Immunohistochemistry. Potential and challenges To be or not to be

Immunohistochemistry Potential and challenges To be or not to be Søren Nielsen Scheme Manager NordiQC Aalborg University Hospital, Denmark Vårmöte 19.05.2016 Karlstad

Overview IHC project coordinator at Institute of Pathology, Aalborg, Denmark & Scheme manager NordiQC > 70.000 IHC slides annually BenchMark Ultra, Ventana Autostainer Link 48, Dako Omnis, Dako Bond III, Leica IHC cooperation partners Biocare Cell Marque Dako / Agilent Leica Thermo Fisher Ventana / Roche + Ad hoc projects/partners 2

Perspective International academic IHC proficiency testing program Founded 2003 by Nordic pathologists Independent non-profit organisation Institute of Pathology, Aalborg University Hospital, DK General module: 3 runs/year 15-18 different markers Breast cancer IHC module: 2 runs/y 3-5 different markers (HER2, ER, PR,..) HER-2 ISH module: 2 runs/year BRISH, FISH (breast cancer) Pilot runs ongoing ALK (lung), PD-L1 (lung) www.nordiqc.org 3

Albert Coons American pathologist and immunologist 1912-78

IHC is a result to be interpreted in cells/tissue heavily being submitted various chemical and physical interactions HE

Hyperplasia or In-situ CK5, CK14, Heavy chain myosin, p63 In-situ or invasive CK5, CK14, Heavy chain myosin, p63 Lobular or ductal lesion E-cadherin, p120 Predictive - Prognostic ER, PR, HER2, Ki67 Intrinsic subtype PAM50 ER, PR, HER2, Ki67, CK5 6

Original nomenclature and grouping of IHC tests: Class I IHC tests: Interpreted in the context of histo- or cytomorphologic and clinical data. Results interpreted and used by pathologists. E.g. CD45, TTF1, SOX10, CDX2, p40 etc Class II IHC tests: Stand-alone tests being interpreted (largely) to provide predictive and prognostic information. Results interpreted by pathologists and used by clinicians to give tailored treatment. E.g. ER, PR, HER2, CD117 etc. Am J Clin Pathol 2010;133:354-365

Class II (Class III, US), IHC companion diagnostics: IHC test Demonstration Application ER Estrogen receptor protein Breast cancer HER2 Overexpression of HER2 protein Breast cancer, gastric cancer CD117 Protein second to gene mutation GIST EGFR Overexpression of HER1 protein Colorectal cancer ALK Fusion protein second to gene rearrangement NSCLC PD-L1 PD-L1 protein expression NSCLC, Melanoma,..

In practice more and more IHC tests become Class II tests: Directly indicated Area Class I Class II Comment CD20 Lymphoma B-cell origin Mabthera Evaluation of theraphy CD30 Lymphoma HL, ALCL Brentuximab CD56 Carcinoma Neuroendo. Lorvotuzumab Class II: Lung SCLC ALK Lymphoma ALCL Crizotinib Class II: Lung NSCLC Indirectly indicated typically due to personalized treatment e.g. Area Class I Class II Comment p40 - lung Carcinoma Squamous TTF1- lung Carcinoma Adeno Crizotinib,. ALK, EGFR, ROS1

IHC as a surrogate test to molecular based tests for gene disorders; IHC test Demonstration Application MMR proteins ROS-1 ALK BRAF V600E Detects DNA repair proteins Detects over-expressed gene fusion product Detects gene translocation protein Detects specific mutant protein Screen for inherited cancer syndrome (Lynch) Seen in <2% of NSCLC, predictive of TKI response Seen in <5% of NSCLC, predictive of crizotinib response Predictive maker for melanoma, screen for colon cancer MMR IHC p16 Detects over-expressed protein Surrogate marker for HPV INI-1 Detects normal INI-1 suppressor protein Diagnostic value in rhabdoid tumors of CNS, kidney, soft tissue HER-2 Detects over-expressed protein Screen in breast cancer

IHC testing - general Molecular testing - general Morphology YES NO Cell location YES NO Minimal sample YES NO Archival FFPE YES YES/NO Multiplex test NO YES Quantifiable NO/YES YES Standardized NO YES/NoO Simple, cost eff. YES YES

To IHC or not to IHC..

1. IHC to identify and sub-type cancers 1. E.g. TTF1, Napsin A, CK5 & p40 for lung NSCLC 2. IHC to guide treatment 1. E.g. evaluation of level of protein level immunotherapy 3. IHC to screen for gene disorders 1. Cheap, fast 4. IHC to visualize heterogenous cancers 1. Architecture intact facilities the identification IHC is an open window for the identification of molecular changes and related theraphies Essential for precision medicine

Major Genetic Alterations in Cancer Mutation Mutant Protein Translocation Loss of Expression Deletion Abnormal Localization Amplification Overexpression Methylation Expression of Fusion Proteins

Major Genetic Alterations in Cancer Mutation Translocation Deletion Amplification Methylation Mutant Protein IDH1 Loss of Expression MMR Abnormal Localization ß-catenin Overexpression p53 Expression of Fusion Proteins

An anti-idh1-r132h-specific monoclonal antibody, IMab-1, is useful for detecting IDH1-R132H in IHC and predicted time to progression in grade III anaplastic astrocytomas.

Mismatch repair gene mutations Lynch syndrome Hereditary non-polyposis colorectal cancers (HNPCC) Autosomal dominant Mutation in MLH1 (~60%), MSH2 (~30%), or MSH6 (~10%) Accounts for 2-5% of colorectal adenocarcinoma Tumors develop at early age, usually found on right side Also develop endometrial adenocarcinoma

Mismatch repair gene mutations Lynch syndrome IHC negative result indicates further analysis

Mismatch repair gene mutations Lynch syndrome MLH1 MSH2 PMS2 MSH6

Mismatch repair gene mutations Lynch syndrome MMR MSI testing IHC Mol test Cost Low High Analyte Protein DNA How much intact tumor material is required Very little Very little Requirements Tumor only Tumor + normal Possibility of contamination by normal No Yes Turnaround Next day 2-7 days Identifies involved gene Yes No Assay sensitive to fixation Yes No

J Clin Oncol 28:3219-26, 2010 n = 457 Outcome of Patients with Stage III Colorectal Adenocarcinoma Treated with Adjuvant 5-FU dmmr pmmr IHC for MMR : Identification of Lynch syndrome Prognosis Treatment tree for patients

β-catenin β-catenin is a dual function protein, regulating the coordination of cell cell adhesion and gene transcription.

β-catenin B-catenin is partner with APC gene / protein If APC gene is mutated, colon cancer may develop APC gene will not keep B-catenin out of nucleus B-catenin inside nucleus bind to e.g. SMADs etc Uncontrolled proliferation and risk of cancer

β-catenin Desmoid type fibromatosis (71%) Modern Pathology 18:68-74, 2005 Solitary fibrous tumor (40%) Desmoid Endometrial stromal sarcoma (40%) Synovial sarcoma (28%) GIST

Major Genetic Alterations in Cancer Mutation Mutant Protein Translocation Loss of Expression Deletion Abnormal Localization Amplification Overexpression Methylation Expression of Fusion Proteins

Tumor Translocation Fusion Generated IHC Target PNET/ES t(11;22)(q24;q12) EWSR1-FLI1 FLI1 ALCL t(2;5)(p23;q35) NPM-ALK ALK ASPS der(17)t(x;17)(p11;q25) ASPL-TFE3 TFE3 Synovial sarcoma t(x;18)(p11.2;q11.2) SYT-SSX1 TLE-1 DSRCT t(11;22)(q11;q12) EWSR1-WT1 WT-1 AML t(8;21)(q22;q22) AML1-ETO AML1-ETO Lung cancer Chromosme 2 inversion EML4-ALK ALK

ALCL NordiQC CD20 CD3 CD30 ALK

www.nordiqc.org 30

~ 90 IHC markers in NordiQC Runs Tested 1-20 times Markers highlighted Mol. derived targets Alpha-methylacyl-CoA racemase Cyclin D1 MLH1 Alpha-smooth muscle actin Cytokeratin 5 MSH2 Anaplastic lymphoma kinase Cytokeratin 7 MSH6 B-cell specific activator protein Cytokeratin 19 Multiple myeloma oncogene 1 bcl-2 protein Cytokeratin 20 Myosin, smooth muscle heavy chain bcl-6 protein Cytokeratin, high molecular weight Napsin A Calretinin Cytokeratin, low molecular weight Neurofilament protein Cancer antigen 125 Cytokeratin, pan- Octamer transcription factor-3/4 Carcinoembryonic antigen Desmin p16 ink4a CD3 Detected on GIST-1 p40 CD4 E-cadherin p53 CD5 Epithelial cell adhesion molecule p57 CD8 Epithelial membrane antigen p63 CD10 Estrogen receptor alpha Paired box gene-2 protein CD14 Factor VIII related antigen Paired box gene-8 protein CD15 GATA3 Placental alkaline phosphatase CD19 Glial fibrillary acidic protein PMS2 CD20 Glypican 3 Podoplanin CD23 Gross cystic disease fluid protein-15 Prostate specific acid phosphatase CD30 HER-2 Prostate specific antigen CD31 Hepatocyte antigen Prostein CD34 Human chorionic gonadotropin Progesterone receptor CD45 Immunoglobulin kappa S-100 protein beta CD56 Immunoglobulin lambda Sal-like protein 4 CD68 Immunoglobubin M SOX10 CD79a Ki-67 Synaptophysin CD99 Mammaglobin Terminal deoxynucl. transferase CD117 Melan-A Vimentin Chromogranin Melanosoma specific antigen Wilm's tumour-1 protein 31

The biomarker protocol trap Caution: not for faint-hearted lab personel!!!!! Decalcification Preparation Tissue Type, Dimension, Laser resection, De-differentiation With 3 choices for 5 variables in each phase = > 4 million protocols. Controls Quantification Reporting Fixation Time, Type, Volume Preanalytic Postanalytic Section Thickness Storage Drying Pre-treatment Manual Stainer Visualization Sensitivity, Specificity Primary antibody Clone, Dilution Buffer, Time, Temp Analytic Interpretation Localization Positive/Negative - cut-off level Development Sensitivity, Localization

IHC Quality Problem 9 nordic labs 2001 33

IHC Quality Problem 9 nordic labs 2001 34

IHC test: Fit for purpose All IHC tests both laboratory developed assays and RTU systems must be calibrated for the diagnostic use E.g. IHC assays for mismatch repair proteins (MMR) Purpose Diagnostic utility Tool Application Disease screening of patients with Lynch syndrome IHC results have been shown to have high concordance to mutation analysis IHC panel for 4 MMR proteins; MLH1, MSH2, MSH6 & PMS2 Identification of a reliable IHC protocol and interpretation guidelines for the pathologist Diagnostic relevant Diagnostic validity Technically possible Diagnostic possible 35

Pass rates (scores; optimal and good) and proportion of optimal scores for MMR in the latest NordiQC assessment run Laboratory developed tests* Company X Ready-To-Use system** Pass rate Optimal Pass rate Optimal MLH1 40 67% (n=44/66) 36% (n=24/66) 89% (n=23/26) 69% (n=18/26) MSH2 41 40% (n=23/57) 12% (n=7/57) 96% (n=22/23) 87% (n=20/23) MSH6 43 64% (n=46/72) 43% (n=31/72) 91% (n=32/35) 69% (n=24/35) PMS2 41 86% (n=42/47) 45% (n=22/47) 96% (n=24/25) 60% (n=15/25) * Using a concentrated primary antibody by a laboratory calibrated system ** Using company X Ready-To-Use system Number of laboratories / protocols

Proportion of protocols based on concentrates and RTU formats in NordiQC AMACR CD10 CK LMW CK HMW MLA BCL2 BCL6 BSAP CD99 EMA WT1 BCL6 CD15 GLP3 MLA PAX8

Proportion of protocols based on concentrates and RTU formats in NordiQC ER HER2 ER HER2 ER HER2

Clone Efficient HIER Titre Detection kit with high sensitivity (FLEX+ Refine OptiView+A)

Interpretation based on internal tissue control. Negative IHC result in neoplastic cells must be confirmed by identification of stromal cells being positive!

Detection kit with high sensitivity (FLEX+ Refine OptiView+A) Modified

Colon: S100, polyclonal Pathos 3h NBF, 6h prog. Pathos 24h NBF, 6h prog. Pathos 48h NBF, 6h prog. Pathos 168h NBF, 6h prog. 48

Tonsil: S100, polyclonal S100 = Soluble in 100% alcohol Pathos 3h NBF, 2h prog. Pathos 24h NBF, 2h prog. Pathos 48h NBF, 2h prog. Pathos 168h NBF, 2h prog. 49

Colon: MLH1, ES05 (same for EPR3947 for PMS2) Pathos 3h NBF, 6h prog. Pathos 24h NBF, 6h prog. Pathos 48h NBF, 6h prog. Pathos 168h NBF, 6h prog.

Ref.: Ole Nielsen EPR3947 EP51 Similar

Clone Titre RTU > In-house

Choice of clone..

MSH6 issues : mab clone 44 used Difficult to calibrate EP49

Colon: MSH2, G219-1129 (same for EPR3945 for MSH6) Pathos 3h NBF, 6h prog. Pathos 24h NBF, 6h prog. Pathos 48h NBF, 6h prog. Pathos 168h NBF, 6h prog.

Clone Detection system CALIBRATION PURPOSE OF TEST

EQA Program Class I IHC result and score is related to 1. Technical quality Class II 2. Calibration level and precision can the test be applied for the intended purpose?

100% pass rate ALK in ALCL 67% pass rate ALK in lung cancer

Issues to be adressed : 1. Calibration of IHC assay and identification of best practice protocol clone, titre, retrieval etc 2. Evaluation of the robustness of the IHC assay impact on pre-analytics 3. Evaluation of the analytical sensitivity/specificity 4. Identification of most robust controls providing information that the established level of detection is obtained in each test performed in daily practice. Tissue controls are key element 63

Analytical validation Laboratory developed tests (concentrates and RTU formats being applied modified to official protocol) Non-predictive markers (- ER, PR, HER-2..) CLSI: 20 cases per entity relevant (pos, neg) CAP: 10 positive, 10 negative The validation set should include high and low expressors for positive cases when appropriate and should span the expected range of clinical results (expression levels) for markers that are reported quantitatively. Ad-Hoc: 10 strongly pos, 10 interm. to low, 5 neg. Number less important compared to use of tissue with full range of expression patterns reflecting the diagnostic use

Mantle cell lymphoma Mantle cell lymphoma Pancreas ad. carc. CD5 - rmab SP19 SP54 Pancreas ad. carc. CD5 - mab 4C7

Challenge: Rare in cancers and/or in benign cells ALK, ROS1, PD-L1 etc and many molecular derived targets Needed to verify IHC method is working ALK lung; 30 cancers used to find 1 pos case.. ALK Appendix / Colon: Peripheral nerves axons and ganglion cells PD-L1 Tonsil: Germinal centre macrophages Precision and metrics of test to be confirmed

Appl Immunohistochem Mol Morphol. Volume 22, Number 4, October 2014

IHC Critical Assay Performance Controls (icapcs) Which tissues are recommended? What is the expected staining pattern? Which tissues / cells are critical? Right antibody Appropriate level of sensitivity Guidance level of specificity

Examples for 17 markers Generel expected patterns High expression (Right antibody) Low expression (Appropriate sensitivity) No expression (Appropriate specificity) Which tissue Which cells Which extension Which intensity

IHC is still and will be a valueable tool for many years Both Class I and Class II tests Many new Class II assays to come to guide treatment Will be used together with molecular based tests For precision medicine we need precise IHC Attention on calibration, validation and consistency

Questions and answers Thank You for the attendance. Questions??