PATHIAM SYSTEM WITH ISCAN FOR P53 AND KI-67

• K Number: K092333
• Device Name: PATHIAM SYSTEM WITH ISCAN FOR P53 AND KI-67
• Manufacturer: BIOIMAGENE, INC.
• Date Cleared: 2010-10-27 ( 449 days)
• Product Code: NQN NON
• Regulation Number: 864.1860

Intended Use

The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores. The p53 results provided by the PATHIAM System are indicated for use for the identification of p53 accumulation in human neoplasias when used with IVD reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score. Ki-67 results provided by the PATHIAM System are indicated for use to assess proliferative activity when used with in vitro diagnostic reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Device Description

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffin-embedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-to-end digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images, add annotations, make measurements, perform image analysis, and generate reports. The iScan slide scanning device captures digital images of formalin-fixed, paraffin-embedded tissues that are suitable for storage and viewing. The device includes a digital slide scanner, racks for loading glass slides, computer, scanner software, keyboard, mouse and monitor. The PATHIAM software is designed to complement the routine workflow of a qualified pathologist in the review of immunohistochemically stained histologic slides. It allows the user to select fields of view (FOVs) in the digital image for analysis and provides quantitative data on these FOVs to assist with interpretation. The software makes no independent interpretations of the data and requires competent human intervention at all steps in the analysis process.

Predicate Devices

K062428, K053520

Reference Devices

Not Found

AI/ML (Artificial Intelligence / Machine Learning)

Unknown
The description mentions "image analysis algorithms" for specific markers, which could potentially utilize AI/ML, but the document does not explicitly state the use of AI, ML, or deep learning, nor does it provide details about training or test sets in a way that clearly indicates an AI/ML approach. The focus is on assisting the pathologist with quantitative assessment based on recognition of cellular objects, which can be achieved with traditional image processing techniques.

Therapeutic

No
The device is an aid to the pathologist for detecting, counting, and classifying cells of clinical interest. It assists in diagnosis and assessment but does not directly treat or cure a disease or condition.

Diagnostic

Yes

The "Intended Use / Indications for Use" states that the system is "intended as an aid to the pathologist to detect, count, and classify cells of clinical interest" and provides "p53 results" and "Ki-67 results...for use for the identification of p53 accumulation in human neoplasias" and "to assess proliferative activity," respectively. These are all functions directly involved in diagnosing diseases.

SaMD (Software as a Medical Device)

No

The device description explicitly states that the system consists of an "instrument and software system" and includes a "slide scanner (iScan)" as a component. This indicates the device is not solely software.

IVD (In Vitro Diagnostic)

Yes, this device is an IVD (In Vitro Diagnostic).

Here's why:

• Intended Use: The intended use explicitly states that the system is "intended as an aid to the pathologist to detect, count, and classify cells of clinical interest" and that the results are "indicated for use for the identification of p53 accumulation in human neoplasias" and "to assess proliferative activity" when used with IVD reagents. This directly aligns with the definition of an IVD, which is used to examine specimens from the human body to provide information for diagnosis, treatment, or prevention of disease.
• Device Description: The device processes "immunohistochemically stained histologic sections from formalin-fixed, paraffin-embedded normal and neoplastic tissues," which are human specimens.
• Use with IVD Reagents: The intended use specifically mentions the use of the system with "IVD reagents marketed for this indication." This further reinforces its role within the IVD workflow.
• Clinical Context: The interpretation of the results is intended to be made "within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist," indicating its use in a clinical diagnostic setting.

While the device is an "aid to the pathologist" and requires human intervention, its function is to analyze human specimens using IVD reagents to provide information relevant to diagnosis and treatment, which are core characteristics of an IVD.

PCCP (Predetermined Change Control Plan) Authorized

N/A

Overview

Intended Use / Indications for Use

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffin-embedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-to-end digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images, add annotations, make measurements, perform image analysis, and generate reports.

The p53 results provided by the PATHIAM System are indicated for use on is a useful tool for the identification of p53 accumulation in human neoplasias when used with IVD reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Ki-67 results provided by the PATHIAM System are indicated for use to assess proliferative activity when used with in vitro diagnostic reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Device Name: iScan Slide Scanner
Intended Use: This device is intended for in vitro diagnostic (IVD) use.
The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.
Indications for Use: This instrument is intended for in-vitro diagnostic use only with those assays for which it has received FDA clearance.
The iScan Slide Scanner System is designed to be used to scan and digitize microscope slides, and compress and view digitized images of microscope slides.
If the Scanner is used in any way not specified in this manual, the protection provided by the equipment may be compromised.

Device Name: PATHIAM System with iScan for Ki-67
Intended Use: This device is intended for in vitro diagnostic (IVD) use.
The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.
The Ki-67 application is intended as an aid to the pathologist to quantify the percentage of positively stained nuclei in formalin-fixed paraffin embedded normal and neoplastic breast tissue specimens immunohistochemically stained with Dako mouse monoclonal anti-human Ki-67 antigen, clone MIB1 visualized with DAB chromogen as specified in the instructions for these reagents. It is the responsibility of a qualified pathologist to employ appropriate morphological studies and controls as specified in the instructions for Dako Ki-67 to assure the validity of the PATHIAM-assisted Ki-67 assessment.
Indication For Use: Ki-67 results provided by the PATHIAM System are indicated for use to assess proliferative activity when used with in vitro diagnostic reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Device Name: PATHIAM System with iScan for p53
Intended Use: This device is intended for in vitro diagnostic (IVD) use.
The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.
The p53 application is intended for use as an aid to the pathologist to quantify the percentage of positively stained nuclei in formalin fixed paraffin embedded breast tissue specimens stained with Dako mouse monoclonal anti-human p53 antibody, clone DO7and visualized with DAB. chromogen, to detect both wild-type and mutant p53, a nuclear protein, as specified in the instructions for these reagents. It is the responsibility of a qualified pathologist to employ appropriate morphological studies and controls as specified in the instructions for Dako p53 to assure the validity of the PATHIAM-assisted p53 assessment.
Indication For Use: The p53 results provided by the PATHIAM System are indicated for use for the identification of p53 accumulation in human neoplasias when used with IVD reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist must verify agreement with the PATHIAM score.

Product codes (comma separated list FDA assigned to the subject device)

NON

Device Description

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffin-embedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-to-end digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images, add annotations, make measurements, perform image analysis, and generate reports.

Hardware: The iScan slide scanning device captures digital images of formalin-fixed, paraffin-embedded tissues that are suitable for storage and viewing. The device includes a digital slide scanner, racks for loading glass slides, computer, scanner software, keyboard, mouse and monitor.

Software: The PATHIAM software is designed to complement the routine workflow of a qualified pathologist in the review of immunohistochemically stained histologic slides. It allows the user to select fields of view (FOVs) in the digital image for analysis and provides quantitative data on these FOVs to assist with interpretation. The software makes no independent interpretations of the data and requires competent human intervention at all steps in the analysis process.

Additional materials required:

• Dako p53, clone DO7TM monoclonal antibody .
• Dako Ki-67, clone MIB1 monoclonal antibody .
• Reagents for visualization, such as DAB chromagen .
• Associated materials for completing immunohistochemical staining according to the appropriate package insert
• Color printer if user wishes to print out color copies

Mentions image processing

Yes

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

Formalin-fixed, paraffin-embedded normal and neoplastic breast tissue specimens

Indicated Patient Age Range

Not Found

Intended User / Care Setting

Qualified pathologist / Pathology labs

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

The Ki67 study involved three investigators (qualified pathologists) affiliated with different clinical labs utilizing 120 de-identified archived breast carcinoma sections in TMA form, stained for the identification of Ki67 protein using Dako clone MIB1 monoclonal antibody and DAB detection. Samples spanned a range of positivity from 0 (negative) to 100%. The slides (test samples) required for the study were scanned by BioImagene.

The p53 study involved three investigators (qualified pathologists) affiliated with different clinical labs utilizing 120 de-identified archived breast carcinoma sections in TMA form, stained for the identification of p53 protein using Dako clone DO7™ monoclonal antibody and DAB detection. Samples spanned a range of positivity from 0 (negative) to 100%. The slides (test samples) required for the study were scanned by BioImagene.

Samples for p53 study were sourced from a single research center, Ohio State University Medical Center (OSU), under IRB oversight and approval. 188 unique archived de-identified invasive breast carcinoma tissue specimens were used to create five TMAs. Sections of the TMAs were stained for p53 by OSU. Individual TMA cores measured 2 mm in diameter, with the total area of tissue for evaluation in each core equivalent to 16 high-power fields of view (400X magnification). The TMA slide set was scored by a qualified pathologist from BioImagene, at which time TMA cores with insufficient tissue/tumor for evaluation and/or artifacts that obscured tissue assessment were excluded. The remainder of the cores (160) were placed into one of four positivity categories: 0-1% (57), >1-5% (24), >5-10% (26) and >10% (53). The study sample set utilized 120 total TMA cores. The sample set of 120 consisted of all of the cores from the two middle scoring categories (>1-5%, 24 cores, and >5-10%, 26 cores). 35 cores from both the lowest and highest scoring categories (0-1% and >10%) were randomly selected from the cores in these categories, for a total of 120 cores.

Samples for Ki-67 study were sourced from a single research center, Ohio State University Medical Center (OSU), under IRB oversight and approval. 188 unique archived de-identified invasive breast carcinoma tissue specimens were used to create five TMAs. Sections of the TMAs were stained for Ki67 by OSU. Individual TMA cores measured 2 mm in diameter, with the total area of tissue for evaluation in each core equivalent to 16 high-power fields of view (400X magnification). The TMA slide set was scored by a qualified pathologist from BioImagene, at which time TMA cores with insufficient tissue/tumor for evaluation and/or artifacts that obscured tissue assessment were excluded. The remainder of the cores (168) were placed into one of four positivity categories: 0-1% (15), >1-5% (29), >5-10% (35) and >10% (89). The study sample set utilized 120 total TMA cores. The sample set of 120 consisted of all of the cores from the three lower scoring categories (0-1%, >1-5%, and >5-10%) and 41 cores from the highest scoring category (>10%), which were randomly selected from the 89 cores in this category. At least 29 (2 10%), which were included from all of the positivity categories with the exception of the 0-1% category. Because Ki67 is a proliferation marker and proliferation rates in breast cancer specimens are typically greater than zero, a smaller number of samples (15) from the 0-1% specifically are present in the TMA slide set, all of which were included in the study.

For analysis in the inter-pathologist study (manual vs PATHIAM-assisted), samples were scored manually by three qualified pathologists. After a minimum of one week, the investigators scored the cases again using the PATHIAM system. Scoring was semi-quantitative using four percent positivity categories: 0-1%, >1-5%, >5-10%, and >10%. PATHIAM quantitative scores were also recorded.

For intra-pathologist reproducibility, a single pathologist scored 20 of the 120 tissue samples for both p53 and Ki67 (five samples randomly chosen from each scoring category) two additional times using the same PATHIAM system. Between reads, the pathologist was given a wash-out period of at least 3 days, and the samples were randomly presented each time.

For precision/reproducibility studies, 8 test samples (selected from four scoring categories) were scanned 5 times on one scanner for intra-system study, and this was repeated on three different PATHIAM Systems for inter-system study. Pre-selected field of views (8) from TMA cores randomly selected by a qualified pathologist from the four scoring categories were used.

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Study Type: PATHIAM System Comparison Studies (Inter and Intra Pathologist Studies), PATHIAM System Reproducibility and Precision Study (Inter and Intra System Studies)

Inter-pathologist study (Manual vs. PATHIAM-assisted Scoring):

• Sample Size: 120 stained tissue test samples for p53 study and 120 stained tissue test samples for Ki-67 study.
• Key Results (Concordance Range for 3 Pathologists, Manual vs PATHIAM-assisted Substantial Equivalence):
  • p53:

    • 1%: 82% - 90%

    • 5%: 77% - 85%

    • 10%: 83% - 89%

  • Ki-67:

    • 1%: 88%-93%

    • 5%: 87%-93%

    • 10%: 81%-89%

Inter-pathologist reproducibility (PATHIAM-assisted vs. PATHIAM-assisted):

• Sample Size: 120 stained tissue test samples for p53 study and 120 stained tissue test samples for Ki-67 study.
• Key Results (Concordance Range for 3 Pathologists, PATHIAM-assisted vs PATHIAM-assisted Reproducibility):
  • p53:

    • 1%: 88% - 93%

    • 5%: 90% - 93%

    • 10%: 93% - 97%

  • Ki-67:

    • 1%: 92%-94%

    • 5%: 90%-93%

    • 10%: 88-95%

Intra-pathologist reproducibility (PATHIAM-assisted vs. PATHIAM-assisted):

• Sample Size: A single pathologist scored 20 of the 120 tissue samples for both p53 and Ki-67.
• Key Results (Concordance for 3 Scoring Events, PATHIAM-assisted vs PATHIAM-assisted Reproducibility):
  • p53:

    • 1%: 85%

    • 5%: 80%

    • 10%: 80%

  • Ki-67:

    • 1%: 80%

    • 5%: 85%

    • 10%: 85%

Intra-system Precision Study:

• Sample Size: Five sets of images (one set = eight test samples), scanned 5 times on one scanner, with 3 systems tested.
• Key Results (Mean, SD, %CV for p53 and Ki-67 across multiple samples): The tables provide detailed mean, standard deviation, and %CV values for 8 different samples for both p53 and Ki-67 across three different systems. The %CV values are generally very low (mostly under 1%, some up to 4.32% for p53 and 2.90% for Ki-67), indicating high precision.

Inter-system Reproducibility Study:

• Sample Size: Data from the three intra-system studies were used (8 test samples, scanned 5 times on each of 3 systems).
• Key Results (Mean, SD, %CV for p53 and Ki-67 across multiple samples): The tables provide detailed mean, standard deviation, and %CV values for 8 different samples for both p53 and Ki-67 across three different systems. The %CV values are generally low (max 4.55% for p53, max 2.14% for Ki-67) across samples, indicating good reproducibility between systems.

Overall Conclusion:
The criterion of ≥75% concordance between manual microscopy and PATHIAM assisted scoring for the evaluation of p53 & Ki67 was met by all three pathologists for all three clinical cut-offs evaluated.
Inter-pathologist reproducibility for three pathologists using the PATHIAM system also exceeded 75% concordance at all three clinical cut-offs. Inter-Pathologist reproducibility using the PATHIAM system was higher than Inter-Pathologist reproducibility using manual microscopy at all three clinical cut-offs, indicating that PATHIAM assisted scoring is more consistent than manual microscopy.
Intra-pathologist reproducibility for 3 scoring sessions using the PATHIAM system exceeded 75% concordance at all three clinical cut-offs.
The precision and reproducibility study data (averages, standard deviation and % CV) showed that PATHIAM System precision and reproducibility is similar to that of the predicate devices.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Concordance

Predicate Device(s): If the device was cleared using the 510(k) pathway, identify the Predicate Device(s) K/DEN number used to claim substantial equivalence and list them here in a comma separated list exactly as they appear in the text. List the primary predicate first in the list.

K062428, K053520

Reference Device(s): Identify the Reference Device(s) K/DEN number and list them here in a comma separated list exactly as they appear in the text.

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information for the subject device only (e.g. presence / absence, what scope was granted / cleared under the PCCP, any restrictions, etc).

Not Found

Regulation Number and Section

§ 864.1860 Immunohistochemistry reagents and kits.

(a)
Identification. Immunohistochemistry test systems (IHC's) are in vitro diagnostic devices consisting of polyclonal or monoclonal antibodies labeled with directions for use and performance claims, which may be packaged with ancillary reagents in kits. Their intended use is to identify, by immunological techniques, antigens in tissues or cytologic specimens. Similar devices intended for use with flow cytometry devices are not considered IHC's.(b)
Classification of immunohistochemistry devices. (1) Class I (general controls). Except as described in paragraphs (b)(2) and (b)(3) of this section, these devices are exempt from the premarket notification requirements in part 807, subpart E of this chapter. This exemption applies to IHC's that provide the pathologist with adjunctive diagnostic information that may be incorporated into the pathologist's report, but that is not ordinarily reported to the clinician as an independent finding. These IHC's are used after the primary diagnosis of tumor (neoplasm) has been made by conventional histopathology using nonimmunologic histochemical stains, such as hematoxylin and eosin. Examples of class I IHC's are differentiation markers that are used as adjunctive tests to subclassify tumors, such as keratin.(2) Class II (special control, guidance document: “FDA Guidance for Submission of Immunohistochemistry Applications to the FDA,” Center for Devices and Radiologic Health, 1998). These IHC's are intended for the detection and/or measurement of certain target analytes in order to provide prognostic or predictive data that are not directly confirmed by routine histopathologic internal and external control specimens. These IHC's provide the pathologist with information that is ordinarily reported as independent diagnostic information to the ordering clinician, and the claims associated with these data are widely accepted and supported by valid scientific evidence. Examples of class II IHC's are those intended for semiquantitative measurement of an analyte, such as hormone receptors in breast cancer.
(3) Class III (premarket approval). IHC's intended for any use not described in paragraphs (b)(1) or (b)(2) of this section.
(c)
Date of PMA or notice of completion of a PDP is required. As of May 28, 1976, an approval under section 515 of the Federal Food, Drug, and Cosmetic Act is required for any device described in paragraph (b)(3) of this section before this device may be commercially distributed. See § 864.3.

Summary

0

K092333

OCT 2 7 2010

SECTION 3 – 510(k) SUMMARY OF SAFETY AND EFFECTIVENESS

1

T 2 7 2010

This summary of 510(k) safety and effectiveness information is being submitted in accordance with the requirements of 21 CFR §807.92(c)

Submitted by: Indu Lakshman, Director of Quality & Regulatory Affairs BioImagene, Inc 919 Hermosa Ct. Sunnyvale, CA 94085 United States

Date summary prepared: June, 2009 Date summary updated: Oct, 2009

Trade Name: PATHIAM™ System with iScan for p53 and Ki-67

Classification Name: Microscope, automated, image analysis, immunohistochemistry, operator intervention, nuclear intensity & percent positivity.

Device Description:

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffin-embedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-toend digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images, add annotations, make measurements, perform image analysis, and generate reports.

The iScan slide scanning device captures digital images of formalin-fixed, Hardware: paraffin-embedded tissues that are suitable for storage and viewing. The device includes a digital slide scanner, racks for loading glass slides, computer, scanner software, keyboard, mouse and monitor.

The PATHIAM software is designed to complement the routine workflow of a Software: qualified pathologist in the review of immunohistochemically stained histologic slides. It allows the user to select fields of view (FOVs) in the digital image for analysis and provides quantitative data on these FOVs to assist with interpretation. The software makes no independent interpretations of the data and requires competent human intervention at all steps in the analysis process.

Indications for Use:

The p53 results provided by the PATHIAM System are indicated for use on is a useful tool for the identification of p53 accumulation in human neoplasias when used with IVD reagents marketed for this indication. Interpretation should be made within the context of the patient's

2

clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Ki-67 results provided by the PATHIAM System are indicated for use to assess proliferative activity when used with in vitro diagnostic reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Predicate Device: Tripath Imaging, Inc. Ventana® Image Analysis System (VIASTM) K062428 - VIAS p53 application K053520 - VIAS Ki-67 application Regulation: 21 CFR §864.1860, Immunohistochemistry Reagents and Kits Product Code: NON Panel: Pathology

Performance:

PATHIAM System Comparison Studies (Inter and Intra Pathologist Studies)

Inter pathologist study

Round 1 Manual Scoring:

Slides were scored by a qualified pathologist at each site manually. The three pathologists read randomly selected 120 stained tissue test samples manually on a microscope and assigned a score to each specimen (test sample) according to the scoring categories.

Round 2 PATHIAM Assisted Scoring:

PATHIAM assisted scoring took place after a minimum of one week passed since manual slide reading. The order that the test samples were accessed (randomized) for scoring was presented to the pathologists at the time the testing was administered and was different from the order presented in Round 1 to further reduce the possibility that the manual scoring influenced the scoring using the PATHIAM system. The same three pathologists reviewed the digital images of the test samples presented by the software on the computer monitor (PATHIAM system). The the toot only is the ability to navigate freely around the images at various magnifications (as in a microscope), select field of views for scoring, and determine the score for each specimen (test sample) with the assistance of the Pathiam system according to the scoring categories.

The above two steps (Round 1 and Round 2) were performed with three investigators on the same set of test samples.

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Table 1: Concordance Results for p53 Scoring

| p53 Cut-Off
Threshold | Manual vs PATHIAM-assisted
Substantial Equivalence
Concordance Range for 3
Pathologists | PATHIAM-assisted vs
PATHIAM-assisted
Reproducibility
Concordance Range for
3 Pathologists | Manual vs Manual
Reproducibility
Concordance Range for
3 Pathologists |
|--------------------------|--------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| >1% | 82% - 90% | 88% - 93% | 78% - 95% |
| >5% | 77% - 85% | 90% - 93% | 78% - 88% |
| >10% | 83% - 89% | 93% - 97% | 86% - 90% |

Table 2: Concordance Results for Ki-67 Scoring

| Ki-67 Cut-Off Threshold | Manual vs. PATHIAM-
assisted Substantial
Equivalence
Concordance Range for
3 Pathologists | PATHIAM-assisted vs.
PATHIAM-assisted
Reproducibility
Concordance Range for
3 Pathologists | Manual vs. Manual
Reproducibility
Concordance Range for
3 Pathologists |
|-------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------|
| >1% | 88%-93% | 92%-94% | 86%-91% |
| >5% | 87%-93% | 90%-93% | 85%-89% |
| >10% | 81%-89% | 88%-95% | 80%-91% |

4

PATHIAM System Reproducibility and Precision Study (Inter and Intra System Studies)

The intra system (PATHIAM system with iScan) study was performed on five sets of images (one set = eight test samples) produced by one scanner and scored on one computer system (consisting of a computer, monitor, keyboard, p53 & Ki-67 image analysis algorithms, MS Windows web browser and a mouse). This study was repeated on a total of three different scanners and computer systems. Test samples were pre-selected (field of views) by a qualified pathologist. See the data analysis tables below.

p53 System Study Precision (between run) Results:

Sample ID	Mean	SD	%CV
A7	0.00	0.00	-
E3	0.00	0.00	-
C9	42.90	0.02	0.06
B5	2.82	0.08	2.67
E3	73.50	0.05	0.07
B9	16.44	0.01	0.09
D4	22.14	0.07	0.32
B3	24.05	0.06	0.23

Table 5: Intra-system Precision Study - System I for p53

5

Sample ID	Mean	SD	%CV
A7	0.00	0.00	-
E3	0.00	0.00	-
C9	42.74	0.02	0.05
B5	2.57	0.01	0.58
E3	72.89	0.04	0.06
B9	16.51	0.04	0.24
D4	22.44	0.04	0.17
B3	22.68	0.06	0.25

Table 6: Intra system Precision Study – System II for p53

Table 7: Intra system Precision Study – System III for p53

Sample ID	Mean	SD	%CV
A7	0.00	0.00	-
E3	0.00	0.00	-
C9	42.60	0.05	0.11
B5	2.71	0.02	0.78
E3	74.07	0.13	0.18
B9	16.49	0.03	0.18
D4	24.42	0.01	0.05
B3	24.90	0.10	0.40

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Ki-67 System Study Precision (between run) Results:

| | Sample
ID | Mean | SD | %CV |
|------------------------------------------|--------------|-------|------|------|
| Ki67 Precision Study -
System 1 (n=5) | A2 | 31.78 | 0.10 | 0.31 |
| | E2 | 64.53 | 0.25 | 0.39 |
| | A3 | 15.45 | 0.15 | 0.99 |
| | D4 | 17.82 | 0.09 | 0.50 |
| | E7 | 9.76 | 0.02 | 0.22 |
| | D6 | 4.85 | 0.02 | 0.40 |
| | E5 | 9.13 | 0.12 | 1.35 |
| | A1 | 0.88 | 0.02 | 1.78 |

Table 8: Intra system Precision Study – System I for Ki-67

Table 9: Intra system Precision Study – System II for Ki-67

| | Sample
ID | Mean | SD | %CV |
|------------------------------------------|--------------|-------|------|------|
| Ki67 Precision Study - System 2
(n=5) | A2 | 32.77 | 0.37 | 1.13 |
| | E2 | 63.29 | 0.08 | 0.12 |
| | A3 | 15.76 | 0.17 | 1.09 |
| | D4 | 17.91 | 0.04 | 0.23 |
| | E7 | 9.41 | 0.04 | 0.44 |
| | D6 | 4.87 | 0.14 | 2.90 |
| | E5 | 9.27 | 0.04 | 0.42 |
| | A1 | 0.85 | 0.01 | 0.89 |

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| | Sample
ID | Mean | SD | %CV |
|------------------------------------------|--------------|-------|------|------|
| Ki67 Precision Study - System 3
(n=5) | A2 | 31.53 | 0.19 | 0.59 |
| | E2 | 62.11 | 0.23 | 0.36 |
| | A3 | 15.05 | 0.12 | 0.78 |
| | D4 | 17.66 | 0.02 | 0.14 |
| | E7 | 9.81 | 0.07 | 0.72 |
| | D6 | 4.95 | 0.03 | 0.68 |
| | E5 | 9.43 | 0.02 | 0.24 |
| | A1 | 0.86 | 0.00 | 0.35 |

Table 10: Intra system Precision Study - System III for Ki-67

Reproducibility (between Run/Inter System) Study

The data from the above three intra-system studies were used to understand the inter-system comparison.

Table 11: Inter system Reproducibility Study - p53

| Sample

ID	Mean	SD	%CV
A7	0.00	0.00	-
E3	0.00	0.00	-
C9	42.75	0.13	0.30
B5	2.70	0.12	4.32
E3	73.49	0.50	0.68
B9	16.48	0.04	0.25
D4	23.00	1.05	4.55
B3	23.88	0.95	3.97

8

Ki67 Inter-System Reproducibility - System 1, 2, 3 (n=3x5)
Line Item #	Sample ID	Mean	SD	%CV
TMA 3
2007	A2	32.03	0.60	1.87
TMA 3
2007	E2	63.31	1.04	1.65
TMA 3
2007	A3	15.42	0.33	2.14
TMA 4
2007	D4	17.79	0.12	0.66
TMA 3
2007	E7	9.66	0.19	1.95
TMA 5
2007	D6	4.89	0.09	1.84
TMA 3
2007	E5	9.28	0.14	1.53
TMA 2
2007	A1	0.86	0.02	2.07

Table 12: Inter system Reproducibility Study – Ki67

Substantial Equivalence

Table 13: Comparison to Predicate Devices to Support Substantial Equivalence Determination for p53 Image Analysis Systems

| Attribute | PATHIAM System for p53 | Tripath (VIAS p53)
K062428 |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Intended Use | This device is intended for in vitro
diagnostic (IVD) use. | This antibody is intended for in vitro
diagnostic (IVD) use. |
| | The PATHIAM System is intended
as an aid to the pathologist to detect,
count, and classify cells of clinical
interest based on recognition of
cellular objects of particular color,
size, and shape, using appropriate
controls to assure the validity of the
scores.

The p53 application is intended for | Ventana® Medical Systems
(Ventana) CONFIRM anti-p53 (DO-
7) primary antibody
is a mouse monoclonal antibody
(IgG1, kappa) directed against
human p53. The antibody is
intended for laboratory use to
qualitatively identify by light
microscopy wild type and mutant
p53 in sections of formalin fixed, |
| Attribute | PATHIAM System for p53 | Tripath (VIAS p53)
K062428 |
| use as an aid to the pathologist to
quantify the percentage of positively
stained nuclei in formalin fixed
paraffin embedded breast tissue
specimens stained with Dako mouse
monoclonal anti-human p53
antibody, clone DO7and visualized
with DAB chromogen, to detect both
wild-type and mutant p53, a nuclear
protein, as specified in the
instructions for these reagents. It is
the responsibility of a qualified
pathologist to employ appropriate
morphological studies and controls
as specified in the instructions for
Dako p53 to assure the validity of
the PATHIAM-assisted p53
assessment. | paraffin embedded tissue on a
Ventana automated slide stainer. | |
| Indications for
use | The p53 results provided by the
PATHIAM System are indicated for
use for the identification of p53
accumulation in human neoplasias
when used with IVD reagents
marketed for this indication.
Interpretation should be made within
the context of the patient's clinical
history and other diagnostic tests by
a qualified pathologist. The
pathologist must verify agreement
with the PATHIAM score. | The Ventana Image Analysis
System (VIASTM) is an adjunctive
computer-assisted image analysis
system functionally connected to an
interactive microscope. It is intended
for use as an aid to the pathologist in
the detection, classification and
counting of cells of interest 2 based
on marker intensity, size and shape
using appropriate controls to assure
the validity
of the VIAS scores. |
| Specimen Type | Formalin-fixed, paraffin embedded
breast cancer specimens stained by
immunohistochemistry reagent for
p53 | Same |
| Image Analysis
System | Histologic observation by a
pathologist through the
BioImagene's PATHIAM image
analysis system with iScan slide
scanner. | Histologic observation by a
pathologist through a specified
interactive microscope/digital
camera with image analysis
software. |
| Hardware and
Software | PATHIAM software, BioImagene
iScan slide scanner, computer, | VIAS with software, computer,
microscope, motorized stage, digital |
| Attribute | PATHIAM System for p53 | Tripath (VIAS p53)
K062428 |
| Components | mouse, keyboard, windows web
browser and monitor. | color video camera, mouse,
keyboard, and monitor. |
| Assay used | The tissues were stained using the
Dako p53, clone DO7TM monoclonal
antibody. | Ventana ConfirmTM anti-p53 (DO-7) |

9

Volume 1 Page 22

.

10

Table 14: Comparison to Predicate Devices to Support Substantial Equivalence Determination for Ki-67 Image Analysis Systems

| Attribute | PATHIAM System for Ki-67 | Tripath (VIAS Ki-67)
K053520 |
|--------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Intended Use | This device is intended for in vitro diagnostic (IVD) use.

The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.

The Ki-67 application is intended as an aid to the pathologist to quantify the percentage of positively stained nuclei in formalin-fixed paraffin embedded normal and neoplastic breast tissue specimens immunohistochemically stained with Dako mouse monoclonal anti-human Ki-67 antigen, clone MIB1 visualized with DAB chromogen as specified in the instructions for these reagents. It is the responsibility of a qualified pathologist to employ appropriate morphological studies and controls as specified in the instructions for Dako Ki-67 to assure the validity of the | This device is intended for in vitro diagnostic (IVD) use.

The Ventana Image Analysis System (VIAS) is an adjunctive computer-assisted image analysis system functionally connected to an interactive microscope. It is intended for use as an aid to the pathologist in the detection, classification and counting of cells of interest based on marker intensity, size and shape using appropriate controls to assure the validity of the VIAS scores. In this application, the VIAS is intended to aid a qualified pathologist in the acquisition and measurement of images to quantify the percentage of positively stained nuclei in paraffin embedded breast cancer tissue specimens immunohistochemically stained for the presence of Ki-67 proteins using Ventana's reagents and nuclear hematoxylin. It is indicated for use in assessing the proliferative activity of normal and neoplastic breast tissue when used with in vitro |

11

| Attribute | PATHIAM System for Ki-67 | Tripath (VIAS Ki-67)
K053520 |
|----------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| | PATHIAM-assisted Ki-67
assessment. | diagnostic reagents marketed for
these indications. |
| Indications for
use | Ki-67 results provided by the
PATHIAM System are indicated for
use to assess proliferative activity
when used with in vitro diagnostic
reagents marketed for this
indication. Interpretation should be
made within the context of the
patient's clinical history and other
diagnostic tests by a qualified
pathologist. The pathologist must
verify agreement with the
PATHIAM score. | It is indicated for use in assessing
the proliferative activity of normal
and neoplastic breast tissue when
used with in vitro diagnostic
reagents marketed for these
indications |
| Specimen Type | Formalin-fixed, paraffin embedded
specimens stained by
immunohistochemistry reagent for
Ki-67 | Same |
| Image Analysis
System | Histologic observation by a
pathologist through the
BioImagene's PATHIAM image
analysis system with/ iScan slide
scanner. | Histologic observation by a
pathologist through a specified
interactive microscope/digital
camera with image analysis
software. |
| Hardware and
Software
Components | PATHIAM software, BioImagene
iScan slide scanner, computer,
mouse, keyboard, windows web
browser and monitor. | VIAS with software, computer,
microscope, motorized stage, digital
color video camera, mouse,
keyboard, and monitor. |
| Assay used | The tissues were stained using Dako
Ki-67, clone MIB1 antibody. | Per Ventana Ki-67 kit product insert
(Catalogue Number 790-2910) |

Standards Employed

None under Section 514

r

FDA Guidance

Guidance for the Content of Premarket Submissions for Software Contained in Medical Devices, May 11, 2005

... . . . . .

12

SECTION 4 – DEVICE DESCRIPTION

:

13

General Description

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffin-embedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-toend digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images, add annotations, make measurements, perform image analysis, and generate reports.

The iScan slide scanning device captures digital images of formalin-fixed, Hardware: paraffin-embedded tissues that are suitable for storage and viewing. The device includes a digital slide scanner, racks for loading glass slides, computer, scanner software, keyboard, mouse and monitor.

Software: The PATHIAM software is designed to complement the routine workflow of a qualified pathologist in the review of immunohistochemically stained histologic slides. It allows the user to select fields of view (FOVs) in the digital image for analysis and provides quantitative data on these FOVs to assist with interpretation. The software makes no independent interpretations of the data and requires competent human intervention at all steps in the analysis process.

Additional materials required:

• Dako p53, clone DO7TM monoclonal antibody .
• Dako Ki-67, clone MIB1 monoclonal antibody .
• Reagents for visualization, such as DAB chromagen .
• Associated materials for completing immunohistochemical staining according to the . appropriate package insert
• . Color printer if user wishes to print out color copies

14

Device Quality Control

The quality of results depends on the laboratory following the quality control instructions recommended in the labeling of the immunohistochemistry (IHC) reagents. The software also performs a quality check on the digital images to determine if they are suitable for further analysis using "Image Quality Assessment" algorithms.

Summary of Procedure

Samples are obtained as formalin-fixed, paraffin-embedded tissue blocks. Histologic sections are prepared and mounted onto glass slides. Slides are reacted with either Ki-67 or p53 primary antibodies. Slides are visualized using DAB. Prepared slides are loaded into the PATHIAM system scanner and scanned. The resulting digital images are reviewed by the pathologist on a computer monitor, and appropriate fields of view (FOVs) are then selected for analysis by the PATHIAM software. The PATHIAM software produces a "percent positive" result for the specific immunohistochemical study (Ki-67 or p53), and the pathologist has the choice of accepting the result or entering his/her own score.

Principal of Operation

After the initial image quality check, the algorithm goes through the following steps before generating the analysis results:

• 1. Field of View (FOV) identification: The algorithm separates the tissue area from the background such that only the tissue area is processed in the following steps.
• 2. Preprocessing: The algorithm generates two images after preprocessing. One of them is a contrast stretched image, and the other is an image with each of the tissue AOI pixels classified as stained or non-stained.
• 3. Segmentation: This processing step consists of extracting the objects of interest from the image. In the current applications, the objects of interest are epithelial cell nuclei. These are separated out from the rest of the identified objects using morphological properties, such as size and shape.
• 4. Classification: The segmented nuclei are classified as stained cells or non-stained cells based on the percentage of stained pixels within them.
• 5. Scoring / Grading: Based on the classification, an overall score for the image is computed using the numbers of stained cells, non-stained cells and total cells for the calculations.

15

Table 15 - BioImagene iScan Slide Scanner Specifications

.

: 、

.

【

·

Input Format	1 x 3 inch (25 x 75mm) microscope slides
Slide Capacity	1 to 160 slides using 8 integrated standard
Sakura racks
Microscope Objective	Olympus 20x/0.50 Plan Fluor (Nikon 20x/0.50
Plan Fluor)
Scanning Resolution	0.46 $\mu$ m/pixel @ 20x
Camera Frame Size	1392x1032
Light Source (Illumination)	Integrated LED
Auto-Scan	Automated barcode reading, tissue
identification, autofocus, scanning and JPEG
2000 compression for up to 160 slides
Manual Scan	User selects scan area for single or batched
slides in automatic or manual mode
Throughput	~ 4 minutes/slide in batch mode (15 x 15mm
scan area @ 20x)

• Time To View (defined as total pre-
  processing time, scanning time and encoding
  time) |
  | Scan Viewing | 24-bit true color |
  | Slide Storage Format | JPEG 2000 |
  | Compression | 1:1 - 20:1 (range) |
  | Barcode Capability | 1D and 2D option |
  | Dimensions | Approximately 18 x 18 x 17 high inches (45 x
  45 x 41 high mm) |
  | Weight | 75 lbs (23 kg) |
  | Power | 110-240 VAC, 50/60 Hz |

16

SECTION 5 – COMPARATIVE INFORMATION

.

17

Substantial Equivalence

Table 16: Comparison to Predicate Devices to Support Substantial Equivalence Determination

| Attribute | PATHIAM System | Tripath (VIAS p53)
K062428 |
|----------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Intended Use | This device is intended for in vitro
diagnostic (IVD) use. | This antibody is intended for
in vitro diagnostic (IVD) use. |
| | The PATHIAM System is intended
as an aid to the pathologist to
detect, count, and classify cells of
clinical interest based on
recognition of cellular objects of
particular color, size, and shape,
using appropriate controls to assure
the validity of the scores.
The p53 application is intended for
use as an aid to the pathologist to
quantify the percentage of
positively stained nuclei in
formalin fixed paraffin embedded
breast tissue specimens stained
with Dako mouse monoclonal anti-
human p53 antibody, clone
DO7and visualized with DAB
chromogen, to detect both wild-
type and mutant p53, a nuclear
protein, as specified in the
instructions for these reagents. It
is the responsibility of a qualified
pathologist to employ appropriate
morphological studies and controls
as specified in the instructions for
Dako p53 to assure the validity of
the PATHIAM-assisted p53
assessment. | Ventana® Medical Systems
(Ventana) CONFIRM anti-
p53 (DO-7) primary antibody
is a mouse monoclonal
antibody (IgG1, kappa)
directed against human p53.
The antibody is intended for
laboratory use to qualitatively
identify by light microscopy
wild type and mutant p53 in
sections of formalin fixed,
paraffin embedded tissue on a
Ventana automated slide
stainer. |
| Indications for use | The p53 results provided by the
PATHIAM System are indicated
for use for the identification of p53
accumulation in human neoplasias | The Ventana Image Analysis
System (VIASTM) is an
adjunctive computer-assisted
image analysis system |
| Attribute | PATHIAM System | Tripath (VIAS p53)
K062428 |
| | when used with IVD reagents
marketed for this indication.
Interpretation should be made
within the context of the patient's
clinical history and other
diagnostic tests by a qualified
pathologist. The pathologist must
verify agreement with the
PATHIAM score. | functionally connected to an
interactive microscope. It is
intended for use as an aid to
the pathologist in the
detection, classification and
counting of cells of interest
based on marker intensity,
size and shape using
appropriate controls to assure
the validity of the VIAS
scores. |
| Specimen Type | Formalin-fixed, paraffin embedded
breast cancer specimens stained by
immunohistochemistry reagent for
p53 | Same |
| Image Analysis
System | Histologic observation by a
pathologist through BioImagene's
PATHIAM image analysis system
with iScan slide scanner. | Histologic observation by a
pathologist through a
specified interactive
microscope/digital camera
with image analysis software. |
| Hardware and
Software
Components | PATHIAM software, BioImagene
iScan slide scanner, computer,
mouse, keyboard, windows web
browser and monitor. | VIAS with software,
computer, microscope,
motorized stage, digital color
video camera, mouse,
keyboard, and monitor. |
| Assay used | Dako p53, clone DO7TM
monoclonal antibody | Ventana ConfirmTM anti-p53
(DO-7) |

18

Table 17: Comparison to Predicate Devices to Support Substantial Equivalence Determination

| Attribute | PATHIAM System | Tripath (VIAS Ki-67)
K053520 |
|----------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Intended Use | This device is intended for in
vitro diagnostic (IVD) use. | This device is intended for in
vitro diagnostic (IVD) use. |
| Intended Use | The PATHIAM System is
intended as an aid to the
pathologist to detect, count, and
classify cells of clinical interest
based on recognition of cellular
objects of particular color, size,
and shape, using appropriate
controls to assure the validity of | The Ventana Image Analysis
System (VIAS) is an adjunctive
computer-assisted image
analysis system functionally
connected to an interactive
microscope. It is intended for
use as an aid to the pathologist in
the detection, classification and |
| Attribute | PATHIAM System | Tripath (VIAS Ki-67)
K053520 |
| | the scores. | counting of cells of interest based
on marker intensity, size and
shape using appropriate controls
to assure the validity of the VIAS
scores. |
| | The Ki-67 application is intended
as an aid to the pathologist to
quantify the percentage of
positively stained nuclei in
formalin-fixed paraffin embedded
normal and neoplastic breast
tissue specimens
immunohistochemically stained
with Dako mouse monoclonal
anti-human Ki-67 antigen,
clone MIB1 visualized with DAB
chromogen as specified in the
instructions for these reagents. It
is the responsibility of a qualified
pathologist to employ appropriate
morphological studies and
controls as specified in the
instructions for Dako Ki-67 to
assure the validity of the
PATHIAM-assisted Ki-67
assessment. | In this application, the VIAS is
intended to aid a qualified
pathologist in the acquisition
and measurement of images to
quantify the percentage of
positively stained nuclei in
paraffin embedded breast cancer
tissue specimens
immunohistochemically stained
for the presence of Ki-67 proteins
using Ventana's reagents and
nuclear hematoxylin. It is
indicated for use in assessing the
proliferative activity of normal
and neoplastic breast
tissue when used with in vitro
diagnostic reagents marketed for
these indications. |
| Indications for
use | Ki-67 results provided by the
PATHIAM System are indicated
for use to assess proliferative
activity when used with in vitro
diagnostic reagents marketed for
this indication. Interpretation
should be made within the
context of the patient's clinical
history and other diagnostic tests
by a qualified pathologist. The
pathologist must verify
agreement with the PATHIAM
score. | It is indicated for use in assessing
the proliferative activity of
normal and neoplastic breast
tissue when used with in vitro
diagnostic reagents marketed for
these indications |
| Specimen Type | Formalin-fixed, paraffin
embedded specimens stained by
immunohistochemistry reagent
for Ki-67 | Same |
| Image Analysis
System | Histologic observation by a
pathologist through
BioImagene's PATHIAM image | Histologic observation by a
pathologist through a specified
interactive microscope/digital |
| Attribute | PATHIAM System | Tripath (VIAS Ki-67)
K053520 |
| Hardware and
Software
Components | analysis system with iScan slide
scanner. | camera with image analysis
software. |
| | PATHIAM software, BioImagene
iScan slide scanner, computer,
mouse, keyboard, windows web
browser and monitor. | VIAS with software, computer,
microscope, motorized stage,
digital color video camera,
mouse, keyboard, and monitor. |
| | Assay used | Dako Ki-67, clone MIB1
monoclonal antibody. |

19

20

Substantial Equivalence Conclusion

Substantial equivalence is demonstrated by identical intended use and similar performance. The technological differences between the device and the predicate do not raise new questions or concerns of safety and effectiveness.

21

SECTION 6 – PERFORMANCE TESTING

।

22

PATHIAM System Comparison Studies (inter and intra pathologist)

Title: Performance of the PATHIAM System for analysis of p53 and Ki-67 nuclear protein immunohistochemistry in breast tissue.

Objective:

The objectives of the study were two-fold:

• 1. To compare the performance of the PATHIAM system to manual microscopy for the assessment of Ki67 & p53 immunohistochemistry.
• 2. To determine whether inter-pathologist and intra-pathologist scoring of Ki67 & p53 immunohistochemistry using the PATHIAM system is reproducible.

Protocol Number: TP-000046 Rev. B

Device Description:

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffinembedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-to-end digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images at various magnifications, add annotations, make measurements, perform image analysis, and generate reports.

Predicates: K053520, K062428

Investigators:

Gist Farr, MD, Spartanburg, SC Lynn Goldstein, MD, PhenoPath Laboratories, Seattle, WA Beiru Chen, MD, Delta Pathology Associates, Stockton, CA

Investigator Training: Investigators received training prior to participation in the study. Training included a review of the protocol, good clinical practice, detailed manual scoring instructions, case report form completion, study timelines, and a microscope session that included a reference slide review, use of the sample list, TMA map, and low power print outs.

Immediately prior to the second round of scoring using the PATHIAM system, a second training was conducted that included a review of a PATHIAM Scoring Presentation, detailed PATHIAM Scoring Instructions and a computer session that consisted of reference slide review, use of the sample list, and assisted scoring with the PATHIAM Software.

23

Sample Procurement Center:

Ohio State University Medical Center 310 Doan Hall, 410 West 10th Av, Columbus, OH CLIA # 36D1046162

Tissue Procurement, Preparation and Staining:

Procurement and slide preparation was under the direction of Dr. Sanford H. Barsky, Chair, Department of Pathology, Ohio State University School of Medicine (OSU). Tissues were acquired from select patient material in the form of archived pathological specimens stored as either paraffin blocks or previously made Tissue Micro Arrays (TMAs). 188 formalin fixed paraffin blocks of breast cancer samples from different patients were used to prepare five tissue micro-arrays (TMAs). Individual TMA cores measured 2 mm in diameter. Sections from each block were prepared at OSU and mounted onto glass slides.

The slides were stained for the identification of Ki67 protein using Dako clone MIB1 monoclonal antibody and DAB detection and for the identification of p53 protein using Dako clone DO7TM monoclonal antibody and DAB detection.

Comparative Study Investigators:

Gist Farr, MD, Spartanburg, SC Lynn Goldstein, MD, PhenoPath Laboratories, Seattle, WA Beiru Chen, MD, Delta Pathology Associates, Stockton, CA

Study Locations:

	Manual Scoring	PATHIAM Scoring
Dr. Farr	University of Puget Sound
Biology Dept.
1500 North Wamer St.
Tacoma, WA 98416	Sound Clinical Research, LLC
3519 N Adams St
Tacoma, WA 98407
Dr. Chen	Division of Pathology and Lab Medicine
Doctors Hospital
1205 E North St,
Manteca, CA 95336	Biolmagene, Inc.
919 Hermosa Court
Sunnyvale, CA 94085
Dr. Goldstein	PhenoPath Laboratories
551 North 34th Street, Suite 100
Seattle, Washington 98103	PhenoPath Laboratories
551 North 34th Street, Suite 100
Seattle, Washington 98103

24

IRBs:

For the Use of Tissue: Ohio State University Office of Responsible Research Practices 300 Research Foundation 1960 Kenny Road Columbus, OH 43210-1063

For the Study Protocol and Investigators: Aspire IRB 9320 Fuerte Drive, Suite 105 La Mesa, CA 91941

Study Design

The Ki67study involved three investigators (qualified pathologists) affiliated with different clinical labs utilizing 120 de-identified archived breast carcinoma sections in TMA form, stained for the identification of Ki67 protein using Dako clone MIB1 monoclonal antibody and DAB detection. Samples spanned a range of positivity from 0 (negative) to 100%. The slides (test samples) required for the study were scanned by BioImagene.

The p53 study involved three investigators (qualified pathologists) affiliated with 'different clinical labs utilizing 120 de-identified archived breast carcinoma sections in TMA form, stained for the identification of p53 protein using Dako clone DO7™ monoclonal antibody and DAB detection. Samples spanned a range of positivity from 0 (negative) to 100%. The slides (test samples) required for the study were scanned by BioImagene.

Application	Computer Analysis of Digitized Image
System	iScan scanner
Requirements	Computer, Monitor
PATHIAM Software
System Input	Microscope slides to scanner
Pathologist Input	Select image to load from scanner
Select test samples
Score test sample under microscope
Choose FOVs from each test sample
Click ANALYZE button

System & Input Requirements for PATHIAM System

25

Review PATHIAM Score
Accept PATHIAM score or Enter own score (PATHIAM-assisted)

Inter pathologist study

Round 1 Manual Scoring:

Slides were scored by a qualified pathologist at each site manually. The three pathologists individually reviewed 120 tissue samples immunohistochemically stained for p53 or Ki67 on a microscope and assigned a score to each specimen (test sample) according to the scoring categories.

Round 2 PATHIAM Assisted Scoring:

PATHIAM assisted scoring took place after a minimum of one week passed since manual slide reading. The order that the test samples were accessed (randomized) for scoring was presented to the pathologists at the time the testing was administered and was different from the order presented in Round 1 to further reduce the possibility that the manual scoring influenced the scoring using the PATHIAM system. The same three pathologists reviewed the digital images of the test samples presented by the software on a computer monitor (PATHIAM system). The pathologists had the ability to navigate freely around the images at various magnifications (as in a microscope), select fields of views for scoring, and determine the score for each specimen (test sample) with the assistance of the PATHIAM system according to the scoring categories.

The above two steps (Round 1 and Round 2) were performed with three investigators on the same set of test samples.

Intra pathologist study

A single pathologist scored 20 of the 120 tissue samples for both for p53 and Ki67 (five samples randomly chosen from each scoring category) two additional times using the same PATHIAM system. Between reads, the pathologist was given a wash-out period of at least 3 days, and the samples were randomly presented each time (to further support wash-out and blinding) to the pathologist in all scoring sessions.

Test Samples for p53 Study:

Samples were sourced from a single research center, Ohio State University Medical Center (OSU), under IRB oversight and approval. 188 unique archived de-identified invasive breast carcinoma tissue specimens were used to create five TMAs. Sections of the TMAs were stained for p53 by OSU. Individual TMA cores measured 2 mm in diameter, with the total area of tissue for evaluation in each core equivalent to 16 high-power fields of view (400X magnification). The TMA slide set was scored by a qualified pathologist from BioImagene, at which time TMA cores with insufficient tissue/tumor for evaluation and/or artifacts that obscured tissue assessment were excluded. The remainder of the cores (160) were placed into one of four positivity categories: 0-1% (57), >1-5% (24), >5-10% (26) and >10% (53).

26

The study sample set utilized 120 total TMA cores spanning a range of positivity from 0 to 100%. The sample set of 120 consisted of all of the cores from the two middle scoring categories (>1-5%, 24 cores, and >5-10%, 26 cores). 35 cores from both the lowest and highest scoring categories (0-1% and >10%) were randomly selected from the cores in these categories, for a total of 120 cores.

TMAs were stained with the following reagents according to the procedure outlined in the table below: Antigen retrieval buffer (citrate, pH 6.0): Dako cat. No. S1699; p53: Clone DO7 (Dako cat. No. M7001); Antibody diluent, Dako cat. No. S0809; LSAB+ detection kit (Dako cat. No. K0690); DAB, (Dako cat. No. K3468).

| Antigen retrieval with S1699 citrate

buffer, pH 6.0	20-25 min
Antibody dilution using S0809	1:50
Antibody incubation	30 min at RT
Link incubation with biotinylated
anti-rabbit, anti-mouse and anti-goat
immunoglobulins	15 min incubation at RT
Streptavidin-Peroxidase incubation	15 min incubation at RT
DAB	5 min
Hematoxylin	15 sec

Table: p53 Staining Procedure

Test Samples for Ki-67 Study:

Samples were sourced from a single research center, Ohio State University Medical Center (OSU), under IRB oversight and approval. 188 unique archived de-identified invasive breast carcinoma tissue specimens were used to create five TMAs. Sections of the TMAs were stained for Ki67 by OSU. Individual TMA cores measured 2 mm in diameter, with the total area of tissue for evaluation in each core equivalent to 16 high-power fields of view (400X magnification). The TMA slide set was scored by a qualified pathologist from BioImagene, at which time TMA cores with insufficient tissue/tumor for evaluation and/or artifacts that obscured tissue assessment were excluded. The remainder of the cores (168) were placed into one of four positivity categories: 0-1% (15), >1-5% (29), >5-10% (35) and >10% (89).

The study sample set utilized 120 total TMA cores spanning a range of positivity from 0 to 100%. The sample set of 120 consisted of all of the cores from the three lower scoring categories (0-1%, >1-5%, and >5-10%) and 41 cores from the highest scoring category (>10%), which were randomly selected from the 89 cores in this category. At least 29 (2 10%), which were included from all of the positivity categories with the exception of the 0-1% category. Because Ki67 is a proliferation marker and proliferation rates in breast cancer specimens are typically greater than zero, a smaller number of samples (15) from the 0-1% specifically are typresent in the TMA slide set, all of which were included in the study.

TMAs were stained with the following reagents according to the procedure outlined in the 11MAs were samed with and really for (citrate, pH 6.0): Dako cat. No. S1699; Ki-67: Clone

27

MIB1 (Dako cat. No. M7240); LSAB+ detection kit (Dako cat. No. K0679); DAB, (Dako cat. No. K3468).

Antigen retrieval	20-25 min
Antibody dilution	1:150
Antibody incubation	30-60 min at RT
Link incubation	15 min incubation at RT
Streptavidin-Peroxidase	15 min incubation at RT
incubation
DAB	5 min
Hematoxylin	15 sec

Table: Ki67 Staining Procedure

Evaluations:

Comparative Study with Manual Microscopy:

For the comparative assessment, samples were scored by each investigator manually. After a minimum of one week had passed, the investigators scored the cases again using the PATHIAM system. Scoring was semi-quantitative using four percent positivity categories of 0-1%, >1-5%, >5-10%, and >10%. PATHIAM quantitative scores were also recorded.

Reproducibility:

The PATHIAM scores from the equivalence assessment were also used to assess Inter-Pathologist reproducibility.

One of the investigators for both p53 and Ki-67 (Dr. Goldstein) scored a subset of 20 cases on the PATHIAM system two additional times for the assessment of intra-reader reproducibility. A minimum of three days' washout occurred between PATHIAM scoring sessions. Additionally, the order the slides were reviewed was randomized between each scoring session.

Analytical Specificity:

The specificity of the test results is dependent on the analytical performance of the immunohistochemical staining of the tissue.

Assay Cut Off:

Clinical cut-offs used for the assessment of p53 & Ki67 varies between laboratories. The performance of the PATHIAM system was evaluated at three commonly used clinical cut-offs: >1%, >5% and >10%.

28

Data Collection, Data Entry, Data Verification, and Query Resolution:

Data Collection

Participating pathologists captured the scoring data on Scoring Case Report Forms. They either entered the data directly onto the forms or dictated the results to a recorder. In all cases, the investigators reviewed the data on the form and signed each page.

Data Entry Verification

Once all data entry was completed, data OC was performed. A single individual or a two person team performed data OC. When a Two Person team was available, Person 1 read the data from the original CRF while person 2 verified the data on the spreadsheet. Corrections to the data were made as needed. Comments were entered describing any changes made. The spreadsheet was designated QC in the title, and the date of the QC noted in the header of each page.

Query Resolution

Query resolution can arise from the data analysis process. Queries were sent to the investigative center in written fax or e-mail form. Corrections were made on the query resolution form, which was signed by the investigator. The forms were faxed or e-mailed back to the study coordinator, with the original also forwarded to the study coordinator. A copy was retained on site. Changes to the excel spreadsheet were noted as comments on the OC version of the file. When query resolution was complete, the final excel spreadsheet was saved as "Final". The final spreadsheets were used for the data analyses used to generate reports for regulatory submissions.

PATHIAM System Traceability

One PATHIAM System was used for this comparison study (to accommodate different study sites, two monitors were used). The details of the system are as follows:

Computer	Lenovo ThinkPad T-series 6460EGU	S/N: L3-R5511 08/09
BROWSER	Internet Exp 7 Version 7.0.5730.11	n/a
Monitor 1	Dell 2407WFPB	S/N: MX-OGM504-
T4262-7BL-2765
Monitor 2	Dell 2407WFPB
PS-000617 Rev. A (V 3.1)	SN: MX-0G283H-74262-
92C-35LS
PATHIAM Software		n/a
iScan - Scanner
Software	PS-000322 Rev. Q (V 2.1.0.2)	S/N: BIO8N0059

29

Data Analysis

Data was analyzed for the comparative performance of manual versus PATHIAMassisted scoring of Ki67 & p53, and for inter-reader and intra-reader reproducibility of the PATHIAM-assisted method of scoring.

Concordance ranges are presented in tables along with upper and lower 95% confidence interval ranges. Concordance calculations were determined by dividing the total number of cases with matching scores ("true" positives and negatives) by the total number of cases scored. .

p53 Data Analysis and Tables Table 18: Concordance Results for p53 Scoring

| p53 Cut-Off
Threshold | Manual vs PATHIAM-assisted
Substantial Equivalence
Concordance Range for 3
Pathologists | PATHIAM-assisted vs
PATHIAM-assisted
Reproducibility
Concordance Range for
3 Pathologists | Manual vs Manual
Reproducibility
Concordance Range for
3 Pathologists |
|--------------------------|--------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| >1% | 82% - 90% | 88% - 93% | 78% - 95% |
| >5% | 77% - 85% | 90% - 93% | 78% - 88% |
| >10% | 83% - 89% | 93% - 97% | 86% - 90% |

Table 19: Concordance Results for p53 Scoring - Exact 95% Upper Confidence Limits

| p53 Cut-Off
Threshold | Manual vs PATHIAM-assisted
Substantial Equivalence
Concordance Range for 3
Pathologists | PATHIAM-assisted vs
PATHIAM-assisted
Reproducibility
Concordance Range for 3
Pathologists | Manual vs Manual
Reproducibility
Concordance Range for 3
Pathologists |
|--------------------------|--------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| >1% | 88% - 95% | 93% - 97% | 85% - 98% |
| >5% | 84% - 91% | 95% - 97% | 85% - 93% |
| >10% | 89% - 94% | 97% - 99% | 92% - 95% |

30

Table 20: Concordance Results for p53 Scoring - Exact 95% Lower Confidence Limits

| p53 Cut-Off Threshold | Manual vs PATHIAM-assisted
Substantial Equivalence
Concordance Range for 3
Pathologists | PATHIAM-assisted vs
PATHIAM-assisted
Reproducibility
Concordance Range for 3
Pathologists | Manual vs Manual
Reproducibility
Concordance Range for 3
Pathologists |
|-----------------------|--------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| >1% | 73% - 83% | 81% - 87% | 69% - 89% |
| >5% | 69% - 77% | 83% - 87% | 70% - 80% |
| >10% | 75% - 82% | 87% - 92% | 78% - 83% |

Table 21: Reproducibility Concordance for Intra-Pathologist Scoring of p53

| Cut-Off Threshold | PATHIAM-assisted vs. PATHIAM-assisted
Reproducibility Concordance for 3 Scoring
Events |
|-------------------|----------------------------------------------------------------------------------------------|
| >1% | 85% |
| >5% | 80% |
| >10% | 80% |

Ki-67 Data Analysis & Tables:

Table 22: Concordance Results for Ki-67 Scoring

| Ki-67 Cut-Off
Threshold | Manual vs. PATHIAM-
assisted Substantial
Equivalence
Concordance Range for
3 Pathologists | PATHIAM-assisted vs.
PATHIAM-assisted
Reproducibility
Concordance Range for
3 Pathologists | Manual vs. Manual
Reproducibility
Concordance Range for
3 Pathologists |
|----------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------|
| >1% | 88%-93% | 92%-94% | 86%-91% |
| >5% | 87%-93% | 90%-93% | 85%-89% |
| >10% | 81%-89% | 88-95% | 80%-91% |

Table 23: Concordance Results for Ki-67 Scoring - Exact 95% Upper Confidence Limits

| Ki-67 Cut-Off
Threshold | Manual vs. PATHIAM-
assisted Substantial
Equivalence
Concordance Range for
3 Pathologists | PATHIAM-assisted vs.
PATHIAM-assisted
Reproducibility
Concordance Range for
3 Pathologists | Manual vs. Manual
Reproducibility
Concordance Range for
3 Pathologists |
|----------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------|
| >1% | 93%-97% | 96%-98% | 92%-95% |
| >5% | 92%-97% | 95%-97% | 91%-94% |
| >10% | 87%-94% | 93%-98% | 87%-95% |

Table 24: Concordance Results for Ki-67 Scoring - Exact 95% Lower Confidence Limits

31

| Ki-67 Cut-Off
Threshold | Manual vs PATHIAM-
assisted Substantial
Equivalence
Concordance Range for
3 Pathologists | PATHIAM-assisted vs
PATHIAM-assisted
Reproducibility
Concordance Range for
3 Pathologists | Manual vs Manual
Reproducibility
Concordance Range for
3 Pathologists |
|----------------------------|------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| >1% | 81%-87% | 85%-88% | 78%-84% |
| >5% | 79%-86% | 83%-87% | 77%-82% |
| >10% | 73%-82% | 80%-89% | 72%-84% |

Table 25: Reproducibility Concordance for Intra-Pathologist Scoring of Ki-67

| Cut Off Threshold | PATHIAM-assisted vs. PATHIAM-assisted
Reproducibility Concordance for 3 Scoring
Events |
|-------------------|----------------------------------------------------------------------------------------------|
| >1% | 80% |
| >5% | 85% |
| >10% | 85% |

Treatment of Samples Rejected for Quality by the PATHIAM system: No cases were rejected.

End Points:

Concordance was examined at three clinically accepted standards/cut-offs for positivity, >1%, >5%, and >10%, similar to the predicates.

Conclusion:

The criterion of ≥75% concordance between manual microscopy and PATHIAM assisted scoring for the evaluation of p53 & Ki67 was met by all three pathologists for all three clinical cut-offs evaluated.

Inter-pathologist reproducibility for three pathologists using the PATHIAM system also exceeded 75% concordance at all three clinical cut-offs. Inter-Pathologist reproducibility using the PATHIAM system was higher than Inter-Pathologist reproducibility using manual microscopy at all three clinical cut-offs, indicating that PATHIAM assisted scoring is more consistent than manual microscopy.

Intra-pathologist reproducibility for 3 scoring sessions using the PATHIAM system exceeded 75% concordance at all three clinical cut-offs.

لمنتريجي

32

Step by Step Scoring Procedure

Manual Scoring

Overview: the pathologist manually scores test samples in tissue microarrays on glass slides under the microscope.

Materials required:

• Sample slides .
• . TMA maps
• Color pictures of samples taken at low magnification to help pathologist locate . specific core on glass slide
• . Scoring Case Report Forms

Materials required but not provided:

• · Microscope
  Step-by-Step Protocol:

• 1. Have pathologist review the training tissue samples for each scoring group (0-1%, >1-5%, >5-10%, >10%).
• 2. Give pathologist the randomly ordered list of test samples to be scored along with the TMA map, the corresponding TMA slide, and the low power print out corresponding to the first test sample.
• 3. Pathologist will locate the correct test sample under the microscope using the TMA map and the low power image of the test sample.
• 4. Pathologist will then review the entire test sample under the microscope as he/she would review other histopathology specimens using various objectives and freely moving the slide to evaluate multiple fields of view to arrive at a score.
• 5. Pathologist will record score on the provided scoring case report form for each test sample following the review of that test sample.
• 6. Pathologist will repeat the process for all 120 test samples.
• 7. Pathologist will review and sign the scoring case report form at the end of the scoring session.

33

PATHIAM Assisted Scoring

Overview: the pathologist will navigate the test sample images and select the field of view (at least two per test sample) on the monitor. After selecting each FOV, the pathologist will click on the "analyze" button. The pathologist will then be presented with the score for that FOV, as well as the aggregate score for all analyzed FOVs. The pathologist will have the ability to accept or reject scores for individual FOVs as well as the aggregate score. After selecting and analyzing at least two FOVs, the pathologist will select an appropriate scoring category for the sample on the case report form (which may or may not correspond to the PATHIAM aggregated score). The pathologist will also record the PATHIAM aggregated raw score for each sample.

Materials required:

• PATHIAM installed on computer .
• Monitor
• . Mouse, keyboard
• . TMA maps
• Color pictures of samples taken at low magnification to help pathologist locate . specific core on digitized slides
• . Scoring Case Report Forms

Materials required but not provided: none

Step-by-Step Protocol:

• 1. Pathologist will open PATHIAM and login using the provided username and password.
• 2. Pathologist will open the case list and select case number corresponding to the first test sample on the case report form.
• 3. Pathologist will open the digital image and navigate to the first test sample using the TMA map. The test sample to be scored in each image will be outlined by a red box. Pathologist will select at least two fields of view (FOV) containing representative areas of the tumor for scoring. After selecting each FOV, the pathologist will click on the "analyze" button. The pathologist will then be presented with the score for that FOV, as well as the aggregate score for all analyzed FOVs. The pathologist will have the ability to accept or reject scores for individual FOVs as well as the aggregate score. After selecting and analyzing at least two FOVs, the pathologist will select an appropriate scoring category for the sample on the case report form (which may or may not correspond to the PATHIAM aggregated score). The pathologist will also record the PATHIAM aggregated raw score for each sample.
• 4. Pathologist will repeat the process for all 120 test samples.
• 5. Pathologist will review and sign the scoring case report form at the end of the scoring session.

34

PATHIAM System Precision/Reproducibility Studies (intra and inter system)

Title: Intersystem and intra-system performance of the PATHIAM System for analysis of Ki-67 & p53 nuclear protein immunohistochemistry in breast carcinoma tissue.

Obiective:

The objectives for this study are to understand the intra system and inter system performance characteristics of the PATHIAM System for p53 and Ki-67 stained breast carcinoma tissue slides.

Sample Procurement Center:

Ohio State University Medical Center 310 Doan Hall, 410 West 10th Av, Columbus, OH CLIA # 36D1046162

Investigators and Study Sites: The PATHIAM system study was performed at Biolmagene under the supervision of Dr. Robert Monroe, Chief Medical Officer of BioImagene.

References: TP-000048 & TP-000049 Pathiam System Study Protocols for p53 & Ki-67 (breast), inter system and intra system studies.

Device Description:

The PATHIAM™ System is an instrument and software system designed to assist the qualified pathologist in the consistent quantitative assessment of protein expression in immunohistochemically stained histologic sections from formalin-fixed, paraffinembedded normal and neoplastic tissues. The system consists of a slide scanner (iScan), computer, monitor, keyboard, mouse, image analysis algorithms for specific immunohistochemical markers, and software with a Windows web browser-based user interface. PATHIAM is a web-based, end-to-end digital pathology software solution that allows pathology labs to acquire, manage, view, analyze, share, and report on digital images of pathology specimens. Using the PATHIAM software, the pathologist can view digital images, add annotations, make measurements, perform image analysis, and generate reports.

35

Study Design

The intra system (PATHIAM system with iScan) study was performed on five sets of images (one set = eight test samples) produced by one scanner and scored on one computer system (consisting of a computer, monitor, keyboard, p53 & Ki-67 image analysis algorithms, MS Windows web browser and a mouse). Pre-selected field of views (8) from TMA cores randomly selected by a qualified pathologist from the four scoring categories were used for this study. Pre-selection of FOVs was necessary to allow the study scientist to locate corresponding FOVs on the multiple digital images generated by the same scanner for scoring. The goal of the inter system study was to assess the consistency and reproducibility of the PATHIAM system (no pathologist) for p53 & Ki-67 scoring on different systems.

This study was repeated on a total of three different scanners and computer systems. The same pre-selected field of views used for the inter system studies were also used for intra system study.

The test sample selection process for the system studies was as follows:

• 120 de-identified test samples were selected for the clinical studies (from the comparison studies above for p53 and Ki-67)

• These 120 test samples were designated by the TMA number and the core position.

• The core position was assigned on the basis of the row (labeled as A-E) and the column (numbered from 1-9)

• Semi-quantitative scores (0-1%, >1-5%, >5-10%, and >10%) based on prior manual microscopic review by a qualified pathologist were available for the 120 test samples - The TMA slides containing the 120 test samples were digitized by the iScan/PATHIAM

system described in detail in the report

• The digitized TMA slides/images were uploaded into the PATHIAM software

• Five test samples from each scoring category (0-1%, >1-5%, >5-10%, and >10%) were randomly selected for the intra pathologist reproducibility study being conducted in parallel

• Two of five test samples from each scoring category (total of 8) from the intra pathologist reproducibility studies were then randomly selected for the intra and inter system studies

• The digital images containing these 8 test samples were reviewed in the PATHIAM system by a qualified pathologist, with one Field of View (FOV) selected for each test sample

• The selected FOVs from the eight cores represented the area used for image analysis for both intra- and inter-system studies

Precision/Reproducibility Study results (intra and inter system)

Each test sample (8 of them) was scanned 5 times on one scanner. Each test sample (FOV) on each scan was scored by PATHIAM (raw score). The PATHIAM raw scores were used for data comparison analysis.

36

This was repeated on three different PATHIAM Systems (including one study from above) and scores are compared and presented in the tables below along with the PATHIAM System identification traceability information.

P53 Data Analysis

	SYSTEM I	SYSTEM II	SYSTEM III
Computer #
Details	DELL PRECISION 5400
INTEL XEON CPU
e5410 S/N 6XBQBTH1	DELL PRECISION 5400
INTEL XEON cpu
e5410 S/N 9G90PJ	DELL PRECISION 5400
INTEL XEON cpu
e5410 S/N DMYWHHI
Monitor # Details	DELL 24" HIGH
RESOLUTION LCD S/N
262 923 195S	DELL 24" HIGH
RESOLUTION LCD S/N
262 930 ID35	DELL 24" HIGH
RESOLUTION LCD S/N
262 84F 1FOS
Scanner # Details	BIOIMAGENE ISCAN
2.1.0.2 (PS-000322)
S/N BIO8N0071	BIOIMAGENE ISCAN
2.1.0.2 (PS-000322)
S/N BIO8N0089	BIOIMAGENE ISCAN
2.1.0.2 (PS-000322)
S/N BIO8N0051
Mouse	DELL DPIN OXN 967
10401GUS	DELL DPIN OXN 967
10401GUS	DELL DPIN OXN 967
10401GUS
Pathiam Software	Version 3.1,
MS Browser 6.0.29	Version 3.1,
MS Browser 6.0.29	Version 3.1,
MS Browser 6.0.29
Keyboard	DELL SK8115 E145614	DELL SK8115 E145614	DELL SK8115 E145614

Table 26: System Identification Traceability

Table 27:p53 System Precision Study SYSTEM I (intra system)

| Line Item # | Sample
ID | Mean | SD | %CV |
|-------------|--------------|-------|------|------|
| TMA 3 2007 | A7 | 0.00 | 0.00 | - |
| TMA 3 2007 | E3 | 0.00 | 0.00 | - |
| TMA 3 2007 | C9 | 42.90 | 0.02 | 0.06 |
| TMA 4 2007 | B5 | 2.82 | 0.08 | 2.67 |
| TMA 5 2007 | E3 | 73.50 | 0.05 | 0.07 |
| TMA 1 2007 | B9 | 16.44 | 0.01 | 0.09 |
| TMA 4 2007 | D4 | 22.14 | 0.07 | 0.32 |
| TMA 4 2007 | B3 | 24.05 | 0.06 | 0.23 |

Volume 1 Page 49

37

Line Item #	Sample ID	Mean	SD	%CV
TMA 3 2007	A7	0.00	0.00	-
TMA 3 2007	E3	0.00	0.00	-
TMA 3 2007	C9	42.74	0.02	0.05
TMA 4 2007	B5	2.57	0.01	0.58
TMA 5 2007	E3	72.89	0.04	0.06
TMA 1 2007	B9	16.51	0.04	0.24
TMA 4 2007	D4	22.44	0.04	0.17
TMA 4 2007	B3	22.68	0.06	0.25

Table 29: p53 System Precision Study SYSTEM III (intra system)

Line Item #	Sample ID	Mean	SD	%CV
TMA 3 2007	A7	0.00	0.00	-
TMA 3 2007	E3	0.00	0.00	-
TMA 3 2007	C9	42.60	0.05	0.11
TMA 4 2007	B5	2.71	0.02	0.78
TMA 5 2007	E3	74.07	0.13	0.18
TMA 1 2007	B9	16.49	0.03	0.18
TMA 4 2007	D4	24.42	0.01	0.05
TMA 4 2007	B3	24.90	0.10	0.40

38

above
	Line
Item #	Sample
ID	Mean	SD	%CV
2, 3	TMA 3
2007	A7	0.00	0.00	-

0.00 .

42.75

2.70

73.49

16.48

23.00

23.88

TMA 3

2007 TMA 3

2007 TMA 4

2007 TMA 5

2007 TMA 1

2007

TMA 4

2007

TMA 4

2007

er-System Reproducibility - System

E3

Ca

B5

ЕЗ

ва

D4

вз

Table 30: p53 Inter-system Reproducibility Study – Results from System I, II, III f

0.00

0:13

0.12

0.50

0.04

1.05

0.95

t

0.30

4.32

0.68

0.25

4.55

39

Ki-67 Data Analysis

	SYSTEM I	SYSTEM II	SYSTEM III
Computer #
Details	DELL PRECISION 5400
INTEL XEON cpu
e5410 S/N 6XBQBTH1	DELL PRECISION 5400
INTEL XEON cpu
e5410 S/N 9G90PJ	DELL PRECISION 5400
INTEL XEON cpu
e5410 S/N DMYWHHI
Monitor # Details	DELL 24" HIGH
RESOLUTION LCD S/N
262 923 1955	DELL 24" HIGH
RESOLUTION LCD S/N
262 930 ID35	DELL 24" HIGH
RESOLUTION LCD S/N
262 84F 1FOS
Scanner # Details	BIOIMAGENE ISCAN
2.1.0.2 (PS-000322)
S/N BIO8N0071	BIOIMAGENE ISCAN
2.1.0.2 (PS-000322)
S/N BIO8N0089	BIOIMAGENE ISCAN
2.1.0.2 (PS-000322)
S/N BIO8N0051
Mouse	DELL DPIN OXN 967
10401GUS	DELL DPIN OXN 967
10401GUS	DELL DPIN OXN 967
10401GUS
Pathiam Software	Version 3.1,
MS Browser 6.0.29	Version 3.1,
MS Browser 6.0.29	Version 3.1,
MS Browser 6.0.29
Keyboard	DELL SK8115 E145614	DELL SK8115 E145614	DELL SK8115 E145614

Table 31: Ki-67 System Precision Study SYSTEM I (intra system)

| | Line
Item # | Sample
ID | Mean | SD | %CV |
|----------------------------------------------------|----------------|--------------|-------|------|------|
| Ki67 Precision Study - System 1
BIO8N0071 (n=5) | TMA 3
2007 | A2 | 31.78 | 0.10 | 0.31 |
| | TMA 3
2007 | E2 | 64.53 | 0.25 | 0.39 |
| | TMA 3
2007 | A3 | 15.45 | 0.15 | 0.99 |
| | TMA 4
2007 | D4 | 17.82 | 0.09 | 0.50 |
| | TMA 3
2007 | E7 | 9.76 | 0.02 | 0.22 |
| | TMA 5
2007 | D6 | 4.85 | 0.02 | 0.40 |
| | TMA 3
2007 | E5 | 9.13 | 0.12 | 1.35 |
| | TMA 2
2007 | A1 | 0.88 | 0.02 | 1.78 |

40

Line Item #	Sample ID	Mean	SD	%CV
TMA 3 2007	A2	32.77	0.37	1.13
TMA 3 2007	E2	63.29	0.08	0.12
TMA 3 2007	A3	15.76	0.17	1.09
TMA 4 2007	D4	17.91	0.04	0.23
TMA 3 2007	E7	9.41	0.04	0.44
TMA 5 2007	D6	4.87	0.14	2.90
TMA 3 2007	E5	9.27	0.04	0.42
TMA 2 2007	A1	0.85	0.01	0.89

Table 32:Ki-67 System Precision Study SYSTEM II (intra system)

Table 33: Ki-67 System Precision Study SYSTEM III (intra system)

| | Line Item

| Sample ID | Mean | SD | %CV |

|----------------------------------------------------|----------------|-----------|-------|------|------|
| Ki67 Precision Study - System 3
BIO8N0051 (n=5) | TMA 3
2007 | A2 | 31.53 | 0.19 | 0.59 |
| | TMA 3
2007 | E2 | 62.11 | 0.23 | 0.36 |
| | TMA 3
2007 | A3 | 15.05 | 0.12 | 0.78 |
| | TMA 4
2007 | D4 | 17.66 | 0.02 | 0.14 |
| | TMA 3
2007 | E7 | 9.81 | 0.07 | 0.72 |
| | TMA 5
2007 | D6 | 4.95 | 0.03 | 0.68 |
| | TMA 3
2007 | E5 | 9.43 | 0.02 | 0.24 |
| | TMA 2
2007 | A1 | 0.86 | 0.00 | 0.35 |

41

| Ki67 Inter-System Reproducibility -

System 1, 2, 3 (n=3x5)	Line Item #	Sample ID	Mean	SD	%CV
	TMA 3
2007	A2	32.03	0.60	1.87
	TMA 3
2007	E2	63.31	1.04	1.65
	TMA 3
2007	A3	15.42	0.33	2.14
	TMA 4
2007	D4	17.79	0.12	0.66
	TMA 3
2007	E7	9.66	0.19	1.95
	TMA 5
2007	D6	4.89	0.09	1.84
	TMA 3
2007	E5	9.28	0.14	1.53
	TMA 2
2007	A1	0.86	0.02	2.07

Table 34: Ki-67 Inter-system Reproducibility Study - Results from System I, II, III above

Discussion:

The field of view analyzed for each test sample was manually drawn with the drawing tool and is therefore not exactly the same for every image analyzed in the intra & inter system studies. The variability in the reproducibility results can therefore be mostly attributed to the slight variations in the composition of the fields of view in for each image analyzed.

Conclusion:

The above tables for the intra- and inter-system studies confirm the precision and reproducibility of Ki-67 and p53 scoring within the same system and between different systems. The precision and reproducibility study data (averages, standard deviation and % CV) showed that PATHIAM System precision and reproducibility is similar to that of the predicate devices, and is therefore acceptable.

42

Image /page/42/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a stylized graphic of an eagle or bird-like figure with three curved lines representing its wings or body. The graphic is positioned to the right of a circular arrangement of text that reads "DEPARTMENT OF HEALTH & HUMAN SERVICES USA".

Food and Drug Administration 10903 New Hampshire Avenue Document Mail Center - WO66-0609 Silver Spring, MD 20993-0002

Bioimagene, Inc. c/o Mr. Indu P. Lakshman Director of Quality and Regulatory Affairs 919 Hermosa Court Sunnyvale, CA 94085

OCT 2 7 2010

Re: K092333

Trade/Device Name: PATHIAM™ System with iScan for p53 and Ki67 Regulation Number: 21CFR§864.1860 Regulation Name: Immunohistochemistry reagents and kits Regulatory Class: Class II Product Code: NON Dated: September 13, 2010 Received: September 15, 2010

Dear Mr. Lakshman:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA), You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration. Iisting of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical

43

Page 2 - Mr. Indu P. Lakshman

device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please go to http://www.fda.gov/AboutFDA/CentersOffices/CDRH/CDRHOffices/ucm115809.htm for the Center for Devices and Radiological Health's (CDRH's) Office of Compliance. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportalProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm.

Sincerely yours,

Maria In Chan

Maria M. Chan, Ph.D. Director Division of Immunology and Hematology Devices Office of In Vitro Diagnostic Device Evaluation and Safety Center for Devices and Radiological Health

Enclosure

44

Indications for Use

510(k) Number: K092333

Device Name: PATHIAM™ System with iScan for p53 and Ki67

Indications For Use:

UCL 8 7 2010

Device Name: iScan Slide Scanner

Intended Use

This device is intended for in vitro diagnostic (IVD) use.

The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.

Indications for Use

This instrument is intended for in-vitro diagnostic use only with those assays for which it has received FDA clearance.

The iScan Slide Scanner System is designed to be used to scan and digitize microscope slides, and compress and view digitized images of microscope slides.

If the Scanner is used in any way not specified in this manual, the protection provided by the equipment may be compromised.

Prescription Use X (Part 21 CFR 801 Subpart D) AND/OR

Over-The-Counter Use (21 CFR 807 Subpart C)

(PLEASE DO NOT WRITE BELOW LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)
---------------------------------------------------------------------

Division Sign-Off
Office of In Vitro Diagnostic
Device Evaluation and Safety
510(k)	K092333
	Page 1 of

510(k)

45

Indications for Use

OCT 2 7 2010

510(k) Number: K092333

Device Name: PATHIAM TM System with iScan for p53 and Ki67

Indications For Use:

Device Name: PATHIAM System with iScan for Ki-67

Intended Use

This device is intended for in vitro diagnostic (IVD) use.

The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.

The Ki-67 application is intended as an aid to the pathologist to quantify the percentage of positively stained nuclei in formalin-fixed paraffin embedded normal and neoplastic breast tissue specimens immunohistochemically stained with Dako mouse monoclonal anti-human Ki-67 antigen, clone MIB1 visualized with DAB chromogen as specified in the instructions for these reagents. It is the responsibility of a qualified pathologist to employ appropriate morphological studies and controls as specified in the instructions for Dako Ki-67 to assure the validity of the PATHIAM-assisted Ki-67 assessment.

Indication For Use

Ki-67 results provided by the PATHIAM System are indicated for use to assess proliferative activity when used with in vitro diagnostic reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. The pathologist must verify agreement with the PATHIAM score.

Prescription Use	X
(Part 21 CFR 801 Subpart D)

AND/OR

Over-The-Counter Use
(21 CFR 807 Subpart C)

(PLEASE DO NOT WRITE BELOW LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Division Sign-Off
-------------------	--

Page 1 of
-----------	--

Office of In Vitro Diagnostic
Device Evaluation and Safety

510(k)	K092333
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46

Indications for Use

510(k) Number: K092333

OCT 2 7 2010

Device Name: PATHIAM™ System with iScan for p53 and Ki67

Indications For Use:

Device Name: PATHIAM System with iScan for p53

Intended Use

This device is intended for in vitro diagnostic (IVD) use.

The PATHIAM System is intended as an aid to the pathologist to detect, count, and classify cells of clinical interest based on recognition of cellular objects of particular color, size, and shape, using appropriate controls to assure the validity of the scores.

The p53 application is intended for use as an aid to the pathologist to quantify the percentage of positively stained nuclei in formalin fixed paraffin embedded breast tissue specimens stained with Dako mouse monoclonal anti-human p53 antibody, clone DO7and visualized with DAB. chromogen, to detect both wild-type and mutant p53, a nuclear protein, as specified in the instructions for these reagents. It is the responsibility of a qualified pathologist to employ appropriate morphological studies and controls as specified in the instructions for Dako p53 to assure the validity of the PATHIAM-assisted p53 assessment.

Indication For Use

The p53 results provided by the PATHIAM System are indicated for use for the identification of p53 accumulation in human neoplasias when used with IVD reagents marketed for this indication. Interpretation should be made within the context of the patient's clinical history and other diagnostic tests by a qualified pathologist must verify agreement with the PATHIAM score.

Prescription Use X (Part 21 CFR 801 Subpart D) AND/OR

Over-The-Counter Use (21 CFR 807 Subpart C)

Division Sign-Off

Office of In Vitro Diagnostic Device Evaluation and

10(k) K092333

Page 1 of