111 Circulating Tumor Cells (CTCs) in Cytology Malini Harigopal MDdn3g20un7godm.cloudfront.net/2011/AM11FNV/111+Circulating... · 2011-10-18 · Malini Harigopal, MD Assistant Professor

111 Circulating Tumor Cells (CTCs) in Cytology

Malini Harigopal MD

2011 Annual Meeting – Las Vegas, NV

AMERICAN SOCIETY FOR CLINICAL PATHOLOGY 33 W. Monroe, Ste. 1600

Chicago, IL 60603

111 Circulating Tumor Cells (CTCs) in Cytology This session will provide an introduction to CTCs. A brief history and background of CTCs will be presented, followed by a review of current technology, supporting literature and a demonstration of how the technology has been implemented in the presenter's laboratory. Key points of the session will include: instrumentation (CellTrack Autoprep system), enumeration of CTCs for predicting progression-free and overall survival in metastatic breast cancer patients, specimen collection, quality control, interpretation of results, limitations, clinical trial conclusions, and novel methods for CTC identification.

• To integrate the methods of CTC detection into the practice of cytopathology. • To be able to identify and evaluate CTCs in peripheral blood using CellSearch System. • To recognize the potential role of the cytopathologist in the process of measuring CTCs.

FACULTY: Malini Harigopal MD Entire Pathology Team New Techniques and Technologies New Techniques & Technologies 1.0 CME/CMLE Credit Accreditation Statement: The American Society for Clinical Pathology (ASCP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Credit Designation: The ASCP designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. ASCP continuing education activities are accepted by California, Florida, and many other states for relicensure of clinical laboratory personnel. ASCP designates these activities for the indicated number of Continuing Medical Laboratory Education (CMLE) credit hours. ASCP CMLE credit hours are acceptable to meet the continuing education requirements for the ASCP Board of Registry Certification Maintenance Program. All ASCP CMLE programs are conducted at intermediate to advanced levels of learning. Continuing medical education (CME) activities offered by ASCP are acceptable for the American Board of Pathology’s Maintenance of Certification Program.

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Malini Harigopal, MDAssistant Professor

Department of Pathology &

Kevin Schofield, CT(ASCP)Managerg

Department of Cytology

Yale School of MedicineNew Haven, CT

1

Malini Harigopal, MDAssistant Professor

Department of Pathology &

Kevin Schofield CT(ASCP)

Financial Disclosure

Kevin Schofield, CT(ASCP)Manager

Department of Cytopathology

We have no financial disclosures.

2

Basic Introduction to Circulating Tumor cells (CTCs)

& The CellSearchTM System

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- Evaluate the use of CTCs and CellSearch (Veridex, Raritan, NJ) in the management of patients with cancer

- Discuss the cytopathologist’s role in measuring

Objectives

Discuss the cytopathologist s role in measuring CTCs

- Describe the integration of CTC assessment into the practice of cytopathology

- Identify and evaluate CTCs in peripheral blood

4

• Circulating tumor cells (CTCs): cancer cells shed from either the primary tumor or its metastases

Definition

metastases- Epithelial cells

derived from solid tumors

- Metastases are responsible for most cancer deaths.

5

- Tumor cells were first identified in the blood stream of patients in (1869) by Thomas AshworthEngel 1955: cancer cells in the peripheral

History of CTCs

- Engel, 1955: cancer cells in the peripheral blood of pts with various types of cancer.

- Hematologists,Cytologists & Surgeons: background in Papanicolou & Romanowsky stains: morphologic criteria for cancer cells

6

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7

Slide Seminar The Circulating Cancer Cell Cooperative(CCCC): NCI(CCCC): NCIIdentification of CTC: Morphologic criteria

8

• The Circulating Cancer Cell Cooperative 1962: Morphology, techniques and patient selection - Conclusion : “More extensive well-controlled studies, improved techniques, sharper criteria

National Cancer InstituteDiagnostic Research Branch

, p q , pfor recognition of tumor cells are required.”

• Immunofluorescence technique by Coons: labeling of antibodies with fluorochromes improved the specificity of detection of CTC.

• Value to cytologic diagnosis of CTC

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• CTC: Rare in healthy women and in patients with benign breast disease (<1 per 7.5ml blood).

• Monitoring CTC (counts) can predict prognosis in many solid tumors, breast, prostate and

l t l

Utility CTC Measurement

colorectal cancers.• Measuring changes in CTC counts help monitor

patient outcome.• Molecular characterization of CTCs enable

treatment to be tailored and limit metastases.

11

• The role of CTC in blood is still under active investigation, biological significance/ therapeutic relevance (debated).

• Identification, enumeration and molecular

Utility CTC Measurement

characterization of CTCs could expand the understanding of the biology of metastases.

• Several strategies have been used for CTC enumeration.

• Nucleic-acid-based (PCR) and antibody-based cytometric assays (intact cells).

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• CellSearch system(Veridex, Warren, NJ): capture of epithelial cells (EpCAM) by ferrofluid

• CTC-chip:microfluid platform

Techniques for CTC Enumeration

• FAST(fiber-optic array scanning technology• Oncoquick: cellular density• MACS: capture of epithelial cells by

immunobeads• ISET: cellular size

13

• CellSearch System (Veridex, Warren NJ): Technology

• Automated, standardized technology for CTC detection

CellSearch™ System

CTC detection• Based immunofluorescence • CellSearch system validated in clinical

trails• FDA approved for CTC detection

14

• Instruments (CellTrack Auto autoprep system) • Specimen collection, processing and Quality con• Enumeration of CTCs for predicting progression-

free and overall survival in patients with

System Overview

free and overall survival in patients with metastatic breast, colorectal and prostate cancer

• Clinical trial background and conclusions• Interpretation of Results• Limitations

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CellSearch™ System

• Sample preparation system- Cell Search Epithelial kit (Veridex Corporation, Warren NJ)

Anti Epcam antibodies: Anticytokeratin antibodies conjugated to phycoerythrin (PE) 8,18 &19)Antibody to CD45 conjugated to allophycocyanin (APC): WBC,

Nuclear dye (DAPI, 4’6-diamidino-2-phenylindole)Controls: Breast cancer cell line (SKBr3)

- CellTracks AutoPrep system: Automated • Sample evaluation - CellSpotter Analyser (Veridex, immunocon): CTC Identification

and enumeration. • Interpretation of images: operators (cytotec &pathologist)

16

17

Transfer to MagNest™

Aspirate fluid and un-labeled cells

Permeabilize andadd Staining

Reagents

Aspirate plasma Add buffer

Add ferrofluid.

Processing by the CellTracks™ AutoPrep SystemOff-Line

7.5 ml blood from CellSave™

Tube + Buffer

Immunomagnetic CTC Selection

Magnetic incubation

Remove magnets. Re-suspend target

cells in bufferCTC leukocyte

Centrifuge

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Anti-EpCAMFerrofluid

EpCAMNucleusDAPI

Immunomagnetic Labeling and Immunomagnetic Labeling and Immunofluorescent Identification of CellsImmunofluorescent Identification of Cells

FOR INTERNAL AND EXTERNAL USE MKG-1866, Rev. 1

Circulating Tumor Cell

Anti-CK-PE

CK

composite

19

Reproducibility of CTC Counts in Duplicate MCRC Samples (n=1627) with Average of <3 or ≥3 CTC per 7.5 mL of blood.

nt 99

999

89

199

299

499399

699599

899799

nt 99

999

89

199

299

499399

699599

899799

99

999

89

199

299

499399

699599

899799

CellSearch™ MCRCCellSearch™ MCRC ReproducibilityReproducibility

FOR INTERNAL AND EXTERNAL USEMKG-1866, Rev. 1Tube 1 CTC Count

Tube

2 C

TC C

ou

0

9

0 9 99 999

1

2

43

65

87

1 2 43 65 87 19 29 4939 6959 8979

19

29

4939

6959

8979

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299

499

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899

799

Tube 1 CTC Count

Tube

2 C

TC C

ou

0

9

0 9 99 999

1

2

43

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87

1 2 43 65 87 19 29 4939 6959 8979

19

29

4939

6959

8979

199

299

499

399

699

599

899

799

0

9

0 9 99 999

1

2

43

65

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1 2 43 65 87 19 29 4939 6959 8979

19

29

4939

6959

8979

199

299

499

399

699

599

899

799

Note: There may be more than one point superimposed over another. For example, on this plot,there are 975 instances (60%) where both tubes had 0 CTC, 116 instances (7%) where Tube 1 had 0 CTC and Tube 2 had 1 CTC, and another 109 instances (7%) where Tube 1 had 1 CTC and Tube 2 had 0 CTC.

20

5mL

of B

lood

Frequency of CTCs:Frequency of CTCs: CellSearchTM System

FOR INTERNAL AND EXTERNAL USEMKG-1866, Rev. 1

CTC

per

7.

1MBC reference population information on page 7 of the clinical IFU.2MCRC reference population information on page 27 of the clinical IFU.3MPC reference population information on page 46 of the clinical IFU. 21

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Clinical Trial

3 Prospective multi-institutional clinical trials assessed the performance of the CellSearchTM

Assay• Metastatic Breast Cancer (MBC) > 5 cutoff( )• Metastatic Colorectal Cancer (MCRC) >3 cutoff• Metastatic Prostate Cancer (MPC) >5 cutoff• Selection of CTC cutoff : Prospectively identified

in patients in a training set and confirmed in a validation set

22

Metastatic Breast Cancer (MBC) cutoff ≥≥ 55 CTC

Circulating tumor cells, Disease Progression,and Survival in Metastatic Breast Cancer, Cristofanilli et al, Sem Oncol. 2006

Cristofanilli M, Budd GT, Ellis MJ, et al: Circulating tumor cells, disease progression, and survival in metastatic breast cancer. N Engl J Med 351:781-791, 2004

-Measurable disease, any type or line of therapy (first line, chemo Rx)

- 177 MBC (metastatic breast cancer)(20 centers) (67%ER/PR+, HER2 52%)

CTC analysis (performed in 7 centers)

MBC Clinical Trial Design

y (p )-145 healthy and 200 pts with benign disease- Imaging and CTC analysis (prior to initiation of therapy)CTC performed, 1 follow-up(~ 4 weeks)Duration of CTC: 6 months or until progressionClinical follow up: 50 monthsImaging and clinical progression of disease at 12 weeks**Circulating tumor cells, disease Progression,and Survival in Metastatic Breast

Cancer, Cristofanilli et al, NEJM 2004 24

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Predictive Value: OS of MBC Patients with <5 or >5 CTC at Baseline (N=177)

ty o

f Sur

viva

l

50%

60%

70%

80%

90%

100%

Logrankp < 0.0001

Cox Hazards Ratio = 2.4chi-square = 19.54(p-value < 0.0001)

21.9 Months

CTC / 7.5mL Median OS in at Baseline N (%) Months (95% C.I.) <5 CTC 89 (50%) 21.9 (20.1 to 28.6) >5 CTC 88 (50%) 10.9 ( 7.0 to 15.2)


%Pr

obab

ilit

0%

10%

20%

30%

40%

50%

Time from Baseline (Months)0 5 10 15 20 30 35 40 45 5025

10.9Months

CellSearchTM Cristofanilli M, Budd T,Ellis M, et al, N Eng J Med. 200425

Predictive Value: PFS of MBC Patients with <5 or ≥5 CTC at Baseline (N=177)

Cox Hazards Ratio = 1.9chi-square = 14.44(p-value = 0.0001)

7 0 Months

CTC / 7.5mL Median PFS in at Baseline N (%) Months (95% C.I.) <5 CTC 89 (50%) 7.0 (5.6 to 8.9) >5 CTC 88 (50%) 2.7 (2.1 to 4.4)

ress

ion

Free

Sur

viva

l

60%

70%

80%

90%

100%


Logrank p = 0.0001

7.0 Months2.7

Months

%Pr

obab

ility

of P

rogr

0%

10%

20%

30%

40%

50%


Cristofanilli M, Budd T,Ellis M, et al, N Eng J Med. 200426

A Reduction in CTC Below 5 After the Initiation of TherapyPredicts Longer OS whereas an Increase in CTC Count to 5 or

above Predicts a Shorter OS

fSur

viva

l

60%

70%

80%

90%

100%

Curve LogrankComparison p-Value* 1 vs. 2 0.2023 1 vs. 3 0.0017 1 vs. 4 <0.0001

2 vs 3 0 1025

Median OS in Group Description N (%) Months (95% C.I.) 1 <5 CTCs at All Time Points 83 (47%) 22.6 (20.4 to >45) 2 >5 at Baseline & <5 CTC at Last Draw 38 (21%) 19.8 (14.6 to 31.6) 3 <5 at Early Draw & >5 CTC at Last Draw 17 (10%) 10.6 ( 6.1 to 16.2) 4 >5 CTCs at All Time Points 39 (22%) 4.1 ( 2.8 to 6.4)


%Pr

obab

ility

of

0%

10%

20%

30%

40%

50%


2 vs. 3 0.1025 2 vs. 4 <0.0001 3 vs. 4 0.0045

1

23

4

*p-values not adjusted for multiple hypothesis testsCristofanilli M, Budd T,Ellis M, et al, N Eng J Med. 2004 27

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Predictive Value: OS of MBC Patients with <5 or ≥5 CTC at different times of Follow-Up

y of

Sur

viva

l

50%

60%

70%

80%

90%

100%

<5 CTCs at: 3- 5 Weeks (n= 92) 6- 8 Weeks (n= 77) 9-14 Weeks (n= 105)15-20 Weeks (n= 70)


%Pr

obab

ility

0%

10%

20%

30%

40%

50%

Time from Blood Draw (Months)0 5 10 15 20 30 35 40 45 5025

>5 CTCs at: 3- 5 Weeks (n= 40) 6- 8 Weeks (n= 22) 9-14 Weeks (n= 24)15-20 Weeks (n= 15)

Cristofanilli M, Budd T,Ellis M, et al, N Eng J Med. 2004 28

Metastatic Colorectal Cancers (MCRC) Cut off ≥≥ 3 CTCs

Cohen SJ, Punt CJ, Iannotti N et al: Relationship of circulating tumor cells to tumor response, progression-free survival, and overall survival in patients with meta-static colorectal cancer. J Clin Oncol 2008 Jul 1;26(19):

- Measurable disease, 1st or 2nd line of therapy (3rd line, only if anti-EGFR (chemo Rx)

- 430 MCRC (metastatic colorectal cancer) CTC analysis (performed in 4 centers)

MCRC Clinical TrialDesign

- 158 healthy and 55 pts with benign disease- Imaging and CTC analysis (prior to initiation of

therapy)- Frequency of CTC: 4 weeks- Duration of CTC: 12 months or until clinical

progression (imaging, clin eval)- Clinical follow up: 36 months

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val

60%

70%

80%

90%

100%

18 5 Months

Cox Hazard Ratio = 2.5chi-square = 31.48(p-value < 0.0001)

CTC / 7.5mL Median OS inat Baseline N (%) Months (95% C.I.)

<3 CTC 305 (74%) 18.5 (15.5 to 21.2)>3 CTC 108 (26%) 9.4 ( 7.5 to 11.6)

Predictive Value: OS of MCRC Patients with <3 or >3 CTC at Baseline (N=413)


%Pr

obab

ility

o

Time from Baseline Blood Draw (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

20

Logrankp < 0.0001

18.5 Months9.4

Months

Cohen SJ, Punt CJ, Iannotti N et al: J Clin Oncol 2008.

Cohen SJ, Punt CJ, Iannotti N et al: J Clin Oncol 2008. 31

essi

on F

ree

Surv

ival

60%

70%

80%

90%

100%

Cox Hazard Ratio = 1.6chi-square = 12.19(p-value = 0.0002)

7 9 Months


Predictive Value: PFS of MCRC Patients with <3 or ≥3 CTC at Baseline (N=413)


%Pr

obab

ility

of P

rogr

e


0%

10%

20%

30%

40%

50%

20

Logrank p = 0.0002

7.9 Months4.5

Months

Cohen SJ, Punt CJ, Iannotti N et al: J Clin Oncol 2008.32

A Reduction in CTC Below 3 After the Initiation of Therapy Predicts Longer OS whereas an Increase in CTC Count to

3 or above Predicts a Shorter OS

Curve LogrankComparison p-Value* 1 vs. 2 0.0007 1 vs. 3 <0.0001 1 vs. 4 <0.0001 2 vs. 3 0.0078of

Sur

viva

l

60%

70%

80%

90%

100%

Median OS inGroup Description N (%) Months (95% C.I.) 1 <3 CTC at All Draws 303 (70%) 18.6 (15.9 to 22.5) 2 >3 CTC at BL & <3 CTC at Last Draw 74 (17%) 11.7 ( 9.4 to 18.7) 3 <3 CTC at Early Draw & >3 CTC at Last Draw 29 ( 7%) 7.1 ( 6.3 to 10.8) 4 >3 CTC at All Draws 24 ( 6%) 3.9 ( 2.5 to 5.4)


*p-values not adjusted for multiple hypothesis tests

1

2

34

2 vs. 4 <0.0001 3 vs. 4 0.0001

%Pr

obab

ility


0%

10%

20%

30%

40%

50%

20

*p-values not adjusted formultiple hypothesis tests

Cohen SJ, Punt CJ, Iannotti N et al: J Clin Oncol 2008.33

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Predictive Value: OS of MCRC Patients with <3 or ≥3 CTC at different times of Follow-Up

of S

urvi

val

60%

70%

80%

90%

100%<3 CTC at: 1- 2 Weeks (n=316) 3- 5 Weeks (n=292) 6-12 Weeks (n=285)13-20 Weeks (n=172)

>3 CTC at: 1- 2 Weeks (n= 41) 3- 5 Weeks (n= 41) 6-12 Weeks (n= 25)13-20 Weeks (n= 21)


%Pr

obab

ility

Time from Blood Draw (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

20

Cohen SJ, Punt CJ, Iannotti N et al: J Clin Oncol 2008. 34

de Bono JS, Sher HI, Montogomery RB et al: Circulating tumor cells predict survival benefit from treatment in metastatic castration-resistant prostate cancer Clin Can Res 2008 oct

Metastatic Prostate Cancers (MPC)-K073338 Cut off ut off ≥≥ 5 CTCs5 CTCs

cancer, Clin Can Res 2008 oct.

- 231 MPC (metastatic prostate cancers), two consecutive increases in serum PSA, androgen independent, hormone resistant prostate cancer

- Bone metastases pos (90%), non-measurable disease 62%

MPC Clinical TrialDesign

- Baseline CTC count prior to initiation of new line of chemotherapy)

- Frequency of CTC:2- 4 weeks- Duration of CTC : 18 months or until progression- Clinical follow-up: 36 months.- Disease progression (PSA, imaging and clinical signs and

symptoms).36

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Predictive Value: OS of MPC Patients with <5 or >5 CTC at Baseline (N=219)

of S

urvi

val

60%

70%

80%

90%

100%

Logrankp < 0.0001

21 7 M th

CTC / 7.5mL Median OS in at Baseline N (%) Months (95% C.I.) <5 CTC 94 (43%) 21.7 (21.3 to ------) >5 CTC 125 (57%) 11.5 ( 9.3 to 13.7)


%Pr

obab

ility

o


0%

10%

20%

30%

40%

50%

20

21.7 Months11.5

Months

Cox Hazard Ratio = 3.3chi-square = 34.48(p-value < 0.0001)

de Bono JS, Sher HI, Montogomery RB et al, Clin Cancer Res. 2008. 37

Predictive Value: PFS of MPC Patients with <5 or >5 CTC at Baseline (N=219)

ress

ion-

Free

Sur

viva

l

50%

60%

70%

80%

90%

100%

5.8 Months

Cox Hazard Ratio = 1.6chi-square = 11.03(p value = 0 0009)



%Pr

obab

ility

of P

rogr


0%

10%

20%

30%

40%

50%

20

Logrankp = 0.0008

4.2Months

(p-value = 0.0009)


A Reduction in CTC Below 5 After the Initiation of Therapy Predicts Longer OS whereas an Increase in CTC Count to 5

or above Predicts a Shorter OS in MPC PatientsMedian OS in

Group Description N (%) Months (95% C.I.)1 <5 CTC at All Draws 88 (38%) >26 (21.4 to ------)2 >5 CTC at BL & <5 CTC at Last Draw 45 (20%) 21.3 (18.4 to ------)3 <5 CTC at Early Draw & >5 CTC at Last Draw 26 (11%) 9.3 ( 8.2 to 11.3)4 >5 CTC at All Draws 71 (31%) 6.8 ( 5.8 to 10.3)

1of S

urvi

val

60%

70%

80%

90%

100%


23

4

Curve LogrankComparison p-Value*

1 vs. 2 0.15281 vs. 3 <0.00011 vs. 4 <0.00012 vs. 3 <0.00012 vs. 4 <0.00013 vs. 4 0.5013

%Pr

obab

ility

o


0%

10%

20%

30%

40%

50%

20

*p-values not adjusted formultiple hypothesis tests


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Predictive Value: OS of MPC Patients with<5 or >5 CTC at different times of Follow-Up

<5 CTC at: 2- 5 Weeks (n=123) 6- 8 Weeks (n=110) 9-12 Weeks (n=100)13-20 Weeks (n= 99)

ty o

f Sur

viva

l

50%

60%

70%

80%

90%

100%


>5 CTC at: 2- 5 Weeks (n= 80) 6- 8 Weeks (n= 53) 9-12 Weeks (n= 49)13-20 Weeks (n= 44)

%Pr

obab

ilit

Time from Blood Draw (Months)0 2 4 6 8 10 12 14 16 18 22 24 26 28 30

0%

10%

20%

30%

40%

50%

20


MCRC• 430 patients• Cut-off = ≥3 CTC• Patients with ≥3 CTC at

baseline = 26% (108/413 evaluable

MBC• 177 patients• Cut-off = ≥5 CTC• Patients with ≥5 CTC

at baseline = 50% (88/177 evaluable patients)

MPC• 231 patients• Cut-off = ≥5 CTC• Patients with ≥5 CTC

at baseline = 57% (125/219 evaluable patients)

MBC, MCRC, and MPC MBC, MCRC, and MPC Summary & ConclusionSummary & Conclusion


patients)• Should be used for

serial monitoring• Predicts PFS and OS• Combination of CTC

and imaging may provide the most accurate assessment of patient prognosis

patients)• Should be used for


and imaging may provide the most accurate assessment of patient prognosis

p )• Should be used for


and PSA may provide the most accurate assessment of patient prognosis

41

0%10%20%30%40%50%60%70%80%90%

100%

0 5 10 15 20 30 35 40 45 5025

1

50%60%70%80%90%

100%

<cut-off at all time points

≥cut-off at all time points

MBC MCRC MPC

22.6 18.6 >26

4 1 3 9 6 8

MBC, MCRC, & MPCMBC, MCRC, & MPCMedian Overall Survival Comparison Median Overall Survival Comparison

(in months)(in months)


0%10%20%30%40%50%60%70%80%90%

100%

0 5 10 15 20 30 35 40 45 5025

2

0%10%20%30%40%50%60%70%80%90%

100%

0 5 10 15 20 30 35 40 45 5025

3

0%10%20%30%40%

0 5 10 15 20 30 35 40 45 50254

p

≥cut-off at baseline and <cut-off at final draw

<cut-off at early draw and ≥cut-off at final draw

4.1 3.9 6.8

19.8 11.7 21.3

10.6 7.1 9.3

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Summary

• Results should be used in conjunction with diagnostic tests (lab, imaging), physical exam and medical history.

CellSearch™ SystemLimitationsLimitations

• Not proven to affect overall health outcomes in patients with metastatic carcinoma

• Potential for monitoring patients• Insufficient evidence as a marker of

disease progression. 43

Yale CTC Experience

CellSearch (Veridex device) 2006•>1000 CTC tests•Clinicians (Oncologists): breast, colorectal

d land lung cancers•Guide treatment, research use•CTCs investigated for HER2/neu protein expression in breast cancer patient’s

44

• Pathologist and cytotechnologist (certified by Veridex)

• CTC are defined as:-Nucleated cells lacking CD 45 and expressing

t k ti (8 18 & 19)

InterpretationInterpretation

cytokeratin (8,18 & 19). -Morphology (round or oval with a nucleus within the cytoplasm).

-Size (4um)-Heterogeneity (morphology and size).

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47

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50

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Cell Analysis

CTC’s

CK-PE+/DAPI+/CD45-APC-

Leucocytes

CK-PE-/DAPI+/CD45-APC+

59

Gallery of images HER2 + CTCs

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CTC REPORT

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Summary

CTC detection in peripheral blood in clinical practice

• Low frequency (rare)• Standardized methods with high degree of

SummarySummary

Standardized methods with high degree of reproducibility

• Currently, most data on the prognostic value, available for breast, prostate and colon cancers.

• Multicenter analysis and validation is needed to confirm clinical significance.

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Summary- Valuable tool for monitoring cancer patient status

and outcome. FDA approved.- Employs immunomagnetic-enrichment based

protocols focused on CTC number as the

Summary Summary CellSearchCellSearchTMTM SystemSystem

indicator of patient status or outcome.- Multi center trial: The number of CTCs was a

significant independent predictor of OS and PFS in patients with MBC, MCRC and MPC

- American Society of Clinical Oncology (ASCO):recommendation 2007: CTC test should not be used to make diagnostic or treatment decisions in patients with MBC

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• Guide prognosis: Metastatic and early stage cancer patients

• Measure response to anticancer Rx: predictive biomarker

Future Potential and Applications: CTCs

• Select patients for adjuvant chemotheray• Detect recurrent disease• ‘Real time biopsy’: Surrogate for Tumor biology• Molecular characterization: Discover and identify

new targets for therapeutic manipulation

64

Summary and Conclusions

• CTC level (< 5): Favorable, this may imply a good response to treatment.

• Caution is warranted because of the lower

ConclusionConclusion

sensitivity of the CTC test. • Radiologic disease progression should not be

ignored on the basis of a favorable CTC level. • Favorable CTC level with overt radiologic

progression may still suggest a better outcome

65

The CellSearch System (Veridex) • Morphology skills highly similar to those of the

Cytopathologist- Interpretation and Enumeration of CTCs.

ConclusionsConclusions

- Protein expression patterns of CTC (ER,PR,HER2, EGFR), additional prognostic information.

• Cytopathology lab with trained cytotechnologists and cytopathologists - Natural location for this technology in the healthcare delivery system.

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History

• Breast Group CEC/CTC Enumeration Study

What does it cost?What does it cost?

Lab cost around $175 per testCPT Codes: 88346 x 3 (immunofluorescent study) = $380 x 3 = $1140 88361 x 2 (morphometric analysis, IHC ) = $505 x 2 = $101088313 x 1 (special stain) = $210Charge $23602360 per test

Total CostsTotal Costs

Medicare Reimbursement Avg: $777.53Medicare Reimbursement Avg: $777.53Labor/Overhead: $386.00Labor/Overhead: $386.00

Labor/Overhead + Cost per test = $386.00 + $175.00 = $561.00 Labor/Overhead + Cost per test = $386.00 + $175.00 = $561.00

10/8/201110/8/2011

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Tests Requirements

• High Complexity Tests• Pathologist and cytotechnologist (certified

by Veridex)C ll I t t ti P fi i A t• Cell Interpretation Proficiency Assessment

• PT Test Requirement

Acknowledgements:Yale University School of Medicine, Dept of Pathology• David L. Rimm• David Chhieng• Diane Kowalski• Lab Manager: Kevin Schofield• Cytotechnologists: Brett Minger, Philip Galullo, Kristina Gordy, Rupay g g , p , y, p

VyasVeridexBrian ZuchelkowskiVera Gibson

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Documents

111 Circulating Tumor Cells (CTCs) in Cytology Malini Harigopal MDdn3g20un7godm.cloudfront.net/2011/AM11FNV/111+Circulating... · 2011-10-18 · Malini Harigopal, MD Assistant Professor