Role of minimal panel immunostaining in accurate diagnosis of lung cancer using small biopsies

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Role of minimal panel immunostaining in accurate diagnosis of lung

cancer using small biopsies

Manar Ahmed Abdel Rahman

a,⇑

, Nadia Abdel Moneim Nada

a

, Khaled Refaat Zalata

a

,

Mohammad Khairy El Badrawy

b

, Iman Mohammed El Salkh

a

, Amr Abdel Hamid

b

a

Department of Pathology, Faculty of Medicine, Mansoura University, Egypt

bDepartment of Thoracic Medicine, Faculty of Medicine, Mansoura University, Egypt

a r t i c l e i n f o

Article history: Received 21 October 2016 Accepted 25 October 2016 Available online xxxx Keywords: Lung cancer Immunohistochemistry Napsin A CK 5/6 CD 56

a b s t r a c t

Introduction: In small biopsies standard morphology cannot specifically subtype the tumor. Histologic subtyping of lung cancer is mandatory for treatment. Immunohistochemical staining is a valuable tool for diagnosis of lung cancer.

Aim: The aim of this study was to evaluate the diagnostic accuracy of minimal panel of Napsin A, CK 5/6 and CD 56 versus H&E of lung cancer in small biopsies.

Methods: 84 small sized tissue samples were obtained. Seventy samples were obtained via fiberoptic bronchoscope (FOB) and 14 samples were obtained with transothoracic CT guided trucut needle. All sam-ples were stained with H&E for morphologic diagnosis, then the same samsam-ples were stained with immunohistochemical (IHC) staining including 3 antibodies (Napsin A, CK 5/6 and CD 56), then we com-pared the diagnostic yield of both methods.

Results: After H&E staining, according to WHO 2004 classification: 40 cases were adenocarcinoma (AC), 10 were squamous cell carcinoma (SCC), 22 were large cell carcinoma (LCC) and 12 were neuroendocrine tumors (NET). After IHC; 54 (64.3%) were AC, 11 (13.1%) were SCC, 11 (13.1%) were NET and 8 (9.5%) were non small cell lung cancer not otherwise specified NSCLC NOS (Counterpart of large cell carcinoma in 2004 WHO classification). Napsin A was expressed in 98% (53/54) and CK 5/6 in 90.9% (10/11) of SCC. CD 56 in 100% (11/11) of neuroendocrine tumors.

Conclusion: IHC with Napsin A, CK 5/6 and CD 56 has a more diagnostic value in precise typing of differ-ent cell types of lung cancer than H&E in small biopsies.

Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

Lung cancer is one of the major causes of cancer deaths world-wide. Lung cancer is the main cause of cancer death cases in men as well as in women, lung cancer is the second leading cause of death cases from cancer globally, following breast cancer[1].

In Egypt, according to The National Cancer Institute lung cancer is the first cause of cancer related death cases in both gender[2]. Seventy percent of lung cancers are presented in advanced stages and can’t be resected, small biopsy specimens remain the main method of diagnosis for the majority of lung cancer patients

[3].

Based on microscopic picture, main types are: Non-small cell lung cancer (NSCLC), representing 85% of the patients. (NSCLC) include types of squamous cell carcinoma, adenocarcinoma, and large cell carcinoma[4]and small cell lung cancer (SCLC), account-ing for about (15%) of the patients. Neuroendocrine tumors are also included among main types of lung cancer.

Recently, classification of lung cancer especially the Non-small variant found to be very important in the field of targeted therapy, so accurate subtyping is important especially in small biopsy[3,5]. IASLC provided recommendation for the use of immune stains as an aid to diagnosis, especially in tumors that do not show estab-lished morphologic criteria by H&E stain[6]. Established morpho-logical criteria are as follow: glandular differentiation or mucin for adenocarcinoma, where the criteria for squamous cell carcinoma are intercellular bridges and or keratinization. When all previous established morphologic criteria absent, we do immunohistochem-istry (seeTable 1).

http://dx.doi.org/10.1016/j.ejcdt.2016.10.011

0422-7638/Ó 2016 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.

⇑ Corresponding author.

E-mail address:dr.mabdelrahman@yahoo.com(M.A.A. Rahman).

Contents lists available atScienceDirect

Egyptian Journal of Chest Diseases and Tuberculosis

j o u r n a l h o m e p a g e : w w w . s c i e n c e d i r e c t . c o m

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Napsin A is a lung-specific marker[7]as it is more sensitive and specific than TTF-1 in diagnosis of lung adenocarcinoma[8]. The diagnosis of SCC typically does not require the use of IHC tech-niques. CK 5/6 is useful in diagnosis of SCC especially in the poorly differentiated cell type[9,10].

CD56 is one of the most helpful neuroendocrine immunohisto-chemical markers[11,12]. It’s the most sensitive marker for SCLC

[13].

The key immunohistochemical stains useful for SCLC diagnosis including keratin, chromogranin, CD56, Ki-67, TTF-1[14]. Aim of the study

The aim of the study was to evaluate the diagnostic accuracy of minimal panel of Napsin A, CK 5/6 and CD 56 versus H&E of lung cancer in small biopsies.

Materials and methods

Prospective case series study included 84 patients with lung cancer; 70 cases were central tumors diagnosed with biopsies obtained via FOB (pentax FB-18V or FB 19 TV) and 14 cases with peripheral tumors diagnosed with transthoracic CT or ultrasound guided biopsies.

All biopsies were formalin fixed paraffin embedded, processed and from which 4-

l

m-thick sections were obtained and stained by H&E then examined at pathology department, Faculty of medi-cine, Mansoura university by 2 pathologists.

Immunostaining

For IHC staining, we routinely deparaffinized 4-m-thick sections from paraffin block. The sections were incubated with 3% hydrogen peroxide for 15 min to block endogenous peroxidase activity. We used EDTA and citrate buffer. The sections were incubated over-night at 37°C, and stained with a HRP (horseradish peroxidase) method. The following antibodies were applied (Napsin-A–C K5/6–CD56). We used 3-30-diaminobenzidine, harris hematoxylin as the chromogen and counter stain, respectively.

Positive immunostaining for CD56 required 10% or more cells with an intensity of at least 2+ on the relevant subcellular localiza-tion [membranous for CD56/Neural Cell Adhesion Molecule (NCAM)].

CK5/6 was considered positive for when it was cytoplasmic. For Napsin A, stain was considered positive when it revealed cytoplas-mic granularity.

Statistics

Data were analyzed with SPSS version 16. The normality of data was first tested with one-sample Kolmogorov-Smirnov test.

Qualitative data were described using number and percent. Association between categorical variables was tested using

Chi-square test. When 25% of the cells have expected count less than 5, Fisher exact test was used.

Continuous variables were presented as mean ± SD (standard deviation). Analysis Of Variance (ANOVA test) used for comparison of means of more than two groups.

Level significance

For all above mentioned statistical tests done, the threshold of significance is fixed at 5% level (p-value).

The results were considered highly significant when the proba-bility of error is less than 0.1% (p < 0.001).

Results

According to established morphologic criteria, adenocarcinoma represented 47.6% of the cases (Table 2). However, after application of immunostain adenocarcinoma was the most prevalent variant among the histologic subtypes of lung cancer representing 64.3% of the total cases (Table 3). It was found that adenocarcinoma rep-resented 47.6% of the cases. The term NSCLC (NOS) was present only in the IASLC 2011 classification and it is the counterpart to large cell carcinoma to WHO 2004 classification.

After the application of immunostain, NSCLC (NOS) cases decreased from 33.3–9.5% (Table 3).

Twenty eight cases initially diagnosed as NSCLC (NOS) where established morphologic criteria of squamous cell carcinoma and adenocarcinoma were absent. With application of three immunes-tain (Napsin A, CK 5/6 and CD 56) the result were as follow: The immuneprofile of nineteen cases was Napsin A +ve, CK 5/6ve, CD 56ve. So, diagnosis changed to NSCLC favour adenocarci-noma. One Case was Napsin Ave, CK 5/6 +ve, CD 56 ve. So, diag-nosis changed to NSCLC favour squamous cell carcinoma (Photo 2). Eight cases were Napsin Ave, CK 5/6 ve, CD 56 ve. So, the diagnosis remained NSCLC (NOS).

Thirteen cases were initially diagnosed as solid predominant adenocarcinoma and stained with Napsin A and CK 5/6. The results were as follow: Twelve cases were Napsin A +ve, CK 5/6ve and one case was Napsin Ave, CK 5/6 ve with positive internal

con-Table 1

Detailed antigen retrieval methods and antibody dilution for each primary antibody.

Antigen Type Manufacturer Catalog Dilution Procedure Antibody incubation

Antigen Retrieval

Napsin A

Rabbit Polyclonal Cell MARQUE 352A-78 Ready to use 7 ml prediluted

Manual Over night Heat induced epitope retrieval (HIER)

CK5/6 Mouse monoclonal

DAKO Clone D5/ 16B4

Ready to use 6 ml Manual Over night Heat induced epitope retrieval (HIER)

CD56 Mouse monoclonal

DAKO Clone 123C3 Ready to use 6 ml Manual Over night Heat induced epitope retrieval (HIER)

Table 2

Histologic subtype of lung cancer among the studied cases according to WHO 2004 classification of lung cancer (morphological diagnosis by H&E) (n = 84).

Types n %

ADC 40 47.6

Acinar pattern 9 Solid pattern with mucin production 8 Papillary pattern 1 Non mucinous bronchioalveolar 2 Mucinous type bronchioalveolar 1 Mixed pattern 19

SCC 10 11.9

LCC 22 26.2

Neuroendocrine tumors Small Cell Carcinoma 10 14.3 Atypical carcinoid 2

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trol. CK 5/6 was added in the previous thirteen cases to exclude squamous cell carcinoma and the diagnosis was confirmed to be adenocarcinoma.

Five cases were diagnosed morphologically as papillary pre-dominant adenocarcinoma. We applied TTF-1 and Napsin A to the previous five cases. All these cases were Napsin A +ve, TTF1 +ve. TTF1 was added to exclude papillary variant of renal cell carcinoma.

One case was diagnosed as micro papillary predominant adeno-carcinoma and it was stained with Napsin A and TTF1 to exclude metastatic ovarian tumor as the case was female. This case was Napsin A +ve and TTF1 +ve.

Sixteen cases were diagnosed as well differentiated adenocarci-noma (fourteen acinar predominant variant, two lepidic predomi-nant variant). All of these cases stained with Napsin A and they were positive (Photo 1). Change in diagnosis of adenocarcinoma after immunohistochemistry is illustrated in (Table 4).

Five cases morphologically diagnosed as moderate squamous cell carcinoma. They all stained with Napsin A and CK 5/6. Napsin A was added to exclude squamoid variant of adenocarcinoma. Four cases were Napsin Ave, CK 5/6 +ve, confirming diagnosis of squa-mous cell carcinoma. One case was Napsin A +ve, CK 5/6ve so diagnosis changed to NSCLC favour adenocarcinoma.

Neuroendocrine tumors

Twelve cases are morphologically diagnosed as neuro-endocrine tumors nine cases were small cell carcinoma, two cases were atypical carcinoid and 1 case as suspected neuroendocrine tumor (there was no definite pattern can be identify).

To prove neuroendocrine features among nine cases of small cell carcinoma we used CD56 alone and it was positive in six cases (Photo 3). All previous six cases were having small hyperchromatic nuclei, scanty cytoplasm and extensive necrosis. For the remaining three cases the immuneprofile was as follow: For two cases, in addition to CD56 we added CK5/6 as there was sheeting of tumor

cells and little necrosis to exclude small cell variant of SCC and it was negative while CD56 was positive, so the diagnosis was con-firmed. For the Last case which was crushed, we added Napsin A, CK5/6 to exclude poorly differentiated adenocarcinoma and small cell variant of SCC and were negative while CD56 was positive con-firming small cell carcinoma.

In the two cases diagnosed morphologically as atypical carci-noid in these cases there were areas formed of crushed cells, one case was CD56 +ve/Napsin Ave where Napsin A was added to exclude poorly differentiated ADC. The other case was CD56 +ve/ CK5/6ve where CK5/6 was added to exclude small cell variant of SCC and it was negative, CK7 was done and it was positive, we couldn’t determine the mitotic count in the two small biopsy spec-imens, so Ki-67 score was low in cases of TC and AC while it was very high in Large Cell Neuroendocrine Carcinoma LCNEC and SCLC cases. In the previous two cases, the mitotic index was very high (>80%) so the diagnosis changed to Non small cell lung cancer with neuroendocrine morphology NSCLC NEM possible LCNEC (Photo 4). Immunohistochemical panel for diagnosis of neuroendocrine tumors (According to IASLC 2011) is illustrated in (Table 5).

Napsin A is mandatory for diagnosis of adenocarcinoma. CK5/6 is mandatory for diagnosis of squamous cell carcinoma. CD56 is mandatory for diagnosis of neuroendocrine tumors (Table 4). Discussion

Lung cancer is one of the most common cancer. Seventy percent of patients are presented in advanced stage, so small biopsy remain the main method of diagnosis[3].

Immunohistochemistry has a major role in accurate diagnosis and precise typing of different pulmonary tumors.

The use of the three antibodies is done in this work aiming to minimize the term NSCLC – NOS on small samples providing as specific a histologic classification as possible to facilitate treatment approach of medical oncologist (Mok et al., 2009 & Boyle and Levin, 2008)[17,18].

In this study adenocarcinoma was the commonest subtype in young male and this was in coordination with Zander and Farver, 2008[15].

In this study histologic subtypes of lung cancer among the stud-ied cases according to WHO 2004 classification of lung cancer were as follow: adenocarcinoma represent 47.6% (83.3% female, 37.9% male), NSCLC was 26.2%, while Squamous cell carcinoma was 11.9% (13.6% male, 5.5% female), Neuroendocrine tumors represent 14.3% (Small cell carcinoma 11.9% and 2.3% atypical carcinoma) and this is different from that reported by Travis et al., 2004[16]. As regarding subtypes of lung cancer after application of recom-mendation of IASLC 2011 classification of lung cancer and by use of immunohistochemistry results were as follows: ADC: 64.3%, NSCL

Table 3

Histologic subtypes of tumors after immunostaining with Napsin A, CK5/6, CD56 (n = 84) (According to IASLC 2011).

Tumor Cell Types n (%) ADC 54(64.3) SCC 11 (13.1) NSCL (NOS) 8 (9.5) Neuroendocrine tumors 11 (13.1) Bold value represented that number of adenocarcinoma cases was the biggest number.

A

B

Photo 1. Acinar predominant adenocarcinoma: A) H&E shows tumor cells consists of round to oval-shaped malignant glands separated by desmoplastic reaction x200. B) Strong intensity staining of tumor cells for napsin A, ImmunoPeroxidase-DAB x400.

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A

B

Photo 2. A case of NSCLC(NOS) proved to be squamous cell carcinoma. A) H&E shows malignant cells with abundant cytoplasm, vesicular nuclei and marked atypia x200. B) Positive cytoplasmic staining of tumor cells for ck5/6 ImmunoPeroxidase-DAB x400. C,D) Negative staining of tumor cells for both napsin A and CD56 respectively ImmunoPeroxidase-DAB x200.

Table 4

Change in diagnosis of adenocarcinoma after immunohistochemistry.

All cases n = 54 Solid Acinar Papillary Lepidic Micro papillary

1 stain Napsin A +ve 14 2

Napsin Ave

2 stains Napsin A +ve – CK5/6ve 12 Napsin Ave – CK5/6 –ve

Napsin A +ve – TTF1 +ve

1 5 1

3 stains Napsin A +ve – CK5/6ve – CD56 ve 19

A

B

Photo 3. A case of small cell carcinoma. A) H&E showing malignant round to fusiform cells growing in sheets and nests. The nuclei appears ovoid with moulding and hyperchromasia x400. B) Positive cytoplasmic staining of tumor cells for CD56 tumor cells (score 3) Immunoperoxidase-DAB x400.

A

B

Photo 4. A case Non small cell lung carcinoma with neuroendocrine morphology possible large cell neuroendocrine carcinoma (NSCLC with NEM possible NCLEC). A) H&E solid pattern of tumor growth morphologically similar toPhoto 1x400. However by doing immunostains proved the following: B) Positive cytoplasmic staining of tumor cells for CD56Immunoperoxidase-DAB x/200.

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(NOS): 9.5%, SCC: 13.1%, Neuroendocrine tumors: 13.1%. Adenocar-cinoma was the most common subtype of lung cancer representing 64.3% of the total cases.

The increasing number of adenocarcinoma cases may be due to the increase of the cases of (Non small cell lung carcinoma favour adenocarcinoma) after use of immunostain and this goes with other reports. This was in agreement with Righiet al., 2011 whose work revealed the increased number of adenocarcinoma cases after the use of immunestain on FNAC samples initially diagnosed as NSCLC NOS.

Non small cell lung carcinoma favour adenocarcinoma (NSCLC favour ADC) was a diagnostic category when lacking classic fea-tures of adenocarcinoma. We diagnosed 14 cases after using of Napsin A antibody[6].

Although adenocarcinoma is still a morphological diagnosis but the variant (NSCLC favour ADC) need the panel done in this study

[6].

In the squamous cell carcinoma either well or moderate cases we are not in need to do immunohistochemistry. However in mod-erate differentiated squamous cell carcinoma cases, we combined Napsin A with CK5/6 to exclude squamoid variant of adenocarci-noma. Robert et al., 2007 [20] mentioned the Pivotal rule of CK5/6 as differentiating marker between squamous cell carcinoma and adenocarcinoma[21,22]. This was in agreement with Kargi et al., 2007 who mentioned that CK 5/6 seem to be useful for differ-entiating AC and SCLC from SCC with 89% specificity and 79% sensitivity.

The category Non Small Cell Lung carcinoma favour squamous cell carcinoma is diagnosed only by using immunohistochemistry. This was in agreement with Kaufmann et al. 2001[19]. Where it is mentioned that CK5/6 can be used to identify poorly differentiated and undifferentiated carcinoma that are typical for squamous cell carcinoma[6]. This where tumor by H&E lacking classic features of squamous cell carcinoma.

As regard neuroendocrine tumors diagnosis of small cell carci-noma not needed immunohistochemistry, however we applied CD56 to confirm neuroendocrine features and to exclude small cell variant of squamous cell carcinoma, lymphoma and other blue round cell tumor. This recommendations was mentioned by other reports[23].

As a whole, immunohistochemical stains should be interpreted with caution especially in the setting of markedly crushed biopsy with otherwise un interpretable morphology. Neuroendocrine markers such as chromogranin and synaptophysin and neuron specific enolase (NSE) may stain some NSCLC cases. CD56 held more promise as a specific neuroendocrine marker and it stained all cases of small cell carcinoma. This was in agreement with Travis, 2010[24].

The diagnosis of LCNEC is difficult to establish based on small biopsies or cytology. This is related to difficulty to do immunohis-tochemistry and to detect neuroendocrine pattern in such small biopsy. For these reasons we had 2 cases diagnosed as atypical car-cinoid morphologically and we stained them by Ki-67 which

revealed more than 80% labeling so the diagnosis changed to LCNEC[12,24].

So we used an algorithm the term of NSCLC (NOS) as little as possible. The percent decreased from 25.9% to 9.4% after immuno-histochemistry and this in contrary to Travis et al., 2011. This dif-ference due to small number of the cases applied [3]. This in contrary to Rigih et al., in whose work the cases of NSCLC NOS reduced from 36% before immunestain to 14% after immunestain. Conclusion

Immunohistochemistry has a valuable role in precise typing and differentiation of different pulmonary tumors. There’s a need to improve WHO 2004 classification that depend on H&E using multidisciplinary approach.

We used Napsin A, CK56 & CD56 as minimal panel in order to reach accurate typing and final diagnosis aiming at good response with chemotherapy.

References

[1]R. Siegel, D. Naishadham, A. Jemal, Cancer statistics, Cancer J. Clin. 62 (1) (2012) 10–29.

[2] National Cancer Institute, Non-Small Cell Lung Cancer Treatment (PDQ): Treatment Option Overview for NSCLC, National Institutes of Health, 2011, Available from: < http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-healthprofessional/page4>.

[3]W.D. Travis, Pathology of lung cancer, Clin. Chest Med. 32 (4) (2011) 669–692. [4]I. Wistubal, A.F. Gazdar, Lung cancer preneoplasia, Annu. Rev. Pathol. 1 (2006)

331–348.

[5]S. Sun, Schiller J. Hand, F. Gazdar, Lung cancer in never smokers – a different disease, Nat. Rev. Cancer 7 (10) (2007) 778–790.

[6]W.D. Travis, E. Brambilla, M. Noguchi, et al., International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma, J. Thorac. Oncol. 6 (2) (2011) 244–285.

[7]N.G. Ordonez, Napsin A expression in lung and kidney neoplasia: a review and update, Adv. Anat. Pathol. 19 (1) (2012) 66–73.

[8]K. Whithaus, J. Fukuoka, J. Thomas, et al., Evaluation of napsin A, cytokeratin 5/ 6, p63, and thyroid transcription factor 1 in adenocarcinoma versus squamous cell carcinoma of the lung, Arch. Pathol. Lab. Med. 136 (2) (2012) 155–162. [9]L. Waal, Treatment of subtypes in non-small cell lung cancer Master literature

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tumor overdiagnosed as small-cell carcinoma on biopsy specimens: a major pitfall in the management of lung cancer patients, Am. J. Surg. Pathol. 29 (2) (2005) 179–187.

[12]X. Lin, R.S. Saad, T.M. Luckasevic, Diagnostic value of CDX-2 and TTF-1 expressions in separating metastatic neuroendocrine neoplasms of unknown origin, Appl. Immunohistochem. Mol. Morphol. 15 (4) (2007) 407–414. [13]K. Hiroshima, A. Iyoda, T. Shida, et al., Distinction of pulmonary large cell

neuroendocrine carcinoma from small cell lung carcinoma: a morphological, immunohistochemical, and molecular analysis, Mod. Pathol. 19 (10) (2006) 1358–1368.

[14]W.D. Travis, Update on small cell carcinoma and its differentiation from squamous cell carcinoma and other non-small cell carcinomas, Mod. Pathol. 25 (S18–S30) (2012) 7.

[15]D. Zander, C.F. Farver, Pulmonary Pathology, Foundations in Diagnostic Pathology, Churchill Livingstone, Elsvier, Philadelphia, 2008, pp. 606–608. Table 5

Immunohistochemical panel for diagnosis of neuroendocrine tumors (According to IASLC 2011).

Final diagnosis Napsin A CK 5/6 CD 56

+ve ve +ve ve +ve ve

SCLC (9 cases) 6

2 2

1 1 1

NSCLC with NEM possible LCNEC (2 cases) 1 1

1 1

SCLC, small cell lung carcinoma; NSCLC with NEM possible LCNEC, Non-small cell lung carcinoma with neuroendocrine morphology possible large cell neuroendocrine carcinoma.

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[16]W.D. Travis, E. Brambilla, H.K. Muller-Hermelink, et al., Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart, IARC Press, Lyon, France, 2004, pp. 10–124, World Health Organization Classification of Tumours, Ch.1. [17]T.S. Mok, Y.L. Wu, S. Thongprasert, et al., Gefitinib or carboplatin paclitaxel in

pulmonary adenocarcinoma, N. Engl. J. Med. 361 (10) (2009) 947–957. [18] Boyleand, B. Levin, World Cancer Report, WHO/IARC, Lyon, Lyon, 2008, p.

P510.

[19]O. Kaufmann, E. Fietze, J. Mengs, et al., Value of p63 and cytokeratin 5/6 as immunohistochemical markers for the differential diagnosis of poorly differentiated and undifferentiated carcinomas, Am. J. Clin. Pathol. 116 (6) (2001) 823–830.

[20]T. Robert, C.W. Yijunand Michael, Utility of WT-1, p63, MOC31,mesothelin, and cytokeratin (K903 and CK5/6) immunostains in differentiating

adenocarcinoma, squamous cell carcinoma, and malignant mesothelioma in effusions, Diagn. Cytopathol. 36 (1) (2007) 20–25.

[21]P.S. Loo, S.C. Thomas, M.C. Nicolson, Subtyping of undifferentiated non-small cell carcinomas in bronchial biopsy specimens, J. Thorac. Oncol. 5 (4) (2010) 442–447.

[22]A. Kargi, D. Gurel, B. Tuna, The diagnostic value of TTF-1, CK 5/6, and p63 immunostaining in classification of lung carcinomas, Appl. Immunohistochem. Mol. Morphol. 15 (4) (2007) 415–420.

[23]A. Moran, S. Suster, D. Coppola, et al., Neuroendocrine carcinomas of the lung a critical analysis cesar, Am. J. Clin. Pathol. 131 (2) (2009) 206–221.

[24]W.D. Travis, Advances in neuroendocrine lung tumors, Ann. Oncol. 21 (7) (2010) 65–71.

Figure

Updating...

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  15. E.Z. Du, P. Goldstraw, J. Zacharias, et al., TTF-1 expression is specific for lungprimary in typical and atypical carcinoids: TTF-1-positive carcinoids are
  16. G. Pelosi, J. Rodriguez, G. Viale, et al., Typical and atypical pulmonary carcinoidtumor overdiagnosed as small-cell carcinoma on biopsy specimens: a major
  17. X. Lin, R.S. Saad, T.M. Luckasevic, Diagnostic value of CDX-2 and TTF-1expressions in separating metastatic neuroendocrine neoplasms of unknown
  18. K. Hiroshima, A. Iyoda, T. Shida, et al., Distinction of pulmonary large cellneuroendocrine carcinoma from small cell lung carcinoma: a morphological,
  19. W.D. Travis, Update on small cell carcinoma and its differentiation fromsquamous cell carcinoma and other non-small cell carcinomas, Mod. Pathol.
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  26. 442–447
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  29. W.D. Travis, Advances in neuroendocrine lung tumors, Ann. Oncol. 21 (7)(2010) 65–71
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