FocalPoint guided screening

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1 FocalPoint guided screening John-Paul BOGERS Ina Benoy Christophe Depuydt University of Antwerp Labo Lokeren campus Riatol - Antwerp -

2 Overview What is focal point guided screening Technical introduction How was FPGS implemented in our laboratory FP Screening characteristics FocalPoint as slide classifier Guided Screening as screening tool Conclusion Lab Lokeren BVBA Campus RIATOL

3 1 Slides 2 Scan: Hardware 3 Analyse: Software 4 Report/ slide score 5 Review

4 BD FocalPoint Design: Slides 4 types of slides can be used with the BD FocalPoint Multiple barcode formats 24 hours per day operation 240 conventional slides/ day 288 BD SurePath slides/ day 65,000 conventional slides/ year 80,000 BD SurePath slides/ year

5 Workflow Human Actions 1 Fill Tray 2 Load and Leave Add barcode labelled BD SurePath slides to a slide tray (8 slides per tray) Load slide trays into input hopper of BD FocalPoint slide profiler (max 36 slide trays at one time = 288 slides) Racks can be loaded and unloaded at any time Minimum 120 slides per run There is no maximum number of slides per run 3 Sort 4 Screen GS

6 BD FocalPoint Design: Hardware Workstation: Record and report results to the lab Unix OS: stable performance Modem: Remote Troubleshooting Instrument: analyze PAP smear slides Printer: Report Printsets System messages

7 System Components Turret, Stage, Camera s, FOV Computers Slide is positioned under microscope Touch sensor detects slide Barcode read 4x & 20x objectives scan slide 3 camera s capture cell images and send them to the computers for analysis up to 25 images/sec FOV processors : image analyzing and classifying

8 BD FocalPoint : The full process 4x scan of specimen area Low resolution (4x) scan of entire specimen area: 3D map of specimen, chooses fields most likely to contain abnormal cells and cellular aggregates = Segmentation Selection of 1000 fields for in-depth analysis, 20x scan FOV processors High resolution (20x) Field Of View scan of the 1000 selected images Feature extraction of single objects, groups and thick groups Single cell Group Thick group Single cell, group and thick group score values for each field of view (FOV) = Object Classification FOV result Slide score FOV result accumulation and integration Slide score value between 0 and 1.0 where 1.0 = highest likelihood of abnormal

9 BD FocalPoint : Ranking and Sorting X = # slides < 25% Normal > 75% Review > 15% QC Negative Abnormal Review slides are sorted into 5 equal quintiles Y = anomaly score Slides with scores below the Primary threshold can be archived with no further review Slides with scores above the Primary Threshold are reviewed by Cytotechnologists Slides with scores above the QC threshold are rescreened by Cytotechnologists

10 Overview cervical cancer screening the RIATOL algorithm SEMI AUTOMATED AUTOMATED Liquid based preparation leftover = 800 µl JANUS TM DNA in 96 deep well LIMS JANUS TM Mmix 2 x 384 well plate LC 480 HPV results Roche remote Cytology / PAP FocalPoint TM prescreening SlideWizard TM HPV targeted screening Lab Lokeren BVBA Campus RIATOL

11 Slide preparation - staining Prepmade Autocyte Lab Lokeren BVBA Campus RIATOL

12 Pre-screening FocalPoint Lab Lokeren BVBA Campus RIATOL

13 DNA preparation - DNA amplification Janus / MultiProbe II Janus + LC480 Lab Lokeren BVBA Campus RIATOL

14 FocalPoint as slide classifier How many positive cases are classified as NFR? (=false negative/sensitivity) What is the performance of the ranking algorithm? - How well does the quintile information represents reality? (=specificity) - 14

15 PI, SurePath Cohort : Study Set-up Focalpoint 3,638 SUREPATH (3 centers) 17 Excluded 3,621 Analyzed CURRENT PRACTICE 1,182 NFR 2,439 REVIEW FULL MANUAL SCREEN TRUTH DETERMINATION - 15

16 Passamonti, 2007 : Study Set-up FPGS 37,306 CONVENTIONAL 3,302 Excluded 34,004 Analyzed 7,399 NFR 26,605 REVIEW GS 15 FOV REVIEW 26,196 NORMAL 409 ABNORMAL INADEQUATE RAPID 2-min REVIEW FULL MANUAL SCREEN NORMAL ABNORMAL INADEQUATE BLIND REVIEW + DISCREPANCY TRUTH DETERMINATION Passamonti B et al. Evaluation of the FocalPoint GS System Performance in an Italian Population-Based Screening of Cervical Abnormalities. Acta Cytologica. 2007;51() - 16

17 NFR in SUREPATH Study (PI - Page 14, Table 19 - Page 18, Table 30 & 31) False Negative Fraction = 10 / 693 = 1.4 % = FN / TP - 17

18 NFR in Passamonti,2007 False Negative Fraction = 9 / 418 = 2.2 % = FN / TP - Histopathology on 2 LSIL + 1 ASCUS = CIN1 ; Histopathology on 2 ASC-H + 1 LSIL = negative ; Colposcopy on 2 ASCUS = negative ; Repeat cytology on 1 ASCUS = negative 18

19 Slide Ranking in SUREPATH Study N = 693 abnormals in the study 10 in NFR = 683 in quintiles % of SurePath abnormal slides FocalPoint Ranked Review Abnormal SurePath slides % Slides in Quintile ~ 72% of the abnormal slides are found in Quintile 1& 2-19

20 Slide Ranking in SUREPATH Study (PI - Page 18, Table 30) N = 693 abnormals in the study 10 in NFR = 683 in quintiles FocalPoint Ranked Review 100% % of Slides 80% 60% 40% 20% CA AIS HSIL LSIL AGUS ASCUS 0% CA AIS HSIL LSIL AGUS ASCUS Quintile - 20

21 Slide Ranking in Passamonti, 2007 N = 418 abnormals in the study 9 in NFR = 409 in quintiles % HSIL+ 97% LSIL 97% other abnormalities HSIL+ LSIL ASC-H ASCUS/AGC 50 0 Q1 Q2 Q3 Q4 Q5 NFR 86 % of all abnormalities - 21

22 Study algorithm Cytology+ HPV + ProEx C + Colposcopy n = women participated Aged between yrs Exclusion: history, pregnancy Aug 2005 Feb 2007 colpo + Immediate biopsy n = 81 (13 CIN2+) 1st visit colpo - + ve - ve Follow up 6 months HPV- Cyt - HPV- Cyt + HPV+ Cyt - HPV+ Cyt + HPV- Cyt + HPV+ Cyt - HPV+ Cyt + HPV- Cyt - 2nd Colposcopy & biopsy n = 165 (30 CIN2+) - ve + ve Follow up guidelines Treatment as required Follow up guidelines Lab Lokeren BVBA Campus RIATOL -

23 Quintile ranking Lab Lokeren BVBA Campus RIATOL

24 What is the screening performance of FPGS Compare detection of abnormal cases in FP versus manually screened slides - 24

25 SUREPATH Study (PI - Page 16 3 centers combined) LSIL+ Disease Detection 2/3 centers detected numerically more LSIL+ disease in FP as compared to manual practice S i t e N o. FP Manual - 25

26 SUREPATH Study (PI - Page 16 3 centers combined) # of Slides HSIL+ Detection FP Manual 3/3 centers detected numerically more HSIL+ disease in FP as compared to manual practice Site No. - 26

27 Wilbur, 2002 : Study Set-up FPGS 1,300 SUREPATH (1049 routine normals seeded with 215 abnormals) 25 Excluded 1,275 Analyzed CURRENT PRACTICE 218 NFR 1,057 REVIEW GS 10 FOV REVIEW 619 FOV NORMAL 2 NO FOV 438 FOV ABNORMAL FULL MANUAL SCREEN TRUTH DETERMINATION Wilbur DC et al: Location-guided screening of liquid-based cervical cytology specimens. A potential improvement in accuracy and productivity is demonstrated in a preclinical feasibility trial. Am J Clin Pathol. 2002;118:

28 FOV- in Wilbur,2002 False Negative Fraction = FN / TP = 8 / 214 = 3.7 % - 28

29 How is the FocalPoint integrated in our laboratory practice? Lab Lokeren BVBA Campus RIATOL

30 Overview cervical cancer screening the RIATOL algorithm SEMI AUTOMATED AUTOMATED Liquid based preparation leftover = 800 µl JANUS TM DNA in 96 deep well LIMS JANUS TM Mmix 2 x 384 well plate LC 480 HPV results Roche remote Cytology / PAP FocalPoint TM prescreening SlideWizard TM HPV targeted screening Lab Lokeren BVBA Campus RIATOL

31 Sensitivity / specificity for CIN2+ detection Screening without prior knowledge of HPV Screening with prior knowledge of HPV Primary HPV Screening Primary HPV Screening with viral load > 0.2 c/c Primary HPV Screening with viral load > 2.8 c/c Sens Spec NPV PPV FPR FNR 58.14% 94.35% 99.34% 13.37% 5.65% 41.86% 74.42% 93.48% 99.59% 14.61% 6.52% 25.58% 95.35% 84.93% 99.92% 8.67% 15.07% 4.65% 95.35% 90.27% 99.92% 12.81% 9.73% 4.65% 88.37% 93.16% 99.81% 16.24% 11.63% 6.84% Lab Lokeren BVBA Campus RIATOL

32 Case 72 year old woman First smear in 2006 HSIL/AGC HPV negative FP Q1 (7/180) Second smear in 2008 HSIL HPV negative FP Q1 (12/138) No histology available Lab Lokeren BVBA Campus RIATOL

33 Case 2006 Lab Lokeren BVBA Campus RIATOL

34 2006 Lab Lokeren BVBA Campus RIATOL

35 2008 Lab Lokeren BVBA Campus RIATOL

36 ProExC Lab Lokeren BVBA Campus RIATOL

37 Conclusion Focal Point guided screening - The ranking algorithm is robust - The NFR ranking is accurate - Is sensitive to detect significant lesions Some HPV negative high grade lesions - ProExC can be useful in finding abnormal cells - HANDOUT see

38 Acknowledgments Pathology Prof. Dr. JP. Bogers Dr. J. Vandepitte R. Baveco K. De Preter I. Goegebeur M. Vervoort Cytology N. Deckers L. De Krijger C. De Maesschalck E. De Wulf K. Franken K. Van Belle S. Van Belle Apr. A. Vereecken Apr. G. Salembier Molecular Biology Dr. C. Depuydt Dr. Apr. I. Benoy L. Boels I. De Brabander B. Gabriels K. Ielegems N. Segers Administration I. De Ceulaer F. De Keersmaecker L. De Lepeleire K. De Schrijver H. Dierckx S. Peeters C. Van Heurck V. Van Hoof Thanks to Peggy Verelst (BD) for providing a lot of slides Labo Lokeren Lab Lokeren BVBA Campus RIATOL

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