Material and Method: Our study included 30 samples of malignant mesothelioma, 30 samples of pulmonary adenocarcinoma and 30 samples of reactive mesothelial hyperplasia selected from the archives of the Fırat University Hospital's Pathology Department Laboratory. The samples were applied GLUT-1 and KOC markers by immunohistochemistry and the place of these markers in the diff erential diagnosis was examined.
Results: GLUT-1 was found positive in 80% of malignant mesothelioma cases, 83.3% of adenocarcinoma cases and 6.6% of reactive mesothelial hyperplasia cases. KOC was positive in 83.3% of malignant mesothelioma cases, 76.6% of adenocarcinoma cases and 46.6% of reactive mesothelial hyperplasia cases. There was no statistically significant diff erence between malignant mesothelioma and lung adenocarcinoma cases in terms of the diffuseness and intensity of staining with GLUT-1, whereas a significant diff erence was established when these groups were compared with reactive mesothelial hyperplasia cases. However, the KOC staining diffuseness and intensity results were similar to those obtained with GLUT-1.
Conclusion: In conclusion, GLUT-1 and KOC markers do not diff erentiate malignant mesotheliomas from pulmonary adenocarcinomas but can be useful in diff erentiating reactive mesothelial hyperplasia from malignant mesothelioma and lung adenocarcinoma.
It may be difficult to diff erentiate MM from pulmonary adenocarcinoma (PAC) and benign mesothelial proliferations due to the similarity and large number of varied histological subtypes[2,4,5,6]. Many immunohistochemical determinants have so far been studied for the diagnosis of MM and numerous articles have been published for the sensitivity and specificity of each[7]. However, many investigators now feel that combinations of two or three antibodies may be useful due to the lack of a specific marker for the diagnosis of MM and the diff erences in the sensitivities of the antibodies[5,8,9].
Th e proliferation of cancer cells is a process associated with energy supported by increased glucose metabolism[10,11]. Th is event is realized by glucose transport facilitating proteins whose secretion and activity are regulated by some growth factors and oncogenes[12-14]. The increased glucose uptake of malignant cells leads to excessive secretion of these carrier proteins[13-15]. GLUT-1 (glucose transporter isoform-1) is a member of the glucose transport facilitator family consisting of 14 members and facilitates the entry of glucose into the cell[12,14,16,17]. It is physiologically secreted and can be found by IHC in all cells and tissues that use glucose and in particular erythrocyte membranes, the blood-brain barrier and the perineurium of peripheral nerves[11]. However, GLUT-1 does not exist or exists in low amounts in most epithelial tissues[12,14,15,17–19].
KOC (K homology domain-containing protein), commonly known as IMP3 (insulin-like growth factor 2 mRNA binding protein 3) in the literature, is an oncofetal RNA-binding protein[20–23]. The IMP family plays an important role in the stabilization of mRNA, cell growth, cell proliferation and cell migration during the early stages of embryogenesis[21,22,24,25]. It's normal secretion in periods following embryogenesis is limited[21,23].
Th e aim of this study was to determine the value of GLUT- 1 and KOC markers in the diff erential diagnosis between reactive mesothelial hyperplasia (RMH) and PAC.
Four-micron thick sections obtained from blocks chosen from the samples of ninety cases were processed on the automated staining device (Ventana Medical System, SN: 712299, REF: 750-700, Arizona, USA) for GLUT-1 and KOC staining. Samples of placental tissue were used as positive control for both GLUT-1 and KOC antibodies.
GLUT-1 and KOC stained slides were evaluated under a light microscope. Predominantly membranous but sometimes cytoplasmic staining was considered positive for GLUT-1, and only cytoplasmic staining for KOC.
The percentage of positively stained areas and staining intensity were recorded in all cases for GLUT-1. Membranous staining in more than 50% of the cells was accepted as (+ + +), a ratio between 10% and 50% as (+ +), below 10% as (+) and no staining as negative (0) (14, 23). In addition, staining intensity was scored from 1 to 3 as weak (+), moderate (+ +) and severe (+ + +) (23).
The percentage of positively stained areas and staining intensity were also recorded in all cases for KOC. Cytoplasmic staining in more than 50% of the cells was (+ + +), a ratio between 10% and 50% (+ +), below 10% (+) and no staining negative (0) (32). Staining intensity was scored from 1 to 3 as weak (+), moderate (+ +) and severe (+ + +) (11, 35).
Statistical analysis was performed on the computer using the SPSS 19 (Statistical Package for Social Sciences) package program. Each determinant was evaluated by the Variance analysis test and Tukey test to determine whether there was any diff erence between the groups. A p value less than 0.05 was considered statistically significant.
GLUT-1 antibody was used in a total of 90 patients and staining was positive in 24 (80%) of 30 MM cases, 25 (83.3%) of 30 PAC cases and in 2 (6.6%) of 30 RMH cases (Table I). GLUT-1 sensitivity was 80% and specificity 93.3% in malignant mesothelioma while the respective figures were 83.3% and 93.3% in PAC.
GLUT-1 staining diffuseness was + in 5 (16.6%), ++ in 9 (30%), and +++ in 10 (33.3%) malignant mesothelioma cases (Table I). GLUT-1 staining intensity was ++ in 6 (20%) cases, +++ in 18 (60%) cases, with no positive staining in one case (Figure 1A)
Staining diffuseness was + in 5 (16.6%), ++ in 4 (13.3%), and +++ in 16 (53.3%) pulmonary adenocarcinoma cases (Table I). GLUT-1 staining intensity was + in 2 (20%) cases, ++ in 6 (20%) cases and +++ in 17 (56.6 %) cases (Figure 1B).
The diffuseness of GLUT-1staining with was + in 1 (3.3%) reactive mesothelial hyperplasia, ++ in 1 (3.3%), while no +++ staining was seen (Table I). The severity of staining was + in 2 cases (6.6%) and no ++ or +++ staining was seen (Figure 1C).
A total of 90 patients included in the study were stained with KOC antibody. Positive staining was found in 25 (83.3%) of 30 MM cases, 23 (76.6%) of 30 AAK cases and 14 (46.6%) of 30 RMH cases (Table I). While sensitivity with KOC was 83.3% and specificity 53.3% in MM, and the respective figures were 76.6% and 53.3% in pulmonary adenocarcinoma.
KOC staining diffuseness was + in 3 (10%) cases, ++ in 2 (6%) cases, and +++ in 20 (66.6%) cases of malignant mesothelioma (Table I). KOC staining intensity was + in 11 (36.6%) cases, ++ in 10 (33.3%) cases, and +++ in 4 (13.3%) cases (Figure 2A).
KOC staining intensity was + in 2 (6.6%) cases, ++ 6 (20.3%) cases, and +++ in 15 (50%) cases with pulmonary adenocarcinoma (Table I). KOC staining intensity was + in 6 (20%) cases, ++ in 14 (46.6%) cases, and +++ in 3 (10 %) cases (Figure 2B).
The diffuseness of KOC staining was ++ in 2 (6.6%) reactive mesothelial hyperplasia cases, +++ in 12 (40%), and no + staining was seen (Table I). KOC staining intensity was + in 1 (3.3%) case, ++ in 4 (13.3%) cases, and +++ in 9 (30%) cases (Figure 2C).
No statistically significant diff erence was found when MM and PAC cases were compared in terms of GLUT-1 and KOC staining diffuseness and intensity (p>0.05). However, a statistically significant diff erence was found (p<0.05) when MM and PAC cases were compared with RMH cases (Table II).
The characteristic of malignant mesothelioma is a wide range of histological patterns and cytomorphological features[31,32]. MM is pathologically diagnosed with the help of IHC to show the diff erentiation of “mesothelial”, “epithelial” and “sarcomatous” diff erentiation of the cells that make up the tumor[29]. However, there is no consensus on the generally accepted antibody panel to be used in various sub-types of MM at present[27,29].
Mesothelial cell hyperplasia can be caused by infections in the pleural space, collagen vascular diseases, pulmonary infarction, drug reactions, pneumothorax, lung carcinomas located close to the pleura, surgery, trauma, and non-specific inflammation[33-35]. RMH can create a pseudoinvasion appearance resembling malignant neoplasm with increased cellularity, cytological atypia, numerous mitotic figures, necrosis, and entry of mesothelial cells into fibrous tissue[33,34]. IHC methods should therefore be used as it can be difficult to diff erentiate benign and malignant mesothelial proliferations by morphology alone, especially in small biopsy samples and in cases where stromal invasion cannot be clearly evaluated[31,33,34]. However, there is no generally accepted IHC marker for the diff erentiation of MM and RMH at present[10,36-38].
Warburg found the proliferation of cancer cells to be an energy-related process supported by glucose metabolism approximately 80 years ago. The increase in glucose use to meet the high energy need in malignant cells requires an increase in carrier proteins. GLUT-1 in particular is responsible for the passage of glucose into the cell in many tumors[11].
GLUT-1 secretion can be seen in carcinomas developing from various organs such as the breast, head and neck, bladder and kidney[10]. GLUT-1 positivity in reactive mesothelial hyperplasia was reported to be 0% by Afify et al.[39], 3% by Zimmermann et al.[40], and 20% by Burstein et al.[41]. Kato et al.[10] found GLUT-1 staining in none of the 40 RMH cases, and in all 48 MM cases in their study[10]. A study conducted at the University of Chicago reported GLUT-1 staining in none of the 40 benign mesothelial proliferation (20 normal, 20 reactive) cases, and weak to strong staining in 46 (80%)of 55 MM cases[42]. Our study findings showed a significant diff erence between MM and RMH cases in terms of GLUT-1 staining diffuseness and intensity.
KOC, commonly known as IMP3 in the literature, is another IHC marker reported to be sensitive and specific for the diff erentiation of RMH and MM, in addition to GLUT-1[20,34]. It was first found in pancreatic carcinoma cells and later reported to be secreted in many malignant tumors in humans[20,31]. The IMP family plays an important role in the regulation of cell growth, diff erentiation, and apoptosis, and increased IMP secretion starts neoplastic cell proliferation[31].
There are a few studies reporting IMP3 to be a useful marker in the diff erentiation of MM and RMH in surgical materials[20,34]. Sojka et al.[43] found IMP3 positivity in 72.7% of malignant pleural mesothelioma cases and no IMP3 staining in normal mesothelial cells. Xu et al.[44] analyzed IMP3 secretion in biopsies containing malignant pleural mesothelioma, simple mesothelial hyperplasia and atypical mesothelial hyperplasia and reported that samples containing simple mesothelial hyperplasia did not stain with IMP3 while 64% of malignant pleural mesothelioma cases showed staining[44].
A significant diff erence was found between RMH and MM cases in terms of the KOC staining diffuseness and intensity in our study (p<0,05). Although KOC positivity was higher than GLUT-1 positivity in MM cases, GLUT-1 is thought to be a useful marker in the diff erentiation of MM and RMH due to the lower specificity of KOC for MM.
KOC positivity is not 100% specific for a diagnosis of malignancy. Studies have shown KOC positivity with other conditions causing mesothelial cell regeneration and proliferation[31]. In fact, while KOC was negative in simple mesothelial hyperplasia composed of a single row of mesothelial cells, moderate (+ +) and severe (+ + +) KOC positivity was found in 14 RHM cases (46.6%) accompanied by intense inflammation in our study.
Epithelioid type MM can be confused with PAC as it shows a wide range of patterns with the tubulopapillary and solid types being most common. IHC methods should be used for the diff erential diagnosis as morphological findings are not adequate[7]. When we take the sensitivity and specificity into account, the best positive mesothelioma markers are calretinin, cytokeratin 5/6, podoplanin and WT-1, and the best positive carcinoma markers are MOC- 31, Ber-EP4, B72.3, CEA, BG-8 and TTF-1. The use of two positive mesothelioma markers and two positive carcinoma markers is recommended for the diff erentiation of epithelioid mesothelioma and PAC[32].
Our study found no significant diff erence between MM and RMH cases in terms of the diffuseness and intensity of GLUT-1 staining (p<0.05). Th is result is similar to the literature, indicating that GLUT-1 is not useful in MM and PAC diff erentiation.
There is little information in the literature on IMP secretion in pulmonary adenocarcinoma[20]. The recent study by Bellezza et al.[45] evaluated 126 cases of non-small cell lung carcinoma and found positive IMP3 staining in 55% of nonsmall cell lung carcinomas and in 25% of bronchoalveolar carcinoma cases. Jennifer et al.[20] found IMP3 staining in 29 of 41 moderate and poorly diff erentiated adenocarcinoma cases, 4 of 10 bronchoalveolar carcinoma cases and 14 of 25 well diff erentiated adenocarcinoma cases. Our study found no significant diff erence between MM and RMH cases in terms of KOC staining diffuseness and intensity (p<0,05).
We therefore concluded that GLUT-1 and KOC markers were not useful for the diff erentiation of MCC and PAC but could be of great benefit in diff erentiating RMH from MM and PAC.
1) Gümürdülü D, Zeren H, Cagle P, Kayaselçuk F, Alparslan
N, Kocabaş A, Tuncer İ: Specifi city of MOC-31 and HBME-
1 immunohistochemistry in the diff erential diagnosis of
adenocarcinoma and malignant mesothelioma: A study on
environmental malignant mesothelioma cases from Turkish
Villages. Pathol Oncol Res 2002, 8:188-193 [ Özet ]
2) Deniz H, Kibar Y, Güldür ME, Bakır K: Is D2-40 a useful marker
for distinguishing malignant mesothelioma from pulmonary
adenocarcinoma and benign mesothelial proliferations? Pathol
Res Pract 2009, 205:749-752 [ Özet ]
3) Wagner JC, Sleegs CA, Marchand P: Diff use pleural mesothelioma
and asbestos exposure in the North Western Cape Province. Br J
Med 1960; 17:260-271 [ Özet ]
4) Aydıner F, Yerci Ö: Malign mezotelyoma ve primer akciğer
adenokarsinomu ayırıcı tanısında immünhistokimyasal analiz.
Turk Patoloji Derg 2004, 20:60-65
5) Ordonez NG: Th e immunohistochemical diagnosis of
mesothelioma: A comparative study of epithelioid mesothelioma
and lung adenocarcinoma. Am J Surg Pathol 2003, 27:1031-1051 [ Özet ]
6) King JE, Th atcher N, Pickering C, Hasleton PS: Sensitivity
and specifi city of immunohistochemical markers used in the
diagnosis of epithelioid mesothelioma: A detailed systematic
analysis using published data. Histopathology 2006, 48:223-232 [ Özet ]
7) Akyıldız EÜ, Öz B, Akı H, Demirkaya A: Plevral epiteloid
malign mezotelyoma ile adenokarsinom ayırıcı tanısında
immünhistokimya; bir panel önerisi. Türk Toraks Dergisi 2010,
11:144-148
8) Tot T: Th e value of cytokeratins 20 and 7 in discriminating
metastatic adenocarcinomas from pleural mesotheliomas. Cancer
2001, 92:2727-2732 [ Özet ]
9) Elagöz Ş, Eğilmez R, Aker H: Plevra biyopsilerinde; reaktif
mezotel hiperplazisi, malign mezotelyoma ve adenokarsinom
metastazının ayırıcı tanısında immünhistokimya (CEA) ve Ag-
NOR metodunun değeri. Turk Patoloji Derg 1999, 1:8-12
10) Kato Y, Tsuta K, Seki K, Maeshima AM, Watanabe S, Suzuki
K, Asamura H, Tsuchiya R, Matsuno Y: Immunohistochemical
detection of GLUT-1 can discriminate between reactive
mesothelium and malignant mesothelioma. Mod Pathol 2007, 20:
215-220 [ Özet ]
11) Dağlı AF, Özercan MR: Endometriumun benign, premalign ve
malign lezyonlarında Glut-1 ile Ki-67’nin ayırıcı tanıdaki yeri.
Fırat Tıp Dergisi 2006, 11:93-97
12) Legan M, Tevzic S, Tolar A, Luzar B, Marolt VF: Glukoz
transporter-1 (GLUT-1) immunoreactivity in benign,
premalignant and malignant lesions of the gallbladder. Pathol
Oncol Res 2010, 10:9281-9287
13) Younes M, Brown RW, Stephenson M, Gondo M, Cagle PT:
Overexpression of Glut1 and Glut3 in stage1 nonsmall cell lung
carcinoma is associated with poor survival. Cancer 1997, 80:
1046-1051 [ Özet ]
14) Ohba S, Fujii H, Ito S, Fujimaki M, Matsumoto F, Furukawa
M, Yokoyama J, Kusunoki T, Ikeda K, Hino O: Overexpression
of GLUT-1 in the invasion front is associated with depth of oral
squamous cell carcinoma and prognosis. J Oral Pathol Med 2010,
39:74-78 [ Özet ]
15) Suganuma N, Segade F, Matsuzu K, Bowden DW: Diff erential
expression of facilitative glucose transporters in normal and
tumour kidney tissues. BJU Int 2007, 99:1143-1149 [ Özet ]
16) William A, Ahrens MD, Ridenour R, Caron BL, Miller DV,
Folpe AL: GLUT-1 expression in mesenchymal tumors: An
immunohistochemical study of 247 soft tissue and bone
neoplasms. Hum Pathol 2008, 39:1519-1526 [ Özet ]
17) Kojika M, Ishii G, Yoshida J, Nishimura M, Hishida T, Ota SJ,
Murata Y, Nagai K, Ochiai A: Immunohistochemical diff erential
diagnosis between thymic carcinoma and type B3 thymoma:
Diagnostic utility of hypoxic marker, GLUT-1, in thymic epithelial
neoplasms. Mod Pathol 2009, 22:1341-1350 [ Özet ]
18) Sung JY, Kim GY, Lim SJ, Park YK, Kim YW: Expression of
the GLUT1 glucose transporter and p53 in carcinomas of the
pancreatobiliary tract. Pathol Res Pract 2010, 206:24-29 [ Özet ]
19) Airley R, Evans A, Mobasheri A, Hewitt SM: Glucose transporter
Glut-1 is detectable in peri-necrotic regions in many human tumor
types but not normal tissues: study using tissue microarrays. Ann
Anat 2010, 192:133-138 [ Özet ]
20) Findeis-Hosey JJ, Xu H: The use of insulin like-growth factor II
messenger RNA binding protein-3 in diagnostic pathology. Hum
Pathol 2011, 42:303-314 [ Özet ]
21) Li S, Cha J, Kim J, Kim KY, Kim HJ, Nam W, Cha IH: Insulinlike
growth factor 2 mRNA-binding protein 3: A novel prognostic
biomarker for oral squamous cell carcinoma. Head Neck 2011
33:368-374 [ Özet ]
22) Righi A, Zhang S, Jin L, Scheithauer BW, Kovacs K, Kovacs G,
Goth MI: Korbonits M, Lloyd RV. Analysis of IMP3 expression
in normal and neoplastic human pituitary tissues. Endocr Pathol
2010, 21:25-31 [ Özet ]
23) Pryor JG, Simon RA, Bourne PA, Spaulding BO, Scott GA,
Xu H: Merkel cell carcinoma expresses K homology domaincontaining
protein overexpressed in cancer similar to other highgrade
neuroendocrine carcinomas. Hum Pathol 2009, 40:238-243 [ Özet ]
24) Jiang Z, Lohse CM, Chu PG, Wu CL, Woda B, Rock K, et al:
Oncofetal protein IMP3: A novel molecular marker that predicts
metastasis of papillary and chromophobe renal cell carcinomas.
Cancer 2008, 112:2676-2682 [ Özet ]
25) Ikenberg K, Fritzsche FR, Zuerrer-Haerdi U, Hofmann I,
Hermanns T, Seifert H, Müntener M, Provenzano M, Sulser T,
Behnke S, Gerhardt J, Mortezavi A, Wild P, Hofstädter F, Burger
M, Moch H, Kristiansen G: Insulin-like growth factor 2 mRNA
binding protein 3 (IMP3) is overexpressed in prostate cancer and
correlates with higher gleason scores. BMC Cancer 2010, 10:341 [ Özet ]
26) Churg A, Roggli V, Cagle PT, Gibbs AR, Hasleton PS, Henderson
DW, et al: Mesothelioma. Travis WD, Brambilla E, Müller-
Hermelink HK, Harris CC. (Eds): World Health Organization
Classifi cation of Tumours Pathology and Genetics: Tumours
of the Lung, Pleura, Th ymus and Heart, Lyon, IARC pres 2004:
125-144
27) Dağlı AF: Diff üz plevral malign mezotelyomada patolojik tanı ve
ayırıcı tanı. Türkiye Klinikleri Tıp Bilimleri Dergisi 2011, 4(1):
50-57
28) Inai K: Pathology of mesothelioma. Environ Health Prev Med
2008, 13:60-64 [ Özet ]
29) Marchevsky AM: Application of immunohistochemistry to the
diagnosis of malignant mesothelioma. Arch Pathol Lab Med
2008, 132:397-401 [ Özet ]
30) Burdorf A, Jarvholm B, Englund A: Explaining diff erences in
incidence rates of pleural mesothelioma between Sweden and the
Netherlands. Int Cancer 2005,113:298 [ Özet ]
31) Hanley KZ, Facik MS, Bourne PA, Yang Q, Spaulding BO,
Bonfi glio TA, Xu H: Utility of anti-L523S antibody in the
diagnosis of benign and malignant serous eff usions. Cancer 2008,
114:49-56
32) Ordonez NG: What are the current best immunohistochemical
markers for the diagnosis of epithelioid mesothelioma? A review
and update. Hum Pathol 2007, 38:1-16 [ Özet ]
33) Moore KL, Persaud TV, Torchia MG: İnsan Embriyolojisi.
Dalçık H, Yıldırım M (Çeviren) s.202-204, İstanbul, Nobel Tıp
Kitabevleri, 2009
34) Ikeda K, Tate G, Suzuki T, Kitamura T, Mitsuya T: IMP3/L523S,
a novel immunocytochemical marker that distinguishes benign
and malignant cells: Th e expression profi les of IMP3/L523S in
eff usion cytology. Hum Pathol 2010, 41:745-750 [ Özet ]
35) King J, Th atcher N, Pickering C, Hasleton P: Sensitivity
and specifi city of immunohistochemical antibodies used to
distinguish between benign and malignant pleural disease: A
systematic review of published reports. Histopathology 2006, 49:
561-568 [ Özet ]
36) Taheri ZM, Mehrafza M, Mohammadi F, Khoddami M,
Bahadori M, Masjedi MR: Th e diagnostic value of Ki-67
and repp86 in distinguishing between benign and malignant
mesothelial proliferations. Arch Pathol Lab Med 2008, 132:
694-697 [ Özet ]
37) Comin CE, Novelli L, Boddi V, Paglierani M, Dini S: Calretinin,
thrombomodulin, CEA and CD15: Useful combination of
immunohistochemical markers for diff erentiating pleural
epithelial mesothelioma from peripheral pulmonary
adenocarcinoma. Hum Pathol 2001, 32: 529-536 [ Özet ]
38) Sandeck HP, Roe OD, Kjaerheim K, Willen H, Larsson E:
Re-evalution of histological diagnoses of malignant mesothelioma
by immunohistochemistry. Diagn Pathol 2010, 5:47 [ Özet ]
39) Afi fy A, Zhou H, Howell L, Paulino AF: Diagnostic utility of
Glut-1 expression in the cytologic evaluation of serous fl uids.
Acta Cytol 2005, 49: 621-626 [ Özet ]
40) Zimmerman RL, Goonewardene S, Fogt F: Glucose transporter
Glut-1 is of limited value for detecting breast carcinoma in serous
eff usions. Mod Pathol 2001, 14:748-751 [ Özet ]
41) Burstein DE, Reder I, Weiser K, Tong T, Pritsker A, Haber
RS: GLUT-1 glucose transporter: A highly sensitive marker
of malignancy in body cavity eff usions. Mod Pathol 1998, 11:
392-396 [ Özet ]
42) Actuaria A, Arif Q, Gattuso P, McIntere M, Krausz T, Husain
AN: Value of immunohistochemical markers in diff erentiating
benign from malignant mesothelial lesions. Lab Invest 2008, 88
(Supp 1): 334A
43) Sojka KM, Spaulding B, Nielsen GK, Dinnogen SA, Dinnogen
SA, Welcher R: Immunoreactivity of anti-L523S on normal
and malignant lung pleural tissue biopsies. Lab Invest 2006, 86
(Supp 1): 317A
44) Xu H, Simon R, Bourne PA, Spaulding BO, Wang HL:
Immunohistochemical analysis of KOC/IMP3 in malignant
pleural mesothelioma. Mod Pathol 2008, 21:353
45) Bellezza G, Cavaliere A, Sidoni A: IMP3 expression in non-small
cell lung cancer. Hum Pathol 2009, 40:1205-1206 [ Özet ]
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