1. Magee-Womens Hospital of UPMC
HER2 Immunohistochemistry: Workflow Experience with Image Analysis Based Interpretation of CB11 and 4B5 Clones
Jeffrey Fine MD, Rohit Bhargava MD, Urvashi Surthi PhD, and David Dabbs MD
Magee-Womens Hospital of UPMC

2. Disclaimer
One of the abstract authors (David Dabbs) is a consultant for Ventana
None of the other authors have any conflicts of interest to report

3. Objectives Overview of Her2/NEU testing (IHC)
Recap of validation results
Discuss implementation of image analysis

4. Her2/NEU Test for responsiveness to Trastuzumab (Herceptin)
Trastuzumab is cardiotoxic and is very expensive
False positives are highly undesirable
Trastuzumab can increase survival or reduce risk of recurrence
False negatives are also undesirable

5. CAP HER2-A Survey (Spring 2007)
40 TMA cores (4 slides)
Stained/interpreted at institutions (350ish)
Consensus (>80%) in 22 of 40 cases
Very variable

6. IHC Variables Pre-analytic Analytic Post-analytic
Fixation issues, tissue processing
Analytic
Validation, Calibration, Antibody clone, Antigen retrieval, Automation, Controls, etc.
Post-analytic
Interpretation criteria
QA procedures
Image analysis (17.9% reported using it)

7. Validation of IA at UPMC
Formalin fixed (8-48 hours) paraffin embedded tissue
Automated IHC platform (Ventana)
CB11 and 4B5 antibodies (Ventana)
VIAS (Ventana Image Analysis System)
FISH (Vysis)

8. VIAS (image from vendor)

9. Validation Results I
System differentiated between tumor and stroma (subjective impression)
Pathologist had to find invasive tumor (and exclude in-situ tumor)

10. Classification (Tumor vs. Stroma)

11. Results CB11 100% Concordance with FISH (n=52) FISH rate (2+ rate):
0/1+ IHC with no amp by FISH
3+ with amp by FISH
FISH rate (2+ rate):
Expert 22.9% (n=118)
VIAS 21.2%
(expert was also 100% concordant)

12. Results 4B5 94.6% Concordance with FISH (n=56) FISH rate (2+):
100% Concordance with new reference range
FISH rate (2+):
Expert 21.9% (n=114)
VIAS 28.9% (n=117)
*new reference range

13. Reference Range
VIAS assigns a raw number score to each case which is then rounded to the nearest whole number.
Out of the box—score 2.5 or higher was rounded to “3+”
New range is conservative—only cases with score 3.5 are called “3+”

14. Demixed to show brown

15. Old Workflow Office Mailbox Order Her2/NEU Retrieve IHC Stain
Interpret
Stain
Dictate Results
Sign out case
Old Workflow

16. New Workflow IA Workstation Office Mailbox Order Her2/NEU Retrieve IHC
Stain
Perform IA
Dictate Results
Sign out case
New Workflow

17. Implementation Details
Billing
Fee code 88361
Technical charge initiated by order in APLIS
Documentation
VIAS results printout retained with other case paperwork (requisition)
IHC results (ER/PR and Her2/NEU) dictated into canned text that includes VIAS blurb

18. Documentation Support
Transcription
New “quick text” with VIAS sentence
Communication with Transcription Team
Slide/paper management personnel
Communication – do not discard results report
Back-up of data
Currently performed manually

19. “Consumables” IA charged per “click”
IHC Laboratory responsible for keeping an adequate supply of the click reagent
Smart Card (100 tests)
Image from nist.gov www site

20. Training Local Domain Expert (me) Fellows Selected Faculty
Other Faculty
Residents

21. Status Report IA is in production for a week Bumps being ironed out
Transcription
Training
End experience varies

22. Good Should increase standardization
Recent switch to 4B5 clone – different appearance and possible differences in interpretation
Documented response to pressure for accurate Her2/NEU testing
Foot in the door for other IA applications
Vendor has been responsive and appears to want to improve shortcomings

23. Bad
IA of new antibody is less accurate than that of discontinued antibody
Reference range work-around
Workflow involves “travel” and is more labor intensive than traditional method
Quality improvement but does not extend the pathologist
Operator error is possible
Data entry
Lighting
Focusing

25. Future IA (More Automation)
Whole Slide Images (some systems do permit IA)
Slide could be scanned in the IHC lab, and results (with the electronic slide) delivered straight to the pathologist
Automated detection of invasive tumor
Transition of IA to non-pathologist staff
Electronic interfaces to support test ordering and resulting (no more paper print outs or dictation)

26. Conclusions
IA is validated and should improve performance of Her2/NEU IHC testing by reducing post-analytic variability
Current IA set-up not ideal but an important first step:
Successful implementation in a busy academic setting
Revenue (digital pathology business case)