current concepts in the diagnosis of lung cancer

Current Concepts in the Diagnosis of Lung Cancers

BY THEINTERNATIONAL ASSOCIATION FOR THE STUDY OF LUNG CANCER

ADELAIDE CONVENTION CENTERADELAIDE, SOUTH AUSTRALIA, AUSTRALIA

FELIPE S TEMPLO JR., MD

PART I: ANATOMICAL PATHOLOGY NEEDS

PHC data (1998-2003). Templo FS, Orillaza MA, Tan CD (2003)

Correct specific diagnosis in 30% (38% SCC and 23% AdenoCA)

NSCLC-NOS is 62% (22.6% SCC and 37.7% AdenoCa)

Incorrect specific diagnosis is 7.5% (10% AdenoCA and 4.7% SCC)

LEPIDIC

ACINAR

PAPILLARY MICROPAPILLARY

SOLID WITH MUCIN

PART II: MOLECULAR PATHOLOGY NEEDS

Testing for research purposes only

MUTATION TESTING

EGFR :exons 19 &21; exons 18-21KRAS :(exon 2/codon12-13(OPTIONAL)

FISHALK

NO TESTINGUNLESS REQUESTEDBY THE ONCOLOGIST

2010

SQUAMOUS CELL CANON-SQUAMOUS CELL CA*

NON-SMALL CELL LUNG CARCINOMAS

5 unstained sections

5 unstained slides

KRAS MUTATION TESTING

EML-4-ALK TESTING

Positive fortranslocation

Negative fortranslocation

Laser microdissection

GENERAL RECOMMENDATIONS FOR EGFR/KRAS TESTING:

Blocks (formalin-fixed, paraffin-embedded) are highly recommended for optimal testing.

Testing can be performed on primary tumor or a site of metastasis1) FFPE tissue block containing 20% to 25% tumor OR2) 3-4 precut unstained slides from paraffin block in 5 micron sections and one H&E reference slide (manual microdissection)

Use special slides for laser microdissection (7 micron) FFPE blocks from surgical resections, excisional biopsies, fine

needle aspirates (FNA) and biopsy, core needle biopsies, cell blocks (pleural effusions, ascites and FNAs) and bone marrow.

A minimum of 300-500 viable tumor cells are required.

EXPERIENCE AT ST VINCENT’S HOSPITAL

TISSUE COLLECTION/FIXATION

FIXATION/TISSUE PROCESSING

PATHOLOGIST’S REVIEW AND REPORT

DECISION FOR EGFR MUTATION ANALYSIS, TUMOR CONTENT REVIEWED

TUMOR MICRODISSECTION IF NEEDED

EGFR MUTATION TESTING

FINAL REPORT WITH TUMOR HISTOLOGY AND MUTATION RESULTS

24 HOURS

1-2 WORKINGDAYSEXCEPT IHC

5-7 WORKING DAYS

BIOPSY

PATHOLOGY

MOLECULARTESTING

FINALREPORT

NEW CANDIDATE PREDICTIVE MARKERS

HER2 RAF PI3KCA–AKT–mTOR pathway C-MET Insulin-like growth factor (IGF1R) Fibroblastic growth factor receptor 1 (FGFR1) and

discoidin domain receptor family, member 2 (DDR2) Target molecules for chemotherapeutic agents

Questions?

1. Which Patients Should Be Tested for the Presence of These Mutations to Determine Their First-line Therapy Options?

First, what is the chance of an activating mutation being present?

Second, what is the cost of testing? How should testing be performed?

Which mutations of the EGFR are clinically significant?2011 by American Society of Clinical

Oncology.

Questions?2. Should Patients with Less than 10 Packs/Year

Smoking History and Non-squamous Histology Be Empirically Treated with Oral EGFR TKIs

in the Absence of EGFR Testing?

3. Should KRAS Testing Be Used to Deny Patients Therapy with Oral EGFR TKI Inhibitors?

4. Is There a Role for EGFR FISH Testing When Considering the Use of First-generation Oral EGFR TKIs? 2011 by American Society of Clinical Oncology.

Questions?

5. How Common Is ALK?

6. What Are the Key Clinical Features Associated with ALK?

7. Should All Patients with NSCLC Be Tested for ALK?

2011 by American Society of Clinical Oncology

Questions?

8. Should Patients with EGFR or KRAS Mutant Lung Cancer be Tested for ALK?

9. What Is the Diagnostic Test of Choice for ALK?

10. Are There Other Diagnostic Modalities for ALK?

2011 by American Society of Clinical Oncology

ACKNOWLEDGEMENT1. DR. LINDY CLARKE, FRCPA The Prince Charles Hospital

Brisbane, Queensland, Australia

2. DR. PRUDENCE RUSSELL, FRCPA St. Vincent’s Hospital and Peter McCallum Cancer Centre Melbourne, Victoria, Australia

3. Ms. KAREN LATHER The Australian Lung Foundation

Adelaide, South Australia, Australia

Copyright © 2012 by the International Association for the Study of Lung Cancer

current concepts in the diagnosis of lung cancer

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