Molecular Diagnostic Tests in Respiratory Tract Cytology:

Experiences in Taiwan

Chih-Yi Liu MD, FIAC

Division of Pathology, Sijhih Cathay General Hospital,

New Taipei City, Taiwan

Conflict of interest: no disclosure

Outlines Personalized medicine and molecular diagnostic tests

Molecular profile of lung cancer

Lung cancer statistics and molecular tests in Taiwan

Current guidelines and trends in specimen management

Cytology in precision medicine

Personalized Medicine is a Multi-Faceted Approach to Patient Care

Risk Assessment: Genetic testing to reveal predisposition to disease

Prevention: Behavior/Lifestyle/Treatment intervention to prevent

disease Detection: Early detection of disease at the molecular level

Diagnosis: Accurate disease diagnosis enabling individualized

treatment strategy

Personalized Medicine is a Multi-Faceted Approach to Patient Care

Treatment: Improved outcomes through targeted

treatments and reduced side effects Management: Active monitoring of treatment response and

disease progression

Lung Cancer Statistics in Taiwan 2015

Lung Cancer Statistics in Taiwan 2015

Lung Cancer Statistics in Taiwan Molecular Profile

Molecular Tests in Taiwan

Molecular Tests in Taiwan

EGFR and ALK testing in patients with (1) Adenocarcinoma (2) Carcinoma with adenocarcinoma component (3) Non-small cell carcinoma, NOS (4) Squamous or small cell carcinoma diagnosed in

biopsy specimen in non-smoking patient

Acceptable sample types: – Primary tumor / Metastasis – Histological samples / Cytological samples – Liquid biopsy

Molecular Tests in Taiwan

EGFR testing method requirement: – Validated methods with proper test performance – Sensitivity: at least 25% mutated allele frequency – Can detect L858R, exon 19 deletions and T790M

ALK testing method recommended: – Dual-labeled break-apart FISH – Specific amplified immunohistochemistry

Tests for Immunotherapy

Programmed death receptor-1 (PD-1) is expressed by T-cells Programmed death ligand-1 (PD-L1) is the ligand for PD-1 : Binding of PD-1 to PD-L1 on tumor cell can diminish the function of the T-cells Drugs developed to disrupt this interaction

• Antibodies target PD-1 • Second-line therapies

Progression following platinum chemotherapy or EGFR/ALK-targeted therapy

https://pbs.twimg.com/media/CmMCAJzUsAACFDM.jpg

Use Test Specimens from Minimally Invasive Procedures: Doing More With Less

Slide modified from Dr. Andre Moreira and Anjali Saqi, ascp.org/2016

Substrates for Molecular Testing

Histology specimens Cytology specimens Cell blocks Prepared slides (direct or imprint smears,

cytospin, LBC smears; cell transfer and scraping)

Residual fixed sample (LBC) Fresh sample

Specimen Preparation and Testing on Cytology

Slide modified from Dr. Natasha Rekhtman

Specimen Preparation and Testing on Cytology

Roy-Chowdhuri S, Stewart J. Preanalytic Variables in Cytology: Lessons Learned From Next-Generation Sequencing-The MD Anderson Experience. Arch Pathol Lab Med. 2016 Jun 22.

National Comprehensive Cancer Network Clinical Guideline

Important points for cytology If limited disease- Surgery If metastatic, need molecular testing Most metastatic disease will be diagnosed

by cytology Obtain sufficient material for molecular testing:

EGFR, ALK- must Other testing may be considered

ROS, KRAS, BRAF, RET, ERBB2 (HER2), PIK3CA, MET, PD-L1, MGMT

How to Enrich Cell Content

Cytolyt solution/Cytorich Red solution Slide enrichment - Laser capture microdissection - Direct microdissection - Cell transfer

45 y/o female, nonsmoker, came to Orthopedics due to intermittent right hip pain for several months.

Imaging study revealed a pelvic mass suggesting malignancy

Example

Courtesy of Dr. Chiung-Ru Lai, TVGH, Taiwan

Bone biopsy: adenoca, TTF1+ Final diagnosis: lung adeno, RUL, cT2aN2M1b with bone, brain and adrenal metastases

EGFR mutation testing

Block number: S104-37042 Percentage of tumor cells in selected region for DNA extraction: 40% Amount of viable tissue submitted: 2 mm x 2 mm x 12 um

FNA of bone lesion Direct smears and LBC

EGFR mutation testing

No more pain killer after one-week of EGFR-TKI treatment

Cytospin from residual material of FNA LBC specimen Percentage of tumor cells in selected region for DNA extraction: 80%

Challenges to the Cytopathologists

Malignancy YES/NO

SCLC vs. NSCLC

Primary vs. Metastasis

NSCLC subtype

Predictive markers

Conclusions

The role of the cytopathologists/cytotechnologists in molecular testing: be the bridge between the clinical team and the molecular lab Provide the best material for molecular testing

Know your test. Know your limitations. Modulate the platform for the specimen (high analytic

sensitivity) Know your specimen Modulate the specimen for the platform (tumor

enrichment) Know your clinical team Prioritize testing to answer clinically relevant questions