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From tumor board, an integrated diagnostic report

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Karen Titus

December 2014—The handling of molecular information bears a certain resemblance to Wall Street’s bundling of mortgages in recent years. You can slice ’em, dice ’em, and repackage them in all sorts of ways. In medicine, however, this is being done—one would hope—without the ensuing meltdown. The goal is to shape personalized medicine, using the results of next-generation sequencing and other technologies to evaluate genetic information ranging from single gene to whole exome or whole genome, with proteomics possibly not too far behind.

It’s entrancing and staggering. “The fundamental problem is we’re generating more information than we can readily interpret as individuals,” says Neal Lindeman, MD, associate professor of pathology, Harvard Medical School, and director of molecular diagnostics, Brigham and Women’s Hospital, Boston.
Adds his colleague Azra Ligon, PhD: “The message has become clear, and it has been clear to us for some time—we can’t all operate in isolation.”

One solution to managing the data implosion is pleasingly simple, says Dr. Ligon. Talking to a pathology colleague about genomic test results “can be as easy as picking up the phone or walking down the hallway.”

But Dr. Ligon, associate professor of pathology, Harvard Medical School, and director, BWH clinical cytogenetics laboratory, is also familiar with an arrangement that is less simplistic, one that draws multiple diagnosticians from different disciplines within pathology to review genomic data in real time. It’s a molecular tumor board, known at BWH as a diagnostic tumor board because of its broader, integrative role. In fact, factor in nearby Dana-Farber Cancer Institute, and Boston appears to be a hotbed of molecular tumor boards.

Dr. Ligon and her colleague (and husband) Keith Ligon, MD, PhD, set up the brain tumor diagnostic tumor board at Brigham and Women’s Hospital in 2012. The goal has been to integrate information generated by multiple tests on the same patient. At their institution this had grown to include cytogenetic (whole genome array CGH, FISH), molecular (targeted exome sequencing), immunohistochemistry, and histopathology data. At this relatively early stage, one element typically present at the traditional tumor board—clinical oncologists and others on the clinical treatment team—remains absent.

Second of two parts on molecular tumor boards. See October 2014.

It’s not an oversight. While the ultimate goal is to align molecular and cytogenetic results with clinical treatment decisions, for now it’s challenging enough to navigate the multiple streams of information flowing forth from multiple labs. Genomic data are like J.S. Bach’s liturgical output, both enriching and vast. Brigham and Women’s Hospital has a Center for Advanced Molecular Diagnostics, with two component labs. Dr. Lindeman heads the molecular diagnostics laboratory; Dr. Azra Ligon runs the clinical cytogenetics laboratory. The brain tumor diagnostic tumor board, which meets weekly, combines results from these two labs with the histopathology re­sults on all adult and pediatric brain cancer patients seen at the Dana-Farber Brigham and Women’s Cancer Center and Dana-Farber Boston Children’s Cancer and Blood Disorders Center. Anywhere from six to 16 people attend each meeting.

Dr. Azra Ligon

Dr. Azra Ligon

A neuropathologist and either a cytogeneticist from Azra’s group or a molecular genetic pathologist from Dr. Lindeman’s group co-sign the diagnostic reports; it’s up to the pathologist to add additional information to the original, surgical pathology, or “root” report, as Keith calls it. At times, that might even call for reanalyzing data. The report is then communicated to the clinical treatment team, including surgeons, oncologists, radiation oncologists, and radiologists, who go over the findings at a separate, more traditional treatment-focused tumor board—in this case, one specializing in brain tumors. Representatives from the diagnostic tumor board, generally the neuropathologists, also attend the treatment tumor board and “bring this valuable experience back to the diagnostic tumor board,” Keith says.

Azra describes several benefits of this approach. First, she says, the treating physicians have all the testing information—histology, IHC, cytogenetics, cytogenomics, and molecular diagnostics—on a single integrated report. “They don’t have to find and go through a half-dozen or so reports and put it all together themselves.”

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