ORIGINAL ARTICLE
Determining the Site of Origin of Mucinous
Adenocarcinoma: An Immunohistochemical
Study of 175 Cases
Peiguo G. Chu, MD, PhD, Lawrence Chung, Lawrence M. Weiss, MD, and Sean K. Lau, MD
Abstract: Mucinous adenocarcinomas (MAs) of various origins
may have a similar histologic appearance and frequently
metastasize to distant sites, which often causes diagnostic
problems in surgical pathology practice. The immunohisto-
chemical profiles of MAs of various origins have not been well
studied. We investigated the expression of 10 immunohisto-
chemical markers (CK7, CK20, CDX-2, b-catenin, MUC-1,
MUC-2, MUC-6, ER, WT-1, and PAX-8) in 175 cases of MA,
including 69 cases from the lower gastrointestinal (GI) tract, 41
from the upper GI tract, 27 from gynecologic organs, 4 from the
urinary bladder, 18 from the breast, and 16 from the lung. We
found that lower GI MAs (colon, rectum, and anus) frequently
expressed CDX-2 (42 of 42, 100%; 33 of 42 with homogenous
positivity, 79%), MUC-2 (42 of 42; 100%), CK20 (41 of 42;
98%), and b-catenin (nuclear) (27 of 42; 64%) and rarely
expressed MUC-6 (2 of 42; 5%) and CK7 (8 of 42; 19%). Most
of the CK7-positive cases were from the rectum and anus (7 of 8;
88%). The expression of these markers in appendiceal MAs was
similar to that of low GI tract MAs, except for a lower
percentage of homogenous CDX-2 (3 of 27; 11%) and nuclear
b-catenin (3 of 27; 11%) expression. Unlike their lower GI tract
counterparts, the upper GI tract MAs (ampulla, pancreas/
biliary tree, and stomach/esophagus) frequently expressed CK7
(38 of 41; 93%) and MUC-6 (31 of 41; 76%) and were rarely
homogenously positive for CDX-2 (4 of 41; 10%) and nuclear
positive for b-catenin (8 of 41; 19%). Breast MAs were
frequently positive for CK7 (18 of 18; 100%), MUC-1 (18 of
18; 100%), MUC-2 (18 of 18; 100%), ER (16 of 18; 89%),
MUC-6 (9 of 18; 50%), and WT-1 (9 of 18; 50%). Lung MAs
were frequently positive for CK7 (16 of 16; 100%) and MUC-1
(15 of 16; 94%). Gynecologic MAs were positive for CK7 (25 of
27; 93%) and PAX-8 (13 of 27; 48%). We conclude that
homogenous CDX-2 and nuclear b-catenin expressions are
commonly seen in lower GI tract MAs. In contrast, appendiceal
MAs are usually heterogenously positive for CDX-2 and show
cytoplasmic positivity for b-catenin. Unlike lower GI tract MAs,
From the Department of Pathology, City of Hope National Medical
Center, Duarte, CA.
Conflicts of Interest and Sources of Funding: The authors have disclosed
that they have no significant relationships with, or financial interest
in, any commercial companies pertaining to this article.
Correspondence: Peiguo G. Chu, MD, PhD, Division of Pathology, City
of Hope National Medical Center, Duarte, CA, 91010. (e-mail:
pchu@coh.org).
Copyright r 2011 by Lippincott Williams & Wilkins
1830 | www.ajsp.com
upper GI tract MAs are frequently positive for CK7 and MUC-6.
As is the case in appendiceal MAs, the upper GI tract MAs may
also be heterogenously positive for CDX-2. Breast MAs are
positive for ER and WT-1, whereas gynecologic MAs are
positive for PAX-8 and negative for WT-1.
Key Word: mucinous adenocarcinoma, CDX-2, b-catenin,
MUC-6, PAX-8, immunohistochemistry
(Am J Surg Pathol 2011;35:1830–1836)
M ucinous adenocarcinomas (MAs) of various origins
often have a similar histologic appearance. They are
composed of glands lined with either columnar mucin-
producing cells with abundant extracellular mucin accu-
mulation (>50% of tumor mass) or mucin-containing
signet ring cells. Although the vast majority of cases of
MA arise from the gastrointestinal (GI) tract, they may
also be seen in the breast, lung, pancreas, and urinary
bladder. MAs frequently metastasize to the ovary,
peritoneal surface, liver, or lung.4,36
MAs of various origins derive from simple gland-
ular epithelia. Similar to their nonmucinous counterparts,
MAs express low-molecular-weight cytokeratins, such as
CK7, CK8, CK18, and CK20. Among them, CK7 and
CK20 have the most diagnostic value.5,32,43 In general,
the lower GI tract MAs express CK20, whereas non-GI
MAs express CK7.43 However, there are exceptions. For
instance, lung MAs may express CK20,10,35 whereas
appendiceal MAs may express CK7.25 Cutaneous MAs
may express high-molecular-weight cytokeratins, such as
CK5/6,22 and MAs from the pancreatic/biliary tree may
express CK17.6,11
Mucins are high-molecular-weight glycoproteins.
Although more than 10 different types of mucins have
been discovered so far, only a few of them have been
found to be useful in pathologic diagnosis.47 These
mucins are differentially expressed by different cells and
organs. The mucin (MUC-1, MUC-2, MUC-5AC, and
MUC-6) expression profiles in nonmucinous adenocarci-
nomas have been well studied.1,19,31 In general, the lower
GI tract adenocarcinomas express MUC-2,12 whereas
non-GI adenocarcinomas express MUC-1. The upper GI
adenocarcinomas may express both MUC-1 and MUC-
2.27,38 A few studies have shown that the unique mucin
expression pattern in certain types of MAs may be useful
Am J Surg Pathol  Volume 35, Number 12, December 2011
Am J Surg Pathol  Volume 35, Number 12, December 2011
for pathologic diagnosis. For instance, unlike regular
breast ductal carcinoma, breast MAs (colloid carcinoma)
express MUC-2 and MUC-6 highly,12,24 and lung MAs
express MUC-2.35
The caudal-related homeobox transcription factor
CDX-2 regulates the differentiation of intestinal epithelial
cells.9 Strong nuclear staining for CDX-2 is always
present in the epithelial cells of the small bowel and
colon.17,45 Scattered gallbladder epithelial cells and
pancreatic ductal and acinar cells may also be positive
for CDX-2. Normal gastric epithelium is negative for
CDX-2. No significant CDX-2 expression is noted outside
the GI tract.45 Colorectal7,17,45 and small intestinal3
adenocarcinomas are strongly and diffusely positive for
CDX-2 (homogenous pattern). The noncolorectal adeno-
carcinomas that express CDX-2 usually arise from
intestinal metaplasia, such as some urinary bladder
adenocarcinomas (chronic cystitis) and gastric intestinal-
type adenocarcinomas (chronic gastritis and Barrett
esophagus).17,45 A few studies have shown that noncolor-
ectal MAs may express CDX-2, such as ovarian,
pancreatic, and lung MAs.35,45 However, CDX-2 expres-
sion in these noncolorectal MAs is usually focal and weak
(heterogenous pattern).
b-catenin plays an important role in colorectal
carcinoma carcinogenesis through activation by mutant
adenomatous polyposis coli (APC) gene and/or activation
of Wnt signaling.25 APC mutation leads to nuclear
accumulation of b-catenin, a feature associated with
progression along the adenoma-carcinoma sequence. Ap-
proximately 90% of cases of colorectal carcinoma express
nuclear b-catenin.8,46 After studying 41 cases of colorectal
MAs, Ikeda et al14 found that more than 90% of cases had
nuclear accumulation of b-catenin, an immunohistochem-
ical feature that may be useful in differential diagnosis of
colorectal MAs from noncolorectal MAs.
Wilms tumor gene (WT-1) is a tumor suppressor gene.
WT-1 protein is exclusively expressed in ovarian non-
MAs.11,39 PAX-8 is a member of the paired box (PAX)
family of transcription factors and is important in organo-
genesis of the thyroid, kidney, and Müllerian system.23
PAX-8 is a nuclear protein and is expressed in a variety of
ovarian epithelial tumors.20,28 The expression of WT-1 and
PAX-8 in ovarian MAs is not well studied. Estrogen
receptor (ER) is a nuclear protein expressed in estrogen-
sensitive organs such as the breast, cervix, endometrium, and
ovary. It is also expressed in breast and endometrial MAs.42
We investigated the expression of CK7, CK20,
CDX-2, b-catenin, MUC-1, MUC-2, MUC-6, ER, WT-1,
and PAX-8 in 175 cases of common MAs. Rare MAs,
such as those from the kidney, prostate, and skin adnexa,
were not included in this study.
MATERIALS AND METHODS
Cases
A total of 175 cases of MAs were selected from the
surgical pathology files of the City of Hope National
Medical Center, USA, from 1989 to 2010 (Table 1). Sites
r 2011 Lippincott Williams & Wilkins
Determining the Site of Origin of Mucinous Adenocarcinoma
of origin of all metastatic MAs were known before this
study on the basis of clinical and radiologic information
or on additional surgical specimen examination. The
tissues had been routinely fixed in 10% neutral formalin
and embedded in paraffin. One paraffin tissue block with
tumor was selected from each case. All cases met the
diagnostic criteria of MAs with >50% of extracellular
mucin (well to moderately differentiated) or signet ring
cells (poorly differentiated).
Immunohistochemistry
Commercially available antibodies to keratin 7
(clone OV-TL 12/30; 1:2000, DAKO Corporation,
Carpenteria, CA), keratin 20 (clone Ks.20.8; 1:50, DAKO
Corporation), CDX-2 (Clone DAK-CDX2; 1:25, DAKO
Corporation), b-catenin (1:2,000; Dako), MUC-1 (Clone
Ma695; 1:100, Novacastra, Burlingame, CA), MUC-2
(Clone Ccp58; 1:100, Novacastra), MUC-6 (Clone MRQ-
20; 1:100, Cell Marque, Rocklin, CA), ER (Clone SP1;
1:100, DAKO Corporation), WT-1 (Clone 6F-H2; 1:50,
DAKO Corporation), and PAX-8 (Polyclonal; 1:100, Cell
Marque) were purchased. All MAs were stained with these
antibodies. Lung MAs were also stained with TTF-1
(Clone 8G7G3/1; 1:75, Dako) and napsin-A (Polyclonal;
1:200, Cell Marque). The sections were deparaffinized and
rehydrated in graded alcohol. The sections were then
brought to an automated stainer (DAKO Corporation,
Carpinteria, CA). For heat-induced epitope retrieval, the
sections for CK7, CK20, CDX-2, ER, napsin-A, WT-1,
TTF-1, PAX-8, and napsin-A were subjected to Dako
TRS High Retrieval buffer, and the sections for MUC-1,
MUC-2, and MUC-6 were subjected to Dako TRS Low
Retrieval Buffer. FLEX and peroxidase detection methods
were used. Positive (known positive tissues) and negative
(without primary antibodies) controls for each antibody
were used simultaneously for each stain.
For CK7, CK20, MUC-1, MUC-2, MUC-6, and
napsin-A, membranous and cytoplasmic immuno-
reactivity was assessed. For CDX-2, b-catenin, ER,
WT-1, TTF-1, and PAX-8, nuclear immunoreactivity
was assessed. For CDX-2, homogenous immunoreactivity
was assessed as >75% of tumor cells positive, and
heterogenous immunoreactivity was assessed as <25%
of tumor cells positive. Only those cases showing >5%
tumor cell positivity were regarded as positive.
RESULTS
By Organs (Table 1)
Lower GI Tract MAs
Of 42 cases of lower GI tract MAs, 5 cases were
from the anus, 18 were from the colon, and 19 were from
the rectum. The lower GI tract MAs were usually positive
for CK20 (41 of 42; 95%) and MUC-2 (42 of 42;100%).
They usually showed homogenous CDX-2 nuclear
positivity (33 of 42; 79%) (Fig. 1A) and nuclear b-catenin
positivity (27 of 32; 63%) (Fig. 1C). Eight of 43 (19%)
cases were focally positive for CK7. Seven of those 8 cases
www.ajsp.com | 1831
Chu et al Am J Surg Pathol  Volume 35, Number 12, December 2011

TABLE 1. Expression of Immunohistochemical Markers in Various MAs

Total CDX-2 Nuclear
Organs Cases CK7 CK20 f+ d+ b catenin MUC-1 MUC-2 MUC-6 ER WT-1 PAX-8
Lower GI tract
Anus 5 2 5 1 4 3 2 5 0 0 0 0
Colon 18 1 18 4 14 11 2 18 1 0 0 0
Rectum 19 5 18 4 15 13 2 19 2 0 0 0
Appendix 27 11 26 24 3 3 4 27 0 0 0 0
Upper GI tract
Ampulla 4 1 1 3 1 1 2 4 3 0 0 0
Pancreas 25 24 15 15 1 2 16 13 21 0 0 0
Stomach 12 11 8 10 2 5 6 11 7 0 0 0
Bladder 4 3 4 2 0 1 1 4 0 0 0 0
Breast 18 18 0 0 0 18 18 9 16 9 0
Cervix 5 5 0 0 0 0 5 2 5 3 0 1
Endometrium 3 3 0 0 0 0 3 1 0 2 0 3
Ovary 19 17 9 4 1 0 6 4 3 2 0 9
Lung 16 16 5 2 0 0 15 4 5 0 0 0
Total 175
CK indicates cytokeratin; d+, diffuse/homogenous, f+: focal/heterogenous; GI, gastrointestinal tract.

were from the rectum (5 cases) and anus (2 cases),
whereas only 1 of 18 colon MAs was CK7 positive.
Appendiceal MAs
Of 27 cases of appendiceal MAs, 21 were peritoneal
metastases, and 6 were primaries. Similar to lower GI
tract MAs, the appendiceal MAs were positive for CK20
(26 of 27; 96%) and MUC-2 (26 of 26; 100%). However,
unlike lower GI tract MAs, only 3 of 26 cases showed
nuclear b-catenin (12%) and diffuse CDX-2 (12%)
nuclear immunoreactivity. Approximately one third of
cases (11 of 27; 37%) were also positive for CK7.
Upper GI Tract MAs
Of 41 cases, 4 cases were from the ampulla, 25 were
from the pancreas/biliary tree, and 12 were from the
stomach and gastroesophageal junction. These MAs had
mixed immunohistochemical profiles of CK20, CDX-2,
MUC-1, and MUC-2 stainings, with immunoreactivities
intermediate between lower GI tract MAs and non-GI
tract MAs. Between one half and one third of cases
expressed CK20 (25 of 42; 60%), CDX-2 (heterogenous
pattern) (33 of 42; 78%) (Fig. 1B), MUC-1 (24 of 42;
57%), and MUC-2 (29 of 42; 69%). The expression
pattern of these immunohistochemical markers was
usually focal. However, unlike lower GI tract MAs, the
upper GI tract MAs usually expressed CK7 (36 of 41;
88%) and MUC-6 (31 of 41; 76%) (Fig. 2A).
Urinary Bladder MAs
The immunohistochemical profile of bladder MAs
was similar to that of appendiceal MAs: positive for CK7
(3/4; 75%), CK20 (4/4; 100%), MUC-2 (4/4; 100%), and
CDX-2 (heterogenous pattern) (2/4; 50%).
Breast MAs
Similar to regular nonmucinous breast ductal
carcinomas, breast MAs were diffusely positive for CK7
(18 of 18; 100%), MUC-1 (18 of 18; 100%), and ER (16
of 18; 89%). However, unlike regular ductal carcinomas,
breast MAs were also positive for MUC-2 (18 of 18;

FIGURE 1. The nuclear CDX-2 expression is observed as homogenous (>75%) (A) in a colon MA and heterogenous (< 25%) in a
pancreatic MA (B). Nuclear and cytoplasmic b-catenin (C) expression in a rectal MA.

1832 | www.ajsp.com r 2011 Lippincott Williams & Wilkins

Am J Surg Pathol  Volume 35, Number 12, December 2011
FIGURE 2. Cytoplasmic expression of MUC-6 in a pancreatic MA (A). Nuclear WT-1 expression is seen in a breast MA (B) and
nuclear PAX-8 expression in an ovarian MA in some tumor cells (C).
100%) and were frequently nuclear positive for WT-1
(9 of 18; 50%) (Fig. 2B).
GYN MAs
The cervical, endometrial, and ovarian MAs were
positive for CK7 (25 of 27; 93%) and MUC-1 (14 of 19;
74%). Approximately half of them were positive for
PAX-8 (13 of 27; 48%) (Fig. 2C) and CK20 (9 of 19;
47%), and about a quarter of them were positive for
MUC-2 (7 of 27; 26%) and CDX-2 (heterogenous
pattern) (5 of 19; 26%).
Lung MAs
The vast majority of lung MAs expressed CK7 (16
of 16; 100%) and MUC-1 (15 of 16; 94%). They were also
occasionally focally positive for CDX-2 (2 of 16; 13%)
and MUC-2 (4 of 16; 16%). However, they were
constantly negative for napsin-A (0 of 16; 0%) and
TTF-1 (0 of 16; 0%) (data not shown).
By Markers (Table 1)
CK7
CK7 expression in MAs could be divided into 3
groups: diffusely positive in breast, GYN, and lung MAs;
focally positive in appendiceal, rectal/anal, upper GI tract,
and bladder MAs; and usually negative in colon MAs.
CK20
CK20 expression in MAs could also be divided into
3 groups: diffusely positive in appendiceal, colon, and
rectal/anal MAs; focally positive in upper GI tract,
bladder, ovarian, and lung MAs; and usually negative
in breast, cervical, and endometrial MAs.
CDX-2
CDX-2 expression in MAs could also be divided
into 3 groups: homogenous nuclear positive in colon and
rectal/anal MAs; heterogenous nuclear positive in appen-
diceal, upper GI tract, ovarian, and lung MAs; and
negative in breast, cervical, and endometrial MAs.
b-catenin
Cytoplasmic b-catenin expression was common in
MAs of various origins. Only nuclear b-catenin was
r 2011 Lippincott Williams & Wilkins
Determining the Site of Origin of Mucinous Adenocarcinoma
regarded as specific. Nuclear expression was frequently
seen in colorectal MAs, was rarely seen in appendiceal,
upper GI tract, and bladder MAs, and was absent in
other types of MAs.
MUC-1
MUC-1 expression in MAs was similar to that of
CK7, except in appendiceal MAs, which were usually
negative for MUC-1.
MUC-2
MUC-2 expression in MAs was similar to that of
CK20, except in breast MAs, which were usually positive
for MUC-2.
MUC-6
MUC-6 was expressed in pancreatic, ampullary,
gastric, and breast MAs and was rarely expressed in
rectal/anal, ovarian, and lung MAs. Colon and other
types of MAs were usually negative for MUC-6.
ER
ER was usually expressed in breast, endometrial, and
cervical MAs. Ovarian MAs were usually negative for ER.
WT-1
WT-1 expression was only present in some breast
MAs and not in ovarian MAs.
PAX-8
PAX-8 expression was only present in GYN MAs
and not in other types of MAs.
DISCUSSION
MAs are relatively common types of adenocarcino-
mas in the GI tract, breast, and ovary but are rare in the
lung and genitourinary organs. Despite their diverse
anatomic origins, they share similar histologic appearances:
glands lined with columnar mucin-producing cells with
excess extracellular mucin accumulation (usually >50% of
tumor mass) or with abundant intracellular mucin accumu-
lation (signet ring cells). MAs are not difficult to diagnose
when they remain in primary sites. However, specific
diagnosis may become challenging or impossible when they
www.ajsp.com | 1833
Chu et al Am J Surg Pathol  Volume 35, Number 12, December 2011

metastasize to distant locations. Immunohistochemistry
plays an important role in determining the site of tissue
origin of metastatic MAs (Table 2).
Ovary is the most common site of metastatic MAs.
Approximately 80% of ovarian MAs are metastases, and
20% of them are primaries. Sources of ovarian metastatic
MAs come from (most common to less common) colo-
rectal, appendiceal, gastric (Krukerberg tumor), breast,
and pancreatic/biliary tree neoplasms.18,25 Although the
gross and histologic features may suggest ovarian primary
MAs (large size, unilateral, and multicystic, without
extraovarian disease) over metastases (small size, bilateral
and surface involvement, and stromal invasion),43 some
metastatic MAs can manifest one or more gross and
microscopic features suggesting a primary ovarian MA
clinically and pathologically. Immunohistochemistry is
usually necessary to distinguish an ovarian primary
tumor from a metastasis. The unique immunohistochem-
ical profile of a primary ovarian MA includes PAX-8 and
ER (stromal cells positive whereas primary ovarian MAs
negative) positivity28,40,42 and b-catenin,4,25 MUC-6, and
WT-1 negativity. Most ovarian primary MAs are low
grade, with well-formed mucinous glands, and are usually
diffusely CK7 25,26,33 and MUC-1 positive and only focally
positive for CDX-2, CK20, and MUC-2.16,21,26,41,44 In
contrast, metastatic breast MAs tend not to form glands
and are positive for ER, MUC-6, and WT-1. Appendiceal
and colorectal MAs are focally or diffusely CDX-246 and
diffusely positive for CK20 and MUC-2.4,9,33 Upper GI
tract MAs may be MUC-6 positive,38 which is usually
negative in primary ovarian MAs.
Determining the site of origin of a metastatic MA in
the peritoneum or the liver may be challenging. In
TABLE 2. Recommendation of Immunohistochemical Panel
for Various MAs
Types of
MAs Positive Markers
Colon CK20, CDX-2 (homogenous),
MUC-2, b-catenin (nuclear)
Rectum/anus CK7, CK20, CDX-2
(homogenous), MUC-2,
b-catenin (nuclear)
Appendix CK7, CK20, CDX-2
(heterognous), MUC-2
Upper GI CK7, CK20, CDX-2
(heterogenous), MUC-2,
MUC-6
Bladder CK7, CK20, CDX-2
(heterogenous), MUC-2
Breast CK7, MUC-1, MUC-2,
MUC-6, ER, WT-1
Ovary PAX-8, CK7, CDX-2
(heterogenous), ER (stromal)
Endometrium CK7, MUC-1,
ER, PAX-8
Cervix CK7, MUC-1,
MUC-6, ER
Lung CK7, CDX-2 (heterogenous),
MUC-1, MUC-2, MUC-6
CK indicates cytokeratin; GI, gastrointestinal tract.
general, a metastatic MA that is diffusely positive for
CDX-2, CK20, and MUC-237,44 and nuclear positive for
b-catenin14 favors a colon primary. A metastatic MA that
is not only diffusely positive for CDX-2, CK20, and
MUC-2 and nuclear positive for b-catenin but also focally
positive for CK7 favors a rectal or anal primary.7,22 A
metastatic MA that is not only diffusely positive for
CK20 and MUC-2 but also focally positive for CDX-2 or
for CK7 favors an appendiceal primary.30,34 A metastatic
MA that is not only focally positive for CK7, CK20,
MUC-1, MUC-2, or CDX-2 but also focally positive for
MUC-6 favors a pancreatic/biliary tree/gastric pri-
mary.15,16,25,38 Unlike pancreatic ductal adenocarcino-
mas, which are usually negative for Dpc4, pancreatic
MAs are positive for Dpc4.2,13 Immunohistochemical
profiles are less helpful in separating a metastatic
pancreatic MA from a metastatic gastric MA (Table 2).
Breast MAs are usually positive for CK7, MUC-1,
and ER and are completely negative for CK20, b-catenin
(nuclear), and CDX-2.25 Unlike Nonaka et al,28,39 we
found that 50% of cases of breast MAs are weakly positive
for WT-1, whereas primary ovarian MAs are completely
negative for WT-1. The aberrant WT-1 expression in breast
MAs makes it a valuable marker for differentiating breast
MA from other types of MAs. The immunohistochemical
profiles of primary bladder MAs are similar to that of
appendiceal MAs: positive for CK7 and CK20.29 The
immunohistochemical profiles of lung MAs are different
from those of nonmucinous lung adenocarcinomas. They
are divided into 2 types: goblet cell type with coexpression
of intestinal makers and signet ring-cell type with
coexpression of pulmonary markers.35Lung MAs are
usually positive for CK7 and MUC-1 but are mostly
negative for TTF-1 and napsin-A. They may be positive for
CK20, CDX-2, MUC-2, or MUC-6.
In summary, we have studied the expression of 10
useful immunohistochemical markers in 175 cases of
Negative Markers
common MAs of various origins. We found that a vast
majority of cases of colorectal MAs are diffusely CK20
CK7, MUC-1, positive, MUC-2 positive, homogenous CDX-2 positive,
MUC-6
MUC-1, MUC-6 and nuclear b-catenin positive. In addition to these
markers, rectal/anal MAs may also be positive for CK7.
Despite the morphologic similarity to colorectal MAs,
MUC-1, MUC-6, appendiceal MAs are heterogenous CDX-2 positive,
b-catenin (nuclear)
ER, WT-1, PAX-8
positive for CK7, and nuclear b-catenin negative.
Gynecologic MAs are positive for CK7, MUC-1, and
PAX-8 but are rarely positive for CK20, CDX-2, and
MUC-1, MUC-6, b-catenin (nuclear). Breast MAs are positive for CK7,
b-catenin (nuclear) MUC-1, MUC-2, ER, and WT-1. Pancreatic, biliary tree,
CK20, CDX-2,
b-catenin (nuclear) and gastric MAs are usually positive for CK7, MUC-1,
MUC-6, WT-1, and MUC-2, focally positive for CK20, and heteroge-
b-catenin (nuclear) nously positive for CDX-2. The high expression of MUC-
CK20, CDX-2, 6 in these tumors makes it a useful marker for
b-catenin (nuclear)
CK20, CDX-2,
distinguishing upper GI tract MAs from low GI tract
b-catenin (nuclear) MAs or from appendiceal MAs. It should be emphasized
TTF-1, napsin-A that these makers should be used in a panel and in an
algorithmic manner and that positive stains should
always count more than negative stains in determination
of the site of origin of MAs.

1834 | www.ajsp.com r 2011 Lippincott Williams & Wilkins

Am J Surg Pathol  Volume 35, Number 12, December 2011
REFERENCES
1. Alos L, Lujan B, Castillo M, et al. Expression of membrane-bound
mucins (MUC1 and MUC4) and secreted mucins (MUC2,
MUC5AC, MUC5B, MUC6 and MUC7) in mucoepidermoid
carcinomas of salivary glands. Am J Surg Pathol. 2005;29:806–813.
2. Biankin AV, Biankin SA, Kench JG, et al. Aberrant p16(INK4A)
and DPC4/Smad4 expression in intraductal papillary mucinous
tumours of the pancreas is associated with invasive ductal
adenocarcinoma. Gut. 2002;50:861–868.
3. Chen ZM, Ritter JH, Wang HL. Differential expression of alpha-
methylacyl coenzyme A racemase in adenocarcinomas of the small
and large intestines. Am J Surg Pathol. 2005;29:890–896.
4. Chou YY, Jeng YM, Kao HL, et al. Differentiation of ovarian
mucinous carcinoma and metastatic colorectal adenocarcinoma
by immunostaining with beta-catenin. Histopathology. 2003;43:151–156.
5. Chu PG, Wu E, Weiss LM. Cytokeratin 7 and cytokeratin 20
expression in epithelial neoplasms: a survey of 435 cases. Mod
Pathol. 2000;13:962–972.
6. Chu PG, Schwarz RE, Lau SK, et al. Immunohistochemical staining
in the diagnosis of pancreatobiliary and ampulla of Vater adeno-
carcinoma: application of CDX2, CK17, MUC1, and MUC2. Am
J Surg Pathol. 2005;29:359–367.
7. De Lott LB, Morrison C, Suster S, et al. CDX2 is a useful marker of
intestinal-type differentiation: a tissue microarray-based study of 629
tumors from various sites. Arch Pathol Lab Med. 2005;129:1100–1105.
8. Fodde R, Smits R, H Clevers. APC signal transduction and genetic
instability in colorectal cancer. Nat Rev Cancer. 2001;1:55–67.
9. Fraggetta F, Pelosi G, Cafici A, et al. CDX2 immunoreactivity in
primary and metastatic ovarian mucinous tumours. Virchows Arch.
2003;443:782–786.
10. Gallardo F, Bellosillo B, Espinet B, et al. Aberrant nuclear BCL10
expression and lack of t(11;18)(q21;q21) in primary cutaneous
marginal zone B-cell lymphoma. Hum Pathol. 2006;37:867–873.
11. Goldstein NS, Uzieblo A. WT1 immunoreactivity in uterine
papillary serous carcinomas is different from ovarian serous
carcinomas. Am J Clin Pathol. 2002;117:541–545.
12. Hanski C, Hofmeier M, Schmitt-Graff A, et al. Overexpression or
ectopic expression of MUC2 is the common property of mucinous
carcinomas of the colon, pancreas, breast, and ovary. J Pathol.
1997;182:385–391.
13. Iacobuzio-Donahue CA, Klimstra DS, Adsay NV, et al. Dpc-4
protein is expressed in virtually all human intraductal papillary
mucinous neoplasms of the pancreas: comparison with conventional
ductal adenocarcinomas. Am J Pathol. 2000;157:755–761.
14. Ikeda S, Shimizu Y, Fujimori M, et al. Immunohistochemical and
mutational analyses of beta-catenin, Ki-ras, and p53 in two subtypes
of colorectal mucinous carcinoma. Clin Cancer Res. 2003;9:5660–5665.
15. Ito H, Endo T, Oka T, et al. Mucin expression profile is related to
biological and clinical characteristics of intraductal papillary-
mucinous tumors of the pancreas. Pancreas. 2005;30:e96–102.
16. Ji H, Isacson C, Seidman JD, et al. Cytokeratins 7 and 20, Dpc4,
and MUC5AC in the distinction of metastatic mucinous carcinomas
in the ovary from primary ovarian mucinous tumors: Dpc4 assists in
identifying metastatic pancreatic carcinomas. Int J Gynecol Pathol.
2002;21:391–400.
17. Kaimaktchiev V, Terracciano L, Tornillo L, et al. The homeobox
intestinal differentiation factor CDX2 is selectively expressed in
gastrointestinal adenocarcinomas. Mod Pathol. 2004;17:1392–1399.
18. Lagendijk JH, Mullink H, Van Diest PJ, et al. Tracing the origin of
adenocarcinomas with unknown primary using immunohistochem-
istry: differential diagnosis between colonic and ovarian carcinomas
as primary sites. Hum Pathol. 1998;29:491–7.
19. Lau SK, Weiss LM, Chu PG. Differential Expression of MUC1,
MUC2, and MUC5AC in Carcinomas of Various Sites. In: 2004:61–9.
20. Laury AR, Hornick JL, Perets R, et al. PAX8 reliably distinguishes
ovarian serous tumors from malignant mesothelioma. Am J Surg
Pathol. 2010;34:627–635.
21. Lee KR, Nucci MR. Ovarian mucinous and mixed epithelial
carcinomas of mullerian (endocervical-like) type: a clinicopathologic
analysis of four cases of an uncommon variant associated with
endometriosis. Int J Gynecol Pathol. 2003;22:42–51.
r 2011 Lippincott Williams & Wilkins
Determining the Site of Origin of Mucinous Adenocarcinoma
22. Lisovsky M, Patel K, Cymes K, et al. Immunophenotypic
characterization of anal gland carcinoma: loss of p63 and cytokeratin
5/6. Arch Pathol Lab Med. 2007;131:1304–11.
23. Macchia PE, Lapi P, Krude H, et al. PAX8 mutations associated
with congenital hypothyroidism caused by thyroid dysgenesis. Nat
Genet. 1998;19:83–86.
24. Matsukita S, Nomoto M, Kitajima S, et al. Expression of mucins
(MUC1, MUC2, MUC5AC and MUC6) in mucinous carcinoma of
the breast: comparison with invasive ductal carcinoma. Histopathology.
2003;42:26–36.
25. McCluggage WG, Wilkinson N. Metastatic neoplasms involving the
ovary: a review with an emphasis on morphological and immuno-
histochemical features. Histopathology. 2005;47:231–247.
26. Moll R, Pitz S, Levy R, et al. Complexity of expression of
intermediate filament proteins, including glial filament protein, in
endometrial and ovarian adenocarcinomas. Hum Pathol. 1991;22:
989–1001.
27. Monges GM, Mathoulin-Portier MP, Acres RB, et al. Differential
MUC 1 expression in normal and neoplastic human pancreatic
tissue: an immunohistochemical study of 60 samples. Am J Clin
Pathol. 1999;112:635–640.
28. Nonaka D, Chiriboga L, Soslow RA. Expression of pax8 as a useful
marker in distinguishing ovarian carcinomas from mammary
carcinomas. Am J Surg Pathol. 2008;32:1566–1571.
29. Osunkoya AO, Epstein JI. Primary mucin-producing urothelial-type
adenocarcinoma of prostate: report of 15 cases. Am J Surg Pathol.
2007;31:1323–1329.
30. Pinto DM, Herrera GA, Mendonca AM, et al. Metastatic malignant
mixed tumor of the skin. Ultrastructural and immunocytochemical
characterization, histogenetic considerations and comparison with
benign mixed tumors of skin and salivary glands. Appl Pathol.
1986;4:199–208.
31. Pinto-de-Sousa J, David L, Reis CA, et al. Mucins MUC1, MUC2,
MUC5AC and MUC6 expression in the evaluation of differentia-
tion and clinico-biological behaviour of gastric carcinoma. Virchows
Arch. 2002;440:304–310.
32. Prayson RA. Clinicopathologic study of 61 patients with ependy-
moma including MIB-1 immunohistochemistry. Ann Diagn Pathol.
1999;3:11–18.
33. Raspollini MR, Amunni G, Villanucci A, et al. Utility of CDX-2
in distinguishing between primary and secondary (intestinal)
mucinous ovarian carcinoma: an immunohistochemical comparison
of 43 cases. Appl Immunohistochem Mol Morphol. 2004;12:127–131.
34. Ronnett BM, Kurman RJ, Shmookler BM, et al. The morphologic
spectrum of ovarian metastases of appendiceal adenocarcinomas: a
clinicopathologic and immunohistochemical analysis of tumors
often misinterpreted as primary ovarian tumors or metastatic
tumors from other gastrointestinal sites. Am J Surg Pathol. 1997;21:
1144–1155.
35. Rossi G, Murer B, Cavazza A, et al. Primary mucinous (so-called
colloid) carcinomas of the lung: a clinicopathologic and immuno-
histochemical study with special reference to CDX-2 homeo-
box gene and MUC2 expression. Am J Surg Pathol. 2004;28:
442–452.
36. Seidman JD, Elsayed AM, Sobin LH, et al. Association of mucinous
tumors of the ovary and appendix. A clinicopathologic study of
25 cases. Am J Surg Pathol. 1993;17:22–34.
37. Semino-Mora C, Liu H, McAvoy T, et al. Pseudomyxoma peritonei:
is disease progression related to microbial agents? A study of
bacteria, MUC2 AND MUC5AC expression in disseminated
peritoneal adenomucinosis and peritoneal mucinous carcinomatosis.
Ann Surg Oncol. 2008;15:1414–1423.
38. Shibahara H, Tamada S, Goto M, et al. Pathologic features of
mucin-producing bile duct tumors: two histopathologic categories as
counterparts of pancreatic intraductal papillary-mucinous neo-
plasms. Am J Surg Pathol. 2004;28:327–338.
39. Shimizu M, Toki T, Takagi Y, et al. Immunohistochemical detection
of the Wilms’ tumor gene (WT1) in epithelial ovarian tumors. Int
J Gynecol Pathol. 2000;19:158–163.
40. Shiohara S, Shiozawa T, Shimizu M, et al. Histochemical analysis of
estrogen and progesterone receptors and gastric-type mucin in
www.ajsp.com | 1835
Chu et al
mucinous ovarian tumors with reference to their pathogenesis.
Cancer. 1997;80:908–916.
41. Tashiro Y, Yonezawa S, Kim YS, et al. Immunohistochemical study
of mucin carbohydrates and core proteins in human ovarian tumors.
Hum Pathol. 1994;25:364–372.
42. Vang R, Gown AM, Barry TS, et al. Immunohistochemistry for
estrogen and progesterone receptors in the distinction of primary
and metastatic mucinous tumors in the ovary: an analysis of
124 cases. Mod Pathol. 2006;19:97–105.
43. Vang R, Gown AM, Barry TS, et al. Cytokeratins 7 and
20 in primary and secondary mucinous tumors of the ovary: analysis
of coordinate immunohistochemical expression profiles and
staining distribution in 179 cases. Am J Surg Pathol. 2006;30:
1130–1139.
1836 | www.ajsp.com
Am J Surg Pathol  Volume 35, Number 12, December 2011
44. Vang R, Gown AM, Wu LS, et al. Immunohistochemical expression
of CDX2 in primary ovarian mucinous tumors and metastatic
mucinous carcinomas involving the ovary: comparison with CK20
and correlation with coordinate expression of CK7. Mod Pathol.
2006;19:1421–1428.
45. Werling RW, Yaziji H, Bacchi CE, et al. CDX2, a highly sensitive
and specific marker of adenocarcinomas of intestinal origin: an
immunohistochemical survey of 476 primary and metastatic
carcinomas. Am J Surg Pathol. 2003;27:303–310.
46. Wong NA, Pignatelli M. Beta-catenin: a linchpin in colorectal
carcinogenesis? Am J Pathol. 2002;160:389–401.
47. Yonezawa S, Sato E. Expression of mucin antigens in human
cancers and its relationship with malignancy potential. Pathol Int.
1997;47:813–830.
r 2011 Lippincott Williams & Wilkins