Challenges and Pitfalls in HNPCC Screening by Microsatellite Analysis and Immunohistochemistry Annegret Müller, Giuseppe Giuffre, Tina Bocker Edmonston,

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Challenges and Pitfalls in HNPCC Screening by Microsatellite Analysis and Immunohistochemistry Annegret Müller, Giuseppe Giuffre, Tina Bocker Edmonston, Micaela Mathiak, Beate Roggendorf, Ernst Heinmöller, Thomas Brodegger, Giovanni Tuccari, Elisabeth Mangold, Reinhard Buettner, Josef Rüschoff The Journal of Molecular Diagnostics Volume 6, Issue 4, Pages 308-315 (November 2004) DOI: 10.1016/S1525-1578(10)60526-0 Copyright © 2004 American Society for Investigative Pathology and Association for Molecular Pathology Terms and Conditions

Figure 1 A–D: Results of MSI analysis in patient 1 diagnosed with a flat adenoma in the cecum. A: An overview of the lesion shows slightly thickened mucosa within the marked area (box) and a minute focus of invasion (arrow). H&E, magnification, ×4. B: Immunohistochemistry showed distinct loss of MLH1 expression in the neoplastic crypts (arrows). Anti-MLH1, magnification, ×10. C: MSI-analysis after crude manual microdissection displayed MSS status. D: MSI-analysis of the mononucleotide markers BAT 25 (upper two lanes) and BAT 26 (lower two lanes) after laser microdissection disclosed the MSI-H nature particularly in the invasive part (normal tissue: lanes 1 and 3; corresponding tumor tissue: lanes 2 and 4). The Journal of Molecular Diagnostics 2004 6, 308-315DOI: (10.1016/S1525-1578(10)60526-0) Copyright © 2004 American Society for Investigative Pathology and Association for Molecular Pathology Terms and Conditions

Figure 2 A–D: MSI analysis in a mucinous carcinoma. A: Histological tumor section after laser microdissection of selected tumor cells. H&E, magnification, ×40. B: Crude manual dissection of the mucinous carcinoma revealed MSS status (shown: BAT25, BAT26, D5S346; normal tissue: lanes 1, 3, and 5; corresponding tumor tissue: lanes 2, 4, and 6). C and D: After laser microdissection MSI analysis revealed a loss of the second peak at the dinucleotide marker (APC, D5S346) in the tumor sample when compared to normal tissues (normal tissue, lane 1; corresponding tumor tissue, lane 2). This result, suggesting LOH, was observed only when less than 50 cells were used for the MSI-analysis, whereas laser microdissection of a larger tumor cell number revealed the correct MSI-H result (C, lane 3). D: Corresponding results for BAT 26 with the PCR artifact resulting from too few analyzed cells in lane 2 and the correct MSI result shown in lane 3. The Journal of Molecular Diagnostics 2004 6, 308-315DOI: (10.1016/S1525-1578(10)60526-0) Copyright © 2004 American Society for Investigative Pathology and Association for Molecular Pathology Terms and Conditions

Figure 3 A-G: Immunohistochemical staining and MSI-analyses of two synchronous colon carcinomas. A–F: The immunohistochemical analysis showed loss of MSH2 protein expression in one adenocarcinoma (B) but clearly detectable MSH2 protein expression in the second, more solid carcinoma (E) (A and D: anti-MLH1, B and E: anti-MSH2, C and F: anti-MSH6 immunostaining, magnification, ×20.). G: Results of MSI-analysis in both tumors (lanes 1 and 4, normal tissue; lanes 2 and 5, second solid tumor; lanes 3 and 6, adenocarcinoma). Less distinct shifts in the MSH2 expressing carcinoma. The Journal of Molecular Diagnostics 2004 6, 308-315DOI: (10.1016/S1525-1578(10)60526-0) Copyright © 2004 American Society for Investigative Pathology and Association for Molecular Pathology Terms and Conditions

Figure 4 A–D: Histological and immunohistological findings in patient 4. A: Carcinoma with dense intratumoral lymphocytic infiltrate suggestive of an MSI-H tumor. H&E, magnification, ×10. B: Strong intranuclear staining of MSH2 in the tumor cells. Anti-MSH2, mgnification, ×40. C: MLH1 immunostaining shows only a perinuclear rim-like reaction, but no distinct intranuclear staining. Anti-MLH1, magnification, ×40. D: Complete loss of PMS2 staining in the tumor cell nuclei (arrows). The Journal of Molecular Diagnostics 2004 6, 308-315DOI: (10.1016/S1525-1578(10)60526-0) Copyright © 2004 American Society for Investigative Pathology and Association for Molecular Pathology Terms and Conditions