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~I Diagnostic
! Immunohistochemistrr
SECONDEDITION

Editedby

David J. Dabbs MD
Professor and Chief of Pathology
Department of Pathology
Magee-Women's Hospital
Pittsburgh, PA, USA

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ELSEVIER
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Contents Ie

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Contributors vii
Foreword ix
Preface to the Second Edition xi
Preface to the First Edition xii
Dedication xiii
How to Use this Book xv

I Techniques of Immunohistochemistry: Principles, Pitfalls and Standardization 1

I
CliveR. Taylor,Shan-~ongShi,NancyJ.Barr and Nancy Wu

2 Immunohistology of Infectious Diseases 43 I

EduardoJ.Eyzaguirre, David H. Walkerand SherifR. Zaki

3 Immunohistology of Soft Tissue and Osseous Neoplasms 65

Lisa A. Cerilli and Mark R. Wick

4 Immunohistology of Hodgkin Lymphoma 121

Parul Bhargava
andMarshallE. Kadin
5 Immunohistology of Non-Hodgkin Lymphoma 137
Christopher Gocke

6 Immunohistology of Melanocytic Neoplasms 162

Mark R.Wick

7 Immunohistology of Metastatic Carcinomas of Unknown Primary 180

DavidJ.Dabbs

8 Immunohistology of Head and Neck Neoplasms 227

JenniferL. Hunt andLeonBarnes
9 Immunohistology of Endocrine Tumors 261
RonaldA. DeLellisandSandraJ. Shin

10 Immunohistology of the Mediastinum 301

Mark R. Wick

I' Immunohistology of Lung and Pleural Neoplasms 329

Samuel P. Hammar

L
 12 Immunohistologyof SkinTumors 404
Mark R. Wick,Paul E. Swansonand Jamesw. Patterson

13 Immunohistology of the Gastrointestinal Tract, Pancreas, Bile Ducts, Gallbladder and Liver 442
Neal S. Goldstein and David S. Bosler

14 Immunohistologyof the Prostate,Bladder,Testisand Kidney 509

David G. Bostwick, Jun Ma, Junqi Qian, Deborah Josefson and Lina Liu
611
15 Immunohistology of Pediatric Neoplasms
Cheryl M. Coffin and Deborah Belchis
637
16 Immunohistology of the Female Genital Tract
Robert A. Saslow, Christina Isacson and Charles Zaloudek

17 Immunohistologyof the Breast 699

DavidJ.Dabbs

18 Immunohistologyof the Nervous System 746

Paul E. McKeever

Index 817

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Contributors

Leon Barnes MD I Lisa A Cerilli MD

Professor of Pathology and Otolaryngology Pathologist
University of Pittsburgh School of Medicine, I Health Partners Regional Laboratory
Professor and Chairman I. Richmond, VA, USA
Department of Medicine and Pathology
University of Pittsburgh School of Dental Medicine I Cheryl Coffin MD
Chief, Division of Head and Neck Pathology Professor of Pathology and Division Head of Pediatrics
University of Pittsburgh Medical Center Pathology Department
Pittsburgh, PA, USA Primary Children's Medical Center
Salt Lake City, UT, USA
Nancy J Barr MD
David J Dabbs MD
Assistant Professor of Clinical Pathology
Professor and Chief of Pathology
Department of Pathology
Keck School of Medicine Department of Pathology
Magee-Women's Hospital
University of Southern California Medical Center
Pittsburgh, PA, USA
Los Angeles, CA, USA
Ronald A DeLellis MD
Deborah Belchis MD Professor of Ppthology and Laboratory Medicine
Pathologist I
Pathologist in Chief
Pathology Department Department of Pathology
Northwest Hospital Center
Randallstown, MD, USA
I Rhode Island Hospital

Parul Bhargava MD I
Eduardo J Eyzaguirre
Prov;dence, RI, USA MD
Instructor in Pathology Assistant Professor
Harvard Medical School Department of Pathology
Beth Israel Deaconess Medical Center I
University of Texas Medical Branch
Boston, MA, USA Galveston, TX, USA
I

David S Bosler MD Christopher Gocke MD

Associate Professor
Pathologist I

Department of Pathology
Department of Anatomic Pathology
Johns Hopkins Medical Institutes
William Beaumont Hospital I
Baltimore, MD, USA
Royal Oak, MI, USA

David G Bostwick MD MBA I Neal S Goldstein MD

Staff Anatomic Pathologist
Yledical Director
Bostwick Laboratories I Department of Anatomic Pathology
I William Beaumont Hospital
Richmond, VA, USA I Royal Oak, MI, USA

vii
Samuel P Hammar MD Sandra J Shin MD
Pathologist and Director Assistant Professor of Pathology and Laboratory Medicine
Diagnostic Specialties Laboratory Department of Pathology and Laboratory Medicine
Bremerton, WA, USA Weill Medical College of Cornell University
New York, NY, USA
Jennifer L Hunt MD
Assistant Professor of Pathology and Otolaryngology Robert A Soslow MD
Department of Pathology Associate Attending Pathologist
UPMC Presbyterian Hospital Department of Pathology
Pittsburgh, PA, USA Memorial Sloane Kettering Cancer Center
Christina Isacson MD New York, NY, USA
Pathologist, Virginia Mason Medical Center Paul E Swanson MD
Department of Pathology
Seattle, WA, USA Professor and Director of Anatomic Pathology
University of Washington Medical Center
Deborah Josefson MD Seattle, WA, USA
Associate Medical Director
Bostwick Laboratories, Clive R Taylor MD PhD
Glen Allen, VA, USA' Professor and Chairman of Pathology
Senior Associate Dean for Educational Affairs
Marshall E Kadin MD Keck School of Medicine
Associate Professor of Pathology University of Southern California
Harvard Medical School
Los Angeles, CA, USA
Boston, MA, USA
David Walker MD
Lina Liu MD
Professor and Chairman
Staff Pathologist
Bostwick Laboratories Department of Pathology
University of Texas Medical Branch
Glen Allen, VA, USA
Galveston, TX, USA
Jun Ma MD
Mark R Wick MD
Staff Pathologist
Bostwick Laboratories Professor & Associate Director of Surgical Pathology
Glen Allen, VA, USA Director of Diagnostic Immunohistochemistry
Division of Surgical Pathology
Paul E McKeever MD University of Virginia Medical Center
Professor of Pathology Charlottesville, VA, USA
Chief Section of Neuropathology
Department of Pathology Nancy Wu MD
University of Michigan Medical Center Assistant Professor of Clinical Pathology
Ann Arbor, MI, USA Department of Pathology
Kenneth Norris Jr Hospital
James W Patterson MD
Los Angeles, CA, USA
Professor and Director of Dermatopathology
University of Virginia Medical Center Sherif R Zaki MD
Charlottesville, VA, USA
Chief, Infectious Disease Pathology Activity
National Center for Infectious Diseases
Junqi Qian MD
Centers for Disease Control and Prevention
Director of Molecular Diagnostics
Bostwick Laboratories Atlanta, GA, USA
Glen Allen, VA, USA
Charles F Zaloudek MD
Shan-Rong Shi MD Professor of Pathology
Associate Professor of Clinical Pathology Department of Pathology
Department of Pathology University of California, San Francisco
Keck School of Medicine San Francisco, CA, USA
University of Southern California
Los Angeles, CA, USA

Vl11

Foreword
Many are the 'special' techniques that pathologists have
used over the years to confirm, complement and refine the
information they were able to obtain with their 'old faithful'
armamentarium, that is, formalin fixation, paraffin embed-
ding and hematoxylin-eosin staining. These techniques
have come and gone, their usual life cycle beginning with
an initial period of unrestrained enthusiasm, turning to a
phase of disappointment and finally leading to a more sober
and realistic assessment. Mimy of these methods have left a
permanent mark on the practice of the profession, even if
often it was not as deep or wide-ranging as initially hoped.
These techniques include special stains, tissue culture, elec-
tron microscopy, immunohistochemistry and molecular
biology methods. Much was expected of the first three, and
infinitely more is anticipated of the last, but it is fair to say
that as of today no special technique has influenced the way
that pathology is practiced as profoundly as immunohisto-
chemistry, or has come even close to it. I don't think it would
be an exaggeration to speak of a revolution, particularly in
the field of tumor pathology. Those of us who have lived
through it certainly feel that way. The newer generations of
pathologists who order so glibly an HMB-45 or a CD31 stain
. to identify melanocytes and endothelial cells, respectively,
I
have very little feeling of the efforts one had to make to
,/ achieve that identification in the past. The virtues of. the
technique are so apparent and numerous as to make It as
I close to ideal as any biologic method carried out in human
tissue obtained under routine (which means under less than
~
ideal) conditions can be: it is compatible with standard fix-
ation and embedding procedures; it can be performed retro-
I spectively in material that has been archived for years; it is
remarkably sensitive and specific; it can be applied to virtu-
ally any immunogenic molecule; and it can be evaluated
against the morphologic backgrounds with which patho-
logists have long been familiar.
As with many other breakthroughs in medicine,
immunohistochemistry started with a brilliant yet disarm-
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116
§
~II
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ingly simple idea: to have antibodies bind the specific anti- ,
I gem; being sought and to make those antibodies visible by
I hooking them to a fluorescent compound. All subsequent
modifications, such as the use of non-fluorescent chro-
I
mogens, the amplification of the reaction and the un- ~~
masking of antigens, merely represented technical
improvements, although certainly not ones to be mini-
mized. It is because of these technical advances that the pro-
cedure spread beyond the research laboratories and is now tlr
I applied so pervasively in pathology laboratories throughout
the world. Alas, it has its drawbacks. Antigens ()nce believed
I to be specific for a given cell type have later been found to be
I expressed by other tissues; cross-reactions may occur ~~i
between unrelated antigens; nonspecific absorption of the
antibody may supervene; entrapped non-neoplastic cells
reacting for a particular marker may be misinterpreted as
I- part of the tumor and, most treacherously, antigen may .
I diffuse out of a normal cell and find its way inside an adja-
cent tumor cell. Any of these pitfalls may lead to a misinter-
pretation of the reaction and a misdiagnosis; worse, it may
lead to a final mistaken diagnosis after an Initially correct
interpretation of the hematoxylin-stained slides. A good
t
protection against this danger is a thorough knowledge of
these pitfalls and how to avoid them. An even more impor-
tant safeguard i~ a solid background in ba~ic anato~ic
I
pathology that wIll allow the observer to question the vahd-
ity of any unexpected immunohistochemical result,
whether positive or negative. There is nothing more dan-
gerous (or expensive) than a neophyte in pathology making Ii
diagnoses on the basis of immunohistochemical 'profiles' in
disregard of the cytoarchitectural features of the lesions.
Alas, this is true of any other 'special' technique applied for I::
,'I~
diagnostic purposes to human tissue, molecular biology
I
being the latest and most blatant example. However, when
applied selectively and judiciously, immunohistochemistry lI .
is a notably powerful tool, in addition to being refreshingly ,
I cost-effective. As a matter of fact, pathologists can no longer
iii
IX
 FOREWORD
afford to do without it, one of the reasons being that failure
to make a diagnosis because of the omission of a key
immunohistochemical reaction may be regarded as
grounds for a malpractice action.
Any listing of the virtues of immunohistochemistry
would be incomplete if it did not include the visual pleasure
derived from the examination of this material. I am only half
kidding when making this remark. There is undoubtedly an
aesthetic component to the practice of histology, as masters
of the technique such as Pio del Rio Hortega and Pierre
Masson used to say. It is sad that these superb artists of mor-
phology left the scene without having had the opportunity
to marvel at the beauty of a well-done immunohistochemi-
cal preparation. As their more fortunate heirs, let's enjoy
this excellent book, edited by one of the foremost experts in
the application of the immunohistochemical technique and
written by a superb group of contributors - a book that
summarizes in a lucid and through fashion the current
knowledge in the field, in terms of both the technical aspects
and the practical applications.
x
The first edition of this book, published in 2002, rapidly
became one of the standard works in the field. This second
edition features a more standardized format, a wider cover-
age of organ systems and an extensive update of markers.
It has incorporated a large number of useful tables listing
the various antibody groups, an algorithmic approach to
the differential diagnosis and the Key Diagnostic Points of
all the major subjects. Special attention has been paid to the
detailed description of the so-called predictive-type markers
(such as Her-2neu in breast carcinoma and CD1l7 in
GIST), which are playing an increasingly important role in
the evaluation of tumors by the pathologist. In summary,
the authors have brilliantly succeeded in producing an
authoritative, comprehensive and updated book which
pathologists will find next to indispensable as a theoretical
backbone for the method and as a practical aide for their
daily diagnostic work.
Juan Rosai, MD
Milan, Italy

Preface to the second edition.
The challenge of recreating Diagnostic Immunohistochem-
istry is to continue to assemble the vast body of knowledge
of Immunohistochemistry into a work that has meaning for
the diagnostic pathologist. Diagnostic pathologists from all
parts of the globe have been very receptive to the format of
this book. Universal comments from pathologists indicate
that they find this book to be of practical use to solve their
daily diagnostic problems.
Indeed, pathologists all over the globe can thank them-
selves for assembling the data that is present in the pages of
this book.
Once again, the challenge of this work has been to make
sure that the base of knowledge in each chapter be relevant
and robust long after the ink has dried. The contributions of
expert authors in each of their respective disciplines has
helped to make this possible. Each chapter includes a base
of time-tested knowledge and more recent experience by an
expert author.
The continuing goal of this book is to provide a reference
for anatomic and surgical pathologists who practice diag-
nostic surgical pathology and cytopathology.
With few exceptions, each chapter is designed to be a
stand-alone work. Inherent with this design is a body of
~l .
-
information that is reproduced and redundant throughout
each chapter. This should aid the investigators and trainees
without having to do extensive cross checking of other
- chapters throughout the book. Each chapter is comprehen-
sive in the diagnostic sense. The book is structured in the
organ system approach to tumor pathology. Each chapter
has a chapter outline, an introduction and a systematic
approach to the diagnostic entities of that organ system.
Each section is punctuated by key diagnostic points that
summarize that section and serve as a rapid summary ref-
erence for the most important informational points in that
section.
My special thanks goes to all of those Eathologists across
the globe who have telephoned, written or emailed me with
their suggestions about this work.
My special thanks also goes to the dedicated investiga-
tors who have contributed their time and talents in order to
serve their colleagues in diagnostic pathology.
David J. Dabbs MD
Professor and Chief of Pathology
Magee-Women's Hospital of UPMC
Pittsburgh, PA
xi
 Preface to fi rst edition
The challenge of creating Diagnostic Immunohistochemistry
has been to bring some semblance of order to the vast body
of knowledge of immunohistochemistry that has been pub-
lished over the past decade. Diagnostic pathology will never
be the same because of the profound contributions that
immunohistochemistry has made to patient care. In reality,
all of us in pathology are contributors to this continually
growing body of- knowledge, and herein lies the second-
challenge for this publication.
We realized that one of the potential pitfalls in creating
Diagnostic Immunohistochemistry was to make sure that the
base of knowledge in each chapter be relevant long after the
ink has dried. The contributions of expert authors in each
of their respective disciplines has helped to make this possi-
ble. Each chapter includes a base of time-tested knowledge
and recent experience by an expert aUthor.
Xll
The goal of this book is to provide a reference for pathol-
ogists who practice diagnostic surgical pathology and
cytopathology. Each chapter is meant to be comprehensive
in the diagnostic sense; this book was not meant to be ency-
clopedic of immunohistochemistry in general. The book is
structured in the organ system approach to tumor pathol-
ogy, and each chapter is capable of standing alone for the
sake of reference convenience so that the user does not have
to scour multiple places in the book to obtain useful diag-
nostic information. Inherent in this approach is redundancy
of content, which not only is efficient for the user but also
helps inculcate concepts that are useful, especially for the
beginner.
David J. Dabbs, MD
 l
Dedication

Dedicated to our colleagues who use this work for the good of their patients.

Special Dedication:

Annette and Kirstie, my co-authors.

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xiii
 ~ ~

How to use this. Book

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The first chapter details the techniques and development of
Immunohistochemistry. The second chapter is a com-
pendium of immunohistochemistry applied to the study of
infectious disease in the anatomic pathology setting.
The remaining chapters represent an organ system:
approach to diagnostic immunohistochemistry related pri-
marily to tumor pathology.
Each chapter is organized to provide a chapter outline, an
introduction, the biology of the antigens and antibodies,
and a literature review of the subject matter. Each chapter
is peppered with "immunohistograms" depicting immunos-
taining patterns of tumors, along with numerous tables well
structured for easy reference. Diagnostic algorithms are
used where relevant. Many areas of the text are punctuated
by summary "key diagnostic points". Diagnostic pitfalls are
also cited where particularly relevant. .
To maintain a constant terminology through out the chap-
ters, the following abbreviations in the text and tables are
used:
+, the result is almost always strong, diffusely positive;
S, sometimes positive;
R, rarely positive, and if so, rare cells are positive;
N or a (-), negative
It's my hope that this text will remain a focal point for con-
tinuous quality improvement of the knowledge base for sur-
gical pathologists everywhere.
David J. Dabbs MD

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xv