integration of transgenes. Such a routine procedure is widely utilized throughout the world and its main limitation resides in the poor efficacy of transgene integration, resulting in a low yield of founder animals. Only few percent of animals born after implantation of injected fertilized oocytes have integrated the transgene. In contrast, lentiviral vectors are powerful tools for integrative gene transfer and their use to transduce fertilized oocytes allows highly efficient production of founder transgenic mice with an average yield above 70%. Furthermore, any mouse strain can be used to produce transgenic animal and the penetrance of transgene expression is extremely high, above 80% with lentiviral mediated transgenesis compared to DNA microinjection. The size of the DNA fragment that can be cargo by the lentiviral vector is restricted to 10 kb and represents the major limitation of this method. Using a simple and easy to perform injection procedure beneath the zona pellucida of fertilized oocytes, more than 50 founder animals can be produced in a single session of microinjection. Such a method is highly adapted to perform, directly in founder animals, rapid gain and loss of function studies or to screen genomic DNA regions for their ability to control and regulate gene expression in vivo.

Here, we present a protocol to promote transgene integration and production of founder transgenic mice with high efficacy by a simple injection of a lentiviral vector in the perivitelline space of a fertilized oocyte.

For almost 40 years, pronuclear DNA injection represents the standard method to generate transgenic mice with random integration of transgenes. Such a ...

Amplification of Near Full-length HIV-1 Proviruses for Next-Generation Sequencing

The Full-Length Individual Proviral Sequencing (FLIPS) assay is an efficient and high-throughput method designed to amplify and sequence single, near full-length (intact and defective), HIV-1 proviruses. FLIPS allows determination of the genetic composition of integrated HIV-1 within a cell population. Through identifying defects within HIV-1 proviral sequences that arise during reverse transcription, such as large internal deletions, deleterious stop codons/hypermutation, frameshift mutations, and mutations/deletions in cis acting elements required for virion maturation, FLIPS can identify integrated proviruses incapable of replication. The FLIPS assay can be utilized to identify HIV-1 proviruses that lack these defects and are&#160;therefore potentially replication-competent. The FLIPS protocol involves: lysis of HIV-1 infected cells, nested PCR of near full-length HIV-1 proviruses (using primers targeted to the HIV-1 5&#39; and 3&#39; LTR), DNA purification and quantification, library preparation for Next-generation Sequencing (NGS), NGS, de novo assembly of proviral contigs, and a simple process of elimination for identifying replication-competent proviruses. FLIPS provides advantages over traditional methods designed to sequence integrated HIV-1 proviruses, such as single-proviral sequencing. FLIPS amplifies and sequences near full-length proviruses enabling replication competency to be determined, and also uses fewer amplification primers, preventing the consequences of primer mismatches. FLIPS is a useful tool for understanding the genetic landscape of integrated HIV-1 proviruses, especially within the latent reservoir, however, its utilization can extend to any application in which the genetic composition of integrated HIV-1 is required.

Full-length individual proviral sequencing (FLIPS) provides an efficient and high-throughput method for the amplification and sequencing of single, near full-length (intact and defective) HIV-1 proviruses and allows for determination of their potential replication-competency. FLIPS overcomes limitations of previous assays designed to sequence the latent HIV-1 reservoir.

The Full-Length Individual Proviral Sequencing (FLIPS) assay is an efficient and high-throughput method designed to amplify and sequence single, near ...

Single Droplet Digital Polymerase Chain Reaction for Comprehensive and Simultaneous Detection of Mutations in Hotspot Regions

Droplet digital polymerase chain reaction (ddPCR) is a highly sensitive quantitative polymerase chain reaction (PCR) method based on sample fractionation into thousands of nano-sized water-in-oil individual reactions. Recently, ddPCR has become one of the most accurate and sensitive tools for circulating tumor DNA (ctDNA) detection. One of the major limitations of the standard ddPCR technique is the restricted number of mutations that can be screened per reaction, as specific hydrolysis probes recognizing each possible allelic version are required. An alternative methodology, the drop-off ddPCR, increases throughput, since it requires only a single pair of probes to detect and quantify potentially all genetic alterations in the targeted region. Drop-off ddPCR displays comparable sensitivity to conventional ddPCR assays with the advantage of detecting a greater number of mutations in a single reaction. It is cost-effective, conserves precious sample material, and can also be used as a discovery tool when mutations are not known a priori.

Here, we present a protocol to accurately quantify multiple genetic alterations of a target region in a single reaction using drop-off ddPCR and a unique pair of hydrolysis probes.

Droplet digital polymerase chain reaction (ddPCR) is a highly sensitive quantitative polymerase chain reaction (PCR) method based on sample fractionation ...

Digital PCR-based Competitive Index for High-throughput Analysis of Fitness in Salmonella

A competitive index is a common method used to assess bacterial fitness and/or virulence. The utility of this approach is exemplified by its ease to perform and its ability to standardize the fitness of many strains to a wild-type organism. The technique is limited, however, by available phenotypic markers and the number of strains that can be assessed simultaneously, creating the need for a great number of replicate experiments. Concurrent with large numbers of experiments, the labor and material costs for quantifying bacteria based on phenotypic markers are not insignificant. To overcome these negative aspects while retaining the positive aspects, we have developed a molecular-based approach to directly quantify microorganisms after engineering genetic markers onto bacterial chromosomes. Unique, 25 base pair DNA barcodes were inserted at an innocuous locus on the chromosome of wild-type and mutant strains of Salmonella. In vitro competition experiments were performed using inocula consisting of pooled strains. Following the competition, the absolute numbers of each strain were quantified using digital PCR and the competitive indices for each strain were calculated from those values. Our data indicate that this approach to quantifying Salmonella is extremely sensitive, accurate, and precise for detecting both highly abundant (high fitness) and rare (low fitness) microorganisms. Additionally, this technique is easily adaptable to nearly any organism with chromosomes capable of modification, as well as to various experimental designs that require absolute quantification of microorganisms.

Digital PCR-based Competitive Index for High-throughput Analysis of Fitness in Salmonella

This molecular-based approach for determining bacterial fitness facilitates precise and accurate detection of microorganisms using unique genomic DNA barcodes that are quantified via digital PCR. The protocol describes calculating the competitive index for Salmonella strains; however, the technology is readily adaptable to protocols requiring absolute quantification of any genetically-malleable organism.

A competitive index is a common method used to assess bacterial fitness and/or virulence. The utility of this approach is exemplified by its ease to ...

Validating Whole Genome Nanopore Sequencing, using Usutu Virus as an Example

Whole genome sequencing can be used to characterize and to trace viral outbreaks. Nanopore-based whole genome sequencing protocols have been described for several different viruses. These approaches utilize an overlapping amplicon-based approach which can be used to target a specific virus or group of genetically related viruses. In addition to confirmation of the virus presence, sequencing can be used for genomic epidemiology studies, to track viruses and unravel origins, reservoirs and modes of transmission. For such applications, it is crucial to understand possible effects of the error rate associated with the platform used. Routine application in clinical and public health settings require that this is documented with every important change in the protocol. Previously, a protocol for whole genome Usutu virus sequencing on the nanopore sequencing platform was validated (R9.4 flowcell) by direct comparison to Illumina sequencing. Here, we describe the method used to determine the required read coverage, using the comparison between the R10 flow cell and Illumina sequencing as an example.

We previously validated a protocol for amplicon-based whole genome Usutu virus (USUV) sequencing on a nanopore sequencing platform. Here, we describe the methods used in more detail and determine the error rate of the nanopore R10 flow cell.

Whole genome sequencing can be used to characterize and to trace viral outbreaks. Nanopore-based whole genome sequencing protocols have been described for ...

Optimization for Sequencing and Analysis of Degraded FFPE-RNA Samples

Gene expression analysis by RNA sequencing (RNA-seq) enables unique insights into clinical samples that can potentially lead to mechanistic understanding of the basis of various diseases as well as resistance and/or susceptibility mechanisms. However, FFPE tissues, which represent the most common method for preserving tissue morphology in clinical specimens, are not the best sources for gene expression profiling analysis. The RNA obtained from such samples is often degraded, fragmented, and chemically modified, which leads to suboptimal sequencing libraries. In turn, these generate poor quality sequence data that may not be reliable for gene expression analysis and mutation discovery. In order to make the most of FFPE samples and obtain the best possible data from low quality samples, it is important to take certain precautions while planning experimental design, preparing sequencing libraries, and during data analysis. This includes the use of appropriate metrics for precise sample quality control (QC), identifying the best methods for various steps during the sequencing library generation, and careful library QC. In addition, applying correct software tools and parameters for sequence data analysis is critical in order to identify artifacts in RNA-seq data, filter out contamination and low quality reads, assess uniformity of gene coverage, and measure the reproducibility of gene expression profiles among biological replicates. These steps can ensure high accuracy and reproducibility for profiling of very heterogeneous RNA samples. Here we describe the various steps for sample QC, library preparation and QC, sequencing, and data analysis that can help to increase the amount of useful data obtained from low quality RNA, such as that obtained from FFPE-RNA tissues.

This method describes the steps to improve the quality and quantity of sequence data that can be obtained from formalin-fixed paraffin-embedded (FFPE) RNA samples. We describe the methodology to more accurately assess the quality of FFPE-RNA samples, prepare sequencing libraries, and analyze the data from FFPE-RNA samples.

Gene expression analysis by RNA sequencing (RNA-seq) enables unique insights into clinical samples that can potentially lead to mechanistic understanding ...