Acurácia dos testes diagnósticos registrados na ANVISA para a COVID-19 / Acurácia dos testes diagnósticos registrados na ANVISA para a COVID-19

INTRODUÇÃO: O coronavírus da Síndrome Respiratória Aguda Grave 2 (abreviado para SARSCoV-2, do inglês Severe Acute Respiratory Syndrome Coronavirus 2), anteriormente conhecido como novo coronavírus (2019-nCoV), é um agente zoonótico recémemergente que surgiu em dezembro de 2019, em Wuhan, China, causando manifestações respiratórias, digestivas e sistêmicas, que se articulam no quadro clínico da doença denominada COVID-19 (do inglês Coronavirus Disease 2019). Ainda não há informações robustas sobre a história natural da doença, tampouco sobre as medidas de efetividade para o manejo clínico dos casos de infecção pelo COVID19, restando ainda muitos detalhes a serem esclarecidos. No entanto, sabe-se que o vírus tem alta transmissibilidade e provoca uma síndrome respiratória aguda que varia de casos leves ­ cerca de 80% ­ a casos muito graves com insuficiência respiratória - entre 5% e 10% dos casos ­, os quais requerem tratamento especializado em unidades de terapia intensiva (UTI). Sua letalidade varia, principalmente, conforme a faixa etária. TECNOLOGIA: Os testes de diagnóstico para a COVID-19 se destacaram na pandemia de coronavírus em andamento como uma ferramenta essencial para rastrear a propagação da doença. Uma ampla gama de testes diagnósticos para o SARS-CoV-2 está disponível comercialmente, alguns dos quais receberam autorizações para uso por várias agências reguladoras nacionais. Com as informações da sequência genética devidamente identificadas, os testes de diagnóstico baseados na detecção da sequência viral por reação em cadeia da polimerase com transcriptase reversa (RT-PCR) ou plataformas de sequenciamento logo se tornaram disponíveis. Isso permitiu a confirmação do diagnóstico e melhores estimativas da atividade da infecção, que vêm aumentando em velocidades alarmantes. Para a detecção mais sensível de SARS-CoV, MERS-CoV e SARS-CoV-2, recomendavam-se a coleta e o teste de amostras respiratórias superiores e inferiores. O diagnóstico de casos suspeitos era confirmado por testes de RNA com RT-PCR em tempo real ou sequenciamento de próxima geração. Foi demonstrado que o RNA viral poderia ser detectado a partir do swab nasal e faríngeo, lavagem broncoalveolar e plasma sanguíneo usando RT-PCR direcionado ao gene do vírus (5). O padrão-ouro para diagnóstico laboratorial da COVID-19 é a reação da transcriptase reversa, seguida de reação em cadeia da polimerase (RT-PCR) para amostras coletadas no trato respiratório superior ou inferior. OBJETIVO: O objetivo deste relatório é analisar a acurácia dos testes diagnósticos registrados na Agência Nacional de Vigilância Sanitária (ANVISA) até a presente data. METODOLOGIA: foi realizada uma busca por diagnósticos para COVID-19 com registros vigentes na ANVISA. Para tal, foram utilizados os termos "COVID 19", SARS e coronavírus no campo de consulta de registro de produtos para saúde no site da Agência (https://consultas.anvisa.gov.br/#/saude/). Os passos para acesso ao banco de dados de produtos diagnósticos na ANVISA são: 1) consulta produtos; 2) consulta a banco de dados; 3) produtos para a saúde e 4) pesquisa de produtos para a saúde registrados. CONCLUSÕES: A ANVISA já avaliou mais de 120 pedidos de registro de produtos para testagens relacionadas à COVID-19 desde o dia 18 de março. A maior parte das petições aguarda complementação de informações por parte das empresas e outras estão sendo analisadas com prioridade. O tempo médio para avaliação dos registros na ANVISA gira em torno de 15 dias. Atualmente, mais da metade dos registros concedidos diz respeito a testes rápidos para anticorpos. Até a presente data, foram registrados 64 testes para diagnóstico da COVID-19, sendo 15 deles moleculares. O teste de polymerase chain reaction em tempo real (RT-PCR) para identificação de SARS-CoV-2 é um teste de elevada sensibilidade e especificidade, ainda que os doentes com maior carga viral possam ter maior probabilidade de um teste positivo. Os testes moleculares baseados em RNA exigem instalações laboratoriais específicas com níveis restritos de biossegurança e técnica. A sensibilidade e especificidade dos testes sorológicos variaram entre os fabricantes. É importante destacar que uma baixa sensibilidade do teste diagnóstico pode resultar em uma maior probabilidade de detectar falsos-negativos, o que poderia interferir principalmente em casos de indivíduos assintomáticos. Em geral, a sensibilidade dos testes foi superior a 85% e a especificidade, superior a 94%. Os testes sorológicos medem a quantidade de dois anticorpos (IgG e IgM) que o organismo produz quando entra em contato com um invasor. Contudo, o desenvolvimento da resposta de um anticorpo à infecção pode ser dependente do hospedeiro e levar tempo. No caso de SARS-CoV-2, estudos iniciais sugerem que a maioria dos pacientes se converte entre 7 e 11 dias após a exposição ao vírus, embora alguns pacientes possam desenvolver anticorpos mais cedo. Devido a esse atraso natural, o teste de anticorpos pode não ser útil no cenário de uma doença aguda (11). Os testes de anticorpos para SARS-CoV-2 podem facilitar (i) o rastreamento de contatos (os testes baseados em RNA também podem ajudar); (ii) a vigilância sorológica nos níveis local, regional, estadual e nacional; e (iii) a identificação de quem já teve contato com o vírus e, portanto, pode (se houver imunidade protetora) ser imune (11,12). Alguns conjuntos de reagentes para testes sorológicos foram autorizados pela ANVISA em caráter emergencial devido à gravidade da situação e à necessidade de ampliar a testagem da população, mas a validação desses reagentes pelos laboratórios é fundamental, uma vez que poucos trabalhos conseguiram ser publicados até o momento. As aprovações estão de acordo com a Resolução da Diretoria Colegiada (RDC) 348/2020, que define os critérios e os procedimentos extraordinários e temporários para tratamento de petições de registro de medicamentos, produtos biológicos e produtos para diagnóstico in vitro, e mudança pós-registro de medicamentos e produtos biológicos em virtude da emergência de saúde pública internacional decorrente do novo coronavírus. Na RDC, para registro de testes diagnósticos, a ausência de qualquer estudo de desempenho ou restrição de dados deve ser justificada por motivações técnicas que permitam a avalição da confiabilidade dos resultados e da efetividade diagnóstica do produto. Os registros concedidos nas condições dessa Resolução terão a validade de um ano, exceto para situações em que a avaliação da estabilidade seja apresentada por comparação com produtos similares e os demais critérios descritos no Regulamento sejam atendidos. Nesse caso, poderão ter a concessão regular de validade de registro de produtos para saúde por um período de 10 anos. Em resumo, as duas categorias de testes para SARS-CoV-2 podem ser úteis nesse surto, pois, eventualmente, a coleta de múltiplas amostras, regiões e em tempos diferentes durante a evolução da doença pode ser necessária para o diagnóstico da COVID-19.

Multiplex immunofluorescence staining and image analysis assay for diffuse large B cell lymphoma.

With the explosion of immuno-oncology and the approval of many immune checkpoint therapies by regulatory agencies in the last few years, understanding the tumor microenvironment (TME) in the context of patients' immune status has become essential. Among available immune profiling techniques, multiplex immunofluorescence (mIF) assays offer the unique advantage of preserving the architectural features of the tumor and revealing the spatial relationships between tumor cells and immune cells. A number of mIF and image analysis assays have been described for solid tumors but most are not sufficiently suitable in lymphoma, where the lack of clear tumor-stromal boundaries and high tumor density present significant challenges. Here we describe the development and optimization of a reliable workflow using Akoya Opal staining kits to label and analyze 6 markers per slide in diffuse large B-cell lymphoma (DLBCL) tissue sections. Five panels totaling 30 markers were developed to characterize infiltrating immune cells and relevant check-point proteins such as PD1, PD-L1, ICOS, SIRP-alpha and Lag3 on 70 DLBCL sections. Multiplexed sections were scanned using an Akoya multispectral scanner. An image analysis workflow using InForm and Matlab was developed to overcome challenges inherent to the DLBCL environment. Using the assays and workflows detailed here, we were able to quantify cell densities of subsets of infiltrating immune cells and observe their spatial patterns within the tumors. We highlight heterogeneous distribution of cytotoxic T cells across tumors with similar T cell density to underscores the importance of considering spatial context when studying the effects of immunological therapies in DLBCL.

Qualifying antibodies for image-based immune profiling and multiplexed tissue imaging.

Multiplexed tissue imaging enables precise, spatially resolved enumeration and characterization of cell types and states in human resection specimens. A growing number of methods applicable to formalin-fixed, paraffin-embedded (FFPE) tissue sections have been described, the majority of which rely on antibodies for antigen detection and mapping. This protocol provides step-by-step procedures for confirming the selectivity and specificity of antibodies used in fluorescence-based tissue imaging and for the construction and validation of antibody panels. Although the protocol is implemented using tissue-based cyclic immunofluorescence (t-CyCIF) as an imaging platform, these antibody-testing methods are broadly applicable. We demonstrate assembly of a 16-antibody panel for enumerating and localizing T cells and B cells, macrophages, and cells expressing immune checkpoint regulators. The protocol is accessible to individuals with experience in microscopy and immunofluorescence; some experience in computation is required for data analysis. A typical 30-antibody dataset for 20 FFPE slides can be generated within 2 weeks.

Analysis of primary cilia in renal tissue and cells.

Primary cilia are singular, sensory organelles that extend from the plasma membrane of most quiescent mammalian cells. These slender, microtubule-based organelles receive and transduce extracellular cues and regulate signaling pathways. Primary cilia are critical to the development and function of many tissue types, and mutation of ciliary genes causes multi-system disorders, termed ciliopathies. Notably, renal cystic disease is one of the most common clinical features of ciliopathies, highlighting a central role for primary cilia in the kidney. Additionally, acute kidney injury and chronic kidney disease are associated with altered primary cilia lengths on renal epithelial cells, suggesting ciliary dynamics and renal physiology are linked. Here we describe methods to examine primary cilia in kidney tissue and in cultured renal cells. We include immunofluorescence and scanning electron microscopy to determine ciliary localization of proteins and cilia structure. Further, we detail cellular assays to measure cilia assembly and disassembly, which regulate cilia length.

Ultra-fast and automated immunohistofluorescent multistaining using a microfluidic tissue processor.

Multistaining of a tissue section targeting multiple markers allows to reveal complex interplays in a tumor environment. However, the resource-intensive and impractically long nature of iterative multiplexed immunostainings prohibits its practical implementation in daily routine, even when using work-flow automation systems. Here, we report a fully automated and ultra-fast multistaining using a microfluidic tissue processor (MTP) in as short as 20 minutes per marker, by immunofluorescent staining employing commercially available tyramide signal amplification polymer precipitation by horse-radish peroxidase (HRP) activation. The reported duration includes (i) 15 minutes for the entire fluidic exchange and reagent incubation necessary for the immunostaining and (ii) 5 minutes for the heat-induced removal of the applied antibodies. Using the automated MTP, we demonstrated a 4-plex automated multistaining with clinically relevant biomarkers within 84 minutes, showing perfect agreement with the state-of-the-art microwave treatment antibody removal. The presented HRP-based method is in principle extendable to multistaining by both tyramides accommodating higher number of fluorescent channels and multi-color chromogenic staining. We anticipate that our automated multi-staining with a turn-around time shorter than existing monoplex immunohistochemistry methods has the potential to enable multistaining in routine without disturbing the current laboratory workflow, opening perspectives for implementation of -omics approaches in tissue diagnostics.

Double Immunohistochemistry and Digital Image Analysis.

Immunohistochemistry (IHC) is a commonly used technique for protein detection in tissue sections. The method requires high-affinity antibodies that are specific for the target proteins of interest. More advanced IHC techniques have been developed to meet the need for simultaneous detection of more than one target protein in the same tissue section. This chapter provides general guidelines for double IHC staining of formalin-fixed, paraffin-embedded tissue sections. Chromogenic substrates are chosen based on their excellent contrast and compatibility with the subsequent digital image analysis.

Multispectral Fluorescence Imaging Allows for Distinctive Topographic Assessment and Subclassification of Tumor-Infiltrating and Surrounding Immune Cells.

Histomorphology has significantly changed over the last decades due to technological achievements in immunohistochemistry (IHC) for the visualization of specific proteins and in molecular pathology, particularly in the field of in situ hybridization of small oligonucleotides and amplification of DNA and RNA amplicons. With an increased availability of suitable methods, the demands regarding the observer of histomorphological slides were the supply of complex quantitative data as well as more information about protein expression and cell-cell interactions in tissue sections. Advances in fluorescence-based multiplexed IHC techniques, such as multispectral imaging (MSI), allow the quantification of multiple proteins at the same tissue section. In histopathology, it is a well-known technique for over a decade yet harboring serious problems concerning quantitative preciseness and tissue autofluorescence of multicolor staining when using formalin-fixed, paraffin-embedded (FFPE) tissue specimen. In recent years, milestones in tissue preparation, fluorescent dyes, hardware imaging, and software analysis were achieved including automated tissue segmentation (e.g., tumor vs. stroma) as well as in cellular and subcellular multiparameter analysis.This chapter covers the role that MSI plays in anatomic pathology for the analysis of FFPE tissue sections, discusses the technical aspects of MSI, and provides a review of its application in the characterization of immune cell infiltrates and beyond regarding its prognostic and predictive value and its use for guidance of clinical decisions for immunotherapeutic strategies.

Characterization of the "Autophagic Flux" in Prostate Cancer Tissue Biopsies by LC3A/LAMP2a Immunofluorescence and Confocal Microscopy.

A method is described for the immunostaining of human prostate cancer biopsies for the autophagic marker LC3 and the lysosomal protein LAMP2A. Using this combination we can provide some information on autophagic flux, and specific patterns of staining have been recognized for normal prostate tissue and prostatic carcinomas.

Assays on DNA Damage and Repair in CLL.

Assays that measure DNA damage and repair are critical in evaluating the extent to which therapeutic agents damage DNA and in identifying whether DNA repair can limit the toxicity of chemotherapy. The COMET assays described in this guide should help readers evaluate single and double-strand breaks cause by chemotherapeutic agents and also monitor the ability of the cells to repair such damage. The EJDR assay described is a valuable tool to assess the ability of drugs and DNA repair proteins to modulate DNA repair capacity. Finally, the immunofluorescence assay described should allow accurate assessments of DNA damage and the kinetics of repair as measured by Ɣ-H2AX foci. This procedure can also be used to mechanistically investigate the recruitment of specific DNA damage and repair proteins in CLL cells.

Methods for Evaluation of Ovarian Granulosa Cells with Exposure to Nanoparticles.

Increasing evidence demonstrates that a substantial number of chemicals including nanoparticles have potential toxic effects on human and wildlife reproductive health. Ovarian granulosa cells (GCs), the functional unit of the ovary, play a pivotal role in the regulation of ovarian reproductive health in females. They are considered to be the main target by the chemicals at all stages of their development. It has been reported that nanoparticles induced toxicity of GCs by interfering with cell cycle. Some basic methods for evaluation of GCs with exposure to nanoparticles are described in this chapter including isolation of GCs, determination of apoptosis by immunofluorescence, and measurement of progesterone level by ELISA.

Determination of Phosphorylated Histone H2AX in Nanoparticle-Induced Genotoxic Studies.

DNA double-strand breaks (DSBs), one of the most severe lesions of DNA damage triggered by various genotoxic insults, can lead to chromosome change, genomic instability, and even tumorigenesis if not repaired efficiently. In response to DNA damage, histone H2AX molecules are rapidly phosphorylated at serine 139 near the site of DNA DSBs and form γ-H2AX foci. As an early important cellular event linked to DNA damage and repair, γ-H2AX is a highly sensitive biomarker for "monitoring" DNA damage and consequently is a useful tool in genetic toxicology screen. We and other researchers have used γ-H2AX as a marker to assess the potential genotoxic effects of some nanoparticles in vitro and in vivo. In this chapter, we describe several useful methods for γ-H2AX detection, which can be used to evaluate the potential genotoxic effects of nanoparticles.

Design and Quantitative Analysis of Cancer Detection System Based on Fluorescence Immune Analysis.

Human blood is an important medical detection index. With the development in clinical medical detection instruments and detection technology, the requirements for detection accuracy and efficiency have been gradually improved. Fluorescent immunochromatography is a new detection technique. It has the characteristics of high efficiency, convenience, no pollution, and wide detection range. Human blood can be detected quickly using fluorescent immunochromatography. At present, it has received great attention from the field of clinical testing. In this paper, a set of fluorescent immunochromatographic analyzer has been designed. It is mainly based on the principle of fluorescence immunochromatography. A new method of signal analysis and system design for fluorescent immunochromatography analyzer is proposed. By using the improved threshold function denoising algorithm, the quantitative detection of fluorescent immunochromatographic strip is realized. The concentration of pathogenic factors (cancer cells) in human serum can be measured conveniently and accurately. The system integrates many peripheral modules, including fluorescence signal acquisition, fluorescence signal processing, quantitative curve fitting, and test results. In this paper, the quantitative detection experiments of the system are carried out in three aspects: linearity, repeatability, and sensitivity. The experimental results show that the linear correlation coefficient is up to 0.9976, and the limit of detection is up to 0.05 ng/ml. The requirements of the system are satisfied. The system performance is good, and the quantitative result is accurate. Therefore, the establishment of a fluorescence analysis system is of great significance.

A novel high-throughput immunofluorescence analysis method for quantifying dystrophin intensity in entire transverse sections of Duchenne muscular dystrophy muscle biopsy samples.

Clinical trials using strategies aimed at inducing dystrophin expression in Duchenne muscular dystrophy (DMD) are underway or at advanced planning stage, including splice switching antisense oligonucleotides (AON), drugs to induce read-through of nonsense mutations and viral mediated gene therapy. In all these strategies, different dystrophin proteins, often internally deleted, are produced, similar to those found in patients with the milder DMD allelic variant, Becker muscular dystrophy (BMD). The primary biological endpoint of these trials is to induce functional dystrophin expression. A reliable and reproducible method for quantification of dystrophin protein expression at the sarcolemma is crucial to monitor the biochemical outcome of such treatments. We developed a new high throughput semi quantitative fluorescent immunofluorescence method for quantifying dystrophin expression in transverse sections of skeletal muscle. This technique is completely operator independent as it based on an automated scanning system and an image processing script developed with Definiens software. We applied this new acquisition-analysis method to quantify dystrophin and sarcolemma-related proteins using paediatric control muscles from cases without a neuromuscular disorder as well as DMD and BMD samples. The image analysis script was instructed to recognize myofibres immunostained for spectrin or laminin while dystrophin was quantified in each identified myofibre (from 2,000 to over 20,000 fibres, depending on the size of the biopsy). We were able to simultaneously extrapolate relevant parameters such as mean sarcolemmal dystrophin, mean spectrin and laminin intensity, fibre area and diameter. In this way we assessed dystrophin production in each muscle fibre in samples of DMD, BMD and controls. This new method allows the unbiased quantification of dystrophin in every myofibre within a transverse muscle section and will be of help for translational research projects as a biological outcome in clinical trials in DMD and BMD.

Studying the Role of AMPK in Autophagy.

AMPK is an energy-sensing kinase and is required for the induction and progression of the autophagy process. In this chapter, we describe experimental approaches to study the steady state and flux of autophagy in response to AMPK activation. For this purpose, we provide detailed protocols for the measurement of general as well as AMPK-specific autophagy markers by immunoblot and immunofluorescence analysis.

An automated staining protocol for seven-colour immunofluorescence of human tissue sections for diagnostic and prognostic use.

Multiplex immunofluorescence (mIF) allows simultaneous antibody-based detection and quantification of the expression of up to six markers, plus a nuclear counterstain, on a single tissue section. Recent studies have shown the potential for mIF to advance our understanding of complex disease processes, including cancer. It is important that the technique be standardised and validated to facilitate its transition into clinical use. Traditional approaches to mIF rely on manual processing of sections, which is time-consuming and a source of significant variation between samples/individuals. Here we determined if an automated diagnostic tissue stainer could be used for mIF incorporating tyramide signal amplification (TSA), and how the final image quality compared with sections stained semi-automatically or manually. Using tissue microarrays of fixed human breast tumour sections, we observed comparable antibody labelling between the diagnostic autostainer and manual technique. The diagnostic autostainer produced higher signal intensity with similar spectral unmixing efficiency. We also found that microwave treatment for antibody stripping during TSA labelling could be replaced by the heating option incorporated within the diagnostic-use autostainer. These data show that diagnostic autostainers used for traditional immunohistochemistry protocols can be readily adapted to achieve rapid preparation of high-quality sections using a TSA method for clinical mIF.

GloSensor assay for discovery of GPCR-selective ligands.

G protein-coupled receptors (GPCRs) are modulators of almost every physiological process, and therefore, are most favorite therapeutic target for wide spectrum of diseases. Ideally, high-throughput functional assays should be implemented that allow the screening of large compound libraries in cost-effective manner to identify agonist, antagonist, and allosteric modulators in the same assay. Taking advantage of the increased understanding of the GPCR structure and signaling, several commercially available functional assays based on fluorescence or chemiluminescence detection are being used in both academia and industry. In this chapter, we provide step-by-step method and guidelines to perform cAMP measurement using GloSensor assay. Finally, we have also discussed the analysis and interpretation of results obtained using this assay by providing several examples of Gs- and Gi-coupled GPCRs.

Multi-Parametric Imaging of Hypoxia and Cell Cycle in Intestinal Organoid Culture.

Dynamics of oxygenation of tissue and stem cell niches are important for understanding physiological function of the intestine in normal and diseased states. Only a few techniques allow live visualization of tissue hypoxia at cellular level and in three dimensions. We describe an optimized protocol, which uses cell-penetrating O2-sensitive probe, Pt-Glc and phosphorescence lifetime imaging microscopy (PLIM), to analyze O2 distribution in mouse intestinal organoids. Unlike the other indirect and end-point hypoxia stains, or point measurements with microelectrodes, this method provides high-resolution real-time visualization of O2 in organoids. Multiplexing with conventional fluorescent live cell imaging probes such as the Hoechst 33342-based FLIM assay of cell proliferation, and immunofluorescence staining of endogenous proteins, allows analysis of key physiologic parameters under O2 control in organoids. The protocol is useful for gastroenterology and physiology of intestinal tissue, hypoxia research, regenerative medicine, studying host-microbiota interactions and bioenergetics.

Horizontal Whole Mount: A Novel Processing and Imaging Protocol for Thick, Three-dimensional Tissue Cross-sections of Skin.

Processing a tissue of interest to generate a microscopic image that supports a scientific argument can be challenging. The acquisition of high-quality microscopic images is not entirely dependent upon the quality of the microscope, but also upon the methods of tissue processing, which often involve multiple critical actions or steps. Furthermore, mesenchymal cell types in the skin and other tissues represent a new challenge for tissue preparation and imaging. Here, we present a complete process, from tissue harvest to microscopy. Our technique, called "horizontal whole mount," is one that novices can quickly become proficient in and that allows for antigen preservation and detection in 60-300 µm-thick sections cut with a cryostat. Sections of this thickness provide enhanced visualization of tissue microarchitecture in a three-dimensional environment. In addition, the protocol preserves mesenchymal cells in a manner that enhances image quality when compared to standard cryostat or paraffin sections, thereby increasing the efficacy and reliability of immunostaining. We believe that this protocol will benefit all laboratories that visualize skin, and possibly other tissues and organs.

Fiber-Optic Array Scanning Technology (FAST) for Detection and Molecular Characterization of Circulating Tumor Cells.

Circulating tumor cell (CTC) as an important component in "liquid biopsy" holds crucial clinical relevance in cancer prognosis, treatment efficiency evaluation, prediction and potentially early detection. Here, we present a Fiber-optic Array Scanning Technology (FAST) that enables antigen-agnostic, size-agnostic detection of CTC. By immunofluorescence staining detection of a combination of a panel of markers, FAST technology can be applied to detect rare CTC in non-small cell lung cancer (NSCLC) setting with high sensitivity and specificity. In combination with Automated Digital Microscopy (ADM) platform, companion markers on CTC such as Vimentin and Programmed death-ligand 1 (PD-L1) can also be analyzed to further characterize these CTCs. FAST data output is also compatible with downstream single cell picking platforms. Single cell can be isolated post ADM confirmation and used for "actionable" genetic mutations analysis.

Microfluidic Capture and Multiplex Immunofluorescence of Circulating Tumor Cells to Identify Cancer of Origin.

Circulating tumor cells (CTCs) are an important biomarker and their analysis can be considered a form of "liquid biopsy." The purpose of this book chapter is to describe the use of the 4-channel CMx (cells captured in maximum) microfluidic chip, containing special micropatterns coated with an antibody-conjugated supported lipid bilayer (SLB) on its surface, to capture and isolate CTCs from the blood of cancer patients. Captured CTCs are subsequently released by an air foam to an immunofluorescence (IF) staining panel that enables further analysis, including the identification of the primary cancer source of the CTCs.