inforMED
MalfunctionOIU

ELECSYS HE4

Received Dec 20, 2023 · Event occurred Dec 6, 2023

Report 1823260-2023-04145 · MDR key 18367603

Device

Generic name

Epithelial Ovarian Tumor Associated Antigen (he4) Test

Manufacturer

Roche Diagnostics

Catalog number

05950929190

Lot number

ASKU

Product problems

  • High Test Results
  • Audible Prompt/Feedback Problem
  • High Test Results
  • Audible Prompt/Feedback Problem

Patient

53 YR · Female

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Additional Manufacturer Narrative

THE SAMPLE WAS SUBMITTED FOR INVESTIGATION. THE CUSTOMER'S HE4 RESULTS WERE REPRODUCED ON AN E601 MODULE (278 PMOL/L). DILUTION AND SPIKING EXPERIMENTS WERE PERFORMED AND THE SAMPLE UNDERWENT HETEROPHILIC BLOCKING TUBE (HBT) TREATMENT; THE RESULTS RECEIVED DID NOT INDICATE THE PRESENCE OF AN INTERFERING SUBSTANCE. THE SAMPLE UNDERWENT POLYETHYLENE GLYCOL (PEG) TREATMENT; THE RESULTS SUGGEST THE PRESENCE OF AN INTERFERING SUBSTANCE, HOWEVER, THE RESULTS GENERATED DO NOT EXPLAIN THE DIFFERENCE IN RESULTS BETWEEN THE ROCHE METHOD AND THE ABBOTT METHOD. FURTHER CLARIFICATION OF THE ROOT CAUSE FOR THE DIFFERENCES BETWEEN THE ROCHE AND ABBOTT RESULTS IS NOT POSSIBLE WITH AVAILABLE METHODS AND THE CURRENT STATE OF THE ART. PRODUCT LABELING STATES: "IN RARE CASES, INTERFERENCE DUE TO EXTREMELY HIGH TITERS OF ANTIBODIES TO ANALYTE-SPECIFIC ANTIBODIES, STREPTAVIDIN OR RUTHENIUM CAN OCCUR. THESE EFFECTS ARE MINIMIZED BY SUITABLE TEST DESIGN." THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE REAGENT PERFORMS WITHIN SPECIFICATION. A GENERAL REAGENT ISSUE CAN BE EXCLUDED.

Additional Manufacturer Narrative

THE CUSTOMER¿S E601 MODULE SERIAL NUMBER WAS (B)(6). THE SERIAL NUMBER FOR THE E601 MODULE AT THE OTHER HOSPITAL WAS NOT PROVIDED. THE COMPETITOR METHOD WAS ABBOTT. SAMPLE MATERIAL FROM THE PATIENT WAS REQUESTED FOR INVESTIGATION.

Description of Event or Problem

THE INITIAL REPORTER QUESTIONED HIGH RESULTS NOT CORRESPONDING TO THE PATIENT¿S CLINICAL PICTURE WHEN TESTED FOR ELECSYS HE4 (HE4) ON TWO COBAS E 601 MODULES. THE INITIAL RESULT FROM THE CUSTOMER'S E601 MODULE WAS 248 PMOL/L. THE PATIENT WAS TESTED FOR HE4 ON AN E601 MODULE AT A DIFFERENT HOSPITAL AND THE RESULT WAS 228.1 PMOL/L. THE PATIENT WAS TESTED BY A COMPETITOR METHOD AT A DIFFERENT HOSPITAL AND THE HE4 RESULT WAS 34.3 PMOL/L.