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Table 1.
ER and PgR IHC assays not subjected to direct clinical validation may be validated by showing 90% agreement for positive results and 95%
agreement for negative results with any of the following:
1. Testing performed on the same blocks in another laboratory that has directly validated its assay against clinical outcome
2. Testing performed on the same blocks using a previously validated ligand binding assay
3. Testing performed on the same blocks in another laboratory that provides written attestation that it is in conformance with ASCO/CAP
testing requirements and is using one of the following:
a. An FDA-approved assay that has been fully validated using an 80-specimen challenge set as described in Table 3, or
b. An LDT or LMT that has been validated according to all other requirements set forth in this document
4. Testing performed on the same blocks in another laboratory that uses an alternative, clinically validated method for measuring hormonereceptor expression (eg, a gene-expression assay)17
5. Testing performed on one of the following:
a. Tissue challenges used in a formal PT program, provided that each case used in the validation study was graded by the PT vendor
and $50 laboratories are included in the participants peer group, or
b. Validation tissues provided by an organization such as the CAP or the NIST, with established ER and PgR status determined through
IHC testing using a technically validated assay24
Abbreviations: ASCO, American Society of Clinical Oncology; CAP, College of American Pathologists; ER, estrogen receptor; FDA, US Food and
Drug Administration; IHC, immunohistochemical; LDT, laboratory-developed test; LMT, laboratory-modified test; NIST, National Institute of
Standards and Technology; PgR, progesterone receptor; PT, proficiency testing.
a
In the case of unmodified, FDA-cleared or FDA-approved ER and PgR IHC assays, an alternative verification procedure may be specified in the
FDA-approved or FDA-cleared package insert.
validated against clinical outcome or against proficiencytesting material that has been validated by showing
consensus results among multiple laboratories in a peer
group (which must include laboratories with validated
assays). Acceptable approaches are listed in Table 1.
Assay validation that relies on comparison with another
unvalidated assay is not sufficient.21,22
The level of agreement required for validating a new
assay (90% agreement for positive specimens and 95%
agreement for negative specimens) has been achieved in
several studies that compared local laboratory and central
laboratory ER results.16,17 If the positive samples in the
validation set are enriched with weakly positive specimens,
as we propose, we believe that laboratories with at least 90%
positive agreement at the time of assay validation under
these conditions are likely to detect considerably more than
90% of ER-positive specimens in clinical practice.
The laboratory director is responsible for ensuring that
all validation steps have been performed according to
these guidelines.
VALIDATION REQUIREMENTS
Initial Validation
Initial validation or verification of ER and PgR IHC
assays must be successfully completed before the tests can
be placed into clinical service.
An IHC predictive-marker assay includes a defined set
of test conditions (reagents, equipment, specimen types,
and standard operating procedures) and an ongoing
quality management regimen that includes, as applicable,
routine quality control, periodic assay recalibration,
employee-competency testing, external proficiency testing, and laboratory inspection. During the interval when a
test is being validated, the test conditions and ongoing
quality-management regimen should be the same as the
conditions and quality-management regimen that will be
used once the assay is placed in clinical service.
Laboratories that intend to use specialized techniques
for scoring, such as image analysis, must use those same
techniques in the validation study.
To ensure that the validation study assesses betweenrun variation, the laboratory validating its assay should
not test all specimens in the validation set on the same
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Acceptable Outcome
For laboratories with unmodified FDA-cleared or FDAapproved ER or PgR assays that were in clinical service
before the publication of the American Society of Clinical
Oncology/College of American Pathologists Guideline Recommendations for Immunohistochemical Estrogen/Progesterone
Receptor Testing in Breast Cancer1 and that have been used
on at least 200 clinical specimens, the verification
procedure may include the results of previously analyzed
cases; however, laboratories introducing an assay after
publication of the guidelines must complete the verification study before the test is placed in service.
A verification study does not need to be repeated if a
previous study conforming to the manufacturers FDAcleared recommendations or with this guideline has been
completed and the records are available for review by
external inspectors. Laboratories that cannot document
initial test verification of an FDA-cleared or FDAapproved assay must complete a new verification study
to show that the test performs as intended.
Laboratory-Developed and Laboratory-Modified Assays.
Laboratories must validate laboratory-developed tests
(LDTs) and any FDA-cleared or FDA-approved laboratory-modified tests (LMTs). Recommended validation
procedures for ER or PgR LDTs or LMTs are described in
Table 3. For laboratories with assays that were in clinical
service before the publication of the American Society of
Clinical Oncology/College of American Pathologists testing
guidelines1 and that have been applied to at least 200 clinical
specimens, the validation set may include the results of
previously analyzed cases provided that the previously
analyzed cases have been tested using one of the methods
listed in Table 1; however, laboratories introducing an LDT
or LMT after publication of the guidelines must complete
the validation study before the test is placed in service.
A validation study does not need to be repeated if a
previous validation study conforming to this guideline
has been completed and the records are available for
review by external inspectors. Laboratories that cannot
document initial validation of an LDT or LMT must
complete a new validation study to show that the test
performs as intended.
Changes in Test Methods
All assays must be revalidated whenever there is a
significant change to the test system, such as a change in
the primary antibody clone, introduction of new antigenretrieval or immunohistochemistry detection systems, or a
significant relaxation of ongoing quality-management
procedures. Assay revalidation after significant changes
should meet the requirements specified in Table 3.
Ongoing Assessment
Regardless of the methodology used, all laboratories
with validated ER and PgR IHC assays must periodically
reassess the assays to ensure that their analytic sensitivity
has not drifted. Required ongoing assay assessment
procedures are described in Table 4. Ongoing assay
reassessment does not require repeating the same procedures used for initial test validation.
LABELING AND REPORTING
Laboratories using LDT and LMT assays must append a
statement to each IHC result indicating that the assay was
developed and its performance characteristics determined
by [name of laboratory]. Laboratories should not make
Validating ER and PgR Immunohistochemistry AssaysFitzgibbons et al
Table 4.
Procedure
Acceptable Outcome
Monitor concordance
between ER and PgR
results and those of gene
expression analyses (if
gene expression analysis
performed)
Demonstrate successful
Laboratories must achieve 90%
performance in an external
correct responses on graded
PT program for each
PT challenges
marker
Monitor ER and PgR results Acceptable variation among
by pathologist (calculated
pathologists should be
at least semiannually)
established by the laboratory
director
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Table 5.
Test
Result
Positivea
Negativeb
New assay
Positive
Negative
38
2
1
39
Total
40
40
An example of a concordance study illustrating calculations with positive and negative percentages of agreement
is provided in Table 5.
References
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