THE VERIFI® PRENATAL TEST –
MAKING A DIFFERENCE IN
PATIENT SAFETY
L A W R E N C E D. P L A T T , M D
PROF OB GYN UCLA SCHOOL OF MEDICINE
PERES CENTER FOR PEACE
T E L AV I V Y A F O J U L Y 1 , 2 0 1 3
THE VERIFI® PRENATAL TEST: NIPT
TECHNOLOGY OVERVIEW
Prenatal Prevalence of Chromosomal Abnormalities
Percent of Reported Chromosome Abnormalities
16
T21
T18
5
8
53
5
Major fetal
aneuploidies
T13
45,X
Sex trisomy
13
Other rare
Data adapted from Wellesley, D, et al., Rare chromosome abnormalities, prevalence and prenatal diagnosis rates
from population-based congenital anomaly registers in Europe. Eur J of Hum Gen, 11 January 2012.
PRENATAL SCREENING OPTIONS – RISK SCORE
Down Syndrome Testing with 5% Screen Positive Rate
NT Ultrasound
1st Trimester
1st Trimester
1st Trimester Blood Screen
Detection Rate
(%)
64-70
NT Ultrasound
82-87
2nd Trimester
Triple Screen
69
2nd Trimester
Quadruple Screen
81
Integrated
Screen
Serum
Integrated
1st Trimester
Blood Screen
NT Ultrasound
1st Trimester Blood Screen
2nd Trimester
Blood Screen
2nd Trimester Blood Screen
ACOG Practice Bulletin No. 77, January 2007
.
94-96
85-88
CURRENT DIAGNOSTIC OPTIONS KARYOTYPE
Trimester - Test
Sensitivity
Specificity
1st – CVS
99.25%1
98.65%1
2nd - Amniocentesis
99.4%2
99.5%2
Definitive answers, but are invasive and come with risk to the patient
Most are unnecessary due to the high rate of false positives in
screening**
1.
Hahnemann JM, Vejerslev LO. Accuracy of cytogenetic findings on chorionic villus sampling (CVS)--diagnostic consequences of CVS mosaicism and
non-mosaic discrepancy in centres contributing to EUCROMIC 1986-1992. Prenat Diagn. 1997 Sep;17(9):801-20.
2.
Mid-trimester amniocentesis for prenatal diagnosis. Safety and accuracy. JAMA. 1976 Sep 27; 236(13): 1471-6.
.
SPECTRUM OF PRENATAL TESTING*
SCREENING
Risk scores are generated and
modified based on
biochemical analysis and
population statistics
DIAGNOSTIC
Results are based entirely
on genetic factors
Serum
Screening
CVS
Combined Serum
Screens, NT, Ultrasound
NIPT
SCREENING
Amnio
DIAGNOSTIC
*Not meant to represent percentage of accuracy
.
WHAT ARE THE GOALS OF NIPT?
Reduce
exposure of
fetus to risk
Reduce
false
positives
Testing that
can easily be
offered to all
pregnant
women
Enable a
high
detection
rate
.
TWO SOURCES OF FETAL DNA IN
MATERNAL BLOOD
• Fetal cells
• 1 in a billion of total cell population
• Require isolation via mechanical
and/or biochemical means
• Cell-free DNA (cfDNA)
• Maternal blood contains both
maternal and fetal cfDNA
• 2–20% of total cfDNA is fetal
.
FETAL CELL-FREE DNA IN MATERNAL
BLOOD
A Reliable Analyte During Pregnancy
• Released through apoptosis
• Fetal cfDNA likely arises from
cytotrophoblastic cells of placenta
• Released into bloodstream as small DNA
fragments (150-200bp)
• Reliably detected after 7+ weeks gestation
• Undetectable within hours postpartum
.
DNA SEQUENCING USING CELL FREE DNA
Fetal DNA
fragments in
maternal blood.
Cell free DNA
fragments are
then sequenced.
Compare the
individual
sequenced
chromosomes
against a
reference for
analysis.
.
VERINATA’S MASSIVELY PARALLEL SEQUENCING
(MPS)- A SUPERIOR APPROACH
MPS Provides Precise, Across the Genome Coverage
Benefits
• Lowest Assay Failure Rates <1%
• Ability to rapidly add new content to test
menu. Verinata’s approach allows rapid
evolution of product
•22.8 Million reads
Targeted Sequencing is Limited to Few Chromosomes, Loci
Drawbacks
•High Assay Failure Rates of 4-12%
•Limited ability to add new content
leads to static product profile
•500K to 6.4M reads
© 2013 Verinata. Content is proprietary and confidential.
DETECTION OF FETAL ANEUPLOIDY
MPS Enables Precise Molecular Counting
Fetal
cfDNA
Counting
NOT TO SCALE
(20%)
10% more
Chr21 cfDNA
in T21
Maternal
cfDNA
VS
……
Chromosomes:
1
2
3
21
Trisomy 21
© 2013 Verinata. Content is proprietary and confidential.
DUAL THRESHOLD CLASSIFICATION
Indicates Borderline Results
Trisomy
Diploid
VS.
0.2 to 0.6 %
verifi® prenatal test
Dual Threshold
© 2013 Verinata. Content is proprietary and
confidential.
Single Threshold
Method
PUBLICATIONS IN MOST PRESTIGIOUS
JOURNALS IN FIELD
• Large-scale, prospective and blinded clinical trials
• Only study in the industry that represents real-world clinical use
• High-risk patient population
• Singleton gestations analyzed
• Over 60 U.S. centers enrolled
.
VERIFI® PRENATAL TEST PERFORMANCE
Sensitivity
95% CI
Specificity
95% CI
Trisomy 21
>99.9%
96.0 – 100.0
99.8%
98.7 – 100.0
Trisomy 18
97.4%
86.2 – 99.9
99.6%
98.5 – 100.0
Trisomy 13
87.5%
61.7 – 98.5
>99.9%
99.2 – 100.0
Sensitivity
95% CI
Specificity
95% CI
Monosomy
X
95.0%
75.1 – 99.9
99.0%
97.6 – 99.7
XX
97.6%
94.8 – 99.1
99.2%
97.2 – 99.9
XY
99.1%
96.9 – 99.9
98.9%
96.9 – 99.8
Limited data of these more rare aneuploidies preclude performance
XXX, XXY,
calculations.
XYY
Verinata Health, Inc. Data on file.
Original Publication: *Bianchi et al. Obstetrics and Gynecology, Vol 119, No. 5, May 2012
LARGE CLINICAL TRIALS
Source: ISPD Position Statement April 2013
SEX CHROMOSOME
ANALYSIS
SEX CHROMOSOMES ANEUPLOIDY
WHY?
CONSIDERATION OF NIPT FOR
CYSTIC HYGROMA
• Highly associated with common aneuploidies
including monosomy X (Turner syndrome) that are
associated with pregnancy loss and are medically
significant at birth.
• Prevalence ~1:285
• To study, we examined performance of NIPT for
patients with cystic hygroma in the MELISSA study
Bianchi, et al, Obstetrics and Gynecology, Vol 121, No. 5, May 2013
Cystic hygroma
20
MPS OF MATERNAL PLASMA DNA IN
CYSTIC HYGROMA
• Electronic clinical database of the MELISSA study
was searched to identify women carrying singleton
fetuses with cystic hygroma
• 113 cases were identified—69 (61%) had
chromosome abnormalities, but 4 had
abnormalities other than T21, T18, T13, or monosomy
X
• Archived plasma samples were sequenced using updated
chemistry
• Samples were classified for aneuploidy status of
chromosomes 21, 18, 13, and presence or absence
of monosomy X
Bianchi, et al, Obstetrics and Gynecology, Vol 121, No. 5, May 2013
21
MPS and Fetal Nuchal Cystic Hygroma
Obstet Gynecol 2013;121:1057–62
CYSTIC HYGROMA:
SEQUENCING RESULTS
•113 cases
•29/30 cases of T21
detected, 1 suspected
•20/21 cases of
monosomy X detected
•10/10 cases of T18
detected
•2/4 cases of T13
detected, 1 suspected
•None of the 44
Bianchi, et al, Obstetrics and Gynecology, Vol 121, No. 5, May 2013
euploid cases was
called positive
CONCLUSIONS AND PRACTICE
IMPLICATIONS
• Using sequencing of 4 chromosomes, 61/65 (94%) of
aneuploid cases were detected and two more
were suspected
• Overall, 107/113 (95%) of cases were correctly
classified
• 4 cases were “other” and 2 aneuploidies were not
detected
• NIPT for aneuploidy can be considered as an
immediate noninvasive point of care test at time of
sonographic diagnosis of cystic hygroma.
• Allow management to move forward for women
who decline, do not have access, or have a
contraindication to an invasive procedure.
24
DISCORDANT RESULTS
Case
Second Trimester Ultrasound
VERIFY
……
Amniocentesis
•
XY
………46,XX
WHAT NEXT???????????
•
Male Genitalia
TEST PERFORMANCE IN
“ REAL WORLD POPULATION”
May 2013
Initial clinical laboratory experience in noninvasive prenatal testing for
fetal aneuploidy from maternal plasma DNA samples
Tracy Futch1, John Spinosa2,3, Sucheta Bhatt1, Eileen De Feo2, Richard P. Rava4 and Amy J. Sehnert5*
DOI: 10.1002/pd.4123
• 5, 974 patients
• Positive Predictive value of 99.8%
• Negative Predictive Value of 99.92%
• Turn around time 5.1 days
• Assay failure rate of 0.7%
Quantity Not Sufficient
0.53%
Cancelled by Phs/Pat
0.23%
Sample received beyond stability
0.22%
Gestational Age less than 10 Weeks
0.15%
Sample Improperly Labeled
0.13%
Test Valid for Singletons Only
0.09%
Interfering Substances (too much cfDNA)
0.08%
Duplicate Specimen
0.04%
Improper sample type
0.03%
NY State Permit Denied
0.03%
Internal Processing Error
0.01%
Unable to isolate sufficient cfDNA
Sample integrity compromised
0.01%
0.01%
Sample lost or destroyed during shipping
0.01%
Expired Tube
0.01%
Red text indicates a technical test failure
© 2013 Verinata. Content is proprietary and confidential.
Test Cancellations:
Rolling 6 month window, ending
May 2013
1.46%
0.10%
Total Samples Reported
Administrative Cancellations
Technical Test Failures
98.4%
KEY DIFFERENTIATORS – CLINICAL TEST
• Low assay failure rate and need for re-draw (<1%)
• Low TAT (Average TAT 4 days, 95% 8 days)
• Sample requirement – 1 tube (7-10 mL) maternal blood
only
Weeks Matter!
• Broadest validated test menu including sex chromosomes
• Accept samples from ART pregnancies including egg
donors
• Result type – Clear and descriptive for physicians
• Non risk score
• Independent of other pre-test factors (i.e., gestational age, maternal
age)
© 2013 Verinata. Content is proprietary and confidential.
NIPT TEST COMPARISON
verifi®
Verinata
Harmony
Ariosa
MaterniT21
Sequenom
NIPT
Natera
Result Types
•Aneuploidy
Detected
•Aneuploidy
Suspected
•No Aneuploidy
Detected
Risk score
incorporating
maternal,
gestational age
•Positive
•Negative
Risk score
incorporating
maternal,
gestational age
Assay
Failure Rate
<0.7%
4.6 – 4.9%
1%
5.9 – 12.6%
Sample
1 tube maternal
blood
2 tubes maternal
blood
2 tubes
maternal blood
2-4 tubes maternal
blood (best with
paternal sample)
Egg Donors
Yes (with data)
No
Yes
No
Test Menu
T21, T18, T13
Optional sex
chromosome
aneuploidies
(Published data)
T21, T18, T13
Y chromosome
(optional)(not
published)
T21, T18, T13
Mandatory sex
chromosome
aneuploidies
(not published)
T21, T18, T13
Sex chromosome
aneuploidies (only
MX published)
Published
Clinical
Validation
Large-scale, blinded
clinical validation
Large-scale, blinded
clinical validation
Large-scale,
blinded clinical
validation
Small, blinded
clinical validation
NIPT IS A
GAME CHANGER
EFFECT OF NIPT ON INVASIVE
TESTING: EVMS
100
90
80
70
60
50
40
30
20
10
0
CVS
2004
2006
2008
2010
2012
INVASIVE PROCEDURE UPDATE BY MONTH
(7/2010 THROUGH 3/2013)
IMPACT OF INVASIVE TESTING IN
PATIENTS WITH A POSITIVE FIRST OR
SECOND TRIMESTER SCREEN
•
•
•
•
NIPT
RESULTS FROM CFFM
6/1/2010 THROUGH 3/31/2013
POSITIVE FIRST AND SECOND TRIMESTER
SCREEN
Total patients seen 6/1/2010 – 3/31/2013:
Total procedures performed 6/1/2010 – 3/31/2013:
Total singleton, non-ONTD patients seen:
Total singleton, non-ONTD procedures performed:
808
539
728
500
6/2010 – 10/2011 10/2011 – 3/2013
Total patients seen
362
446
Total singleton, non-ONTD,
patients seen
323
405
Total procedures performed
283
256
Total singleton, non-ONTD
procedures performed
262
238
.
NIPT STATUS AND DECLINING INVASIVE
TESTING
CHANGING TRENDS IN PRENATAL DIAGNOSIS
THE PLATT EXPERIENCE
2010 (%)
2011 (%)
2012 (%)
2013 (%)
Amnio
8.0
6.0
4.2
Next slide
CVS
4.0
3.9
3.0
Next slide
Total
12.0
9.9
7.2
CHANGING TRENDS IN PRENATAL DIAGNOSIS
THE PLATT EXPERIENCE
JANUARY THROUGH MAY BY YEAR
2010 (%)
2011 (%)
2012 (%)
2013 (%)
Amnio
7.5
7.5
5.3
2.7
CVS
4.4
4.6
3.5
3.4
Total
11.9
12.1
8.8
6.1
UPTAKE OF NIPT IN WOMEN FOLLOWING POSITIVE
ANEUPLOIDY SCREENING
CHETTY S, GARABEDIAN MJ, NORTON ME. PRENAT DIAGN 2013; 33: 542-546
• Norton et al observed an increased uptake of NIPT
following abnormal 1st ∆ screening compared with
abnormal 2nd ∆ screening (56% vs 37%)
• This study revealed that women with a positive
aneuploidy screening result are influenced by NIPT
for their follow-up testing
• When the procedure-associated risk is eliminated,
women may be less likely to decline testing
CALIFORNIA PDC EXPERIENCE WITH NIPT
Data for patients with initial PDC visit (January – March
2013)
Totals
# of pts offered NIPT at PDC
3,400
# of PNS screen positive pts offered/requested NIPT
1,063
PNS screen positive patients accepting NIPT
454
PNS screen positive patients declining NIPT
609
# of patients offered/requesting NIPT for other
indications (i.e., maternal age, US abnormality, US
marker, etc.)
2337
Pts with other indications accepting NIPT
661
Pts with other indications declining NIPT
1676
# of patients coming to PDC with prior NIPT results
through OB
147
TOTAL PATIENTS HAVING NIPT PERFORMED
1,262
CALIFORNIA PDC EXPERIENCE WITH NIPT
Data for patients with initial PDC visit (January – March
2013)
Totals
Total # of NIPT positive results
53
Number of NIPT positive patients having diagnostic
procedures:
29
T21 confirmed by CVS/amnio/other
16
T18 confirmed by CVS/amnio/other
3
T13 confirmed by CVS/amnio/other
3
45,X/other confirmed by CVS/amino/other
2
Normal karyotype (false positive) confirmed by
CVS/amnio/other
5
SUB-TOTAL OF NIPT POSITIVE RESULTS W/ DIAGNOSIS
29
OFFICIAL SOCIETY
STATEMENTS
The National Society of Genetic Counselors (NSGC) currently supports
Noninvasive Prenatal Testing/Noninvasive Prenatal Diagnosis (NIPT/NIPD)
as an option for patients whose pregnancies are considered to be at an
increased risk for certain chromosome abnormalities.
NSGC urges that NIPT/NIPD only be offered in the context of informed
consent, education, and counseling by a qualified provider, such as a
certified genetic counselor.
Patients whose NIPT/NIPD results are abnormal, or who have other factors
suggestive of a chromosome abnormality, should receive genetic
counseling and be given the option of standard confirmatory diagnostic
testing
•
•
•
•
•
cfDNA should not be part of routine prenatal lab assessment, but should be an
informed patient choice after pretest counseling
cfDNA should not be offered to low-risk women or women with multiple gestations –
not yet sufficiently evaluated
Negative cfDNA test result does not ensure an unaffected pregnancy
Patient with a positive test should be referred for genetic counseling and offered
invasive PND for confirmation
cfDNA does not replace the accuracy and diagnostic precision of PND w/ CVS or
amnio
•Reliable cfDNA screening methods have only been reported for trisomy 21 and
18. cfDNA screening results have been reported for trisomy 13 but the numbers
are not large and efficacy appears to be less than for trisomies 21 and 18. cfDNA
screening results have also been reported for sex chromosome aneuploidy and
the efficacy is unacceptably low.
•There are insufficient data available to judge whether any specific cfDNA
screening method is most effective.
•The tests should not be considered to be fully diagnostic and therefore are not
a replacement for amniocentesis and CVS.
•Analytic validity trials have been mostly focused on patients who are at high
risk. Efficacy in low risk populations has not yet been fully demonstrated.
•There is insufficient information to know how well the test will perform in
multiple gestation pregnancies
ISPD Position Statement April 2013
•In a proportion of cases there is insufficient fetal cfDNA in the maternal
plasma specimen or there is test failure for other reasons.
•Specific independently developed laboratory minimum standards, quality
control, proficiency testing and inspection requirements have not yet been
developed for this testing.
•It has not been demonstrated that the test can be provided in a cost-effective,
timely, and equitable manner to total populations
ISPD Position Statement April 2013
FUTURE HORIZONS
FUTURE HORIZONS
• Large studies in low-risk populations
• Studies in multiple gestations
• Detection of sub-chromosomal abnormalities
• cfDNA and pregnancy complications
• Treatment of genetic syndromes (Downs)
CELL-FREE FETAL DNA IN MULTIPLES
Presented at SMFM, Feb. 2013
Study Objective:
Effects of Multiple
Gestation on Aneuploidy
Detection and the
Relative Cell-free Fetal
DNA (cffDNA) per Fetus
About.com
RESULTS: FF/FETUS DISTRIBUTION FOR
TWIN AND SINGLETON PREGNANCIES
0.3
Relative Frequency
0.25
0.2
0.15
Twins
Singletons
0.1
0.05
0
0
0.05
0.1
0.15
0.2
0.25
Fetal Fraction per Fetus
© 2013 Verinata. Content is proprietary and
confidential.
0.3
0.35
RESULTS: CALCULATED FFS FOR TWINS
Chorionicity
Karyotype
Total FF
FF/Fetus
Dichorionic (n=19)
(Both male)
46,XY/46,XY
47,XY+21/46,XY
0.124
0.082
0.062
0.041
Dichorionic ([n=26)
(different genders)
46,XY/46,XX
0.068
0.068
46,XY/46,XY
47, XY+18/47,XY+18
0.113
0.073
0.057
0.037
46,XY
0.126
0.126
Monochorionic (n=3)
Singleton (n=160)
RESULTS: DEEPER SEQUENCING (16 TWINS)
NCVs for Trisomy 21 and 18 Increase with Deeper Sequencing
• Sequencing with more
sequence tags/sample
(180M versus 25M) reduces
the standard deviation of the
measurement and increases
the NCV
• The measurement leads to
more confidence at the same
FF per fetus
© 2013 Verinata. Content is proprietary and confidential.
CONCLUSIONS FROM THE STUDY
•
Autosomal Aneuploidies in 2 Twin Cases Here Were
Correctly Classified
•
However, Deeper Sequencing is Required to Classify
Samples from Multiple Gestations with High Confidence
due to the Lower Fetal Fraction per Fetus
•
The Deeper Sequencing Approach Provides a “Safety
Net”, Thereby Reducing the Potential Number of False
Negative Cases
© 2013 Verinata. Content is proprietary and confidential.
The performance of screening for trisomy 21 and trisomy
18 by NIPT using chromosome-selective sequencing in a
routine population is as effective as previously reported in
high-risk groups with DR 99% and FPR 1%.
Am J Obstet Gynecol 2012;207:374.e1-6.
On the basis of existing data, NIPT can potentially be
used in universal screening for trisomies 21 and 18 in all
singleton pregnancies and the main limiting factor for
such widespread application of the test at present is
the associated cost.
Am J Obstet Gynecol 2012;207:374.e1-6.
CHROMOSOMAL MICROARRAY FOR
PND
N Engl J Med 2012; 367 (23): 2175-84
NON-INVASIVE SUBCHROMOSOMAL ANALYSIS
Noninvasive Detection of Fetal Subchromosome
Abnormalities via Deep Sequencing of Maternal Plasma
Anupama Srinivasan1, Diana W. Bianchi2, Hui Huang1, Amy J. Sehnert1 and
Richard P. Rava1
The American Journal of Human Genetics, Volume 92, Issue 2, 167-176, 10 Jan 2013
CFDNA AND DETECTION OF 22Q11
Clin chem. 2012; 58:1148-51
This work shows that in nonmosaic cases, it is possible to obtain a fetal
molecular karyotype by MPS of maternal plasma cfDNA that is equivalent to a
chromosome microarray and in some cases is better than a metaphase
karyotype
Am J Hum Genet 2013;92:167-76
Exciting Time
•Advancement in ultrasound technology
•Early & accurate diagnosis of fetal congenital abnormalities
•NIPT on cfDNA in maternal plasma
•Early screening of fetal karyotypic abnormalities
Expand access for fetal intervention
© 2013 Verinata. Content is proprietary
and confidential.
How does Verifi® make
pregnancy safer?
NIPT
MAKING PRENATAL DIAGNOSIS SAFER
1. NIPT broadens the available prenatal testing
options for women
2. NIPT offers an alternative to invasive diagnostic
testing for women with screen positive fetuses
• With high sensitivity and specificity for T18 and T21
(T13 performance somewhat poorer
comparatively)
•
NIPT
MAKING PRENATAL DIAGNOSIS SAFER
3. NIPT offers reassurance to those women for
whom invasive diagnostic testing was not an
acceptable option
4. NIPT removes the risk of procedure-related
risks and women may be less likely to
decline testing
THANK YOU
‫תודה‬
1ST TRIMESTER CONTINGENT SCREENING FOR T21 BY
BIOMARKERS AND MATERNAL BLOOD CELL-FREE DNA TESTING
NICOLAIDES KH, ET AL. ULTRASOUND OBSTET GYNECOL 2013; DOI:
10.1002/UOG.12511 (AHEAD OF PUBLICATION)
• Objective of study is to define cut-offs w/DRs and
FPRs in T21 screening using maternal age and
combinations of 1st ∆ biomarkers to determine
which women should undergo contingent maternal
blood cell-free DNA (cfDNA) testing
• March 2006 through May 2012, prospective analysis
using biomarkers (NT, DV-PIV at 11+0 to 13+6 weeks,
and ß-hCG, PAPP-A, PIGF, and AFP at 8+0 to 13+6
weeks
1ST TRIMESTER CONTINGENT SCREENING FOR T21 BY
BIOMARKERS AND MATERNAL BLOOD CELL-FREE DNA TESTING
NICOLAIDES KH, ET AL. ULTRASOUND OBSTET GYNECOL 2013; DOI:
10.1002/UOG.12511 (AHEAD OF PUBLICATION)
• Contingent screening offers 98% DR of T21 fetuses;
overall invasive testing rate <0.5% can be
potentially achieved through cfDNA testing to
• 36% combined test alone
• 21% using combined test + PIGF and AFP
• 11% using combined test + PIGF, AFP and DV-PIV
• Conclusion:
• Effective 1st trimester screening for T21 with DR of 98% and
invasive testing rate <05% can be potentially achieved by
contingent screening incorporating biomarkers and cfDNA.
POTENTIAL REASONS FOR
DISCORDANT RESULTS
Technology
• MPS counting statistics follow
a normal distribution
• Classification cut-off sets likely
false positive rate
• 3 standard deviations above
mean cut-off yields 0.13% FP
• 4 standard deviations above
mean cut-off yields 0.003% FP
Biology
• Placental mosaicism reflected
in cfDNA (similar to CVS)
• Vanishing twin may be
reflected in cfDNA
• Maternal
• Fetal fraction
DISCORDANT RESULTS
Case Discussion
• Maternal aneuploidy
• NIPT: Detected XXX
• CVS: 46,XX
• Maternal karyotype: Mosaic 46,XX[44]/45,X[5]/47,XXX[1]
• Co-twin demise
• NIPT: Detected 13
• Amnio: normal karyotype
• Co-twin demise reported in first trimester
• Low fetal fraction
• False negative T21
DISCORDANT RESULTS
Case Discussion
• Confined placental mosaicism
•
•
•
•
NIPT: Detected 13
CVS FISH: mosaicism for trisomy 13
Cultured CVS: normal karyotype
Amnio (FISH and cultured cells): normal karyotype
• Maternal malignancy
• NIPT: Double detected 13 and 18 (confirmed on repeat testing)
• Amnio: normal karyotype
• Patient diagnosed with cancer postpartum
DISCORDANT RESULTS
Case Discussion
• Maternal aneuploidy
• NIPT: Detected XXX
• CVS: 46,XX
• Maternal karyotype: Mosaic 46,XX[44]/45,X[5]/47,XXX[1]
• Co-twin demise
• NIPT: Detected 13
• Amnio: normal karyotype
• Co-twin demise reported in first trimester
• Low fetal fraction
• False negative T21
SUMMARY VERIFI® TEST
• Low assay failure rate and need for re-draw (<1%)
• Lowest TAT in industry (Average TAT 4 days, 95% 8 days)
• Sample requirement – 1 tube (7-10 mL) maternal blood
only
Weeks Matter!
• Broadest validated test menu including sex chromosomes
• Accept samples from ART pregnancies including egg
donors
• Result type – Clear and descriptive for physicians
• Non risk score
• Independent of other pre-test factors (i.e., gestational age, maternal
age)
© 2013 Verinata. Content is proprietary and confidential.
APPENDIX
Product Profile
Chromosomes
Analyzed
21, 18, 13, and (Optional) X and Y
Blood draw
requirement
1 blood tube (7-10mL)
Patient Eligibility
Validated in high risk pregnancies
Singletons at ≥10 weeks gestation
Sample collection
On-site collection kits, ambient shipping
Turn-around time
Average of 4 days with 95% within 8
days⃰
Clinical Support
In-house genetic counselors for
consultation with healthcare providers
Cancellation Rate
<1% (0.14% current rate)
77
VERIFI® PRENATAL
TEST
Test Report
• Red alert at top to
highlight abnormal results
• Abnormal results are
highlighted in red
• Comments included to
provide additional
guidance
• Test claims restated as
reference
VERIFI® PRENATAL TEST
LIMITATIONS
Test designed to detect full chromosomal aneuploidies, and has been validated
for chromosomes 21, 18, 13, X and Y.
Possibility test results might not reflect the chromosomes of the fetus, but may
reflect chromosomal changes to the placenta or of the mother.
Does not eliminate the possibility of other chromosomal abnormalities, birth
defects, or other genetic disorders.
Not currently for use in multiple gestations.
© 2013 Verinata. Content is proprietary and confidential.
VERIFI® PRENATAL TEST DISCLAIMERS
If definitive diagnosis desired, invasive
procedures are suggested to confirm detected
and suspected (borderline) results.
Test results should always be used in the context
of all available clinical findings.
How the test is used is at the discretion of the
healthcare provider.
© 2013 Verinata. Content is proprietary and confidential.
FOLLOW-UP AND OUTCOMES
• All “Detected” and “Suspected” results are called out to a
client by a Genetic Counselor
• Outbound Calls
• Collect relevant pre-test indication when calling result
• Indicate interest to collect follow-up information if/when available
• Call (or fax request) for follow-up at or near due date
• Inbound Calls
• Record information that is called from sites
• If discordance, file complaint and follow internal process
VERIFI® TEST ADVANTAGES
• Non-invasive reassurance, available as early 10 weeks
• Not affected by maternal factors (like serum screen)
• Can be used in IVF and with egg-donor pregnancies
• Higher sensitivity and specificity compared to analyte
screen
• Low (<1%) false positive rate
• Very low false negative rate
• TAT: Average of 4 days with 95% within 8 days⃰
• Failure rate of <1%
CASE EXAMPLES
CASE 1
Primary Screen for High Risk Patients
• Patient Profile: 33 year old woman at 10 weeks gestation with a history of a prior
miscarriage affected with Down syndrome
• Genetic Counseling:
• Screening
• CVS/amniocentesis
• verifi® prenatal test
• Ultrasound
• Too early for conventional serum screening and detailed ultrasound and
concerned about undergoing CVS/amniocentesis due to procedural loss rate
• verifi® prenatal test Results (option of sex chromosome analysis elected):
• Chromosome 21 – aneuploidy detected
• Chromosome 18 – no aneuploidy detected
• Chromosome 13 – no aneuploidy detected
• Sex chromosomes – no aneuploidy detected (XY)
CASE 1
Counseling considerations
• verifi® prenatal test – chromosome 21 aneuploidy detected
• Received results prior to 12 weeks gestation
Suggestive of trisomy 21 in fetus
Patient now has information earlier in pregnancy and has more time to
make informed decisions regarding testing options and pregnancy
management.
CASE 2
Secondary Screen for Screen Positive Patients
• Patient Profile: 40 year old woman with 1 in 32 risk for Down
syndrome on serum screening.
• Genetic Counseling:
• amniocentesis
• verifi® prenatal test
• ultrasound
• verifi® prenatal test Results:
• Chromosome 21 – no aneuploidy detected
• Chromosome 18 – no aneuploidy detected
• Chromosome 13 – no aneuploidy detected
CASE 2
Counseling Considerations
• Serum screen - screen positive for Down syndrome (1 in 32)
• Serum screening can have screen/false positive rate (FPR) in women 40+ of 20%
(NOTE: FPR dependent upon type of screening utilized)
• verifi® prenatal test – no aneuploidy detected for chromosomes 21,
18 and 13
• Normal ultrasound - reassuring but need to discuss limitations
Patient comfortable declining amniocentesis and avoids risk of
procedural loss
CASE 3
High Risk Patient Considering CVS/Amniocentesis
• Patient Profile: 38 year old woman with history of infertility who conceived via in vitro
fertilization (IVF).
• Genetic Counseling:
• Screening
• Declined serum screening due to sub-optimal detection rates for trisomies
• CVS/Amniocentesis
• Considering invasive testing but fearful of procedural loss
• verifi® prenatal test
• Ultrasound
• verifi® prenatal test Results (option of sex chromosome analysis elected):
• Chromosome 21 – no aneuploidy detected
• Chromosome 18 – no aneuploidy detected
• Chromosome 13 – no aneuploidy detected
• Sex chromosomes – no aneuploidy detected (XX)
CASE 3
Counseling Considerations
• verifi® prenatal test – no aneuploidy detected
• Normal ultrasound - reassuring but need to discuss
limitations
Patient comfortable declining invasive testing due to NIPT
results and normal ultrasound. Procedural risks avoided.
CASE 4
Patients Who Have Abnormal Ultrasound Findings
• Patient Profile: 41 year old woman at 34 weeks gestation diagnosed
with ultrasound findings of large echogenic kidneys and ventricular
septal defect
• Negative integrated screen (1/800 DS; 1/5000 T18; negative ONTD)
• Genetic Counseling:
• Ultrasound findings suspicious for trisomy 13
• Amniocentesis
• Patient declined as she would not alter course of pregnancy
• verifi® prenatal test
• verifi® prenatal test Results:
• Chromosome 21 – no aneuploidy detected
• Chromosome 18 – no aneuploidy detected
• Chromosome 13 – aneuploidy detected
CASE 4
Counseling Considerations
• verifi® prenatal test – chromosome 13 aneuploidy detected
• Consistent with ultrasound findings
Suggestive of trisomy 13 in fetus
Patient continues to decline amniocentesis but now pregnancy
management decisions can be made regarding delivery.
POTENTIAL FUTURE DIRECTIONS
Testing in lowrisk population
Other whole
autosomes
Subchromosomal
abnormalities
© 2013 Verinata. Content is proprietary and confidential.
Further testing in
multiple
gestations
Further study of
mosaicism
NON-INVASIVE SUBCHROMOSOMAL ANALYSIS
Noninvasive Detection of Fetal Subchromosome
Abnormalities via Deep Sequencing of Maternal Plasma
Anupama Srinivasan1, Diana W. Bianchi2, Hui Huang1, Amy J. Sehnert1 and
Richard P. Rava1
The American Journal of Human Genetics, Volume 92, Issue 2, 167-176, 10 Jan 2013
SUB-CHROMOSOME PUBLICATION
Proof-of-Principle Study in AJHG
• Purpose of the Study:
• To determine sequencing analysis necessary to detect fetal
subchromosomal abnormalities from a maternal blood sample
• Blinded Analysis of 11 Samples from MELISSA
• 10 cases with subchromosomal abnormalities
• Duplications, deletions, derivative chromosomes, mosaic cases
• Trisomy 20 was used as a control
RESULTS
All Subchromosomal Abnormalities Detected in Non-Mosaic Samples
• 7 Non-Mosaic Samples: All Subchromosomal
Abnormalities Detected.
• For karyotypes with unknown genetic material, deep MPS
identified both translocation breakpoint as well as chromosomal
origin of unknown material
• Detected microdeletion as small as 300kb
• 4 Mosaic Samples: Subchromosomal Abnormalities not
Detected.
• Non-detection due to lack of sequence in human genome, or
post-zygotic error
SUBCHROMOSOME
ANALYSIS
Example
• Sample from the
study
• Multiple subchromosome
abnormalities detected
in one sample
• Laboratory personnel
were blinded to
karyotype
RESULTS
Abnormalities Detected by Deep MPS Concordant with Karyotype
• Abnormalities
as small as
300kb detected
• Precise
location of
abnormalities
concordant with
karyotype
RESULTS
Additional Abnormalities Detected by Deep MPS
• Deep MPS provided
additional detection of
abnormalities NOT
identified by karyotype
• Provides additional
information not seen on
karyotype
• All abnormalities < 1 Mb
SUBCHROMOSOME ANALYSIS
Proof-of-Principle Study Recently Published in AJHG
• Study Shows the Ability of Deep MPS Technology to
Detect Fetal Subchromosomal Abnormalities NonInvasively
• Deep MPS Can Provide Greater Resolution and Can
Detect Fetal Subchromosomal Abnormalities at a
Resolution of 100kb Across the Genome
• Given the Cost of the Method, a Deep MPS Test for SubChromosome Abnormalities Could Be Available in the
Near Future…
NIPT STATUS AND INVASIVE PROCEDURE
UPTAKE
NIPT STATUS AND INVASIVE PROCEDURE
UPTAKE
INVASIVE PROCEDURE UPDATE BY MONTH
(7/2010 THROUGH 3/2013)
THE VERIFI® PRENATAL TEST –
MAKING A DIFFERENCE IN
PATIENT SAFETY
L AW R E N C E D. P L A T T, M D
T E L AV I V J U L Y 2 , 2 0 1 3