Utility of Antiphosphorylated H2AX Antibody (γ-H2AX) in Diagnosing Metastatic Renal Cell Carcinoma:

The differential diagnosis of metastatic renal cell carcinoma (RCC) includes, although is not limited to, hepatocellular carcinoma (HCC) and adrenocortical carcinoma (ACC) due to overlapping morphology. Immunohistochemical markers, including RCC marker (RCC-Ma) have been employed with varying success in the differential diagnosis of RCC. Our preliminary tissue microarray study demonstrated that gamma-H2AX, an antibody that specifically reacts with phosphorylated historic H2AX, stained many primary RCC strongly and did not stain HCC or ACC, prompting us to evaluate its utility in these tumors and to compare it with RCC-Ma. Seventy-one cases of metastatic RCC, 18 HCC, and 21 ACC were stained with gamma-H2AX and RCC-Ma and the sensitivity and specificity of each marker was compared. RCC-Ma demonstrated a membranous pattern of staining in 70% of RCC cases (50/71), and none of the ACC or HCC (100% specificity for RCC). Nuclear staining by gamma-H2AX had a similar sensitivity of 70% for RCC but a lower specificity of 77%, as it was seen in 1 of 18 HCC (5%) and 8 of 21 (38%)ACC. In metastatic RCC, 83% (39/47) of tumors with a higher nuclear grade stained with gamma-H2AX, compared with 46% (11/24) of low nuclear grade (equivalent of Fuhrman 2 and lower) tumors. RCC-Ma had a similar rate of staining in low and high-grade tumors, 75% (18/24) and 68% (32/47), respectively. More importantly, of RCCs that were negative for RCC-Ma, 14 of 21 (67%) were positive for gamma-H2AX. The results suggest gamma-H2AX is a useful adjunct in diagnosis of metastatic RCC when RCC-Ma is negative and in higher grade RCC, which are often a diagnostic challenge. A nuclear pattern of staining of gamma-H2AX has a comparable sensitivity with RCC-Ma, and the interpretation is easier and more reliable. RCC-Ma is 100% specific for RCC, but only when a membranous pattern of staining is interpreted as positive.