1
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La Salvia A, Meyer ML, Hirsch FR, Kerr KM, Landi L, Tsao MS, Cappuzzo F. Rediscovering immunohistochemistry in lung cancer. Crit Rev Oncol Hematol 2024; 200:104401. [PMID: 38815876 DOI: 10.1016/j.critrevonc.2024.104401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/23/2024] [Indexed: 06/01/2024] Open
Abstract
Several observations indicate that protein expression analysis by immunohistochemistry (IHC) remains relevant in individuals with non-small-cell lung cancer (NSCLC) when considering targeted therapy, as an early step in diagnosis and for therapy selection. Since the advent of next-generation sequencing (NGS), the role of IHC in testing for NSCLC biomarkers has been forgotten or ignored. We discuss how protein-level investigations maintain a critical role in defining sensitivity to lung cancer therapies in oncogene- and non-oncogene-addicted cases and in patients eligible for immunotherapy, suggesting that IHC testing should be reconsidered in clinical practice. We also argue how a panel of IHC tests should be considered complementary to NGS and other genomic assays. This is relevant to current clinical diagnostic practice but with potential future roles to optimize the selection of patients for innovative therapies. At the same time, strict validation of antibodies, assays, scoring systems, and intra- and interobserver reproducibility is needed.
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Affiliation(s)
- Anna La Salvia
- National Center for Drug Research and Evaluation, National Institute of Health (ISS), Rome 00161, Italy
| | - May-Lucie Meyer
- Center for Thoracic Oncology/Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fred R Hirsch
- Center for Thoracic Oncology/Tisch Cancer Institute and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Keith M Kerr
- Aberdeen University School of Medicine & Aberdeen Royal Infirmary, Aberdeen, UK
| | - Lorenza Landi
- Medical Oncology, Istituto Nazionale Tumori IRCCS "Regina Elena", Rome, Italy
| | - Ming-Sound Tsao
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Federico Cappuzzo
- Medical Oncology, Istituto Nazionale Tumori IRCCS "Regina Elena", Rome, Italy.
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2
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Malapelle U, Leighl N, Addeo A, Hershkovitz D, Hochmair MJ, Khorshid O, Länger F, de Marinis F, Peled N, Sheffield BS, Smit EF, Viteri S, Wolf J, Venturini F, O'Hara RM, Rolfo C. Recommendations for reporting tissue and circulating tumour (ct)DNA next-generation sequencing results in non-small cell lung cancer. Br J Cancer 2024; 131:212-219. [PMID: 38750115 PMCID: PMC11263606 DOI: 10.1038/s41416-024-02709-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 07/24/2024] Open
Abstract
Non-small cell lung cancer is a heterogeneous disease and molecular characterisation plays an important role in its clinical management. Next-generation sequencing-based panel testing enables many molecular alterations to be interrogated simultaneously, allowing for comprehensive identification of actionable oncogenic drivers (and co-mutations) and appropriate matching of patients with targeted therapies. Despite consensus in international guidelines on the importance of broad molecular profiling, adoption of next-generation sequencing varies globally. One of the barriers to its successful implementation is a lack of accepted standards and guidelines specifically for the reporting and clinical annotation of next-generation sequencing results. Based on roundtable discussions between pathologists and oncologists, we provide best practice recommendations for the reporting of next-generation sequencing results in non-small cell lung cancer to facilitate its use and enable easy interpretation for physicians. These are intended to complement existing guidelines related to the use of next-generation sequencing (solid and liquid). Here, we discuss next-generation sequencing workflows, the structure of next-generation sequencing reports, and our recommendations for best practice thereof. The aim of these recommendations and considerations is ultimately to ensure that reports are fully interpretable, and that the most appropriate treatment options are selected based on robust molecular profiles in well-defined reports.
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Affiliation(s)
- Umberto Malapelle
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Natasha Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alfredo Addeo
- Oncology Unit, Geneva University Hospital, Geneva, Switzerland
| | | | - Maximilian J Hochmair
- Department of Respiratory & Critical Care Medicine, Karl Landsteiner Institute of Lung Research & Pulmonary Oncology, Klinik Floridsdorf, Vienna, Austria
| | - Ola Khorshid
- National Cancer Institute, Cairo University, Cairo, Egypt
| | - Florian Länger
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Filippo de Marinis
- Division of Thoracic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Nir Peled
- Helmesely Cancer Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Brandon S Sheffield
- Division of Advanced Diagnostics, William Osler Health System, Brampton, ON, Canada
| | - Egbert F Smit
- Department of Pulmonary Diseases, Leiden University Medical Centre, Leiden, The Netherlands
| | - Santiago Viteri
- UOMI Cancer Center, Clínica Mi Tres Torres, Barcelona, Spain
| | - Jürgen Wolf
- Lung Cancer Group Cologne, Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
| | | | | | - Christian Rolfo
- Center for Thoracic Oncology, Tisch Cancer Institute, Mount Sinai Medical System & Icahn School of Medicine, New York, NY, USA.
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3
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Borczuk AC. Molecular Testing in Lung Cancer: Recommendations and Update. Surg Pathol Clin 2024; 17:307-320. [PMID: 38692813 DOI: 10.1016/j.path.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Adoption of molecular testing in lung cancer is increasing. Molecular testing for staging and prediction of response for targeted therapy remain the main indications, and although utilization of blood-based testing for tumor is growing, the use of the diagnostic cytology and tissue specimens is equally important. The pathologist needs to optimize reflex testing, incorporate stage-based algorithms, and understand types of tests for timely and complete assessment in the majority of cases. When tissue is limited, testing should capture the most frequent alterations to maximize the yield of what are largely mutually exclusive alterations, avoiding the need for repeat biopsy.
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Affiliation(s)
- Alain C Borczuk
- Anatomic Pathology, Northwell Health, 2200 Northern Boulevard Suite 104, Greenvale, NY 11548, USA.
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4
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Souza da Silva R, Pina MJ, Cirnes L, Gouveia L, Albergaria A, Schmitt F. Comprehensive Genomic Studies on the Cell Blocks of Pancreatic Cancer. Diagnostics (Basel) 2024; 14:906. [PMID: 38732320 PMCID: PMC11083533 DOI: 10.3390/diagnostics14090906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Pancreatic cancer is one of the deadliest malignancies, characterized by late-stage diagnosis and limited treatment options. Comprehensive genomic profiling plays an important role in understanding the molecular mechanisms underlying the disease and identifying potential therapeutic targets. Cell blocks (CBs), derived from EUS-FNA, have become valuable resources for diagnosis and genomic analysis. We examine the molecular profile of pancreatic ductal adenocarcinoma (PDAC) using specimens obtained from CB EUS-FNA, across a large gene panel, within the framework of next-generation sequencing (NGS). Our findings revealed that over half (55%) of PDAC CB cases provided adequate nucleic acid for next-generation sequencing, with tumor cell percentages averaging above 30%. Despite challenges such as low DNA quantification and degraded DNA, sequencing reads showed satisfactory quality control statistics, demonstrating the detection of genomic alterations. Most cases (84.6%) harbored at least one gene variant, including clinically significant gene mutation variants such as KRAS, TP53, and CDKN2A. Even at minimal concentrations, as long as the extracted DNA is of high quality, performing comprehensive molecular profiling on PDAC samples from cell blocks has remained feasible. This strategy has yielded valuable information about the diagnosis, genetic landscape, and potential therapeutic targets, aligning closely with a precision cytopathology approach.
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Affiliation(s)
- Ricella Souza da Silva
- IPATIMUP Diagnostics, IPATIMUP—Institute of Molecular Pathology and Immunology of Porto University, 4200-135 Porto, Portugal; (R.S.d.S.)
| | - Maria João Pina
- IPATIMUP Diagnostics, IPATIMUP—Institute of Molecular Pathology and Immunology of Porto University, 4200-135 Porto, Portugal; (R.S.d.S.)
| | - Luís Cirnes
- IPATIMUP Diagnostics, IPATIMUP—Institute of Molecular Pathology and Immunology of Porto University, 4200-135 Porto, Portugal; (R.S.d.S.)
| | - Luís Gouveia
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - André Albergaria
- IPATIMUP Diagnostics, IPATIMUP—Institute of Molecular Pathology and Immunology of Porto University, 4200-135 Porto, Portugal; (R.S.d.S.)
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- I3S—Instituto de Investigação e Inovação em Saúde, University of Porto, 4200-135 Porto, Portugal
| | - Fernando Schmitt
- IPATIMUP Diagnostics, IPATIMUP—Institute of Molecular Pathology and Immunology of Porto University, 4200-135 Porto, Portugal; (R.S.d.S.)
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- CINTESIS@RISE (Health Research Network), Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
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5
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Planchard D, Sanborn RE, Negrao MV, Vaishnavi A, Smit EF. BRAF V600E-mutant metastatic NSCLC: disease overview and treatment landscape. NPJ Precis Oncol 2024; 8:90. [PMID: 38627602 PMCID: PMC11021522 DOI: 10.1038/s41698-024-00552-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/15/2024] [Indexed: 04/19/2024] Open
Abstract
In this review, we cover the current understanding of BRAF mutations and associated clinical characteristics in patients with metastatic NSCLC, approved and emerging treatment options, BRAF sequencing approaches, and unmet needs. The BRAFV600E mutation confers constitutive activity of the MAPK pathway, leading to enhanced growth, proliferation, and survival of tumor cells. Testing for BRAF mutations enables patients to be treated with therapies that directly target BRAFV600E and the MAPK pathway, but BRAF testing lags behind other oncogene testing in metastatic NSCLC. Additional therapies targeting BRAFV600E mutations provide options for patients with metastatic NSCLC. Emerging therapies and combinations under investigation could potentially overcome issues of resistance and target non-V600E mutations. Therefore, because targeted therapies with enhanced efficacy are on the horizon, being able to identify BRAF mutations in metastatic NSCLC may become even more important.
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Affiliation(s)
- David Planchard
- Thoracic Cancer Group, Department of Medical Oncology, Gustave Roussy, Villejuif, France.
| | - Rachel E Sanborn
- Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, OR, USA
| | - Marcelo V Negrao
- Department of Thoracic/Head and Neck Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aria Vaishnavi
- Department of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Egbert F Smit
- Department of Pulmonary Disease, Leiden University Medical Centre, Leiden, Netherlands
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6
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Hofman P, Berezowska S, Kazdal D, Mograbi B, Ilié M, Stenzinger A, Hofman V. Current challenges and practical aspects of molecular pathology for non-small cell lung cancers. Virchows Arch 2024; 484:233-246. [PMID: 37801103 PMCID: PMC10948551 DOI: 10.1007/s00428-023-03651-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
The continuing evolution of treatment options in thoracic oncology requires the pathologist to regularly update diagnostic algorithms for management of tumor samples. It is essential to decide on the best way to use tissue biopsies, cytological samples, as well as liquid biopsies to identify the different mandatory predictive biomarkers of lung cancers in a short turnaround time. However, biological resources and laboratory member workforce are limited and may be not sufficient for the increased complexity of molecular pathological analyses and for complementary translational research development. In this context, the surgical pathologist is the only one who makes the decisions whether or not to send specimens to immunohistochemical and molecular pathology platforms. Moreover, the pathologist can rapidly contact the oncologist to obtain a new tissue biopsy and/or a liquid biopsy if he/she considers that the biological material is not sufficient in quantity or quality for assessment of predictive biomarkers. Inadequate control of algorithms and sampling workflow may lead to false negative, inconclusive, and incomplete findings, resulting in inappropriate choice of therapeutic strategy and potentially poor outcome for patients. International guidelines for lung cancer treatment are based on the results of the expression of different proteins and on genomic alterations. These guidelines have been established taking into consideration the best practices to be set up in clinical and molecular pathology laboratories. This review addresses the current predictive biomarkers and algorithms for use in thoracic oncology molecular pathology as well as the central role of the pathologist, notably in the molecular tumor board and her/his participation in the treatment decision-making. The perspectives in this setting will be discussed.
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Affiliation(s)
- Paul Hofman
- Côte d'Azur University, FHU OncoAge, IHU RespirERA, Laboratory of Clinical and Experimental Pathology, BB-0033-00025, Louis Pasteur Hospital, 30 avenue de la voie romaine, BP69, 06001, Nice cedex 01, France.
- Côte d'Azur University, IRCAN, Inserm, CNRS 7284, U1081, Nice, France.
| | - Sabina Berezowska
- Department of Laboratory Medicine and Pathology, Institute of Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel Kazdal
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
- Centers for Personalized Medicine (ZPM), Heidelberg, Germany
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Baharia Mograbi
- Côte d'Azur University, FHU OncoAge, IHU RespirERA, Laboratory of Clinical and Experimental Pathology, BB-0033-00025, Louis Pasteur Hospital, 30 avenue de la voie romaine, BP69, 06001, Nice cedex 01, France
- Côte d'Azur University, IRCAN, Inserm, CNRS 7284, U1081, Nice, France
| | - Marius Ilié
- Côte d'Azur University, FHU OncoAge, IHU RespirERA, Laboratory of Clinical and Experimental Pathology, BB-0033-00025, Louis Pasteur Hospital, 30 avenue de la voie romaine, BP69, 06001, Nice cedex 01, France
- Côte d'Azur University, IRCAN, Inserm, CNRS 7284, U1081, Nice, France
| | - Albrecht Stenzinger
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
- Centers for Personalized Medicine (ZPM), Heidelberg, Germany
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Véronique Hofman
- Côte d'Azur University, FHU OncoAge, IHU RespirERA, Laboratory of Clinical and Experimental Pathology, BB-0033-00025, Louis Pasteur Hospital, 30 avenue de la voie romaine, BP69, 06001, Nice cedex 01, France
- Côte d'Azur University, IRCAN, Inserm, CNRS 7284, U1081, Nice, France
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7
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Fassan M, Angerilli V, Normanno N, Pruneri G, Marchetti A, Grillo F, Tonini G, Scarpa A, Rimassa L. Practical guidelines for molecular testing of cholangiocarcinoma in clinical practice: Italian experts' position paper. Crit Rev Oncol Hematol 2024; 194:104224. [PMID: 38211900 DOI: 10.1016/j.critrevonc.2023.104224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 01/13/2024] Open
Abstract
Biliary tract cancers (BTCs) represent a spectrum of malignancies associated with a dismal prognosis. Recent genomic profiling studies have provided a deeper understanding of the complex and heterogenous molecular landscape of BTCs, identifying several actionable genetic alterations, and expanding treatment options. Due to the high number and complexity of genetic alterations which require testing, next-generation sequencing (NGS) is currently the preferred approach over conventional methods (i.e., immunohistochemistry, fluorescence in-situ hybridization and PCR) for molecular profiling of BTCs and should be performed upfront in all BTC patients. However, BTC sampling often yields low tumor cellularity tissue, hampering NGS analysis. Future perspectives to overcome this obstacle include liquid biopsy and optimization of biopsy protocols. In this position paper, the authors discuss the current histopathologic, molecular, and therapeutic landscape of BTCs, provide a critical overview of the available testing methods for molecular diagnostics, and propose a practical diagnostic algorithm for molecular testing of BTC samples.
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Affiliation(s)
- Matteo Fassan
- Department of Medicine (DIMED), University of Padua, Padua, Italy; Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | | | - Nicola Normanno
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Giancarlo Pruneri
- Pathology Unit 2, Department of Innovation Diagnostics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; University of Milan, School of Medicine, Milan, Italy
| | - Antonio Marchetti
- Department of Medical, Oral and Biotechnological Sciences, Centre for Advanced Studies and Technology (CAST), University of Chieti, Chieti, Italy
| | - Federica Grillo
- Pathology Unit, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Italy; IRCCS-Ospedale Policlinico San Martino, Genoa, Italy.
| | - Giuseppe Tonini
- Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy; Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Aldo Scarpa
- Section of Pathology, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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8
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Kerr KM, Bubendorf L, Lopez-Rios F, Khalil F, Roy-Chowdhuri S, Joubert P, Hartmann A, Guerini-Rocco E, Yatabe Y, Hofman P, Cooper WA, Dacic S. Optimizing tissue stewardship in non-small cell lung cancer to support molecular characterization and treatment selection: statement from a working group of thoracic pathologists. Histopathology 2024; 84:429-439. [PMID: 37957137 DOI: 10.1111/his.15078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 11/15/2023]
Abstract
Many patients with non-small cell lung cancer do not receive guideline-recommended, biomarker-directed therapy, despite the potential for improved clinical outcomes. Access to timely, accurate, and comprehensive molecular profiling, including targetable protein overexpression, is essential to allow fully informed treatment decisions to be taken. In turn, this requires optimal tissue management to protect and maximize the use of this precious finite resource. Here, a group of leading thoracic pathologists recommend factors to consider for optimal tissue management. Starting from when lung cancer is first suspected, keeping predictive biomarker testing in the front of the mind should drive the development of practices and procedures that conserve tissue appropriately to support molecular characterization and treatment selection.
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Affiliation(s)
- Keith M Kerr
- Department of Pathology, Aberdeen Royal Infirmary and Aberdeen University Medical School, Aberdeen, UK
| | - Lukas Bubendorf
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Fernando Lopez-Rios
- Department of Pathology, 12 de Octubre University Hospital-CIBERONC, Research Institute 12 de Octubre University Hospital (i+12), Universidad Complutense, Madrid, Spain
| | | | | | - Philippe Joubert
- Québec Heart and Lung Institute-Laval University (IUCPQ-UL), Quebec, QC, Canada
| | - Arndt Hartmann
- Institute of Pathology, University Erlangen-Nürnberg, Erlangen, Germany
| | - Elena Guerini-Rocco
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Paul Hofman
- Nice University Hospital, FHU OncoAge, BB-0033-00025, University Côte d'Azur, Nice, France
| | - Wendy A Cooper
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
- Western Sydney University, Campbelltown, NSW, Australia
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9
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Malapelle U, Donne AD, Pagni F, Fraggetta F, Rocco EG, Pasello G, Perrone G, Pepe F, Vatrano S, Pignata S, Pinto C, Pruneri G, Russo A, Soto Parra HJ, Vallone S, Marchetti A, Troncone G, Novello S. Standardized and simplified reporting of next-generation sequencing results in advanced non-small-cell lung cancer: Practical indications from an Italian multidisciplinary group. Crit Rev Oncol Hematol 2024; 193:104217. [PMID: 38040072 DOI: 10.1016/j.critrevonc.2023.104217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Abstract
Molecular biomarker testing is increasingly becoming standard of care for advanced non-small cell lung cancer (NSCLC). Tissue and liquid biopsy-based next-generation sequencing (NGS) is now highly recommended and has become an integral part of the routine management of advanced NSCLC patients. This highly sensitive approach can simultaneously and efficiently detect multiple biomarkers even in scant samples. However full optimization of NGS in clinical practice requires accurate reporting and interpretation of NGS findings. Indeed, as the number of NSCLC biomarkers continues to grow, clinical reporting of NGS data is becoming increasingly complex. In this scenario, achieving standardization, simplification, and improved readability of NGS reports is key to ensuring timely and appropriate treatment decisions. In an effort to address the complexity and lengthy reporting of NGS mutation results, an Italian group of 14 healthcare professionals involved in NSCLC management convened in 2023 to address the content, structure, and ease-of-use of NGS reporting practices and proposed a standard report template for clinical use This article presents the key discussion points addressed by the Italian working group and describes the essential elements of the report template.
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Affiliation(s)
- Umberto Malapelle
- Department of Public Health, University Federico II of Naples, Naples, Italy
| | | | - Fabio Pagni
- Pathology Unit, University Bicocca of Milan, Italy
| | - Filippo Fraggetta
- Pathology Unit, Gravina Hospital Caltagirone, ASP Catania, Caltagirone, Italy
| | - Elena Guerini Rocco
- Anatomia Patologica, Istituto Europeo Oncologia, Milano, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Giulia Pasello
- Dipartimento di Scienze Chirurgiche, Oncologichee Gastroenterologiche (DiSCOG) dell'Università di Padova, Oncologia 2, Istituto Oncologico Veneto IRCCS, Padova, Italy
| | - Giuseppe Perrone
- Research Unit of Anatomical Pathology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Anatomical Pathology Operative Research Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Francesco Pepe
- Department of Public Health, University Federico II of Naples, Naples, Italy
| | - Simona Vatrano
- Pathology Unit, Gravina Hospital Caltagirone, ASP Catania, Caltagirone, Italy
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale Napoli, Italy
| | - Carmine Pinto
- Medical Oncology, Comprehensive Cancer Centre, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giancarlo Pruneri
- Dipartimento di Diagnostica Avanzata, Fondazione IRCCS Istituto Tumori di Milano; Università degli Studi di Milano, Italy
| | - Antonio Russo
- Oncologia Medica, Università degli studi di Palermo, AOUP "Paolo Giaccone", Palermo, Italy
| | | | | | - Antonio Marchetti
- Unit of Diagnostic Molecular Oncology, Center for Advanced Studies and Technology, University of Chieti, Italy
| | - Giancarlo Troncone
- Department of Public Health, University Federico II of Naples, Naples, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, AOU S. Luigi Gonzaga, Orbassano, TO, Italy.
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10
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Svoboda M, Lohajova Behulova R, Slamka T, Sebest L, Repiska V. Comprehensive Genomic Profiling in Predictive Testing of Cancer. Physiol Res 2023; 72:S267-S275. [PMID: 37888970 PMCID: PMC10669951 DOI: 10.33549/physiolres.935154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 12/01/2023] Open
Abstract
Despite the rapid progress in the field of personalized medicine and the efforts to apply specific treatment strategies to patients based on the presence of pathogenic variants in one, two, or three genes, patient response to the treatment in terms of positive benefit and overall survival remains heterogeneous. However, advances in sequencing and bioinformatics technologies have facilitated the simultaneous examination of somatic variants in tens to thousands of genes in tumor tissue, enabling the determination of personalized management based on the patient's comprehensive genomic profile (CGP). CGP has the potential to enhance clinical decision-making and personalize innovative treatments for individual patients, by providing oncologists with a more comprehensive molecular characterization of tumors. This study aimed to highlight the utility of CGP in routine clinical practice. Here we present three patient cases with various advanced cancer indicated for CGP analysis using a combination of SOPHiA Solid Tumor Solution (STS, 42 genes) for DNA and SOPHiA RNAtarget Oncology Solution (ROS, 45 genes and 17 gene fusions with any random partners) for RNA. We were able to identify actionable genomic alterations in all three cases, thereby presenting valuable information for future management of these patients. This approach has the potential to transform clinical practice and greatly improve patient outcomes in the field of oncology.
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Affiliation(s)
- M Svoboda
- Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University, Bratislava, Slovak Republic.
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11
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Lim TKH, Skoulidis F, Kerr KM, Ahn MJ, Kapp JR, Soares FA, Yatabe Y. KRAS G12C in advanced NSCLC: Prevalence, co-mutations, and testing. Lung Cancer 2023; 184:107293. [PMID: 37683526 DOI: 10.1016/j.lungcan.2023.107293] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/15/2023] [Accepted: 07/05/2023] [Indexed: 09/10/2023]
Abstract
KRAS is the most commonly mutated oncogene in advanced, non-squamous, non-small cell lung cancer (NSCLC) in Western countries. Of the various KRAS mutants, KRAS G12C is the most common variant (~40%), representing 10-13% of advanced non-squamous NSCLC. Recent regulatory approvals of the KRASG12C-selective inhibitors sotorasib and adagrasib for patients with advanced or metastatic NSCLC harboring KRASG12C have transformed KRAS into a druggable target. In this review, we explore the evolving role of KRAS from a prognostic to a predictive biomarker in advanced NSCLC, discussing KRAS G12C biology, real-world prevalence, clinical relevance of co-mutations, and approaches to molecular testing. Real-world evidence demonstrates significant geographic differences in KRAS G12C prevalence (8.9-19.5% in the US, 9.3-18.4% in Europe, 6.9-9.0% in Latin America, and 1.4-4.3% in Asia) in advanced NSCLC. Additionally, the body of clinical data pertaining to KRAS G12C co-mutations such as STK11, KEAP1, and TP53 is increasing. In real-world evidence, KRAS G12C-mutant NSCLC was associated with STK11, KEAP1, and TP53 co-mutations in 10.3-28.0%, 6.3-23.0%, and 17.8-50.0% of patients, respectively. Whilst sotorasib and adagrasib are currently approved for use in the second-line setting and beyond for patients with advanced/metastatic NSCLC, testing and reporting of the KRAS G12C variant should be included in routine biomarker testing prior to first-line therapy. KRAS G12C test results should be clearly documented in patients' health records for actionability at progression. Where available, next-generation sequencing is recommended to facilitate simultaneous testing of potentially actionable biomarkers in a single run to conserve tissue. Results from molecular testing should inform clinical decisions in treating patients with KRAS G12C-mutated advanced NSCLC.
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Affiliation(s)
| | - Ferdinandos Skoulidis
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith M Kerr
- Department of Pathology, Aberdeen University Medical School and Aberdeen Royal Infirmary, Aberdeen, UK
| | - Myung-Ju Ahn
- Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Fernando A Soares
- D'Or Institute for Research and Education (IDOR), São Paulo, Brazil; Faculty of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Yasushi Yatabe
- Department of Diagnostic Pathology, National Cancer Center, Tokyo, Japan.
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12
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Yan JT, Jin Y, Lo E, Chen Y, Hanlon Newell AE, Kong Y, Inge LJ. Real-World Biomarker Test Utilization and Subsequent Treatment in Patients with Early-Stage Non-small Cell Lung Cancer in the United States, 2011-2021. Oncol Ther 2023; 11:343-360. [PMID: 37330972 PMCID: PMC10447355 DOI: 10.1007/s40487-023-00234-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
INTRODUCTION Biomarker testing is increasingly crucial for patients with early-stage non-small cell lung cancer (eNSCLC). We explored biomarker test utilization and subsequent treatment in eNSCLC patients in the real-world setting. METHODS Using COTA's oncology database, this retrospective observational study included adult patients ≥ 18 years old diagnosed with eNSCLC (disease stage 0-IIIA) between January 1, 2011 and December 31, 2021. Date of first eNSCLC diagnosis was the study index date. We reported testing rates by index year for patients who received any biomarker test within 6 months of eNSCLC diagnosis and by each molecular marker. We also evaluated treatments received among patients receiving the five most common biomarker tests. RESULTS Among the 1031 eNSCLC patients included in the analysis, 764 (74.1%) received ≥ 1 biomarker test within 6 months of eNSCLC diagnosis. Overall, epidermal growth factor receptor (EGFR; 64%), anaplastic lymphoma kinase (ALK; 60%), programmed death receptor ligand 1 (PD-L1; 48%), ROS proto-oncogene 1 (ROS1; 46%), B-Raf proto-oncogene (40%), mesenchymal epithelial transition factor receptor (35%), Kirsten rat sarcoma viral oncogene (29%), RET proto-oncogene (22%), human epidermal growth factor receptor 2 (21%), and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (20%) were the 10 most frequently tested biomarkers. The proportion of patients undergoing biomarker testing rose from 55.3% in 2011 to 88.1% in 2021. The most common testing methods were Sanger sequencing for EGFR (244, 37%), FISH (fluorescence in situ hybridization) for ALK (464, 75%) and ROS1 (357, 76%), immunohistochemical assay for PD-L1 (450, 90%), and next-generation sequencing testing for other biomarkers. Almost all the 763 patients who received the five most common biomarker tests had a test before the initiation of a systemic treatment. CONCLUSION This study suggests a high biomarker testing rate among patients with eNSCLC in the US, with testing rates for various biomarkers increasing over the past decade, indicating a continuous trend towards the personalization of treatment decisions.
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Affiliation(s)
- Jessie T Yan
- Roche Information Solutions, Roche Diagnostics, Santa Clara, CA, USA.
| | - Yue Jin
- Roche Information Solutions, Roche Diagnostics, Santa Clara, CA, USA
| | - Ernest Lo
- Roche Information Solutions, Roche Diagnostics, Santa Clara, CA, USA
| | - Yilin Chen
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Amy E Hanlon Newell
- Clinical Development/Medical Affairs, Global, Roche Diagnostics Solutions, Tucson, AZ, USA
| | - Ying Kong
- Clinical Development/Medical Affairs, Global, Roche Diagnostics Solutions, Tucson, AZ, USA
| | - Landon J Inge
- Clinical Development/Medical Affairs, Global, Roche Diagnostics Solutions, Tucson, AZ, USA
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13
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Gosney JR, Paz-Ares L, Jänne P, Kerr KM, Leighl NB, Lozano MD, Malapelle U, Mok T, Sheffield BS, Tufman A, Wistuba II, Peters S. Pathologist-initiated reflex testing for biomarkers in non-small-cell lung cancer: expert consensus on the rationale and considerations for implementation. ESMO Open 2023; 8:101587. [PMID: 37356358 PMCID: PMC10485396 DOI: 10.1016/j.esmoop.2023.101587] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/18/2023] [Accepted: 05/18/2023] [Indexed: 06/27/2023] Open
Abstract
Biomarker tests in lung cancer have been traditionally ordered by the treating oncologist upon confirmation of an appropriate pathological diagnosis. The delay this introduces prolongs yet further what is already a complex, multi-stage, pre-treatment pathway and delays the start of first-line systemic treatment, which is crucially informed by the results of such analysis. Reflex testing, in which the responsibility for testing for an agreed range of biomarkers lies with the pathologist, has been shown to standardise and expedite the process. Twelve experts discussed the rationale and considerations for implementing reflex testing as standard clinical practice.
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Affiliation(s)
- J R Gosney
- Department of Cellular Pathology, Royal Liverpool University Hospital, Liverpool, UK
| | - L Paz-Ares
- Hospital Universitario 12 de Octubre, H12O-CNIO Lung Cancer Unit, Ciberonc and Complutense University, Madrid, Spain
| | - P Jänne
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - K M Kerr
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - N B Leighl
- Princess Margaret Cancer Centre, Toronto, Canada
| | - M D Lozano
- Pathology, Universidad de Navarra-Clínica Universidad de Navarra, Pamplona, Spain
| | - U Malapelle
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - T Mok
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - B S Sheffield
- Department of Pathology and Laboratory Medicine, William Osler Health System, Brampton, Canada
| | - A Tufman
- Department of Internal Medicine V, Thoracic Oncology Centre Munich, Ludwig Maximilian University, Munich; Comprehensive Pneumology Center Munich (CPC-M), Munich; German Center for Lung Research (DZL), Munich, Germany
| | - I I Wistuba
- Departments of Thoracic/Head and Neck Medical Oncology; Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - S Peters
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.
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14
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Normanno N, De Luca A, Abate RE, Morabito A, Milella M, Tabbò F, Curigliano G, Masini C, Marchetti P, Pruneri G, Guarneri V, Frassineti GL, Fasola G, Adamo V, Daniele B, Berardi R, Feroce F, Maiello E, Pinto C. Current practice of genomic profiling of patients with advanced solid tumours in Italy: the Italian Register of Actionable Mutations (RATIONAL) study. Eur J Cancer 2023; 187:174-184. [PMID: 37167765 DOI: 10.1016/j.ejca.2023.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The Italian Register of Actionable Mutations (RATIONAL) is a multicentric, observational study collecting next-generation sequencing (NGS)-based tumour profiling data of patients with advanced solid tumours. METHODS The study enrols patients who had available an NGS-based tumour profiling (Pathway-A) or undergo comprehensive genomic profiling (CGP) with FoundationOne CDx assays within the trial (Pathway-B). The primary endpoint was the rate of actionable mutations identified. RESULTS Sequencing data were available for 738 patients in Pathway-A (218) and -B (520). In Pathway-A, 154/218 (70.6%) tests were performed using NGS panels ≤52 genes, and genomic alterations (GAs) were found in 164/218 (75.2%) patients. In Pathway-B, CGP revealed GAs in 512/520 (98.5%) patients. Levels I/II/III actionable GAs according to the European Society of Medical Oncology Scale for Clinical Actionability of molecular Targets (ESCAT) were identified in 254/554 (45.8%) patients with non-small-cell lung cancer, cholangiocarcinoma, colorectal, gastric, pancreatic and breast cancer. The rate of patients with level I GAs was similar in Pathways A and B (69 versus 102). CGP in Pathway-B revealed a higher number of patients with level II/III GAs (99 versus 20) and potentially germline pathogenic/likely pathogenic variants (58 versus 15) as compared with standard testing in Pathway-A. In patients with cancer of unknown primary, CGP detected OncoKB levels 3B/4 GAs in 31/58 (53.4%) cases. Overall, 67/573 (11.7%) of patients received targeted therapy based on genomic testing. CONCLUSION The Italian Register of Actionable Mutations represents the first overview of genomic profiling in Italian current clinical practice and highlights the utility of CGP for identifying therapeutic targets in selected cancer patients.
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Affiliation(s)
- Nicola Normanno
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy.
| | - Antonella De Luca
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Riziero Esposito Abate
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Alessandro Morabito
- Thoracic Department, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Michele Milella
- U.O.C. Oncology, Azienda Ospedaliera Universitaria Integrata, University and Hospital Trust of Verona, Verona, Italy
| | - Fabrizio Tabbò
- Department of Oncology, Università degli Studi di Torino, AOU San Luigi, Orbassano, Italy
| | - Giuseppe Curigliano
- Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy; Division of Early Drug Development, European Institute of Oncology IRCCS, Milano, Italy
| | - Cristina Masini
- Medical Oncology, Comprehensive Cancer Centre IRCCS - AUSL Reggio Emilia, Reggio Emilia, Italy
| | - Paolo Marchetti
- Istituto Dermopatico dell'Immacolata (IDI-IRCCS), Roma, Italy
| | - Giancarlo Pruneri
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - Valentina Guarneri
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy; Oncology 2, Istituto Oncologico Veneto (IOV) IRCCS, Padova, Italy
| | - Giovanni L Frassineti
- Department of Medical Oncology-IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Gianpiero Fasola
- Department of Medical Oncology, University Hospital of Udine, Udine, Italy
| | - Vincenzo Adamo
- Scientific Direction Oncology Department, Papardo Hospital, Messina, Italy
| | | | | | - Florinda Feroce
- Surgical Pathology Unit, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Evaristo Maiello
- Oncology Unit, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Carmine Pinto
- Medical Oncology, Comprehensive Cancer Centre IRCCS - AUSL Reggio Emilia, Reggio Emilia, Italy
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15
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Dacic S. State of the Art of Pathologic and Molecular Testing. Hematol Oncol Clin North Am 2023; 37:463-473. [PMID: 36964109 DOI: 10.1016/j.hoc.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Advances in the treatment of non-small cell lung carcinoma have resulted in improved histologic classification and the implementation of molecular testing for predictive biomarkers into the routine diagnostic workflow. Over the past decade, molecular testing has evolved from single-gene assays to high-thoroughput comprehensive next-generation sequencing. Economic barriers, suboptimal turnaround time to obtain the results, and limited tissue available for molecular assays resulted in adoption of liquid biopsies (ctDNA) into clinical practice. Multiplex immunohistochemical/immunofluorescence assays evaluating tumor microenvironment together with the AI approaches are anticipated to translate from research into clinical care.
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Affiliation(s)
- Sanja Dacic
- Department of Pathology, Yale School of Medicine, 200 South Frontage Road, EP2-631, New Haven, CT 06510, USA.
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16
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Souza da Silva R, Pinto R, Cirnes L, Schmitt F. Tissue management in precision medicine: What the pathologist needs to know in the molecular era. Front Mol Biosci 2022; 9:983102. [DOI: 10.3389/fmolb.2022.983102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/13/2022] [Indexed: 11/13/2022] Open
Abstract
Precision medicine is “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.” Among many medical specialists involved in precision medicine, the pathologists play an important and key role in the implementation and development of molecular tests that are in the center of decision of many therapeutic choices. Besides many laboratory procedures directly involved in the molecular tests, is fundamental to guarantee that tissues and cells collected for analysis be managed correctly before the DNA/RNA extraction. In this paper we explore the pivotal and interconnected points that can influence molecular studies, such as pre-analytical issues (fixation and decalcification); diagnosis and material selection, including the calculation of nuclei neoplastic fraction. The standardization of sample processing and morphological control ensures the accuracy of the diagnosis. Tissue or cytological samples constitutes the main foundation for the determination of biomarkers and development of druggable targets. Pathology and precision oncology still have a long way to go in terms of research and clinical practice: improving the accuracy and dissemination of molecular tests, learning in molecular tumor boards for advanced disease, and knowledge about early disease. Precision medicine needs pathology to be precise.
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Parente P, Biancofiore G, Graziano P. Letter to Editor: A simple and cheap workflow to standardize cell block method in non small cell lung cancer patients. Virchows Arch 2022; 481:677-678. [PMID: 35997824 DOI: 10.1007/s00428-022-03399-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Paola Parente
- Pathology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, 71013, San Giovanni Rotondo, FG, Italy.
| | - Giovanni Biancofiore
- Pathology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, 71013, San Giovanni Rotondo, FG, Italy
| | - Paolo Graziano
- Pathology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, 71013, San Giovanni Rotondo, FG, Italy
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18
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Expert opinion on NSCLC small specimen biomarker testing - Part 2: Analysis, reporting, and quality assessment. Virchows Arch 2022; 481:351-366. [PMID: 35857103 PMCID: PMC9297263 DOI: 10.1007/s00428-022-03344-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 10/31/2022]
Abstract
The diagnostic work-up for non-small cell lung cancer (NSCLC) requires biomarker testing to guide therapy choices. This article is the second of a two-part series. In Part 1, we summarised evidence-based recommendations for obtaining and processing small specimen samples (i.e. pre-analytical steps) from patients with advanced NSCLC. Here, in Part 2, we summarise evidence-based recommendations relating to analytical steps of biomarker testing (and associated reporting and quality assessment) of small specimen samples in NSCLC. As the number of biomarkers for actionable (genetic) targets and approved targeted therapies continues to increase, simultaneous testing of multiple actionable oncogenic drivers using next-generation sequencing (NGS) becomes imperative, as set forth in European Society for Medical Oncology guidelines. This is particularly relevant in advanced NSCLC, where tissue specimens are typically limited and NGS may help avoid tissue exhaustion compared with sequential biomarker testing. Despite guideline recommendations, significant discrepancies in access to NGS persist across Europe, primarily due to reimbursement constraints. The use of increasingly complex testing methods also has implications for the reporting of results. Molecular testing reports should include clinical interpretation with additional commentary on sample adequacy as appropriate. Molecular tumour boards are recommended to facilitate the interpretation of complex genetic information arising from NGS, and to collaboratively determine the optimal treatment for patients with NSCLC. Finally, whichever testing modality is employed, it is essential that adequate internal and external validation and quality control measures are implemented.
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