Results of College Exam 2022 (Council Meeting 28 September 2022)

Fellowship Assessment:

Membership Examination:

Volume 31, Issue 1 (click here to download the full pdf version)

Message from the President

It gave me great pleasure in writing this message, as the College Newsletter always has a special place in my heart.

It seems like yesterday when I first joined the College Council and took up the College Newsletter Chief Editor position in 2004. It has come a long way for the College newsletter to evolve from a black-and-white hard copy, to the current colourful electronic soft copy. I still remember the days when the Editorial Board meeting took place in a casual atmosphere in a restaurant in Admiralty, how the name “Pathologue” was proposed by the scholarly Dr LOO Ka Tai, and how the various new ideas were born through members of the Editorial Board. I am happy to see the continuous development of the newsletter over the subsequent years.

The COVID-19 pandemic has revolutionalized the practice of medicine. Various College meetings have been conducted via teleconferencing, and such practice has extended to the participation by External Examiners in various College examinations, and to Trainee Presentation Session in form of a hybrid mode. Later this year, I shall also join the International Liaison of Pathology Presidents (ILPP) meeting in Chicago via teleconferencing. The world is changing fast, and our College will adapt to the change. The COVID-19 pandemic has pushed us to embrace technology in our daily practice: teleconferencing, web-based seminars, the possibility of telepathology, just to name a few. Our College shall keep a close look at the latest outbreak situation and the related policy, and adjust our practice accordingly.

We managed to host our College Conferment Ceremony in 2021 despite the COVID-19 outbreak, taking various infection control precautions. For this year, our Annual General Meeting and Conferment Ceremony have been tentatively planned for 26 November 2022 (Saturday): please mark your diary, and we look forward to seeing you all.

Our profession has been facing manpower shortage for some time. The situation has been escalating, with the expansion of services in various pathology specialties and the attrition subsequent to various reasons. Together with the Academy, our College shall aim to uphold the professional standards while considering different options to address the matter.

We are pleased to see an increasing number of trainees and young Fellows in our College. The recent establishment of the Young Fellows Chapter in the Academy and in our College has provided an excellent opportunity to engage our younger generation in Academy’s and College’s activities. Young Fellows have brought in new ideas and have helped to organize various activities, and they are the future of our College.

After several years of preparation, our College rolled out the Genetic and Genomic Pathology training programme last year. More and more trainees have now registered for this programme, and we hope many new Fellows will complete this programme in the near future to cater for the needs of this rapidly expanding field.

The establishment of the Genetic and Genomic Pathology programme has brought our College “Into a New Era”, and it happens that the year 2021 marked the 30th Anniversary of our College. An anniversary book is currently under preparation, and I thank the team from the Professional & General Affairs Committee for their hard work. I also thank all the previous Presidents for their contributions, and this book will certainly become a valuable item of memorabilia.

As College President, I attended the 4th AMM-AMS-HKAM Tripartite Congress & the 55th Singapore-Malaysia Congress of Medicine on 22-24 July 2022 in Singapore virtually. A summary of the event is included in this newsletter.

There are challenges ahead, and let’s ride out the storm together. After all, tomorrow is another day.

Dr. CHAN Chak Lam, Alexander
President

Molecular diagnostics for breast cancer

Volume 17, Issue 2, July 2022  (download full article in pdf)

Editorial note:

New molecular techniques have contributed to the ever-expanding armamentarium for breast cancer diagnosis, treatment and prognostication. Since the molecular classification of breast cancer was established, pathologists have been using immunohistochemistry and DNA sequencing techniques to routinely grade and subtype breast cancer. RNA expression profiling using various platforms such as microarrays, quantitative PCR and Nanostring has also been used to guide patient treatment in early diseases. This topical update provides a concise review on the current diagnostic and prognostic modalities in breast cancer management. We welcome any feedback or suggestions. Please direct them to Dr. Alvin Cheung of Education Committee, the Hong Kong College of Pathologists. Opinions expressed are those of the authors or named individuals, and are not necessarily those of the Hong Kong College of Pathologists.

Dr. Alvin Ho-Kwan Cheung¹ and Dr. Karen Ka-Wan Yuen²

1. Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, the Chinese University of Hong Kong
 
2. Department of Clinical Pathology, North District Hospital

Introduction

Since the seminal report on breast cancer classification in 2000[1], increased understanding in the molecular biology of breast cancer has led to numerous immunohistochemical markers and molecular panels used as adjunct biomarkers. These biomarkers mainly serve the following purposes: As prognostic markers, to gauge the likelihood of a clinical event, disease recurrence or progression; as predictive markers, to assess the likelihood of favourable or unfavourable effect from exposure to a medical product or a therapeutic agent[2]. In this review, the classical biomarkers of breast cancer will be briefly discussed, followed by a more detailed elaboration of molecular panels which are based on DNA alterations and gene expression levels. 

Hormonal receptor and proliferative index markers

Unlike other cancers, the molecular classification of breast cancer (luminal A/B, HER2 positive, and basal-like cancers) have been translated well to the clinic[3], and immunohistochemical markers have been established to facilitate such classification without resorting to molecular methods[4, 5]. Some authorities believe that normal-like breast cancer are an artifact of contamination by normal cells[6, 7]. The Estrogen Receptor (ER) and Progesterone Receptor (PR) are predictive biomarkers for endocrine therapy[8]. ER or PR-expressing tumours tend to have a better outcome than those lacking the receptors.

The expression of Human Epidermal growth factor Receptor 2 (HER2) defines the molecular basis of the “HER2-positive” group of cancer. They account for slightly less than 20% of breast cancers, and have a worse prognosis compared to ER+/PR+/HER2- cancers[9]. It serves as a therapeutic target for trastuzumab and pertuzumab. While ER and PR are routinely detected by immunohistochemistry (IHC), HER2 expression can be detected by IHC, Dual in situ hybridization (DISH) or Fluorescence in situ hybridization (FISH)[10].

The proliferation marker Ki-67 serves as a useful adjunct investigation in the grading of breast cancer[11]. Calculated as the percentage of nuclear staining in cancer cells, the prognosis is said to be better when Ki-67 is 30% for early disease[12].

Molecular tests at the DNA level

Some genetic aberrations in breast cancer are worth mentioning because they may be susceptible to targeted therapy and can predict treatment response. PIK3CA mutation occurs in about 36% of breast cancer[13, 14]. In advanced or metastatic hormonal receptor-positive cancer, or in patients with disease progression on endocrine-based regimen, combination therapy with the PI3K inhibitor, alpelisib, together with fulvestrant may be a treatment option if there is PIK3CA mutation[15]. The mutation can be detected by the companion diagnostic kit Therascreen, with Sanger sequencing, or with next generation sequencing. In secretory carcinoma, NTRK fusion is targetable by larotrectinib or entrectinib[16]. The presence of translocation can be detected with immunohistochemistry, next generation sequencing (NGS), Reverse-transcriptase (RT)-PCR or FISH. In non-secretory type breast cancers, NTRK fusion is very rare[17], such that the routine testing of this gene is unnecessary. For triple-negative breast cancer, BRCA aberrations can be present in about 6.5-34% of the cases[18]. The BRCA proteins constitute a part of the homologous recombination repair pathway. They are encoded by relatively large genes, with BRCA1 being present on chromosome17q21, having 23 exons; and BRCA2 on chromosome 13q13.1, having 27 exons. The incidence of aberrations is markedly higher among Ashkenzi Jews (2.5%) than the general population (0.1%)[19]. BRCA-mutated tumour highly depends on PARP, another DNA repair protein, to maintain the tumour genome integrity. Therefore, PARP inhibitor therapy are useful in BRCA-mutated tumours, and this treatment approach is termed a “synthetic lethality”[20].  Due to the size of these genes, NGS would be the preferred detection platform, while multiplex ligation-dependent probe amplification (MLPA) is also suitable[21]. 

For other advanced cancer or triple negative breast cancer, immune checkpoint inhibitor may be indicated in some patients. Besides testing for PD-L1 expression by the companion diagnostic kits for atezolizumab and pembrolizumab, some data support the testing for microsatellite instability (MSI) and tumour mutation burden (TMB) as well[22]. MSI-high breast cancer may be treated with pembrolizumab, as are tumours with high TMB as assessed by the FoundationOne companion diagnostic or other NGS platforms[23].

Molecular tests at the RNA expression level

Oncotype Dx

Oncotype Dx was launched in year 2004. It involves mRNA extraction from formalin-fixed paraffin-embedded (FFPE) tissues[24]. The detection panel includes 21 genes (16 cancer-related genes and 5 reference genes), and the detection platform is by quantitative-PCR (qPCR). The test had been studied in several trials, including the NASBP trial (National Surgical Adjuvant Breast and Bowel Project)[25], TAILORx trial (including 10273 women), and TxPONDER trial (5018 women)[26]. The test generates a recurrence score (RS) in the range of 0-100. In the TAILORx trial, patients of age >50 years had a substantial benefit from chemotherapy when RS >=26, whereas younger patients may be benefited when RS >=16.

MammaPrint

MammaPrint was launched in 2007. It consists of a 70-gene microarray, which accepts both fresh frozen or FFPE tissue for testing. It categorizes patients into “High risk” or “Low risk”. The MINDACT trial included 6693 patients and the RASTER trial included 427 patients for this test[27, 28]. There are some preliminary data to suggest systemic treatment can be recommended for the patients in the “High risk” group.

Blueprint

The Blueprint assay was developed by the same company as Mammaprint, and the test can be used together with MammaPrint. It involves a 80-gene panel, and serves to categorize tumour into luminal-A, luminal-B, HER2, or basal subtypes. Although this may overlap with the objective of IHC study described above, one important difference is that the luminal A and B groups can be associated with a different chemosensitivity and prognosis according to the Blueprint schema. Particularly, in the luminal B, Her2, and basal subtypes, chemotherapy can be beneficial to some patients with an improved survival. In contrast, for the luminal A group, the benefit for chemotherapy is not pronounced[29].

Prosigna (PAM50)

The Prosigna assay was launched in 2013. Following RNA extraction from FFPE tissue, the expression of a panel of 50 genes are detected by the NanoString “nCounter” platform[30]. This test is indicated for post-menopausal patients. Two large trials were conducted, including The ABCSG-8 study (Austrian Breast and Colorectal Cancer Study Group 8) and TransATAC study (translational arm of the anastrozole or tamoxifen alone or combined)[31]. While a scoring scheme of 0-100 is used, the risk stratification is different depending on the lymph node status. For node-negative cancers, they are classified as low (0-40), intermediate (41-60), or high (61-100) risk; as for node-positive cancers, they are classified as low (0-40) or high (41-100) risk. The suggested treatment for low risk disease is hormonal therapy alone, while for high risk disease, chemotherapy in addition to hormonal therapy may be beneficial.

The Breast Cancer Index

The Breast Cancer Index was launched in 2008[32]. As an RT-PCR assay on FFPE tissue, it features a 11-gene panel with two major testing endpoints: Whether there is a benefit of extended endocrine therapy (for 5 years), and the risk of recurrence 5 to 10 years after diagnosis. The ratio of expression between estrogen signaling pathway genes HOXB13 and IL17BR (H/I ratio) is an important parameter, as in the MA.17 trial, high H/I indicated a higher risk of late recurrence and a benefit from extended letrozole therapy. Another trial, the aTTom study, included H/I high patients for an extended therapy and found up to 15% reduction in recurrence risk[33, 34]. The test results for the Breast Cancer Index are simple enough to be interpreted even by patients, with “Yes” and “No” to the question of whether extended endocrine therapy is beneficial, and recurrence risk in percent to report the chance of late distant recurrence.

Comparisons between test modalities

When the included genes are compared, it is noted that the Oncotype Dx and PAM50 panels have the most overlap. 11 genes are in common for Oncotype Dx and PAM50, for example BCL2, CCNB1, MMP11, which are markers for apoptosis, cell cycle, and tumour invasiveness[35]. Interestingly, for the 70 genes included in Mammaprint, only one gene, SCUBE2, overlaps with Oncotype DX, and two genes, MELK and ORC6L, overlap with Prosigna PAM50[35]. It remains to be studied whether the results in one test can be correlated with another test, but some key differences are still worth to be noted. For hormonal receptor positive stage I-II invasive breast cancer, all the tests have some use for prognostication. However, concerning whether chemotherapy is recommended, only Oncotype DX has an established predictive value, while there is insufficient evidence for Mammaprint, Blueprint and Prosigna [36]. The Breast Cancer Index has predictive value for extended endocrine therapy. Some efforts have also been taken to translate some of these tests to hormonal receptor positive DCIS. Oncotype DX DCIS and DCISionRT have some use in patient prognostication, however, both tests have insufficient evidence to guide chemotherapy[37, 38].

For the regulatory status, Oncotype DX has been included in the NCCN/ASCO guidelines for the management of breast cancer patients. As for Mammaprint and Prosigna, these kits have been FDA-cleared for specific clinical settings. Logistically, both Oncotype DX and Mammaprint require end users to deliver specimens to a central laboratory for testing. Prosigna is available in a kit format for local laboratories to perform the test.

Conclusions and future perspectives

Unlike most other cancer types, RNA expression profiling has found remarkable translational use in breast cancer treatment. This can be attributed to an increased understanding of molecular classifications, hormonal receptor functions and breast cancer biology. While panels including other RNA expression signatures can be expected to emerge, it is important to understand the indications and differences for each testing system, as an increased number of testing options can be confusing to patients, while contradicting results among platforms can complicate the interpretation. Because RNA expression level has an inherent variability among patients, the subgrouping of patients into risk groups may not be ideal, and some patients may be placed in the wrong group using only one particular panel. Hopefully, with further elucidation of the breast cancer genome, novel molecular targets based on DNA alterations can be uncovered, as the presence of a particular mutation or translocation is a more consistent marker of susceptibility to targeted therapy. As we enter the era of personalized medicine, histologic assessments, immunohistochemical studies such as hormonal receptors and PD-L1 status, and molecular diagnostics can be expected to go hand in hand in the formulation of management plans and prognostication in breast cancer patients.

Reference

1. Perou CM, Sørlie T, Eisen MB, Van De Rijn M, Jeffrey SS, Rees CA, et al. Molecular portraits of human breast tumours. nature. 2000;406(6797):747-52.
2. Califf RM. Biomarker definitions and their applications. Experimental Biology and Medicine. 2018;243(3):213-21.
3. Sotiriou C, Pusztai L. Gene-expression signatures in breast cancer. New England Journal of Medicine. 2009;360(8):790-800.
4. Goldhirsch A, Winer EP, Coates A, Gelber R, Piccart-Gebhart M, Thürlimann B, et al. Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Annals of oncology. 2013;24(9):2206-23.
5. Cheang MC, Martin M, Nielsen TO, Prat A, Voduc D, Rodriguez‐Lescure A, et al. Defining breast cancer intrinsic subtypes by quantitative receptor expression. The oncologist. 2015;20(5):474-82.
6. Tsang J, Tse GM. Molecular classification of breast cancer. Advances in anatomic pathology. 2020;27(1):27-35.
7. Peppercorn J, Perou CM, Carey LA. Molecular subtypes in breast cancer evaluation and management: divide and conquer. Breast Cancer. 2007:125-42.
8. Prat A, Baselga J. The role of hormonal therapy in the management of hormonal-receptor-positive breast cancer with co-expression of HER2. Nature Clinical Practice Oncology. 2008;5(9):531-42.
9. Cooke T, Reeves J, Lanigan A, Stanton P. HER2 as a prognostic and predictive marker for breast cancer. Annals of oncology. 2001;12:S23-S8.
10. Kurozumi S, Padilla M, Kurosumi M, Matsumoto H, Inoue K, Horiguchi J, et al. HER2 intratumoral heterogeneity analyses by concurrent HER2 gene and protein assessment for the prognosis of HER2 negative invasive breast cancer patients. Breast cancer research and treatment. 2016;158(1):99-111.
11. Cheang MC, Chia SK, Voduc D, Gao D, Leung S, Snider J, et al. Ki67 index, HER2 status, and prognosis of patients with luminal B breast cancer. JNCI: Journal of the National Cancer Institute. 2009;101(10):736-50.
12. Nielsen TO, Leung SCY, Rimm DL, Dodson A, Acs B, Badve S, et al. Assessment of Ki67 in breast cancer: updated recommendations from the international Ki67 in breast cancer working group. JNCI: Journal of the National Cancer Institute. 2021;113(7):808-19.
13. Anderson EJ, Mollon LE, Dean JL, Warholak TL, Aizer A, Platt EA, et al. A systematic review of the prevalence and diagnostic workup of PIK3CA mutations in HR+/HER2–metastatic breast cancer. International Journal of Breast Cancer. 2020;2020.
14. Deng L, Zhu X, Sun Y, Wang J, Zhong X, Li J, et al. Prevalence and prognostic role of PIK3CA/AKT1 mutations in Chinese breast cancer patients. Cancer Research and Treatment: Official Journal of Korean Cancer Association. 2019;51(1):128.
15. André F, Ciruelos E, Juric D, Loibl S, Campone M, Mayer I, et al. Alpelisib plus fulvestrant for PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor-2–negative advanced breast cancer: final overall survival results from SOLAR-1. Annals of Oncology. 2021;32(2):208-17.
16. Ricciuti B, Genova C, Crinò L, Libra M, Leonardi GC. Antitumor activity of larotrectinib in tumors harboring NTRK gene fusions: a short review on the current evidence. OncoTargets and therapy. 2019;12:3171.
17. Remoué A, Conan‐Charlet V, Bourhis A, Flahec GL, Lambros L, Marcorelles P, et al. Non‐secretory breast carcinomas lack NTRK rearrangements and TRK protein expression. Pathology International. 2019;69(2):94-6.
18. Hartman AR, Kaldate RR, Sailer LM, Painter L, Grier CE, Endsley RR, et al. Prevalence of BRCA mutations in an unselected population of triple‐negative breast cancer. Cancer. 2012;118(11):2787-95.
19. Warner E, Foulkes W, Goodwin P, Meschino W, Blondal J, Paterson C, et al. Prevalence and penetrance of BRCA1 and BRCA2 gene mutations in unselected Ashkenazi Jewish women with breast cancer. Journal of the National Cancer Institute. 1999;91(14):1241-7.
20. Cong K, Peng M, Kousholt AN, Lee WTC, Lee S, Nayak S, et al. Replication gaps are a key determinant of PARP inhibitor synthetic lethality with BRCA deficiency. Molecular cell. 2021;81(15):3128-44. e7.
21. Wallace AJ. New challenges for BRCA testing: a view from the diagnostic laboratory. European Journal of Human Genetics. 2016;24(1):S10-S8.
22. Rozenblit M, Huang R, Danziger N, Hegde P, Alexander B, Ramkissoon S, et al. Comparison of PD-L1 protein expression between primary tumors and metastatic lesions in triple negative breast cancers. Journal for Immunotherapy of Cancer. 2020;8(2).
23. Sivapiragasam A, Ashok Kumar P, Sokol ES, Albacker LA, Killian JK, Ramkissoon SH, et al. Predictive biomarkers for immune checkpoint inhibitors in metastatic breast cancer. Cancer medicine. 2021;10(1):53-61.
24. Carlson JJ, Roth JA. The impact of the Oncotype Dx breast cancer assay in clinical practice: a systematic review and meta-analysis. Breast cancer research and treatment. 2013;141(1):13-22.
25. McVeigh TP, Hughes LM, Miller N, Sheehan M, Keane M, Sweeney KJ, et al. The impact of Oncotype DX testing on breast cancer management and chemotherapy prescribing patterns in a tertiary referral centre. European Journal of Cancer. 2014;50(16):2763-70.
26. Lafitte E, Sabatier R. Genomic/transcriptomic signatures in breast cancer. A review of three prospective studies. Innovations & Thérapeutiques en Oncologie. 2022;8(1):5-11.
27. Metzger O, Cardoso F, Poncet C, Desmedt C, Linn S, Wesseling J, et al. Clinical utility of MammaPrint testing in invasive lobular carcinoma: results from the MINDACT phase III trial. European Journal of Cancer. 2020;138:S5-S6.
28. Drukker CA, Bueno‐de‐Mesquita J, Retèl VP, van Harten WH, van Tinteren H, Wesseling J, et al. A prospective evaluation of a breast cancer prognosis signature in the observational RASTER study. International journal of cancer. 2013;133(4):929-36.
29. Mittempergher L, Delahaye LJ, Witteveen AT, Snel MH, Mee S, Chan BY, et al. Performance characteristics of the BluePrint® breast cancer diagnostic test. Translational oncology. 2020;13(4):100756.
30. Wallden B, Storhoff J, Nielsen T, Dowidar N, Schaper C, Ferree S, et al. Development and verification of the PAM50-based Prosigna breast cancer gene signature assay. BMC medical genomics. 2015;8(1):1-14.
31. Lænkholm A-V, Jensen M-B, Eriksen JO, Roslind A, Buckingham W, Ferree S, et al. Population-based study of Prosigna-PAM50 and outcome among postmenopausal women with estrogen receptor-positive and HER2-negative operable invasive lobular or ductal breast cancer. Clinical breast cancer. 2020;20(4):e423-e32.
32. Ma X-J, Salunga R, Dahiya S, Wang W, Carney E, Durbecq V, et al. A five-gene molecular grade index and HOXB13: IL17BR are complementary prognostic factors in early stage breast cancer. Clinical cancer research. 2008;14(9):2601-8.
33. Noordhoek I, Treuner K, Putter H, Zhang Y, Wong J, Kranenbarg EM-K, et al. Breast cancer index predicts extended endocrine benefit to individualize selection of patients with HR+ early-stage breast cancer for 10 years of endocrine therapy. Clinical Cancer Research. 2021;27(1):311-9.
34. Bartlett J, Sgroi D, Treuner K, Zhang Y, Ahmed I, Piper T, et al. Breast Cancer Index and prediction of benefit from extended endocrine therapy in breast cancer patients treated in the Adjuvant Tamoxifen—To Offer More?(aTTom) trial. Annals of Oncology.
2019;30(11):1776-83.
35. Pennock ND, Jindal S, Horton W, Sun D, Narasimhan J, Carbone L, et al. RNA-seq from archival FFPE breast cancer samples: molecular pathway fidelity and novel discovery. BMC medical genomics. 2019;12(1):1-18.
36. Duffy M, Harbeck N, Nap M, Molina R, Nicolini A, Senkus E, et al. Clinical use of biomarkers in breast cancer: Updated guidelines from the European Group on Tumor Markers (EGTM). European journal of cancer. 2017;75:284-98.
37. Nofech-Mozes S, Hanna W, Rakovitch E. Molecular evaluation of breast ductal carcinoma in situ with oncotype DX DCIS. The American journal of pathology. 2019;189(5):975-80.
38. Shah C, Bremer T, Cox C, Whitworth P, Patel R, Patel A, et al. The Clinical Utility of DCISionRT® on Radiation Therapy Decision Making in Patients with Ductal Carcinoma In Situ Following Breast-Conserving Surgery. Annals of surgical oncology. 2021;28(11):5974-84.

Results of College Written Exam 2022 (Council Meeting 20 July 2022)

Results of College Written Exam 2022 in Chemical Pathology, Clinical Microbiology & Infection and Haematology

Passed candidates can proceed further in Fellowship Assessment / Membership Examination in 2022.

Measurable residual disease (MRD) for Haematological Malignancy

Volume 17, Issue 1, January 2022  (download full article in pdf)

Editorial note:

Measurable residual disease (MRD) monitoring has emerged as an important indicator for risk stratification and treatment planning in patients with haematological malignancies. In the past decade, various techniques in measuring MRD have become available in Hong Kong. In this Topical Update, Dr. YIP Sze-fai provides an overview of the current techniques available for MRD monitoring. We welcome any feedback or suggestions. Please direct them to Dr. Alvin IP of Education Committee, the Hong Kong College of Pathologists. Opinions expressed are those of the authors or named individuals, and are not necessarily those of the Hong Kong College of Pathologists.

Dr. YIP Sze-fai

Consultant Haematologist, Department of Clinical Pathology, Tuen Mun Hospital

Introduction

Measurable residual disease (MRD) describes the application of assays for detection of submicroscopic level of residual disease burden which cannot be detected by morphology. Numerous studies have observed the association of MRD level and disease prognosis. It provides an objective parameter on the tumor burden, and guide stratified treatment including the application of haemopoietic stem cell transplantation (HSCT). Its ability to monitor disease and to detect molecular relapse enables preemptive therapy to prevent frank disease relapse [1]. For all these reasons, we see an increasing use of MRD in the field of haematological malignancy.

Different technologies are used for MRD measurement

1. Multiparametric flow cytometry (MFC)

MFC is commonly used for MRD detection in acute leukaemias. At diagnosis, the leukaemia-associated immunophenotype (LAIP) of the blasts can be determined by using a multitude of fluorochrome-labeled monoclonal antibodies against different cellular markers that aids identification of the leukaemic population as well as detecting the aberrant cellular marker expression. If the LAIP was not determined at diagnosis, a different-from-normal (DfN) approach can be used to detect the abnormal cells, as well as detecting any new or disappearance of known phenotypic aberrancies [1,2]. With technological advancement, more fluorochromes are available and 8 to 12-colour panels are commonly used. Flow cytometry has the advantage of a short turnaround time which can provide timely results for clinical decision making. The sensitivity of MRD detection is at the level of 10^-4 to 10^-5.

2. Next generation flow (NGF) for plasma cell myeloma

Novel Euroflow-based next generation flow (NGF) approach is being developed for highly sensitive and standardized MRD detection, primarily in plasma cell myeloma, using an optimized 2-tube 8-color antibody panel [3]. The NGF approach uses tools and procedures that are developed by the EuroFlow Consortium for a standardized sample preparation, antibody panel (including the type of antibody and fluorochrome), and automatic identification of plasma cells against reference databases of normal and patient BM using Infinicyt software. The sensitivity of MRD detection is close to 10^-6.

3. Quantitative polymerase chain reaction (qPCR) technique

a. Detection of leukaemia-specific fusion transcript

The MRD can be measured by detecting the amount of leukaemia-specific fusion transcripts present. The classical example is BCR-ABL1 fusion in chronic myeloid leukaemia (CML). The sensitivity is higher than that of flow cytometry, reaching the level of 10^-4 to 10^-6. The test is relatively easy to be performed in hospital service laboratory. The MRD is represented in a ratio of normalized copy number of the fusion transcript and the control gene transcript (e.g. ABL1). For CML monitoring, an international scale (IS) ratio is developed for standardization of results among different laboratories [4]. Yet, this method is limited to cases with targetable fusion transcripts available for detection.

b. Allele-specific oligonucleotide (ASO) qPCR for immunoglobulin (IG) or T cell receptor (TCR) gene rearrangement

ASO qPCR can be employed to detect the disease-specific sequence of rearranged IG gene or TCR gene in the sample. The sensitivity of this method is 10-4 to 10-5. It is applicable to most of the cases of acute lymphoblastic leukemia (ALL) and plasma cell myeloma as long as a disease-specific rearrangement can be determined by sequencing. Patient-specific primers would need to be designed for each case. It has a disadvantage that if there is a clonal evolution, the disease-specific rearrangement can be lost and a false-negative result can be generated.

4. Digital droplet polymerase chain reaction (ddPCR)

In ddPCR, the sample is compartmentalized into very large number of separate small volume reactions. As a result, either zero or one target molecule could be detected inside any individual reaction. Thermal cycling would be performed to endpoint using same primer and probes as qPCR. Any target-containing compartments will become brightly fluorescent while compartments without targets will have only background fluorescence. Total number of ‘positive’ reactions is equal to the number of original target molecules in the entire volume, and the total number of reactions multiplied by the individual reaction volume equals the total volume assayed. Therefore, ddPCR provides an absolute quantification of the target molecules. The ddPCR has the advantage of very high sensitivity of ~10^-6, does not require a standard curve unlike qPCR, and is tolerant to PCR inhibitors due to small partition volume. The application of ddPCR includes monitoring of NPM1 and ASO IG or TCR gene rearrangement [5,6].

5. Next generation sequencing (NGS)

NGS is a robust method to perform multiple sequencing in parallel which can also be used for MRD detection apart from the detection of mutations that are of diagnostic, prognostic and therapeutic importance. For MRD detection, the LymphoTrack platform can be used to detect disease-specific IG or TCR gene rearrangements. The sensitivity of the method can be up to 10^-5 or higher [7]. A diagnostic sample would be required for identification of the disease-specific rearrangement. However, this method is also capable of detecting clonal evolution.

Reference

1. Schuurhuis GJ, Heuser M, Freeman S, et al. Minimal/measurable residual disease in AML: a consensus document from the European LeukemiaNet MRD Working Party. Blood. 2018 Mar 22;131(12):1275-1291. doi: 10.1182/blood-2017-09-801498.
2. Baer MR, Stewart CC, Dodge RK, et al. High frequency of immunophenotype changes in acute myeloid leukemia at relapse: implications for residual disease detection (Cancer and Leukemia Group B Study 8361). Blood. 2001 Jun 1;97(11):3574-80. doi: 10.1182/blood.v97.11.3574.
3. Flores-Montero J, Sanoja-Flores L, Paiva B, et al. Next Generation Flow for highly sensitive and standardized detection of minimal residual disease in multiple myeloma. Leukemia. 2017 Oct;31(10):2094-2103. doi: 10.1038/leu.2017.29.
4. Hughes T, Deininger M, Hochhaus A, et al. Monitoring CML patients responding to treatment with tyrosine kinase inhibitors: review and recommendations for harmonizing current methodology for detecting BCR-ABL transcripts and kinase domain mutations and for expressing results. Blood. 2006 Jul 1;108(1):28-37. doi: 10.1182/blood-2006-01-0092.
5. Bill M, Grimm J, Jentzsch M, et al. Digital droplet PCR-based absolute quantification of pre-transplant NPM1 mutation burden predicts relapse in acute myeloid leukemia patients. Ann Hematol. 2018 Oct;97(10):1757-1765. doi: 10.1007/s00277-018-3373-y. Epub 2018 May 22. PMID: 29785446.
6. Takamatsu H, Wee RK, Zaimoku Y, et al. A comparison of minimal residual disease detection in autografts among ASO-qPCR, droplet digital PCR, and next-generation sequencing in patients with multiple myeloma who underwent autologous stem cell transplantation. Br J Haematol. 2018 Nov;183(4):664-668. doi: 10.1111/bjh.15002. Epub 2017 Dec 22. PMID: 29270982.
7. Yao Q, Bai Y, Orfao A, Chim CS. Standardized Minimal Residual Disease Detection by Next-Generation Sequencing in Multiple Myeloma. Front Oncol. 2019 Jun 6;9:449. doi: 10.3389/fonc.2019.00449.

Volume 30, Issue 1 (click here to download the full pdf version)

Message from the President

In this issue of the College Newsletter, I am delighted to announce that Professor Dennis LO, Professor Joseph Sriyal Malik PEIRIS and Professor Kwok Yung YUEN (in the order of their surnames) have received the prestigious Royal Medal of The Royal Society as well as the Future Science Prize 2021 in life sciences for their contributions in the discoveries of cell-free DNA for noninvasive prenatal diagnosis and zoonotic transfer of coronavirus to human causing Severe Acute Respiratory Syndrome (SARS) in 2003, respectively. My heartfelt congratulations!

Under the new normal of COVID-19, all examinations in 2021 were still conducted using video conferencing technology. I would also like to thank all external and local examiners for their hard work and to congratulate all successful candidates in the College Membership Examination and Fellowship Assessment. They have added new workforce to the diagnostic services in Hong Kong.

Another issue of postgraduate education under the new normal is how to receive training without a face-to-face arrangement. The Academy recently held a Medical Education Conference to discuss the way forward on e-learning, competency-based training and continuous workplace-based assessment. Both educators and students need to acquire new skills and improve their resilience to training progress.

Dr Derek HUNG and Professor KY YUEN wrote a Topical Update in this issue of newsletter titled “Diagnosis of COVID-19”. It is a timely topic to review all the diagnostic modalities to combat COVID-19.

Last but not least, our College, jointly with Academy, has prepared promotional materials for COVID-19 vaccination including posters and videos. They are uploaded to the COVID corner of our College website and Facebook. Please feel free to share them with your friends and family.

Finally, allow me to wish you all ‘good health’ going forward !

Dr. CHAN Ho Ming
President

Volume 29, Issue 2 (click here to download the full pdf version)

Message from the President

In this issue of the College Newsletter, I am delighted to announce that the Genetic and Genomic Pathology (GGPath) Training Programme and all successful First Fellows of GGPath have been fully accredited by The Hong Kong Academy of Medicine and this new specialty has been listed as one of the sixty-three specialties in the Specialist Register of The Medical Council of Hong Kong. Therefore, College would like to remind all concerned Fellows about the proper quotation of this new qualification. Also, I would like to thank the joint effort of all members of GGPath Training Programme Working Group, GGPath First Fellow Assessment Team and the newly established GGPath Specialty Board for their hard work. Hopefully, our College can enroll the first batch of GGPath trainees very soon.

As President of the College, I participated in Academy of Medicine’s 27th Annual General Meeting held last December. The Sir David Todd Orator 2020 was Professor Francis CHAN with his talk titled ‘Being a Leader’. The Conferment Ceremony was conducted in the Academy Building in a very unusual way due to precautionary measures for COVID-19 with all the Fellowship recipients joining via video conferencing. Each College President announced his/her new Academy Fellows on screen.

I would like to send my heartfelt congratulations to Dr FOO Ka Chung, our new Distinguished Young Fellow, who also wrote a Topical Update in this issue of newsletter as well as all new Fellows and Members who were successful in College Examinations 2020 conducted via video conferencing during COVID-19 pandemic. I would also take this chance to thank our External Examiners, Chief Examiners, Deputy Chief Examiner and Local Examiners for their tremendous effort in making it possible for the College Examinations to be conducted as scheduled.

In the Out of the Whitecoat article, Dr LEE Kam Cheong shared with us about his fascinating bird-watching stories.

Professor Paul CHAN was recently interviewed by ‘PathWay’ of The Royal College of Pathologists of Australasia to share how Hong Kong managed COVID-19.

Finally, allow me to wish you all ‘good health’ going forward !

Dr. CHAN Ho Ming
President

Trainee Presentation Session 2021

Venue: Pao Yue Kong Auditorium, Hong Kong Academy of Medicine Jockey Club Building

Time: 27 Nov 2021 9:00 - 12:30

Detail schedule in pdf

Introduction

Dr. YAU Tsz Wai Derek

9:00 - 9:10

Platform Oral Presentation

9:10 - 11:30

2021 TPS Abstract Book in pdf

Dr. CHIU Hei-Yung Kelvin

Emergence of Staplyococcus Lugdunensis as a Cause of Urinary Tract Infection: Results of the Routine Use of MALDI-TOF MS

Dr. SIN Ching-Tai Eugene

A Risk Stratification Model for Vancomycin-Resistant Enterococcus Colonization Amongst Traced Hospital Contacts

Dr. LAM Wing-Kit

MYD88 Mutation in Diffuse Large B-cell Lymphoma: Single Center Study in Hong Kong

Dr. LAM Ki

Single sIgE for Dermatophagoides pteronyssinus (Dp) is a Good Screening Tool for Atopic Sensitization

Dr. HUNG Ling-Yin

X-Chromosome Inactivation and PCDH19- associated Epileptic Encephalopathy: A Novel PCDH19 variant in a Chinese family

Dr. TSANG Yat-Ming

Evaluation of Nanopore-based 16S rDNA Amplicons Sequencing for Detection of Bacteria on Culture-Negative Specimens with Clinical Evidence of Infection

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Dr. LI Ting-Hon Stanford

A Retrospective Observational Study On The Red Cell Morphological Changes And Changes In Haematological Parameters Associated With Alectinib

Dr. FUNG Ching-Ki

Uterine Sarcoma with MEIS1-NCOA2 fusion - A Case Report and Review of the Literature

Dr. LI Xin

Asymptomatic Shedding of SARS-CoV-2 in Conjunctival Secretions

Poster Presentation

11:30 - 12:30

Dr. GAO Yang

Splenic Littoral Cell Haemangioendothelioma: Case Report

Download poster in pdf

Dr. LO Chun-Hai Haison

A Retrospective Study on Cytogenetic Features and Prognosis of Chinese Myeloma Patients in a Tertiary Referral Centre in Hong Kong

Download poster in pdf

Dr. HAU Man-Nga

Intestinal Ganglioneuromatosis: An Unusual Presenting Feature in MEN2B Syndrome As Acute Toxic Megacolon

Download poster in pdf

Dr. WONG Yuen-Sze Sivia

Microscopic Colitis: Report of Two Cases of Collagenous Colitis

Download poster in pdf

Dr. LI Wai-Yan Jamilla

Langerhans Cell Sarcoma: A Case Report

Download poster in pdf

Dr. LEUNG Hoi Shan

Biotin Interference and Biotin-Depletion Protocol

Download poster in pdf

Dr. LI Ting-Hon Stanford

A Retrospective Study on Cytogenetic Features and Prognosis of Chinese Myeloma Patients in a Tertiary Referral Centre in Hong Kong

Download poster in pdf

Judges Meeting and Words from Judges

12:05 - 12:15

Prize and Certificates Presentation

12:15 - 12:30

Results of College Exam 2021 (Council Meeting 29 Septmeber 2021)

Fellowship Assessment:

Membership Examination: