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Specimen Handling IOMC.pptx
- 1. Specimen Handling in Biomarker TestingNon Small Cell Lung Cancer
- 2. Relative Frequency ofLung Adenocarcinoma Oncogene Drivers2 • The development of targeted systemic cancer therapies has been enabled by the identification of tumor genetic markers that drive oncogenesis1 • At present, some marker mutations are not actionable and do not have approved therapies1 Current Developments in Driver Mutations for Lung Cancer AKT = v-akt murine thymoma viral oncogene; ALK = anaplastic lymphoma kinase; BRAF = B-Raf proto-oncogene, serine/threonine kinase; EGFR = epidermal growth factor receptor; HER2 = human epidermal growth factor receptor 2; HRAS = Harvey Rat Sarcoma Viral Oncogene Homolog; KRAS = Kirsten rat sarcoma viral oncogene homolog; MAP3K1 = mitogen-activated protein triple kinase 1; MET = mesenchymal-to-epithelial transition factor; NRAS = neuroblastoma RAS viral (v-ras) oncogene homolog; NTRK1 = non-receptor tyrosine kinase 1; PIK3CA = phosphatidylinositol- 4,5-bisphosphate 3-kinase, catalytic subunit alpha; RET = ret proto-oncogene; ROS1 = ROS proto-oncogene 1, receptor tyrosine kinase. 1. Blakely CM, Bivona TG. Cancer Discov. 2012;2(10):872–875. 2. Bubendorf L et al. Eur Respir Rev. 2017;26:17.0007. Image adapted from Bubendorf L et al. Eur Respir Rev. 2017;26:17.0007. 25% 10% 4% 1.9% 0.9% 1% 3% 3% 2% 1% 1% 1% 3% 1% 42% KRAS EGFR ALK ROS1 RET NTRK1 HER2 BRAF PI3KCA HRAS NRAS AKT MET exon 14 MAP3K1 Unknown Unknown KRAS EGFR ALK
- 4. ID-KEY-00090 Biomarker Status canbe a Roadmap in personalizingTreatment in Advanced NSCLC • Biomarkers help guide the selection of effective targeted therapies based on an individual’s tumor biology1 • Targeted therapies selectively inhibit molecular pathways that drive tumor growth and proliferation1 1. Domvri K et al. J Cancer. 2013;4(9):736–754. 2. Modur V et al. Clin Chem. 2013;59(1):102–109. Improve Prevention2 Improve Detection2 Improve Diagnosis2 Improve Treatment2
- 5. NSCLC: Patient pathwayto diagnosis and treatment 5 IHC Testing Molecular ID-KEY-00090
- 6. TheWorkflow of DiagnosingLung Cancer Ipsos HealthCare, September 2015 ID-KEY-00090 Diagnostic imaging whole organ Biopsy Tissue sample Histological classification Cellular structure / staining and protein analysis protein analysis by IHC and mutational analysis DNA
- 7. TissueSamplingMethodsinNSCLC Excised during surgeryBronchoscopic biopsy Biopsy Cytology Fine Needle Aspiration ID-KEY-00090 Brush Cytology
- 8. Schematic workflow ofvarious cytology specimen preparations and processing methods ID-KEY-00090 Jain D et al. Arch Pathol Lab Med. 2018;142(9):1127-1133. doi:10.5858/arpa.2017-0444-RA
- 9. Whyisfixation SoImportant?? • Prevent autolysis •Ensure that the level of protein expression measured is correct and not an artefact • Preserve tissue as near to its original form as possible ID-KEY-00090
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- 11. SpecimenHandling TISSUE SPECIMEN • Immediatelyplace biopsy/surgical resection specimens into 10% buffered formalin within the first 20 minutes (maximum) after the specimens are obtained • Fixation volume is 5-10x specimen volume. All part of specimens should be completely covered by formalin CYTOLOGY SPECIMEN • Smear slides are immediately place into 96% alcohol fixation, and allow other smear slides to air-dry at room temperature • Place the specimen into 10% buffered formalin for cell block preparation • Fluid specimens, such as pleural effusion, should be transported immediately to Department of Anatomical Pathology • How to handle specimens on non-working day? • Smear slides are prepared as the aforementioned procedures • Fluid specimens should be stored in refrigerator. Do not store fluid specimens in freezer as it may alter/damage cell morphology ID-KEY-00090
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- 13. Chest clinician, assessment andchest X ray, onto CT scan and biopsy (usually EBUS – can be sample size challenge). Sometimes surgeon will take sample. Sample sent to hospital path lab, is booked in, prepared and then is “cut” for diagnosis – cancer type, histology. Biomarker testing is requested by the pathologist – usually automatic/reflex and parallel/ (EGFR/ALK and PD-L1 at same time). Sample ready for sending Tissue block sent to testing centre (usually daily van collection or post) Sample is booked in, prepared and examined. Result(s) are sent via e-mail or loaded onto “portal”. Remaining tissue block returned to requesting lab Results received by Pathologist/Oncologist/Onc Nurse – results and treatment options discussed/agreed at next weekly MDT Patient appointment – Oncologists and patient agree treatment option 2-5 days 1-3 days 5-10 days 0-2 days 1-6 days 1-2 days Laboratory TAT : 5-8 days Total TAT: 8-18 days Total pathway TAT: 10-28 Collected during interviews with testing labs across the UK Sample Collection Sample Preparation Test Ordering Result Reporting Lab Testing Sample Transport Treatment Decision Biomarker Testing Pathway and How it Varies ID-KEY-00090
- 14. PotentialIssuesinLungCancerBiomarkerTesting • Lung cancer 90 % cytology sample • Tissue heterogeneity • A tumor biopsy is a mixture of normal and tumor tissue • Protein expression is dynamic • IVD tests require verification prior to clinical use • Validation for each IHC marker for each cancer type • Obtaining validation materials and controls can be a challenge • Interpretative proficiency • Pathology will have to be attentive to which scoring algorithm is needed Standardization and harmonization of assays & Improve MDT collaboration ID-KEY-00090
- 15. Time to slicing andfixation Method of tissue processing Type of fixation Equipment calibration Laboratory procedures Time of fixation Assay validation Staff competence Type of antigen retrieval Test reagents Controls Assay conditions Use of image analysis Interpretation criteria Reporting elements Scoring system PD-L 1 testing variation Post-analytic Pre-analytic Analytic The Important process of IHCTesting to minimize potential issues ID-KEY-00090
- 16. Pulmonologist conducts bronchoscopy (orEBUS in minority of cases) if tumor accessible via bronchial tube Radiologist conducts CT guided biopsy (if tumor accessible transthoracically) Surgeon conducts surgical biopsy for minority of late stage patients suitable for surgery Pathologist may attend CT scan guided biopsy procedures to ensure tissue sample is good quality Tissue extraction Pathologist typically sends results with some degree of interpretation (i.e., whether patient is positive or negative, and suitability for specific therapies) In some markets pathologists will present results to MDT Will discuss results with oncologist if necessary Pulmonologist/Oncologist will make treatment decision, often in conjunction with an MDT, consisting of: Pulms, Surgeons, Paths, palliative care, radiotherapy Treatment initiation Pulmonologist/Oncologist typically requests – need to ensure patient will be suitable candidate for treatment (i.e., good PS) Pathologist may conduct test reflexively if routine in hospital (esp. PD-L 1 as a more established test) Tissue extractor may request upfront if test routine (minority) Pathologist conducts or outsources depending on specialism of lab EGFR and Pd-L1 often outsourced as molecular testing is required Pathologist may discuss need for re- biopsy with Tissue Extractor if needed Biomarker testing Source: MK-3475 NSCLC Biomarker Landscape, Mature Markets, Q2-2014 (Research Partnership) MDT: Multi-disciplinary teams Tissue Extractor Pathologist Oncologist Stakeholders in Biomarker testing ID-KEY-00090
- 17. Patient Technician Pulmonologist Pathologist Pulmonologist /Surgeon Wolff AC,Hammond ME, Hicks DG, Dowsett M, McShane LM Allison KH, et. al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. Arch Pathol Lab Med 2007; Successful andTimely Pathology and BiomarkerTesting Require a Multidisciplinary Approach ID-KEY-00090
- 18. Summary Good process inpre-analytic, analytic & post-analytic phase can help achieve improvements in result and quality of biomarker testing ID-KEY-00090
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