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Immunohistochemistry on Limited Tissue Samples: Do’S and Don’Ts

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Immunohistochemistry on Limited Tissue Samples: Do’S and Don’Ts 3/31/2016 Disclosures • I fretted over this . Immunohistochemistry on Limited Tissue Samples: Do’s and Don’ts Andrew M Bellizzi, M.D. Department of Pathology University of Iowa Hospitals and Clinics andrew‐[email protected] Disclosures • Last night I was sleepless . in Seattle 1 3/31/2016 Disclosures • Otherwise, I have nothing to disclose Goals Outline • To make an accurate, specific diagnosis with as • Competing interests: other ancillary studies few immunostains as possible • Technical aspects of immunocytochemistry • Enemies of the state: non‐specific immunos • To provide (prognostic and) predictive info • Next‐generation immunohistochemistry • To avoid less useful immunostains • Favorite markers/panels • To perform clinically valid immunohistochemistry – Carcinoma of unknown origin – Lung adenocarcinoma vs. squamous cell carcinoma • To triage tissue for other ancillary studies – Mesothelioma – Solid pancreatic tumors – Sarcoma – Lymphoma 2 3/31/2016 63‐year‐old woman with liver, lung, and adrenal masses; presumed lung primary based on FNA of liver lesion 4‐months prior; EGFR/ALK/ROS1 wild‐type; progression on platinum‐ based chemotherapy; biopsy for cancer mutation profiling TTF‐1 3 3/31/2016 Taher, Thanks for raising this issue in the setting of our increasingly engaging in this era of personalized medicine. This was my case, as staff pathologist. I ordered the TTF‐1 because I believed it was necessary to the diagnosis. In fact, in this case, it was negative. I had already ordered it BEFORE your call to the hot seat. So, there was no communication breakdown. I was aware of the prior diagnosis. I read your note while I was evaluating the glass slides. I was aware that the primary driver of this biopsy was to perform NGS. There was actually much more tumor present in the immunostained slide than on the initial H&E, fortunately. I was pessimistic of the prospects for NGS success based on the initial H&E. I was acutely sensitive of the purpose of this biopsy, which is why I limited myself to ONE critical immunostain. Taking one 5 micron section off the tissue block (for IHC) DOES NOT compromise the ability to perform molecular, especially if the sections for molecular are taken simultaneously. The anatomic pathologist is first and foremost responsible that a correct diagnosis is rendered. So, in this case I have to reasonably reassure myself that this is, in fact, metastatic lung adenocarcinoma. In this instance, both purposes should be served. Your note on the consult sheet WAS CRITICAL. If you hadn't made this comment, I would have performed a more extensive immunopanel. As always, communication is key. I would be happy to discuss this issue at greater length or in person. Best, Andrew Tension Between Diagnosis and Predictive Ancillary Tests in FNA/Small Biopsy Testing is Increasing Tumor Type Standard Applications Extended Applications Breast Cancer ER, PR, HER2 Esophagus/Gastric AdCA HER2 • Use of IHC in pre‐op lung cytologic specimens Oropharygeal SCC and p16 or HPV ISH Head and Neck SCC of Study Period Diagnosis of AdCA Diagnosis of SCC Occult Origin IHC Frequency IHC Frequency Lung Adenocarcinoma EGFR,NGS ALK ROS1, PD‐L1 2000‐2004 14% (22/156) 11% (5/46) RET, MET, LKB1, PTEN 2005‐2010 86% (134/156) 89% (41/46) Colon Cancer KRAS, NRAS, BRAF, MSI PIK3CA, PTEN, EGFR CN Mesothelioma p16 FISH • >600% increase in IHC utilization Thyroid Aspirate MultigeneBRAF, KRAS Pancreatic Cyst Aspirate Cyst fluid analysis KRAS, DNA content Melanoma BRAF KIT Sarcoma FISH or RT/PCR (forPanel specific diagnosis) Hematolymphoid Flow cytometry, IgH/TCR gene rearrangements, FISH (for diagnosis or prognosis) Ocque R, Tochigi N, Ohori P, Dacic S. Am J Clin Pathol 2011;136:81‐7. 4 3/31/2016 Aisner DL, Sams SB. Diagn Cytopathol 2012;40:511‐24. What’s Old is New Gailey MP, et al. Cancer Cytopathol 2015. 123;30‐9. Knoepp SM, Roh MH. Cancer Cytopathol 2013. 121:120‐8. Snow AM, et al. BMC Clin Pathol 2014. 14;30. Hunt JL, et al. Diagn Cytopathol 1998;18:377‐80. 5 3/31/2016 Lessons Learned • Do consider every biopsy of a tumor to be a potential molecular diagnostics specimen • Do consider cutting unstained sections up‐front for molecular testing, if ordering IHC • Do communicate with your clinical colleagues about priorities for the specimen • Do not give up hope if you’ve exhausted a specimen: you may be able to recover DNA from routinely processed material FNA of a Mural‐Based Gastric Mass Cell block KIT KIT and DOG1 Intensity by FNA Method • Cell blocks of 52 GIST, 24 LMS, 10 other • No significant difference in number of cells in EUS vs CT cellblocks • EUS‐FNA: FNA collected into CytoLyt (methanol‐based DOG1 KIT on subsequent resection fixative) • CT‐FNA: FNA collected into RPMI • plasma and thrombin added to produce cell block, fixed in 10% formalin, processed for paraffin embedding Hwang DG, et al. Am J Clin Pathol 2011;135:448‐53. 6 3/31/2016 The staining of cytologic We This Might Be So . preparations with a battery of antibodies to the various cell • Surgical Pathologists • Cytopathologists may request components or products is very order IHC on FFPE tissue IHC on: costly and rarely rewarding . – Direct Smears The results of ICC vary according • Air‐dried to the batch of antibodies and – Unfixed – Post‐fixed the technical skills of the • Alcohol‐fixed laboratories, the interpretation – Unstained – Stained of the results is not always easy, – Destained and the problem with – Cytospins borderline positive stains is – Monolayer Preparations often perplexing. – Cell Blocks Koss LG. The future of cytology. The Wachtel lecture for 1988. Acta Cytol 1990;34:1‐9. Cell Block Cell Blocks: Advantages and Disadvantages • Mandelbaum FS. • Advantages Diagnosis of malignant – Processed similarly to surgical pathology material tumors by paraffin – Facilitates multiple sections sections of centrifuged exudates. J Lab Clin – Easy to store Med. 1917; 2:580. • Disadvantages – Not amenable to on‐site adequacy assessment – May be pauci/acellular • 10.6% of 246 lung/thoracic FNA’s (Rafael OC, et al 2014) • 57% of 76 consecutive EBUS FNA’s (Knoepp, Roh 2013) 7 3/31/2016 Performance in Other Cytology Potential Sources of Pre‐Analytic Variation Specimen Types • Delay in fixation • Type, concentration, pH of fixative • Fixation time • Tissue Processing • Paraffin impregnation (paraffin melting point) • Block/slide storage Engel KB, Moore HM. Arch Pathol Lab Med 2011;135:537‐43. Potential Sources of Analytic Variation Optimization and Validation • Antigen retrieval • Optimization: determination of provisional – Yes or no assay conditions, which is most often involves – Enzyme or heat‐induced staining a single case or small number of cases • For heat‐induced: buffer, pH, heat source at varying assay conditions • Primary antibody dilution • Validation: testing and appropriate tissue set • Duration of primary antibody incubation to determine analytic sensitivity and • Detection chemistry (ABC, polymer‐based) specificity, to reasonably assure that the test performs as expected Goldsmith J. CAP Today Q&A. July 13, 2013. Goldsmith J. CAP Today Q&A. July 13, 2013. Fitzgibbons PL, et al. Arch Pathol Lab Med 2014;138:1432‐43. 8 3/31/2016 Recommendation • Tissue should be fixed in 10% neutral‐pH, phosphate‐buffered formalin for a minimum of 8 hours. Non‐formalin‐based fixatives and or alternative fixation methodologies are strongly discouraged in regard to IHC, in large part because performance data are limited and extrapolation from formalin‐fixed data is unreliable. Goldstein NS, et al. Appl Immunohistochem Mol Morphol 2007;15:124‐33. Recommendation Antigen Retrieval • Antigen retrieval (AR) is presumed to “restore” • Air‐dried smears theoretically should require the antigenicity after the formalin fixation. (less or) no AR The parameters of an AR protocol must be • Alcohol‐fixed smears (coagulation, rather than balanced to match the unique length and type cross‐linking, fixation) theoretically should of tissue fixation of the individual laboratory require (less or) no AR and the characteristics of the individual • Over‐AR produces high‐background staining antibody. and strong edge staining • Under‐AR produces false negative IHC 9 3/31/2016 Recommendations • Laboratories must validate all IHC tests before placing them into clinical service • For initial analytic validation of nonpredictive factor assays, laboratories should test a minimum of 10 positive and 10 negative tissues Fitzgibbons PL, et al. Arch Pathol Lab Med 2014;138:1432‐43. Recommendations Controls • “If IHC is regularly done on cytologic specimens that • “Unless the laboratory has a large bank of are not processed in the same manner as the tissues used for assay validation (eg, alcohol‐fixed cell blocks, similarly prepared cytology material for air‐dried smears, formalin‐postfixed specimens), positive and negative IC controls (non‐ laboratories should test a sufficient number of such formalin‐fixed cytology specimen by the exact cases to ensure that assays consistently achieve expected results . The strength of evidence was same preparation method as the current inadequate to address the criteria and number of sample being tested), then criteria for having samples needed for validation with cytology “proper controls” is not met and any specimens. If an assay has not been fully validated on interpretation of IC results should be suspect.” cytologic specimens, laboratories may include a disclaimer in their report that results should be interpreted with caution.” Fowler LJ, Lachar WA. Arch Pathol Lab Med 2008;132:372‐83. 10 3/31/2016 Controls Multiplexing • “In our experience, unstained direct smears in • Double‐staining, triple‐staining, etc. high quantities can be prepared using • Performing a second IHC on a previously IHC‐ centrifuged cellular material for effusion stained slide (if negative) specimens and these can be used for positive control ICC reactions.” Knoepp SM, Roh MH. Cancer Cytopathol 2013. 121:120‐8. Dabbs DJ, Wang X. Diagn Cytopathol 1998;18:166‐9.
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