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. 2014 Mar;8(1):59-65.
doi: 10.1007/s12105-013-0475-7. Epub 2013 Jul 12.

Among sinonasal tumors, CDX-2 immunoexpression is not restricted to intestinal-type adenocarcinomas

Matthew P Tilson  1 , Gary L Gallia, Justin A Bishop
Affiliations

Among sinonasal tumors, CDX-2 immunoexpression is not restricted to intestinal-type adenocarcinomas

Matthew P Tilson et al. Head Neck Pathol. 2014 Mar.

Abstract

Intestinal-type adenocarcinoma (ITAC) is a rare form of sinonasal cancer characterized by an association with exposure to industrial dusts, aggressive clinical behavior, and histologic/immunophenotypic similarity to tumors of the gastrointestinal tract. ITAC is sometimes very poorly differentiated and difficult to distinguish from other sinonasal neoplasms, particularly in a limited biopsy. CDX-2 and cytokeratin 20 are consistently immunoreactive in ITAC and as a result, these immunostains are often used to support the diagnosis. However, CDX-2 and cytokeratin 20 have not been tested on a broad range of sinonasal tumors, so their specificities remain unknown. Immunohistochemistry for CDX-2 and cytokeratin 20 was performed on 6 sinonasal ITACs as well as 176 non-intestinal-type sinonasal neoplasms. CDX-2 and cytokeratin 20 were positive in all 6 cases of ITAC. CDX-2 immunoexpression was also observed in 17 of 176 (10 %) non-intestinal-type tumors including 6 of 16 (38 %) sinonasal undifferentiated carcinomas, 8 of 81 (10 %) squamous cell carcinomas (including 5 of 39 non-keratinizing variants), 2 of 20 (10 %) salivary-type adenocarcinomas, and 1 of 2 (50 %) small cell carcinomas. In contrast, among non-intestinal types of sinonasal tumors, cytokeratin 20 was only focally observed in 1 of 176 non-intestinal tumors (a non-keratinizing squamous cell carcinoma). All cases of non-intestinal surface-derived adenocarcinoma and esthesioneuroblastoma were negative for both markers. Both CDX-2 and cytokeratin 20 are highly sensitive for the diagnosis of sinonasal ITAC, but cytokeratin 20 is more specific. CDX-2 staining may be observed in other high grade tumor types, especially sinonasal undifferentiated carcinoma and non-keratinizing squamous cell carcinoma. As a result, in the setting of a poorly differentiated sinonasal carcinoma the diagnosis of ITAC should not be based on CDX-2 immunoexpression alone. Clear-cut glandular differentiation and cytokeratin 20 immunoexpression are more reliable features.

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Figures

Fig. 1
Fig. 1
This example of sinonasal intestinal-type adenocarcinoma is very poorly differentiated, growing as nests and sheets of pleomorphic cells with necrosis (a) and exhibiting only focal gland formation (b) and mucin production demonstrated by a mucicarmine stain (inset of b). CDX-2 (c) and cytokeratin 20 (d) immunostains were consistently positive in the sinonasal intestinal-type adenocarcinomas
Fig. 2
Fig. 2
CDX-2 immunohistochemistry was not limited to sinonasal intestinal-type adenocarcinoma. Varying degrees of staining were also observed in some cases of squamous cell carcinoma (a, b) and sinonasal undifferentiated carcinoma (c, d) as well as one small cell carcinoma (e, f)
Fig. 3
Fig. 3
This is a case of non-keratinizing squamous cell carcinoma (a) as supported by diffuse and strong staining for the squamous marker p40 (b), but it also expressed CDX-2 (c) and cytokeratin 20 (d). This was the only sinonasal tumor aside from the intestinal-type adenocarcinomas that was cytokeratin 20 positive
See this image and copyright information in PMC

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