Diagnostic Immunohistochemistry: Theranostic and Genomic Applications, Third Edition

952 Pages·2010·118.17 MB·English

by  David J. Dabbs MD

1600 John F. Kennedy Blvd
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Philadelphia, PA 19103-2899
DIAGNOSTIC IMMUNOHISTOCHEMISTRY    ISBN: 978-1-4160-5766-6
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience 
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The Publisher
Library of Congress Cataloging-in-Publication Data
Diagnostic immunohistochemistry: theranostic and genomic
applications / [edited by] David J. Dabbs.—3rd ed.
       p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-1-4160-5766-6
 1.  Diagnostic immunohistochemistry.  I. Dabbs, David J. 
  [DNLM: 1.  Immunohistochemistry—methods. 2.  Diagnostic Techniques
and Procedures. 3.  Neoplasms—diagnosis.  QW 504.5 D536 2009]
  RB46.6.D33 2009
  616.07’583—dc22                                                                 2009018160
Chapter 20, Immunohistology of the Nervous System, by Paul E. McKeever: Contributor holds 
 copyright and assigns to us limited rights in and to the contribution.
Acquisitions Editor: William R. Schmitt
Developmental Editor: Kathryn DeFrancesco
Publishing Services Manager: Linda Van Pelt
Design Direction: Ellen Zanolle
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to the patients we serve
and to my colleagues in pathology and oncology,
especially those who inspire me in very special ways.
CONTRIBUTORS
N. Volkan Adsay, MD Jessica M. Comstock, MD
Professor and Vice Chair Visiting Instructor
Pathology and Laboratory Medicine University of Utah School of Medicine
Director of Anatomic Pathology Attending Physician
Emory University Hospital Primary Children’s Medical Center
Atlanta, Georgia Salt Lake City, Utah
Nancy J Barr, MD David J. Dabbs, MD
Assistant Professor of Clinical Pathology Professor and Chief of Pathology
Department of Pathology Department of Pathology
Keck School of Medicine Magee-Womens Hospital 
University of Southern California Medical Center University of Pittsburgh School of Medicine
Los Angeles, California Pittsburgh, Pennsylvania
Olca Basturk, MD Sanja Dacic, MD
Pathology Resident Associate Professor
Department of Pathology Department of Pathology
New York University School of Medicine UPMC Presbyterian Hospital
New York, New York University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Parul Bhargava, MD
Instructor in Pathology Ronald A. DeLellis, MD
Harvard Medical School Professor and Associate Chair
Medical Director, Hematology Laboratory Department of Pathology and Laboratory Medicine
Beth Israel Deaconess Medical Center Alpert Medical School of Brown University
Boston, Massachusetts  Pathologist in Chief
Rhode Island Hospital and The Miriam Hospital
Rohit Bhargava, MD Providence, Rhode Island
Assistant Professor of Pathology
Co-Director, Surgical Pathology Jonathan I. Epstein, MD
Magee-Womens Hospital Professor of Pathology, Urology, and Oncology 
University of Pittsburgh School of Medicine The Reinhard Professor of Urologic Pathology
Pittsburgh, Pennsylvania Johns Hopkins University School of Medicine 
Director
Mamatha Chivukula, MD Division of Surgical Pathology
Assistant Professor of Pathology Johns Hopkins Medical Institutions
Associate Director of Immunohistochemistry  Baltimore, Maryland
Laboratory
Magee-Womens Hospital Nicole N. Esposito, MD
University of Pittsburgh School of Medicine Assistant Professor
Pittsburgh, Pennsylvania Department of Pathology and Cell Biology
College of Medicine
Cheryl M. Coffin, MD University of South Florida
Goodpasture Professor of Investigative Pathology Assistant Member
Vice Chair for Anatomic Pathology  Anatomic Pathology Division, Breast Program
Department of Pathology  H. Lee Moffitt Cancer Center 
Vanderbilt University  Tampa, Florida
Executive Medical Director of Anatomic Pathology
Vanderbilt Medical Center  Eduardo J. Ezyaguirre, MD
Nashville, Tennessee Assistant Professor
Department of Pathology
University of Texas Medical Branch
Galveston, Texas
vii
viii
CONTRIBUTORS
Alton B. Farris III, MD Alvin W. Martin, MD
Assistant Professor Clinical Professor of Pathology
Department of Pathology University of Louisville School of Medicine
Emory University School of Medicine Medical Director
Atlanta, Georgia CPA Laboratory
Norton Healthcare 
Jeffrey D. Goldsmith, MD Louisville, Kentucky
Assistant Professor of Pathology
Harvard Medical School Paul E. McKeever, MD, PhD
Staff Pathologist Professor of Pathology
Beth Israel Deaconess Medical Center and Children’s  Chief
Hospital Section of Neuropathology
Boston, Massachusetts Department of Pathology
University of Michigan Medical Center
Samuel P. Hammar, MD Ann Arbor, Michigan
Clinical Professor of Pathology
University of Washington George J. Netto, MD
Seattle, Washington Associate Professor of Pathology, Urology, and 
Staff Pathologist Oncology
Harrison Medical Center Johns Hopkins University School of Medicine
Director Baltimore, Maryland
Diagnostic Specialties Laboratories
Bremerton, Washington Yuri E. Nikiforov, MD, PhD
Professor and Director
Jason L. Hornick, MD, PhD Division of Molecular Anatomic Pathology
Associate Professor of Pathology UPMC Presbyterian Hospital
Harvard Medical School University of Pittsburgh School of Medicine
Associate Director of Surgical Pathology Pittsburgh, Pennsylvania
Department of Pathology
Brigham and Women’s Hospital Marina N. Nikiforova, MD
Boston, Massachusetts Assistant Professor
Department of Pathology 
Jennifer L. Hunt, MD Associate Director
Associate Professor Molecular Anatomic Pathology Laboratory
Harvard Medical School University of Pittsburgh Medical Center
Associate Chief of Pathology Pittsburgh, Pennsylvania
Director of Quality and Safety
Massachusetts General Hospital James W. Patterson, MD
Boston, Massachusetts Professor and Director of Dermatopathology
University of Virginia Medical Center
Marshall E. Kadin, MD Charlottesville, Virginia
Professor of Dermatology
Boston University School of Medicine Joseph T. Rabban, MD, MPH
Boston, Massachusetts Associate Professor
Director of Immunopathology and Imaging Core Department of Pathology
Center for Biomedical Research Excellence University of California, San Francisco
Roger Williams Medical Center San Francisco, California
Providence, Rhode Island 
Shan-Rong Shi, MD
Alyssa M. Krasinskas, MD Professor of Clinical Pathology
Assistant Professor of Pathology Department of Pathology
UPMC Presbyterian Hospital Keck School of Medicine
University of Pittsburgh School of Medicine University of Southern California Medical Center
Pittsburgh, Pennsylvania Los Angeles, California
Sandra J. Shin, MD
Assistant Professor of Pathology and Laboratory 
Medicine
Weill Medical College of Cornell University
New York, New York
ix
CONTRIBUTORS
Robert A. Soslow, MD Jeremy C. Wallentine, MD
Professor of Pathology and Laboratory Medicine Hematopathology Fellow
Weill Medical College of Cornell University University of Utah School of Medicine
Attending Pathologist University of Utah Health Sciences Center and ARUP 
Memorial Sloane-Kettering Cancer Center Laboratories
New York, New York Salt Lake City, Utah
Paul E. Swanson, MD Mark R. Wick, MD
Professor and Director of Anatomic Pathology Professor and Associate Director of Surgical Pathology
University of Washington Medical Center Director of Diagnostic Immunohistochemistry
Seattle, Washington Division of Surgical Pathology
University of Virginia Medical Center
Clive R. Taylor, MD, PhD Charlottesville, Virginia
Professor of Pathology
Senior Associate Dean for Educational Affairs Sherif R. Zaki, MD
Keck School of Medicine Branch Chief
University of Southern California Infectious Disease Pathology Branch
Los Angeles, California Centers for Disease Control and Prevention
Atlanta, Georgia
Diana O. Treaba, MD
Assistant Professor of Pathology Charles Z. Zaloudek, MD
Alpert Medical School of Brown University Professor of Pathology
Director of the Hematopathology Laboratory Department of Pathology
Rhode Island Hospital and The Miriam Hospital University of California, San Francisco Medical Center
Providence, Rhode Island San Francisco, California
David H. Walker, MD
Professor and Chairman
Department of Pathology
University of Texas Medical Branch at Galveston
The Carmage and Martha Walls Distinguished 
University Chair in Tropical Diseases
Executive Director, UTMB Center for Biodefense and 
Emerging Infectious Diseases
Director, WHO Collaborating Center for Tropical 
Diseases
Galveston, Texas
FOREWORD
Many are the “special” techniques that pathologists  for a given cell type were later found to be expressed by 
have used over the years to confirm, complement, and  other tissues; cross-reactions may occur between unre-
refine the information obtained with their “old faith- lated antigens; nonspecific absorption of the antibody 
ful” armamentarium; that is, formalin fixation, paraf- may supervene; entrapped non-neoplastic cells reacting 
fin embedding, and hematoxylin-eosin staining. These  for a particular marker may be misinterpreted as part 
special techniques have come and gone, their usual life  of the tumor; and—most treacherously—antigen may 
cycle beginning with an initial period of unrestrained  diffuse out of a normal cell and find its way inside an 
enthusiasm, turning to a phase of disappointment, and  adjacent tumor cell. Any of these pitfalls may lead to 
finally leading to a more sober and realistic assessment.  a misinterpretation of the reaction and a misdiagnosis. 
Many of these methods have left a permanent mark  Ironically, this may lead to a final mistaken diagnosis 
on the practice of the profession, even if often this was  after an initially correct interpretation of the hema-
not as deep or wide-ranging as initially touted. These  toxylin-stained slides. A good protection against this  
techniques include special stains, tissue culture, elec- danger is a thorough knowledge of these pitfalls and 
tron microscopy, immunohistochemistry, and molecu- how to avoid them. An even more important safeguard 
lar biology methods. Much was expected of the first  is a solid background in basic anatomic pathology that 
three, and infinitely more is anticipated of the last, but  will allow the observer to question the validity of any 
it is fair to say that as of today no special technique  unexpected immunohistochemical result, whether posi-
has influenced the way that pathology is practiced as  tive or negative. There is nothing more dangerous (or 
profoundly as immunohistochemistry, or has come even  expensive) than a neophyte in pathology making diag-
close to it. I don’t think it would be an exaggeration to  noses on the basis of immunohistochemical profiles in 
speak of a revolution, particularly in the field of tumor  disregard of the cytoarchitectural features of the lesions. 
pathology. Those of us whose working experience ante- Alas, this is true of any other special technique applied 
dated diagnostic immunohistochemistry certainly feel  for diagnostic purposes to human tissue, molecular biol-
that way. The newer generations of pathologists who  ogy being the latest and most blatant example. However, 
order so glibly an HMB-45 or a CD31 stain to iden- when applied selectively and judiciously, immunohis-
tify melanocytes and endothelial cells, respectively, have  tochemistry is a notably powerful tool, in addition to 
very little feeling for the efforts made to achieve those  being refreshingly cost effective. As a matter of fact, 
identifications in the past. The virtues of the technique  pathologists can no longer afford to do without it, one 
are so apparent and numerous as to make it as close to  of the reasons being that failure to make a diagnosis 
ideal as any biologic method carried out in human tis- because of the omission of a key immunohistochemical 
sue obtained under routine (which usually means under  reaction may be regarded as grounds for a malpractice 
less than ideal) conditions can be. To wit: It is compat- action.
ible with standard fixation and embedding procedures;  Any listing of the virtues of immunohistochemistry 
it can be performed retrospectively in material that has  would be incomplete if it did not include the visual 
been archived for years; it is remarkably sensitive and  pleasure derived from the examination of this mate-
specific; it can be applied to virtually any immunogenic  rial. I am only half kidding when making this remark. 
molecule; and it can be evaluated against the morpho- There is undoubtedly an aesthetic component to the 
logic backgrounds with which pathologists have long  practice of histology, as masters of the technique such 
been familiar. as Pio del Rio Hortega and Pierre Masson liked to 
As  with  many  other  breakthroughs  in  medicine,  point out. It is sad that these superb artists of morphol-
immunohistochemistry started with a brilliant yet dis- ogy left the scene without having had the opportunity 
armingly simple idea: to have antibodies bind the spe- to marvel at the beauty of a well-done immunohisto-
cific antigens being sought and to make those antibodies  chemical preparation. As their more fortunate heirs, 
visible by hooking to them a fluorescent compound.  let us enjoy this excellent book, edited by one of the  
All subsequent modifications, such as the use of non- foremost experts in the application of the immuno-
fluorescent chromogens, the amplification of the reac- histochemical  technique  and  written  by  a  superb 
tion, and the unmasking of antigens, merely represented  group of contributors—a book that summarizes in a 
technical improvements, although certainly not ones to  lucid and thorough fashion the current knowledge in 
be minimized. It is because of these technical advances  the field, in terms of both the technical aspects and the 
that the procedure spread beyond the confines of the  practical applications.
research laboratories and is now applied so pervasively  The first edition of this book, published in 2002,  
in pathology laboratories throughout the world. Alas, it  rapidly became one of the standard works in the field. 
has its drawbacks. Antigens once believed to be specific  The second edition featured a more standardized  format, 
xi
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FOREWORD
a wider coverage of organ systems, and an extensive  The title of this new third edition has been changed 
update of markers. It incorporated a large number of  to Diagnostic Immunohistochemistry: Theranostic and
useful tables listing the various antibody groups, an  Genomic Applications to emphasize the fact that immu-
algorithmic  approach  to  differential  diagnosis,  and  nohistochemistry is no longer used solely for diagnosis. 
key diagnostic points for all the major subjects. Special  Rather, the growing body of knowledge of cancer genom-
attention was paid to the detailed description of the so- ics, transcriptomics, and the new therapeutic armamen-
called predictive-type markers (such as HER2/neu in  tarium of biologics forces pathologists to be cognizant 
breast carcinoma and CD117 in GIST), which are play- of the emerging field of therapeutic and genomic appli-
ing an increasingly important role in the evaluation of  cations of immunohistochemistry.  Accordingly, each 
tumors by the pathologist. chapter of the book includes a synoptic coverage of 
In this third edition, a new chapter has been added  theranostic and genomic applications. As a result, each 
that describes, in a simplified and condensed fashion,  organ-based chapter provides detailed information on 
the rationale, technology, and applications of molecu- how gene-based disease can be diagnosed through the 
lar anatomic pathology techniques to aid the surgical  microscope with immunohistochemistry. In a similar 
pathologist in acquiring a basic understanding of these  vein, the presence or absence of markers predictive of 
molecular tests. the beneficial effects of targeted therapies is determined, 
A new, very timely chapter on immunocytology has  launching the age of theranostic immunohistochemistry.
been included by Dr. Chivukula, which discusses proper  Last but not least, each chapter provides a bridge to 
cytologic technique for fixation and processing speci- new molecular anatomic pathology menus for patholo-
mens obtained for hormone receptors and HER2/neu  gists, in order to empower them with additional diag-
testing. nostic modalities whenever immunohistochemistry falls 
Overall,  each  organ-based  chapter  addresses  the  short.
state-of-the-art body of knowledge and is summarized  In summary, the authors have again brilliantly suc-
in bulleted format for ease of understanding. ceeded in producing an authoritative, comprehensive, 
There are several new completely rewritten chapters  and updated book that pathologists will find next to 
with new authors, all of them experts in their respective  indispensable as a theoretical backbone for the various 
fields, including N. Volkan Adsay, Jonathan Epstein,  methods discussed and of invaluable assistance in their 
Alyssa M. Krasinskas, Alvin W. Martin, George Netto,  daily work.
and Yuri E. Nikiforov. The latest recommendations for 
proper fixation and processing of hormone receptor test- Juan Rosai, MD
ing are authoritatively discussed by Dr. Clive R. Taylor. Milan, italy
PREFACE
The title of this third edition of Diagnostic Immunohisto­  surrogate markers for gene expression profiles for breast 
chemistry has been lengthened to include the terms   carcinomas can further identify the gene expression pro-
“Theranostic and Genomic Applications.”  Fundamen- file subsets of carcinomas as luminal A, luminal B, and 
tally, the continuing challenge of this book is to assemble  HER2 categories. 
the vast body of knowledge of immunohistochemistry  It  becomes  clear  that  immunohistochemistry  is  a 
into a work that has meaning for the diagnostic surgi- powerful tool with overlapping features among diag-
cal pathologist. The discipline of immunohistochemistry  nostic,  theranostic,  and  genomic  applications.  Ther-
for the surgical pathologist has been evolving rapidly  anostic applications may also be genomic, and genomic 
since the first edition of this book, and it can further be  immunohistochemistry may also be theranostic. These 
broken down into subsets of theranostic and genomic  categories admittedly are artificial and simplistic but 
applications. The diagnostic aspect of immunohisto- give the surgical pathologist and the student of surgical 
chemistry  in  surgical  pathology  is  straightforward.  pathology a conceptual framework for recognition of 
Pathologists use this tool to assign lineage to neoplasms  the enormous power of the immunohistochemical test.
that include carcinomas, melanomas, lymphomas, sar- Molecular testing in surgical pathology has many 
comas, and germ cell tumors. The term “theranostics”  important diagnostic, theranostic, and genomic applica-
is used to describe the proposed process of diagnostic  tions as well, but it is the immunohistochemistry plat-
therapy for individual patients—to test them for pos- form that lays the groundwork for our understanding of 
sible reactions to a new medication and/or to tailor a  what is normal and what is diseased in tissue by virtue 
treatment for them based on a test result. Theranostics  of the direct visualization of molecular morphology.
is a rapidly emerging field in oncology, and patholo- In this edition, most chapters have been completely 
gists need to be prepared to serve oncologic patients  revised, and there are several new authors. There is a 
with a vast and emerging array of individualized patient  new chapter on molecular anatomic pathology, with 
therapies. The prototype for understanding the concept  new authorships in non-Hodgkin lymphoma; immuno-
of theranostics is hormone receptor testing for breast  histology of the gastrointestinal tract; immunohistol-
cancer and HER2/neu analysis. These were among the  ogy of the pancreas, bile ducts, gallbladder, and liver; 
first and most widely known immunohistochemical tests  and immunohistology of the genitourinary system. An 
with theranostic applications. With the proper applica- additional new chapter on immunocytology is patterned 
tion of these immunohistochemical tests, individualized  after the chapter that appeared in the first edition.  
therapy in the form of selective estrogen receptor modu- Each chapter format may include subsections that 
lation therapy for the patient with an estrogen-receptor  discuss relevant theranostic and genomic applications of 
positive breast carcinoma can be designed. Trastuzumab  immunohistochemistry. These are included to highlight 
is administered for the patient with a HER2-positive  to the pathologist that these important applications go 
breast carcinoma. beyond  traditional  diagnostic  immunohistochemistry 
In addition, the genomic application of immunohis- for individual organ systems.  
tochemistry  (i.e.,  genomic  immunohistochemistry)  is  Immunohistochemistry has undergone a tremendous 
a tool for the surgical pathologist to facilitate recog- change, with new stresses and demands throughout the 
nition of specific genomic aberrations in the patients’  last decade. A critical factor affecting the surgical pathol-
tissues by identifying (or not identifying) the presence  ogist/immunohistochemist is the proper standardization 
or absence of specific proteins or immunohistochemi- of procedures in the laboratory to assure the highest 
cal profiles that directly imply, or connote, a specific  quality  immunohistology  for  diagnostic,  theranostic, 
genomic  abnormality,  aberration,  or  gene  signature.  and  genomic  applications.  Recent  recommendations 
A prototype for genomic application could be immu- by the CAP-ASCO and additional new recommenda-
nohistochemical testing for microsatellite instability in  tions for hormone receptor testing have highlighted the 
colorectal carcinomas, where the surgical pathologist  importance of proper standardization of procedures and 
applies antibodies to detect proteins for MLH1, MSH2,  internal and external quality assurance programs.
MSH6, or PMS2. The presence or absence of this pro- Once  again,  the  challenge  of  putting  this  work 
tein is in essence a genetic test, a direct genomic appli- together has been to assure that the base of knowledge 
cation for immunohistochemistry. A genetic signature  in each chapter is relevant and robust long after the ink 
application might include the identification of basal-like  has dried. The contributions of expert authors in each 
breast carcinoma, in which the signature profile typi- discipline are unique to this work. The continuing goal 
cally is a high-grade ER, PR and HER2 negative, CK5  of this book is to provide a reference for pathologists 
positive, CK14 positive, CK17 positive, variably EGFR  who  practice  contemporary  surgical  pathology  and 
positive  tumor.  Furthermore,   immunohistochemical  cytopathology. 
xiii
xiv
PREFACE
With few exceptions, each chapter is designed to be  out typographical errors or informational errors. Please 
a stand-alone work. Inherent in this design is a body of  contact me at [email protected] or dabbsihc@gmail.
information that is reproduced and redundant through- com.
out each chapter. Each chapter is comprehensive in  My special thanks go to the dedicated investigators 
a diagnostic sense, which should limit the need to do  and pathologists across the globe who have given me 
extensive cross-checking to other chapters. Each section  feedback on this work. 
is punctuated by key diagnostic points that summarize 
the section and that serve as a rapid summary reference  David J. Dabbs, MD
for the most important points in that section.
The positive feedback on this work continues to 
grow exponentially. I welcome personally any feedback 
regarding this book, no matter how small, even to point