PD-L1 testing on the EBUS-FNA cytology specimens of non-small cell lung cancer

doi:10.1016/j.lungcan.2019.07.033

Lung Cancer

Volume 136, October 2019, Pages 1-5

https://doi.org/10.1016/j.lungcan.2019.07.033 Get rights and content

Highlights

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86.8% of the EBUS-FNA specimens were adequate for PD-L1 testing.
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PD-L1 in EBUS-FNA had 91.3% agreement with histology samples in the same patient.
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PD-L1 in EBUS-FNA 100% agrees with histology samples from the same anatomic site.
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Lymph nodes metastasis had higher PD-L1 positive rate than in primary tumors.

Abstract

Objectives

The FDA approved PD-L1 tests for anti-PD-L1 immunotherapy are for surgical or histology specimens. It is not clear if cytology specimens could be used for PD-L1 testing to guide immunotherapy. In this study, we assess the suitability of EBUS-FNA cytology specimens for the testing of PD-L1.

Materials and methods

Consecutive patients with Non-small cell lung cancer (NSCLC) underwent EBUS procedure between January 1, 2017 and March 31, 2018 for PD-L1 testing were included. The cell blocks of EBUS-FNA cytology specimens were used for PD-L1 testing using Dako 22C3 phamDx antibody according to the Dako protocol. PD-L1 protein expression in tumor cells is determined by using Tumor Proportion Score (TPS).

Results and conclusion

Of the 265 EBUS-FNA specimens from 262 patients sent for testing, 230 (86.8%) were adequate for PD-L1 testing. Of the 34 NSCLC patients with both histology and EBUS-FNA cytology specimens tested for PD-L1, the results from different specimen types had a concordance of 91.3%. The PD-L1 results from 16 paired specimens from the same anatomic site had 100% agreement. The rates of PD-L1 TPS ≥ 50% were significantly higher in the metastatic tumors in the lymph nodes than in the lung primary lesions. Therefore, EBUS-FNA cytology specimen is suitable for PD-L1 testing in patients with advanced NSCLC. The metastatic tumors in mediastinal lymph nodes appear to have higher PD-L1 expression than primary lesions.

Introduction

According to Canadian Cancer Statistics 2017, lung cancer is one of the most common malignancies, accounting for 14% of all newly diagnosed cancers and it is also the leading cause of cancer-related mortality, accounting for 25% of all cancer deaths [1]. The recently introduced immune checkpoint inhibitors have dramatically changed the treatment and management of NSCLC. The FDA approved anti–PD-1 immune checkpoint inhibitor pembrolizumab for the treatment of NSCLC requires testing PD-L1 as a companion test done by the immunohistochemistry (IHC) using Dako clone 22C3 pharmDx kit [[2], [3], [4]].

Currently, the evaluation of PD-L1 expression in tumor cells is typically performed on surgical or histological specimens because clinical trials of checkpoint inhibitors approval by FDA to date have required biopsies or resection specimen for PD-L1 IHC. However, many patients with advanced NSCLC are diagnosed by small-volume cytology or biopsy specimens obtained by endobronchial ultrasound guided transbronchial fine needle aspiration (EBUS-FNA) and, in fact, these samples may be the only material available for testing without putting a patient through further invasive sampling. The use of EBUS-FNA has become the procedure of first choice to diagnose and stage locally metastatic lung cancer and is considered the preferred initial diagnostic procedure for the diagnosis of suspected lung cancer [[5], [6], [7]]. Herein, the feasibility and efficacy of PD-L1 testing using EBUS-FNA cytological specimens of NSCLC were explored in this study.

Section snippets

Patient sample selection

The current study was approved by the institutional review board of the University of British Columbia. Between January 1, 2017, and March 31, 2018, a total of 262 patients with NSCLC underwent transbronchoscopic FNA for which PD-L1 testing was clinically requested.

Patient clinical and pathologic characteristics

A total of 265 specimens from 262 patients had PD-L1 testing requested on EBUS-FNA samples. There were 143 female and 119 male patients, with an average age of 68.7 years (±10.2 years), 193 Caucasian and 69 non-Caucasian, 102 never smokers and 160 smokers (ex-smoker or current smoker). The diagnoses include 203 adenocarcinomas, 17 squamous cell carcinomas, 4 adenosquamous carcinomas, 2 adenoid cystic carcinomas and 36 NSCLC, not otherwise specified. 199 specimens were from EBUS-FNA of the

Discussion

We conducted this study to examine the feasibility of using EBUS-FNA samples for the evaluation of tumor PD-L1 expression in NSCLC. A total of 265 specimens from 262 patients with PD-L1 testing were included in this study. Our results showed that EBUS-FNA specimens had high success rate and high concordance with surgical specimens for PD-L1 testing. We also showed that the tumors at metastatic lymph nodes have significantly higher percentage of PD-L1 TPS ≥ 50% than in tumors at primary site.

Funding

This work is partially supported by the British Columbia Cancer Foundation.

Precis

1. EBUS-FNA cytology specimen is suitable for PD-L1 testing in patients with advanced NSCLC. 2. Metastatic tumors in mediastinal lymph nodes have significantly higher percentage of PD-L1 TPS ≥ 50% than those in primary tumors.

Author contributions

Gang Wang: Conception and design of study, data acquisition, data analysis and interpretation, manuscript drafting and revising. Diana N. Ionescu: Conception and design of study, data acquisition, data interpretation, manuscript revising. Cheng-Han Lee: Data acquisition. Tadaaki Hiruki: Data acquisition. Renelle Myers: Data acquisition. Tawimas Shaipanich: Data acquisition. Stephen Lam: Data acquisition, data interpretation, manuscript revising. Barbara Melosky: Data interpretation, manuscript

Declaration of Competing Interest

All authors have no conflicts of interest.

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What is the sensitivity and specificity of PD-L1 testing performed in cytologic vs paired histologic specimens in patients with NSCLC?
The MEDLINE, Embase, Web of Science, and Cochrane Library databases were searched through June 1, 2021. The primary outcome was pooled sensitivity and specificity of PD-L1 testing performed on cytologic specimens compared with the reference standard of histologic specimens, analyzed at the PD-L1 expression cutoffs (tumor proportion score) ≥ 1% and ≥ 50%. Pooled sensitivity and specificity, and associated 95% CIs, were estimated using bivariate generalized linear mixed models.
Twenty-six articles were included, encompassing a total of 1,064 pairs of histology specimens and cytology cell blocks, and 267 pairs of histology specimens and direct smears. Among these, 946 paired specimens were acquired without interval treatment between the collection of histology and cytology samples. The pooled sensitivity and specificity of cytology specimens compared with paired histology specimens at the PD-L1 expression cutoff ≥ 1% were 0.84 (95% CI, 0.77-0.89) and 0.88 (95% CI, 0.82-0.93), respectively, whereas the pooled sensitivity and specificity at cutoff ≥ 50% were 0.78 (95% CI, 0.69-0.86) and 0.94 (95% CI, 0.91-0.96), respectively. When only paired specimens acquired without interval treatment were considered, the pooled sensitivity and specificity of cytology specimens at PD-L1 expression cutoff ≥ 1% were 0.84 (95% CI, 0.76-0.90) and 0.89 (95% CI, 0.82-0.94), respectively, whereas the pooled sensitivity and specificity at cutoff ≥ 50% were 0.80 (95% CI, 0.71-0.89) and 0.94 (95% CI, 0.91-0.96), respectively.
Cytologic specimens provide an accurate assessment of PD-L1 expression in most patients with NSCLC, at both ≥ 1% and ≥ 50% cutoffs, when compared with histologic specimens.
PROSPERO; No.: CRD42020153279; URL: https://www.crd.york.ac.uk/prospero/
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Molecular testing has become a more frequent necessity in NSCLC management. Using next-generation sequencing, multiple targets for therapy can be identified with small amounts of nuclear material. The authors evaluated the performance of robotic-assisted bronchoscopy in acquiring tissue that meets pre-analytic criteria for PD-L1 immunohistochemistry and/or next-generation sequencing.
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Robotic-assisted bronchoscopy yielded samples that met preanalytic criteria for molecular testing in 72% of cases. These results support the use of robotic-assisted bronchoscopy for both the diagnosis and molecular testing of early-stage lung cancer.
Molecular analysis in cytological samples obtained by endobronchial or oesophageal ultrasound guided needle aspiration in non-small cell lung cancer
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Citation Excerpt :
Immunotherapy with checkpoint inhibitors was recently approved to treat NSCLC. Wang et al.25 demonstrated 87% feasibility to determine the expression of PD-L1 (programmed death ligand 1) in samples obtained by EBUS-TBNA with a good correlation between the cytological and surgical samples. Likewise, the incorporation of second-generation sequencing (NGS) allowed the analysis of numerous genetic alterations simultaneously, with the use of small amounts of DNA (nanograms).
Cytological samples obtained by endobronchial ultrasound (EBUS) are capital for diagnosis, staging and molecular profile in non-small cell lung carcinoma (NSCLC).
To assess the success rate of complete, partial and individual of molecular analysis in samples obtained by EBUS-guided transbronchial needle aspiration (TBNA) and/or by oesophageal ultrasound-guided fine needle aspiration with an echobronchoscope (EUS-B-FNA) in patients with NSCLC.
Prospective study including 90 patients with non-squamous NSCLC, or non-smoking squamous. Cytological samples were classified into two groups. Group 1: PEN membrane slide and/or cell blocks for the determination of mutations of EGFR, KRAS, ERBB2 and BRAF. Group 2: silane coated slides or cell blocks for rearrangements of ALK, ROS1 and MET amplification.
The success rate was 78.6% for 4 molecular alterations (EGFR, KRAS, ALK and ROS1), and 44% for 7 determinations. The individual success rate for EGFR was 97%, KRAS 96.3%, ALK 85%, ROS1 82.3%, ERBB2 71.4%, BRAF 67.7% and MET 81.1%. There were no significant differences (p = 0.489) in the number of molecular analyses (1–3 vs. 4) in group 1, depending on the types of samples (cell block vs. PEN membrane slide vs. cell block and PEN membrane slide).
In patients with NSCLC, the cytological material obtained by ultrasound-guided needle aspiration is sufficient for individual and partial molecular analysis in the vast majority of cases. Membrane slides such as cell blocks are valid samples for molecular analysis.
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EBUS-TBNA, in particular, has gained widespread acceptance as a first-line invasive procedure in patients with lung cancer, hence the importance of ensuring PD-L1 results in EBUS samples provide adequate guidance for immunotherapy. Previous studies have confirmed the feasibility of PD-L1 testing in EBUS-TBNA samples.8,9,18-20 A recent multi-center study by Perrotta et al21 demonstrated that PD-L1 testing could be successfully performed in 94.7% of EBUS-TBNA samples.21
Programmed death-ligand 1 (PD-L1) testing is feasible in most specimens acquired using endobronchial ultrasound-guided needle aspiration (EBUS-TBNA).
Are the outcomes of patients with advanced non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICI) on the basis of PD-L1 expression in EBUS-TBNA samples significantly different from those of patients who are treated on the basis of PD-L1 expression in histological samples?
Patients treated with pembrolizumab or nivolumab between June 2016 and 2019 were included. Patient characteristics, PD-L1 expression, line of treatment, response (Response Evaluation Criteria in Solid Tumors [RECIST] criteria), and vital status (May 14, 2020) were recorded. Progression-free survival (PFS) and overall survival (OS) were assessed, and hazard ratios (HR) estimated.
A total of 145 patients were treated with pembrolizumab or nivolumab on the basis of PD-L1 expression in EBUS-TBNA (31.7%) or histological (68.3%) samples. Most had metastatic disease, with a predominance of adenocarcinomas (64.1%). First-line pembrolizumab was administered to 61 patients with tumor proportion score ≥50% in EBUS-TBNA (n = 16) or histology samples (n = 45). Median OS and PFS of patients who received first-line pembrolizumab on the basis of PD-L1 results in EBUS-TBNA vs histology samples were not significantly different (OS 25.8 months vs not reached, respectively; HR, 0.82 [95% CI, 0.34-1.95], P = .651). Similarly, the median OS and PFS of patients who received subsequent lines of treatment on the basis of PD-L1 results in EBUS-TBNA vs histological samples were not significantly different (including after adjustment for PD-L1 expression).
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^⋆: Part of the content was presented as abstract at the 2018 annual conference of the United State and Canadian Academy of Pathology.

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PD-L1 testing on the EBUS-FNA cytology specimens of non-small cell lung cancer⋆

Highlights

Abstract

Objectives

Materials and methods

Results and conclusion

Introduction

Section snippets

Patient sample selection

Patient clinical and pathologic characteristics

Discussion

Funding

Precis

Author contributions

Declaration of Competing Interest

Cancer Treat. Rev.

Lancet Respir. Med.

Chest

Lung Cancer

Ann. Thorac. Surg.

Chest

Lung Cancer

Lung Cancer

J. Thorac. Oncol.

Clin. Lung Cancer

Chest

Lung Cancer

Eur. J. Cancer