Immunochemistry is now an established ancillary technique in lung cancer diagnosis. Not only does it help in supporting the morphological diagnosis of malignancy, but its role now extends to the determination of cell lineage, ascertaining the primary site of tumour origin and contributing to decisions on prognosis and treatment. Early detection and confirmation of lung cancer facilitate early treatment decisions. Lung cancer management now has a multidisciplinary approach which includes cytopathologists and clinicians. Some clinicians may not understand what immunochemistry is and what its role is in lung cancer diagnosis, prognosis and therapy. The purpose of this paper is to define immunochemistry, on the background of basic respiratory airway epithelial structure and cancer biology, and discuss its application in the diagnosis, treatment and determination of prognosis of lung cancer.

1.
Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, Thun MJ: Cancer statistics, 2008. CA Cancer J Clin 2008;58:71–96.
2.
Weibel ER: Design of airways and blood vessels considered as branching trees; in Crystal RG, West BJ, Weibel ER, Barnes PJ (eds): The Lung: Scientific Foundations. Philadelphia, Lippincott-Raven, 1997, pp 1061–1071.
3.
Kuhn C: The cytology of the lung: ultrastructure of the respiratory epithelium and extracellular lining layers; in Farrell MP (ed): Lung Development: Biological and Clinical Perspectives. London, Academic Press Inc, 1982, pp 27–55.
4.
Plopper CG, Hyde DM, Buckpitt AR: Clara cells; in Crystal GR, West JB, Weibel E, Barnes PJ (eds): The Lung: Scientific Foundations. Philadelphia, Lippincott-Raven, 1997, pp 517–533.
5.
Plopper CG, Dungworth DL: Structure, function, cell injury and cell renewal of bronchiolar and alveolar epithelium; in McDowell EN (ed): Lung Carcinoma. London, Churchill Livingstone, 1987, pp 29–44.
6.
Devereux TR, Domin BA, Philpot RM: Xenobiotic metabolism by isolated pulmonary cells. Pharmacol Ther 1989;41:243–256.
7.
Mason RJ, Shannon JM: Alveolar type II cells; in Crystal GR, West JB, Weibel E, Barnes PJ (eds): The Lung Scientific Foundations. Philadelphia, Lippincott-Raven, 1997, pp 543–555.
8.
Van Golde LMG, Batenburg JJ, Robertson B: The pulmonary surfactant system: biochemical aspects and functional significance. Physiol Rev 1988;68:374–455.
9.
Hage E: Morphology and histochemistry of the normal and abnormal pulmonary endocrine cell; in Becker KL, Gazdar AF (eds): The Endocrine Lung in Health and Disease. Philadelphia, WB Saunders, 1984, pp 193–209.
10.
Scheuermann DW: Morphology and cytochemistry of the endocrine epithelial system in the lung. Int Rev Cytol 1987;106:35–88.
11.
Schmechel D, Marangos PJ, Brightman M: Neuron-specific enolase is a molecular marker for peripheral and central neuroendocrine cells. Nature 1978;276:834–836.
12.
Franklin WA: The biology of bronchial premalignancy. Semin Respir Crit Care Med 1996;17:309–321.
13.
Zhang X, Chang A: Somatic mutations of the epidermal growth factor receptor and non-small cell lung cancer. J Med Genet 2007;44:166–172.
14.
Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, Harris PL, Haserlat SM, Supko JG, Haluska FG, Louis DN, Christiani DC, Settleman J, Haber DA: Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small cell lung cancer to gefitinib. N Engl J Med 2004;350:2129–2139.
15.
Kerbel RS: Tumour angiogenesis. N Engl J Med 2008;358:2039–2049.
16.
Kitaguchi S, Takeshima Y, Nishisaka T, Inai K: Proliferative activity, p53 expression and loss of heterozygosity on 3p, 9p and 17p in atypical adenomatous hyperplasia of the lung. Hiroshima J Med Sci 1998;47:17–25.
17.
Breuer RH, Pasic A, Smit EF, van Vliet E, Vonk Noordegraaf A, Risse EJ, Postmus PE, Sutedja TG: The natural course of preneoplastic lesions in bronchial epithelium. Clin Cancer Res 2005;11:537–543.
18.
Travis W, Brambilla E, Muller-Hermelink HK, Harris CC: Pathology and Genetics of Tumours of the Lung, Pleura, thymus and Heart. World Health Organization Classification of Tumours. Lyon, IARC Press, 2004.
19.
Rossi A, Maione P, Bareschino MA, Schettino C, Sacco PC, Ferrara ML, Castaldo V, Gridelli C: The emerging role of histology in the choice of first-line treatment of advanced non-small cell lung cancer: implication in the clinical decision-making. Curr Med Chem 2010;17:1030–1038.
20.
Wang GF, Lai MD, Yang RR, Chen PH, Su YY, Lv BJ, Sun LP, Huang Q, Chen SZ: Histological types and significance of bronchial epithelial dysplasia. Mod Pathol 2006;19:429–437.
21.
Idowu MO, Powers CN: Lung cancer cytology: potential pitfalls and mimics – a review. Int J Clin Exp Pathol 2010;3:367–385.
22.
Jackson EL, Willis N, Mercer K, Bronson RT, Crowley D, Montoya R, Jacks T, Tuveson DA: Analysis of lung tumor initiation and progression using conditional expression of oncogenic K-ras. Genes Dev 2001;15:3243–3248.
23.
Miller RR, Nelems B, Evans KG, Muller NL, Ostrow DN: Glandular neoplasia of the lung: a proposed analogy to colonic tumors. Cancer 1988;61:1009–1014.
24.
Westra WH, Baas IO, Hruban RH, Askin FB, Wilson K, Offerhaus GJA, Slebos RJC: K-ras oncogene activation in atypical alveolar hyperplasias of the human lung. Cancer Res 1996;56:2224–2228.
25.
Kitamura H, Kameda Y, Nakamura N, Nakatani Y, Inayama Y, Iida M, Noda K, Ogawa N, Shibagaki T, Kanisawa M: Proliferative potential and p53 overexpression in precursor and early stage lesions of bronchioloalveolar lung carcinoma. Am J Pathol 1995;146:876–887.
26.
Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger RK, Yatabe Y, Beer DG, Powell CA, Reily JG, Van Schil PE, Garg K, Austin JHM, 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 2011;6:244–285.
27.
Yatabe Y, Kosaka T, Takahashi T, Mitsudomi T: EGFR mutation is specific for terminal respiratory unit type adenocarcinoma. Am J Surg Pathol 2005;29:633–639.
28.
Fabbro D, Di Loreto C, Stamerra O, Beltrami CA, Lonigro R, Damante G: TTF-1 gene expression in human lung tumours. Eur J Cancer 1996;32A:512–517.
29.
Sturm N, Rossi G, Lantuejoul S, Laverriere MH, Papotti M, Brichon PY, Brambilla C, Brambilla E: 34βE12 expression along the whole spectrum of neuroendocrine proliferations of the lung, from neuroendocrine cell hyperplasia to small cell carcinoma. Histopathology 2003;42:156–166.
30.
Anbazhagan R, Tihan T, Bornman DM, Johnston JC, Saltz JH, Weigering A, Piantadosi S, Gabrielson E: Classification of small cell lung cancer and pulmonary carcinoid by gene expression profiles. Cancer Res 1999;59:5119–5122.
31.
Turbat-Herrera EA, D’Agostino H, Herrera GA: The use of electron microscopy to refine diagnoses in the daily practice of cytopathology. Ultrastruct Pathol 2004;28:55–66.
32.
Suthipintawong C, Leong AS, Vinyuvat S: Immunostaining of cell preparations: A comparative evaluation of common fixatives and protocols. Diagn Cytopathol 1996;15:167–174.
33.
Abendroth CS, Dabbs DJ: Immunocytochemical staining of unstained versus previously stained cytologic preparations. Acta Cytol 1995;39:379–386.
34.
Travis WD, Wold LE: Immunoperoxidase staining of fine needle aspiration specimens previously stained by the Papanicolaou technique. Acta Cytol 1986;31:517–520.
35.
Bhatia P, Dey P, Uppal R, Shifa R, Srinivasan R, Nijhawan R: Cell blocks from scraping of cytology smear: comparison with conventional cell block. Acta Cytol 2008;52:329–333.
36.
Civitareale D, Lonigro R, Sinclair AJ, Di Lauro R: A thyroid-specific nuclear protein essential for tissue-specific expression of the thyroglobulin promoter. EMBO J 1989;8:2537–2542.
37.
Katoh R, Miyagi E, Nakamura N, Li X, Suzuki K, Kakudo K, Kobayashi M, Kawaoi A: Expression of thyroid transcription factor-1 (TTF-1) in human C cells and medullary carcinomas. Hum Pathol 2000;31:386–393.
38.
Sturm N, Lantuejoul S, Laverriere MH, Papotti M, Brichon PY, Brambilla C, Brambilla E: Thyroid transcription factor 1 and cytokeratins 1, 5, 10, 14 (34βE12) expression in basaloid and large-cell neuroendocrine carcinomas of the lung. Hum Pathol 2001;32:918–925.
39.
Moll R, Franke WW, Schiller DL, Geiger B, Krepler R: The catalogue of human cytokeratins: patterns of expression in normal epithelia, tumours and cultured cells. Cell 1982;31:11–24.
40.
Chu PG, Weiss LM: Keratin expression in human tissues and neoplasms. Histopathology 2002;40:403–439.
41.
Ramaekers F, van Niekerk C, Poels L, Schaafsma E, Huijsmans A, Robben H, Schaart G, Vooijs P: Use of monoclonal antibodies to keratin 7 in the differential diagnosis of adenocarcinoma. Am J Pathol 1990;136:641–655.
42.
Moll R, Löwe A, Laufer J, Franke WW: Cytokeratin 20 in human carcinomas. A new histodiagnostic marker detected by monoclonal antibodies. Am J Pathol 1992;140:427–447.
43.
Hamden P, Allam A, Joyce AD, Patel A, Selby P, Southgate J: Cytokeratin 20 expression by non-invasive transitional cell carcinomas: potential for distinguishing recurrent disease. Histopathology 1995;27:169–174.
44.
Miettinen M: Keratin 20: immunohistochemical marker for gastrointestinal, urothelial, and Merkel cell carcinomas. Mod Pathol 1995;8:384–388.
45.
Shah RN, Badve S, Papreddy K, Schindler S, Laskin WB, Yeldandi AV: Expression of cytokeratin 20 in mucinous bronchioloalveolar carcinoma. Hum Pathol 2002;33:915–920.
46.
Saad RS, Cho P, Silverman JF, Liu Y: Usefulness of Cdx2 in separating mucinous bronchioloalveolar adenocarcinoma of the lung from metastatic mucinous colorectal adenocarcinoma. Am J Clin Pathol 2004;122:421–427.
47.
Rosai J: Special techniques in surgical pathology; in Rosai J (ed): Ackerman’s Surgical Pathology, 8th edition. St. Louis, Mosby, 1996, pp 29–62.
48.
Mraz-Gernhard S, Natkunam Y, Hoppe RT, LeBoit P, Kohler S, Kim KH: Natural killer/natural killer-like T-cell lymphoma, CD56+, presenting in the skin: an increasingly recognized entity with an aggressive course. J Clin Oncol 2001;19:2179–2188.
49.
Jagirdar J: Application of immunohistochemistry to the diagnosis of primary and metastatic carcinoma to the lung. Arch Pathol Lab Med 2008;132:384–396.
50.
Bejarano PA, Baughman RP, Biddinger PW, Miller MA, Fenoglio-Preiser C, al-Kafaji B, Di Lauro R, Whitsett JA: Surfactant proteins and thyroid transcription factor-1 in pulmonary and breast carcinomas. Mod Pathol 1996;9:445–452.
51.
Massion PP, Taflan PM, Jamshedur Rahman SM, Yildiz P, Shyr Y, Edgerton EM, Westfall MD, Roberts JR, Pietenpol JA, Carbone DP, Gonzalez AL: Significance of p63 amplification and overexpression in lung cancer development and prognosis. Cancer Res 2003;63:7113–7121.
52.
Mori K, Shimizu H, Konno A, Iwanaga T: Immunohistochemical localization of napsin and its potential role in protein catabolism in renal proximal tubules. Arch Histol Cytol 2002;65:359–368.
53.
Martin B, Paesmans M, Mascaux C, Berghmans T, Lothaire P, Meert AP, Lafitte JJ, Sculier JP: Ki-67 expression and patients survival in lung cancer: systematic review of the literature with meta-analysis. Br J Cancer 2004;91:2018–2025.
54.
Rossi G, Pelosi GP, Graziano P, Barbareschi M, Papotti M: A reevaluation of the clinical significance of histological subtyping of non-small-cell lung carcinoma: diagnostic algorithms in the era of personalized treatments. Int J Surg Pathol 2009;17:206–218.
55.
Lam B, Wong MP, Fung SL, Lam DC, Wong PC, Mok TY, Lam FM, Ip MS, Ooi CG, Lam WK: The clinical value of autofluorescence bronchoscopy for the diagnosis of lung cancer. Eur Respir J 2006;28:915–919.
56.
Kennedy TC, McWiliams A, Edell E, Sutedja T, Downie G, Yang R, Gazdar A, Mathur PN, American College of Chest Physicians: Bronchial intraepithelial neoplasia/early central airways lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132(3 suppl):221S–233S.
57.
Du EZ, Goldstraw P, Zacharias J, Tiffet O, Craig PJ, Nicholson AG, Weidner N, Yi ES: TTF-1 expression is specific for lung primary in typical and atypical carcinoids: TTF-1-positive carcinoids are predominantly in peripheral location. Hum Pathol 2004;35:825–831.
58.
Rossi G, Cavazza A, Sturm N, Migaldi M, Facciolongo N, Longo L, Maiorana A, Brambilla E: Pulmonary carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements: a clinicopathologic and immunohistochemical study of 75 cases. Am J Surg Pathol 2003;27:311–324.
59.
Brambilla E, Lantuejoul S: Pathology and immunohistochemistry of lung cancer; in Spiro SG, Huber RM, Janes SM (eds): Thoracic Malignancies. European Respiratory Society Monograph, 2009, vol 44, pp 15–35.
60.
Wang NP, Zee S, Zarbo RJ, Bacchi CE, Gown AM: Coordinate expression of cytokeratins 7 and 20 defines unique subsets of carcinomas. Appl Immunohistochem 1995;3:99–107.
61.
Yang M, Nonaka D: A study of immunohistochemical differential expression in pulmonary and mammary carcinomas. Mod Pathol 2010;23:654–661.
62.
Bishop JA, Sharma R, IIIei PB: Napsin A and thyroid transcription factor-1 expression in carcinomas of the lung, breast, pancreas, colon, kidney, thyroid, and malignant mesothelioma. Hum Pathol 2010;41:20–25.
63.
Ordoóñez NG: Value of thyroid transcription factor-1 immunostaining in distinguishing small cell lung carcinomas from other small cell carcinomas. Am J Surg Pathol 2000;24:1217–1223.
64.
Lantuejoul S, Moro D, Michalides RJAM, Brambilla C, Brambilla E: Neural cell adhesion molecules (NCAM) and NCAM-PSA expression in neuroendocrine tumours. Am J Surg Pathol 1998;22:1267–1276.
65.
Brambilla E, Lantuejoul S, Sturm N: Divergent differentiation in neuroendocrine lung tumors. Semin Diagn Pathol 2000;17:138–148.
66.
Azzopardi JG: Oat-cell carcinoma of the bronchus. J Pathol Bacteriol 1959;78:513–519.
67.
Aslan DL, Gulbahce HE, Pambuccian SE, Manivel JC, Jessurun J: Ki-67 immunoreactivity in the differential diagnosis of pulmonary neuroendocrine neoplasms in specimens with extensive crush artifact. Am J Clin Pathol 2005;123:874–878.
68.
Chan JKC, Suster S, Wenig BM, Tsang YW, Chan JB, Lau AL: Cytokeratin 20 immunoreactivity distinguishes Merkel cell (primary cutaneous neuroendocrine) carcinoma and salivary gland small cell carcinomas from small cell carcinomas of various sites. Am J Surg Pathol 1997;21:226–234.
69.
Folpe AL, Gown A, Lamps LW, Garcia R, Dail DH, Zarbo RJ, Schmidt RA: Thyroid transcription factor-1: immunohistochemical evaluation in pulmonary neuroendocrine tumors. Mod Pathol 1999;12:5–8.
70.
Kaufmann O, Dietel M: Expression of thyroid transcription factor-1 in pulmonary and extrapulmonary small cell carcinoma and other neuroendocrine carcinomas of various primary sites. Histopathology 2000;36:415–420.
71.
Pahlman S, Esscher T, Nilsson K: Expression of γ-subunit of enolase, neuron-specific enolase, in human non-neuroendocrine tumors and derived cell lines. Lab Invest 1986;54:554–560.
72.
Agoff SN, Lamps LW, Philip AT, Amin MB, Schmidt RA, True LD, Folpe AL: Thyroid transcription factor-1 is expressed in extrapulmonary small cell carcinomas but not in other extrapulmonary neuroendocrine tumors. Mod Pathol 2000;13:238–242.
73.
Cai YC, Banner B, Glickman J, Odze RD: Cytokeratin 7 and 20 and thyroid transcription factor 1 can help distinguish pulmonary from gastrointestinal carcinoid and pancreatic endocrine tumors. Hum Pathol 2001;32:1087–1093.
74.
Zamecnik J, Kodet R: Value of thyroid transcription factor-1 and surfactant apoprotein A in the differential diagnosis of pulmonary carcinomas: a study of 109 cases. Virchows Arch 2002;440:353–361.
75.
Sturm N, Rossi G, Lantuejoul S, Papotti M, Franchon S, Claraz C, Brichon PY, Brambilla C, Brambilla E: Expression of thyroid transcription factor-1 in the spectrum of neuroendocrine cell lung proliferations with special interest in carcinoids. Hum Pathol 2002;33:175–182.
76.
Wick MR, Swanson PE: Carcinosarcomas: current perspectives and historical review of nosological concepts. Semin Diagn Pathol 1993;10:118–127.
77.
Mc Menamin ME, Goh SG, Poblet E, Gostelow BE, Robson A, Calonje E: Sarcomatoid basal cell carcinoma – predilection for osteosarcomatous differentiation: a series of 11 cases. Am J Surg Pathol 2006;30:1299–1308.
78.
West H, Harpole D, Travis W: Histologic considerations for individualized systemic therapy approaches for the management of non-small cell lung cancer. Chest 2009;136:1112–1118.
79.
Sequist LV, Joshi VA, Jänne PA, Muzikansky A, Fidias P, Meyerson M, Haber DA, Kucherlapati R, Johnson BE, Lynch TJ: Response to treatment and survival of patients with non-small cell lung cancer undergoing somatic EGFR mutation testing. Oncologist 2007;12:90–98.
80.
Minna JD, Gazdar AF, Sprang SR, Herz J: Cancer, a bull’s eye for targeted lung cancer therapy. Science 2004;304:1458–1461.
81.
Sharma SV, Bell DW, Settleman J, Haber DA: Epidermal growth factor receptor mutations in lung cancer. Nat Rev Cancer 2007;7:169–181.
82.
Ladanyi M, Pao W: Lung adenocarcinoma: guiding EGFR-targeted therapy and beyond. Mod Pathol 2008;21:S16–S22.
83.
Brevet M, Arcila M, Ladanyi M: Assessment of EGFR mutation status in lung adenocarcinoma by immunohistochemistry using antibodies specific to the two major forms of mutant EGFR. J Mol Diagn 2010;12:169–176.
84.
Kitamura A, Hosoda W, Sasaki E, Mitsudomi T, Yatabe Y: Immunohistochemical detection of EGFR mutation using mutation-specific antibodies in lung cancer. Clin Cancer Res 2010;16:3349–3355.
85.
Yang J, Ramnath N, Moysich KB, Asch HL, Swede H, Alrawi SJ, Huberman J, Geradts J, Brooks JSJ, Tan D: Prognostic significance of MCM2, Ki-67 and gelsolin in non-small cell lung cancer. BMC Cancer 2006;6:203.
86.
Pugsley JM, Schmidt RA, Vesselle H: The Ki-67 index and survival in non-small cell lung cancer: a review and relevance to positron emission tomography. Cancer J 2002;8:222–233.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.