PD-L1 Assessment in Needle Core Biopsies of Non-Small Cell Lung Cancer: Interpathologist Agreement and Potential Associated Histopathological Features

Abstract

Objective: Immune checkpoint inhibitors are used in the treatment of non-small cell lung cancer (NSCLC). Programmed cell death-ligand 1 (PD-L1) immunohistochemistry (IHC) assessed by pathologists is subject to interobserver variability. In advanced/metastatic disease and inoperable patients, PD-L1 assessment relies on biopsy specimens, commonly needle core biopsies (NCB). We aimed to determine the interobserver agreement for PD-L1 tumor proportion score (TPS) in NSCLC NCBs and identify histopathological features that may be related to interobserver variability.

Material and methods: Sixty NSCLC NCBs with PD-L1 IHC were evaluated independently by four pathologists from different institutions. PD-L1 TPS was evaluated in three categories: no/low expression ( < 1%), intermediate expression (1%49%), and high expression (≥50%). Histological tumor type, necrosis, tumor-infiltrating lymphocytes, tumor length/percentage in the biopsy, and crush/squeeze artifact was evaluated.

Results: The statistical analysis of the three PD-L1 TPS categories demonstrated moderate agreement (Fleiss Kappa 0.477) in the no/low category, fair agreement (Fleiss Kappa 0.390) in the intermediate category, and almost perfect agreement (Fleiss Kappa 0.952) in the high category. A significant correlation (p=0.003) was found between the crush/squeeze artifact in NCB and rate of discordant TPS categories. There was no significant correlation between pathologists' agreement in the TPS categories and histological tumor type, tumor length, tumor ratio, necrosis, and tumor-infiltrating lymphocytes.

Conclusion: Our results demonstrated moderate agreement among pathologists for the PD-L1 TPS 1% cut-off in NSCLC NCB, which is lower than that reported in resection materials. The presence of crush/squeeze artifact in NCBs is significantly related to the rate of discordant TPS categories, suggesting that PD-L1 assessment of pulmonary NCBs requires an awareness of this artifact.

Figure 1

A-C) PD-L1 expression levels in tumor cells in NSCLC cases (x100). A) No/low expression (<1%) - Tumor cells are negative for PD-L1, while some tumor-associated immune cells show positive staining. B) Intermediate expression (1–49%) - A small proportion (1-10%) of the tumor cells show partial/complete membrane staining with PD-L1. C) High expression (≥50%) - Almost all tumor cells show membrane staining with PD-L1 at varying intensities.

Figure 2

A-D) Examples of crush/squeeze artifact in PD-L1 immunohistochemistry studies (x100). A) The image illustrates some PDL1 staining cells in which the cell type (tumor cell/immune cell/stroma cell) cannot be determined clearly (circle). B) The details of the cell structure and the staining of PD-L1 cannot be clearly assessed due to the crush/squeeze artifact in this example. C) The tumor cells overlap with the immune cells at the edge of the biopsy specimen, making the identification of the correct cell types more challenging in PD-L1 staining (arrow). D) The area that shows staining with PD-L1 in this example contains crush artifacts that make it difficult to determine whether PD-L1 staining tumor cells are present among the immune cells (circle).