How To Obtain Tissue, Which Tissue; How To Coordinate With Pathology. Harvey I. Pass, MD NYU Langone Medical Center

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1 How To Obtain Tissue, Which Tissue; How To Coordinate With Pathology Harvey I. Pass, MD NYU Langone Medical Center

2 Disclosures Research Funding from NCI/NIH, DOD, CDC, Covidien, Mensanna, Rosetta Genomics, SomaLogic, Celera, SourceMDx, Fujirebio, Pfizer, Response Genetics, Meso Scale Diagnostics, Integrated Diagnostics, Transgenomics, Belluck and Fox, Stephen Banner Lung Foundation, Simmons Mesothelioma Foundation, Levi Phillips Konigsberg Medical Advisory Boards for Rosetta Genomics, Prometheus, Champions, Pinpoint Genomics, Precision Therapeutics, and GSK Research collaborations with Foundation Medicine, Response Genetics. Patents for use of osteopontin for diagnosis of mesothelioma; pending for microrna for diagnosis/prognosis of mesothelioma; pending for EFEMP1 and mesothelioma diagnosis/prognosis

3 Caveats The impact of genomic testing for therapy of lung cancer demands reflex, proactive tissue acquisition by interventional radiologists, pulmonary physicians trained in endobronchial techniques, and thoracic surgeons. Hence, the standard of care is shifting towards the paradigm that when the diagnosis of lung cancer is considered, enough tissue must be harvested to guarantee that a sufficient sample is available for both diagnosis and molecular analysis. Although guidelines may exist for the handling of tissues with other malignancies, i.e. breast, SOPs for individual biopsy techniques for lung cancer remain a work in progress

4 The Buck Stops with Adequate Tissue Limited tissue that results from a lack of surgical biopsy specimens contributes to the difficulty of molecular and histologic subtyping in NSCLC. Tumor location is a key consideration in selecting a tissue sampling technique At least available malignant cells at a minimum must be available When it is feasible, sampling attempts should continue until real time tissue sufficiency is ensured. Study Number of Samples Number sufficient for Genomic testing Number Successfully analyzed/number sufficient BR21 (2005) 328/ (54%) SATURN (2009) 742/ (66%) IPASS (2009) 683/ (64%) MERIT (2010) 255/ / (84%)* *Fresh Tissue; 93 contained no tumor, 37 contained no suitable tumor for testing Modified from Reck et al: Lung Cancer Oct;74(1):1-6

5 Patient under consideration for biopsy Discussion at Multidisciplinary Lung Conference Where is the target? Who is going to biopsy it? How to maximize the amount of specimen available? Discussion What exactly at are Multidisciplinary the tests that must be performed Lung with the specimen? Conference When and where is the biopsy going to be done? Surgical Biopsy Trans Thoracic Needle/Core Biopsy Bronchosopy/EBUS/EUS/EMN Logistics of the Day of the Biopsy Coordination for Proper Harvesting Rapid On-Site Evaluation with pathologist, cytopathologist, or cytotechnician Specimen quantity and quality Proper Preservation Transport and Preservation Tissue Procurement Nurse Pathology/cytopathology Technicians Documentation of Ischemic Time Preparation of Cell Block/embedding OCT Frozen Preparation of Fresh Material

6 Scenarios Which May Occur The patient presents with an outside biopsy but there is not enough tissue for molecular testing REBIOPSY VIA THE EASIEST AND SAFEST TECHNIQUE The patient has had a resection with stored surgical tissue and now returns with progression or recurrence SEND THE ORIGINAL SURGICAL SPECIMEN FOR MOLECULAR ANALYSIS, I.E. OBTAIN THE SURGICAL BLOCKS The patient presents with synchronous nodules IDEALLY BOTH NODULES SHOULD BE BIOPSIED FOR DIAGNOSIS AND MOLECULAR ANALYSES The patient has an effusion OBTAIN SUFFICIENT MATERIAL BY DRAINAGE SUCH THAT THE CELLS CAN BE MADE INTO A CELL BLOCK FOR MOLECULAR ANALYSES

7 Biopsy Techniques and Processing Endobronchial Biopsy Visible lesion: diagnostic yield for endobronchial biopsy = 70% 90% 4 samples of lesion Highest yields: Bronchial brush biopsy bronchial washing However. ~ 300 malignant cells in aggregate biopsies. mean percentage area of tumour is 33% fewer than half of endobronchial biopies contain tumour Although 4 specimens may be enough to make a diagnosis of lung cancer, they may not provide enough tissue to perform a more detailed molecular analysis. Consideration should be given to obtaining up to 6 specimens. Ofiara et al. Curr Oncol, Vol. 19, pp. S16-S23; Coghlin CL et al. J Thorac Oncol 2010;5:448 52

8 Biopsy Techniques and Processing: EBUS/EUS Jung et al: Cancer (Cancer Cytopathol) 2012;120: Adams et al:. Thorax 2006;61:795 8; Nakajima et al: J Thorac Oncol. 2011;6: Procedure back and forth vacuum retrieval 3 aspirations per lymph node station Processing tissue coagulum technique ROSE Immediate interpretation of air-dried smears by Diff-Quik. Ethanol-fixed smears are sent for Papanicolaou staining Molecular Efficacy 72-77% success for EGFR and KRAS

9 Biopsy Techniques and Processing: FNA and Core Needles FNAB: lesions smaller than 2 cm, close to the hilum or major blood vessels. ~ cells by needle biopsy Increased pneumothorax rates (> 12%) 2 cm or less, more than one puncture, lesion depths of cm, experience of the radiologist, FEV1<70%. ROSE during FNAB increases diagnostic accuracy significantly (by 20%) Austin J and Cohen M: American Journal of Roentgenology, 160: , Zhuang et al: Acta Radiologica 2011; 52: ; Hasanovic A: Pathology Research International, Volume 2011

10 CORE Biopsy and Molecular Analyses Peripheral lung more than 2 cm away from pulmonary hilum Sampling 4-5 times = 90% adequate tissue 2-23 mg of tissue Pneumothorax rate = 12-15% for all patients Pigtail, 3% for all patients Hemoptysis rate = 6% Cheung Y et al: Lung Cancer 67 (2010)

11 TTNA and Molecular Analyses Core biopsy vs. FNA? size, location, and morphology of target lesion. Often both specimen types can be obtained. Cytotechnologist for ROSE reduces time, efforts, and complications if a new biopsy specimen is required Problem: CytoTechnologist use generally cannot be billed Solution: Teach operator how to make the slides, stain immediately, and use telepathology Rekhtman N et al: J Thorac Oncol 2011; 6:451-8; Moreira A et al: Clinical Lung Cancer, epub 2012

12 Efficacy of Core Biopsy: BATTLE Kim et al: Cancer Discovery; 1(1); % of the 255 had a complete marker profile Pneumothorax: 11.5%, 16/139 1 grade 3 pneumothorax requiring hospitalization Coaxial biopsy technique 18- or 19-gauge guide needle to obtain 2 or 3 core biopsy samples with a 20-gauge biopsy needle. Core average length = 1.5 cm. Considered adequate for biomarker analysis had 200 malignant cells.

13 Conclusions and Thoughts Going Forward Molecular analysis for NSCLC is presently the standard of care, and sufficient tissue by the easiest and safest biopsy methods can be obtained successfully at least 80% of the time. Re-biopsy is indicated for most patients who had an unsuccessful initial biopsy To insure success, tissue procurement must be carefully planned pre biopsy, and ideally the logistics for harvest should have standard operating procedures These SOPs must involve close cooperation of cytologists and pathologists and the tissue harvester to insure adequacy of the biopsy, both in quality and quantity, and to insure proper preservation and delivery Effusions represent an ideal source of material for molecular analyses Tissue harvesters must keep appraised of the newest technical advances to maximize tissue use and decrease potential complications.