As you may recall last month I shared common barriers to biomarker testing for cancer patients in the community. I also began to dive-in to a few solutions that I have seen implemented to overcome the barriers. Last month I shared solutions that may help with high cost and long turnaround times for biomarker testing. This month I would like to discuss issues with tissue including quantity.
Here are the top 10 barriers that I’ve seen to biomarker testing in the community:
- High cost of testing.
- Long turnaround time for results.
- Limited tissue quantity.
- Preanalytical issues with tissue.
- Low biomarker testing rates.
- Lack of standardization in biomarker testing.
- Siloed disciplines.
- Low reimbursement.
- Lengthy complex reports.
- Lack of education on guidelines.
Sample quantity and quality are both important when considering biomarker testing. If we don’t have enough material we cannot perform the test (quantity not sufficient or QNS). If we have poor quality we cannot trust the results. The old adage of garbage in garbage out holds true for biomarker testing just as it does for all other lab tests.
I’ll start with sample quantity this month and cover quality issues next month. The issue here is that a variety of biopsy types are performed on patients depending on the location and size of a suspicious mass. Historically we only needed enough material for the pathologist to make a diagnosis. Now we often need enough material for diagnosis and biomarker testing. Some tumor types such as breast and ovarian cancers produce enough material in locations that are easily accessible that tissue quantity is rarely an issue, however other tumor types such as lung and pancreatic cancers there is often an issue with tissue quantity. These tumor types must be handled with care to ensure no tissue recovered is lost.
The first step in addressing tissue insufficiency is knowing where you are starting. Do you have an issue with quantity not sufficient (QNS) rate? If you don’t know how many of your cases are insufficient for biomarker testing, then you can’t determine if you have an issue. If your testing is performed at a reference laboratory, you can request your QNS rate from the lab. They may also be able to provide you with the national QNS rate and then you could benchmark yourself against your peers. It is important to have an accurate QNS rate, so if there are blocks that are not sent to the reference lab because the pathologist has determined the block to be exhausted (no tissue is left) then the QNS rate provided by the reference lab may be artificially low.
It is important to agree upon what is QNS. We consider a specimen to be QNS if we cannot perform biomarker testing on the block. Others may consider the block QNS only if there wasn’t sufficient material for diagnosis. We have to ensure there is enough tumor content in the tissue to proceed with biomarker testing, in our case 10% of the nucleated cells (not volume) must be tumor (determined by pathology review of an H&E slide). If we have enough tumor, we can still end up with a QNS block due to low DNA and RNA yield. So we need sufficient tumor and sufficient tissue.
Here is a brief overview of solutions I have seen work to address limited tissue that can lead to high QNS rates:
- Education. The person collecting the biopsy needs to understand how much material is needed. Remember we have moved the goal post. Sufficient material for diagnosis was enough in the past, now we need more material to perform biomarker testing. Educating the team on why we need more material is valuable in ensuring sufficient material is collected.
- ROSE. Rapid onsite evaluation (ROSE) by a pathologist in the procedure room to determine sufficiency has been shown to decrease the repeat biopsy rate . The pathologist can ensure the biopsy is being collected in a tumor rich region and help ensure areas of necrosis are avoided.
- Embedding cores separately. We often get core needle biopsies on lung cancer specimens. We prefer 3-5 cores. It is best practice to independently embed the cores in separate blocks. I have also seen labs that embed no more than 2 cores in one block. This would allow one block to be conserved for diagnosis and the other to be used for biomarker testing.
- Visual cue for limited tissue. Someone far more creative than me developed a process in histology where in cases of limited tissue the tissue was embedded in a red cassette. This cassette color was a visual cue for everyone handling the block that the tissue was limited and care should be taken when facing into the block. This has evolved over time to a red bead being embedded beside the tissue. Any visual cue and an associated procedure to ensure tissue conservation can help ensure we are conserving tissue in cases where it matters.
- Limited IHC Stains. The primary reason a biopsy is performed is for diagnosis. It is recommended that as few IHC stains as possible be used to make the diagnosis. This will conserve tissue for biomarker testing.
- Unstained Slides. Cutting 15-20 unstained slides is considered best practices in tumor types such as lung where biomarker testing will be performed within 30 days. Long term storage of unstained slides is not recommended.
- Reduce the number of times the block goes on the microtome, because every time the block is put back on the microtome it must be refaced. This results in wasted tissue. This can be prevented by thinking ahead and cutting everything you know will be needed while the block is on the microtome.
- Collins BT, Murad FM, Wang JF, Bernadt CT. Rapid on-site evaluation for endoscopic ultrasound-guided fine-needle biopsy of the pancreas decreases the incidence of repeat biopsy procedures. Cancer Cytopathol. 2013;121:518-24.
-Tabetha Sundin, PhD, HCLD (ABB), MB (ASCP)CM, has over 10 years of laboratory experience in clinical molecular diagnostics including oncology, genetics, and infectious diseases. She is the Scientific Director of Molecular Diagnostics and Serology at Sentara Healthcare. Dr. Sundin holds appointments as Adjunct Associate Professor at Old Dominion University and Assistant Professor at Eastern Virginia Medical School and is involved with numerous efforts to support the molecular diagnostics field.