PAX-5: a valuable immunohistochemical marker in the differential diagnosis of lymphoid neoplasms.
ABSTRACT Undifferentiated tumors and hematolymphoid neoplasms can be diagnostically challenging due to potential overlap of morphologic features and variant antigen expression. PAX-5, a transcription factor expressed throughout B-cell maturation, is detected in most B-cell neoplasms including those that lack expression of mature B-cell markers, such as classical Hodgkin lymphoma (cHL), B-lymphoblastic leukemia and B-cell lymphomas following rituximab therapy. The lack of PAX-5 expression in most CD30-positive non-hematopoietic malignancies (embryonal carcinoma and seminoma) and T-cell lymphomas, such as anaplastic large cell lymphoma (ALCL), suggests that the absence of PAX-5 may be used to confirm non-B-cell lineage. The goal of this study was to retrospectively assess PAX-5 immunoreactivity in diagnostic samples of hematolymphoid and other non-hematopoietic malignancies.
Diagnostic lymph node, decalcified core bone marrow biopsies and tissue sections from 111 archived paraffin-embedded tissue blocks and a tissue lymphoma microarray were immunostained using a monoclonal antibody to PAX-5. The corresponding hematoxylin and eosin stained tissue sections and additional immunostains were simultaneously evaluated. PAX-5 immunoreactivity in neoplastic cells was scored as positive or negative. This study was exempted by the Institutional Review Board for Human Research.
Nuclear PAX-5 immunoreactivity was detected in 88% (36/41) of Hodgkin lymphoma, all cases of diffuse large B-cell lymphoma (n=72), small B-cell lymphomas (n=5), B-lymphoblastic leukemia/lymphoma and mixed phenotype acute leukemia with B-cell lineage (n=5). PAX-5 was not detected in ALCL (n=22), T-cell lymphoblastic leukemia/lymphoma, mixed phenotype acute leukemia with T-cell lineage (n=5), acute myeloid leukemia (n=4), carcinoid tumors with typical morphology (n=5), melanoma (n=3), and undifferentiated/metastatic tumors (n=8). Non-neoplastic bone marrow sections showed scattered nuclear staining in small B-cell lymphocytes/hematogones. The detection of PAX-5 immunoreactivity resulted in the reclassification of two cases of ALCL to cHL.
Overall, our results demonstrate that including PAX-5 in a panel with other immunomarkers helps establish B-cell lineage and increases diagnostic yield.
- [Show abstract] [Hide abstract]
ABSTRACT: Uncommon tumors in the uterus present diagnostic challenges. In some cases, the tumor subtype is usually seen outside of the gynecologic tract and the possibility of a uterine primary is not considered. In other cases, histologic overlap with more common uterine tumors leads to potential misdiagnosis. Finally, metastatic carcinoma may the uterus and cervix. Rarely, symptoms related to the uterine metastasis may precede diagnosis of an extra uterine primary. Without the proper clinical context, the possibility of a missed diagnosis is increased. One must first be aware of these possibilities, but immunoperoxidase studies are often necessary to confirm the diagnosis. In this review, unusual and metastatic tumors involving the uterine corpus and cervix and immunoperoxidase studies used to diagnosis such tumors are discussed.Seminars in Diagnostic Pathology 05/2014; · 1.80 Impact Factor
Article: Biomarkers of HIV-associated Cancer.[Show abstract] [Hide abstract]
ABSTRACT: Cancer biomarkers have provided great opportunities for improving the management of cancer patients by enhancing the efficiency of early detection, diagnosis, and efficacy of treatment. Every cell type has a unique molecular signature, referred to as biomarkers, which are identifiable characteristics such as levels or activities of a myriad of genes, proteins, or other molecular features. Biomarkers can facilitate the molecular definition of cancer, provide information about the course of cancer, and predict response to chemotherapy. They offer the hope of early detection as well as tracking disease progression and recurrence. Current progress in the characterization of molecular genetics of HIV-associated cancers may form the basis for improved patient stratification and future targeted or individualized therapies. Biomarker use for cancer staging and personalization of therapy at the time of diagnosis could improve patient care. This review focuses on the relevance of biomarkers in the most common HIV-associated malignancies, namely, Kaposi sarcoma, non-Hodgkin's lymphoma, and invasive cervical cancer.Biomarkers in cancer. 01/2014; 6:11-20.
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ABSTRACT: A 7-month-old castrated male French Bull dog was presented with vomiting, lethargy, anorexia and weight loss of 2 weeks duration. The patient's history and clinical manifestations of suspected hepatopathy were subjected to ultrasonography, radiography, biochemical investigations and cytology of hepatic lesion. The cytologic impression was hepatic lymphoma, which was later confirmed by histopathology. The neoplastic cells were strongly diffusely immunoreactive for PAX5, but not immunoreactive for CD3, and B lymphocyte specific clonal proliferation was detected using by assay of antigen receptor rearrangement. Large numbers of immunoreactive mature non-neoplastic lymphocytes were admixed with the neoplastic cell population. Therefore, the immunohistochemical results were definitively consistent with a T-cell rich B-cell lymphoma (TCRBCL). This is the first description of a hepatic TCRBCL in a juvenile dog showing a poor response to aggressive chemotherapy.Journal of Veterinary Medical Science 10/2014; · 0.88 Impact Factor
Clinical Medicine & Research
Volume 8, Number 2: 84-88
©2010 Marshfield Clinic
PAX-5: A Valuable Immunohistochemical Marker
in the Differential Diagnosis of Lymphoid Neoplasms
Mohamed M. Desouki, MD, PhD; Ginell R. Post, MD, PhD; Daniel Cherry, MD; and John Lazarchick, MD
Objective: Undifferentiated tumors and hematolymphoid neoplasms can be diagnostically challenging
due to potential overlap of morphologic features and variant antigen expression. PAX-5, a transcription
factor expressed throughout B-cell maturation, is detected in most B-cell neoplasms including those
that lack expression of mature B-cell markers, such as classical Hodgkin lymphoma (cHL),
B-lymphoblastic leukemia and B-cell lymphomas following rituximab therapy. The lack of PAX-5
expression in most CD30-positive non-hematopoietic malignancies (embryonal carcinoma and
seminoma) and T-cell lymphomas, such as anaplastic large cell lymphoma (ALCL), suggests that the
absence of PAX-5 may be used to confirm non-B-cell lineage. The goal of this study was to
retrospectively assess PAX-5 immunoreactivity in diagnostic samples of hematolymphoid and other
Design: Diagnostic lymph node, decalcified core bone marrow biopsies and tissue sections from 111
archived paraffin-embedded tissue blocks and a tissue lymphoma microarray were immunostained
using a monoclonal antibody to PAX-5. The corresponding hematoxylin and eosin stained tissue
sections and additional immunostains were simultaneously evaluated. PAX-5 immunoreactivity in
neoplastic cells was scored as positive or negative. This study was exempted by the Institutional
Review Board for Human Research.
Results: Nuclear PAX-5 immunoreactivity was detected in 88% (36/41) of Hodgkin lymphoma, all
cases of diffuse large B-cell lymphoma (n=72), small B-cell lymphomas (n=5), B-lymphoblastic leukemia/
lymphoma and mixed phenotype acute leukemia with B-cell lineage (n=5). PAX-5 was not detected in
ALCL (n=22), T-cell lymphoblastic leukemia/lymphoma, mixed phenotype acute leukemia with T-cell
lineage (n=5), acute myeloid leukemia (n=4), carcinoid tumors with typical morphology (n=5),
melanoma (n=3), and undifferentiated/metastatic tumors (n=8). Non-neoplastic bone marrow sections
showed scattered nuclear staining in small B-cell lymphocytes/hematogones. The detection of PAX-5
immunoreactivity resulted in the reclassification of two cases of ALCL to cHL.
Conclusion: Overall, our results demonstrate that including PAX-5 in a panel with other
immunomarkers helps establish B-cell lineage and increases diagnostic yield.
Corresponding Author: John Lazarchick, MD; Department of Pathology &
Laboratory Medicine; Medical University of South Carolina; Charleston, SC
29425; Tel: 843-792-0217; Email: email@example.com
Received: October 1, 2009
1st Revision: January 11, 2010
2nd Revision: March 18, 2010
Accepted: March 24, 2010
Keywords: Anaplastic large cell lymphoma; Diffuse large B-cell lymphoma; Hodgkin lymphoma; PAX-5;
CM&R 2010 : 2 (July)
Desouki et al.
Undifferentiated, anaplastic, and certain hematolymphoid
malignancies can constitute a diagnostic challenge due to
overlap of morphologic features and antigen expression. In
most cases, immunohistochemical characterization using a
panel of antibodies can resolve cell lineage, providing
valuable diagnostic information, and would typically include
antibodies to CD45 (hematolymphoid), cytokeratin
(carcinoma), vimentin (sarcoma), and synaptophysin
(neuroendocrine). The initial immunohistochemical panel for
lymphomas would include CD20 (B-cells), CD3 (T-cells),
CD138 (plasma cells) and CD30 (Reed-Sternberg cells of
classical Hodgkin lymphoma (cHL), anaplastic B- and T-cell
lymphomas.) Multiple antibodies are then utilized for
subtyping the B- and T-cell lymphomas to make a specific
diagnosis. However, cHL, a tumor of B-cell lineage that is
CD45 negative, often lacks expression of pan B-cell markers
(CD20 and CD79a) and/or may paradoxically express T-cell
antigens. Absence of CD20 and expression of CD30 can
make cHL particularly difficult to distinguish from anaplastic
large cell lymphoma (ALCL), a T-cell malignancy. The latter
may lack the expression of many T-cell antigens.1 Similarly,
rituximab therapy in patients with B-cell lymphomas is
associated with loss of CD20 immunoreactivity,2-4 making
the use of CD20 immunohistochemistry unreliable for
detection of residual disease.
The B-cell-specific activator protein, PAX-5, is a nuclear
transcription factor which plays a major role in B-cell
differentiation and proliferation.5,6 PAX-5 gene expression is
increased during early B-cell development and retained
throughout maturation, but is absent in plasma cells7-9 and
T-cells.10 PAX-5 is expressed in the vast majority of B-cell
malignancies.10,11 In addition, PAX-5 immunoreactivity is
detected in subsets of epithelial and mesenchymal tumors,
including poorly differentiated neuroendocrine carcinoma,
mesonephric carcinoma, cervical carcinoma,12 Merkel
cell carcinoma, small cell carcinomas, aggressive
neuroblastoma,10, 12-15 squamous cell carcinoma of the oral
cavity,16 Wilms tumors, and alveolar rhabdomyosarcoma.17
The primary aim of this study was to establish the utility of
including PAX-5 in a panel of antibodies to distinguish
CD30-positive lymphoproliferative disorders with an
emphasis on cHL and ALCL. A smaller number of other
B- and T-cell hematopoietic neoplasms and non-hematopoietic
malignancies were included as a secondary goal. We found
that PAX-5 immunoreactivity lead to revision of the diagnosis
to cHL in two cases that were originally diagnosed as ALCL.
Cases and tissue microarray
A total of 111 cases of undifferentiated, anaplastic, and
hematolymphoid malignancies from archived paraffin-
embedded formalin-fixed tissue blocks from the Department
of Pathology at the Medical University of South Carolina and
Trident Medical Center, (Charleston, SC) from the period of
1997 to 2008, and a 69 sample tissue microarray (Imgenex,
San Diego, CA) were examined for PAX-5 expression.
The cases included cHL with differential expression of CD30
and CD15 (n=41), diffuse large B-cell lymphoma (n=72),
small B-cell lymphoma (n=5), B-cell lymphoblastic leukemia/
lymphoma (LBL) and mixed phenotype acute leukemias with
B-cell lineage (n=5), ALCL with differential expression of
CD30, ALK-1, and CD3 (n=22), and T-cell LBL and mixed
phenotype acute leukemias with T-cell lineage (n=5). PAX-5
expression was also evaluated in acute myeloid leukemia
(AML) (n=4), carcinoid tumors (n=5), melanomas (n=3),
Figure 1: Left side panels (hematoxylin and eosin stain) and
right side panels (PAX-5 immunohistochemical stain) of
representative fields for (A and B) classical Hodgkin lymphoma;
(C and D) diffuse large B-cell lymphoma (DLBCL); (E and F)
anaplastic large cell lymphoma (ALCL); (G and H) acute
myeloid leukemia (AML); and (I and J) undifferentiated
carcinoma. Note strong nuclear PAX-5 immunostaining in
DLBCL (D) in contrast to faint staining in Reed-Sternberg
Hodgkin lymphoma cells (B). ALCL (F), AML (H) and
undifferentiated carcinoma (J) cases are totally negative for
PAX-5 staining (original magnification ×400).
CM&R 2010 : 2 (July)
undifferentiated/metastatic tumors (n=8), and benign bone
marrow (n=10). The corresponding hematoxylin and eosin
stained tissue sections (n=111) and available immunostains
were re-evaluated for diagnostic confirmation.
Tissue sections from decalcified bone marrow core biopsies,
lymph nodes, and other soft tissue sections were processed for
immunohistochemistry using a Dako autostainer (Dako
Cytomation, Carpinteria, CA). The immunostain panel used
in the study included antibodies to PAX-5, CD45, CD20,
CD3, CD30, CD15 and ALK-1. Because some antibodies do
not work well in decalcified specimens, we optimized the
antigen retrieval and staining protocol for PAX-5. We utilized
positive and negative control cases from decalcified bone
marrow biopsies and non-decalcified sections and found no
differences in PAX-5 nuclear immunoreactivity. Briefly,
slides were deparaffinized with heating and xylene incubation.
Antigen retrieval was performed using high pH EDTA at
99.3°C for 20 minutes followed by incubation in 3% hydrogen
peroxide for 10 minutes. Sections were then incubated with
monoclonal anti-PAX-5 antibody at 1:100 dilution (Biocare
Medical, Concord, CA) at room temperature for 30 minutes,
followed by anti-mouse (Envision+ kit, Dako, Carpinteria,
CA) for 30 minutes. Color was developed with Dako DAB+
chromogenic substrate system for 10 minutes, followed by
Dako DAB enhancer for 5 minutes. Hematoxylin was used as
counterstain. The appearance of nuclear immunoreactivity for
PAX-5 was scored as positive or negative.
There were 36 of 41 (88%) Hodgkin lymphoma cases positive
for PAX-5 staining (figure 1A and 1B). The five cases that
were negative for PAX-5 were distributed among the
morphologic subtypes of Hodgkin lymphoma. There was no
difference in PAX-5 immunoreactivity among the tissue
sources (core biopsy vs soft tissue sections). Two cases
initially diagnosed as ALCL showed PAX-5 immunoreactivity
and were subsequently reclassified as cHL NOS (not
otherwise specified) (table 1). The immunophenotype of
these two cases was as follows: positive for CD30 and
negative for CD15, CD20, CD3, ALK-1 and epithelial
membrane antigen. The nodular lymphocyte predominance
Hodgkin’s cases (n=4) were also PAX-5 positive (table 1).
All cases of diffuse large B-cell lymphoma (72/72) (figure 1C
and 1D), including the 57 cases from tissue microarray, small
B-cell lymphomas (5/5), and B-cell LBL and mixed phenotype
acute leukemia with B-cell lineage (5/5) were positive for
PAX-5 was not detected in any of the cases of ALCL (n=22)
(table 2) (figure 1E and 1F), T-cell LBL, or mixed phenotype
acute leukemia with T-cell lineage (n=5). Three cases of
ALCL that were negative for PAX-5 were also ALK-1
negative by immunohistochemistry. One case was negative
for a translocation involving 2p23.
PAX-5 immunoreactivity was found in scattered B-cells in a
patient with AML but was negative in blasts (figure 1G and
1H). Carcinoid tumors (n=5), melanomas (n=3), and
undifferentiated/metastatic tumors (n=8) were all negative for
PAX-5 (table 3) (figure 1I and 1J). Non-neoplastic bone
marrow sections (n=10) showed scattered positive nuclear
staining in small B-lymphocytes/hematogones.
PAX-5 is a transcription factor expressed throughout B-cell
development.5-8 PAX-5 expression is not detected in plasma
cells7-9 or T-cells.10 The results of this study showed that all
Use of PAX-5 in the diagnosis of lymphoid neoplasms
Table 2: Immunophenotype of anaplastic large cell lymphoma (n=22).
PAX-5 CD30 ALK-1 CD20 CD3 CD45
Table 1: Morphology and immunophenotype of Hodgkin lymphoma (n=41).
PAX-5 CD30 CD15
Positive Negative Positive Negative ND Positive Negative ND
MCHL: Mixed cellularity Hodgkin lymphoma; NSHL: Nodular sclerosis Hodgkin lymphoma; LRHL: Lymphocyte-rich classic Hodgkin lymphoma; cHL NOS: classic
Hodgkin lymphoma not otherwise specified; NLPHL: Nodular lymphocyte-predominant Hodgkin lymphoma; ND: Not determined
CM&R 2010 : 2 (July)
Desouki et al.
previously diagnosed B-cell lymphomas and leukemias
showed diffuse and strong nuclear PAX-5 expression in tissue
sections and decalcified bone marrow biopsies. These results
confirm the ability of PAX-5 nuclear reactivity to mark
tumors of mature B-cell lineage9-11,18-21 and extend these
findings by demonstrating PAX-5 expression in B-cell LBLs
and mixed phenotype acute leukemias with B-cell lineage.
In contrast to the B-cell malignancies, none of the T-cell or
myeloid malignancies tested were positive for PAX-5. The
absence of PAX-5 expression in all cases of T-cell LBL and
ALCL confirmed T-cell lineage and diagnosis in these cases.
Of note, three of the ALCL cases were also negative for
ALK-1 expression by immunohistochemistry and molecular
studies (one of three cases tested). PAX-5 expression has been
reported in AML with t(8;21)22-24 and a subset of acute
promyelocytic leukemia.18,25 In agreement, our cases of
AML, which were negative for these translocations, were also
negative for PAX-5. Thus, the addition of PAX-5 to a panel of
immunostains can help rule out T-cell lineage in leukemia,
ALK-1-negative ALCL, and a subset of AML with recurring
Similar to other reports, we found faint PAX-5 nuclear
staining in the Hodgkin’s and Reed-Sternberg cells in the
majority of cHL cases (88%) irrespective of morphologic
subtype.10,11,26 An important finding of this retrospective
study was that the presence of PAX-5 immunoreactivity led to
the reclassification of two cases originally diagnosed as
ALCL to cHL NOS. The immunophenotype of these lymph
node cases showed immunoreactivity for CD30 but not other
markers (CD15, CD20, CD3, ALK-1 and epithelial membrane
antigen) (table 1). The correct classification of these
malignancies is important, as the therapy and prognosis for
cHL and ALCL differs.27
All non-hematolymphoid neoplasms examined were negative
for PAX-5 immunoreactivity (table 3). Torlakovic et al12
reported weak positivity PAX-5 in two atypical carcinoid
tumors, while others have reported persistent PAX-5 negativity
in all typical carcinoid cases.10,15 In agreement, the carcinoid
cases in our small series were negative for PAX-5 and showed
typical morphology. Similar to our findings, Jensen et al11
reported negative PAX-5 expression in melanomas and
different epithelial adenocarcinomas and squamous
Our results highlight the beneficial role of including PAX-5
in an immunohistochemical panel to diagnose lymphoid
neoplasms of B-cell origin. Furthermore, absence of PAX-5
expression is helpful to establish T-cell lineage and rule out
non-lymphoid tumors with anaplastic cell morphology
(undifferentiated and metastatic tumors).
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Table 3: PAX-5 immunophenotype in acute myeloid leukemia, normal bone marrow and non-lymphoid neoplasms.
Diagnosis Positive Negative Total
Acute myeloid leukemia
Normal bone marrow
CM&R 2010 : 2 (July)
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Mohamed M. Desouki, MD, PhD*; Ginell R. Post, MD, PhD*‡;
Daniel Cherry, MD†; John Lazarchick, MD*
*Department of Pathology & Laboratory Medicine,
Medical University of South Carolina, Charleston,
South Carolina, USA
†Department of Pathology, Trident Medical Center,
Charleston, South Carolina, USA
‡Current affiliation: University of Arkansas for Medical
Sciences, Little Rock, Arkansas, USA