Second Generation of Liquid-Based Cytology

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LGM International Inc., Melbourne, Florida
USA
Second Generation of Liquid-Based Cytology
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Liqui-PREPTM System
Conventional Pap Smears

• Testing for Cervical Cancer Screening was
  introduced in 1947 by Dr. George Papanicolaou
  called the PAP Smear.
• The PAP smear reached its maximum effectiveness
  over 25 years ago. The mortality rate from
  Cervical cancer has remained constant for the
  last 25 years.
• Today Cervical Cancer is the 1st or 2nd cause of
  premature death of women throughout the world.
• However, the disease (cervical cancer) can be
  prevented and, if found in the early stages, it
  is 100 curable. (Quote form the Canadian
  International Development Agency, Cancer Care
  International).

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Liqui-PREPTM System
Conventional Pap Smears

• The National Institute of Health (NIH) US
  consensus panel agreed that any single PAP Smear
  has a 20 change of being a false negative.
  Depending on study design, the NIH Preventative
  Task Force, estimates that the prevalence of
  false negatives range between 1 to 80.
• The old pap smear has an intrinsic sensitivity
  of only 51 for the detection of Cervical
  Cancer. (Confirmed by the Agency for Health Care
  Policy and Research (AHCPR) after reviewing over
  600 publications).
• As has been pointed out, the sensitivity of
  conventional pap smears for histologic dysplasia
  is not very good. It is a little better than
  flipping a coin but not much . The traditional
  approach to that problem has been to repeat the
  test on a frequent basis. (Statement by Dr.
  Kenny, Premanente Medical Group when testifying
  before the Microbiology Devices Panel of the FDA
  on 12/8/2000).

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Is this a diagnostic test?
Conventional Pap Smears

• If introduced today, the PAP smear would never be
  accepted because
• Sensitivity of 51 (no better than flipping a
  coin).
• 20 false negatives.
• Detects 65 less pre-cancerous lesions.
• Physicians would resist the collection
  procedures.
• Cytologists and Pathologists would not accept the
  quality of the slides for diagnosis.

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Liqui-PREPTM System
Introduction of Liquid-Based Cytology

• In the early 1990s a new replacement technology
  for Cervical Cancer Screening was introduced
  named Liquid-Based Cytology (LBC).
• Overall increase in detection of epithelial cell
  abnormalities using LBC.
• Versus the old PAP smear, over 200 technical
  publications demonstrated a 65 increase in
  detection of cancerous lesions with LBC.
  Overall, there is less indeterminate specimens.
• Pre-cancerous lesions can be detected 8 to10
  years earlier than old PAP Smear, thus ensuring a
  complete and inexpensive cure of cervical cancer.
• Original specimen can be further tested by
  immunochemistry (chlamydia Dako p16) and
  molecular methods (new HPV screening guidelines).
• Reduces specimen recollection for further testing
  or reflexive testing.
• Negates need to recollect specimen eliminating
  patient anxiety and saving money.

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Liqui-PREPTM System
What makes LBC technology superior ??
? All Cells collected (100) are preserved for
analysis. ? Preservation fixation of cells is
immediate better preserving detailed nuclear
morphology. ? Remove the blood and mucus, and
clinically relevant cells are no longer occluded
from field of vision (hidden cell). ? With
clearer field of vision, slides can be scanned
with greater accuracy (missed cell). LBC
Marketing Myth ? HOWEVER, LBC is only as
accurate as the cytologist who reads it!!!! ? LBC
is a new tool for qualified cytologists to read
with greater accuracy.
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Comparison of Gyn Data
CPS (n) HSIL LBC (n) HSIL Change
ThinPrep 20,917 2.44 (511) 10,226 3.90 (399) 59.8
SurePath 58,988 0.42 (248) 58,580 0.69 (405) 64.2
Liqui-PREP 218,548 2.50 (5,464) 26,178 3.90 (1,021) 56.0
Conclusions gt Statistically methods are
equivalent, confirming trend for 50-60 increased
detection by LBC methods versus conventional pap
smear. gt Adoption should be based upon ease of
use, capital investment costs (maintenance) and
cost in use.
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Liqui-PREPTM System
Benefits of LBC
LBC (by Liqui-PREPTM)
Conventional Pap Smear
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Liqui-PREPTM System
Benefits of LBC

• Most major markets are converting to LBC methods
• In the US, of the 55 million cervical screenings
  performed yearly, over 75 use the new
  technology, LBC.
• In Canada, over 70 of the market has adopted LBC
  as the primary screen.
• UK National Institute for Clinical Excellence
  (October 2003), concluded It is recommended
  that LBC is used as the primary means of
  processing samples in the cervical screening
  programme in England and Wales.
• WHY
• ? Clearer slides ? Better accuracy - saves
  lives
• ?Improved productivity - improved turn around
  time - fewer slides rejected
• ?Reflex testing without the need to worry the
  client (HPV) or recollect another specimen

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Liqui-PREPTM System
LBC Products Market Evolution

• First Generation mechanical separation
  technology using filters, vacuums and
  centrifugation, developed in mid-1990s.
• ThinPrepTM from Cytyc - market leader in US.
• SurePathTM from TriPath Imaging (formerly
  Autocyte)
• Second Generation separation chemistry and
  novel chemistry solutions. Operate on standard
  lab equipment.
• Liqui-PREPTM from LGM International first 2nd
  gen chemistry
• All products have FDA and Canadian approval.
• All are USA companies.

1927
1995
1999
2004
1st Generation LBC
PAP
ThinPrepTM
SurePathTM
2nd Generation LBC
Liqui-PREPTM
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Cytology Technology Evolution
1980 1985 1990
1995 2003
Readers
1st Gen. Reagents
Readers
NeoPath 1st automated reader
ThinPrep monolayer to fix reader
ThinPrep released
ThinPrep Imager released
Cytyc Reader Didnt work!
SurePath Imager1 released
SurePath-Developed buys NeoPath patents
SurePath Released StainMate1
2nd Gen Reagents
Liqui-PREP released
2004- SurePath sues ThinPrep for patent
infringement
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Liqui-PREPTM System
Issues of LBC

• Obstacles to adoption have been significant (10
  years now!)
• Higher reagent cost per test (4-6 times or more).
• Capital equipment cost.
• Throughput/productivity.
• Waste disposal costs (Hazmat) and bulky plastics.
• Workload shift from collection site to lab.
• New collection devices for liquid transport to
  lab.
• LBC process changed cell appearance so training
  in reading had to be implemented.
• But adoption continues because lives can be saved
  and new technology is over coming the objections.

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Liqui-PREPTM System
Comparison LBC Products
Item Liqui-PREP ThinPrep SurePath Manual SurePath Instrument
Collection (All Direct to Vial) Detached head preferred. Fixed head wit stirring acceptable. Fixed head only with stirring. Detached head. Detached head.
Preservative Non-hazardous Hazardous Non-hazardous Non-hazardous
Equipment Any centrifuge pipettes TP2000 TP3000 Swinging bucket centrifuge Aspiration system Slide racks Pipettes Swinging bucket centrifuge Aspiration System PrepMate StainMate
Equipment Cost (USD) 500 to 9000 TP2000 - 40,000 TP3000 - 200,000 Total System - 14,000 125,000
Throughput (Maximum) 1 Person 720 / 8hrs TP2000 200/ 8hrs TP3000 320/ 8hrs 480 / 8hrs 360 / 8hrs
Manual Steps of Process 9 TP2000 5 TP3000 7 16 15
Major Registrations FDA Canada China All major markets FDA Canada China All major markets FDA Canada China All major markets FDA Canada China All major markets
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1st Generation LBC Fundamental Design Flaws

• Reagent design was to accommodate limitation of
  1980 readers i.e. ?ThinPrep monolayer
• ?SurePath StainMate (standardized stains
  required for readers)
• No cost considerations
• i.e. ?hazmat reagents cost more to ship to
  dispose ?chemically charged slides
  /pre-treated slides (poly-L-lysine) ?expensive
  plastic disposables
• Specimen Variation (gyn vs non-gyn)
• i.e. ?bloody/mucoid specimens (clogged
  filters), acid pre-treatments ?50ul (FNA) to
  1500 ml (plural fluid)
• Instrumentation or mechanization
  ?? i.e. ?one specimen at a time
  (TP2000) ?already own a slide stainer
  (StainMate is a microplate pipettor)

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Better Solutions through Better Chemistry!
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Liqui-PREPTM System
LBC Products Market Evolution
First Generation
Second Generation

• High cost pert test.
• Special Equipment (capital funds).
• Change in cellular morphology.
• Specialized training to read.
• Utilize only portion of specimen.
• Bloody specimens/clogged filters.
• HAZMAT disposal costs.
• What is missed in residual vial?

• Low cost per test.
• Standard centrifuge, vortex pipette.
• Classic morphology.
• Utilizes whole specimen.
• No filters to clog.
• Separation chemistry to clean specimens.
• Non-HAZMAT formulations.
• Designed for non-gyn as well.

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Liqui-PREPTM System
Liqui-PREPTM 1st Second Generation LBC
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Its in the chemistry!

• Preservative Solution-
• - alcohol based, non-hazmat - no
  morphologic changes, no special teaching to
  read - patent pending
• Cleaning Solution- - optional usage
  - separation gradient removes blood and
  mucus
• Lytic Reagent- - to clean mucoid specimens
  - 3/4 bloody specimens - supplement
  to Cleaning Solution
• Cell Base - - adhesive with porous
  properties - uses standard slides -
  protects nucleic acids and proteins

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Liqui-PREPTM System
Liqui-PREPTM Method
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Liqui-PREPTM System
Liqui-PREPTM Method
WorkFlow Options
Option 1
Option 2
Clean Specimens
Bloody, Mucoid Specimens
All Specimens
Cytology Kit
Special Cytology Kit
Special Cytology Kit
Most Economical
Standardized WorkFlow
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