Approximately one in 500 individuals carries a reciprocal translocation. Balanced translocations are usually associated with a normal phenotype unless the translocation breakpoints disrupt a gene(s) or cause a position effect. We investigated breakpoint junctions at the sequence level in phenotypically normal balanced translocation carriers. Eight breakpoint junctions derived from four nonrelated subjects with apparently balanced translocation t(1;22)(p36;q13) were examined. Additions of nucleotides, deletions, duplications, and a triplication identified at the breakpoints demonstrate high complexity at the breakpoint junctions and indicate involvement of multiple mechanisms in the DNA breakage and repair process during translocation formation. Possible detailed nonhomologous end-joining scenarios for t(1;22) cases are presented. We propose that cryptic imbalances in phenotypically normal, balanced translocation carriers may be more common than currently appreciated.[Supplemental material is available online at www.genome.org.]With the exception of benign copy number variation, it is generally assumed that a normal phenotype is associated only with a balanced genotype. However, a balanced translocation may produce an abnormal phenotype by disruption of a gene at the translocation breakpoint, through the formation of a novel fusion gene product, or by a position effect. Moreover, in apparently balanced translocations with abnormal phenotypes, duplications and deletions at the breakpoints have been identified that impact the phenotype. Baptista et al. (2005) hypothesized that breakpoints of normal individuals with apparently balanced chromosome rearrangements are relatively simple. However, their study was based on molecular cytogenetic methods (fluorescence in situ hybridization [FISH] and microarray-based comparative genomic hybridization [array CGH]) only. Breakpoints in only a few constitutional rearrangements in individuals with normal phenotypes have been examined at the DNA sequence level. These include translocations t(11;22) (Kurahashi et al. 2000(Kurahashi et al. , 2007, the most common constitutional translocation in humans, in which junction fragments were identified, and other translocation events including t(1;22)(p21.2;q11.2) (Gotter et al. 2004), t(4;22)(q35.1;q11.2) (Nimmakayalu et al. 2003), and t(8;22)(q24.13;q11.21) (Gotter et al. 2007). We have previously examined apparently balanced translocations in phenotypically normal individuals and found evidence that translocation junctions may show sequence inconsistency at the breakpoints created by addition of nucleotides and duplications (Gajecka et al. 2006b).The resolution of DNA double-strand breaks (DSBs) can result in translocation formation through a variety of different pathways. In homologous recombination repair, the DNA ends can be aligned and joined using sequence homology. Alternatively, the broken ends can be brought together and rejoined in the absence of long tracks of sequence homology through nonhomologous end-joining (NHEJ). Two ...