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    MA13 - Interventional Pulmonology (ID 914)

    • Event: WCLC 2018
    • Type: Mini Oral Abstract Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 2
    • Moderators:
    • Coordinates: 9/25/2018, 10:30 - 12:00, Room 206 AC
    • +

      MA13.02 - PD-L1 Expression in EBUS-Guided Cytology Specimens of Non-Small Cell Lung Cancer is Not Affected by Type of Fixation: A Study of Matched Pairs (ID 11867)

      10:35 - 10:40  |  Author(s): John Roy Gosney

      • Abstract
      • Presentation
      • Slides

      Background

      No previous trials of immune modulators (IMs) to treat non-small cell lung cancer (NSCLC) have included ‘cytology’ specimens, dispersed cells aspirated from a tumour deposit or body cavity, for immunochemical assessment of PD-L1, a useful complementary or compulsory companion diagnostic test. This has led to the widely-held view that, in the absence of such ‘validation’, cytology specimens cannot be used to assess it. In many centres, endobronchial ultrasound (EBUS)-guided aspiration of the tumour or intra-thoracic lymph nodes is the preferred means of diagnosis and staging of NSCLC and such specimens account for the majority received for analysis. Failure to asses them has serious implications for appropriate management and might deny patients effective therapy. Much of this reluctance centres on the alleged effect of fixation in alcohol-based fixatives, the preferred method of cytopathologists, rather than formalin, the standard fixation medium for tissue specimens, on the expression of PD-L1 on the cell surface.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      We compared expression of PD-L1 in 50 paired specimens of NSCLC, one fixed in an alcohol-based fixative and one in neutral-buffered formalin, taken from the same tumour deposit or lymph node during the same procedure. All were spun down and formed into a cell block before assessment for PD-L1 expression, which was by two appropriately-trained pathologists with extensive experience in its interpretation.

      4c3880bb027f159e801041b1021e88e8 Result

      In none of the 50 pairs studied was there any significant difference, qualitative or quantitative, in the pattern or extent of PD-L1 expression and, in the great majority, it was identical irrespective of fixation.

      8eea62084ca7e541d918e823422bd82e Conclusion

      There is no evidence from this study that the use of alcohol-based fixatives has any effect on the expression of PD-L1 or its interpretation. Notwithstanding the general challenges in accurately assessing such expression, which are common to specimens of tissue as well as dispersed cells, pathologists should feel able to interpret cytology specimens with confidence and clinicians able to rely on the results.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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      MA13.04 - Discussant - MA 13.01, MA 13.02, MA 13.03 (ID 14629)

      10:45 - 11:00  |  Presenting Author(s): John Roy Gosney

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    MA26 - New Therapies and Emerging Data in ALK, EGFR and ROS1 (ID 930)

    • Event: WCLC 2018
    • Type: Mini Oral Abstract Session
    • Track: Targeted Therapy
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/26/2018, 13:30 - 15:00, Room 201 BD
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      MA26.06 - Crizotinib-Treated ALK Immunopositive Metastasized NSCLC is Associated with an Unfavorable Prognosis when FISH Negative  (ID 13179)

      14:05 - 14:10  |  Author(s): John Roy Gosney

      • Abstract
      • Presentation
      • Slides

      Background

      Metastasized NSCLC with an ALK fusion are sensitive to a range of tyrosine kinase inhibitors. ALK-positive NSCLC has been identified in the pivotal phase III trial with fluorescence in situ hybridization (ALK FISH+). These tumors are also expressing the fusion product (ALK immunohistochemistry (IHC)+). However, discrepant cases occur, including ALK IHC+ FISH-. The aim of this study was to collect ALK IHC+ cases and compare within this group response to crizotinib treatment of ALK FISH+ cases with ALK FISH- cases.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      A prospective multicenter investigator initiated research study was started in Europe. Stage IV ALK IHC+ NSCLC cases treated with crizotinib were collected centrally. Slides were validated centrally for ALK IHC (with 5A4 ETOP and D5F3 Ventana protocol) and ALK FISH (Vysis probes).

      4c3880bb027f159e801041b1021e88e8 Result

      The study started April 1, 2014 and closed in November 2017. Fifteen centers participated. Registration of 3523 ALK IHC tests revealed prevalence of 2.6% ALK IHC+ cases. Local ALK FISH analysis resulted in 46 concordant (ALK IHC+/FISH+) and 18 discordant (ALK IHC+/FISH-) cases. Central validation revealed 37 concordant and 6 discordant cases, 5 of which had follow-up. Validation was hampered by limited amount of tissue in biopsy samples. The time to treatment failure did not differ for concordant nor discordant cases, and neither for local nor validated ALK testing (HR=0.78; 95% CI= 0.27-2.3; p=0.64) and (HR=2.2; 95% CI= 0.72-6.5; p=0.16), respectively). However, overall survival was significantly better for concordant cases than discordant cases after central validation (HR=4.5; 95% CI= 1.2-15.9; p=0.010), but not according to local testing (HR=1.7; 95% CI= 0.45-6.2; p=0.44).

      8eea62084ca7e541d918e823422bd82e Conclusion

      ALK IHC+ FISH- NSCLC cases are an infrequent finding. We recommend such cases to be validated carefully because our data indicate that ALK IHC+ FISH- cases have a worse survival when treated by crizotinib compared to ALK IHC+ FISH+ cases.

      This study was funded by an independent research grant by Pfizer

      6f8b794f3246b0c1e1780bb4d4d5dc53

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    P1.04 - Immunooncology (Not CME Accredited Session) (ID 936)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/24/2018, 16:45 - 18:00, Exhibit Hall
    • +

      P1.04-24 - Digital Core Needle-Biopsy to Assess PD-L1 Expression in Non-Small Cell Lung Cancer: Optimal Sampling and Need for Re-Biopsy (ID 12059)

      16:45 - 18:00  |  Author(s): John Roy Gosney

      • Abstract
      • Slides

      Background

      Assessing expression of PD-L1 on tumour cell membranes by immunochemistry is an important complementary or crucial companion diagnostic test to guide the use of immune modulating checkpoint inhibitors in the treatment of non-small cell lung cancer (NSCLC). Unfortunately, the known temporal and spatial heterogeneity of PD-L1 expression raises the important question of how to ensure that the small biopsy specimens with which this assessment is usually made are adequately representative of PD-L1 expression by the whole tumour.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      Expression of PD-L1 was assessed in sections of 94 tissue blocks from 50 primary pulmonary adenocarcinomas using the Ventana SP263 antibody and a validated protocol. Scoring was performed by two appropriately-trained pathologists with extensive experience in its interpretation. After conventional assessment, slides were digitally scanned and divided into squares of 1mm² area to form a digital database (mean of 150 data-points per tumour), which were assigned co-ordinates and re-scored. By these means, multiple, “digital core biopsies” (DCBx) approximating a 17 gauge needle were simulated in sequential fashion, and expression in these was compared to that in the whole tumour and categorised by current UK prescribing guidelines*

      4c3880bb027f159e801041b1021e88e8 Result

      PD-L1 score (%)

      Total number of cases

      Cases where PD-L1% from single DCBx changed scoring category vs whole tumour*

      Cases where PD-L1% from two DCBx changed scoring category vs whole tumour*

      Cases where PD-L1% from three DCBx changed scoring category vs whole tumour*

      Cases where PD-L1% from four DCBx changed scoring category vs whole tumour*

      Cases where PD-L1% from five DCBx changed scoring category vs whole tumour*

      Focal expression primary pattern in non-correlative cases

      <1

      14

      2

      2

      2

      2

      2

      Y

      1-10

      13

      6

      3

      1

      1

      0

      Y

      11-49

      10

      1

      1

      0

      0

      0

      Y

      50-100

      13

      0

      0

      0

      0

      0

      n/a

      All

      50

      9 (18%)

      6 (12%)

      3 (6%)

      3 (6%)

      2 (4%)

      PD-L1, programmed death ligand 1; DCBx, Digital Core Biopsy

      *Based on pembrolizumab categories as: 1st line ≥50%, 2nd line 1-49%; nivolumab categories as: ≥1% (for adenocarcinoma)

      8eea62084ca7e541d918e823422bd82e Conclusion

      In the majority of cases, three digital core biopsies achieved closest correlation with the whole tumour, with little greater accuracy achieved by assessing four cores or more. Correlation was weakest when expression was low and very focal, an important consideration in view of the importance of the ‘1% cut-off’ used commonly to guide immune checkpoint therapy. Using this model as a guide, a single good quality biopsy (2x10mm² area) is sufficient for most tumours scoring 11% or greater PD-L1 expression. However, in the lower range of expression, re-biopsy might be routinely considered if there is doubt about specimen adequacy.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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    P2.09 - Pathology (Not CME Accredited Session) (ID 958)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 2
    • Moderators:
    • Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
    • +

      P2.09-06 - Expression of PD-L1 on Routine Non-Small Cell Lung Carcinoma Sections: Comparative Assessment of SP263 (Ventana) and 22C3 (DAKO pharmDx) (ID 13019)

      16:45 - 18:00  |  Author(s): John Roy Gosney

      • Abstract
      • Slides

      Background

      The SP263 (Ventana Benchmark) antibody as a predictive immunohistochemical marker for pembrolizumab therapy provides an avenue for local testing. Pathologists without access to the Dako Autostainer Link 48 platform (certified for the Dako 22C3 antibody) have been restricted to referrals at external departments, resulting in an increased turnaround time. Here we report the results of our local verification of SP263.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      Specimens previously assessed for 22C3 PD-L1 expression at either Royal Liverpool Hospital or Queen Elizabeth Hospital Birmingham were selected from the archives of Wythenshawe Hospital. Cases with less than 100 viable residual tumour cells were excluded. The same tumour block was selected for staining with the Roche SP263 clone and specimens were assessed for tumour proportion score (TPS), immune cell proportion and staining intensity. Assays were reported as disagreeing if a differing TPS changed the therapeutic cut-off ranges.

      4c3880bb027f159e801041b1021e88e8 Result

      Expression levels of 22C3 and SP263 were compared across 100 cases (43 resections, 26 biopsies, 26 lymph node aspirates, 5 node excisions); 59 adenocarcinomas, 33 squamous carcinomas, 8 not otherwise specified (70 primary, 30 metastatic). The TPS ranges (<1%, 1 - 49%, > 50%) were in agreement for 78 samples. Of the 22 cases with differing ranges, 15 reflected a TPS of <10% and 7 had greater differences e.g. 10% versus 60%. Reasons for discrepancies included faint membranous staining on a few of the 22C3 sections (not apparent on SP263), scoring of carcinoma in situ, possible scoring of cells at a deeper block level, and variation in interpretation by the scoring pathologists. The overall Pearson correlation coefficient (r) was 0.9025, p < 0.00001.

      Table 1 Comparison of PD-L1 Ventana SP263 and Dako 22C3 tumour proportion scores
      SAMPLE DIAGNOSIS SP263 >/= 1% >/= 50%

      Liverpool

      22C3

      Birmingham

      22C3

      Discrepancy

      Pleural biopsy

      Adenocarcinoma

      1

      No

      No

      1

      N/A

      No

      Pleural biopsy

      Adenocarcinoma

      10

      No

      No

      60

      N/A

      Yes

      EBUS node

      Metastatic adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      EBUS node

      Metastatic adenocarcinoma

      0

      No

      No

      1

      N/A

      Yes

      Resection

      Adenocarcinoma

      40

      Yes

      No

      10

      N/A

      No

      EBUS node

      Metastatic squamous carcinoma

      2

      No

      No

      10

      N/A

      No

      Resection

      Adenocarcinoma

      5

      Yes

      No

      <1

      N/A

      Yes

      EBUS node

      Metastatic adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      Bronchial biopsy

      Squamous carcinoma

      10

      Yes

      No

      70

      N/A

      Yes

      Bronchial biopsy

      Squamous carcinoma

      0

      No

      No

      0

      N/A

      No

      EBUS node

      Metastatic squamous carcinoma

      <1

      No

      No

      <1

      N/A

      No

      EBUS node

      Metastatic adenocarcinoma

      <1

      No

      No

      0

      N/A

      No

      Bronchial biopsy

      Squamous carcinoma

      40

      Yes

      No

      40

      N/A

      No

      Resection

      Squamous carcinoma

      5

      Yes

      No

      10

      N/A

      No

      Lung biopsy

      Adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      Lymph node biopsy

      Metastatic adenocarcinoma

      100

      Yes

      Yes

      100

      N/A

      No

      Resection

      Adenocarcinoma

      <1

      No

      No

      N/A

      <1

      No

      Lung biopsy

      Adenocarcinoma

      0

      No

      No

      N/A

      0

      No

      Resection

      Adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      Resection

      Adenocarcinoma

      10

      Yes

      No

      N/A

      5 to 10

      No

      Resection

      Adenocarcinoma

      20

      Yes

      Yes

      N/A

      20-30

      No

      Resection

      Squamous carcinoma

      2 to 4

      Yes

      No

      N/A

      3 to 5

      No

      Bronchial biopsy

      Squamous carcinoma

      <1

      No

      No

      N/A

      <1

      No

      Bronchial biopsy

      Squamous carcinoma

      2 to 4

      Yes

      No

      1

      N/A

      No

      Lymph node biopsy

      Metastatic adenocarcinoma

      100

      Yes

      Yes

      100

      N/A

      No

      Bronchial biopsy

      NOS

      <1

      No

      No

      N/A

      <1

      No

      Bronchial biopsy

      Adenocarcinoma

      0

      No

      No

      1

      N/A

      Yes

      Resection

      Adenocarcinoma

      2 to 4

      Yes

      No

      10

      N/A

      No

      Lymph node biopsy

      Metastatic squamous carcinoma

      80

      Yes

      Yes

      70

      N/A

      No

      EBUS node

      Metastatic adenocarcinoma

      80

      Yes

      Yes

      80

      N/A

      No

      Bronchial biopsy

      Squamous carcinoma

      0

      No

      No

      N/A

      <1

      No

      EBUS node

      Metastatic adenocarcinoma

      90

      Yes

      Yes

      80

      N/A

      No

      Pleural biopsy

      Adenocarcinoma

      0

      No

      No

      10

      N/A

      Yes

      Bronchial biopsy

      Squamous carcinoma

      0

      No

      No

      0

      N/A

      No

      Bronchial biopsy

      Squamous carcinoma

      5

      Yes

      No

      N/A

      0

      Yes

      EBUS node

      Metastatic squamous carcinoma

      50

      Yes

      Yes

      50

      N/A

      No

      Bronchial biopsy

      Squamous carcinoma

      2 to 4

      Yes

      No

      10

      N/A

      No

      EBUS node

      Metastatic adenocarcinoma

      70

      Yes

      Yes

      N/A

      70

      No

      EBUS node

      Metastatic adenocarcinoma

      100

      Yes

      Yes

      100

      N/A

      No

      Bronchial biopsy

      Squamous carcinoma

      1

      Yes

      No

      20

      N/A

      No

      Resection

      Adenocarcinoma

      5

      Yes

      No

      0

      N/A

      Yes

      Resection

      Adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      EBUS node

      Adenocarcinoma

      <1

      No

      No

      0

      N/A

      No

      Resection

      Adenocarcinoma

      5

      Yes

      No

      10

      N/A

      No

      EBUS node

      Sarcomatoid carcinoma

      0

      No

      No

      0

      N/A

      No

      Resection

      Adenocarcinoma

      0

      No

      No

      N/A

      <1

      No

      Lymph node biopsy

      Metastatic squamous carcinoma

      0

      No

      No

      N/A

      <1

      No

      Resection

      Adenocarcinoma

      60

      Yes

      Yes

      N/A

      60-70

      No

      Bronchial biopsy

      Squamous carcinoma

      0

      No

      No

      0

      N/A

      No

      Pleural biopsy

      Adenocarcinoma

      2 to 4

      Yes

      No

      10

      N/A

      No

      Lung biopsy

      Squamous carcinoma

      0

      No

      No

      5

      N/A

      Yes

      EBUS node

      Metastatic adenocarcinoma

      5

      Yes

      No

      30

      N/A

      No

      Resection

      Pleomorphic carcinoma

      70

      Yes

      Yes

      80

      N/A

      No

      Resection

      Squamous carcinoma

      0

      No

      No

      1

      N/A

      Yes

      Bronchial biopsy

      Squamous carcinoma

      10

      Yes

      No

      20

      N/A

      No

      Resection

      Adenocarcinoma

      50

      Yes

      Yes

      N/A

      10 to 20

      Yes

      Resection

      Adenocarcinoma

      0

      No

      No

      N/A

      <1

      No

      Resection

      Pleomorphic carcinoma

      1

      Yes

      No

      20

      N/A

      No

      Resection

      Adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      Resection

      Adenocarcinoma

      10

      Yes

      No

      N/A

      2 to 3

      No

      EBUS node

      Metastatic adenocarcinoma

      100

      Yes

      Yes

      100

      N/A

      No

      Resection

      Adenocarcinoma

      5

      Yes

      No

      N/A

      <1

      Yes

      EBUS node

      Metastatic adenocarcinoma

      100

      Yes

      Yes

      100

      N/A

      No

      EBUS node

      Metastatic squamous carcinoma

      50

      Yes

      Yes

      N/A

      80

      No

      Resection

      Adenocarcinoma

      90

      Yes

      Yes

      95

      N/A

      No

      Resection

      Adenocarcinoma

      <1

      No

      No

      N/A

      <1

      No

      Resection

      Adenocarcinoma

      0

      No

      No

      1

      0

      Yes

      Resection

      Adenocarcinoma

      <1

      No

      No

      5

      N/A

      Yes

      Resection

      Adenocarcinoma

      20

      Yes

      No

      20

      N/A

      No

      Bronchial biopsy

      NOS

      50

      Yes

      Yes

      60

      N/A

      No

      Resection

      Adenocarcinoma

      2 to 4

      Yes

      No

      N/A

      5 to 10

      No

      Resection

      Adenocarcinoma

      0

      No

      No

      10

      N/A

      Yes

      Soft tissue

      NOS

      1

      Yes

      No

      20

      N/A

      No

      Bronchial biopsy

      Sarcomatoid carcinoma

      <1

      No

      No

      N/A

      <1

      No

      EBUS node

      Metastatic adenocarcinoma

      70

      Yes

      Yes

      N/A

      60 to 70

      No

      Pleural biopsy

      Adenocarcinoma

      80

      Yes

      Yes

      N/A

      70

      No

      Resection

      Squamous carcinoma

      <1

      No

      No

      1

      0

      Yes

      Resection

      Adenocarcinoma

      50

      Yes

      Yes

      N/A

      5 to 10

      Yes

      Resection

      Adenocarcinoma

      10

      Yes

      No

      50

      N/A

      Yes

      Resection

      Adenocarcinoma

      0

      No

      No

      0

      N/A

      No

      Resection

      Squamous carcinoma

      1

      Yes

      No

      N/A

      <1

      Yes

      Resection

      Squamous carcinoma

      100

      Yes

      Yes

      100

      N/A

      No

      Resection

      Squamous carcinoma

      5

      Yes

      No

      10

      No

      Resection

      Squamous carcinoma

      70

      Yes

      Yes

      N/A

      70 to 80

      No

      Resection

      Squamous carcinoma

      90

      Yes

      Yes

      N/A

      10 to 20

      Yes

      EBUS node

      Squamous carcinoma

      <1

      No

      No

      N/A

      <1

      No

      EBUS node

      Adenocarcinoma

      0

      No

      No

      N/A

      0

      No

      EBUS node

      Metastatic adenocarcinoma

      70

      Yes

      Yes

      N/A

      80

      No

      EBUS node

      Metastatic squamous carcinoma

      50

      Yes

      No

      N/A

      70

      No

      Resection

      Adenocarcinoma

      <1

      No

      No

      N/A

      <1

      No

      EBUS node

      Metastatic adenocarcinoma

      40

      Yes

      No

      30

      N/A

      No

      Resection

      Squamous carcinoma

      90

      Yes

      Yes

      N/A

      100

      No

      Resection

      Adenocarcinoma

      40

      Yes

      No

      40

      N/A

      No

      EBUS node

      Metastatic adenocarcinoma

      80

      Yes

      Yes

      N/A

      70 to 80

      No

      EBUS node

      Metastatic squamous carcinoma

      1

      Yes

      No

      N/A

      <1

      Yes

      Bronchial biopsy

      Squamous carcinoma

      1

      Yes

      No

      1

      N/A

      No

      EBUS node

      Metastatic adenocarcinoma

      5

      Yes

      No

      60

      N/A

      Yes

      Primary EBUS

      Pleomorphic carcinoma

      100

      Yes

      Yes

      90

      N/A

      No

      Resection

      Adenocarcinoma

      90

      Yes

      Yes

      90

      N/A

      No

      Lymph node biopsy

      Adenocarcinoma

      <1

      No

      No

      <1

      N/A

      No

      8eea62084ca7e541d918e823422bd82e Conclusion

      Tumour expression profiles of PD-L1 are similar for the 22C3 and SP263 antibodies, with a rate of variation similar to previous reports. Cases that are discrepant may reflect differences in pathologist interpretation rather than the assay.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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      P2.09-19 - Utilising Heterogeneity: Using a Digital Database of Lung Cancers and Immune Profile to Complement Subjective Assessment (ID 12594)

      16:45 - 18:00  |  Author(s): John Roy Gosney

      • Abstract
      • Slides

      Background

      Traditional pathological assessment of tissue sections involves subjective analysis of complex and heterogeneous features, typified by the challenge of ‘measuring’ PD-L1 expression in non-small cell lung cancer (NSCLC) as a guide to its treatment with immune checkpoint inhibitors. Such heterogeneity is generally perceived as a problem but might, in fact, reflect not only biologically important epitope variation, but also important features of the tumour microenvironment and, by extension, be a tool for predicting behaviour. In-depth analysis of a single slide of a tumour by digital pathology, image analysis and machine learning makes more accurate and meaningful analysis a possibility.

      a9ded1e5ce5d75814730bb4caaf49419 Method

      Expression of PD-L1 was assessed by immunochemistry in 250 sections from 137 resected NSCLCs using the Ventana SP263 antibody and a validated protocol and its distribution compared with morphology as revealed by corresponding H&E-stained sections. Slides were scanned to create a digital image using Aperio Scanscope with division of images into 1mm² squares using QuPath opensource software, each of which was assigned x and y co-ordinates. Squares were assessed subjectively by two pathologists for morphological features and PD-L1 expression and also subject to automatic image analysis including cell counting and membrane detection. Co-ordinates and values were stored in Microsoft Excel and a digital database was generated for every slide. In-depth analysis of digital data points was achieved using “R” software custom algorithms that included simulating biopsy sampling and applying spatial analysis packages.

      4c3880bb027f159e801041b1021e88e8 Result

      The resulting database, comprising approximately 30,000 data points from the 137 tumours, is being used to simulate needle-core biopsies, assess heterogeneity of PD-L1 expression and relate this to the tumour micro-environment including immune cell populations, immune signature and tumour mutational burden.

      8eea62084ca7e541d918e823422bd82e Conclusion

      The vast amount of information in every NSCLC cannot be extracted by conventional histopathological analysis. By utilising new technologies and considering alternative paradigms for data acquisition, powerful new approaches may be developed that give information pertaining to not just diagnostic and prognostic features of a tumour, but behavioural traits including likely responses and resistances to novel drugs such as immune checkpoint inhibitors. The methodology described here is an attempt to extract these data in a more objective way and complement the still crucial subjective analysis that is traditionally the prerogative of the histopathologist.

      6f8b794f3246b0c1e1780bb4d4d5dc53

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