Immunohistochemistry of clear cell tumours. What are clear cell tumours? Jan Klos 1

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1 Immunohistochemistry of clear cell tumours J. Klos MD Department of Pathology Stavanger University Hospital Norway What are clear cell tumours? Multiple factors in etiology of clear cell changes: - technical artifact because of improper cellular preservation - hydropic cell degeneration - abundance of: - Glycogen - Mucin - Lipid - Mucopolysaccharides - Phagocytosed foreign material Jan Klos 1

2 Metastatic carcinoma of the pancreas with mucin production Clear cell change may affect any cell primarily and appear or become more extensive during progression of tumour Certain clear cell neoplasms may give metastases to organs in which typical clear cell tumors have potential to arise primarily Antibodies Cytokeratin wide spectrum Vimentin S-100 Cytokeratin HMW (5, 5/6, 14) CK-7 CK-8/18 P63 Melan A / HMB45 Hepatocyte antigen Glypican 3 CD10 RCC Jan Klos 2

3 Antibodies Cytokeratin wide spectrum important to cover low and high molecular weight cytokeratins Cytokeratin subtypes Vimentin Intermediary filament single subunit 57kDa with structural function in cytoplasm Presence: at early stages of differentiation is present in all cells types but is replaced in later development by other IF types. Found in wide variety of cells of mesenchymal origin but also in thyroid gland, epithelia of mesodermal derivation like adrenals, kidneys, endometrium, Sertoli and granulosa cell tumours, mesothelium, melanocytes,... Co-expression with cytokeratins an other IFs S-100 protein Isolated 1965 by Moore BW. Ca+ binding, 20 kda acidic protein (soluble in 100% in ammonium sulfate), engaged in forming of microtubules and cell growth consists of α- and β-units forming homo- or heterodimers Presence: astrocytes, oligodendrocytes, ependymal cells, Schwann cells (ββ), melanocytes (αβ), endoneural cells, myoepithelial cells, Langerhans cells (ββ) and interdigitating reticulum cells, neurons follicular dendritic cells (αα), fat cells, chondrocytes, some epithelial cells and tumors with these differentiations.!!! Lower frequency in desmoplastic and neurotropic melanoma as well as metastatic deposits. Jan Klos 3

4 NordiQC Workshop 2010 Clear cell squamous carcinoma skin Clear cell squamous carcinoma skin CK5/6 CK5/6 Clones 5D3/LP34 Poor choice p63 PAN-CK Hepatocellular Carcinoma Patterns: pseudoglandular, clear cell, fatty change, spindle cell, scirrhous, poorly differentiated, pleomorphic Specials: bile production, Mallory hyaline bodies, globular hyaline bodies, pale bodies, ground glass inclusions Immunohistochemistry: Hepatocyte antigen+(80-100%), Glypican 3+(~ 60-70%) CK8/18+ (~ 100%), CK19-/+ (10%), CK7/CK20-/+ (20%) 80% CK7CK7-/CK20/CK20-, 15% CK7+/CK20CK7+/CK200% CK7CK7-/CK20+, 5% CK7+/CK20+ Ber-EP4-/+, AFP+/- (50%), α-1-antitrypsin+/-(50%), CD10+/pCEA+ in bile ducts m-cea-, Vimentin-, CA125-, WT-1neuroendocrine markers-, but CD56 often weakly positive CD34+ in endothelium of sinusoids Jan Klos 4

5 NordiQC Workshop 2010 Hepatocellular carcinoma PAS PASD Hepatocyte antigen Hepatocellular carcinoma Mitochondrial protein present in 70% of hepatocellular carcinomas and 100% hepatoblastomas. Found also in many adenocarcinomas (mostly gastric of signet ring type (50%) and hepatoid variants) in other organs, intestinal metaplasia (100%), but very rare in other tumors. Use: in panel with other antibodies! Intestinal mpl in stomach Signet ring cell carcinoma Hepatocellular carcinoma CD10 Hepatocyte antigen Jan Klos CEA/CD66 polyclonal AFP 5

6 Normal liver CD31 Hepatocellular carcinoma CD34 CD31 CD34 Glypican 3 Glypicans are extracellular proteins predominantly expressed during growth and development. They show modulatory activity on growth regulators signaling through interactions with a number of growth and morphogenic factors. GPC3 is normally expressed in trophoblast and a wide spectrum of fetal tissues, but has limited expression in adult tissues (gastric glands, kidney tubules). Tumours: with high percentage of positive staining include hepatocellular carcinoma, hepatoblastoma, yolk sac tumour, choriocarcinoma, Wilms`tumor, neuroblastoma, liposarcoma, squamous cell carcinoma of the lung, small cell neuroendocrine carcinomas including Merkel cell carcinoma and rhabdomyosarcoma. Few cases in many tumor categories are also found positive. Positive staining for Glypican 3 in hepatocellular carcinoma Jan Klos 6

7 GLP3 - Expression in liver* Non-neoplastic liver tissue Cases tested/positive %. Liver cirrhosis 95/11 12** Large regenerative nodule 8/ 0 0 Normal liver tissue 16/ 0 0 Preneoplastic nodular liver lesions Low-grade dysplastic nodule 7/ 7 0 High-grade dysplastic nodule 31/ 6 19 Primary malignant liver tumors Hepatocellular carcinoma 220/ ** HBV+ in 73%. *Modified from Baumhoer D et al.. Am J Clin Pathol Jun;129(6): CAVE! 84% of HCV+ active hepatitis is also reported GLP 3 positive Abdul-Al HM et al. Hum Pathol. 2008;39: Hepatoblastoma Malignant embryonal tumour in children with divergent pattern of differentiation including foetal embryonal hepatocytes and other differentiated tissues AFP CK8 Hepatoblastoma Hepatocyte Antigen Hepatocyte Antigen Α-fetoprotein Jan Klos 7

8 Renal Cell Carcinoma marker Identifies human proximal nephrogenic renal antigen (200 kd glycoprotein, gp200) expressed in renal cell carcinoma, normal proximal tubule and luminal surface and Bowman's capsule Staining is membranous and/or granular in the cytoplasm! Cross reactivity with epitopes of α-fetoprotein and α-1-antitrypsin (30% of embryonal ca!) may be observed It has also been found on luminal surface of breast lobules, thyroid follicles, syncytiotrophoblast, parathyroid adenomas, some breast carcinomas of both lobular and ductal type, embryonal carcinoma, single cases of mesothelioma are also reported positive Expression found in 90% of papillary type and 85% of clear cell types, some reports indicate lower reactivity in metastases (60-70%) Chromophobe type is positive under 10% Sarcomatoid variants, collecting duct carcinoma, renal cell carcinoma with t(6;11)(p21;q12) and oncocytoma are negative as a rule Renal cell tumours (WHO 2004) Clear cell renal cell carcinoma 75-80% Multilocular clear cell renal cell carcinoma (cystic) 1% (?) Papillary renal cell carcinoma (Type I and II) 10% Chromophobe renal cell carcinoma 5% Carcinoma of collecting ducts of Bellini >1% Renal medullary carcinoma rare Xp11 translocation carcinoma rare Carcinoma associated with neuroblastoma rare Mucinous tubular and spindle cell neoplasm rare Renal cell carcinoma unclassified - Papillary adenoma - Oncocytoma 5% Multilocular cystic clear cell renal cell carcinoma CK18 RCC CD10 Jan Klos 8

9 NordiQC Workshop 2010 Clear Cell Renal Cell Carcinoma vs. Chromophobe Clear Cell RCC Chromophobe RCC Renal Cell Clear Cell Carcinoma Vimentin CD117 RCC CD10 Renal Cell Chromophobe Carcinoma Vimentin RCC CD117 CK7 Jan Klos 9

10 Differential diagnosis of clear cell renal epithelial neoplasms RCC CD10 CD117 CK7 Vim Other Clear cell type +/- 85% + 95% EMA+ CK18/19+ Chromophobe type - <10% -/+ 30% +/- 80% + - EMA+ CKHMW-/+ Clear cell carcinoma Malignant tumour composed mainly of glycogen rich cells found in ovary, endometrium, cervix and vagina. Immunoprofile: CK+, CK7+, EMA+, CD15+, m-cea-/+, Vimentin -/+, AFP- Clear cell carcinoma - ovary m-cea ER Vimentin WT-1 Jan Klos 10

11 HMB 45 Human Melanoma Black Generated by Gown & co-workers 1986 Against 10 kda cytoplasmic glycoprotein believed to be a component of premelanosomal matrix (stage 1-3 nonmelanized). Cells of melanocytic lineage: benign and malignant variants of melanocytic tumours (junctional component in melanocytic and dysplastic nevus, intramucosal /conjunctival nevi, nevi in hormonally active areas, Spitz nevus, congenital and spindle cell nevi, common blue nevi and cellular blue nevi, some of S-100 negative cases e.g. neurotropic melanoma are positive) Many non-melanocytic tumours such as: neuroblastoma, eppendymoma, epitheloid schwannoma, PNET, pheochromocytoma, carcinoid, melanotic progonoma, hepatoblastoma, epitheloid muscle cells (PEComas = angiomyolipoma, cardiac rhabdomyoma, pulmonary clear cell tumour and pulmonary LAM etc), clear cell sarcoma,.! Amelanotic malignant melanoma may show weak focal reactivity!! Desmoplastic melanomas may be negative Melan A /MART-1 Gene cloned independently by two research groups in Against kd protein associated with melanosomes and endoplasmic reticulum - largely unknown cellular function. Background: Coded on Melan-A/MART-1 gene and is fairly specific to melanin producing cells and melanoma, but found also in steroid producing cells of adrenal cortex, ovary and testis. Application: diagnosis of melanocytic tumors and melanin producing tumors (considered to be more sensitive than HMB-45 because of higher percentage labeled tumors/tumor cells). It covers about the same spectrum of tumors as HMB-45, but also includes even adult melanocytes. Clone A103 stains adrenal cortical tumors and other steroid producing tumors but other clones do not. Neoplasms with perivascular epithelioid cell differentiation (PEComas) Include renal angiomyolipoma*, clear cell tumor of the lung, lymphangioleiomyomatosis, clear cell myomelanotic tumor of the falciform ligament/ ligamentum teres, clear cell tumors of the pancreas, rectum, abdominal serosa, uterus, vulva, thigh and heart * association with tuberous sclerosis Immunophenotype: Actin+, HMB45+, Melan A+, MITF, Tyrosinase, CD117+, Desmin-/+, S-100-, CK-, Vim- (?) Jan Klos 11

12 Sugar tumour Scalp tumor in 69 yrs old male Scalp tumor in 69 yrs old male S-100 PanCK Jan Klos 12

13 NordiQC Workshop 2010 Cytokeratin positive melanoma Melan A HMB 45 Clear cell sarcoma (of (of soft tissue) Soft tissue sarcoma of mainly young adults (3-rd-4th decade) with melanocytic differentiation Involves extremities mainly foot/ankle region Often late recurrences and metastases Long term survival is poor (10% after 20 yrs)! Clear cell sarcoma of kidney is a different tumour pediatric! Clear cell sarcoma Rare soft tissue tumour involving tendons and aponeuroses, 3rd-4th decade Immunophenotype: Vimentin+, S-100+, HMB-45+, Melan A+, MITF+, NSE+, Synaptophysin+, CD57+, CK- Jan Klos 13

14 NordiQC Workshop 2010 Clear cell sarcoma Vimentin S-100 HMB45 HMB45 Clear cell sarcoma Melan A MITF NSE CD57 Clear cell sarcoma vs. malignant melanoma Identical immunohistochemical profiles with melanoma Genetics: CCS has a typical t(12;22(q13;q12) translocation giving fusion of EWS/ATF1 genes and production of splice form of MITF transcript Clear cell sarcoma Jan Klos Melanoma with clear cell changes 14

15 Adrenal cortical carcinoma Very rare tumour of adrenal gland Peak incidence 7th -8th decade of life Symptoms often related to hypersecretion of steroid hormones Relatively good prognosis with 5yrs survival 50-70% Adrenal cortical carcinoma Malignant neoplasm of adrenal gland with cortical differentiation, ~3% of endocrine neoplasms, 7th decade Immunoprofile: CK8/18 -/+, Vimentin+, Melan A+, Inhibin+ Synaptophysin+, Chromogranin A-, S-100- PANCK PANCK Adrenal cortical carcinoma Vimentin Melan A Synaptophysin Jan Klos 15

16 Chordoma Low to intermediate malignant tumour recapitulating notochord Rare 1-4% of all bone tumours Most commonly at 4th decade Axial spine - 60% located at sacral and 25% at spheno-occipital region Chordoma Rare bone neoplasm recapitulating notochord, involving axial spine, ~1-4% of all primary malignant, bone tumours, 4-6th decade of life. Immunoprofile: CK8/18/19+, S-100+, Vimentin+, EMA+, NSE+, D2-40-, CK7-, CK20- Chordoma PANCK-1996 PANCK-2009 Jan Klos 16

17 Chordoma S-100 NSE EMA Vimentin Chordoma vs. chondroid tumour Cytokeratin (8/18/19) EMA Podoplanin (D2-40) Vimentin S-100 Chordoma Chondroid tumour Am J Surg Pathol 2009;33: Chordoma vs. Chondroid neoplasm Chordoma Chondrosarcoma Chondrosarcoma - D2-40 Jan Klos 17

18 NordiQC Worshop 2010 Table 5. (Modified from M.Vyberg 2007) Immunophenotyping of clear cell tumours Neoplasm Marker ASMA CK5 CK8 Melan A S-100β Vimentin CD117 p63 Other useful antibodies Squamous cell carcinoma - + -/+ - -/+ -/+ +/- + p63+; CKHMW+/-; EpCAM+(2); CK14+; -? - CGA+/-(5); SYP+(6) Neuroendocrine tumour (3) Renal cell carcinoma (clear cell) - -/+ (4) - - +/- - - (7) CD10+; CD15+/-; RCC+/- Adrenal cortical carcinoma - - -/ INH+/- (8); SYP+ (6) Thyroid carcinoma ? -/+ TG+ (9); TTF-1+(10) Ovarian clear cell carcinoma /-? - CA125+/- (11); ER-/+(12) Myoepithelial tumour +/ ? -/+ Calponin+; GFAP-/+(13) Thymic carcinoma ? - (1) Malignant melanoma and clear cell sarcoma. Leiomyomatous tumour (16) + - -/ (1) Gastrointestinal stromal tumour (GIST) PEComa +/- + -/+ + - (1)? + CD5+/ /+ - HMB-45+/- (14); MITF+/-(15) Desmin+/-; H-Caldesmon+/- +/ CD34+/-; H-Caldesmon+/ HMB-45+/-; MITF+/- Chordoma - +/ ? - CEA+/- GFAP+/-(13) Clear cell chondrosarcoma /+ - - Seminoma/ Dysgerminoma - - -/ /+ + - OCT4+; D2- (3) 40+(17); PLAP+(18) Explanations: + >90% positive; +/ % positive; - / % positive; - < 10% positive Jan Klos

19 NordiQC Worshop 2010 Comments to Table 5 Immunophenotyping of clear cell tumours ASMA = alpha smooth muscle actin 1. Occasionally positive. 2. Epithelial cell adhesion molecule (detected by e.g. Ber-EP4 or MOC-31) 3. Occasionally dot-like staining pattern. 4. Stains only sustentacular cells. 5. Chromogranin A. 6. Synaptophysin. 7. Occasionally focally positive. 8. Inhibin α 9. Thyroglobulin. 10. Thyroid transcription factor Cancer antigen Estrogen receptor. 13. Glial fibrillary acidic protein. 14 Melanosoma specific antigen (clone HMB45). 15. Microphtalmia transcription factor Leiomyosarcoma and epitheloid leiomyoma. 17. Podoplanin. 18. Placental alkaline phosphatase. Jan Klos