KRAS mutation testing in colorectal cancer as an example of the pathologist's role in personalized targeted therapy: a practical approach

TL;DR

This paper discusses the role of pathologists in KRAS mutation testing for colorectal cancer, emphasizing recent advances, suitable testing methods, and the importance of in-house testing with approved assays for personalized therapy.

Contribution

It highlights the critical involvement of pathologists in KRAS testing, reviews current high-sensitivity assays, and advocates for in-house testing with approved methods for optimal patient care.

Findings

High-sensitivity assays improve detection of resistant CRC patients.

Direct sequencing is less optimal for clinical KRAS testing.

In-house testing with approved assays is recommended for best patient outcomes.

Abstract

Identifying targets for personalized targeted therapy is the pathologist's domain and a treasure. For decades, pathologists have had to learn, understand, adopt and implement many new laboratory techniques as they arrived on the scene. Pathologists successfully integrate the results of those tests into final pathology reports that were, and still are, the basis of clinical therapeutic decisions. The molecular methods are different but no more difficult to comprehend in the era of "kit procedures". Pathologists have the knowledge and expertise to identify particular gene mutations using the appropriate molecular tests currently available. This review focuses on the most important recent developments in KRAS mutation testing in metastatic colorectal cancer (CRC), and shows that a pathologist is involved in 10 stages of this procedure. Recent studies have shown that highly sensitive, simple, reliable and rapid assays may significantly improve the identification of CRC patients resistant to anti-EGFR therapy. Thus, direct sequencing does not seem to be an optimal procedure of KRAS testing for clinical purposes. Twelve currently available high-sensitivity diagnostic assays (with the CE-IVD mark) for KRAS mutation testing are briefly described and compared. The suggested pathology report content for somatic mutation tests is described. In conclusion, evidence is presented that sending away paraffin blocks with tumor tissue for KRAS mutation testing may not be in the best interest of patients. Instead, an evidence-based approach indicates that KRAS mutation testing should be performed in pathology departments, only with the use of CE-IVD/FDA-approved KRAS tests, and with the obligatory, periodic participation in the KRAS EQA scheme organized by the European Society of Pathology as an independent international body.