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9 - In situ techniques for protein analysis in tumor tissue

from Part 1.2 - Analytical techniques: analysis of RNA

Published online by Cambridge University Press:  05 February 2015

By
Valsamo K. Anagnostou  and
David L. Rimm
Edited by
Edward P. Gelmann ,
Charles L. Sawyers  and
Frank J. Rauscher, III
Valsamo K. Anagnostou
Affiliation:
Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
David L. Rimm
Affiliation:
Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
Edward P. Gelmann
Affiliation:
Columbia University, New York
Charles L. Sawyers
Affiliation:
Memorial Sloan-Kettering Cancer Center, New York
Frank J. Rauscher, III
Affiliation:
The Wistar Institute Cancer Centre, Philadelphia
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Summary

Overview of the analytical techniques

Assessment of protein expression is a vital part of diagnostic pathology routinely used in addition to morphologic evaluation for establishing a definite diagnosis and histological subclassification of tumors. Immunohistochemistry (IHC)-based technologies have expanded the spectrum of clinical applications beyond histological diagnosis towards identifying prognostic biomarkers and guiding selection of patients for personalized treatment. This chapter reviews the current analytical techniques for protein detection.

Chromagenic immunohistochemistry

IHC selectively detects specific proteins in tissue and provides complementary diagnostic information to morphological observations; IHC has thus become a routine technique for diagnostic purposes (a subset of popular IHC-assessed proteins contributing to tumor diagnosis, characterization, and prognosis are summarized in Table 9.1). In contrast, it has also been used as a companion diagnostic test to predict response to specific therapies. The classic examples of this usage are estrogen receptor (ER; 1) and human epidermal growth factor receptor 2 (HER2; 2) in breast cancer. Advantages of IHC include application in formalin-fixed paraffin-embedded (FFPE) tissue, wide availability, low cost, and simplicity when coupled with a pathologist's assessment at the light microscope. However, conventional IHC can be restricted by low sensitivity or differences in sample preparation and fixation (3,4). These issues have been addressed by developing signal-amplification techniques and antigen retrieval methods, respectively (5). In principle, IHC requires at least an antibody detecting the antigen of interest that is linked to an enzymatic system (most commonly peroxidase or alkaline phosphatase), used to visualize the site of antigen–antibody reaction.

Type
Chapter
Information
Molecular Oncology
Causes of Cancer and Targets for Treatment
 , pp. 76 - 84
Publisher: Cambridge University Press
Print publication year: 2013

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References

Yaziji, H, Taylor, CR, Goldstein, NS, et al. Consensus recommendations on estrogen receptor testing in breast cancer by immunohistochemistry. Applied Immunohistochemistry and Molecular Morphology 2008;16: 513–20.CrossRef
Jacobs, TW, Gown, AM, Yaziji, H, Barnes, MJ, Schnitt, SJ. Specificity of HercepTest in determining HER-2/neu status of breast cancers using the United States Food and Drug Administration-approved scoring system. Journal of Clinical Oncology 1999;17:1983–7.CrossRefGoogle ScholarPubMed
Rait, VK, O’Leary, TJ, Mason, JT. Modeling formalin fixation and antigen retrieval with bovine pancreatic ribonuclease A: I-structural and functional alterations. Laboratory Investigation 2004;84:292–9.CrossRef
Rait, VK, Xu, L, O’Leary, TJ, Mason, JT. Modeling formalin fixation and antigen retrieval with bovine pancreatic RNase A II. Interrelationship of cross-linking, immunoreactivity, and heat treatment. Laboratory Investigation 2004;84: 300–6.CrossRef
Shi, SR, Key, ME, Kalra, KL. Antigen retrieval in formalin-fixed, paraffin-embedded tissues: an enhancement method for immunohistochemical staining based on microwave oven heating of tissue sections. Journal of Histochemistry and Cytochemistry 1991;39:741–8.CrossRefGoogle ScholarPubMed
Schaumburg-Lever, G. The alkaline phosphatase anti-alkaline phosphatase technique in dermatopathology. Journal of Cutaneous Pathology 1987;14:6–9.CrossRefGoogle ScholarPubMed
Cordell, JL, Falini, B, Erber, WN, et al. Immunoenzymatic labeling of monoclonal antibodies using immune complexes of alkaline phosphatase and monoclonal anti-alkaline phosphatase (APAAP complexes). Journal of Histochemistry and Cytochemistry 1984;32:219–29.CrossRefGoogle Scholar
Heyderman, E. Immunoperoxidase technique in histopathology: applications, methods, and controls. Journal of Clinical Pathology 1979;32: 971–8.CrossRefGoogle ScholarPubMed
Bayer, EA, Skutelsky, E, Wilchek, M. The avidin-biotin complex in affinity cytochemistry. Methods in Enzymology 1979;62:308–15.CrossRef
Livnah, O, Bayer, EA, Wilchek, M, Sussman, JL. Three-dimensional structures of avidin and the avidin-biotin complex. Proceedings of the National Academy of Sciences USA 1993;90:5076–80.CrossRef
Guesdon, JL, Ternynck, T, Avrameas, S. The use of avidin-biotin interaction in immunoenzymatic techniques. Journal of Histochemistry and Cytochemistry 1979;27:1131–9.CrossRefGoogle ScholarPubMed
Hsu, SM, Raine, L, Fanger, H. Use of avidin-biotin-peroxidase complex (ABC) in immunoperoxidase techniques: a comparison between ABC and unlabeled antibody (PAP) procedures. Journal of Histochemistry and Cytochemistry 1981;29:577–80.CrossRefGoogle ScholarPubMed
Happerfield, LC, Bobrow, LG, Bains, R, Miller, KD. Peroxidase labelling immunocytochemistry: a comparison of eleven commercially-available avidin-biotin systems. British Journal of Biomedical Science 1993;50:21–6.Google ScholarPubMed
Hsu, SM, Raine, L. Protein A, avidin, and biotin in immunohistochemistry. Journal of Histochemistry and Cytochemistry 1981;29:1349–53.CrossRefGoogle ScholarPubMed
Chilosi, M, Lestani, M, Pedron, S, et al. A rapid immunostaining method for frozen sections. Biotechnic and Histochemistry 1994;69:235–9.CrossRef
Richter, T, Nahrig, J, Komminoth, P, Kowolik, J, Werner, M. Protocol for ultrarapid immunostaining of frozen sections. Journal of Clinical Pathology 1999;52:461–3.CrossRefGoogle ScholarPubMed
Van der Loos, CM, Naruko, T, Becker, AE. The use of enhanced polymer one-step staining reagents for immunoenzyme double-labelling. Histochemical Journal 1996;28:709–14.CrossRef
Kammerer, U, Kapp, M, Gassel, AM, et al. A new rapid immunohistochemical staining technique using the EnVision antibody complex. Journal of Histochemistry and Cytochemistry 2001;49:623–30.CrossRefGoogle ScholarPubMed
Sabattini, E, Bisgaard, K, Ascani, S, et al. The EnVision++ system: a new immunohistochemical method for diagnostics and research. Critical comparison with the APAAP, ChemMate, CSA, LABC, and SABC techniques. Journal of Clinical Pathology 1998;51:506–11.CrossRefGoogle ScholarPubMed
Bobrow, MN, Harris, TD, Shaughnessy, KJ, Litt, GJ. Catalyzed reporter deposition, a novel method of signal amplification. Application to immunoassays. Journal of Immunological Methods 1989; 125:279–85.CrossRefGoogle ScholarPubMed
Bobrow, MN, Shaughnessy, KJ, Litt, GJ. Catalyzed reporter deposition, a novel method of signal amplification. II. Application to membrane immunoassays. Journal of Immunological Methods 1991; 137:103–12.CrossRefGoogle ScholarPubMed
King, G, Payne, S, Walker, F, Murray, GI. A highly sensitive detection method for immunohistochemistry using biotinylated tyramine. Journal of Pathology 1997;183:237–41.3.0.CO;2-0>CrossRefGoogle ScholarPubMed
von Wasielewski, R, Mengel, M, Gignac, S, et al. Tyramine amplification technique in routine immunohistochemistry. Journal of Histochemistry and Cytochemistry 1997;45:1455–9.CrossRefGoogle ScholarPubMed
Bobrow, MN, Litt, GJ, Shaughnessy, KJ, Mayer, PC, Conlon, J. The use of catalyzed reporter deposition as a means of signal amplification in a variety of formats. Journal of Immunological Methods 1992; 150(1–2):145–9.CrossRefGoogle Scholar
Hopman, AH, Ramaekers, FC, Speel, EJ. Rapid synthesis of biotin-, digoxigenin-, trinitrophenyl-, and fluorochrome-labeled tyramides and their application for In situ hybridization using CARD amplification. Journal of Histochemistry and Cytochemistry 1998;46:771–7.CrossRefGoogle ScholarPubMed
Speel, EJ, Ramaekers, FC, Hopman, AH. Sensitive multicolor fluorescence in situ hybridization using catalyzed reporter deposition (CARD) amplification. Journal of Histochemistry and Cytochemistry 1997;45:1439–46.CrossRefGoogle ScholarPubMed
Buki, A, Walker, SA, Stone, JR, Povlishock, JT. Novel application of tyramide signal amplification (TSA): ultrastructural visualization of double-labeled immunofluorescent axonal profiles. Journal of Histochemistry and Cytochemistry 2000;48:153–61.CrossRefGoogle ScholarPubMed
Gusev, Y, Sparkowski, J, Raghunathan, A, et al. Rolling circle amplification: a new approach to increase sensitivity for immunohistochemistry and flow cytometry. American Journal of Pathology 2001;159:63–9.CrossRefGoogle ScholarPubMed
Hudis, CA. Trastuzumab–mechanism of action and use in clinical practice. New England Journal of Medicine 2007;357:39–51.CrossRefGoogle ScholarPubMed
Hede, K. Breast cancer testing scandal shines spotlight on black box of clinical laboratory testing. Journal of the National Cancer Institute 2008;100: 836–7, 44.CrossRefGoogle ScholarPubMed
Moeder, CB, Giltnane, JM, Harigopal, M, et al. Quantitative justification of the change from 10% to 30% for human epidermal growth factor receptor 2 scoring in the American Society of Clinical Oncology/College of American Pathologists guidelines: tumor heterogeneity in breast cancer and its implications for tissue microarray based assessment of outcome. Journal of Clinical Oncology 2007;25:5418–25.CrossRefGoogle Scholar
McCabe, A, Dolled-Filhart, M, Camp, RL, Rimm, DL. Automated quantitative analysis (AQUA) of in situ protein expression, antibody concentration, and prognosis. Journal of the National Cancer Institute 2005;97:1808–15.CrossRefGoogle ScholarPubMed
Taylor, CR, Levenson, RM. Quantification of immunohistochemistry–issues concerning methods, utility and semiquantitative assessment II. Histopathology 2006;49:411–24.CrossRef
Walker, RA. Quantification of immunohistochemistry –issues concerning methods, utility and semiquantitative assessment I. Histopathology 2006;49:406–10.CrossRef
Gokhale, S, Rosen, D, Sneige, N, et al. Assessment of two automated imaging systems in evaluating estrogen receptor status in breast carcinoma. Applied Immunohistochemistry and Molecular Morphology 2007;15:451–5.CrossRef
Harvey, JM, Clark, GM, Osborne, CK, Allred, DC. Estrogen receptor status by immunohistochemistry is superior to the ligand-binding assay for predicting response to adjuvant endocrine therapy in breast cancer. Journal of Clinical Oncology 1999;17:1474–81.CrossRefGoogle ScholarPubMed
Sklarew, RJ, Pertschuk, LP. Quantitation of the immunocytochemical assay for estrogen receptor protein (ER-ICA) in human breast cancer by television imaging. Journal of Histochemistry and Cytochemistry 1987;35:1253–9.CrossRefGoogle ScholarPubMed
Bacus, S, Flowers, JL, Press, MF, Bacus, JW, McCarty, KS. The evaluation of estrogen receptor in primary breast carcinoma by computer-assisted image analysis. American Journal of Clinical Pathology 1988;90:233–9.CrossRefGoogle ScholarPubMed
Baddoura, FK, Cohen, C, Unger, ER, DeRose, PB, Chenggis, M. Image analysis for quantitation of estrogen receptor in formalin-fixed paraffin-embedded sections of breast carcinoma. Modern Pathology 1991;4:91–5.
Layfield, LJ, Saria, EA, Conlon, DH, Kerns, BJ. Estrogen and progesterone receptor status determined by the Ventana ES 320 automated immunohistochemical stainer and the CAS 200 image analyzer in 236 early-stage breast carcinomas: prognostic significance. Journal of Surgical Oncology 1996;61:177–84.3.0.CO;2-8>CrossRefGoogle ScholarPubMed
Colley, M, Kommoss, F, Bibbo, M, et al. Assessment of hormone receptors in breast carcinoma by immunocytochemistry and image analysis. II. Estrogen receptors. Analytical and Quantitative Cytology and Histology 1989;11:307–14.
Rostagno, P, Birtwisle, I, Ettore, F, et al. Immunohistochemical determination of nuclear antigens by colour image analysis: application for labelling index, estrogen and progesterone receptor status in breast cancer. Annals of Cell Pathology 1994;7:275–87.
Biesterfeld, S, Kraus, HL, Reineke, T, et al. Analysis of the reliability of manual and automated immunohistochemical staining procedures. A pilot study. Analytical and Quantitative Cytology and Histology 2003;25:90–6.
Diaz, LK, Sahin, A, Sneige, N. Interobserver agreement for estrogen receptor immunohistochemical analysis in breast cancer: a comparison of manual and computer-assisted scoring methods. Annals of Diagnostic Pathology 2004;8:23–7.CrossRef
Joshi, AS, Sharangpani, GM, Porter, K, et al. Semi-automated imaging system to quantitate Her-2/neu membrane receptor immunoreactivity in human breast cancer. Cytometry A 2007;71: 273–85.CrossRef
Sharangpani, GM, Joshi, AS, Porter, K, et al. Semi-automated imaging system to quantitate estrogen and progesterone receptor immunoreactivity in human breast cancer. Journal of Microscopy 2007;226:244–55.CrossRefGoogle ScholarPubMed
Soenksen, D. Digital pathology at the crossroads of major health care trends: corporate innovation as an engine for change. Archives of Pathology and Laboratory Medicine 2009;133(4): 555–9.
Rexhepaj, E, Brennan, DJ, Holloway, P, et al. Novel image analysis approach for quantifying expression of nuclear proteins assessed by immunohistochemistry: application to measurement of oestrogen and progesterone receptor levels in breast cancer. Breast Cancer Research 2008; 10:R89.
Levenson, RM, Mansfield, JR. Multispectral imaging in biology and medicine: slices of life. Cytometry A 2006;69:748–58.CrossRef
Shi, SR, Liu, C, Pootrakul, L, et al. Evaluation of the value of frozen tissue section used as “gold standard” for immunohistochemistry. American Journal of Clinical Pathology 2008; 129:358–66.CrossRefGoogle ScholarPubMed
Yamashita, S, Okada, Y. Application of heat-induced antigen retrieval to aldehyde-fixed fresh frozen sections. Journal of Histochemistry and Cytochemistry 2005;53:1421–32.CrossRefGoogle ScholarPubMed
Larrson, L. Theory and Practice. Boca Raton, FL: CRC Press; 1988.
Eltoum, I, Fredenburgh, J, Myers, R. Introduction to the theory and practice of fixation of tissues. Journal of Histotechnology 2001:173–90.Google Scholar
Sompuram, SR, Vani, K, Messana, E, Bogen, SA. A molecular mechanism of formalin fixation and antigen retrieval. American Journal of Clinical Pathology 2004;121:190–9.CrossRefGoogle ScholarPubMed
Chu, WS, Liang, Q, Liu, J, et al. A nondestructive molecule extraction method allowing morphological and molecular analyses using a single tissue section. Laboratory Investigation 2005;85:1416–28.CrossRef
Shi, SR, Liu, C, Balgley, BM, Lee, C, Taylor, CR. Protein extraction from formalin-fixed, paraffin-embedded tissue sections: quality evaluation by mass spectrometry. Journal of Histochemistry and Cytochemistry 2006;54:739–43.CrossRefGoogle ScholarPubMed
Shi, SR, Gu, J, Turrens, J. Development of the Antigen Retrieval Technique: Philosophical and Theoritical Bases. Natick, MA: Eaton Publishing; 2000.
Giltnane, JM, Rimm, DL. Technology insight: Identification of biomarkers with tissue microarray technology. Nature Clinical Practice 2004;1:104–11.CrossRef
Anagnostou, V, Welsh, AWGiltnane, JM, et al. Analytic variability in immunohistochemistry biomarker studies. Cancer Epidemiology Biomarkers and Prevention 2010; 19:982–91.CrossRef
Wolff, AC, Hammond, ME, Schwartz, JN, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. Journal of Clinical Oncology 2007;25:118–45.CrossRefGoogle Scholar
Owens, MA, Horten, BC, Da Silva, MM. HER2 amplification ratios by fluorescence in situ hybridization and correlation with immunohistochemistry in a cohort of 6556 breast cancer tissues. Clinical Breast Cancer 2004;5:63–9.CrossRef
Allred, DC, Carlson, RW, Berry, DA, et al. NCCN Task Force Report: Estrogen receptor and progesterone receptor testing in breast cancer by immunohistochemistry. Journal of the National Comprehensive Cancer Network 2009;7 Suppl 6:S1–S21; quiz S2–3.Google Scholar
Allred, DC, Harvey, JM, Berardo, M, Clark, GM. Prognostic and predictive factors in breast cancer by immunohistochemical analysis. Modern Pathology 1998;11:155–68.
Hammond, ME, Hayes, DF, Dowsett, M, et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. Archives of Pathology and Laboratory Medicine 2010;136(6):907–22.
Lichtman, JW, Conchello, JA. Fluorescence microscopy. Nature Methods 2005;2:910–9.CrossRef
Petty, HR. Fluorescence microscopy: established and emerging methods, experimental strategies, and applications in immunology. Microscopy Research and Technique 2007;70:687–709.CrossRef
Buchwalow, IB, Minin, EA, Boecker, W. A multicolor fluorescence immunostaining technique for simultaneous antigen targeting. Acta Histochemica 2005;107:143–8.CrossRef
Shindler, KS, Roth, KA. Double immunofluorescent staining using two unconjugated primary antisera raised in the same species. Journal of Histochemistry and Cytochemistry 1996;44:1331–5.CrossRefGoogle ScholarPubMed
Sun, XJ, Tolbert, LP, Hildebrand, JG. Using laser scanning confocal microscopy as a guide for electron microscopic study: a simple method for correlation of light and electron microscopy. Journal of Histochemistry and Cytochemistry 1995;43:329–35.CrossRefGoogle ScholarPubMed
Todd, AJ. A method for combining confocal and electron microscopic examination of sections processed for double- or triple-labelling immunocytochemistry. Journal of Neuroscience Methods 1997;73:149–57.CrossRefGoogle ScholarPubMed
Deitch, JS, Smith, KL, Lee, CL, Swann, JW, Turner, JN. Confocal scanning laser microscope images of hippocampal neurons intracellularly labeled with biocytin. Journal of Neuroscience Methods 1990;33:61–76.CrossRefGoogle ScholarPubMed
Squire, A, Bastiaens, PI. Three dimensional image restoration in fluorescence lifetime imaging microscopy. Journal of Microscopy 1999;193:36–49.CrossRefGoogle ScholarPubMed
Piston, DW, Kremers, GJ. Fluorescent protein FRET: the good, the bad and the ugly. Trends in Biochemical Sciences 2007;32:407–14.CrossRef
Vogel, SS, Thaler, C, Koushik, SV. Fanciful FRET. Science STKE 2006:re2.
Camp, RL, Chung, GG, Rimm, DL. Automated subcellular localization and quantification of protein expression in tissue microarrays. Nature Medicine 2002;8:1323–7.CrossRef
Gustavson, MD, Bourke-Martin, B, Reilly, DM, et al. Development of an unsupervised pixel-based clustering algorithm for compartmentalization of immunohistochemical expression using Automated QUantitative Analysis. Applied Immunohistochemistry and Molecular Morphology 2009;17: 329–37.CrossRef
Divito, KA, Berger, AJ, Camp, RL, et al. Automated quantitative analysis of tissue microarrays reveals an association between high Bcl-2 expression and improved outcome in melanoma. Cancer Research 2004;64:8773–7.CrossRef
Zerkowski, MP, Camp, RL, Burtness, BA, Rimm, DL, Chung, GG. Quantitative analysis of breast cancer tissue microarrays shows high cox-2 expression is associated with poor outcome. Cancer Investigation 2007;25: 19–26.CrossRef
Dolled-Filhart, M, McCabe, A, Giltnane, J, et al. Quantitative in situ analysis of beta-catenin expression in breast cancer shows decreased expression is associated with poor outcome. Cancer Research 2006;66:5487–94.CrossRef
Giltnane, JM, Ryden, L, Cregger, M, et al. Quantitative measurement of epidermal growth factor receptor is a negative predictive factor for tamoxifen response in hormone receptor positive premenopausal breast cancer. Journal of Clinical Oncology 2007;25:3007–14.CrossRefGoogle ScholarPubMed
Anagnostou, VK, Bepler, G, Syrigos, KN, et al. High expression of mammalian target of rapamycin is associated with better outcome for patients with early stage lung adenocarcinoma. Clinical Cancer Research 2009;15:4157–64.CrossRef
Anagnostou, VK, Syrigos, KN, Bepler, G, Homer, RJ, Rimm, DL. Thyroid transcription factor 1 is an independent prognostic factor for patients with stage I lung adenocarcinoma. Journal of Clinical Oncology 2009;27:271–8.CrossRefGoogle ScholarPubMed
Giepmans, BN, Adams, SR, Ellisman, MH, Tsien, RY. The fluorescent toolbox for assessing protein location and function. Science 2006;312:217–24.CrossRef
Berney, C, Danuser, G. FRET or no FRET: a quantitative comparison. Biophysical Journal 2003;84:3992–4010.CrossRef
Jares-Erijman, EA, Jovin, TM. FRET imaging. Nature Biotechology 2003; 21:1387–95.CrossRef
Kenworthy, AK. Imaging protein-protein interactions using fluorescence resonance energy transfer microscopy. Methods 2001;24:289–96.CrossRef
Stryer, L. Fluorescence energy transfer as a spectroscopic ruler. Annual Review in Biochemistry 1978;47:819–46.CrossRef
Nagai, Y, Miyazaki, M, Aoki, R, et al. A fluorescent indicator for visualizing cAMP-induced phosphorylation in vivo. Nature Biotechology 2000;18: 313–16.CrossRef
Ponsioen, B, Zhao, J, Riedl, J, et al. Detecting cAMP-induced Epac activation by fluorescence resonance energy transfer: Epac as a novel cAMP indicator. EMBO Reports 2004;5: 1176–80.CrossRef
Jaiswal, JK, Mattoussi, H, Mauro, JM, Simon, SM. Long-term multiple color imaging of live cells using quantum dot bioconjugates. Nature Biotechology 2003;21:47–51.CrossRef
Gao, X, Yang, L, Petros, JA, et al. In vivo molecular and cellular imaging with quantum dots. Current Opinion in Biotechnology 2005;16:63–72.CrossRef
Jamieson, T, Bakhshi, R, Petrova, D, et al. Biological applications of quantum dots. Biomaterials 2007;28:4717–32.CrossRef

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