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Khalifa MA, Gagner B, Chen L, Murugan P, Klein ME, Racila E, Amin K, Miller D, Stewart J, Ding Y, Farooqui M, Dasaraju S, Adeyi OA. Immunohistochemistry and immunofluorescence utilization audit by subspecialty in an academic setting: A step toward stewardship. Ann Diagn Pathol 2023; 67:152214. [PMID: 37783147 DOI: 10.1016/j.anndiagpath.2023.152214] [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: 07/27/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023]
Abstract
There are immunohistochemistry (IHC) and immunofluorescence (IF) panels described in the literature and established by personal and institutional experiences that are in common use by pathologists in their daily practice. Stewardship is a difficult discussion because IHC utilization is influenced by many factors including the pathologist's experience, background, practice setting, personal bias, and medicolegal culture. We developed the methodology to audit the IHC/IF utilization in our academic subspecialty practice. We aim to share this methodology and to provide our data that can be used for consideration by other subspecialized academic practices. This analysis included a total of 63,157 specimens that were accessioned during 2022, representing 38,612 cases. The likelihood of ordering IHC/IF ranged from 1 % (in genitourinary pathology) to 59 % (in renal pathology). The average percentage of specimens with IHC/IF was 21 % for the entire practice. In cases where IHC/IF was ordered, the number of stained slides averaged 4.9 per specimen for the entire practice. The number of IHC/IF slides per specimen ranged from 1.9 (in gastrointestinal pathology) to 12.2 (in renal pathology). The highest number of antibodies ordered for a single specimen by subspecialty ranged from 11 (in cardiac pathology) to 63 (in dermatopathology). Renal pathology was the only subspecialty that had an average number of IHC/IF slides that was statistically significantly different from all other subspecialties. We described the various patterns of utilization by subspecialty and rationalized their subtle differences. We also analyzed the types of cases that exceeded the reimbursement limits set by the Centers for Medicare and Medicaid Services (CMS).
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Affiliation(s)
- Mahmoud A Khalifa
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America.
| | - Brooke Gagner
- MHealth Fairview Laboratories, Minneapolis, MN, United States of America
| | - Liam Chen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Paari Murugan
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Molly E Klein
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Emilian Racila
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Khalid Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Daniel Miller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Jimmie Stewart
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Yanli Ding
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Mariya Farooqui
- MHealth Fairview Laboratories, Minneapolis, MN, United States of America
| | - Sandhyarani Dasaraju
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Oyedele A Adeyi
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
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Alshaikh S, Lapadat R, Atieh MK, Mehrotra S, Barkan GA, Wojcik EM, Pambuccian SE. The utilization and utility of immunostains in body fluid cytology. Cancer Cytopathol 2020; 128:384-391. [PMID: 32163239 DOI: 10.1002/cncy.22256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/06/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Body fluid cytology (BFC) is an important tool in the diagnosis and staging of malignancy and is aided by the judicious use of immunohistochemistry (IHC). The aim of this study was to determine the usage rates of IHC stains in BFC, their type and indications, and their diagnostic impact. We also attempted to estimate the optimal rate of IHC use in BFC by comparing the entire laboratory's and each individual cytopathologist's IHC use rates with their respective indeterminate and malignant diagnosis rates. METHODS We conducted a retrospective study of IHC stain use in BFC during a 5.5-year interval (2013-2018) and determined the laboratory's and each individual cytopathologist's IHC usage patterns according to the final diagnosis, site, and indications for their use. RESULTS A total of 477 out of 4144 (11.5%) BFC cases had 2128 individual immunostains performed, with an average of 4.5 immunostains per case. Individual cytopathologists used IHC stains on 6.7% to 22% of their BFC cases. Pathologists with higher rates of IHC stain use than the laboratory's mean were less experienced and had higher rates of indeterminate but not of malignant diagnoses. The most common indication for the use of IHC stains was differentiating mesothelial from malignant cells. MOC31, calretinin, Ber-EP4, CD68, and D2-40 were the most commonly used of the 67 different IHC stains used in BFC. CONCLUSIONS The laboratory's mean may represent the optimal IHC use rate, as higher IHC use rates did not lead to more diagnostic certainty or higher pickup rates of malignant cells.
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Affiliation(s)
| | - Razvan Lapadat
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Mohammed K Atieh
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Swati Mehrotra
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Güliz A Barkan
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Eva M Wojcik
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Stefan E Pambuccian
- Department of Pathology and Laboratory Medicine, Loyola University Medical Center, Maywood, Illinois
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Compton ML, Hogan M, Reisenbichler ES. Differences in immunohistochemistry utilization by general and breast subspecialty pathologists at a large academic institution. Ann Diagn Pathol 2019; 42:92-95. [PMID: 31445409 DOI: 10.1016/j.anndiagpath.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Immunohistochemistry (IHC) can be a useful adjunct in diagnostic breast pathology, but best practices have not been clearly established. We sought to compare the patterns of p63 utilization between general pathologists (GP) and subspecialized breast pathologists (BP), analyze diagnostic discrepancy rates, and identify types of lesions requiring immunohistochemistry. METHODS The pathology database was searched over 6-year period to identify breast needle core biopsy cases utilizing p63 and subsequent excision results. RESULTS P63 was ordered more frequently by BP (2.3% of cores) compared to GP (1.1% of cores, p = 0.0005). The most frequent utilization of p63 by GP for benign lesions (44.0%) followed by invasive carcinomas (36.0%) while BP most frequently ordered p63 on invasive carcinomas (49.5%) and DCIS (26.6%). CONCLUSIONS While IHC use may be thought to be most helpful to those with less experience or knowledge in breast pathology, these results suggest that utilization is increased with subspecialty training.
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Affiliation(s)
- Margaret L Compton
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, MCN CC3322, Nashville, TN 37232-2561, United States of America.
| | - Melissa Hogan
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, United States of America
| | - Emily S Reisenbichler
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, United States of America; Department of Pathology, Yale-New Haven Health System, United States of America
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Leung SCY, Nielsen TO, Zabaglo LA, Arun I, Badve SS, Bane AL, Bartlett JMS, Borgquist S, Chang MC, Dodson A, Ehinger A, Fineberg S, Focke CM, Gao D, Gown AM, Gutierrez C, Hugh JC, Kos Z, Laenkholm AV, Mastropasqua MG, Moriya T, Nofech-Mozes S, Osborne CK, Penault-Llorca FM, Piper T, Sakatani T, Salgado R, Starczynski J, Sugie T, van der Vegt B, Viale G, Hayes DF, McShane LM, Dowsett M. Analytical validation of a standardised scoring protocol for Ki67 immunohistochemistry on breast cancer excision whole sections: an international multicentre collaboration. Histopathology 2019; 75:225-235. [PMID: 31017314 DOI: 10.1111/his.13880] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/19/2019] [Indexed: 01/12/2023]
Abstract
AIMS The nuclear proliferation marker Ki67 assayed by immunohistochemistry has multiple potential uses in breast cancer, but an unacceptable level of interlaboratory variability has hampered its clinical utility. The International Ki67 in Breast Cancer Working Group has undertaken a systematic programme to determine whether Ki67 measurement can be analytically validated and standardised among laboratories. This study addresses whether acceptable scoring reproducibility can be achieved on excision whole sections. METHODS AND RESULTS Adjacent sections from 30 primary ER+ breast cancers were centrally stained for Ki67 and sections were circulated among 23 pathologists in 12 countries. All pathologists scored Ki67 by two methods: (i) global: four fields of 100 tumour cells each were selected to reflect observed heterogeneity in nuclear staining; (ii) hot-spot: the field with highest apparent Ki67 index was selected and up to 500 cells scored. The intraclass correlation coefficient (ICC) for the global method [confidence interval (CI) = 0.87; 95% CI = 0.799-0.93] marginally met the prespecified success criterion (lower 95% CI ≥ 0.8), while the ICC for the hot-spot method (0.83; 95% CI = 0.74-0.90) did not. Visually, interobserver concordance in location of selected hot-spots varies between cases. The median times for scoring were 9 and 6 min for global and hot-spot methods, respectively. CONCLUSIONS The global scoring method demonstrates adequate reproducibility to warrant next steps towards evaluation for technical and clinical validity in appropriate cohorts of cases. The time taken for scoring by either method is practical using counting software we are making publicly available. Establishment of external quality assessment schemes is likely to improve the reproducibility between laboratories further.
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Affiliation(s)
| | | | | | | | - Sunil S Badve
- Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Anita L Bane
- Juravinski Hospital and Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - John M S Bartlett
- Ontario Institute for Cancer Research, Toronto, ON, Canada.,Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh, UK
| | - Signe Borgquist
- Division of Oncology and Pathology, Department of Clinical Science, Lund University, Lund, Sweden
| | - Martin C Chang
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT, USA
| | - Andrew Dodson
- Ralph Lauren Centre for Breast Cancer Research, The Royal Marsden Hospital, London, UK
| | - Anna Ehinger
- Department of Clinical Genetics and Pathology, Skane University Hospital, Lund University, Lund, Sweden
| | - Susan Fineberg
- Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Dongxia Gao
- University of British Columbia, Vancouver, BC, Canada
| | | | - Carolina Gutierrez
- Lester and Sue Smith Breast Center and Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Zuzana Kos
- University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | | | | | - Sharon Nofech-Mozes
- University of Toronto Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - C Kent Osborne
- Lester and Sue Smith Breast Center and Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Tammy Piper
- Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh, UK
| | | | - Roberto Salgado
- Department of Pathology, GZA-ZNA, Antwerp, Belgium.,Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jane Starczynski
- Birmingham Heart of England, National Health Service, Birmingham, UK
| | | | | | - Giuseppe Viale
- European Institute of Oncology, Milan, Italy.,University of Milan, Milan, Italy
| | - Daniel F Hayes
- University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
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Valero A, Roldán ML, Ruiz MF, Teijeiro JM, Marquez SB, Marini PE. Deleted in Malignant Brain Tumor 1 (DMBT1) Expression Pattern in Normal Cervix and at Different Stages of Squamous Intraepithelial Lesions. ACTA ACUST UNITED AC 2018. [DOI: 10.2174/1875318301808010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background:
Cervical cancer is one of the most frequently occurring malignancies in women worldwide, with high mortality rates. Cervical Squamous Cell Carcinoma (SCC) presents previous states of non-invasive precursor lesions, and early stage Low-Grade Squamous Intraepithelial Lesions (LSIL) regress to normal or Atypical Squamous Cells of Undetermined Significance (ASCUS) in approximately 50% of cases. Deleted in Malignant Brain Tumors 1 (DMBT1) is a tumour suppression glycoprotein, which absence is considered a malignancy marker in many epithelial cancers.
Objective:
To analyse DMBT1’s presence and localization in SCC and precursor lesions.
Method:
Immunohistochemistry for DMBT1 was performed in cervix biopsies classified as normal, LSIL, HSIL and SCC.
Results:
DMBT1 was detected at the supranuclear and sometimes infranuclear regions of the endocervix monolayer epithelial cells in normal and HSIL biopsies. In LSIL samples the detection of DMBT1 in endocervix was variable between patients. Also variable was DMBT1 staining in cells of glandular epithelium. The glycoprotein was not detected in the stratified epithelium of the exocervix, regardless of the lesion grade; nor in dysplastic cells.
Conclusion:
The absence of DMBT1 from endocervix only in some samples of LSIL is promising as a candidate for possible lesion regression potential marker.
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Al Diffalha S, Shaar M, Barkan GA, Wojcik EM, Picken MM, Pambuccian SE. Immunohistochemistry in the workup of prostate biopsies: Frequency, variation and appropriateness of use among pathologists practicing at an academic center. Ann Diagn Pathol 2017; 27:34-42. [PMID: 28325359 DOI: 10.1016/j.anndiagpath.2017.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES We studied the frequency, inter-pathologist variation, appropriateness and utility of immunohistochemistry (IHC) performed on prostate biopsies (PB) to determine the significance of foci of suspicious glands/atypical small acinar proliferations (ASAP). METHODS We calculated the rate of IHC use and diagnostic rate of ASAP and adenocarcinoma in PB from 01/01/2008 to 06/30/2015 for individual pathologists working in a tertiary academic institution, and correlated them with the pathologists' experience, subspecialization and PB volume with the aim of determining the interpathologist variation and appropriateness of use of IHC according to recently published recommendations, and the usefulness of IHC to resolve foci of ASAP as either benign or adenocarcinoma. RESULTS IHC was used in 966/2652 (36.4%, 95% CI 33.4-39.4%) PB cases and 1915 of 16,359 (11.7%, 95% CI 11.2%-12.2%) of PB blocks and allowed definitive diagnosis of either benign or malignant in 75.8% (95% CI 73.9-77.7%) of blocks. By pathologist, IHC use rates varied more than twofold (22.8-50.5%); higher use was found for pathologists with genitourinary pathology specialization, higher PB volume and more experience, and correlated with higher rates of both ASAP and adenocarcinoma diagnoses. The use of IHC stains was considered appropriate in 822/966 (85.1%, 95% CI 82.9-87.4%) cases. CONCLUSIONS Despite the fact that the use of IHC stains was considered useful and deemed appropriate in the majority of cases, it showed wide variation between pathologists, suggesting monitoring of IHC use rates may be useful to standardize its use.
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Affiliation(s)
- Sameer Al Diffalha
- Department of Pathology, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Mohanad Shaar
- Department of Pathology, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Güliz A Barkan
- Department of Pathology, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Eva M Wojcik
- Department of Pathology, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Maria M Picken
- Department of Pathology, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Stefan E Pambuccian
- Department of Pathology, Loyola University Medical Center, Maywood, IL 60153, United States.
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7
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Leung SCY, Nielsen TO, Zabaglo L, Arun I, Badve SS, Bane AL, Bartlett JMS, Borgquist S, Chang MC, Dodson A, Enos RA, Fineberg S, Focke CM, Gao D, Gown AM, Grabau D, Gutierrez C, Hugh JC, Kos Z, Lænkholm AV, Lin MG, Mastropasqua MG, Moriya T, Nofech-Mozes S, Osborne CK, Penault-Llorca FM, Piper T, Sakatani T, Salgado R, Starczynski J, Viale G, Hayes DF, McShane LM, Dowsett M. Analytical validation of a standardized scoring protocol for Ki67: phase 3 of an international multicenter collaboration. NPJ Breast Cancer 2016; 2:16014. [PMID: 28721378 PMCID: PMC5515324 DOI: 10.1038/npjbcancer.2016.14] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/22/2016] [Accepted: 04/01/2016] [Indexed: 11/09/2022] Open
Abstract
Pathological analysis of the nuclear proliferation biomarker Ki67 has multiple potential roles in breast and other cancers. However, clinical utility of the immunohistochemical (IHC) assay for Ki67 immunohistochemistry has been hampered by unacceptable between-laboratory analytical variability. The International Ki67 Working Group has conducted a series of studies aiming to decrease this variability and improve the evaluation of Ki67. This study tries to assess whether acceptable performance can be achieved on prestained core-cut biopsies using a standardized scoring method. Sections from 30 primary ER+ breast cancer core biopsies were centrally stained for Ki67 and circulated among 22 laboratories in 11 countries. Each laboratory scored Ki67 using three methods: (1) global (4 fields of 100 cells each); (2) weighted global (same as global but weighted by estimated percentages of total area); and (3) hot-spot (single field of 500 cells). The intraclass correlation coefficient (ICC), a measure of interlaboratory agreement, for the unweighted global method (0.87; 95% credible interval (CI): 0.81–0.93) met the prespecified success criterion for scoring reproducibility, whereas that for the weighted global (0.87; 95% CI: 0.7999–0.93) and hot-spot methods (0.84; 95% CI: 0.77–0.92) marginally failed to do so. The unweighted global assessment of Ki67 IHC analysis on core biopsies met the prespecified criterion of success for scoring reproducibility. A few cases still showed large scoring discrepancies. Establishment of external quality assessment schemes is likely to improve the agreement between laboratories further. Additional evaluations are needed to assess staining variability and clinical validity in appropriate cohorts of samples.
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Affiliation(s)
- Samuel C Y Leung
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Torsten O Nielsen
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lila Zabaglo
- Academic Department of Biochemistry, Royal Marsden Hospital and Institute of Cancer Research, London, United Kingdom
| | - Indu Arun
- Department of Pathology, Tata Medical Center, Kolkata, West Bengal, India
| | - Sunil S Badve
- Department of Pathology and Laboratory Medicine, Indiana University Simon Cancer Center, Indianapolis, Indiana, USA
| | - Anita L Bane
- Department of Pathology and Molecular Medicine, Juravinski Hospital and Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - John M S Bartlett
- Transformative Pathology, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Signe Borgquist
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - Martin C Chang
- Department of Pathology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Andrew Dodson
- Academic Department of Biochemistry, Royal Marsden Hospital and Institute of Cancer Research, London, United Kingdom
| | | | - Susan Fineberg
- Department of Pathology, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, USA
| | - Cornelia M Focke
- Department of Pathology, Dietrich-Bonhoeffer Medical Center, Neubrandenburg, Mecklenburg-Vorpommern, Germany
| | - Dongxia Gao
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allen M Gown
- PhenoPath Laboratories, Seattle, Washington, USA
| | - Dorthe Grabau
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - Carolina Gutierrez
- Lester and Sue Smith Breast Center and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Judith C Hugh
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Zuzana Kos
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Ming-Gang Lin
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Mauro G Mastropasqua
- Division of Pathology and Laboratory Medicine, European Institute of Oncology, Milan, Italy
| | - Takuya Moriya
- Department of Pathology, Kawasaki Medical School, Kurashiki, Okayama Prefecture, Japan
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - C Kent Osborne
- Lester and Sue Smith Breast Center and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | | | - Tammy Piper
- Biomarkers & Companion Diagnostics Group, Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh, United Kingdom
| | - Takashi Sakatani
- Department of Pathology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Roberto Salgado
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Brussels, Belgium
| | - Jane Starczynski
- Department of Cellular Pathology, Birmingham Heart of England, National Health Service, Birmingham, United Kingdom
| | - Giuseppe Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology and University of Milan, Milan, Italy
| | - Daniel F Hayes
- Breast Oncology Program, Department of Internal Medicine, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan, USA
| | - Lisa M McShane
- Biometric Research Branch, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, Maryland, USA
| | - Mitch Dowsett
- Academic Department of Biochemistry, Royal Marsden Hospital and Institute of Cancer Research, London, United Kingdom
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