1 CLINICAL TRIALS Digital Pathology in Clinical Trials Arnold B. Gelb, M.D. Senior Staff Pathologist...
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Digital Pathology in Clinical Trials
Arnold B. Gelb, M.D.Senior Staff Pathologist
Quest Diagnostics Clinical Trials
Potential Conflict of Interest Statement
Employee of Quest Diagnostics Owner of stock in Quest DiagnosticsNo financial interest in any imaging company
Quest Diagnostics Clinical Trials: Overview
One of the world's largest Central Laboratories, working to accelerate clinical drug development
Scientific Expertise– > 900 in-house scientists and pathologists covering all therapeutic areas– Extensive test menu and consultative capabilities– Full service Biomarkers and Anatomical Pathology capabilities
Laboratory Management– GCP/ICH operating philosophy– Extensive resources, knowledge and experience in handling and
managing clinical specimens, logistics, and data in regulatory compliant environment
Global Reach– Quest owned central lab facilities in North America, Europe, and India– Affiliate laboratories in China, Singapore, and Australia– >4,000 cities in 60 countries– >99% assays performed in-house.
PCPC Viewing Stationsrunning ImageScope
digital slidesfirewallsinternal networks
Digital Pathology Systems and Networks
Case Details Page
The Digital Slide Image
•There is a toolbar at the top.
• Slide information such as the slide barcode or the slide ID can be seen in the title bar.
•Zoom tool is present
• The thumbnail and label can be turned off in the View toolbar.
Digital Slide Viewing Software
Image Analysis Window
Over 50 assays developed and validated, including esoteric and novel markers, e.g.– Apoptosis– Cell cycle control– mTOR pathway– erbB receptor inhibition– IGF pathway– Angiogenesis– CD antigens
Quantitative Analysis of IHC Biomarkers
Identify and quantify morphology and intensity Subcellular localization – algorithm selection
– Nuclear, membranous or cytoplasmic Tissue (tumor) specific classification
– Manual selection of representative tumor regions by pathologist
– Automatic feature extraction (pattern recognition)
Enables analysis of invasive tumor from entire image
Image Analysis Algorithms
May need to adjust intensity of staining – Scanning typically based on % transmittance
Customize or “tune” algorithm to a laboratory’s unique staining process– Controls– Future: batch to batch “tuning”
Validation– Sufficient number of (de-identified) slides across
percentage range and intensity scores– 3 blind evaluation arms
“Tuning” Nuclear Segmentation
Original Image Normal Segmentation
Over Segmented Under Segmented
Digital Slide Scoring
Manual Slide Scoring
Validate Algorithm Performance
Histone H3 has a key role in the folding and inter-association of the chromatin fiber.
Phosphorylation of Histone H3, at serine-10 and -28, coincides with the induction of mitotic chromosome condensation.
H3 phosphorylation may contribute to proto-oncogene induction by modulating chromatin structure and releasing blocks in elongation.
Digital assessment of the nuclear stain:
– Index = 13.7%
Members of the RXR family, including RXRα, β and γ, are activated by 9-cis retinoic acid, that is expressed in both liver and kidney.
RXRα is an orphan nuclear receptor encoded on chromosome 9q34.2.
It plays roles in a variety of processes including embryonic patterning and organogenesis, cell proliferation and differentiation.
The forkhead family of transcription factors mediate signaling via a pathway involving IGF-1R, PI3K and Akt.
The gene is located on chromosome 6q21. Spliced transcript variants encoding the same protein have
been observed. In the presence of survival factors, Akt phosphorylates
FOXO3a, leading to its retention in the cytoplasm. Survival factor withdrawal leads to its dephosphorylation,
nuclear translocation, and target gene activation. Within the nucleus, it triggers apoptosis most likely by
inducing the expression of genes that are critical for cell death, such as the Fas ligand gene.
LIMK1 and LIMK2 are serine/threonine kinases that are involved in actin cytoskeletal reorganization, cell growth regulation and tumor suppression via cofilin phosphorylation downstream of distinct Rho-dependent protein kinase signaling pathways.
Both are activated by various extracellular stimuli, including stromal cell-derived factor-1a and insulin, through activation of small GTPases and their downstream kinases, ROCK and PAK1.
Both LIMK 1 and 2 have been related to tumorigenesis and, thus, are studied in conjunction with anti-cancer therapies that target this pathway.
Heterodimers composed of noncovalently associated transmembrane α and β subunits.
16 subunits yield over 20 receptors.Roles in cell adhesion, cytoskeletal
organization, and signaling.Involved in cell growth, differentiation,
migration and apoptosis.
Digital assessment of membrane staining component:
– 3+ cells = 54.7%– 2+ cells = 23.4%– 1+ cells = 21.9%
Advantages of digital pathology for global clinical trials– Avoids time delays and costs of shipping slides
Read slides from different locations
– Education of satellite groups in trial host countries– Ensure high level of agreement/ consistency– Conferencing between central lab pathologist(s) and
sponsor’s study pathologist(s) or experts Fairer resolution than a simple majority or expert rule
Digital substitute for glass slides– When a clinical trial host country has export limitations – Primary diagnosis H&E (breast cancer) in progress
Clinical Trials Laboratories & Offices Affiliate Laboratories
Adjudication: Global Clinical Trials Laboratories
Adjudication - Validation
FDA– Validate as much as one can ahead of time– Awaiting completion of FDA approval process
Validation– Ideally study and tissue specific validation– Compare performance of digital to glass slides
Can compute intra- and inter-observer kappa coefficients
Static images → whole slides– Third party multi-format image support– Third party information systems
Scan Types– Bright field: dry, oil– Fluorescence
Advantages– Circumvents problems of slide breakage or stain fading– Real-time access possible
Length of storage– Duration of study
On server– Long-term
Meet minimum retention requirements FDA – 5 years post application (21 CFR §58.195)
• But when is it submitted by sponsor? CAP – 10 years for glass slides Default – 15 years
Removable media/ hard drives Costs of storage tend to decrease over time
Other– Use in submission of data to FDA
Digital sides more compelling evidence than static images e.g., hepatitis C
Image Analysis– Customize staining and algorithms– Validation– Software advances → entire-slide analysis
Adjudication– Decrease TAT– Harmonization– Conferencing
Digital Archiving– Real-time access– Long term storage– Regulatory submission
Stephanie AstrowMarc EdwardsVicki FreemanRon LuffMaribeth Raines
Thank you very much for your time and attention
Arnold B. Gelb, [email protected]