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DR DEBRA L ZYNGER (Orcid ID : 0000-0003-1038-5699)
Article type
: Short Report
Utility of GATA3 in the Differential Diagnosis of Pheochromocytoma
Carmen M. Perrino, MD Alex Ho Christopher P. Dall, BS
Debra L. Zynger, MD
Department of Pathology (C.M.P., A.H., C.P.D., D.L.Z.)
The Ohio State University Medical Center
410 W 10th Ave.
401 Doan Hall
Columbus, OH 43210
Address correspondence and reprint requests to: Department of Pathology (D.L.Z.) The Ohio State University 410 W 10th Ave. 401 Doan Hall Columbus, OH 43210 debra.zynger@osumc.edu Phone (614) 293-7705 Fax (614) 293-2779
Running title: GATA3 IHC in Pheochromocytoma
Keywords: adrenal, pheochromocytoma, GATA3, immunohistochemistry
A portion of this data was presented at the annual United States and Canadian Academy of Pathology annual meeting in Seattle in March 2016.
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/his.13229
This article is protected by copyright. All rights reserved.
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Abstract
Aims
GATA3 is a relatively new immunohistochemical marker which shows consistent nuclear expression in a variety of tumors, including breast and urothelial carcinoma. The staining pattern of GATA3 in adrenal lesions is not well established. We aim to describe the expression of GATA3 in adrenal tumors and determine if there is differential staining between pheochromocytoma and adrenal cortical carcinoma.
Methods and results
A retrospective search was performed to identify 74 adrenal lesions which were immunohistochemically tested for GATA3 expression. GATA3 was negative in 90% of adrenal cortical carcinoma. In contrast, pheochromocytomas were frequently positive (71%) including benign pheochromocytoma, pheochromocytoma with features concerning for malignancy, malignant (metastatic) pheochromocytoma, and composite pheochromocytoma with ganglioneuroma. Metastatic lung adenocarcinoma in the adrenal gland had occasional (36%) expression while metastatic clear cell renal cell carcinoma in the adrenal gland did not express GATA3.
Conclusion
As the most common pitfall in diagnosing adrenal cortical carcinoma is mistaking it for pheochromocytoma or vice versa, GATA3 may be useful in narrowing the differential diagnosis as a part of a panel of immunohistochemical markers. However, the occasional GATA3 expression in the most common source of metastases within the adrenal gland, metastatic pulmonary adenocarcinoma, may confound the diagnosis due to the overlapping expression with pheochromocytoma and other carcinomas.
Introduction
GATA3 is an important transcription factor involved in cellular differentiation and development. One of its many critical functions includes ensuring the survival of sympathetic neurons in both embryonic development and adults.1,2 It has gained use as an immunohistochemical marker, primarily in the differential diagnosis of breast and urothelial carcinoma, which both express GATA3.3 Recently, GATA3 has been described to have high expression in paraganglioma of the bladder.4 GATA3 expression has not been widely established in other types of lesions of the adrenal gland, specifically pheochromocytoma and adrenal cortical carcinoma. In addition, the 2 most frequent carcinomas to metastasize to the adrenal,
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lung adenocarcinoma and clear cell renal cell carcinoma, are reported to have low expression in their primary location but metastases to the adrenal have not been examined.3,5,6 We aimed to assess the expression of GATA3 within a histologic spectrum of pheochromocytomas as well as in other adrenal lesions including adrenal cortical carcinoma, metastatic lung adenocarcinoma, and clear cell renal cell carcinoma to establish the diagnostic utility of GATA3 within the adrenal gland.
Material and methods
A retrospective search of the pathology database at our institution from 2007 to 2016 was conducted. This study was approved by the institutional review board (protocol 2015E0418, approval 7/30/2015). A single block from the following adrenal tumors was selected for immunohistochemical testing: pheochromocytoma (n=14), pheochromocytoma with features concerning for malignancy (n=15), malignant pheochromocytoma (n=9), composite pheochromocytoma with ganglioneuroma (n=3), adrenal cortical carcinoma (n=10), metastatic lung adenocarcinoma in the adrenal gland (n=11), and metastatic clear cell renal cell carcinoma in the adrenal gland (n=12). Adrenal cortical carcinoma and malignant pheochromocytoma had histologically confirmed metastases. Pheochromocytomas were defined as concerning for malignancy if they had a score of ≥4 using the following weighted features from the Pheochromocytoma of the Adrenal gland Scaled Score (PASS)7: periadrenal adipose tissue invasion (+2), >3 mitosis per 10 high powered fields (+2), atypical mitoses (+2), necrosis (+2), spindling (+2), marked nuclear pleomorphism (+2), cellular monotony (+2), large nests or diffuse growth (+2), high cellularity (+2), capsular invasion (+1), vascular invasion (+1), hyperchromasia (+1). All specimens were excisions, except for needle core biopsies from 1
malignant pheochromocytoma, all 11 metastatic lung adenocarcinomas, and 3 metastatic clear cell renal cell carcinomas.
GATA3 staining with a monoclonal antibody was performed on a representative unstained slide (clone L50-823, 1:400, Biocare Medical, Pacheco, CA, USA). Heat-induced epitope retrieval was performed (Bond Epitope Retrieval Solutions 2, Leica Biosystems, Buffalo Grove, IL, USA). Sections were incubated in primary antibody for fifteen minutes then detected using a polymer-based detection system (Bond Polymer Refine Detection Kit, Leica Biosystems, Buffalo Grove, IL, USA). Nuclear reactivity was semi-quantitatively evaluated for percent of cells stained (0, <5%; 1+, 5-10%; 2+, 11-50%; 3+, >50%) and intensity (0-3). Urothelial carcinoma was used as a GATA3 positive control.
A two-sided exact Fischer test was performed to evaluate differences in GATA3 reactivity between malignant and benign/histologically concerning pheochromocytomas. To assess differences in staining intensity between the three groups of pheochromocytomas (malignant, benign, and histologically concerning), a two-tailed Kruskal-Wallis test was utilized. A P-value less than or equal to 0.05 was considered significant.
Results
Immunohistochemical results are summarized in Table 1. Pheochromocytomas were frequently positive. The majority (90%) of malignant pheochromocytomas had strong positivity for GATA3 (0, 11%; 3+, 89%; mean intensity 3.0) (Figure 1A). Most benign pheochromocytomas (71% positive; 0, 29%; 2+, 29%; 3+, 43%; mean intensity 2.4) and pheochromocytomas with histologically concerning features (53% positive; 0, 47%; 2+, 13%; 3+, 40%; mean intensity 2.3) were also positive with differential staining intensity not identified
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(P = 0.20) (Figure 1B). There was no statistically significant difference in the GATA3 semi- quantitative percent positivity between the malignant and benign/histologically concerning pheochromocytomas (P = 0.22). All cases of composite pheochromocytoma with ganglioneuroma were strongly positive (100% positive; 3+, 100%; mean intensity 3.0). Areas of pheochromocytoma were strongly positive, ganglion cells were weakly positive, and Schwann cells were negative. In contrast, GATA3 was negative in 90% of adrenal cortical carcinomas with weak nuclear staining in a single case (0, 90%; 2+, 10%; mean intensity 1.0) (Figure 1C). GATA3 was expressed in 36% of metastatic lung adenocarcinomas to the adrenal gland with strong expression in all cases that had reactivity (0, 64%; 1+, 9%; 2+, 9%; 3+, 18%) (Figure 1D). GATA3 was negative in all cases of metastatic clear cell renal cell carcinoma to the adrenal gland (0, 100%).
Discussion
GATA3 was initially touted as a sensitive and specific nuclear immunohistochemical marker for urothelial carcinoma and invasive ductal carcinoma of the breast. Since that time, GATA3 expression has been reported in a diverse array of normal tissues including the chromaffin cells of the adrenal medulla, epidermis, hair follicles, parathyroid gland, mammary duct epithelium, salivary gland epithelium, urothelium, and subsets of T-lymphocytes.6,8 It is also expressed in an increasing repertoire of tumors, including a subset of squamous cell carcinoma, chromophobe renal cell carcinoma, and salivary gland tumors.6 However, its expression in primary and metastatic adrenal lesions is not well characterized in the literature.6,8,9 It is important to elucidate the expression profile within adrenal lesions as adrenal metastases are more frequent than primary malignant adrenal tumors and an overlapping expression profile may
represent a diagnostic pitfall.” In this investigation, we observed differential expression of GATA3 within adrenal gland lesions.
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Most pheochromocytomas had nuclear reactivity using GATA3 (29/41, 71%). These results are somewhat lower than 2 prior publications describing GATA3 in pheochromocytoma in which GATA3 expression was identified in 95% (20/21) and 92% (22/24) of cases.6,8 Previous reports did not distinguish between benign pheochromocytoma, pheochromocytoma with histologic features concerning malignancy, and overtly malignant pheochromocytoma (pheochromocytoma with metastases). These researchers used the same GATA3 clone (L50-823) as that used in our study. We found robust expression of GATA3 in almost all malignant pheochromocytomas tested, with no significant difference between malignant, benign, or pheochromocytomas with histologic features concerning for malignancy. Composite pheochromocytomas with ganglioneuroma also had GATA3 expression. As most cases of pheochromocytoma had GATA3 positivity, the expression pattern is not useful for prognostication.
Adrenal cortical carcinoma rarely expressed GATA3 and the single case with expression showed weak reactivity. Previously, researchers tested a few cases of adrenal cortical carcinoma (n=4 and n=3) with no expression of GATA3 observed8,9 and others reported rare positivity (3/27, 11%),’ similar to our findings. Authors used the same clone as our investigation in 2 of the studies and did not specify the clone utilized in the third article.6,8,9
Additionally, we investigated the 2 most common metastases to the adrenal gland, pulmonary adenocarcinoma and clear cell renal cell carcinoma. All cases of metastatic clear cell renal cell carcinoma were negative for GATA3 but 36% of metastatic pulmonary adenocarcinoma were positive, and the intensity of expression was strong. Our rate of GATA3
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reactivity in lung adenocarcinoma (4/11, 36%) was greater than that reported in a previous publication in which GATA3 expression was identified in 9% (6/71) of cases using clone L50- 823.6
Reactivity of GATA3 in pheochromocytoma, metastatic lung adenocarcinoma, and breast ductal carcinoma present diagnostic challenges to pathologists unaware of the expression profile. With regard to primary adrenal lesions, our findings show that GATA3 reactivity favors the diagnosis of pheochromocytoma over other adrenal lesions. As the most common pitfall in diagnosing adrenal cortical carcinoma is mistaking it for pheochromocytoma or vice versa, GATA3 may be helpful in this differential diagnosis.10
In conclusion, GATA3 immunohistochemistry successfully differentiates pheochromocytoma (diffuse, strong positivity) from adrenal cortical carcinoma (usually negative) and has clinical utility to differentiate these two lesions when used in conjunction with other immunohistochemical markers. It is important to be aware of the reactivity of GATA3 in pheochromocytoma to avoid interpreting the expression as evidence of metastases from other sources such as breast or urothelial carcinoma. Additionally, we found occasional expression in metastatic pulmonary adenocarcinoma, the most common source of metastases in the adrenal gland, in which the overlapping expression with pheochromocytoma and other carcinomas represents a potential diagnostic pitfall.
Table and Figure Legends
Table 1. GATA3 immunohistochemical results
Figure 1. Photomicrographs of adrenal lesions with GATA3 immunostains. A, Pheochromocytoma with features concerning for malignancy (cellular spindling) with diffuse
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GATA3 reactivity (H&E on left, 20x; GATA3 on right, 40x). B, Malignant pheochromocytoma with diffuse GATA3 positivity (H&E on left, 10x; GATA3 on right, 10x). C, Adrenal cortical carcinoma with no GATA3 expression (H&E on left, 40x; GATA3 on right, 40x). D, Lung adenocarcinoma metastatic to the adrenal gland with diffuse GATA3 expression (H&E on left, 10x; GATA3 on right,10x).
Acknowledgments
Carmen M. Perrino, M.D .: literature review, collected data, analyzed data, wrote majority of manuscript
Alex Ho: collected data, analyzed data, began draft of manuscript
Christopher P. Dall, B.S .: collected data, analyzed data, critical revisions of manuscript
Debra L. Zynger, M.D .: conceived idea, collected data, critical revisions of manuscript
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| Benign Pheochromocytoma (n=14) Pheochromocytoma with Concerning Features (n=15) Malignant Pheochromocytoma (n=9) Composite Pheochromocytoma (n=3) Adrenal Cortical Carcinoma (n=10) AGRARIA | % Positive | Percentage of cells stained | Intensity (mean) | ||||
|---|---|---|---|---|---|---|---|
| 0 (<5%) | 1+ (5%- 10%) | 2+ (11%- 50%) | 3+ (>50%) | ||||
| 71% | 4 | 0 | 4 | 6 | 2.4 | ||
| 53% | 7 | 0 | 2 | 6 | 2.3 | ||
| 89% | 1 | 0 | 0 | 8 | 3.0 | ||
| 100% | 0 | 0 | 0 | 3 | 3.0 | ||
| 10% | 9 | 0 | 1 | 0 | 1.0 | ||
| Metastatic Lung Adenocarcinoma (n=11) | 36% | 7 | 1 | 1 | 2 | 3.0 | |
| Metastatic Clear Cell Renal Cell Carcinoma (n=12) | 0% | 12 | 0 | 0 | 0 | 0.0 | |
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B
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D