Hello, welcome. I am Dr. Marilyn Bui. I'm the immediate past president of the Florida Society of Pathologists. Today I'm going to moderate the Precision Medicine Academy of the FSP. Today's lecture is on application of molecular and the genomic biomarker testing in solid tumors. Next slide. So this is a CME event. You will earn one AMA PRA category one credit and the conflict of interests of the meeting planner and the faculty are listed here. This program is supported by educational grants from AstraZeneca, the CME is provided by the accreditation council for continued medical education. Next slide. So we're very excited to share FSP's Precision Medicine Academy with everyone. And with this funding, we're able to open up FSP's learning center. So this is a hub that hosts many educational activities there in addition to Precision Medicine Academy. At this center, we have educational enrichment activity. We have specialized curriculum on molecular pathology, bioinformatics, digital pathology, and eye and biomarker testing. Our goal is to facilitate the multidisciplinary communication between the pathologists and the medical oncologists, starting by arming the pathologists in biomarker testing. Next slide. Today we have the privilege to welcome two distinguished faculty. One is Dr. Newsome, Director of Molecular Pathology Informatics at the University of Florida. The second is Dr. Terry Boyle. Welcome back, Dr. Boyle. She is a molecular pathologist at the Moffitt Cancer Center. Next slide, please. So we're going to start with some polling questions. You can see it on the screen, and you have the ability to choose one single best choice. And we have two questions on the screen, so please click away. Once we're done with the polling, Dr. Jo Kim will reveal the correct answer for us. So as a reminder to everyone, please be sure to scroll down and to click an answer for each of the three questions. All right, there is a number three. It's on clouding two. So everyone should see a pop-up window. Be sure to click on the answer and then scroll down, click on your answers. We'll give everyone about 10 more seconds. Okay, we're going to end the poll and then we will go over the results. So this is how you all responded to the questions. The correct answer for the first question was N-Trek gene fusions. The correct answer for the second question is B, it allows detection of a broader range of genetic alterations, including copy number variations and structural variants. And then for the third question, the correct answer is also B, gastric and pancreatic cancers. All right, so now you did not get a chance to answer the question correctly. Now let's listen to the lectures and we're learning from this. So let's welcome Dr. Newsom to take this away first. Thank you. Thank you very much. This slide is showing the objectives of the study today. And by the end of this, hopefully you will be able to explain the methodology and clinical utility of molecular and genomic testing in various solid tumors, evaluate the interpretation and reporting of molecular biomarker testing results, discuss newer solid tumor biomarkers that are clinically actionable, and apply genomic testing results to support personalized treatment plans and inform prognosis. We're going to break this talk up into two different parts. I'm going to present part one, and Dr. Boyle is going to present part two. In part one, I'm going to cover an introduction to molecular and genomic biomarker testing, as well as talk briefly about newer clinically actionable biomarkers, including HER2, CLAUDIN 18.2, and NRG1 gene fusions. I'll discuss methodologies in molecular and genomic testing, as well as some challenges and opportunities in molecular and genomic testing. In Part 2, Dr. Boyle is going to cover the clinical utility of molecular and genomic testing in solid tumors, including looking at some of the predictive values for targeted therapies and some of the tumor agnostic biomarkers, and then interpretation and reporting of molecular and biomarker testing results, including best practices for interpreting this genomic data, guidelines for generating clear and actionable reports, as well as integration of these test results with clinical and pathological findings, and also the application of these genomic testing and personalized treatment plans, including matching biomarker test results with targeted therapies, and their role in clinical trial enrollment and experimental therapies. So as cancer treatment continues to move towards personalized medicine, the role of molecular and genomic biomarkers has become increasingly important, and molecular biomarkers refer to specific molecules, such as DNA, RNA, or proteins, that provide insight into the genetic makeup of a tumor. These biomarkers can help us to understand cancer's diagnostic, prognostic, molecular drivers, help us predict the likelihood of response to specific therapies, and to monitor disease progression and or minimal and measurable residual disease. And by analyzing these biomarkers, we can move from a one-size-fits-all treatment approach to a more tailored precision approach, where the treatment is matched to the individual genetic profile of the tumor. Molecular biomarkers refer to any molecule that can be measured and evaluated as an indicator of biological processes, diseases, or treatment responses, and these can include both genetic and non-genetic molecules, such as proteins, tabolites, and lipids. Genomic biomarkers are going to specifically refer to biomarkers that are derived from DNA or RNA, and they can provide insights into genetic alterations, such as mutations, amplifications, deletions, or rearrangements. We can further classify biomarkers by their clinical role, and this can include diagnostic biomarkers that can help us to identify diseases, such as elevated PSA levels in prostate cancer. Prognostic biomarkers that can help us to predict outcomes, such as HER2 amplification in breast cancer, which can predict a more aggressive disease and poorer prognosis. Predictive biomarkers can help us to guide therapies. Monitoring biomarkers can help us in recurrence detection, as well as pharmacodynamic biomarkers can help us to measure the biological response of a drug. So there's a lot of different molecular biomarkers in solid tumors, and this is a nice reference that has been put together by the Association for Molecular Pathology Training Education Committee, and these are these molecular in-my-pocket reference cards. And this is a nice tool that helps us to look at different biomarkers that are, it classifies the different genes and biomarkers that are associated with a different disease or tissue type, as well as what the significance of these biomarkers is. And then it will also tell us what are the primary assays that are involved in detecting these different biomarkers. And one of the things about this is you can see some of these are straightforward in different biomarkers for the different tumor types. However, some of these can be much more complex and more extensive. And so these would have their own separate card, such as colorectal cancer and lung cancer, which I'll briefly touch on now. So if we look at some of these different biomarkers in colorectal cancer, we might look at KRAS, NRAS, and BRAF, and these would help us to figure out what kind of therapies we might use for colorectal cancer, as well as we can use, you know, MLH1 promoter methylation analysis or tumor mutation burden. And then if we look at the molecular biomarkers of lung cancer, these biomarkers are somewhat different and we can look at EGFR, ALPRET-RAS fusion proteins, or some of these other biomarkers that are listed here. And we can also see on this list of maybe some emerging biomarkers that are there, such as MET amplification. So we have a lot of these different biomarkers that are tumor-specific. And however, we do have a lot of newer applications for established biomarkers. And one of these examples is HER2, in which originally this was identified in breast tumors and we have treatment therapies available for that. And however, over time, we have extended the clinical utility of this biomarker into different tumors. We also have newer clinically actionable biomarkers, such as CLAUDIN 18.2. CLAUDINs are tight junction proteins that are present throughout the body, but there's two specific isoforms that are localized to the lung, as well, and 18.2 is actually specifically located in the gastric tissue. And what they've found is that this can be overexpressed in tumors and therefore makes a nice target, since it is such specifically localized to the gastric tissue. And the mechanism or the assays that we can use in order to look at CLAUDIN 18.2 is IHC. And what we would look for there is to see if you have moderate or strong staining would be an indication of overexpression of this protein in the gastric tissue. Another new clinical actionable biomarker is the neuroregulin 1 gene, or NRG1. This is typically a ligand protein that's binding for HER2 and HER3. However, when it becomes a fusion protein, it retains the EGF-like domain of NRG1 and activates the ERBB2 and ERBB3 receptor signaling, which can lead to the downstream constitutive activation of the PI3, AKT, and MAP kinase pathways. This does make it a potential sensitivity to ERBB2 and ERBB3 inhibitors, and this fusion has been found in lung, pancreatic, breast cancer, and other solid tumors. And the methodologies in which we can use to detect this fusion protein are next-generation sequencing that is specifically designed for fusion detection, as well as RNA sequencing or FISH hybridization. Now there's a number of different methodologies in molecular and genomic biomarker testing. These can be broadly characterized into nucleic acid amplification techniques, such as PCR and digital PCR. These techniques are going to be highly sensitive for known mutations, and they can detect low levels of variants or different biomarkers in heterogeneous samples. This can be quick and inexpensive. However, to all of these biomarker testing techniques, there's going to be many different pros and cons. The con to the PCR side would be that you're going to be limited to a known mutation, and it may not detect complex alterations, and this technique is going to require careful primer design. High-throughput sequencing techniques, such as next-generation sequencing, whole-genome and whole-exome sequencing, RNA sequencing, all these methods can detect a broad range of mutations, and they provide a comprehensive analysis, as they can analyze many genes at once. However, the downside of these assays is they can have a high cost, and they require complex data analysis, as they have a lot of data to look at, and these can be time-consuming and require high sequencing depth. Hybridization techniques, such as FISH and CGH, can be used to detect large-scale alterations and chromosomal rearrangements. However, these can be limited to specific alterations and can be less sensitive for mutations and require specialized equipment, and these can have lower resolution than next-generation sequencing. Immunohistochemistry is a simple and inexpensive technique that can provide information on protein expression. However, you can get variable staining due to antibody quality. So, if we take a high-level look at next-generation sequencing techniques, there's two main ways that DNA can be manipulated in order to utilize next-generation sequencing. One way is an amplicon-based approach, and this is where you would use about 20 base pair oligos in order to target specific regions of the DNA. Now, these might be small, specific regions, and this could be called sometimes a hotspot panel, and so primers can only play so well together to a certain number, so you have a limited number of primers that can go into a mix at one time, so you'd be targeting a very specific regions and small number of targets, versus hybridization. You would use longer hybridization DNA probes, usually maybe 120 base pairs long, and this would allow you to look at longer regions of DNA and to pull down more regions of DNA, and so the hybridization capture can allow for more targets to be enriched in sequence per panel, and these can perform better with respect to uniformity and complexity, and that's due to the fact that with primer-based amplification, if you only have a 20 base pair amplicon and you have a mutation in that region, your primer, your assay may suffer from primer dropout, and so in this case, hybridization capture assays can allow for the detection of not only single nucleotide variants, but also copy number and structural variants as well as indels. However, hybridization techniques can be higher cost and more complex workflow. So the clinical utility of any of these assays is going to be highly dependent on the state of the sample that comes into the lab. And so if we look at tissue versus liquid biopsy, tissue testing is going to be the gold standard for molecular diagnostic testing. And this is because you're going to have a higher enrichment of tumor-specific DNA, and you'll have greater DNA resolution. However, you can have limitations in this, whereas this tissue biopsy can be invasive or you may have a limited sample quantity. Versus with liquid biopsy testing, this is a nice non-invasive alternative role and can be useful in monitoring and detecting resistant mutations. However, the sensitivity and specificity should be taken into consideration for this assay, where cell-free DNA can have a lower variable sensitivity, where you can get up to a 30% false negative rate due to the fact that you may have a limited number of tumor samples in the sample population that you're evaluating. So liquid biopsy may be a good option when the patient is unfit for an invasive tissue biopsy or diagnostic biopsy and is insufficient for molecular analysis. However, if there's no oncogenic driver detected, tissue analysis should be planned on for a follow-up. So there's a number of different pre-analytical variables to consider when thinking about biomarker testing. And so there's many different biopsy methods that occur before a sample can get to the lab. And you can have tissue biopsy, cytology, and, you know, one of the types of tissues that we get that we typically have trouble with is maybe a fine-needle aspiration sample. These can be small and not have a lot of tissue available, and sometimes can be over-fixed and reduces the sensitivity of our assays. And so when you have these cell blocks or tissue pellets or FFPE blocks, these can be analyzed for morphological assessment, and from there decisions can be made upon what assessment methods we want to use, and that would dictate which kind of extraction methods we want to do. And it's key to point out that each one of these steps can have its own variability and cause, introduce variables to the assays that you're performing. So one issue that we see in the lab is you can have analytical issues where you may see a false negative because of low tumor cellularity. And so in this case, when you don't enrich for the tumor, you can reduce the sensitivity and potentially reduce the ability to detect an important variant. So on this slide, in the top slide, you see that if there's only 10% tumor available, then your variant allele fraction for a potential driver mutation is only at 2.5%, versus if you enrich for that tumor and now you have 30% tumor cells, you would get a much higher variant allele frequency, and you would be more likely to detect a driver mutation in this case. So some financial considerations that we like to think about when you're considering molecular and genomic biomarker testing is to think, so if I do next-gen sequencing paneling, this may be a more expensive assay and take a little more time, versus if I do a sequential or a hotspot panel, which can be a little bit quicker. However, if I'm only looking at one mutation at a time, and if I'm only looking at one mutation at a time, and if I, you know, so if I have the first mutation and I see a positive for an alteration, I might go ahead and initiate appropriate therapy. But if I have a negative test, then I would have to go back for more testing. And then if I keep continuing to test there, you know, I might have to go back for a re-biopsy and continue testing. And that can all increase the amount, the total time that I'm looking at for a, to find a potential appropriate biomarker that would lead, guide my therapy. And that can be true for either sequential or the hotspot panels. And now I will pass this off to Dr. Boyle, who will cover our part two. DR. BOYLE Great. Thank you, Kim. Wonderful presentation and great background to start my discussion of the clinical utility of molecular testing, interpretation of results, reporting of results, and also the importance of a team-based approach for communicating about the results for best patient care. And I'm including this slide really as an example of how important it is to perform this molecular testing to help make sure that the patient gets on the best targeted therapy for their care. But the molecular testing is also important for diagnosis and prognosis. So in this example with the Lung Cancer Mutation Consortium study, you can see on the black line on the survival curve that these are patients who had a driver mutation identified in lung cancer, and the patient received the match targeted therapy. And you can see that their survival is really better than the patients who are on the green line who had a driver identified but no targeted therapy, and also better than the patients on the blue line who might have had the testing but no driver was identified, and maybe these patients received chemotherapy, immunotherapy, but there wasn't a marker for targeted therapy. So it's really important not only in lung cancer anymore but many cancer types to perform comprehensive testing to identify this whole variety of different mutations that can lead to targeted therapy or enrollment in clinical trials. And beginning in 2017, the FDA had its first cancer site agnostic approval for solid tumors. Up to that point in time, all the FDA approvals were really more targeted to a site-specific cancer like lung cancer, EGFR mutation, given EGFR inhibitor, but here with the FDA approval of microsatellite instability, high status, or deficient mismatch repair by immunohistochemistry, the FDA approved targeted therapy if a patient had progressed following prior treatment or had no satisfactory alternative treatment options, and this was really a new way of approving medicine, and it really means that for the genetic testing that we need to be more comprehensive for all of our patients with solid tumors to provide them this opportunity for targeted therapy. The third FDA approval was for tumor mutation burden, and just like the microsatellite instability, if high tumor mutation burden is identified in any solid tumor, then the FDA approved the immunotherapy after progression on prior treatment in patients who have no satisfactory alternative treatment options. Now, this was based on the keynote 158 study, and in lung cancer, tumor mutation burden was initially received with great excitement, but we also had the biomarker of PD-L1, and so patients could already receive immunotherapy based on being PD-L1 positive, so the impact in lung cancer ended up being smaller in some other cancer types, which did not have alternative ways to allow patients the opportunity to receive immunotherapy. So, this was the third cancer site agnostic approval. Does anybody know what the second cancer site agnostic FDA approval was? So, that was for Ntrek fusions. With Ntrek fusions, they were identified in multiple cancer types, and there were several competing clinical trials, but the trial to receive the first FDA approval was larotractinib for adult and pediatric patients with solid tumors that had Ntrek gene fusions without a known acquired resistance mutation, and this is a really rare fusion to identify in most solid tumors. It's more common in some tumors than other tumors. In lung cancer, it's probably less than one in a thousand, so that's why I have this purple needle in the haystack. You don't want to miss that one patient out of the thousand that has the Ntrek fusion because there's a dramatic response to the Ntrek inhibitor in such patients, but you don't want to use up the tissue on the other 999 patients on a single gene test for Ntrek. So, again, it highlights how helpful it is to have comprehensive molecular profiling such as with next-generation sequencing to identify this one needle in the haystack that can be really life-saving in the patients that do have the Ntrek fusions. And then in June 22nd, 2022, BRAF V600E mutations had their day. FDA granted accelerated approval for dibraphinib in combination with tremetinib in metastatic solid tumors with BRAF V600E mutations, and so originally BRAF V600E mutations were associated with melanomas and targeted therapy in melanomas, but people observed that BRAF V600E mutations were observed in other cancer types, and there was the clinical trial, several clinical trials, including NCI MATCH that associated response to targeted therapy, not just melanoma, but multiple cancer types. And so, again, FDA approved targeted therapy in multiple cancer types, and in this case, they did make an exception with colorectal cancer because in colorectal cancer, there's intrinsic resistance to BRAF inhibition, so the interpretation of these results is really important, too, and we still do need to know the origin of these tumors, but these FDA approvals in multiple cancer types highlights how it's important first to do comprehensive genomic profiling in all cancer types, and also that it's important to interpret the results specific to the cancer type. So, more recently, in 2022, the FDA approved targeted therapy in RET fusions. For many, many years, different companies tried to develop RET inhibitors, and there really was not great response to the RET inhibitors until selprocatinib came along, and this drug really showed great response in solid tumors with RET gene fusions, and so this was another tumor cytognostic FDA approval. There have been more approvals since then. I'm not sure if I put that, but we had the very most recent approval of HER2 immunohistochemistry in 2024. The FDA granted accelerated approval for famtrestuzumab, derextuchen, and XKI for patients with metastatic HER2-positive solid tumors who have received prior systemic treatment with no satisfactory alternative treatment options. So, there's a similar tune to all of these FDA approvals. The FDA really is allowing consideration of this targeted therapy in multiple tumor types with the caveat that if there's some other therapy in the first line or some more well-established alternative, that should be considered first, but this has really opened the door for more patients with even very rare tumor types to receive target therapy where there isn't this strong weight of established evidence and trials to support that the trial will work in this very rare cancer with this broad FDA approval in solid tumors. It opens the opportunity for targeted therapy to more patients. It puts the onus on us to perform this testing in solid tumors. So, like the survival curve showed, if you don't test and you don't know, then the patient might not have the opportunity to benefit from the targeted therapies. So, we've seen this increase in FDA approvals of targeted therapies, multiple cancer types, and we're doing this comprehensive testing. How do we interpret the results? Some of the FDA approvals are very specific to a mutation, but in some cases it's more expensive, such as EGFR exon 20 insertions or HRD genes, homologous recombination deficiency genes. What genes are there within those genes? Which mutations are pathogenic or just germline polymorphisms? Fortunately, we have guidelines and standards from the American College of Medical Genetics and Genomics and the Association for Molecular Pathology to help with this complex interpretation of the molecular results. Here, we need to remove benign polymorphisms off of the reports and filter them out, and we have this guidance to help us understand which of these variants or changes in the sequence should be removed from the report. I see Lamise on this call, and Dr. Sayeed, she was a fellow with us, and during her molecular fellowship, she became quite proficient at figuring out which of these mutations to put high on the report. These are the very strong pathogenic mutations in the red to removing the benign variants that you don't want the oncologist to be distracted by benign changes where there won't be response to therapy. So, how do we do this? We're looking at population data. We're looking at computerized predictive data. We're looking at functional data, segregation data, de novo data, allelic data. We're looking at PubMed to see what's been published. Now, we aren't doing experiments in our own lab to produce functional data. We're more likely to look that up, and for our turnaround time of NGS results, we really need to consider how much time we spend looking up the 50 different variants and deciding how to level them versus getting the results to the oncologist in a timely fashion or to the pathologist because this is also ordered for diagnosis, and the AP pathologist, the anatomic pathologist is often involved in the communication of these results with the oncologists and other members of the teams. So, we have resources to help us. The exome aggregation consortium helps us to filter out the nine variants automatically. We set up filters based on database SNP and 1,000 genomes so that variants that are found in the normal population are filtered out. We have to be careful with patients with minority ethnicities where they might have more variations that have not been automatically filtered out in these databases, and we also have disease databases such as ClinVar, which has received an FDA stamp of approval, and in ClinVar, you can see what have different organizations done to try to better understand the clinical significance of the variant that you're seeing on your report, and so we can look up variants that we've never seen before and see if somebody else has performed some functional data analysis. Have they called it pathogenic? Have they called it likely pathogenic? Is it a variant of uncertain significance or just a benign polymorphism? OncoKB is another great resource that has some FDA approval. Most of what's in OncoKB is also in ClinVar, but not everything, so I find these two resources very time-efficient ways to distinguish between pathogenic and non-pathogenic variants, and it has an ID number associated with it so other people can look up that variant with the ID number. So with time, we are becoming more standardized with our interpretation of these variants, so if something is reported with Dr. Kim Newsom's group in Gainesville, Florida, she'll be interpreting at the same level as we are here at Moffitt Cancer Center, so the goal is to to have more standardized practices in how we perform the reporting, and we also have resources outside our country. The European Society for Medical Oncologists came up with this great publication with recommendations on best practices for reporting genomic test results, and they recommend inclusion of some of the usual things, patient and sample characteristics, and the genetic alterations, implications for diagnosis, prognosis, and therapy selection. That's routine, and they also recommend put at the top of the report the very most important findings. We don't want to wait till the end of the report for the punchline. Oncologists don't really have that much time to necessarily read to the bottom of the report, so right up at the top we're putting the most clinically actionable changes. They recommend a summary statement and narrative form with the main findings and this is right for us right below the automatic reporting of the top actionable variants. We have a space where we as molecular pathologists can highlight what is important for the oncologist to know. Maybe that a combination of the results is pointing to a diagnosis and that when you put the data together that you have stronger evidence to suggest a diagnosis than just any one particular result. There's many different ways that you can use this editable field to communicate what you think the oncologist most needs to know for the care of the patient. This last recommendation we haven't entirely embraced it yet that they're recommending the inclusion of visual aids and graphic solutions and the genomic reports but it's really great food for thought and I think that's something that we can strive for because a picture is worth a thousand words and I think with time patients are going to receive more serial testing and to see how the variants change over time is going to be important and that could be a visual picture. And lastly that this is one of my favorite slides and I included in a lot of my presentations I believe I included in my last one but it's just so important that after you've gone through the work of receiving a sample and doing this genetic testing and creating a report and filtering and coming up with interpretations and signing it out and that there's some thought about what does it all mean for the patient and we're always working towards improvement on this. It's a team effort and the care provider, the oncologist, the surgeon, the pulmonologist might see the patient first and get the sample and then the sample goes to the pathology department and it gets processed and a slice of tissue may be put onto a glass slide and stained and they'll put it under the microscope and make a diagnosis and there might be an order by the anatomic pathologist or maybe the oncologist has indicated that they want genetic testing and then these unstained slides are sent to the molecular lab and the recut is reviewed by the molecular pathologist to look at the tumor cellularity to annotate regions where there might be higher tumor cellularity to make sure that you get the most DNA and RNA from the tumor and it's not too diluted by normal background tissue. And then the DNA and RNA are extracted, sequencing is performed, the sequence data goes into the informatics pipeline and the pathologist, the molecular pathologist gets the raw report and removes benign variants, highlights the most important clinically actionable variants and puts in that summary statement about what's most important for the oncologist to know and then signs it off and when that sign out occurs, a message goes to the message center of the oncologist right away or the ordering provider, it could be the anatomic pathologist and there needs to be communication about the result between all of the care providers and fortunately here at Moffitt, we also have a precision medicine group and so they're also getting a copy of the report as it's signed out and they're looking at the report and thinking about the patient, their PharmDs and they include genetic counselors during their meetings and they take this information and they think about what stage is the patient at, what line of therapy are they in, are they experiencing any side effects from the medicines they're taking, what are the clinical trials that are available at Moffitt or in Florida or near where the patient might live, maybe they're a snowbird and they go between two states so they're really thinking about the patient specifically and these genetic results. They might be reviewing the solid tumor genetic results and the patient has had a prior liquid biopsy with the blood testing and they might compare the results from different assays and are they the same, what does that mean for the diagnosis, what does that mean for this patient's care ultimately and so they will summarize the findings and what trials might be available, what targeted therapies might be available and they'll communicate with the oncologist. They have a consult note and they'll include other members of the team as needed, genetic counselors and that really, it's this application, this team, this communication, a lot of it is by email these days but we do talk to and that's really what leads to the best patient care because you remember in that first slide I showed you that in patients that have a targetable marker identified, if they don't receive the targeted therapy, they do worse than if no driver is identified and so it's really, really important that there's some process after the reporting, make the report as clear as you can but there's some communication, some team effort to make sure that if there are any significant actionable findings that the action occurs. There's also off-label therapies and I can understand from the insurance perspective you don't want to pay for an expensive therapy if a patient is not going to respond and so when an oncologist tries to prescribe an off-label therapy based on an NGS result, it might initially be denied and so that's another thing the Precision Medicine Group does here. They will help write a letter to the insurance company with references, with data, with justification to prove that indeed that off-label therapy really is the best option for that patient. So I think I've taken you through a whirlwind of this process and communication. It's in constant development and improvement, QA, and I'm really happy for this opportunity to talk with all of you and with that I'm going to turn this over to Dr. Bowie. Thank you so much Dr. Boyle and Dr. Newsom. Those lectures are just excellent from the content, the scientific expertise, and the delivery. I'm constantly impressed by the talent at our Florida, at FSP, and I just learned so much from you guys. So from your last slide, it's really struck a chord with me because as pathologists, we provide this magic sword to the medical oncologists. They are the dragon slayers, the dragons are the cancers, right? So we are here to match the targeted therapy by identifying these biomarkers. So what we do is important and this education is important. So let's see if we have any specific questions toward the content of this lecture today. So we have a comment here, it's from Dr. Saeed, and thanks the speakers for their teaching and questions. All right, so then I will start with a question. If I'm in a community practicing pathology, how do I know what to test? So where do I find these guidelines and resources to just to direct how I practice and order what test? I could take a first try at that. I think in some ways it's almost gotten simpler because of these FDA approvals in all solid tumors. These days, you really do in advanced stage cancers want the NGS testing, the comprehensive testing. And so there may be still be some situations where you would not want to test, but I think it's fair to consider NGS testing on all patients with advanced solid tumors. In terms of resources, I thought Dr. Newson brought up the AMP genomic markers in a pocket. Do you want to talk about that a little more? Yeah, I think that's a great resource. And I agree with Dr. Boyle with next-gen sequencing, most of the panels that you'll be getting today should cover the large majority of the mutations that would be involved in solid tumors. And then the only thing I would add on to that is, if there is no driver mutation to consider RNA sequencing as an option, because the RNA sequencing will cover all known and unknown fusions that may be present in some of these solid tumors. And so, I mean, if that's an option that you can, if you have that testing available to you, but that would make it a little bit easier than knowing each specific assay that I need to order for which specific individual, you know, different type of tumor. So in bottom line is there are so many FDA-approved pan-tumor biomarkers, so almost every single solid tumor warrants NGS testing, period. However, not all organization has the mechanisms to order. So at Moffitt, pathologists can order like Moffitt STAR 2.0. It's very similar to Foundation 1 testing. But if you are in community and you may wait for the medical oncologist to trigger that ordering, then you got to keep in mind every single solid tumor warrants NGS testing. So then make sure the quality of the tissue, the fixation time, and the efficiency, it's really, really important. So that's, if we can drive home that message, it's really important because Dr. Boyle showed that chart. When you test it, you don't treat, has the worst prognosis. When you test it, there's no target you can treat with target therapy. That's just bad luck. But if the patient has the target, you can treat with target therapy, that's really good for the patient outcome. So that message we need to really drive home about. Then the second question is, how should we prioritize the test when the tissue is very limited? You're struggling with IHC, FISH, and NGS. Can you put it to perspective at what point it's really economical just to do the NGS testing? You want to go first or you want me to go, Dr. Boyle? Go ahead, go ahead. Yeah, I was going to say, so in our laboratory, the way we would prioritize is that our molecular technologist received the tissue first. And we can evaluate and see, I mean, after a pathologist has reviewed it, but then sometimes they don't know how much tissue was left on a block. And so we might see a block and then say, there's not enough tissue here to do all of these things. And so with lung cancer, we prioritize next-gen sequencing. But that is because our panel covers a lot of the targets that may not be covered in other panels. So I would say that is something to look at when you're, if you just go for next-gen sequencing, is to make sure that the panel you're ordering covers, like if you're looking at lung, that you're covering your Alparette-Ras fusions and the specific things that you want to be covered. Because not all next-gen sequencing panels are created the same. Yeah. There's a saying, the tissue is the issue. And particularly in lung cancer, you get these tiny specks of tissue. And there's just more and more FDA approvals. So you really have to maximize what you learn from that tiny bit of tissue. And you cannot waste it on one marker. If we did, say, NTRK immunohistochemistry to screen, we wouldn't have anything left for NGS for all the 50 other markers. So our reflex pathway for lung now is, there's the HNE for the diagnosis. There's PD-L1 and NGS. If it's a more limited sample, outcome immunohistochemistry might be performed because that's not impacted by tumor cellularity as much as the NGS. But otherwise, it's going to NGS. We want to do HER2 and MET and immunohistochemistry. But that's prioritized after the tissue going to NGS. And when there's a turnaround time urgency, there's a high index of suspicion or a patient not doing well and they need a really fast EGFR result, we can get a result within hours upon receipt in the lab. And that's one reason why we might spend tissue on one marker. But if you have limited tissue, really, you want to do a comprehensive assay with that little bit of tissue. Very good. See, at Moffitt, we have molecular pathologists, we have precision medicine, and then everybody is specialized. Everybody's on top of the game. So that's great. But then if you don't have that resource, so you're going to send it to the reference laboratories. Many reference laboratories offer biomarker testing services, but how can community pathologists evaluate the performances of their tests? What should we look for as an indication for high quality results? I think for regular solid tumor NGS, probably going with the companies that have a reputation for high quality that have published and demonstrated that they have accurate findings and that they've performed their validations carefully. And again, it might be helpful in the community to hire somebody to help with a practice for the interpretation of the results, because they are getting more and more complex. And questions like a genetic counselor or a pharmacy, the interpretation of the results that the interpretation of those reports can really be benefited by having an expert in a community practice. It doesn't have to be a pathologist. Very good. Very good. So thank you so much for both of you. And our time is almost up, but we're going to move to the next slide. Yes, this is our FSP's Learning Center. So this is a digital platform within this Learning Center. You will see the recorded lecture of this, today's lecture. And if you attend it live, you get a free CME. But if you attend it later, you can still review it. But then there is, after today's lecture, in order to receive CME, you're going to receive an email. Then you will just go there to complete your evaluation and receive the CME right away. Please check out our Learning Center. Next slide. So this cup of a flyer is to promote the future educational activities of the FSP. As you know that we have three meetings per year. The first one we just finished, that was in Orlando, Grand Floridian. That was our annual meeting. It was such a success. Great scientific content. A lot of activities for everybody that was there. That was just fantastic. So we're working on the second one now. So that's in July 11th to 13th. It's at Miami in JW. Turnberry, Miami. It has a water park there. It's going to be fantastic. You see, we have speakers listed here. The topics are lymphoma, GYN pathology, and the dermatopathology. Next slide, please. So we're also working on a precision medicine multidisciplinary conference. That date is not set yet. Please look out for that. So that's our three big conference. And then for 2016, and we also have this annual meeting again. We're going to go back to Grand Floridians. The faculties are here. The topics. So we have, these are the faculty and these are the topics. So please mark your calendar and prepare to join us again for a fantastic educational activity. Next slide. So thank you very much for attending the FSP's Precision Medicine Academy webinar today. Our next one is going to be on March 12th at noon. The topic is application of molecular genomic biomarker testing in hematopathology. We talk about solid tumor today. And then next month, we're going to talk about hematopathology. We have Dr. Ruth Cardigaro from University of Miami, Dr. Knepper from Moffitt Cancer Center. So again, please complete the evaluation in the Online Learning Center to claim CME for today. With that said, we thank both our faculties and FSP and Dr. Jo Kim for organizing this lecture. And I hope you have a rest of the, enjoying the rest of your afternoon. Bye everyone. Bye-bye.

precision medicine

molecular testing

genomic biomarkers

solid tumors

CME credits

HER2

next-generation sequencing

FDA approvals

ClinVar

OncoKB