Hannes Vogel Neuropath Lecture

Practical approach to the use of immunohistochemical markers used in neuropathology

Hannes Vogel, M.D.Director of Neuropathology

Stanford University

Educational goals

Understand the role of IHC in neuropathology in: Making the correct diagnosis Providing clinically useful information

Whats new in neuropathology IHC

Tumors

Neuroepithelial tumors Astrocytomas Oligodendrogliomas and mixed gliomas Ependymomas Choroid plexus tumors Glioneuronal tumors Neuroblastic tumors Pineal parenchymal tumors Embryonal tumors

More tumors

Meningiomas Peripheral nerve tumors Lymphomas Germ cell tumors Sellar tumors Metastatic tumors

The basics

Glial differentiation GFAP (glial fibrillary acidic protein)

Astrocytes Gliofibrillary oligodendrocytes Ependymocytes

S-100 Gliomas Chordomas Melanocytic tumors Schwannomas

The basics

Neuronal differentiation Neurofilament

Cytoplasmic and cell processes Synaptophysin

Cytoplasmic and cell surface Neu-N

Nuclear

The basics EMA

Meningiomas Ependymomas

CD 20, CD3, CD138, etc. Lymphomas, plasmacytomas Microglia and macrophages; CD68 or CD163

CD31 and CD34 SFT (solitary fibrous tumor) Hemangiopericytoma

Cytokeratins CK 20, CK7, TTF-1, etc. Metastatic carcinomas

The basics OCT4, CD30, alpha fetoprotein, beta HCG

Germ cell tumors Inhibin-A

Capillary hemangioblastoma MIB-1

Proliferative index

SV40 PML (progressive multifocal leukoencephalopathy)

Herpes Toxoplasmosis

The basics GFAP S-100 Neurofilament Synaptophysin EMA CD 20, CD3, CD138, CD68

or CD163, etc. CD31 and CD34 Cytokeratins CK 20, CK7,

TTF-1, etc.

OCT4, CD30, alpha -fetoprotein, beta HCG

Inhibin-A MIB-1

SV40 Herpes Toxoplasmosis

Astrocytomas and glioblastoma

GFAP of limited usefulness (Vogel, unpublished) Highlights perivascular processes in ependymoma ?Exclude other diagnoses i.e. metastasis ?Coarse glial processes in neoplastic astrocytes vs.

delicate in reactive Gliosarcomas are GFAP negative in sarcomatous

regions

Gliosarcoma

Gliosarcoma GFAP

Gliosarcoma - reticulin

Differential dx: CNS clear cell tumors

Oligodendroglioma Neurocytoma Clear cell ependymoma Clear cell meningioma DNT (dysembryoplastic neuroepithelial tumor) Metastasis i.e. clear cell RCC, neuroendocrine

tumors

Oligodendroglioma GFAP, S-100 positive 1p 19q co-deletion by FISH

Neurocytoma Synaptophysin positive, most GFAP negative

Clear cell ependymoma GFAP positive, focally EMA positive

Clear cell meningioma GFAP negative, EMA positive

Differential dx of a clear cell tumor

Oligodendroglioma 1p19q co-deleted

Oligodendroglioma 1p19q co-deleted - GFAP

Central neurocytoma

Central neurocytoma - synaptophysin

Central neurocytoma

clear cell meningioma h&e

Clear cell meningioma WHO Grade II

Clear cell meningioma - EMA

DNT (dysembryoplastic neuroepithelial tumor) Rely on histology

Choroid plexus carcinoma May need EM

Metastasis i.e. neuroendocrine tumors, clear cell RCC

Cytokeratins Chromogranin, other neuroendocrine markers


Dysembryoplastic neuroepithelial tumor (DNET) WHO Grade I

DNT (dysembryoplastic neuroepithelial tumor) Rely on histology

Choroid plexus carcinoma May need EM

Metastasis i.e. neuroendocrine tumors, clear cell RCC

Cytokeratins Chromogranin, other neuroendocrine markers


Beware of the greatest imitator of a CNS clear cell tumor!

Pilocytic astrocytoma


Pilocytic astrocytoma mistaken as oligodendroglioma

Tumors


Oligoastrocytoma

Dx rests largely upon nuclear morphology Oligodendrocytes: round, minigemistocytes Astrocytes: angular, hyperchromatic

GFAP brings out the neoplastic astrocytic component

Mixed oligoastrocytoma WHO Grade II

Mixed oligoastrocytoma WHO Grade IIGFAP

Tumors


Ependymoma

Clear cell and tanycytic variants are not obvious ependymomas

Some ependymomas are cortical

GFAP positive EMA: dot-like cytoplasmic positivity

Ependymoma WHO Grade II

Ependymoma WHO Grade IIGFAP

Ependymoma WHO Grade IIEMA

Tumors


Choroid plexus tumors

Transthyretin and S-100 positive, but less frequent in choroid plexus carcinomas

GFAP positive in 25-55% of papillomas, 20% of carcinomas

Synaptophysin positive Beware of other papillary tumors

Meningioma Ependymoma Metastases

Choroid plexus carcinoma WHO Grade III

Transthyretin

Synaptophysin

Tumors


Glioneuronal tumors Gangliogliomas

Histology: dysplastic ganglion cells, EGBs (eosinophilic granular bodies), lymphocytic cuffing

DIG (desmoplastic infantile ganglioglioma) Need to confirm glial (GFAP) and neuronal differentiation

(NF, synaptophysin) DNT

Oligodendroglioma-like cells: neu-N positive Papillary or rosetted glioneuronal tumors

Neuropil islands positive for neuronal markers

Synaptophysin GFAP

Neuroblastic tumors

Esthesioneuroblastoma, neuroblastoma

Exclude: Lymphoma - CDs SNUC (sinonasal undifferentiated carcinoma) Metastatic small cell carcinoma - cytokeratins Pituitary adenoma anterior pituitary markers Ewings and rhabdomyosarcoma

esthesioneuroblastoma h&e

Esthesioneuroblastoma

Esthesioneuroblastoma -Synaptophysin

Esthesioneuroblastoma -S-100

Embryonal tumors

Medulloblastoma IHC not diagnostic IHC approaching utility in prognosis

Supratentorial PNET Synaptophysin and GFAP positive

AT/RT INI immunonegative

Atypical teratoid rhabdoid tumor (ATRT) WHO Grade IVBAF47/SNF5 Mab

Large cell medulloblastoma WHO Grade IV

Large cell medulloblastoma WHO Grade IVBAF47/SNF5 Mab

Meningiomas

EMA generally positive, but may be weak in: Fibroblastic meningiomas Atypical meningiomas Malignant meningiomas

CEA positive in secretory meningiomas Beware of mimics:

SFT/hemangiopericytoma: CD31 and CD34 Schwannoma: nuclear S-100 positivity

Vascular tumors

Differential dx Metastatic clear cell renal cell ca (CRCC): 70-90% are

EMA and low-molecular-weight cytokeratin (CAM 5.2) positive

Paraganglioma: chromogranin positive Angiomatous meningioma: EMA and vimentin positive SFT/hemangiopericytoma: CD31/34 positive Capillary hemangioma

Capillary hemangioblastoma Inhibin A positive

Capillary hemangioblastoma WHO Grade I

Capillary hemangioblastoma WHO Grade I Inhibin

More tumors

Meningiomas Peripheral nerve tumors Lymphomas

B cell: CD20+ T-cell: CD3+; may appear reactive! EBV+ in immunocompromised MIB-1: prognostic?

Germ cell tumors Sellar tumors Metastatic tumors

cd3

1 2 3

4 5 6

Cd20

1 2 3

4 5 6

More tumors

Germ cell tumors Germinoma: 100% OCT4+ vs. 92% PLAP+ Embryonal ca: CD30, PLAP, OCT4 Choriocarcinoma: HCG, +/- PLAP, cytokeratins Yolk sac tumor: AFP, +/- PLAP, cytokeratins Teratoma: AFP, cytokeratins

get pics from eyas

More tumors

Meningiomas Peripheral nerve tumors Lymphomas Germ cell tumors Sellar tumors

Adenomas cytokeratin and synaptophysin + Routine panel: prolactin, ACTH, GH, LH, FSH Beware of metastatic mimics of adenomas!

Metastatic tumors

More tumors

Meningiomas Peripheral nerve tumors Lymphomas Germ cell tumors Sellar tumors Metastatic tumors

Educational goals

Understand the role of IHC in neuropathology to: Make the right diagnosis Provide clinically useful information

Whats new in neuropathology IHC

Front Biosci. 2000 5:213-231

Survival by grade

Grading gliomas

WHO Grade I a unique category Pilocytic astrocytoma, ganglioglioma, DNT, choroid plexus

papilloma, subependymoma, etc.

WHO Grade II nuclear atypia WHO Grade III add significant mitotic activity WHO Grade IV add vascular proliferation and/or

necrosis

WHO and astrocytoma grading

The presence of a single mitosis in a resection specimen does not necessarily connote a worse behavior than that of grade II astrocytoma (might not be true for needle biopsies)

High proliferation indices indicate more anaplastic, higher grade tumors, but both interobserver and interinstitutionalvariability precluded the MIB-1 index as a sole criterion used to distinguish grade II from grade III astrocytomas.

Proliferative index in gliomas Grade 2: < 3mitoses or < 9% MIB-1+ cells/10 HPFs Grade 3: > 3mitoses or > 9% MIB-1+ cells/10 HPFs MIB-1 brings out infiltrating neoplastic astrocytes (Vogel,

unpublished) Many MIB-1+ cells in pilocytic astrocytomas are endothelial Reactive gliosis generally less proliferative

p53 not generally helpful in distinguishing reactive gliosis from neoplasia

Grading meningiomas Most are Grade 1 Atypical (Grade 2)

Clear cell, chordoid 4-20 mitoses/10 hpf Other combined criteria (Perry et al, Cancer, 1999)

Malignant (Grade 3) Rhabdoid, papillary >20 mitoses/10 hpf Carcinomatous or sarcomatous differentiation

Proliferation in meningiomas % of MIB-1 positive cells has been reported to correlate well

with histologic grade and recurrence Mean MIB-1 LI of benign, atypical, and anaplastic

meningiomas was 1.5%, 8.1%, and 19.5%, respectively (Amatya, 2001)

MIB-1 LI of 4.2% or more was strongly associated with decreased recurrence-free survival rate in gross, totally resected meningiomas (Perry, 1998)

Use random fields, not highest staining areas

POP QUIZ!

Selected case(s) testing the use of a practical approach in the choice of immunohistochemical markers used in neuropathology.

Dx: Clear cell ependymoma

GFAPGFAP

EMAEMA

S-100Vimentin

Dx: Myxoid (metaplastic) meningioma

Practical approach to the use of immunohistochemical markers used in neuropathology Educational goalsTumorsMore tumorsThe basicsThe basicsThe basicsThe basicsThe basicsAstrocytomas and glioblastomaDifferential dx: CNS clear cell tumorsDifferential dx of a clear cell tumorDifferential dx of a clear cell tumorDifferential dx of a clear cell tumorDifferential dx of a clear cell tumorclear cell meningioma h&eDifferential dx of a clear cell tumorDifferential dx of a clear cell tumorDifferential dx of a clear cell tumorTumorsOligoastrocytomaTumorsEpendymomaTumorsChoroid plexus tumorsTumorsGlioneuronal tumorsNeuroblastic tumorsesthesioneuroblastoma h&eEmbryonal tumorsMeningiomasVascular tumorsMore tumorscd3Cd20More tumorsget pics from eyasMore tumorsMore tumorsEducational goalsSurvival by gradeGrading gliomasWHO and astrocytoma gradingProliferative index in gliomasGrading meningiomasProliferation in meningiomasPOP QUIZ!

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Hannes Vogel Neuropath Lecture