Evidence-based Guidelines for the Utilization of Immunostains in Diagnostic Pathology: Pulmonary Adenocarcinoma Versus Mesothelioma

There are no firmly established guidelines for the use of antibodies in immunohistology as individual tests or panels. Practicing pathologists must rely on information available in individual publications, review articles, books, and internet-based databases to develop diagnostic immunohistochemical algorithms for their individual practices. In contrast, other medical specialties have crafted many evidence-based practice guidelines (EBG) that are widely used; these have helped to augment standardization and cost effectiveness. In particular, the use of several “epithelial” and “mesothelial” antibodies has been proposed to distinguish epithelioid malignant mesothelioma from metastatic pulmonary adenocarcinoma. Other authors have previously done systematic literature reviews of this subject up through 2004 and integrated the results of 88 publications into summarized test-performance values for 15 preselected immunohistochemical markers. The results suggested that 7 tests provide optimal sensitivity and specificity (MOC-31, BG8, CEA, TTF-1, CK5/6, WT-1, and HBME-1), but they provide no guidance for integration of such data into EBG. Odds ratios (ORs) were employed to compare the effectiveness of any single test, and chosen combinations thereof, in the differential diagnosis of malignant mesothelioma and metastatic pulmonary adenocarcinoma. Surprisingly, selected single immunostains or antibody pairs yielded ORs (varying from 96.34 to 1233.19) that were equal or better in efficacy when compared with more comprehensive panels. These results support the potential value of systematic reviews, meta-analysis, and OR calculations for development of EBG in diagnostic immunohistology.

[1]  N. Ordóñez.  Immunohistochemical diagnosis of epithelioid mesothelioma: an update. , 2009, Archives of pathology & laboratory medicine.

[2]  J. Mason,et al.  A new method of analysis enabled a better understanding of clinical practice guideline development processes. , 2006, Journal of clinical epidemiology.

[3]  D. Peterson,et al.  Developing evidence-based guidelines for management of alimentary mucositis: process and pitfalls , 2006, Supportive Care in Cancer.

[4]  A. Gown,et al.  Evaluation of 12 antibodies for distinguishing epithelioid mesothelioma from adenocarcinoma: identification of a three-antibody immunohistochemical panel with maximal sensitivity and specificity , 2006, Modern Pathology.

[5]  P. Hasleton,et al.  Sensitivity and specificity of immunohistochemical markers used in the diagnosis of epithelioid mesothelioma: a detailed systematic analysis using published data , 2006, Histopathology.

[6]  Dewesh Agrawal,et al.  Inappropriate Interpretation of the Odds Ratio: Oddly Not That Uncommon , 2005, Pediatrics.

[7]  H. Battifora.  Mesothelioma versus carcinoma: getting easier? , 2005, Human pathology.

[8]  A. Folpe,et al.  Distribution of Cytokeratins and Vimentin in Adult Renal Neoplasms and Normal Renal Tissue: Potential Utility of a Cytokeratin Antibody Panel in the Differential Diagnosis of Renal Tumors , 2005, The American journal of surgical pathology.

[9]  A. Gown,et al.  Do we need two more mesothelial markers? , 2005, Human pathology.

[10]  N. Ordóñez.  D2-40 and podoplanin are highly specific and sensitive immunohistochemical markers of epithelioid malignant mesothelioma. , 2005, Human pathology.

[11]  Jianfen Shu,et al.  Proportional odds ratio model for comparison of diagnostic tests in meta-analysis , 2004, BMC medical research methodology.

[12]  Alberto M Marchevsky,et al.  Evidence-based medicine, medical decision analysis, and pathology. , 2004, Human pathology.

[13]  Kenneth J Rothman,et al.  The reporting odds ratio and its advantages over the proportional reporting ratio , 2004, Pharmacoepidemiology and drug safety.

[14]  J. Burgers,et al.  Beyond the evidence in clinical guidelines , 2004, The Lancet.

[15]  Sverre Sandberg,et al.  Evidence-based guidelines in laboratory medicine: principles and methods. , 2004, Clinical chemistry.

[16]  J. Monson,et al.  Evaluation of quality of life after laparoscopic surgery: evidence-based guidelines of the European Association for Endoscopic Surgery , 2004, Surgical Endoscopy.

[17]  P. Bossuyt,et al.  The diagnostic odds ratio: a single indicator of test performance. , 2003, Journal of clinical epidemiology.

[18]  N. Ordóñez,et al.  Application of Mesothelin Immunostaining in Tumor Diagnosis , 2003, The American journal of surgical pathology.

[19]  N. Ordóñez.  The Immunohistochemical Diagnosis of Mesothelioma: A Comparative Study of Epithelioid Mesothelioma and Lung Adenocarcinoma , 2003, The American journal of surgical pathology.

[20]  J. Byers,et al.  Meta-Analysis and Decision Analysis Bridge Research and Practice , 2003, Western journal of nursing research.

[21]  N. Ordóñez.  Immunohistochemical diagnosis of epithelioid mesotheliomas: a critical review of old markers, new markers. , 2002, Human pathology.

[22]  G. Acton.  Meta-analysis: a tool for evidence-based practice. , 2001, AACN clinical issues.

[23]  J. Sterne,et al.  Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. , 2001, Journal of clinical epidemiology.

[24]  N. Goldstein,et al.  Mucinous and nonmucinous bronchioloalveolar adenocarcinomas have distinct staining patterns with thyroid transcription factor and cytokeratin 20 antibodies. , 2001, American journal of clinical pathology.

[25]  N. Goldstein,et al.  WT1 is an integral component of an antibody panel to distinguish pancreaticobiliary and some ovarian epithelial neoplasms. , 2001, American journal of clinical pathology.

[26]  Jonathan A C Sterne,et al.  Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis. , 2001, BMJ.

[27]  D. Christakis.  Systematic reviews: a critical first step. , 2001, Archives of pediatrics & adolescent medicine.

[28]  P. Hasleton,et al.  Immunohistochemistry and the diagnosis of malignant mesothelioma , 2001, Histopathology.

[29]  R. Gross.  Decisions and Evidence in Medical Practice: Applying Evidence-Based Medicine to Clinical Decision Making , 2001 .

[30]  Adrian F. M. Smith,et al.  Evidence-based medicine as Bayesian decision-making. , 2000, Statistics in medicine.

[31]  B. Delahunt,et al.  Immunohistochemical evidence for mesothelial origin of paratesticular adenomatoid tumour , 2000, Histopathology.

[32]  A M Marchevsky,et al.  Reasoning with uncertainty in pathology: artificial neural networks and logistic regression as tools for prediction of lymph node status in breast cancer patients. , 1999, Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc.

[33]  A. Marchevsky,et al.  Estimation of tumor stage and lymph node status in patients with colorectal adenocarcinoma using probabilistic neural networks and logistic regression. , 1999, Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc.

[34]  N. Jensen,et al.  Using evidence to make decisions. , 1999, WMJ : official publication of the State Medical Society of Wisconsin.

[35]  G. A. Pinto,et al.  Antibody panel in diagnosis of lymphoid neoplasms. , 1998, Journal of clinical pathology.

[36]  Mark A. Stephenson,et al.  Artificial neural networks and logistic regression as tools for prediction of survival in patients with Stages I and II non-small cell lung cancer. , 1998, Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc.

[37]  S. Satya‐Murti.  Evidence-based Medicine: How to Practice and Teach EBM , 1997 .

[38]  D. Gutterman,et al.  American College of Chest Physicians evidence-based guidelines--the next generation: considering resource use and evolution to a single grading system. , 2006, Chest.

[39]  S. Doherty.  Evidence-based implementation of evidence-based guidelines. , 2006, International journal of health care quality assurance incorporating Leadership in health services.

[40]  B. Charlton,et al.  The uses and abuses of meta-analysis. , 1996, Family practice.