Development and validation of a supervised deep learning algorithm for automated whole-slide programmed death-ligand 1 tumour proportion score assessment in non-small cell lung cancer

Aims Immunohistochemical programmed death-ligand 1 (PD-L1) staining to predict responsiveness to immunotherapy in patients with advanced non-small cell lung cancer (NSCLC) has several drawbacks: a robust gold standard is lacking, and there is substantial interobserver and intraobserver variance, with up to 20% discordance around cutoff points. The aim of this study was to develop a new deep learning-based PD-L1 tumour proportion score (TPS) algorithm, trained and validated on a routine diagnostic dataset of digitised PD-L1 (22C3, laboratory-developed test)-stained samples. Methods and results We designed a fully supervised deep learning algorithm for whole-slide PD-L1 assessment, consisting of four sequential convolutional neural networks (CNNs), using aiforia create software. We included 199 whole slide images (WSIs) of 'routine diagnostic' histology samples from stage IV NSCLC patients, and trained the algorithm by using a training set of 60 representative cases. We validated the algorithm by comparing the algorithm TPS with the reference score in a held-out validation set. The algorithm had similar concordance with the reference score (79%) as the pathologists had with one another (75%). The intraclass coefficient was 0.96 and Cohen's kappa coefficient was 0.69 for the algorithm. Around the 1% and 50% cutoff points, concordance was also similar between pathologists and the algorithm. Conclusions We designed a new, deep learning-based PD-L1 TPS algorithm that is similarly able to assess PD-L1 expression in daily routine diagnostic cases as pathologists. Successful validation on routine diagnostic WSIs and detailed visual feedback show that this algorithm meets the requirements for functioning as a 'scoring assistant'.Pathogenesis and treatment of chronic pulmonary disease

The impact of a pathologist's personality on the interobserver variability and diagnostic accuracy of predictive PD-L1 immunohistochemistry in lung cancer

OBJECTIVES: Programmed death-ligand 1 (PD-L1) is the only approved predictive biomarker for immunotherapy in non-small cell lung cancer (NSCLC). However, predictive PD-L1 immunohistochemistry is subject to interobserver variability. We hypothesized that a pathologist's personality influences the interobserver variability and diagnostic accuracy of PD-L1 immunoscoring. MATERIALS AND METHODS: Seventeen pathologists performed PD-L1 immunoscoring on 50 resected NSCLC tumors in three categories (<1%;1-49%;≥50%). Also, the pathologists completed a certified personality test (NEO-PI-r), assessing five personality traits: neuroticism, extraversion, openness, altruism and conscientiousness. RESULTS: The overall agreement among pathologists for a series of 47 tumors was substantial (kappa = 0.63). Of these, 23/47 (49%) tumors were entirely negative or largely positive, resulting in a kappa value of 0.93. The remaining 24/47 (51%) tumors had a PD-L1 score around the cutoff value, generating a kappa value of 0.32. Pathologists with high scores for conscientiousness (careful, diligent) had the least interobserver variability (r = 0.6, p = 0.009). Also, they showed a trend towards higher sensitivity (74% vs. 68%, p = 0.4), specificity (86% vs. 82%, p = 0.3) and percent agreement (83% vs. 79%, p = 0.3), although not significant. In contrast, pathologists with high scores for neuroticism (sensitive, anxious) had significantly lower specificity (80% vs. 87%, p = 0.03) and percent agreement (78% vs. 85%, p = 0.03). Also, a trend towards high interobserver variability (r = -0.3, p = 0.2) and lower sensitivity (68% vs. 74%, p = 0.3) was observed, although not significant. Pathologists with relatively high scores for conscientiousness scored fewer tumors PD-L1 positive at the ≥ 1% cut-off (r = -0.5, p = 0.03). In contrast, pathologists with relatively high scores for neuroticism score more tumors PD-L1 positive at ≥ 1% (r = 0.6, p = 0.017) and ≥ 50% cut-offs (r = 0.6, p = 0.009). CONCLUSIONS: This study is the first to demonstrate the impact of a pathologist's personality on the interobserver variability and diagnostic accuracy of immunostaining, in the context of PD-L1 in NSCLC. Larger studies are needed for validation of these findings

Population Impact of Girls-Only Human Papillomavirus 16/18 Vaccination in the Netherlands: Cross-Protective and Second-Order Herd Effects

Background: Human papillomavirus (HPV) vaccination programs achieve substantial population-level impact, with effects extending beyond protection of vaccinated individuals. We assessed trends in HPV prevalence up to 8 years postvaccination among men and women in the Netherlands, where bivalent HPV vaccination, targeting HPV types 16/18, has been offered to (pre)adolescent girls since 2009 with moderate vaccination coverage. Methods: We used data from the PASSYON study, a survey initiated in 2009 (prevaccination) and repeated biennially among 16-to 24-year-old visitors of sexual health centers. We studied genital HPV positivity from 2009 to 2017 among women, heterosexual men, and unvaccinated women using Poisson generalized estimating equation models, adjusted for individual-and population-level confounders. Trends were studied for 25 HPV types detected by the SPF10-LiPA25 platform. Results: A total of 6354 women (64.7% self-reported unvaccinated) and 2414 heterosexual men were included. Percentual declines in vaccine types HPV-16/18 were observed for all women (12.6% per year [95% confidence interval {CI}, 10.6-14.5]), heterosexual men (13.0% per year [95% CI, 8.3-17.5]), and unvaccinated women (5.4% per year [95% CI, 2.9-7.8]). We observed significant declines in HPV-31 (all women and heterosexual men), HPV-45 (all women), and in all high-risk HPV types pooled (all women and heterosexual men). Significant increases were observed for HPV-56 (all women) and HPV-52 (unvaccinated women). Conclusions: Our results provide evidence for first-order herd effects among heterosexual men against HPV-16/18 and cross-protective types. Additionally, we show second-order herd effects against vaccine types among unvaccinated women. These results are promising regarding population-level and clinical impact of girls-only bivalent HPV vaccination in a country with moderate vaccine uptake

Prehistorische raatakkers op de Hoorneboegse Heide bij Hilversum: Rapportage Archeologische Monumentenzorg 225

In maart 2012 ontving de Rijksdienst voor het Cultureel Erfgoed het bericht dat op beelden van het Actueel Hoogtebestand Nederland (AHN2) verschillende structuren zichtbaar waren. De beelden waren gemaakt van het gebied van de Hoorneboegse Heide, ten zuiden van Hilversum, door R. Wortelboer. Een van deze structuren was een dambordvormig patroon dat sterk leek op het walsysteem van een prehistorisch akkercomplex, ook wel ‘raatakker’ of ‘Celtic field’ genoemd. Dit zijn uitgestrekte akkercomplexen van vele tientallen hectaren in omvang. De aaneengesloten, vaak vierkante akkertjes van ongeveer 35-40 meter zijn begrensd door 30 tot 100 cm hoge wallen, die aan de basis 8 tot 12 meter breed zijn. De oostelijke randzone van dit mogelijke raatakkercomplex bevindt zich in het oostelijke deel van de Hoorneboegse Heide, dat onder de bescherming van de Monumentenwet valt. Twee terreinen met een gezamenlijk oppervlak van 17,8 ha zijn wettelijk beschermd vanwege de aanwezigheid van prehistorische grafheuvels en bundels karrensporen uit de late middeleeuwen. In overleg met het Goois Natuurreservaat, de terreinbeherende instantie, is besloten een veldtoets uit te voeren. Het doel daarvan was tweeledig: enerzijds vast te stellen of er op de Hoorneboegse Heide inderdaad een raatakkercomplex aanwezig is en anderzijds na te gaan of het afplaggen van de heide een negatief (nivellerend) effect heeft gehad op de reliëfverschillen in het landschap. De veldtoets bestond uit een visuele inspectie en een booronderzoek. Daaraan voorafgaand is een bureauonderzoek uitgevoerd. De resultaten van deze activiteiten zijn in deze rapportage samengebracht. De visuele inspectie en het booronderzoek zijn uitgevoerd op 10 en 11 december 2012. In totaal zijn met een Edelmanboor twaalf boringen gezet, waarbij ook een aantal monsters is genomen. Op twee onderzoekslocaties zijn in totaal twee boorraaien uitgezet, waarbij zowel in de wallichamen als in de velden is geboord en zowel in geplagde stroken als in niet-geplagde zones. De wallichamen van het raatakkercomplex waren op het AHN2-beeld wél en in het veld niet zichtbaar. De hoogteverschillen zijn minimaal en de begroeiing met grote heidestruiken was zo dicht dat de wallen ter plekke niet herkenbaar zijn. Door vooraf kruispunten van wallen met jalons te markeren alsook de begin- en eindpunten van de boorraaien, konden de onderzoekers zich visueel goed oriënteren en konden zij gericht in wallichaam en veld boren. Uit het booronderzoek werd duidelijk dat op de locatie van de verwachte wallichamen een begraven bodem aanwezig is. Het gaat om een afgedekt pakket met een dikte van 30-40 cm. Dit pakket bevat kleine fragmenten handgevormd aardewerk dat zeer waarschijnlijk uit de ijzertijd dateert. De visuele inspectie wees daarnaast uit dat er op de wandelpaden op bepaalde afstanden grindconcentraties zichtbaar waren. Na inmeting bleek dat deze samenhangen met de wallichamen die op de AHN-beelden zichtbaar zijn. Op die locaties waar de paden de oude wallichamen hebben aansneden, heeft het erosieproces geleid tot het verdwijnen van de fijne fractie van het sediment, waardoor de grovere fractie (grind) is achtergebleven. Monsters van sediment afkomstig uit en onder de wallichamen bleken uitsluitend houtskoolfragmenten te bevatten. Het houtskool is voornamelijk afkomstig van eik, gevolgd door wilg, appel/peer/meidoorn, sleedoorn en den. Kortom, met de veldtoets is aangetoond dat er inderdaad een prehistorisch akkersysteem op de Hoorneboegse Heide aanwezig is. De identificatie is positief en daarmee is dit raatakkercomplex het meest westelijke van Nederland. Ook is vastgesteld dat de fysieke kwaliteit matig is: het akkercomplex is slechts gedeeltelijk geconserveerd. Het eeuwenlange gebruik van de heide – onder meer als bron voor onder andere zand en plaggen – heeft geleid tot afvlakking van het oorspronkelijke raatakkerreliëf. De recente, eenmalige plagactiviteiten hebben een veel minder nivellerend effect gehad dan op voorhand – op basis van de AHN-beelden – werd gedacht. Maximaal 5 cm van de top van het bodemprofiel is in de afgeplagde stroken verdwenen. Omdat in die stroken ook de grote heidestruiken zijn verdwenen, lijkt het effect veel groter. De Hoorneboegse Heide is een rijk archeologisch gebied, waar verschillende overblijfselen uit een ver en minder ver verleden aanwezig en zichtbaar zijn. De grafmonumenten en het raatakkercomplex zijn belangrijke getuigen van een prehistorisch cultuurlandschap. Het duidelijke wegenpatroon van bundels karrensporen en de opgevulde antitankgracht uit de Tweede Wereldoorlog zijn andere bijzondere elementen. Hun gezamenlijke aanwezigheid op de Hoorneboegse Heide maakt dit tot een aansprekend voorbeeld van een gelaagd landschap dat het bewaren waard is. Deze archeologische rijkdom maakt het eveneens een kwetsbaar landschap. Het Goois Natuurreservaat is zich daarvan bewust. Het beheer is daar ook op afgestemd. Duidelijk is dat ingrijpende werkzaamheden die het reliëf zouden kunnen aantasten, moeten worden vermeden. Het gebied wordt intensief gebruikt, vooral door wandelaars met (loslopende) honden, maar dit gebruik beperkt zich vooral tot de paden. Het is juist voor deze recreanten dat het bijzondere verhaal van de Hoorneboegse Heide meer beleefbaar kan worden gemaakt

Cumulative pregnancy rates after three cycles of minimal stimulation IVF and results according to subfertility diagnosis: a multicentre cohort study

BACKGROUND: In minimal stimulation IVF, treatment is aimed at using the single oocyte that spontaneously develops to dominance. To prevent untimely ovulation, a GnRH antagonist is administered in the late follicular phase of the natural cycle together with recombinant FSH for substitution. Owing to the lack of ovarian stimulation, minimal stimulation IVF is a low-risk and patient-friendly treatment. In this study, effectiveness of minimal stimulation IVF was studied. METHODS: In this prospective multicentre cohort study, minimal stimulation IVF was offered to 350 patients. All indications for conventional IVF were included. Main outcome measures were pregnancy rates per cycle and cumulative pregnancy rates after three cycles. RESULTS: A total of 336 patients completed 844 cycles (2.5 per patient). The overall ongoing pregnancy rate per started cycle was 8.3% [95% confidence interval (CI) 6.4-10.2%]. The cumulative ongoing pregnancy rate after up to three cycles was 20.8% (95% CI 16.4-25.3%) per patient. No differences were found according to indication for IVF. CONCLUSIONS: Minimal stimulation IVF seems suitable for all indications studied. Pregnancy rates are encouraging. Owing to the low-risk and patient-friendly nature of this protocol, it seems a feasible treatment option for patients requiring IV

Prevalence, clinical and molecular characteristics of early stage EGFR-mutated lung cancer in a real-life West-European cohort: Implications for adjuvant therapy

Objectives: The landmark ADAURA study recently demonstrated a significant disease-free survival benefit of adjuvant osimertinib in patients with resected EGFR-mutated lung adenocarcinoma. However, data on prevalence rates and stage distribution of EGFR mutations in non-small cell lung cancer in Western populations are limited since upfront EGFR testing in early stage lung adenocarcinoma is not common practice. Here, we present a unique, real-world, unselected cohort of lung adenocarcinoma to aid in providing a rationale for routine testing of early stage lung cancers for EGFR mutations in the West-European population. Material and methods: We performed routine unbiased testing of all cases, regardless of TNM stage, with targeted next-generation sequencing on 486 lung adenocarcinoma cases between 01- January 2014 and 01 February 2020. Clinical and pathological data, including co-mutations and morphology, were collected. EGFR-mutated cases were compared to KRAS-mutated cases to investigate EGFR-specific characteristics. Results: In total, 53 of 486 lung adenocarcinomas (11%) harboured an EGFR mutation. In early stages (stage 0-IIIA), the prevalence was 13%, versus 9% in stage IIIB-IV. Nine out of 130 (7%) stage IB-IIIA patients fit the ADAURA criteria. Early stage cases harboured more L858R mutations (p = 0.02), fewer exon 20 insertions (p = 0.048), fewer TP53 co-mutations (p = 0.007), and were more frequently never smokers (p = 0.04) compared to late stage cases with EGFR mutations. The KRAS-mutated cases were distributed more evenly across TNM stages compared to the EGFR-mutated cases. Conclusion: As (neo-)adjuvant targeted therapy regimes enter the field of lung cancer treatment, molecular analysis of early stage non-small cell lung cancer becomes relevant. Testing for EGFR mutations in early stage lung adenocarcinoma holds a substantial yield in our population, as our number needed to test ratio for adjuvant osimertinib was 14.4. The observed differences between early and late stage disease warrant further analysis to work towards better prognostic stratification and more personalised treatment

Real-World Approach for Molecular Analysis of Acquired EGFR Tyrosine Kinase Inhibitor Resistance Mechanisms in NSCLC

Introduction: With the approval of first-line osimertinib treatment in stage IV EGFR-mutated NSCLC, detection of resistance mechanisms will become increasingly important—and complex. Clear guidelines for analyses of these resistance mechanisms are currently lacking. Here, we provide our recommendations for optimal molecular diagnostics in the post-EGFR tyrosine kinase inhibitor (TKI) resistance setting. Methods: We compared molecular workup strategies from three hospitals of 161 first- or second-generation EGFR TKI–treated cases and 159 osimertinib-treated cases. Laboratories used combinations of DNA next-generation sequencing (NGS), RNA NGS, in situ hybridization (ISH), and immunohistochemistry (IHC). Results: Resistance mechanisms were identified in 72 first-generation TKI cases (51%) and 85 osimertinib cases (57%). RNA NGS, when performed, revealed fusions or exon-skipping events in 4% of early TKI cases and 10% of osimertinib cases. Of the 30 MET and HER2 amplifications, 10 were exclusively detected by ISH or IHC, and not detected by DNA NGS, mostly owing to low tumor cell percentage (<30%) and possibly tumor heterogeneity. Conclusions: Our real-world data support a method for molecular diagnostics, consisting of a parallel combination of DNA NGS, RNA NGS, MET ISH, and either HER2 ISH or IHC. Combining RNA and DNA isolation into one step limits dropout rates. In case of financial or tissue limitations, a sequential approach is justifiable, in which RNA NGS is only performed in case no resistance mechanisms are identified. Yet, this is suboptimal as—although rare—multiple acquired resistance mechanisms may occur

The impact of a pathologist's personality on the interobserver variability and diagnostic accuracy of predictive PD-L1 immunohistochemistry in lung cancer

Objectives: Programmed death-ligand 1 (PD-L1) is the only approved predictive biomarker for immunotherapy in non-small cell lung cancer (NSCLC). However, predictive PD-L1 immunohistochemistry is subject to interobserver variability. We hypothesized that a pathologist's personality influences the interobserver variability and diagnostic accuracy of PD-L1 immunoscoring.& nbsp;Materials and Methods: Seventeen pathologists performed PD-L1 immunoscoring on 50 resected NSCLC tumors in three categories (= 50%). Also, the pathologists completed a certified personality test (NEO-PI-r), assessing five personality traits: neuroticism, extraversion, openness, altruism and conscientiousness.& nbsp;Results: The overall agreement among pathologists for a series of 47 tumors was substantial (kappa = 0.63). Of these, 23/47 (49%) tumors were entirely negative or largely positive, resulting in a kappa value of 0.93. The remaining 24/47 (51%) tumors had a PD-L1 score around the cutoff value, generating a kappa value of 0.32. Pathologists with high scores for conscientiousness (careful, diligent) had the least interobserver variability (r = 0.6, p = 0.009). Also, they showed a trend towards higher sensitivity (74% vs. 68%, p = 0.4), specificity (86% vs. 82%, p = 0.3) and percent agreement (83% vs. 79%, p = 0.3), although not significant. In contrast, pathologists with high scores for neuroticism (sensitive, anxious) had significantly lower specificity (80% vs. 87%, p = 0.03) and percent agreement (78% vs. 85%, p = 0.03). Also, a trend towards high interobserver variability (r =-0.3, p = 0.2) and lower sensitivity (68% vs. 74%, p = 0.3) was observed, although not significant. Pathologists with relatively high scores for conscientiousness scored fewer tumors PD-L1 positive at the >= 1% cut-off (r =-0.5, p = 0.03). In contrast, pathologists with relatively high scores for neuroticism score more tumors PD-L1 positive at > 1% (r = 0.6, p = 0.017) and >= 50% cut-offs (r = 0.6, p = 0.009).& nbsp;Conclusions: This study is the first to demonstrate the impact of a pathologist's personality on the interobserver variability and diagnostic accuracy of immunostaining, in the context of PD-L1 in NSCLC. Larger studies are needed for validation of these findings

The impact of a pathologist's personality on the interobserver variability and diagnostic accuracy of predictive PD-L1 immunohistochemistry in lung cancer

Objectives: Programmed death-ligand 1 (PD-L1) is the only approved predictive biomarker for immunotherapy in non-small cell lung cancer (NSCLC). However, predictive PD-L1 immunohistochemistry is subject to interobserver variability. We hypothesized that a pathologist's personality influences the interobserver variability and diagnostic accuracy of PD-L1 immunoscoring. Materials and Methods: Seventeen pathologists performed PD-L1 immunoscoring on 50 resected NSCLC tumors in three categories (<1%;1–49%;≥50%). Also, the pathologists completed a certified personality test (NEO-PI-r), assessing five personality traits: neuroticism, extraversion, openness, altruism and conscientiousness. Results: The overall agreement among pathologists for a series of 47 tumors was substantial (kappa = 0.63). Of these, 23/47 (49%) tumors were entirely negative or largely positive, resulting in a kappa value of 0.93. The remaining 24/47 (51%) tumors had a PD-L1 score around the cutoff value, generating a kappa value of 0.32. Pathologists with high scores for conscientiousness (careful, diligent) had the least interobserver variability (r = 0.6, p = 0.009). Also, they showed a trend towards higher sensitivity (74% vs. 68%, p = 0.4), specificity (86% vs. 82%, p = 0.3) and percent agreement (83% vs. 79%, p = 0.3), although not significant. In contrast, pathologists with high scores for neuroticism (sensitive, anxious) had significantly lower specificity (80% vs. 87%, p = 0.03) and percent agreement (78% vs. 85%, p = 0.03). Also, a trend towards high interobserver variability (r = -0.3, p = 0.2) and lower sensitivity (68% vs. 74%, p = 0.3) was observed, although not significant. Pathologists with relatively high scores for conscientiousness scored fewer tumors PD-L1 positive at the ≥ 1% cut-off (r = −0.5, p = 0.03). In contrast, pathologists with relatively high scores for neuroticism score more tumors PD-L1 positive at ≥ 1% (r = 0.6, p = 0.017) and ≥ 50% cut-offs (r = 0.6, p = 0.009). Conclusions: This study is the first to demonstrate the impact of a pathologist's personality on the interobserver variability and diagnostic accuracy of immunostaining, in the context of PD-L1 in NSCLC. Larger studies are needed for validation of these findings