What specimen types are suitable for mutation testing in NSCLC patients?

From Cancer Guidelines Wiki

Systematic Review Evidence

Advanced stage lung adenocarcinomas, NSCLC with any glandular differentiation or NSCLC, not otherwise specified, all require mutation testing to assess for targetable mutations in the epidermal growth factor receptor (EGFR) gene or translocations involving the anaplastic lymphoma kinase (ALK) gene.[1][2][3] This information is required to help determine the most appropriate 1st line treatment due to the availability of tyrosine kinase inhibitors that specifically target these alterations.[1][2][3] Pathologists and treating physicians need to know which specimens are suitable for mutation testing to ensure the mutation status of each patient’s tumour is accurately determined.

Most studies compared the concordance of mutation status in tissue samples obtained from primary tumours versus metastases; or the mutation status in histology tissue samples versus cytology samples. While there was generally high concordance across the different groups in keeping with the underlying biology of these genetic alterations as driver alterations, slightly lower rates of mutations were sometimes found in samples obtained from metastatic tumours compared to primary tumours, possibly relating to technical factors such as smaller tumour samples from these sites. Little information was provided on the sample size, quantity or proportion of tumour cells which could all effect the results. Lower concordance was also generally found when lower sensitivity techniques were used to assess mutation status. To avoid false negatives, primary tumours or samples with the greatest tumour volume should be used for mutation testing where available. In the setting of EGFR mutant tumours that have developed resistance to an EGFR-TKI, repeat testing may be undertaken to assess for acquisition of targetable resistance mutations (such as EGFR T790M mutation) and tissue or “liquid biopsy” specimens (circulating tumour DNA in plasma) could potentially be used, however, this was not specifically addressed in the literature review.

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Evidence summary and recommendations

Evidence summary Level References
There is generally high concordance in the mutation status of tumours obtained by using samples from histology or cytology samples, or from primary tumours versus metastases III-1, III-2 [4], [5], [6]
Evidence-based recommendationQuestion mark transparent.png Grade
Any tumour sample can be used for mutation testing (sample from primary or metastatic site; histology or cytology sample).

Practice pointQuestion mark transparent.png

It is advisable to use the optimal specimen available from each patient for mutation testing (if more than one specimen is available). This would be the specimen with the highest content and proportion of tumour cells and could be a histology specimen such as a core biopsy or a cytology specimen. This should be determined on a case by case basis by a pathologist.


  1. 1.0 1.1 Lindeman NI, Cagle PT, Beasley MB, Chitale DA, Dacic S, Giaccone G, et al. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. J Thorac Oncol 2013 Jul;8(7):823-59 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23552377.
  2. 2.0 2.1 Cooper WA, O'toole S, Boyer M, Horvath L, Mahar A. What's new in non-small cell lung cancer for pathologists: the importance of accurate subtyping, EGFR mutations and ALK rearrangements. Pathology 2011 Feb;43(2):103-15 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21233671.
  3. 3.0 3.1 Cancer Council Australia Lung Cancer Guidelines Working Party. Clinical practice guidelines for the treatment of lung cancer. [homepage on the internet] Sydney: Cancer Council Australia; Available from: http://wiki.cancer.org.au/australia/Guidelines:Lung_cancer.
  4. Bruno P, Mariotta S, Ricci A, Duranti E, Scozzi D, Noto A, et al. Reliability of direct sequencing of EGFR: comparison between cytological and histological samples from the same patient. Anticancer Res 2011 Dec;31(12):4207-10 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22199282.
  5. Park S, Holmes-Tisch AJ, Cho EY, Shim YM, Kim J, Kim HS, et al. Discordance of molecular biomarkers associated with epidermal growth factor receptor pathway between primary tumors and lymph node metastasis in non-small cell lung cancer. J Thorac Oncol 2009 Jul;4(7):809-15 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19487967.
  6. Wang F, Fang P, Hou DY, Leng ZJ, Cao LJ. Comparison of epidermal growth factor receptor mutations between primary tumors and lymph nodes in non-small cell lung cancer: a review and meta-analysis of published data. Asian Pac J Cancer Prev 2014;15(11):4493-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24969875.

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