BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COBAS® EGFR MUTATION TEST V2

    MDR report key: 14569221 · Received June 1, 2022

    Report

    Report Number
    2243471-2022-00519
    Event Type
    Malfunction
    Date Received
    June 1, 2022
    Date of Event
    April 28, 2022
    Report Date
    June 1, 2022
    Manufacturer
    ROCHE MOLECULAR SYSTEMS, INC. - BRANCHBURG
    Product Code
    OWD
    UDI-DI
    00875197005448
    PMA / PMN Number
    P150047
    Removal / Correction Number
    2243471-08-24-2021-003-C
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TW
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    ROCHE RECEIVED COMPLAINTS FROM CUSTOMERS REPORTING THE GENERATION OF FALSE MUTATION DETECTED RESULTS FOR THE EXON 20 INSERTION (EX20INS) MUTATION WHEN USING THE COBAS® EGFR MUTATION TEST V2. DURING IN-HOUSE TESTING USING CUSTOMER-PROVIDED FFPET SAMPLES, AN EX20INS FALSE MUTATION DETECTED RESULT WAS REPRODUCED FOR ONE OUT OF 8 FFPET SAMPLES, WHICH WAS PROCESSED FOLLOWING THE VALIDATED SAMPLE PREPARATION METHOD FROM THE INSTRUCTIONS FOR USE. ALTHOUGH THE MAJORITY OF CASES REPORTED WERE FROM USERS USING FFPET SAMPLES, THE GENERATION OF FALSE MUTATION DETECTED EX20INS RESULTS WITH PLASMA SPECIMENS WAS REPORTED IN ONE CASE. A FALSE MUTATION DETECTED EX20INS RESULT COULD LEAD TO HARM UNDER SPECIFIC SCENARIOS. CONSIGNEES WILL BE NOTIFIED OF THE ISSUE WITH INSTRUCTION TO FOLLOW THE INSTRUCTIONS FOR USE FOR SAMPLE INPUT REQUIREMENTS. ADDITIONALLY, IF AN EX20INS MUTATION DETECTED RESULT IS GENERATED WITH THE COBAS® EGFR MUTATION TEST V2, CUSTOMERS MUST CONFIRM THE RESULT WITH ANOTHER METHOD (E.G., SEQUENCING OR OTHER PCR-BASED TESTS). FOR THE MUTATION CHANGE FROM EXON19DEL TO L858R, MISHANDLING OR CONTAMINATION IS SUSPECTED. (B)(4).

    Description of Event or Problem · 0

    A CUSTOMER FROM TAIWAN ALLEGED DISCREPANT RESULTS FOR A PATIENT TESTED WITH COBAS EGFR MUTATION TEST V2. THE PATIENT WAS TESTED (BIOPSY) IN 2018 AND 2021. BOTH TESTS GENERATED AN EX19DEL "MUTATION DETECTED" RESULT. A RESECTION WAS THEN TESTED ON (B)(6) 2022 WHICH GENERATED A "MUTATION DETECTED" RESULT FOR L858R AND EX20INS. SEQUENCING WAS PERFORMED ON THE SAMPLE WHICH DID NOT DETECT THE EXON20INS MUTATION. NO HARM OR INJURY WAS INDICATED. THE EX19DEL "MUTATION DETECTED" WAS REPORTED OUT FOR THE 2018 AND 2021 TESTS. THE L858R "MUTATION DETECTED" WAS REPORTED OUT FOR THE 2022 TEST.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    323881 COBAS® EGFR MUTATION TEST V2 SOMATIC GENE MUTATION DETECTION SYSTEM OWD ROCHE MOLECULAR SYSTEMS, INC. - BRANCHBURG NA H14612 00875197005448

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown