Multicenter Immunohistochemical ALK-Testing of Non–Small-Cell Lung Cancer Shows High Concordance after Harmonization of Techniques and Interpretation.

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Multicenter Immunohistochemical ALK-Testing of Non–Small-Cell Lung Cancer Shows High Concordance after Harmonization of Techniques and Interpretation Criteria Maximilian von Laffert, MD, Arne Warth, MD, PhD, Roland Penzel, MD, Peter Schirmacher, MD, PhD, Keith M. Kerr, MD, PhD, Göran Elmberger, MD, PhD, Hans-Ulrich Schildhaus, MD, PhD, Reinhard Büttner, MD, PhD, Fernando Lopez-Rios, MD, PhD, Simone Reu, MD, Thomas Kirchner, MD, PhD, Patrick Pauwels, MD, PhD, Katja Specht, MD, PhD, Enken Drecoll, MD, Heinz Höfler, MD, PhD, Daniela Aust, MD, PhD, Gustavo Baretton, MD, PhD, Lukas Bubendorf, MD, PhD, Sonja Stallmann, MD, PhD, Annette Fisseler-Eckhoff, MD, PhD, Alex Soltermann, MD, PhD, Verena Tischler, MD, Holger Moch, MD, PhD, Frederique Penault-Llorca, MD, PhD, Hendrik Hager, MD, PhD, Frank Schäper, MD, Dido Lenze, MD, Michael Hummel, MD, PhD, Manfred Dietel, MD, PhD Journal of Thoracic Oncology Volume 9, Issue 11, Pages 1685-1692 (November 2014) DOI: 10.1097/JTO.0000000000000332 Copyright © 2014 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Preparation and testing modality of the tissue microarrays (TMA): each of the two TMAs was cut into 43 slides. Slides 1, 2, 22, 24, 42, and 43 were tested by means of ALK-FISH in Berlin (B) and Heidelberg (HD). Slides 5, 23, and 39 were stained by H&E and were electronically available as scans. Journal of Thoracic Oncology 2014 9, 1685-1692DOI: (10.1097/JTO.0000000000000332) Copyright © 2014 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 Ten NSCLC cases stained with H&E, ALK-IHC (10× objective), and FISH (63× objective). Two ALK-negative cases with challenging IHC due to positivity of macrophages and necrosis are shown in cases 4 and 9. The latter displays a single green signal pattern (SGS) in FISH. At the bottom the interpretation of all 16 observers (negative versus positive) is given. Note the heterogeneous staining pattern in case 11. Journal of Thoracic Oncology 2014 9, 1685-1692DOI: (10.1097/JTO.0000000000000332) Copyright © 2014 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 ALK-IHC-testing-proposal: a reliable IHC approach needs to be embedded in upcoming algorithms of NSCLC ALK-status testing. ALK-IHC may deliver three results: (a) ALK-IHC negative: in future, no additional ALK-FISH testing may be required (EMA-based concept). Therefore, upcoming clinical trials need to evaluate incidence and therapy-response data in patients with IHC-/FISH+ tumors. At the moment ALK-FISH should be performed if TKI-therapy is an option (FDA-based concept). (b) ALK-IHC equivocal (“stippled” staining pattern): at the moment and in future add-on ALK-FISH should be performed to define the final ALK-status. Therapy decision is based upon FISH (FDA-based concept). (c) ALK-IHC unequivocal (positive): in future, no additional ALK-FISH testing may be required (EMA-based concept). Therefore, upcoming clinical trials need to evaluate incidence and therapy-response data in patients with IHC+/FISH- tumors. It will be of highest interest if those samples show false negativity in FISH due to technical reasons and if the fusion transcript can be detected by PCR. At the moment ALK-FISH should be performed even if ALK-IHC is unequivocally positive (FDA-based concept). Journal of Thoracic Oncology 2014 9, 1685-1692DOI: (10.1097/JTO.0000000000000332) Copyright © 2014 International Association for the Study of Lung Cancer Terms and Conditions