Immunohistochemical staining

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Immunohistochemical staining is a godsend. It helps when ya can't quite figure it out from the histology or with conventional stains.

General (malignant) differential diagnosis

 
 
 
 
 
 
 
 
 
 
Malignancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Carcinoma
 
Sarcoma
 
Germ Cell
Tumour
 
Neuroendocrine
carcinoma
 
Lymphoma
 
Melanoma
  • Carcinoma.
    • AE1/AE3 - pankeratin.
    • Others: EMA, HMWK, LMWK.
  • Sarcoma.
    • Vimentin.
      • Many pathologists think this stain is totally useless.
  • Germ cell tumours.
    • PLAP (placental-like alkaline phosphatase) - not very sensitive.[1]
  • Neuroendocrine carcinoma.
    • Chromogranin.
    • Synaptophysin.
    • CD56.
  • Melanoma.
    • S-100, HMB-45, Melan A (MART-1).
  • Lymphoma.
    • CD45 (common leukocyte antigen).

Keratins

Classification:[2]

  • Low molecular weight keratins (LMWK): 7, 8/18, 19, 20.
  • High molecular weight keratins (HWMK): 4, 10, 13, 14, 17.

Uses:

  • CK8 (CAM5.2)[3] - used to look for mets from breast cancer in axillary lymph nodes.
  • HWMK - squamous cell carcinoma.

Organ specific

Thyroid

  • TTF-1 (thyroid transcription factor-1).
    • Very good for breast vs. lung.[4]
      • Negative in squamous cell carcinoma of the lung (as with CK7 & CK20), though HMWK is usually positive.

Breast markers

  • GCDFP-15 (aka BRST2) -- specific, but NOT sensitive.
  • ER (estrogen receptor) - in normal breast.
  • PR (progesterone receptor) - in normal breast.
  • HER2/neu - pathological, assoc. with worse prognosis.
    • HER2/neu+ cancers Tx'ed with trastuzumab (Herceptin).

Prostate

  • PSA - prostatic specific antigen.
  • PSAP - prostatic specific acid phosphatase.
  • p63 - stains nuclei of basal cell in normal prostate.
  • 34betaE12 - stains basals cells in normal prostate.
  • AMACR (racemase, P504S[5]) - present in adenocarcinoma (NOT in normal prostate).
  • CAP cocktail - AKA CAP (AMACR p63 and 34βE12).

CRC markers

  • CEA.

Small bowel

  • CDX2.
  • Villin.

Kidney

Renal cell carcinoma

  • RCC, EMA, CD10.
  • CK7 -ve in clear cell RCC.
  • AMACR +ve in papillary RCC.
  • D2-40 +ve in ChRCC.

Xanthogranulomatous pyelonephritis

  • CD68 (for macrophages).

Ovary

  • CA125, CK7+, CK20-.
  • WT1 -- 90% in serous +ve.

Serous markers

  • WT-1, CA-125, D2-40.

Liver

  • AFP (alpha-fetaprotein).
  • Glypican-3.
    • HCC stains with glypican 3, while liver with dysplastic changes and/or cirrhotic changes does not.[6]
  • HepPar-1 (hepatocytes paraffin antibody 1) - labels hepatocellular mitochondria.[7]

HCC vs. cholangiocarcinoma:

  • TTF-1: ~90-100% +ve (cytoplasmic) in HCC vs. ~10% in choleangiocarcinoma.[8]

Mesothelium

  • Calretinin.
  • WT-1.
  • D2-40.
  • CK5/6.

Typically negative:

  • CEA.
  • TTF-1.

Macrophages

  • CD68.
  • CD1a -- +ve in Langerhans histocytes.

Less common:

Pancreas

  • CK17 - approx. 50% of pancreaticobiliary adenocarcinomas & patchy.[10]
  • CK19.[11]

One organ vs. another

Cervix vs. uterus

  • Cervix (typically): CEA +ve,[12] p16 +ve.
    • ... and ER -ve, PR -ve, vimentin -ve.
  • Uterus (typically): vimentin +ve, ER +ve, PR +ve.[13]
    • ... and CEA -ve, p16 -ve.

Additional Ref.:[14]

Liver vs. bile duct

Intrahepatic cholangiocarcinoma (ICC) vs. hepatocellular carcinoma (HCC):[15]

  • ICC: CK19 (92.5%), MUC-1 (73.8%) +ve.
  • HCC: HepPar-1 (85.6%), CD34 (87.8%) +ve.

Lymphomas

Lymphocytes

  • CD45 (AKA common leukocyte antigen).

B-cells

  • CD20.
  • CD19 (flow only).

Follicular lymphoma:

  • CD10+, bcl-6+.

CLL:

  • CD5+, CD23+.

Mantle cell lymphoma:

  • Cyclin D1+.

T-cells

  • CD3 - general T-cell marker (marks both CD4 +ve and CD8 +ve cells).
  • CD4.
  • CD8.

Hodgkin's lymphoma

Classic types:

  • CD30 Reed-Sternberg cells (RSCs) +ve ~98%.[16]
  • CD15 Reed-Sternberg cells +ve ~80%, stains neutrophils.

Germ cell tumours

Seminoma

Embryonal carcinoma

  • CD30+ - cytoplasm, cell membrane, Golgi.
    • NOT positive in seminoma.

Yolk sac tumour (endodermal sinus tumour)

  • AFP (alpha fetoprotein).

Choriocarcinoma

  • beta-hCG.

Mnemonic

The germ cell tumour (GCT) IHC mnemonic ABCD:

  • AFP = yolk sac tumour.
  • Beta-hCG = choriocarcinoma.
  • CD30 = embryonal carcinoma.
  • D2-40 = seminoma.

Sarcomas

MFH panel (MSH):

  • CD34 - GISTs, solitary fibrous tumour/hemangiopericytoma, DFSP, angiosarcoma.
  • S-100 - neural differentiation, melanoma.
  • Desmin - smooth muscle.
  • MIB1 - proliferation marker (target is Ki-67 protein).
  • CD99 - blue small cell tumours, membranous staining EWS.
  • Bcl-2.
  • PGP 9.5.
  • SMMS - smooth muscle.
  • Caldesmon - muscle.
  • PDGFR - GIST.

Muscle markers

  • Desmin - all three types.
  • Caldesmon - smooth muscle.
  • Smooth muscle myosin - smooth muscle.
  • MyoD1 - skeletal muscle.

Proliferation markers

  • MIB1 - an antibody against the protein Ki-67 (a protein expressed in proliferating cells).

Note: MIB1 should not be confused with mindbomb homolog 1 (MIB-1), a gene that regulates apoptosis.[17]

Carcinomas

CK7 and CK20

CK7+ CK20-

  • Ovary (but not mucinous).
  • Breast.
  • Endometrial.
  • Lung (adenocarcinoma).
  • Mesothelium.
  • Salivary.
  • Thyroid (all).

Mnemonic: OBE + lung x2 + H&N x2

CK7- CK20+

  • Colorectal adenocarcinoma.
  • Merkel cell tumour.

CK7+ CK20+

  • Pancreatic adenocarcinoma.
  • Ovary, mucinous subtype.
  • Occasionally gastric adeno, cholangiocarcinoma.
  • Transistional cell carcinoma or urothelial cell carcinoma (UCC).
  • Esophagus (adenocarcinoma).

Mnemonic: POOTE.

CK7- CK20-

  • Neuroendocrine lung (small cell carcinoma).
  • Adrenocortical carcinoma (ACC).
  • Squamous cell carcinoma (all sites of the body).
  • Hepatocellular carcinoma (HCC).
  • Thymoma.
  • Urogenital tumours - germ cell tumours.
  • Renal cell carcinoma (clear cell type).
  • Prostate adenocarcinoma.

Mnemonic: NASH TURP.

Vimentin & cytokeratin

A few tumours are positive for both vimentin and cytokeratins.

References

  1. ↑ 1.0 1.1 Iczkowski KA, Butler SL, Shanks JH, et al (February 2008). "Trials of new germ cell immunohistochemical stains in 93 extragonadal and metastatic germ cell tumors". Hum. Pathol. 39 (2): 275-81. doi:10.1016/j.humpath.2007.07.002. PMID 18045648.
  2. ↑ http://www.nordiqc.org/Epitopes/Cytokeratins/cytokeratins.htm
  3. ↑ Murata T, Nakashima Y, Takeuchi M, Sueishi K, Inomata H (September 1993). "The diagnostic use of low molecular weight keratin expression in sebaceous carcinoma". Pathol. Res. Pract. 189 (8): 888–93. PMID 7508102.
  4. ↑ Jagirdar J (March 2008). "Application of immunohistochemistry to the diagnosis of primary and metastatic carcinoma to the lung". Arch. Pathol. Lab. Med. 132 (3): 384–96. PMID 18318581. http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=132&page=384.
  5. ↑ http://www.antibodies-online.com/antibody/125649/P504S+alphaMethylacylCoA+Racemace+AMACR+Human/
  6. ↑ Anatelli F, Chuang ST, Yang XJ, Wang HL. (2008). "Value of glypican 3 immunostaining in the diagnosis of hepatocellular carcinoma on needle biopsy". Am J Clin Pathol. 130 (2): 219-23?. doi:10.1309/WMB5PX57Y4P8QCTY. PMID 18628090.
  7. ↑ The diagnostic value of hepatocyte paraffin antibody 1 in differentiating hepatocellular neoplasms from nonhepatic tumors: a review. Lamps LW, Folpe AL. Adv Anat Pathol. 2003 Jan;10(1):39-43. Review. PMID 12502967.
  8. ↑ Lei JY, Bourne PA, diSant'Agnese PA, Huang J (April 2006). "Cytoplasmic staining of TTF-1 in the differential diagnosis of hepatocellular carcinoma vs cholangiocarcinoma and metastatic carcinoma of the liver". Am. J. Clin. Pathol. 125 (4): 519–25. doi:10.1309/59TN-EFAL-UL5W-J94M. PMID 16627262.
  9. ↑ Pernick NL, DaSilva M, Gangi MD, Crissman J, Adsay V (November 1999). ""Histiocytic markers" in melanoma". Mod. Pathol. 12 (11): 1072–7. PMID 10574605.
  10. ↑ Goldstein NS, Bassi D (May 2001). "Cytokeratins 7, 17, and 20 reactivity in pancreatic and ampulla of vater adenocarcinomas. Percentage of positivity and distribution is affected by the cut-point threshold". Am. J. Clin. Pathol. 115 (5): 695–702. doi:10.1309/1NCM-46QX-3B5T-7XHR. PMID 11345833.
  11. ↑ Geller SA, Dhall D, Alsabeh R (March 2008). "Application of immunohistochemistry to liver and gastrointestinal neoplasms: liver, stomach, colon, and pancreas". Arch. Pathol. Lab. Med. 132 (3): 490–9. PMID 18318589.
  12. ↑ 12.0 12.1 Alkushi A, Irving J, Hsu F, et al. (March 2003). "Immunoprofile of cervical and endometrial adenocarcinomas using a tissue microarray". Virchows Arch. 442 (3): 271-7. doi:10.1007/s00428-002-0752-4. PMID 12647218.
  13. ↑ URL: http://www.nature.com/modpathol/journal/v19/n8/full/3800620a.html
  14. ↑ LAE 15 Jan 2009.
  15. ↑ [Evaluation of immunohistochemical markers for differential diagnosis of hepatocellular carcinoma from intrahepatic cholangiocarcinoma] Dong H, Cong WL, Zhu ZZ, Wang B, Xian ZH, Yu H. Zhonghua Zhong Liu Za Zhi. 2008 Sep;30(9):702-5. Chinese. PMID 19173916.
  16. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 567. ISBN 978-0781765275.
  17. ↑ http://www.genenames.org/data/hgnc_data.php?hgnc_id=21086
  18. ↑ Llombart-Bosch A, Lopez-Guerrero JA, Peydro-Olaya A (2002). "Synovial sarcoma (SS): new perspectives supported by modern technology". Arkh. Patol. 64 (3): 39–47. PMID 15338724.
  19. ↑ http://cat.inist.fr/?aModele=afficheN&cpsidt=2504165
  20. ↑ http://www.nature.com/modpathol/journal/v14/n9/full/3880401a.html

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