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Leung ML, Abdullaev Z, Santana-Santos L, Skaugen JM, Moore S, Ji J. Microarray-Based DNA Methylation Profiling: Validation Considerations for Clinical Testing. J Mol Diagn 2024; 26:447-455. [PMID: 38378079 DOI: 10.1016/j.jmoldx.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
Microarray-based methylation profiling has emerged as a valuable tool for refining diagnoses and revealing novel tumor subtypes, particularly in central nervous system tumors. Despite the increasing adoption of this technique in clinical genomic laboratories, no technical standards have been published in establishing minimum criteria for test validation. A working group with experience and expertise in DNA-based methylation profiling tests on central nervous system tumors collaborated to develop practical discussion points and focus on important considerations for validating this test in clinical laboratory settings. The experience in validating this methodology in a clinical setting is summarized. Specifically, the advantages and challenges associated with utilizing an in-house classifier compared with a third-party classifier are highlighted. Additionally, experiences in demonstrating the assay's sensitivity and specificity, establishing minimum sample criteria, and implementing quality control metrics are described. As methylation profiling for tumor classification expands to other tumor types and continues to evolve for various other applications, the critical considerations described here are expected to serve as a guidance for future efforts in establishing professional guidelines for this assay.
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Affiliation(s)
- Marco L Leung
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio; Departments of Pathology and Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.
| | - Zied Abdullaev
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lucas Santana-Santos
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John M Skaugen
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen Moore
- Department of Molecular and Medical Genetics and Knight Diagnostic Laboratory, Oregon Health & Science University, Portland, Oregon
| | - Jianling Ji
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California; Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
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Gatesman TA, Hect JL, Phillips HW, Johnson BJ, Wald AI, McClung C, Nikiforova MN, Skaugen JM, Pollack IF, Abel TJ, Agnihotri S. Characterization of low-grade epilepsy-associated tumor from implanted stereoelectroencephalography electrodes. Epilepsia Open 2024; 9:409-416. [PMID: 37798921 PMCID: PMC10839351 DOI: 10.1002/epi4.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Low-grade epilepsy-associated tumors (LEATs) are a common cause of drug-resistant epilepsy in children. Herein, we demonstrate the feasibility of using tumor tissue derived from stereoelectroencephalography (sEEG) electrodes upon removal to molecularly characterize tumors and aid in diagnosis. An 18-year-old male with focal epilepsy and MRI suggestive of a dysembryoplastic neuroepithelial tumor (DNET) in the left posterior temporal lobe underwent implantation of seven peri-tumoral sEEG electrodes for peri-operative language mapping and demarcation of the peri-tumoral ictal zone prior to DNET resection. Using electrodes that passed through tumor tissue, we show successful isolation of tumor DNA and subsequent analysis using standard methods for tumor classification by DNA, including Glioseq targeted sequencing and DNA methylation array analysis. This study provides preliminary evidence for the feasibility of molecular diagnosis of LEATs or other lesions using a minimally invasive method with microscopic tissue volumes. The implications of sEEG electrodes in tumor characterization are broad but would aid in diagnosis and subsequent targeted therapeutic strategies.
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Affiliation(s)
- Taylor A. Gatesman
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Cellular and Molecular PathologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Jasmine L. Hect
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - H. Westley Phillips
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Brenden J. Johnson
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Abigail I. Wald
- Molecular and Genomic PathologyUniversity of Pittsburgh Medical Center Health SystemPittsburghPennsylvaniaUSA
| | - Colleen McClung
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Marina N. Nikiforova
- Molecular and Genomic PathologyUniversity of Pittsburgh Medical Center Health SystemPittsburghPennsylvaniaUSA
| | - John M. Skaugen
- Molecular and Genomic PathologyUniversity of Pittsburgh Medical Center Health SystemPittsburghPennsylvaniaUSA
| | - Ian F. Pollack
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Taylor J. Abel
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Sameer Agnihotri
- Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- Department of Cellular and Molecular PathologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
- John G. Rangos Sr. Research CenterChildren's Hospital of PittsburghPittsburghPennsylvaniaUSA
- Department of NeurobiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
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Naous R, Skaugen JM, Zilla ML, Burgess M, John I. VIM::KMT2A rearranged sarcoma: a rare emerging entity. Histopathology 2023; 83:822-824. [PMID: 37575084 DOI: 10.1111/his.15028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/04/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Rana Naous
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John M Skaugen
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Megan L Zilla
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa Burgess
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ivy John
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Rammal R, Korentzelos D, Skaugen JM, Quiroga-Garza GM. Molecular Characterization of Malignant Renal Epithelioid Angiomyolipoma: A Review of Two Cases. Am J Clin Pathol 2023; 159:211-220. [PMID: 36661215 DOI: 10.1093/ajcp/aqac152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/31/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Epithelioid angiomyolipoma (EAML, perivascular epithelioid cell tumor) is an uncommon primary renal tumor that may recur or metastasize, although there remain limited data for prediction of these outcomes. Here, we report two cases of renal EAML with molecular testing, adding to the existing literature of potential alterations associated with malignant behavior. METHODS Tumors diagnosed as malignant renal EAML were identified, and clinical data, radiology, histology, immunohistochemistry, and molecular testing results were reviewed. RESULTS Two cases of malignant renal EAML were identified, both of which demonstrated TSC2 and TP53 mutations. In ATRX, one had a mutation and the other had a variant of uncertain significance. In addition, one patient had a synchronous classic angiomyolipoma that lacked TP53 and ATRX alterations. CONCLUSIONS These findings highlight the molecular landscape of malignant renal EAML and expand on the existing literature suggesting a role for TP53 and ATRX alterations in malignant progression of these tumors. The presence of synchronous benign and malignant tumors within the same patient offers a unique opportunity to directly compare the molecular alterations, further supporting the association with aggressive behavior.
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Affiliation(s)
- Rayan Rammal
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dimitrios Korentzelos
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John M Skaugen
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Skaugen JM, Taneja C, Liu JB, Wald AI, Nikitski AV, Chiosea SI, Seethala RR, Ohori NP, Karslioglu-French E, Carty SE, Nikiforova MN, Yip L, Nikiforov YE. Performance of a Multigene Genomic Classifier in Thyroid Nodules with Suspicious for Malignancy Cytology. Thyroid 2022; 32:1500-1508. [PMID: 35864811 PMCID: PMC9807251 DOI: 10.1089/thy.2022.0282] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background: Molecular testing is increasingly used to refine the probability of cancer and assess recurrence risk in thyroid nodules with Bethesda III/IV fine needle aspiration (FNA) cytology. However, limited data exist for Bethesda V (suspicious for malignancy [SFM]) samples. This study evaluated the performance of ThyroSeq v3 (TSv3) in thyroid nodules with SFM cytology. Methods: In this single-institution retrospective cohort study, consecutive thyroid FNA samples diagnosed as SFM with TSv3 testing and known surgical outcome were identified. Clinical, pathology, and molecular findings were reviewed. The TSv3 Cancer Risk Classifier was used to determine molecular risk groups (MRGs). For test-negative cases diagnosed as cancer/noninvasive follicular thyroid neoplasm with papillary-like nuclear features, TSv3 was performed on the resected tumors. Results: Among 128 SFM samples studied, 100 (78.1%) were TSv3 positive, and 28 (21.9%) were negative. The cancer prevalence on surgery was 82.8%. Among test-positive samples, 95% were malignant and 5% benign. Among test-negative samples, 17 (60.7%) were benign and 11 (39.3%) malignant. Overall, TSv3 had a sensitivity of 89.6% (confidence interval; CI 82.4-94.1) and a specificity of 77.3% (CI 56.6-89.9). For a cancer prevalence of 50-75% expected in SFM cytology by the Bethesda system, the negative predictive value was expected to range from 71.2% to 88.1% and the positive predictive value from 79.8% to 92.2%. Among test-positive nodules, 20% were MRG-Low (mostly RAS-like alterations), 66% MRG-Intermediate (mostly BRAF-like alterations), and 14% MRG-High. Among patients with cancer, 65 (61.3%) were American Thyroid Association low risk, 25 (23.6%) intermediate risk, and 6 (5.7%) high risk. During the mean follow-up of 51.2 months (range: <1 to 470 months), 12 (13.0%) patients had disease recurrence, which was more common in MRG-High (54.6%) compared with MRG-Intermediate (9.5%) and MRG-Low (0%) cancers (p < 0.001). Upon reexamining tumors with false-negative results, half of evaluable cases had alterations likely missed due to limiting FNA sampling, and the remainder represented low-risk tumors. Potentially targetable alterations were identified in 10 samples. Conclusions: In this large series of SFM thyroid nodules, TSv3 further improved cancer prediction and detected RAS-like, BRAF-like, high-risk, and potentially targetable alterations, all of which may inform more optimal patient management. MRGs were associated with recurrence-free survival, offering potential preoperative cancer risk stratification.
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Affiliation(s)
- John M. Skaugen
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Address correspondence to: John M. Skaugen, MD, Department of Pathology, University of Pittsburgh School of Medicine, 3477 Euler Way, Room 7028, Pittsburgh, PA 15213, USA
| | - Charit Taneja
- Division of Endocrinology, Department of Medicine; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jason B. Liu
- Division of Endocrine Surgery, Department of Surgery; and Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Abigail I. Wald
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alyaksandr V. Nikitski
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Simion I. Chiosea
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Anatomic Pathology, Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raja R. Seethala
- Division of Anatomic Pathology, Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - N. Paul Ohori
- Division of Anatomic Pathology, Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Esra Karslioglu-French
- Division of Endocrinology, Department of Medicine; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sally E. Carty
- Division of Endocrine Surgery, Department of Surgery; and Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marina N. Nikiforova
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linwah Yip
- Division of Endocrine Surgery, Department of Surgery; and Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yuri E. Nikiforov
- Division of Molecular and Genomic Pathology, Department of Pathology; Department of Pathology; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Skaugen JM, Sayre C, Hassett AC, Chibisov I, Bontempo F, Meyer MP, Seheult JN. Performance Characteristics of DOAC-Remove for Neutralization of the Effects of Apixaban and Rivaroxaban in Lupus Anticoagulant Assays. Am J Clin Pathol 2022; 157:457-469. [PMID: 34698336 DOI: 10.1093/ajcp/aqab149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study established the performance characteristics of DOAC-Remove for neutralization of the effects of rivaroxaban and apixaban in lupus anticoagulant (LAC) testing. METHODS Normal donor, LAC control, and patient samples were spiked with rivaroxaban or apixaban to simulate their effects on the dilute Russell's viper venom time (dRVVT), activated partial thromboplastin time (APTT), and dilute prothrombin time (dPT). Anti-Xa activity was measured after spiking and after DOAC-Remove neutralization. Accuracy, complex precision, and reference interval verification were evaluated. RESULTS DOAC-Remove neutralized rivaroxaban and apixaban concentrations as high as 415 ng/mL and 333 ng/mL, respectively. Percentage positive and negative agreement between the baseline and postneutralization interpretations were 75% or higher for the dRVVT and APTT methods but not for the dPT method. Coefficients of variation (CVs) were 10% or less for all assays except the Staclot-LA delta, which had a standard deviation of 2.5 seconds or CV of 25% or less depending on the level. The laboratory's reference intervals were verified for the dRVVT and APTT assays after DOAC-Remove treatment but not for the dPT assays. CONCLUSIONS DOAC-Remove appears to have acceptable performance characteristics for neutralizing the effects of rivaroxaban and apixaban in the dRVVT and APTT methods but not in the dPT method.
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Affiliation(s)
- John M Skaugen
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Irina Chibisov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
| | - Franklin Bontempo
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Jansen N Seheult
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
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Skaugen JM, Seethala RR, Chiosea SI, Landau MS. Evaluation of NR4A3 immunohistochemistry (IHC) and fluorescence in situ hybridization and comparison with DOG1 IHC for FNA diagnosis of acinic cell carcinoma. Cancer Cytopathol 2020; 129:104-113. [PMID: 32809265 DOI: 10.1002/cncy.22338] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Acinic cell carcinoma (AcCC) is diagnostically challenging on fine-needle aspiration because it can mimic several other neoplasms or even normal acinar tissue. Immunopositivity for DOG1, especially circumferential membranous staining, can support the diagnosis of AcCC but is not entirely specific, and it is prone to technical and interpretive challenges on small specimens. NR4A3 (nuclear receptor subfamily 4 group A member 3) translocation and nuclear NR4A3 overexpression were recently described in the majority of AcCCs. Here, the authors evaluate the performance of NR4A3 immunohistochemistry (IHC) and NR4A3 break-apart fluorescence in situ hybridization (FISH) on cell block preparations and compare them with DOG1 IHC in distinguishing AcCC from other entities in the differential diagnosis. METHODS The authors identified 34 cytology cell blocks with lesional cells, including 11 specimens of AcCC (2 of which derived from 1 patient and showed high-grade transformation) as well as 2 secretory carcinomas, 7 salivary duct carcinomas, 4 mucoepidermoid carcinomas, 3 oncocytomas, 3 renal cell carcinomas, and 6 specimens containing nonneoplastic salivary gland tissue. NR4A3 IHC, DOG1 IHC, and NR4A3 FISH were attempted for all cases. RESULTS NR4A3 IHC had 81.8% sensitivity and 100% specificity for AcCC, whereas NR4A3 FISH had 36.4% sensitivity and 100% specificity, although 4 cases (3 mucoepidermoid carcinomas and 1 salivary gland tissue sample) could not be analyzed because of low cellularity. Notably, no normal acinar tissue specimens showed NR4A3 positivity by IHC or FISH. In addition, DOG1 IHC had 72.7% sensitivity and 92% specificity. CONCLUSIONS NR4A3 IHC is highly specific for the diagnosis of AcCC and is more sensitive than DOG1 IHC and NR4A3 FISH. In addition, NR4A3 IHC performance is not improved by the inclusion of DOG1 IHC. Finally, NR4A3 positivity resolves the perennial problem of distinguishing AcCC from normal acinar tissue.
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Affiliation(s)
- John M Skaugen
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raja R Seethala
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael S Landau
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Skaugen JM, Scoccimarro A, Pizon AF, Rymer JA, Giannoutsos S, Ekins S, Krasowski MD, Tamama K. Novel ketamine analogues cause a false positive phencyclidine immunoassay. Ann Clin Biochem 2019; 56:598-607. [DOI: 10.1177/0004563219858125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Immunoassays are commonly used to test for drugs of abuse in patients in a variety of settings. The increasing prevalence of ‘designer’ drugs causes difficulties for the toxicology laboratory and may result in unexpected false positives and identification of unfamiliar compounds. Within the past decade, there have been a variety of ketamine and phencyclidine analogues identified, particularly as drugs of abuse. Method We present a case of intoxication with a novel ketamine analogue, deschloro-N-ethyl-ketamine, causing a false positive phencyclidine immunoassay. Additionally, we performed spiking studies and 2D molecular similarity calculations for deschloro-N-ethyl-ketamine, ketamine and three other analogues on the Siemens Viva-E EMIT-II phencyclidine assay to assess their cross-reactivity. Results Four of the tested compounds (deschloro-N-ethyl-ketamine, 3-methoxy-phencyclidine, 3-methoxy-eticyclidine and methoxetamine) cause false positive phencyclidine immunoassay results, while ketamine gives a negative result. The cross-reactivity data are in accord with the similarity calculations of these molecules, further validating the ability of 2D molecular similarity analysis to predict the molecular cross-reactivity in immunoassays. Conclusions The cross-reactivity data of phencyclidine and ketamine analogues presented in this study could help toxicology laboratories and clinicians in evaluating unexpected results, particularly when novel PCP and ketamine analogues are being considered.
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Affiliation(s)
- John M Skaugen
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Laboratories, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
| | - Anthony Scoccimarro
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anthony F Pizon
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jacqueline A Rymer
- Clinical Laboratories, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
| | - Spiros Giannoutsos
- Clinical Laboratories, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
| | - Sean Ekins
- Collaborations Pharmaceuticals, Inc., Raleigh, North Carolina, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Kenichi Tamama
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Laboratories, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical Laboratory, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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