NOTCH2 VUS Interpretation in Pediatric Cholestasis: A 365-Variant Landscape and Genotype–Phenotype Analysis of 7 Cases

Background/Objectives: Interpretation of NOTCH2 variants of uncertain significance (VUSs) remains challenging in pediatric cholestasis and suspected Alagille syndrome (ALGS) due to incomplete penetrance, phenotypic variability, and extensive genetic variation. Although disease-specific variant classification criteria have identified pathogenic hotspots within epidermal growth factor (EGF)-like repeats 8–12 and ankyrin repeat domains 3–6, characterizing these VUSs requires a robust framework.

Methods

We reviewed aggregate deidentified data from 519 multigene cholestasis panel entries and evaluated genotype–phenotype data from a consortium cohort of 7 pediatric patients with heterozygous NOTCH2 VUSs using a clinical–genomic prioritization framework informed by disease-specific ACMG criteria and domain location.