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TTF-1 is a highly sensitive but not fully specific marker for pulmonary and thyroidal cancer: a tissue microarray study evaluating more than 17,000 tumors from 152 different tumor entities
Thyroid transcription factor 1 (TTF-1) immunohistochemistry (IHC) is routinely used for the distinction of primary pulmonary adenocarcinomas. However, TTF-1 can also occur in other malignancies. A tissue microarray containing 17,772 samples from 152 different tumor types was analyzed. Napsin-A, CK20, SATB2, FABP1, and Villin-1 IHC data were available from previous studies. TTF-1 staining was seen in 82 of 152 tumor categories including thyroidal cancers (19–100%), adenocarcinomas (94%), neuroendocrine tumors (67%) of the lung, small cell neuroendocrine carcinomas (71–80%), mesenchymal tumors (up to 42%), and thymomas (39%). Comparative analysis of TTF-1 and Napsin-A revealed a sensitivity/specificity of 94%/86% (TTF-1), 87%/98% (Napsin-A), and 85%/99.1% (TTF-1 and Napsin-A) for the distinction of pulmonary adenocarcinomas. Combined analysis of TTF-1 and enteric markers revealed a positivity for TTF-1 and at least one enteric marker in 22% of pulmonary adenocarcinomas but also a TTF-1 positivity in 6% of colorectal, 2% of pancreatic, and 3% of gastric adenocarcinomas. TTF-1 is a marker of high sensitivity but insufficient specificity for pulmonary adenocarcinomas. A small fraction of TTF-1-positive gastrointestinal adenocarcinomas represents a pitfall mimicking enteric-type pulmonary adenocarcinoma. Combined analysis of TTF-1 and Napsin-A improves the specificity of pulmonary adenocarcinoma diagnosis.
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Introduction
Thyroid transcription factor 1 (TTF-1) also termed homeobox protein Nkx-2.1 is a member of the NKX2 family of homeodomain transcription factors which promotes transcription in a tissue-specific manner and exerts a critical role in the development of the thyroid, the lung, and the brain. TTF-1 knock-out causes developmental disorders of these organs. In the thyroid gland, TTF-1 stimulates the expression of thyroid peroxidase, thyroglobulin, and thyrotropin receptors (summarized in [1]). In the lung, TTF-1 stimulates transcription of the surfactant proteins A to D and the Clara cell secretory protein [2, 3]. The molecular targets of TTF-1 in the brain are still unknown.
In normal adult extracranial tissues, TTF-1 expression is largely limited to specific cell types of the thyroid, the lung, and the pituitary gland [4‐6]. Also in cancer, TTF-1 was shown to have high specificity for tumors derived from the lung and the thyroid. TTF-1 immunohistochemistry (IHC) is therefore routinely used in surgical pathology to support the difficult distinction of primary pulmonary adenocarcinomas which are often TTF-1 positive from malignant mesothelioma and metastatic adenocarcinoma to the lung which are usually TTF-1 negative [7]. Data on the rate of TTF-1 expression in cancer are heterogeneous, however (supplementary Fig. 1 and supplementary Table 1). Most studies evaluating TTF-1 by IHC have focused on pulmonary and thyroidal tumors and identified TTF-1 positivity in 42–100% of pulmonary adenocarcinomas [8‐11], 15–93% of pulmonary small cell carcinomas [12‐15], 0–50% of squamous cell carcinomas of the lung [12, 16‐18], and 0–42% of malignant mesotheliomas [19‐22] as well as in 88–100% of follicular [23, 24], 66–100% of papillary [23, 24], 50–100% of medullary [25, 26], and 5–100% of anaplastic cancers of the thyroid [27, 28]. Considerably, fewer authors analyzed TTF-1 expression in non-pulmonary/non-thyroidal cancers and reported—for example, TTF-1 positivity in 23–75% of endometrioid carcinomas of the ovary [29, 30], 5–80% of serous carcinomas of the endometrium [29, 30], 0–80% of Merkel cell carcinomas [31, 32], and 7–25% of endometrial clear cell carcinomas [29, 30]. Some of the divergent findings are likely due to the use of different antibodies, staining protocols, and criteria for defining TTF-1 positivity. For many tumor entities, immunochemical studies of TTF-1 expression in sizable cohorts are yet lacking.
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To better understand the prevalence of TTF-1 expression in cancer, an extensive survey of TTF-1 immunostaining under standardized conditions in a broad range of tumor types is desirable. In this study, we therefore evaluated TTF-1 expression in more than 17,000 tumor tissue samples from 152 different tumor types and subtypes as well as 76 different non-neoplastic tissue types by IHC in a tissue microarray (TMA) format.
Materials and methods
Tissue microarrays (TMAs)
Our normal tissue TMA was composed of 8 samples from 8 different donors from 76 different normal tissue types (608 samples on one slide). The cancer TMAs contained a total of 17,772 primary tumors from 152 tumor types and subtypes. The composition of both normal and cancer TMAs is described in detail in the results section. All samples were from the archives of the Institute of Pathology, University Hospital of Hamburg, Germany, the Institute of Pathology, Clinical Center Osnabrueck, Germany, and Department of Pathology, Academic Hospital Fuerth, Germany. Tissues were fixed in 4% buffered formalin and then embedded in paraffin. The TMA manufacturing process was described earlier in detail [33, 34]. In brief, one tissue spot (diameter, 0.6 mm) per patient was used. The use of archived remnants of diagnostic tissues for manufacturing of TMAs and their analysis for research purposes as well as patient data analysis has been approved by local laws (HmbKHG, §12) and by the local ethics committee (Ethics commission Hamburg, WF-049/09). All work has been carried out in compliance with the Helsinki Declaration. Data on Napsin-A, cytokeratin 20 (CK20), DNA-binding protein SATB2 (SATB2), fatty acid-binding protein 1 (FABP1), Villin-1, progesterone receptor (PR), estrogen receptor (ER), and p53 were available for subsets of our tumors from previous studies [35‐40] (data on ER and p53 are not published).
Immunohistochemistry (IHC)
Freshly cut TMA sections were immunostained on one day and in one experiment. Slides were deparaffinized with xylol, rehydrated through a graded alcohol series and exposed to heat-induced antigen retrieval for 5 min in an autoclave at 121 °C in Dako Target Retrieval Solution, pH9 (Agilent Technologies, Santa Clara, CA, USA; #S2367). Endogenous peroxidase activity was blocked with Dako REAL Peroxidase-Blocking Solution (Agilent Technologies, Santa Clara, CA, USA; #S2023) for 10 min. Primary antibody specific for TTF-1 (recombinant rabbit monoclonal, MSVA-312R, MS Validated Antibodies, Hamburg, Germany; #5805-312R) was applied at 37 °C for 60 min at a dilution of 1:150. Bound antibody was then visualized using the Dako REAL EnVision Detection System Peroxidase/DAB + , Rabbit/Mouse kit (Agilent, Santa Clara, CA, USA; #K5007) according to the manufacturer’s directions. The sections were counterstained with hemalaun. For the purpose of antibody validation, the normal tissue TMA was also analyzed by the rabbit recombinant monoclonal anti-TTF1 antibody [EP1584Y] (Abcam, Cambridge, UK, #ab76013) at a dilution of 1:50 and an otherwise identical protocol. For tumor tissues, the percentage of positive neoplastic cells was estimated, and the staining intensity was semi-quantitatively recorded (0, 1 + , 2 + , 3 +). For statistical analyses, the staining results were categorized into four groups. Tumors without any staining were considered negative. Tumors with 1 + staining intensity in ≤ 70% of tumor cells and 2 + intensity in ≤ 30% of tumor cells were considered weakly positive. Tumors with 1 + staining intensity in > 70% of tumor cells, 2 + intensity in 31–70%, or 3 + intensity in ≤ 30% of tumor cells were considered moderately positive. Tumors with 2 + intensity in > 70% or 3 + intensity in > 30% of tumor cells were considered strongly positive.
Sensitivity and specificity of positive staining of TTF-1 alone, Napsin-A alone, or of both TTF-1 and Napsin-A for the distinction between adenocarcinomas of the lung and adenocarcinomas originating from other organs (including endometrium, ovary, breast, colon, stomach, esophagus, liver, bile ducts, pancreas, prostate, and adrenal gland), mesotheliomas, and renal cell carcinomas were calculated using the formulas “sensitivity = number of true positive / number of true positive + number of false negative” and “specificity = number of true negative / number of true negative + number of false positive.”
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Results
Technical issues
A total of 15,564 (87.6%) of 17,772 tumor samples were interpretable in our TMA analysis. Non-interpretable samples demonstrated a lack of unequivocal tumor cells or an absence of entire tissue spots. A sufficient number of samples (≥ 4) of each normal tissue type was evaluable.
TTF-1 in normal tissues
A strong nuclear TTF-1 staining was seen in all epithelial cells of the thyroid, pituicytes of the neurohypophysis, all pneumocytes of the lung, basal cell layers of respiratory epithelium of the bronchus, and in mucinous cells of bronchiolar glands. All these findings were obtained by using the recombinant rabbit monoclonal antibody MSVA-312R and the anti-TTF1 antibody [EP1584Y] and therefore considered to be specific. For MSVA-312R, TTF-1 staining was absent in skeletal muscle, heart muscle, smooth muscle, myometrium of the uterus, corpus spongiosum of the penis, ovarian stroma, fat, skin (including hair follicle and sebaceous glands), oral mucosa of the lip, oral cavity, surface epithelium of the tonsil, and transitional mucosa of the anal canal, ectocervix, squamous epithelium of the esophagus, urothelium of the renal pelvis and the urinary bladder, decidua, placenta, lymph node, spleen, thymus, tonsil, mucosa of the stomach, duodenum, ileum, appendix, colon, rectum and gall bladder, liver, pancreas, parotid gland, submandibular gland, sublingual gland, Brunner gland of the duodenum, cortex and medulla of the kidney, prostate, seminal vesicle, epididymis, breast, endocervix, endometrium, fallopian tube, adrenal gland, parathyroid gland, adenohypophysis, cerebellum, and the cerebrum. Representative images are shown in Fig. 1. By using the anti-TTF1 antibody clone [EP1584Y], additional cytoplasmic staining was seen in spermatogonia and spermatids of the testis (strong), smooth muscle (strong) as well as in several other normal tissues such as for example in renal tubule kidney (weaker). These stainings were considered antibody-specific cross-reactivities of [EP1584Y] (supplementary Fig. 2).
Fig. 1
TTF-1 immunostaining in normal tissues. The panels show a moderate to strong nuclear TTF-1 staining of all epithelial cells of the thyroid (A), pneumocytes of the lung (B), basal cell layers of the respiratory epithelium of the bronchus (C), mucinous cells of bronchial glands (D), and in pituicytes of the neurohypophysis (E). TTF-1 staining is absent in all cells of the liver (F)
TTF-1 immunostaining was detectable in 1389 (8.9%) of the 15,564 analyzable tumors, including 245 (1.6%) with weak, 139 (0.9%) with moderate, and 1005 (6.5%) with strong staining. Overall, 82 (53.9%) of 152 tumor categories showed detectable TTF-1 expression with 42 (27.6%) tumor categories including at least one case with strong positivity (Table 1). Representative images of TTF-1-positive tumors are shown in Fig. 2. The highest rate of TTF-1 positivity was found in various subtypes of thyroidal cancers (19.0–100%), adenocarcinomas of the lung (94.3%), neuroendocrine tumors (NET) of the lung (66.7%), small cell neuroendocrine carcinomas (NEC) of various organs of origin (71.4–80.0%), various categories of mesenchymal tumors (16.7–41.9%), and in thymomas (39.1%). TTF-1 expression in less than 15% of cases and often at lower intensity was also seen in various other cancer types such as gallbladder adenocarcinoma (14.3%), NEC of the ileum (14.3%), NET of the pancreas (5.4%), high-grade endometrial carcinoma (12.5%), urothelial carcinoma of the kidney pelvis (11.5%), adenocarcinoma of the prostate (up to 11.5%), carcinosarcoma of the uterus (9.3%), endometrial serous carcinoma (8.1%), tumors of the salivary gland (0.4–7.4%), pancreatic/ampullary adenocarcinoma (7.3%), squamous cell carcinomas from different organs (up to 6.8%, without lung), gastric adenocarcinoma (up to 5.9%), adenocarcinoma of the colon (5.2%), mucinous carcinoma of the ovary (4.7%), yolk sac tumor of the testis (4.7%), clear cell carcinoma of the ovary (4.3%), endometrioid endometrial carcinoma (4.1%), T-cell non-Hodgkin’s lymphoma (4.0%), and in cholangiocarcinoma (3.5%). The prevalence of TTF-1 in different categories of neuroendocrine neoplasms is also shown separately in Table 2. Four out of nine TTF-1 positive endometrial carcinomas with data on ER, PR, and p53 from previous studies ([40] data on ER and p53 are not published) demonstrated a wildtype pattern of p53 and absence of ER and PR immunostaining, in combination with the morphological features in line with the “mesonephric-like endometrial carcinoma” subtype.
Table 1
TTF-1 immunostaining in human tumors
Tumor category
Tumor entity
TTF-1 immunostaining
TMA (n)
Analyzable (n)
Negative (%)
Weak (%)
Moderate (%)
Strong (%)
Tumors of the skin
Pilomatricoma
35
13
100.0
0.0
0.0
0.0
Basal cell carcinoma of the skin
89
79
98.7
1.3
0.0
0.0
Benign nevus
29
22
100.0
0.0
0.0
0.0
Squamous cell carcinoma of the skin
145
130
96.9
2.3
0.8
0.0
Malignant melanoma
65
57
100.0
0.0
0.0
0.0
Malignant melanoma lymph node metastasis
86
85
98.8
0.0
1.2
0.0
Merkel cell carcinoma
48
28
92.9
0.0
7.1
0.0
Tumors of the head and neck
Squamous cell carcinoma of the larynx
109
100
97.0
3.0
0.0
0.0
Squamous cell carcinoma of the pharynx
60
59
93.2
5.1
1.7
0.0
Oral squamous cell carcinoma (floor of the mouth)
130
126
97.6
2.4
0.0
0.0
Pleomorphic adenoma of the parotid gland
50
36
100.0
0.0
0.0
0.0
Warthin tumor of the parotid gland
104
89
100.0
0.0
0.0
0.0
Adenocarcinoma, NOS (Papillary Cystadenocarcinoma)
14
11
100.0
0.0
0.0
0.0
Salivary duct carcinoma
15
9
100.0
0.0
0.0
0.0
Acinic cell carcinoma of the salivary gland
181
103
99.0
0.0
1.0
0.0
Adenocarcinoma NOS of the salivary gland
109
54
92.6
3.7
1.9
1.9
Adenoid cystic carcinoma of the salivary gland
180
64
100.0
0.0
0.0
0.0
Basal cell adenocarcinoma of the salivary gland
25
21
100.0
0.0
0.0
0.0
Basal cell adenoma of the salivary gland
101
58
100.0
0.0
0.0
0.0
Epithelial-myoepithelial carcinoma of the salivary gland
53
43
100.0
0.0
0.0
0.0
Mucoepidermoid carcinoma of the salivary gland
343
261
99.6
0.0
0.0
0.4
Myoepithelial carcinoma of the salivary gland
21
15
93.3
0.0
6.7
0.0
Myoepithelioma of the salivary gland
11
9
100.0
0.0
0.0
0.0
Oncocytic carcinoma of the salivary gland
12
6
100.0
0.0
0.0
0.0
Polymorphous adenocarcinoma, low grade, of the salivary gland
Small cell neuroendocrine carcinoma of the prostate
19
7
28.6
0.0
0.0
71.4
Seminoma
682
575
100.0
0.0
0.0
0.0
Embryonal carcinoma of the testis
54
37
100.0
0.0
0.0
0.0
Leydig cell tumor of the testis
31
31
100.0
0.0
0.0
0.0
Sertoli cell tumor of the testis
2
2
100.0
0.0
0.0
0.0
Sex cord stromal tumor of the testis
1
1
100.0
0.0
0.0
0.0
Spermatocytic tumor of the testis
1
1
100.0
0.0
0.0
0.0
Yolk sac tumor
53
43
95.3
2.3
2.3
0.0
Teratoma
53
39
94.9
0.0
2.6
2.6
Squamous cell carcinoma of the penis
92
90
96.7
2.2
1.1
0.0
Tumors of endocrine organs
Adenoma of the thyroid gland
113
107
0.0
1.9
0.9
97.2
Papillary thyroid carcinoma
391
373
0.8
0.0
0.8
98.4
Follicular thyroid carcinoma
154
145
0.0
0.0
2.1
97.9
Medullary thyroid carcinoma
111
96
0.0
1.0
18.8
80.2
Parathyroid gland adenoma
43
42
100.0
0.0
0.0
0.0
Anaplastic thyroid carcinoma
45
42
81.0
2.4
2.4
14.3
Adrenal cortical adenoma
50
38
100.0
0.0
0.0
0.0
Adrenal cortical carcinoma
28
28
100.0
0.0
0.0
0.0
Pheochromocytoma
50
50
100.0
0.0
0.0
0.0
Tumors of hematopoietic and lymphoid tissues
Hodgkin’s lymphoma
103
89
98.9
1.1
0.0
0.0
Small lymphocytic lymphoma, B-cell type (B-SLL/B-CLL)
50
50
100.0
0.0
0.0
0.0
Diffuse large B-cell lymphoma (DLBCL)
113
113
98.2
1.8
0.0
0.0
Follicular lymphoma
88
88
100.0
0.0
0.0
0.0
T-cell non-Hodgkin’s lymphoma
25
25
96.0
0.0
0.0
4.0
Mantle cell lymphoma
18
18
100.0
0.0
0.0
0.0
Marginal zone lymphoma
16
16
100.0
0.0
0.0
0.0
Diffuse large B-cell lymphoma (DLBCL) in the testis
16
16
100.0
0.0
0.0
0.0
Burkitt lymphoma
5
5
100.0
0.0
0.0
0.0
Tumors of soft tissue and bone
Tendosynovial giant cell tumor
45
16
100.0
0.0
0.0
0.0
Granular cell tumor
53
29
100.0
0.0
0.0
0.0
Leiomyoma
50
44
100.0
0.0
0.0
0.0
Leiomyosarcoma
94
86
98.8
1.2
0.0
0.0
Liposarcoma
145
105
99.0
0.0
1.0
0.0
Malignant peripheral nerve sheath tumor (MPNST)
15
14
78.6
7.1
14.3
0.0
Myofibrosarcoma
26
26
100.0
0.0
0.0
0.0
Angiosarcoma
74
50
100.0
0.0
0.0
0.0
Angiomyolipoma
91
89
98.9
1.1
0.0
0.0
Dermatofibrosarcoma protuberans
21
16
100.0
0.0
0.0
0.0
Ganglioneuroma
14
12
100.0
0.0
0.0
0.0
Kaposi sarcoma
8
5
100.0
0.0
0.0
0.0
Neurofibroma
117
117
99.1
0.0
0.0
0.9
Sarcoma, not otherwise specified (NOS)
74
71
94.4
2.8
1.4
1.4
Paraganglioma
41
40
100.0
0.0
0.0
0.0
Ewing sarcoma
23
18
83.3
11.1
0.0
5.6
Rhabdomyosarcoma
7
7
71.4
0.0
14.3
14.3
Schwannoma
122
117
58.1
10.3
12.0
19.7
Synovial sarcoma
12
9
100.0
0.0
0.0
0.0
Osteosarcoma
44
27
100.0
0.0
0.0
0.0
Chondrosarcoma
40
16
100.0
0.0
0.0
0.0
Rhabdoid tumor
5
5
80.0
20.0
0.0
0.0
Solitary fibrous tumor
17
17
100.0
0.0
0.0
0.0
Fig. 2
TTF-1 immunostaining in cancer tissues. The panels show a strong, nuclear TTF-1 positivity of all tumor cells in papillary (A) and medullary carcinoma (B) of the thyroid, pulmonary adenocarcinoma (C), adenocarcinoma (D), and neuroendocrine tumor of the pancreas (E), endometrioid carcinoma of the endometrium (F), and colorectal adenocarcinoma (G). In TTF-1 negative squamous cell carcinoma of the lung, TTF-1 staining is limited to retained normal pneumocytes (H)
TTF-1 vs. Napsin-A and markers for enteric differentiation
The comparative analysis of TTF-1 vs. Napsin-A for their sensitivity and specificity for the distinction of pulmonary adenocarcinomas from other tumors (except thyroidal cancers) in a subset of 4567 cancers with data for both TTF-1 and Napsin-A revealed a higher sensitivity for TTF-1 (94.1%) while the specificity was higher for Napsin-A (97.8%, Table 3). The combination of TTF-1 and Napsin-A positivity resulted in a specificity of 99.1% for pulmonary adenocarcinoma (Table 3). The relationship between the expression of TTF-1, Napsin-A, and several enteric markers (CK20, SATB2, FABP1, Villin-1) in pulmonary, colorectal, pancreatic, and gastric adenocarcinomas is given in Table 4. This analysis revealed an expression of at least one enteric marker in 22.1% of 68 TTF-1 positive pulmonary adenocarcinomas while TTF-1 positivity was also seen in 66 colorectal, 9 pancreatic, and 8 gastric adenocarcinomas. Of these, 4 pancreatic adenocarcinomas were negative for all 4 enteric markers. Of note, Napsin-A was negative in all TTF-1-positive gastrointestinal adenocarcinomas.
Table 3
Comparison of the sensitivity and specificity of TTF-1 and Napsin-A (alone or together) for the distinction between lung adenocarcinomas and adenocarcinomas of other origin
Sensitivity
Specificity
TTF-1 positive
0.941
0.861
Napsin-A positive
0.874
0.978
TTF-1 and Napsin-A positive
0.849
0.991
Table 4
Expression of typical enteric markers, including cytokeratin 20 (CK20), DNA-binding protein SATB2 (SATB2), fatty acid-binding protein 1 (FABP1), and Villin-1 in pulmonary, colorectal, pancreatic, and gastric adenocarcinomas
n
Enteric markers
Number of positive enteric markers
Napsin-A positive (%)
CK20 positive (%)
SATB2 positive (%)
FABP1 positive (%)
Villin-1 positive (%)
4 positive (%)
3 positive (%)
2 positive (%)
1 positive (%)
Colon Carcinoma (TTF-1 positive)
66
0
100
95.5
84.8
100
84.8
10.6
4.5
0
Pancreatic carcinoma (TTF-1 positive)
9
0
22.2
22.2
0
22.2
0
0
11.1
44.4
Gastric carcinoma (TTF-1 positive)
8
0
50
62.5
25
100
25
12.5
37.5
25
Lung adenocarcinoma (TTF-1 positive)
68
89.7
2.9
10.3
0
16.2
0
0
7.4
14.7
Lung adenocarcinoma (TTF-1 negative)
4
50
0
0
0
0
0
0
0
0
Lung adenocarcinoma with enteric features
15
86.7
Discussion
TTF-1 IHC is widely used by pathologists for the distinction of primary pulmonary adenocarcinoma—typically TTF-1 positive—from pulmonary squamous cell carcinoma, metastatic adenocarcinoma to the lung, and pleural mesothelioma which are TTF-1 negative in most cases [7, 13, 41]. TTF-1 IHC has also been suggested to assist in the distinction of pulmonary from non-pulmonary neuroendocrine neoplasms [42], the distinction of Merkel cell carcinoma of the skin from cutaneous metastases of pulmonary small cell carcinoma [43], and as a marker for thyroidal carcinomas of all types including medullary carcinoma [44]. The results from our successful analysis of more than 15,000 cancers from 152 tumor entities confirm the suggested utility of TTF-1 IHC for these applications but also highlight important pitfalls and emphasize the significance of combining TTF-1 analysis with Napsin-A and other immunohistochemical markers.
Because the lung is a common site of metastases, the distinction of primary lung adenocarcinoma from metastatic adenocarcinoma is a frequent diagnostic problem with substantial therapeutic implications [45]. Although our data show a very high sensitivity (94.1%) of TTF-1 IHC for lung adenocarcinomas, it is conspicuous that its specificity (86%) is not optimal for a safe separation of pulmonary adenocarcinomas from morphologically similar metastatic cancers. The suboptimal specificity is due to small but significant fractions of TTF-1 positive cases in many common tumor entities such as adenocarcinomas of the colorectum, stomach, pancreas, prostate, ovary, and uterus, as well as urothelial carcinomas. All these tumors do often metastasize to the lung (summarized in [46]). Napsin-A is another commonly used marker for the distinction of pulmonary adenocarcinoma which was analyzed in our tumor cohort earlier [35]. While the sensitivity of Napsin-A (87.4%) is lower than for TTF-1, Napsin-A positivity is markedly more specific (97.8%) for pulmonary adenocarcinoma. In a combined analysis of both markers, our data suggest a good sensitivity (84.9%) and a close to perfect specificity (99.1%) for the combination TTF-1 + /Napsin-A + to distinguish pulmonary adenocarcinoma from its differential diagnoses.
Several authors had suggested that occasional TTF-1-positive gastrointestinal adenocarcinomas would be distinguishable from pulmonary adenocarcinomas by their additional expression of “gastrointestinal markers” [47‐49]. That a large fraction of our TTF-1 positive gastric, pancreatic, and colorectal carcinomas was indeed positive for at least one of the markers CK20, Villin-1, SATB2, and FABP1 is supportive of this concept, but expression of at least one of these markers also occurred in 22% of our TTF-1 positive pulmonary adenocarcinomas. Such “enteric type” pulmonary adenocarcinomas have been described to make up for 3–28% of pulmonary adenocarcinomas [50‐52]. Based on our set of data, these tumors represent an important pitfall which can often (> 80%) be distinguished from gastrointestinal tumors by their Napsin-A positivity, a feature that was not seen in any of our gastrointestinal neoplasms.
Our data also enabled an assessment of the previously proposed utility of TTF-1 IHC for the distinction of pulmonary from extrapulmonary neuroendocrine neoplasms and demonstrated that this separation can best be made in highly differentiated tumors. The 67% TTF-1 positivity of pulmonary NETs (carcinoids) is close to the average of 47% TTF-1 positive lung carcinoids described in previous studies although the reported positivity rates in these tumors ranged from 0 to 86% [16, 53]. Pancreatic NETs may show the second-highest rate of TTF-1 positivity among NETs. Our rate of TTF-1 positivity in 5.4% of 93 pancreatic NETs is close to the 7% of 44 described by Tseng et al. [42] while Koo et al. [54] had not found TTF-1 expression in a series of 33 cases. The complete absence of TTF-1 staining in NETs from the ileum (n = 51), appendix (n = 16), and colorectum (n = 11) is consistent with reports describing a lack of TTF-1 positivity in 17 and 23 NETs of the ileum [42, 54], 6 NETs of the appendix [42], and 14 and 23 NETs of the rectum [42, 54]. It is of note that the frequency of TTF-1 positivity in extrapulmonary neuroendocrine neoplasms increases with tumor dedifferentiation (summarized in [55]). Accordingly, at least a few TTF-1 positive cases were seen in NECs from almost every site of origin and an even higher TTF-1 positivity rate occurred in small cell NECs from extra-thoracic sites of origin in this study. Similar findings had been described by other authors [42]. It is generally accepted that TTF-1 immunostaining cannot be used to distinguish the site of origin in case of small cell NEC (summarized in [55]). That two (7%) of our 28 Merkel cell carcinomas showed a moderate TTF-1 positivity is consistent with the sum of earlier data describing TTF-1 positivity in 0% of 12 [56], 0% of 20 [31], 8% of 52 [57], 11% of 103 [58], and 80% of 5 [32] Merkel cell carcinomas. These findings demonstrate that TTF-1-positive small cell tumors of the skin are not always of metastatic origin.
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The comprehensive evaluation of more than 15,000 tumors identified several further tumor entities with frequent TTF-1 positivity some of which were previously underrecognized. These include several mesenchymal neoplasms. Of these, malignant peripheral nerve sheath tumors (MPNST) can for example occur in the thyroid and may mimic anaplastic thyroid cancer [59]. TTF-1-positive Ewing sarcoma may erroneously give rise to the diagnosis of a bone metastasis derived from a small cell NEC of the lung or of another site of origin. TTF-1 positivity in thymoma, T-cell lymphoma, and large cell B-cell lymphoma may also cause diagnostic confusion if seen in thoracic or lympho-nodal tumor masses.
Given the large scale of our study, emphasis was placed on a thorough validation of our assay. The International Working Group for Antibody Validation (IWGAV) has proposed that antibody validation for IHC on formalin-fixed tissues should include either a comparison of the findings obtained by two different independent antibodies or a comparison with expression data obtained by another independent method [60]. RNA data obtained in three independent RNA screening studies [61‐64] had identified TTF-1 RNA only in the thyroid, lung, pituitary gland, and brain. That TTF-1 staining by MSVA-312R was also restricted to thyroid, neurohypophysis, and pulmonary tissues, and that all cell types that were TTF-1 positive by MSVA-312R were also labeled by [EP1584Y] constitutes a strong validation of our assay. It is of note that our broad panel of 76 different normal tissues for antibody validation results in a high likelihood for detecting undesired cross-reactivities because virtually all proteins occurring in normal cells of adult humans are subjected to the validation experiment. The cytoplasmic TTF-1 staining seen in various tissues by [EP1584Y] but not by MSVA-312R represents an antibody-specific cross-reactivity of [EP1584Y] which was identified by our resource-intensive validation procedure.
Conclusion
Our data reveal that TTF-1 is a marker of high sensitivity but insufficient specificity for the distinction of pulmonary adenocarcinomas. A small fraction of TTF-1-positive gastrointestinal adenocarcinomas represents a significant pitfall mimicking enteric-type pulmonary adenocarcinoma. The combined analysis of TTF-1 and Napsin-A significantly improves the specificity of pulmonary adenocarcinoma diagnosis.
Acknowledgements
We are grateful to Melanie Steurer, Laura Behm, Inge Brandt, Maren Eisenberg, and Sünje Seekamp for excellent technical assistance.
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Declarations
Ethics approval
The usage of archived diagnostic left-over tissues for manufacturing of TMAs and their analysis for research purposes as well as patient data analysis has been approved by local laws (HmbKHG, §12,1) and by the local ethics committee (Ethics commission Hamburg, WF-049/09). All work has been carried out in compliance with the Helsinki Declaration.
Conflict of interest
The recombinant rabbit monoclonal TTF-1-antibody clone MSVA-312R was provided by MS Validated Antibodies GmbH, Hamburg, Germany (owned by a family member of GS).
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TTF-1 is a highly sensitive but not fully specific marker for pulmonary and thyroidal cancer: a tissue microarray study evaluating more than 17,000 tumors from 152 different tumor entities
Verfasst von
Katharina Möller
Tayyaba Gulzar
Maximilian Lennartz
Florian Viehweger
Martina Kluth
Claudia Hube-Magg
Christian Bernreuther
Ahmed Abdulwahab Bawahab
Ronald Simon
Till S. Clauditz
Guido Sauter
Ria Schlichter
Andrea Hinsch
Simon Kind
Frank Jacobsen
Eike Burandt
Nikolaj Frost
Martin Reck
Andreas H. Marx
Till Krech
Patrick Lebok
Christoph Fraune
Stefan Steurer
Bingle CD (1997) Thyroid transcription factor-1. Int J Biochem Cell Biol 29(12):1471–1473PubMedCrossRef
2.
Zhang L, Whitsett JA, Stripp BR (1997) Regulation of Clara cell secretory protein gene transcription by thyroid transcription factor-1. Biochim Biophys Acta 1350(3):359–367PubMedCrossRef
3.
Whitsett JA, Glasser SW (1998) Regulation of surfactant protein gene transcription. Biochim Biophys Acta 1408(2–3):303–311PubMedCrossRef
4.
Nakamura N et al (2002) Expression of thyroid transcription factor-1 in normal and neoplastic lung tissues. Mod Pathol 15(10):1058–1067PubMedCrossRef
5.
Katoh R et al (2000) Thyroid transcription factor-1 in normal, hyperplastic, and neoplastic follicular thyroid cells examined by immunohistochemistry and nonradioactive in situ hybridization. Mod Pathol 13(5):570–576PubMedCrossRef
6.
Lee NO et al (2007) TTF-1 regulates growth hormone and prolactin transcription in the anterior pituitary gland. Biochem Biophys Res Commun 362(1):193–199PubMedCrossRef
7.
Moldvay J et al (2004) The role of TTF-1 in differentiating primary and metastatic lung adenocarcinomas. Pathol Oncol Res 10(2):85–88PubMedCrossRef
8.
Rossi G et al (2014) Napsin-A, TTF-1, EGFR, and ALK status determination in lung primary and metastatic mucin-producing adenocarcinomas. Int J Surg Pathol 22(5):401–407PubMedCrossRef
9.
Roberts EA et al (2020) Chromogenic immunohistochemical quadruplex provides accurate diagnostic differentiation of non-small cell lung cancer. Ann Diagn Pathol 45:151454PubMedCrossRef
10.
Nakra T et al (2021) Correlation of TTF-1 immunoexpression and EGFR mutation spectrum in non-small cell lung carcinoma. J Pathol Transl Med 55(4):279–288PubMedPubMedCentralCrossRef
11.
Shanzhi W et al (2014) The relationship between TTF-1 expression and EGFR mutations in lung adenocarcinomas. PLoS ONE 9(4):e95479PubMedPubMedCentralCrossRef
12.
Hassan A et al (2022) Accuracy of classifying lung carcinoma using immunohistochemical markers on limited biopsy material: a two-center study. Cureus 14(12):e32956PubMedPubMedCentral
13.
Zhang H et al (2005) Distinction of pulmonary small cell carcinoma from poorly differentiated squamous cell carcinoma: an immunohistochemical approach. Mod Pathol 18(1):111–118PubMedCrossRef
14.
Misch D et al (2015) Value of thyroid transcription factor (TTF)-1 for diagnosis and prognosis of patients with locally advanced or metastatic small cell lung cancer. Diagn Pathol 10:21PubMedPubMedCentralCrossRef
15.
Yu S et al (2020) Differential expression of PD-L1 in central and peripheral and TTF1-positive and -negative small-cell lung cancer. Front Med (Lausanne) 7:621838PubMedCrossRef
16.
Vidarsdottir H et al (2018) Comparison of three different TTF-1 clones in resected primary lung cancer and epithelial pulmonary metastases. Am J Clin Pathol 150(6):533–544PubMedCrossRef
17.
Micke P et al (2016) The impact of the fourth edition of the WHO classification of lung tumours on histological classification of resected pulmonary NSCCs. J Thorac Oncol 11(6):862–72
18.
Tsuta K et al (2011) Utility of 10 immunohistochemical markers including novel markers (desmocollin-3, glypican 3, S100A2, S100A7, and Sox-2) for differential diagnosis of squamous cell carcinoma from adenocarcinoma of the Lung. J Thorac Oncol 6(7):1190–1199PubMedCrossRef
19.
Abutaily AS, Addis BJ, Roche WR (2002) Immunohistochemistry in the distinction between malignant mesothelioma and pulmonary adenocarcinoma: a critical evaluation of new antibodies. J Clin Pathol 55(9):662–668PubMedPubMedCentralCrossRef
20.
Klebe S et al (2016) An immunohistochemical comparison of two TTF-1 monoclonal antibodies in atypical squamous lesions and sarcomatoid carcinoma of the lung, and pleural malignant mesothelioma. J Clin Pathol 69(2):136–141PubMedCrossRef
21.
Mawas AS et al (2018) MUC4 immunohistochemistry is useful in distinguishing epithelioid mesothelioma from adenocarcinoma and squamous cell carcinoma of the lung. Sci Rep 8(1):134PubMedPubMedCentralCrossRef
22.
Mimura T et al (2007) Novel marker D2–40, combined with calretinin, CEA, and TTF-1: an optimal set of immunodiagnostic markers for pleural mesothelioma. Cancer 109(5):933–938PubMedCrossRef
23.
Fenton CL et al (2001) Nuclear localization of thyroid transcription factor-1 correlates with serum thyrotropin activity and may be increased in differentiated thyroid carcinomas with aggressive clinical course. Ann Clin Lab Sci 31(3):245–252PubMed
24.
Choi YL et al (2005) Immunoexpression of HBME-1, high molecular weight cytokeratin, cytokeratin 19, thyroid transcription factor-1, and E-cadherin in thyroid carcinomas. J Korean Med Sci 20(5):853–859PubMedPubMedCentralCrossRef
25.
Bejarano PA et al (2000) Thyroid transcription factor-1, thyroglobulin, cytokeratin 7, and cytokeratin 20 in thyroid neoplasms. Appl Immunohistochem Mol Morphol 8(3):189–194PubMedCrossRef
26.
Katoh R et al (2000) Expression of thyroid transcription factor-1 (TTF-1) in human C cells and medullary thyroid carcinomas. Hum Pathol 31(3):386–393PubMedCrossRef
27.
Kuhn E et al (2019) Angiosarcoma and anaplastic carcinoma of the thyroid are two distinct entities: a morphologic, immunohistochemical, and genetic study. Mod Pathol 32(6):787–798PubMedCrossRef
28.
Veits L et al (2014) KRAS, EGFR, PDGFR-alpha, KIT and COX-2 status in carcinoma showing thymus-like elements (CASTLE). Diagn Pathol 9:116PubMedPubMedCentralCrossRef
29.
Iwamoto M et al (2015) Napsin A is frequently expressed in clear cell carcinoma of the ovary and endometrium. Hum Pathol 46(7):957–962PubMedCrossRef
30.
Moritz AW et al (2019) Expression of neuroendocrine markers in non-neuroendocrine endometrial carcinomas. Pathology 51(4):369–374PubMedCrossRef
31.
Llombart B et al (2005) Clinicopathological and immunohistochemical analysis of 20 cases of Merkel cell carcinoma in search of prognostic markers. Histopathology 46(6):622–634PubMedCrossRef
32.
Czapiewski P et al (2016) TTF-1 and PAX5 are frequently expressed in combined Merkel cell carcinoma. Am J Dermatopathol 38(7):513–516PubMedCrossRef
33.
Dancau AM et al (2016) Tissue microarrays. Methods Mol Biol 1381:53–65PubMedCrossRef
34.
Kononen J et al (1998) Tissue microarrays for high-throughput molecular profiling of tumor specimens. Nat Med 4(7):844–847PubMedCrossRef
35.
Weidemann S et al (2021) Napsin A expression in human tumors and normal tissues. Pathol Oncol Res 27:613099PubMedPubMedCentralCrossRef
36.
Dum D et al (2023) SATB2 expression in human tumors: a tissue microarray study on more than 15 000 tumors. Arch Pathol Lab Med 147(4):451–464PubMedCrossRef
37.
Dum D et al (2022) FABP1 expression in human tumors: a tissue microarray study on 17,071 tumors. Virchows Arch 481(6):945–961PubMedPubMedCentralCrossRef
38.
Dum D et al (2022) Villin expression in human tumors: a tissue microarray study on 14,398 tumors. Expert Rev Mol Diagn 22(6):665–675PubMedCrossRef
39.
Dum D et al (2022) Cytokeratin 7 and cytokeratin 20 expression in cancer: a tissue microarray study on 15,424 cancers. Exp Mol Pathol 126:104762PubMedCrossRef
40.
Viehweger F et al (2022) Diagnostic and prognostic impact of progesterone receptor immunohistochemistry: a study evaluating more than 16,000 tumors. Anal Cell Pathol (Amst) 2022:6412148PubMed
41.
Porcel JM (2018) Biomarkers in the diagnosis of pleural diseases: a 2018 update. Ther Adv Respir Dis 12:1753466618808660PubMedPubMedCentralCrossRef
42.
Tseng IC et al (2015) NKX6-1 Is a Novel immunohistochemical marker for pancreatic and duodenal neuroendocrine tumors. Am J Surg Pathol 39(6):850–857PubMedCrossRef
43.
Leech SN et al (2001) Merkel cell carcinoma can be distinguished from metastatic small cell carcinoma using antibodies to cytokeratin 20 and thyroid transcription factor 1. J Clin Pathol 54(9):727–729PubMedPubMedCentralCrossRef
44.
Ordonez NG (2012) Value of thyroid transcription factor-1 immunostaining in tumor diagnosis: a review and update. Appl Immunohistochem Mol Morphol 20(5):429–444PubMedCrossRef
45.
Mangiameli G et al (2022) Lung metastases: current surgical indications and new perspectives. Front Surg 9:884915PubMedPubMedCentralCrossRef
46.
Jagirdar J (2008) Application of immunohistochemistry to the diagnosis of primary and metastatic carcinoma to the lung. Arch Pathol Lab Med 132(3):384–396PubMedCrossRef
47.
Alabdullah B, Hadji-Ashrafy A (2022) Identification of the most specific markers to differentiate primary pulmonary carcinoma from metastatic gastrointestinal carcinoma to the lung. Diagn Pathol 17(1):7PubMedPubMedCentralCrossRef
48.
Su YC, Hsu YC, Chai CY (2006) Role of TTF-1, CK20, and CK7 immunohistochemistry for diagnosis of primary and secondary lung adenocarcinoma. Kaohsiung J Med Sci 22(1):14–19PubMedCrossRef
De Michele S et al (2021) SATB2 in neoplasms of lung, pancreatobiliary, and gastrointestinal origins. Am J Clin Pathol 155(1):124–132PubMedCrossRef
51.
Moll R et al (1987) Villin: a cytoskeletal protein and a differentiation marker expressed in some human adenocarcinomas. Virchows Arch B Cell Pathol Incl Mol Pathol 54(3):155–169PubMedCrossRef
52.
Sun F et al (2018) Diagnosis, clinicopathological characteristics and prognosis of pulmonary mucinous adenocarcinoma. Oncol Lett 15(1):489–494PubMed
53.
Zamecnik J, Kodet R (2002) Value of thyroid transcription factor-1 and surfactant apoprotein A in the differential diagnosis of pulmonary carcinomas: a study of 109 cases. Virchows Arch 440(4):353–361PubMedCrossRef
54.
Koo J et al (2012) Value of Islet 1 and PAX8 in identifying metastatic neuroendocrine tumors of pancreatic origin. Mod Pathol 25(6):893–901PubMedCrossRef
55.
Pelosi G et al (2017) Classification of pulmonary neuroendocrine tumors: new insights. Transl Lung Cancer Res 6(5):513–529PubMedPubMedCentralCrossRef
56.
Lewis JS Jr, Duncavage E, Klonowski PW (2010) Oral cavity neuroendocrine carcinoma: a comparison study with cutaneous Merkel cell carcinoma and other mucosal head and neck neuroendocrine carcinomas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110(2):209–17PubMedCrossRef
57.
Pasternak S et al (2018) Immunohistochemical profiles of different subsets of Merkel cell carcinoma. Hum Pathol 82:232–238PubMedCrossRef
58.
Kervarrec T et al (2019) Diagnostic accuracy of a panel of immunohistochemical and molecular markers to distinguish Merkel cell carcinoma from other neuroendocrine carcinomas. Mod Pathol 32(4):499–510PubMedCrossRef
Lizio M et al (2019) Update of the FANTOM web resource: expansion to provide additional transcriptome atlases. Nucleic Acids Res 47(D1):D752–D758PubMedCrossRef
63.
Lizio M et al (2015) Gateways to the FANTOM5 promoter level mammalian expression atlas. Genome Biol 16(1):22PubMedPubMedCentralCrossRef
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