Optimization of Tissue Handling and Processing in the Era of Precision Medicine: A Practical Recommendation from a Multidisciplinary Panel of Indian Experts

Abstract

Molecular analysis of biospecimens is the key to diagnostic and therapeutic decisions in clinical practice. However, there is a lack of consolidated guidelines for biospecimen collection, tissue handling, and storage in India. Therefore, this study aims to generate expert recommendations for the optimization of tissue handling and processing practices in India in the era of precision medicine. This study aimed to evaluate the clinical gaps related to tissue handling for molecular analysis and develop expert recommendations to mitigate preanalytical issues associated with biospecimen processing. These expert recommendations will help in increasing the diagnostic yield and accuracy of biomarker testing in clinical practice. A virtual advisory board meeting was convened with 19 experts, including pathologists, molecular biologists, medical oncologists, surgical oncologists, interventional radiologists, and a senior histology technician from 10 hospitals in India, along with an accreditation officer for testing and calibration of laboratory procedures. The scientific coordinators developed specific questions to address the salient issues associated with the preanalytic phase of tissue specimen preparation. The experts discussed each question until a complete set of recommendations was obtained. The expert panel provided recommendations for tissue collection, processing, fixation, and block preparation to ensure high-quality biospecimens. As per the expert panel recommendations, tissue sampling can be performed from any easily accessible site, regardless of the primary or metastatic locations. In addition, the cold ischemia time should be <1 hour, 10% neutral-buffered formalin should be used as the fixative, isopropyl alcohol should be used as the dehydrating agent, the volume of tissue to fixative ratio should be 1:10, and all the paraffin blocks should be archived in dry, pest-free conditions at room temperature. The experts suggested that the formalin used for fixation should be freshly prepared and its pH should be checked daily; moreover, the pH and date of formalin preparation should be mentioned on the containers. The experts highlighted the need to educate multidisciplinary teams on the optimization of tissue handling practices and emphasized that a pathologist should always check the tissue for adequate quality and quantity for biomarker testing. The existing routine clinical procedures for collecting and handling biospecimens adversely affect their quality. The expert recommendations for preanalytical quality control would ensure high-quality biospecimens for molecular analysis and precision medicine.

Keywords

biospecimens - cold ischemia time - fixation - tissue processing - paraffin blocks

Patient Consent

 

Authors' Contribution

All authors have contributed equally toward the conception, design, manuscript preparation, manuscript editing, review, and finalization of the manuscript.

Publikationsverlauf

Artikel online veröffentlicht:
27. September 2023

• References

• 1 Compton CC, Robb JA, Anderson MW. et al. Preanalytics and precision pathology: pathology practices to ensure molecular integrity of cancer patient biospecimens for Precision Medicine. Arch Pathol Lab Med 2019; 143 (11) 1346-1363
• 2 Ascierto PA, Bifulco C, Palmieri G, Peters S, Sidiropoulos N. Preanalytic variables and tissue stewardship for reliable next-generation sequencing (NGS) clinical analysis. J Mol Diagn 2019; 21 (05) 756-767
• 3 Fassan M. Molecular diagnostics in pathology: time for a next-generation pathologist?. Arch Pathol Lab Med 2018; 142 (03) 313-320
• 4 Tian SK, Killian JK, Rekhtman N. et al. Optimizing workflows and processing of cytologic samples for comprehensive analysis by next-generation sequencing: Memorial Sloan Kettering Cancer Center Experience. Arch Pathol Lab Med 2016; 140 (11) 1200-1205
• 5 Kuo FC, Mar BG, Lindsley RC, Lindeman NI. The relative utilities of genome-wide, gene panel, and individual gene sequencing in clinical practice. Blood 2017; 130 (04) 433-439
• 6 Penault-Llorca F, Kerr KM, Garrido P. et al. Expert opinion on NSCLC small specimen biomarker testing - part 2: analysis, reporting, and quality assessment. Virchows Arch 2022; 481 (03) 351-366
• 7 Compton C. Getting to personalized cancer medicine: taking out the garbage. Cancer 2007; 110 (08) 1641-1643
• 8 Faktor J, Goodlett DR, Dapic I. Trends in sample preparation for proteome analysis. 2021 . Accessed February 20, 2023, at: https://cdn.intechopen.com/pdfs/75004.pdf
• 9 BBRB. Biospecimens.cancer.gov. 2022 . Accessed on February 20, 2023, at: https://biospecimens.cancer.gov/bestpractices/to/bcpsrd.asp
• 10 Ellervik C, Vaught J. Preanalytical variables affecting the integrity of human biospecimens in biobanking. Clin Chem 2015; 61 (07) 914-934
• 11 Rao S, Masilamani S, Sundaram S, Duvuru P, Swaminathan R. Quality measures in pre-analytical phase of tissue processing: understanding its value in histopathology. J Clin Diagn Res 2016; 10 (01) EC07-EC11
• 12 Lippi G, Chance JJ, Church S. et al. Preanalytical quality improvement: from dream to reality. Clin Chem Lab Med 2011; 49 (07) 1113-1126
• 13 Bussolati G, Leonardo E. Technical pitfalls potentially affecting diagnoses in immunohistochemistry. J Clin Pathol 2008; 61 (11) 1184-1192
• 14 CLSI GP 41: Collection of diagnostic venous blood specimens. 7th ed. Clinical Laboratory Standards Institute; 2017. Accessed January 20, 2022, at: https://clsi.org/standards/products/generallaboratory/documents/gp41/
• 15 CLSI IL28-A2: Quality assurance for design control and implementation of immunohistochemistry assays; Approved Guideline. 2nd ed. Clinical Laboratory Standards Institute; 2011
• 16 NCI best practices for biospecimen resources. National Cancer Institute. 2016 . Accessed January 19, 2022, at: https://biospecimens.cancer.gov/bestpractices/2016-NCIBestPractices.pdf
• 17 European committee for standardization (CEN). Technical specification CEN/TS 16945. Molecular in vitro diagnostic examinations—specifications for pre-examination processes for metabolomics in urine, venous blood serum and plasma. 2016
• 18 Simundic AM, Church S, Cornes MP. et al. Compliance of blood sampling procedures with the CLSI H3-A6 guidelines: an observational study by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group for the preanalytical phase (WG-PRE). Clin Chem Lab Med 2015; 53 (09) 1321-1331
• 19 Hewitt SM, Lewis FA, Cao Y. et al. Tissue handling and specimen preparation in surgical pathology: issues concerning the recovery of nucleic acids from formalin-fixed, paraffin-embedded tissue. Arch Pathol Lab Med 2008; 132 (12) 1929-1935
• 20 De Las Casas LE, Hicks DG. Pathologists at the leading edge of optimizing the tumor tissue journey for diagnostic accuracy and molecular testing. Am J Clin Pathol 2021; 155 (06) 781-792
• 21 Nakamura RM, Kasahara Y. Chapter 19 - Molecular Diagnostics in the Evaluation of Cancer: Modern Concepts and Overview. In: Grody WW, Nakamura RM, Strom CM. et al. (eds) Molecular Diagnostics. San Diego: Academic Press; 215-223
• 22 Planchard D, Popat S, Kerr K. et al; ESMO Guidelines Committee. Metastatic non-small cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29 (Suppl. 04) iv192-iv237 [published correction appears in Ann Oncol 2019 May;30(5):863-870]
• 23 Liu A, Collins C, Diemer S. Biobanking metastases and biopsy specimens for personalized medicine. J Biorepository Sci Appl Med 2015; 3 (01) 57-67
• 24 Guan YF, Li GR, Wang RJ. et al. Application of next-generation sequencing in clinical oncology to advance personalized treatment of cancer. Chin J Cancer 2012; 31 (10) 463-470
• 25 Limaye S. Synchronized tissue acquisition techniques for novel biomarker discovery: are you ready to waltz?. J Immunother Precis Oncol 2021; 4 (03) 168-169
• 26 Kerr KM, Bubendorf L, Edelman MJ. et al; Panel Members. Second ESMO consensus conference on lung cancer: pathology and molecular biomarkers for non-small-cell lung cancer. Ann Oncol 2014; 25 (09) 1681-1690
• 27 Roy-Chowdhuri S, Dacic S, Ghofrani M. et al. Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies: Guideline From the College of American Pathologists in Collaboration With the American College of Chest Physicians, Association for Molecular Pathology, American Society of Cytopathology, American Thoracic Society, Pulmonary Pathology Society, Papanicolaou Society of Cytopathology, Society of Interventional Radiology, and Society of Thoracic Radiology. Arch Pathol Lab Med 2020; 144 (08) 933-958
• 28 Tuzi A, Bolzacchini E, Suter MB. et al. Biopsy and re-biopsy in lung cancer: the oncologist requests and the role of endobronchial ultrasounds transbronchial needle aspiration. J Thorac Dis 2017; 9 (Suppl. 05) S405-S409
• 29 Bussolati G, Annaratone L, Maletta F. The pre-analytical phase in surgical pathology. Recent Results Cancer Res 2015; 199: 1-13
• 30 David KA, Unger FT, Uhlig P. et al. Surgical procedures and postsurgical tissue processing significantly affect expression of genes and EGFR-pathway proteins in colorectal cancer tissue. Oncotarget 2014; 5 (22) 11017-11028
• 31 Dash A, Maine IP, Varambally S, Shen R, Chinnaiyan AM, Rubin MA. Changes in differential gene expression because of warm ischemia time of radical prostatectomy specimens. Am J Pathol 2002; 161 (05) 1743-1748
• 32 Srinivasan M, Sedmak D, Jewell S. Effect of fixatives and tissue processing on the content and integrity of nucleic acids. Am J Pathol 2002; 161 (06) 1961-1971
• 33 Lou JJ, Mirsadraei L, Sanchez DE. et al. A review of room temperature storage of biospecimen tissue and nucleic acids for anatomic pathology laboratories and biorepositories. Clin Biochem 2014; 47 (4-5): 267-273
• 34 Singh H, Narayan B, Urs AB, Kumar Polipalli S, Kumar S. A novel approach for extracting DNA from formalin-fixed paraffin-embedded tissue using microwave. Med J Armed Forces India 2020; 76 (03) 307-311
• 35 Chung JY, Braunschweig T, Williams R. et al. Factors in tissue handling and processing that impact RNA obtained from formalin-fixed, paraffin-embedded tissue. J Histochem Cytochem 2008; 56 (11) 1033-1042
• 36 Comanescu M, Annaratone L, D'Armento G, Cardos G, Sapino A, Bussolati G. Critical steps in tissue processing in histopathology. Recent Pat DNA Gene Seq 2012; 6 (01) 22-32
• 37 Leyakathali KS, Mohammed H, Sarah D. et al. How do cytology samples compare with histology specimens when used for EGFR testing in patients with NSCLC?. Eur Respir J 2012; 40: 4405
• 38 Sanderson T, Wild G, Cull AM. et al. In: Suvarna SK, Layton C, Bancroft JD. eds. Bancroft's Theory and Practice of Histological Techniques. . 8th ed Elsevier; London: 2019
• 39 Leiva IM, Emmert-Buck MR, Gillespie JW. Handling of clinical tissue specimens for molecular profiling studies. Curr Issues Mol Biol 2003; 5 (02) 27-35
• 40 Cree IA, Deans Z, Ligtenberg MJ. et al; European Society of Pathology Task Force on Quality Assurance in Molecular Pathology, Royal College of Pathologists. Guidance for laboratories performing molecular pathology for cancer patients. J Clin Pathol 2014; 67 (11) 923-931
• 41 Susman S, Berindan-Neagoe I, Petrushev B. et al. The role of the pathology department in the preanalytical phase of molecular analyses. Cancer Manag Res 2018; 10: 745-753
• 42 Bussolati G, Annaratone L, Medico E, D'Armento G, Sapino A. Formalin fixation at low temperature better preserves nucleic acid integrity. PLoS One 2011; 6 (06) e21043
• 43 Bauer DR, Otter M, Chafin DR. A new paradigm for tissue diagnostics: tools and techniques to standardize tissue collection, transport, and fixation. Curr Pathobiol Rep 2018; 6 (02) 135-143
• 44 Sadeghipour A, Babaheidarian P. Making formalin-fixed, paraffin embedded blocks. Methods Mol Biol 2019; 1897: 253-268
• 45 Aisner DL, Rumery MD, Merrick DT. et al. Do more with less: tips and techniques for maximizing small biopsy and cytology specimens for molecular and ancillary testing: the University of Colorado Experience. Arch Pathol Lab Med 2016; 140 (11) 1206-1220
• 46 Hubel A, Spindler R, Skubitz AP. Storage of human biospecimens: selection of the optimal storage temperature. Biopreserv Biobank 2014; 12 (03) 165-175
• 47 Groelz D, Viertler C, Pabst D, Dettmann N, Zatloukal K. Impact of storage conditions on the quality of nucleic acids in paraffin embedded tissues. PLoS One 2018; 13 (09) e0203608
• 48 Grzych G, Sivadas A. The rising importance of pre-analytical phase in medical and research laboratory, a new challenge in the omics era. Biomed J Sci Tech Res 2020; 27: 20889-20891
• 49 Mukhopadhyay T, Shekhar S, Dagar VK. et al. Characterization of pre-analytical errors using six sigma metrics and process capability index in a clinical biochemistry laboratory. Int J Health Sci Res 2021; 11: 171-176
• 50 Yildiz-Aktas IZ, Dabbs DJ, Bhargava R. The effect of cold ischemic time on the immunohistochemical evaluation of estrogen receptor, progesterone receptor, and HER2 expression in invasive breast carcinoma. Mod Pathol 2012; 25 (08) 1098-1105
• 51 Hammond ME, Hayes DF, Dowsett M. et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol 2010; 28 (16) 2784-2795
• 52 Agrawal L, Engel KB, Greytak SR, Moore HM. Understanding preanalytical variables and their effects on clinical biomarkers of oncology and immunotherapy. Semin Cancer Biol 2018; 52 (Pt 2): 26-38
• 53 Chu WS, Furusato B, Wong K. et al. Ultrasound-accelerated formalin fixation of tissue improves morphology, antigen and mRNA preservation. Mod Pathol 2005; 18 (06) 850-863
• 54 von Wasielewski R, Mengel M, Wiese B, Rüdiger T, Müller-Hermelink HK, Kreipe H. Tissue array technology for testing interlaboratory and interobserver reproducibility of immunohistochemical estrogen receptor analysis in a large multicenter trial. Am J Clin Pathol 2002; 118 (05) 675-682
• 55 Bass BP, Engel KB, Greytak SR, Moore HM. A review of preanalytical factors affecting molecular, protein, and morphological analysis of formalin-fixed, paraffin-embedded (FFPE) tissue: how well do you know your FFPE specimen?. Arch Pathol Lab Med 2014; 138 (11) 1520-1530
• 56 Dash RC, Robb JA, Booker DL, Foo WC, Witte DL, Bry L. Biospecimens and biorepositories for the community pathologist. Arch Pathol Lab Med 2012; 136 (06) 668-678