NanoString Prosigna assay

The tissue input for the Prosigna assay was FFPE tissue that had been previously diagnosed to contain viable invasive breast carcinoma. The breast tumor tissue must be classified by a pathologist as invasive carcinoma (ductal, lobular, mixed, or no special type). A pathologist reviews an H&E stain of a slide mounted tumor section to identify and circle the region of viable invasive breast carcinoma. The tumor surface area on the H&E stained section must be ≥ 4 mm² per slide, with tumor cellularity ≥ 10%. Non-tumor tissue from outside the circled area is removed by macrodissection of the corresponding unstained slides. RNA was extracted from slide mounted breast tissue sections using a RNA extraction kit manufactured by Roche to NanoString’s specifications [26]. For RNA isolation, a single 10-micron slide mounted tissue section was input for RNA extraction when the tumor surface area measured ≥ 100 mm², whereas 3 slides were input when the tumor surface measured 4-99 mm². Following extraction of total RNA and removal of genomic DNA, RNA was eluted (30 μL volume) and tested to ensure it met the specifications for concentration (≥ 12.5 ng/ μL) and purity (OD 260/280 nm 1.7-2.5).

The NanoString Prosigna assay [26] measures the expression levels of 50 target genes plus eight constitutively expressed normalization genes [15, 27, 28]. Assay controls are included to ensure that test samples and the test process meet pre-defined quality thresholds. Exogenous probes with no sequence homology to human RNA sequences are included as positive and negative assay controls. Positive controls are comprised of a six point linear titration of in vitro transcribed RNA covering an approximately 1000 fold RNA concentration range (0.125 – 128 fM) and corresponding probes [29, 30]. Negative controls consist of a set of probes without the corresponding targets. Each assay run includes two reference control samples comprising in vitro transcribed RNA of the 58 targets for qualification and normalization purposes.

Extracted RNA samples meeting quality and concentration specifications were hybridized (without reverse transcription or amplification) to capture and reporter probes for the measured genes and assay controls. The multiplexed hybridizations are carried out in a single-tube for 15 – 21 hrs at 65°C using 125 – 500 ng RNA (nominal input of 250 ng). After hybridization, the target-probe complexes were processed on the nCounter Analysis System. Test sample data must meet a minimum threshold for expression of normalizing genes to ensure that the assay signal is high enough for the algorithm to produce precise results. The linearity of the positive control target titration and the non-specific background from negative control probes included in each assay is used to determine whether each assay performed within specification. Since the test is designed to be run in local molecular pathology labs, all quality thresholds are applied automatically to the data by embedded software; any failing metric causes an assay failure notice which prevents output of a Prosigna assay result. For samples meeting all quality thresholds, a clinically validated algorithm is used to determine the intrinsic subtype and ROR score, which are prognostic indicators of risk of distant recurrence of breast cancer [19, 21]. The normalized gene expression profile of each breast tumor sample is correlated to prototypical gene expression profiles of the four breast cancer intrinsic subtypes (Luminal A, Luminal B, HER2-enriched, and Basal-like). The primary tumor size (categorical input of ≤ 2 cm or > 2 cm) and normalized gene expression profile of each breast tumor sample is used to calculate the numerical ROR score. Risk categories are assigned to allow interpretation of the ROR score by using pre-specified cutoffs (defined in a clinical validation study) related to risk of distant recurrence after 10 years [19].

Operators for these studies were required to undergo training procedures to demonstrate proficiency, equivalent to what will be used to train users in molecular pathology laboratories for the decentralized test. Each site was given an overview of the NanoString technology and Prosigna assay procedures followed by an in-lab exercise where users were trained and qualified on tissue processing and assay procedures (requiring 10-12 hours of total hands-on time). Briefly, each user extracted RNA from three FFPE breast tumor tissue samples to demonstrate proficiency in tissue processing, and each user processed four prototypical breast tumor RNA samples (one of each intrinsic subtype with known expected ROR score values) along with a negative control sample to demonstrate proficiency on the nCounter Analysis System.

The analytical studies described herein were performed using pre-specified SOPs, statistical analysis plans and acceptance criteria using clinical-grade reagents, instrumentation, and software formatted such that no comparison of results between test centers could even be possible until the study was completed.

RNA precision: study design

The RNA Precision study assessed the reproducibility of the Prosigna assay using a common template of purified RNA, thereby isolating the device-specific components of analytical validity from variables associated with tissue processing. The experimental design for analytically validating the precision of the assay from RNA was based on Clinical Laboratory and Standards Institute (CLSI) guidelines for the evaluation of precision of in vitro diagnostic devices outlined in EP05-A2 [25]. This design measured the variability between and within a number of assay variables including testing site (n = 3), operator (n = 6), reagent lot (n = 3) and assay run (n = 18/site). Two of the three sites used were CLIA-certified, CAP-accredited laboratories at the British Columbia Cancer Agency (Vancouver), and Washington University (St. Louis); the third site was NanoString Technologies (Seattle).

Single use aliquots of each pooled breast tumor RNA sample and three reagent lots were distributed to each of the three testing sites to complete the following testing scheme (Figure 1). Each of the five RNA pooled samples was tested in duplicate during each run at the nominal RNA input level for the assay of 250 ng. The positions of the tumor RNA samples within the system (cartridge and strip tube position) were pre-assigned in a randomized and balanced manner for each run. Each operator completed one run on a given day since the assay includes an overnight hybridization step qualifying it as a “long run method” per CLSI EP05-A2. Following a device and study protocol familiarization run, each site completed 18 valid runs (9 by each operator) (Figure 1).

Upon completion of the study the blinded data were collected from each site and merged with the expected test result and study variables (site, operator, reagent lot, etc.) associated with each unique sample ID. The prospectively defined analysis plan was then executed on the merged analysis dataset.

RNA precision: statistical analysis

The pre-specified primary aim of the RNA precision validation was to demonstrate that there was no significant differences for the continuous ROR score assay output across the three testing sites.

The following variance components model was used to characterize the sources of variability:

ROR Score = site + operator + lot + run + within-run

where all components were treated as random components, and the RNA assay component of variation was defined as the sum of all these components. Variance components were estimated using the R procedure “lmer”. To test whether sites were significantly different, the following versions of the above model were fitted:

ROR Score = site + operator + lot + run + within-run

& ROR Score = operator + lot + run + within-run

where site was now treated as fixed and all other components were treated as random. A likelihood ratio test with 2-degrees of freedom was performed using the fitted models to determine whether the effect of site was significant (α = 0.05). A similar analysis was performed for the assay reagent lots.

For each of the 5 pooled samples, the classifications into the 4 intrinsic subtype categories (Luminal A, Luminal B, Basal-Like, HER2-enriched) were summarized using frequency tables.

Reproducibility: study design

The reproducibility study assessed the analytical validity of the Prosigna assay, including all steps involving in clinical lab implementation (i.e. tissue handling and RNA isolation SOPs as well as the device-specific assay steps), using a common set of breast cancer tissue samples.

The experimental design for analytically validating the reproducibility from tissue was based on CLSI guidelines for the evaluation of precision of in vitro diagnostic devices outlined in CLSI EP05-A2. This design allows for the measurement of variability between and within a number of assay variables including testing site, FFPE sample block, operator, reagent lot, and assay run.

The criterion that at least 10 cases contain ≥ 100 mm² and at least 10 cases contain 4 - 99 mm² tumor area was implemented to validate the number of slides required for the assay. The blocks were not prescreened with the assay prior to inclusion, but it was anticipated that the 43 samples would cover a broad range of ROR scores representative of the intended use population, including both node-negative and node-positive patients, and each risk classification group. Seventeen tissue samples were from node-negative patients, 6 from node-positive patients and 20 were from patients whose regional lymph node status was provided by the biobank as NX.

For reproducibility testing (Figure 2), three sets of serially cut sections, each comprised of one H&E 4-micron stained slide and three 10-micron thick unstained slides, were prepared from each FFPE block. All cut and slide mounted sections were shipped to NanoString and then one set from each of the 43 blocks was distributed to the appropriate testing site for processing. All 43 specimens were reviewed independently by a separate pathologist for each of the three sites.

For each tissue sample, a test run consisting of macrodissection, RNA extraction, and testing with the Prosigna assay was performed by a single operator at each site following the provided standard operating procedures. Each operator performed a minimum of four test runs consisting of up to 10 tissue samples per run. Each batch of tissue samples required a minimum run time of 3 days from tissue processing to result. Isolated RNA that met the quantity and quality specifications from each of the slide mounted sections was tested twice in separate assay runs. Different lots of RNA isolation kit reagents were used at each site, and a single lot of the Prosigna assay kit was used at all three sites.

The test results for all samples remained blinded to all personnel at all sites until the study was complete. Upon completion of the study the blinded Prosigna assay data were collected from each site and merged with the expected test result and study variables (site, operator, reagent lot, etc.) associated with each unique sample ID. The prospectively defined analysis plan was then executed on the merged analysis dataset.

Reproducibility: statistical analysis

The pre-specified primary aim of the tissue reproducibility validation was to demonstrate the Prosigna assay is highly reproducible, when combining all sources of variation. For this study, “highly reproducible” was defined as a total standard deviation (SD) of less than 4.3 ROR units. The value of <4.3 was chosen because if two samples have true ROR scores that differ by 10 units, a total SD of 4.3 means that 95% of the time the higher of the two will still have a higher individual observed ROR score. A change of 10 ROR units corresponds to an average change in 10-year distant recurrence free survival of 7% and 6% for node negative and node positive patients respectively [19].

The following variance components model was used to characterize the sources of variability:where FFPE Block was treated as a fixed component, and site and section were treated as random components. The “site” term measured the systematic site-specific variation that was constant across all tissue samples (pathologist, technician, extraction kit). The tissue section component measures random variation that differed as a function of review/processing or within FFPE block variation. The error term was derived from the duplicate RNA samples and estimated the combination of run-to-run and within-run variance. Variance components were estimated using the R procedure “lmer”. In the above model, the variance components were estimated from a combined analysis of all FFPE blocks after verifying that were no systematic changes in tissue-specific variation as a function of ROR score.

Measurement = FFPE Block + site + tissue section + error

where ${\mathit{\sigma }}_{\mathit{tissue}}^2$ was estimated as the sum of the site-to-site and section component estimated in the tissue reproducibility study, and ${\mathit{\sigma }}_{\mathit{RNA}\mathit{assay}}^2$ was estimated as the total variation from the RNA precision study.

Additional categorical analyses were performed using two classifications:

RNA from each tissue sample was tested twice at each site so there are 4 possible comparisons between sites for each tissue sample leading to a total number of possible comparisons of 4*number of tissue samples. For each of the two classification schemes (risk category or subtype), the pair-wise concordance between sites was estimated as the fraction of all possible comparisons that were concordant and an exact-type 95% confidence interval was calculated.

In addition, a post hoc analysis compared the normalized gene expression from the 50 classifier genes between the tissue replicates from all valid specimens tested at each site using a linear regression and correlation analysis

RNA input: study design

Thirteen FFPE breast tumor blocks containing pathologically-confirmed infiltrating ductal carcinoma were obtained and RNA was extracted from multiple slide mounted tissue sections from each block using the defined procedure (Figure 3). The individual RNA isolates from each FFPE block were pooled. Each pooled tumor RNA sample was tested in duplicate across three RNA input levels within the assay specification range (500, 250, and 125 ng) and in singlet at two additional RNA input levels outside of the specification range (625, 62.5 ng). Two no-target (water) measurements were also tested in duplicate on every run. All tumor RNA samples were assumed to be node-negative with a tumor size of ≤ 2 cm for this analytical study since these clinical covariates have no impact on the measured variation in the ROR score. All samples were tested using two different Prosigna assay reagent lots.

RNA input: statistical analysis

where the average is across the n different samples. In this equation, ${\overline{\mathrm{ROR}}}_{\mathrm{Nj}}$ is the average of two replicates at the nominal level and ${\overline{\mathrm{ROR}}}_{\mathrm{Lj}}$ s the average of two replicates for input levels within specification, or is the single result for input levels outside of specification. Equivalence was pre-defined as an observed absolute average ROR difference significantly less than 3. To test the non-equivalence hypothesis that the true absolute mean difference is greater than 3, a 90% confidence interval for the difference was calculated. This 90% confidence interval corresponds to the two one-sided test approach for bioequivalence [31]. The input level was determined to be equivalent to the nominal level if the 90% confidence interval is completely contained within -3 and 3.

For each pooled sample a linear regression and correlation analysis was also performed between each replicate at each RNA input level and one of the two replicates run at 250 ng of RNA. The difference in the ROR score (ΔROR) from the nominal RNA input level (250 ng) for each replicate at each RNA input level was calculated by subtracting the ROR score calculated from one of the two replicates run at 250 ng from ROR scores calculated at the other input levels. Additionally, the ΔROR was calculated and linear regression and correlation analyses were also performed between the two replicates at 250 ng. The mean ΔROR, slope, intercept, and correlation values (with 95% confidence intervals) were calculated using the pairwise comparisons for all passing samples at each input level for both kit lots.

For the no-target (water) samples, the percentage of samples failing the minimum threshold for expression of normalizing genes was calculated. All no-target samples were required to give a failing test result.

Tissue interferents: study design and analysis

Twenty three FFPE breast tumor blocks were obtained containing pathologically-confirmed infiltrating ductal carcinoma microscopically-assessed to have 10 – 95% of the total tissue area containing normal/non-tumor tissue. Pathologists identified additional tumor interferents (DCIS, necrotic tissue, or blood/hemorrhagic tissue) within or near the margins of the tumor in ten of the 23 blocks.

For each FFPE breast tumor block, H&E stained slides were prepared and up to nine unstained sections were cut and mounted on slides. For the inclusion of the interferent, the sections were processed according to the assay procedure with the exception that identified normal/non-tumor tissue or any additional interferents were included in the isolation (“non-macrodissected slides”). For the macrodissection where the non-tumor and other interferents were removed, three or (in the case of small tumor surface areas) three and six slides were processed according to the Prosigna assay protocol.

The change in ROR (ΔROR) due to the interferent was calculated using the ROR score from the non-macrodissected slides minus the ROR score from the macrodissected slides (Figure 4). For the tissue blocks where three and six macrodissected slides were independently isolated and both produced a passing assay result, the average of the two ROR scores were used to calculate the ΔROR.

RNA precision: variance components analysis

The distribution of measured ROR scores for each of the five pooled RNA samples was also examined across the three lots, six users and three test sites. The range of ROR scores for the 108 independent measurements was ≤4 units for each of the 5 sample pools (Figure 5).

Reproducibility: test sample quality control and characterization

The call rate for the 43 tissue samples evaluated was 95%, 93%, and 100% for sites 1, 2, and 3 respectively. Forty samples yielded results at all sites (RNA isolation of one sample at one site required repeating). One tissue sample yielded results at 2 sites, and 2 samples yielded results at a single site, while the other sites did not obtain sufficient RNA to perform the assay for these samples. The measured tumor surface area for 4/5 RNA isolation failures was very small (≤ 15 mm²). One hundred percent (100%) of samples passing tissue review and RNA isolation specifications yielded passing results from the Prosigna assay.

The calculated test results from the 43 tissues across all sites represent a wide range (94 units) of ROR scores (Figure 6) and all risk categories when applying the node-negative or node-positive ROR score cutoffs to all samples. All four intrinsic subtypes were also represented among the 43 specimens. The two samples where RNA could only be successfully isolated at one site were excluded from all subsequent statistical analysis as there was no available data for comparing across sites. Both of these samples had ROR scores of less than 10 and were classified as Luminal A.

Reproducibility: variance components analysis (primary objective)

The total SD including all source of variation (tissue and RNA processing variability) was 2.9 indicating that the Prosigna assay can measure a difference between two ROR scores of 6.75 with 95% confidence.

Reproducibility: subtype and risk category classifications concordance

The site-to-site concordances for the two categorical classifications are shown in Table 4, in each case with exact-type 95% confidence intervals. For each comparison (subtype and node negative and positive risk categories), the average concordance between sites was at least 90%. There were no samples where the risk category changed from low risk to high risk (or vice versa) between or within sites when the samples were assumed to be from node negative patients. There were only two intermediate/high risk samples that did not give identical subtypes across all 6 replicates:

Reproducibility: pairwise correlation coefficients of gene expression

RNA input: test sample quality control

The average ROR score for the tested samples covered a broad range (20 – 82) and all intrinsic subtypes – including 5 Luminal A, 4 Luminal B, 3 HER2-enriched and 1 Basal-like sample (Additional file 4: FigureS2). One FFPE block was tested with a single kit lot due to insufficient RNA mass from the isolation for the second lot. Two runs (each with different samples) failed to provide passing results for one of the two lots tested due to a processing error detected by system controls with insufficient RNA to repeat the assay. All measured no-target samples (n = 46) were well below the threshold for signal and yielded a failing test result (0% call rate). All tumor RNA measurements within assay specification (n = 138) yielded a passing test result (100% call rate). One hundred percent (100%) of specimens with input above specification (625 ng) yielded a passing test result. Eighty-three percent (83%) of specimens (10/12) tested at input below specification (62.5 ng) yielded a test result in lot 1, as did 100% in lot 2.

RNA input: ROR score difference and pairwise correlation coefficients of gene expression

For each of the two reagent lots tested, the confidence interval around the mean ROR score difference between the nominal input and the RNA input limits (125 and 500 ng) were completely contained within -3 and 3 ROR units. The ROR scores at 125 and 500 ng RNA were therefore equivalent to those at the target input concentration of 250 ng for each of the two reagent kit lots tested meeting the primary objective of the study. Of note, when characterizing the RNA levels outside of the assay specification, the ROR scores at 62.5 ng RNA were not equivalent (with an upper confidence limit at 3.26) to those at the target input concentration of 250 ng for one of the two lots tested. This illustrates the importance of performing the assay according to the defined procedure.

Tissue interferents: test sample quality control

Out of 23 samples six were Luminal A, seven were Luminal B, two were HER2-enriched, and eight were Basal-like. The average ROR score for the 23 samples covered a broad range (10 – 83), (Additional file 5: Figure S3).

Tissue interferents: impact on ROR score

As the amount of adjacent non-tumor tissue increases there is an increasing risk that the reported ROR score will be an underestimate or negatively biased (up to -19 ROR score units for samples containing 95% non-tumor tissue) estimate of a patient’s risk of recurrence (Figure 7). Elimination of the macrodissection step required by the assay also caused a change in subtype determination for five out of 23 samples. Three Luminal B samples, one HER2-enriched, and one basal-like sample were classified as Luminal A due to inclusion of adjacent non-tumor tissue. In contrast, the presence of intratumor hemorrhage, necrosis or DCIS (not removed by macrodissection) had little effect on ROR.