Clin Chem Lab Med 2023; aop
Editorial
Jan Damoiseaux*
The International Consensus on ANA Patterns
(ICAP): from conception to implementation
https://doi.org/10.1515/cclm-2023-1211
Introduction
Assays for anti-nuclear antibodies (ANA) have been intro-
duced in the second half of the previous century, first on
rodent tissue as substrate and next on the human laryngeal
epidermoid carcinoma HEp-2 cell line [1]. The HEp-2 indirect
immunofluorescence assay (IFA) has appeared of added
value in the diagnosis of systemic autoimmune rheumatic
diseases (SARD), in particular systemic lupus erythematosus
(SLE), mixed connective tissue disease (MCTD) and systemic
sclerosis (SSc), but to a lesser extend Sjögren’s syndrome (SS)
and idiopathic inflammatory myopathies (IIM) [2–4]. Next to
SARD, HEp-2 IFA is also included in the diagnostic work-up of
autoimmune liver diseases and juvenile idiopathic arthritis
[5, 6]. Over the years alternative solid-phase immuno-assays
(SPA) have entered the clinical laboratories, but HEp-2 IFA
remained the gold standard as screening method [7, 8].
Nevertheless, more recently the combination of HEp-2 IFA
with SPA seems to be of added value [3]. One advantage of
HEp-2 IFA is the recognition of immunofluorescence pat-
terns, not only restricted to the nucleus, but also including
the cytoplasm and the mitotic apparatus. This pattern pro-
vides information on the autoantigens that might be recog-
nized and in case of the centromere pattern even is part of
classification criteria [9, 10]. Initiatives to harmonize the
definitions and nomenclature of HEp-2 IFA patterns have
culminated in the International Consensus on ANA Patterns
(ICAP), an initiative that is increasingly being incorporated
in routine clinical practice, as illustrated in the paper pub-
lished by Infantino and Colleagues in this issue of the Journal
describing the Italian experience of adopting the ICAP clas-
sification [11]. The current editorial elaborates on the history
of ICAP, the major achievements in terms of implementa-
tion, and the anticipated perspectives.
*Corresponding author: Jan Damoiseaux, Central Diagnostic Laboratory,
Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht,
The Netherlands, E-mail: jan.damoiseaux@mumc.nl. https://orcid.org/
0000-0003-4007-6985
Open Access. © 2023 the author(s), published by De Gruyter.
Historical perspective
The history of ICAP is with less than one decade rather short
(Figure 1). The initiative of Luis Andrade (Sao Paulo, Brazil)
and Ed Chan (Gainesville, Florida) was preceded by contri-
butions of the late Allan Wiik (Copenhagen, Denmark), who
recently was honored at the 16th Dresden Symposium on
Autoantibodies (2023) by Johan Rönnelid (Uppsala, Sweden)
for his legacy in autoimmune diagnostics [12, 13], as well as his
humanity. In 2010 Allan Wiik published an extended
contemporary nomenclature for HEp-2 IFA patterns which, in
combination with the recommendations of the European
Autoimmunity Standardisation Initiative (EASI), was the base
for the ICAP classification [8, 14, 15]. For his contribution Allan
Wiik was appointed “ICAP honorary member” at the 7th ICAP
Workshop in Dresden (2023). Since consensus meetings on
HEp-2 IFA patterns already took place in Brazil from 2000
onward [16], it was not surprising that the first ICAP workshop
was organized in Sao Paulo as a satellite to the 12th Interna-
tional Workshop on Autoantibodies and Autoimmunity. As a
result 28 HEp-IFA patterns were defined, divided in three
categories: nuclear, cytoplasmic and mitotic [15]. Besides a
name, each pattern was assigned an anti-cellular (AC)-code
ranging from AC-1 to AC-28, analogous to the cluster of dif-
ferentiation (CD) nomenclature for monoclonal antibodies
that recognize leukocyte differentiation molecules. The first
ICAP report was combined with the launch of the ICAP web-
site (www.anapatterns.org) enabling widespread access to
the initiative. In particular the recognition that also cyto-
plasmic patterns may be clinically relevant resurged the
discussion if such autoantibodies are to be referred to as ANA
[17]. As reviewed by Von Mühlen et al. the ICAP experts did not
yet reach consensus on the terminology to be used [18]. At the
subsequent six ICAP workshops the classification system was
elaborated upon by defining a few new patterns (HEp-2 IFA
negative [AC-0], HEp-2 IFA undefined [AC-XX], and anti-Topo
I-like [AC-29]) and subpatterns for the nuclear fine speckled
pattern (AC-4a and AC-4b), by rearranging the classification
tree (removing the nuclear dense fine speckled [AC-2] and the
nuclear anti-Topo I-like [AC-29] patterns from the category of
nuclear speckled patterns and the cytoplasmic discrete dot
pattern [AC-18] from the cytoplasmic speckled patterns) [19].
This work is licensed under the Creative Commons Attribution 4.0 International License.
2 Damoiseaux: The International Consensus on ANA Patterns (ICAP)
In addition, it was anticipated that the association between
pattern and disease, as indicated in the first ICAP report [15],
could better be replaced by clinical relevance of the individual
patterns [20].
Implementation in clinical practice
The number of publications on ICAP enlisted in PubMed re-
mains scarce with only 35 items found when searching for
“ICAP HEp-2” and “ICAP ANA”. Eight of these publications
originate from the ICAP committee itself, while 5 publications
were the result of a close collaboration with the ICAP com-
mittee. Several of the remaining 22 publications, including
the publication of Infantino et al. [11], address the topic of
implementation in clinical practice. Obviously, the number
of scientific publications is not necessarily representative of
clinical implementation. Indeed, world-wide implementation
is evident from the strong increase in users of the website,
from 5,667 in 2015 to 181,782 in 2022 [11]. The excellent
website, mastered by Wilson de Melo Cruvinel (Goiânia,
Brazil), has strongly attributed to implementation of the ICAP
initiative. The website is anticipated as very informative, up-
to-date, and useful in clinical practice. Technicians and labo-
ratory specialists that have to evaluate the slides have easy
access to pattern definitions and representative images, while
clinicians have easy access to clinical relevance of the pat-
terns and recommendations for follow-up testing. It is to be
expected that the recent launch of the ICAP-App for mobile
phones will further enhance access to the content of the
website and implementation of the ICAP classification of HEp-
2 IFA patterns. Also the diagnostic industry and providers of
external quality assessment (EQA), such as UK NEQAS, have
adopted the ICAP classification, further propelling the con-
version towards harmonization of HEp-2 IFA results. A recent
international survey to evaluate reporting, familiarity, and
considered clinical value of HEp-2 IFA patterns revealed that
the major nuclear and cytoplasmic patterns are considered
clinically important, but that there exist apparent differences
2014 2015 2016 2017
Workshops 1st ICAP 2nd ICAP 3rd ICAP 4th ICAP
Sao Paulo Dresden Kyoto Dresden
Time-line InternaƟonal Consensus on ANA PaƩerns 2014 - 2024
2015
1st ICAP
Consensus
Report
Output
2016 2018
2nd ICAP DefiniƟon
Consensus AC-0/AC-XX
Report AC-29
in appreciation of the distinct patterns between laboratory
specialists and clinicians [21]. Apparently, there remains a gap
to be filled and this may be effectuated by the novel recom-
mendations on the detection of ANA, a collaborative action
from the European Federation of Laboratory Medicine
(EFLM), EASI and ICAP [22]. These recommendations, as far as
appropriate, follow the ICAP classification and it is stated that
patterns should preferentially be reported according to the
ICAP nomenclature.
Implementation is also evident from reports, such as the
publication of Infantino et al. [11], on how ICAP is introduced
in distinct countries. At the Medlab Asia meeting in Bangkok
(2023) the implementation in Thailand was presented, while
at the 7th ICAP Workshop in Dresden (2023) the Italian
experience was presented. From these presentations, as well
as from the translation of the website in many languages, it is
apparent that minor changes are being introduced, either in
the definition of the pattern or the position in the classifica-
tion tree. Obviously, this may affect the goal of world-wide
harmonization, but it at least aligns the test-results within a
national health care system. However, shifting for instance
the NuMA-like pattern (AC-26) from the mitotic category to the
nuclear category, as being done in Thailand because of the
evident nuclear staining in interphase cells, may impact on
future epidemiological evaluations. Consistent assignment of
the AC-codes may overcome this caveat. Of note, the
NuMA-like pattern (AC-26) was by ICAP integrated in the
mitotic category because parts of the mitotic apparatus,
i.e., the spindle fibers, were recognized by the autoantibodies.
Conclusions and future
perspectives
Broad implementation of the ICAP classification has been a
major achievement within a time-frame of less than ten
years. Infantino et al. suggested some further improvements,
such as defining the competence level of technicians and
2019 2021 2023
5th ICAP 6th ICAP 7th ICAP
Dresden Dresden Dresden
2019 2021 2023
DefiniƟon Consensus Mobile
Clinical HEp-2 IFA ApplicaƟon
Relevance ReporƟng Figure 1: Historical overview of the International
2020 2022 Consensus on ANA Patterns (ICAP). On top the
1st ICAP 3rd ICAP
Training Consensus subsequent workshops are mentioned; at the
Module Report
bottom major achievements are mentioned.
 Damoiseaux: The International Consensus on ANA Patterns (ICAP)
laboratory specialists and incorporation of multiple and
mixed patterns in the ICAP classification [11]. The compe-
tence level might be assessed by future training modules that
are planned. The issue on multiple patterns, due to two or
more autoantibodies that react with distinct cellular com-
partments, or mixed patterns, due to two or more autoan-
tibodies that react with the same cellular compartment, is
highly relevant because patient sera often do not contain a
single autoantibody revealing the currently defined HEp-2
IFA patterns. Especially in case of autoimmune liver diseases
multiple patterns are quite common. Combinations of mul-
tiple nuclear dots (AC-6) and reticular/AMA (AC-21), centro-
mere (AC-3) and reticular/AMA (AC-21), or nuclear
homogeneous (AC-1) and cytoplasmic fibrillary linear (AC-15)
are easily recognized and such combinations may even
enhance the clinical relevance for primary biliary chol-
angitis and autoimmune hepatitis, respectively. Mixed pat-
terns, on the other hand, might be more difficult to decipher
as they include combinations of centromere (AC-3) and
multiple nuclear dots (AC-6), or nuclear homogeneous (AC-1)
and nuclear dense fine speckled (AC-2). For such combina-
tions the clinical relevance will be more difficult to define. As
a matter in fact, this shortcoming also becomes an issue if
patterns are reported on competent level since clinical
relevance is provided at the expert level [20]. Combining the
clinical relevance of the nucleolar patterns (AC-8, AC-9, and
AC-10) is not a problem, but this is different for nuclear dots
(AC-6 and AC-7) and nuclear membrane (AC-11 and AC-12) for
which one pattern (AC-6 and AC-12), but not the other (AC-7
and AC-11), has definite clinical relevance.
Another concern raised by Infantino et al. [11] involves
the need for further expansion of the number of novel pat-
terns. When looking at the analogy with the CD-system for
monoclonal antibodies recognizing molecules expressed by
leukocytes, the first Human Leukocyte Differentiation
Workshop in Paris (1982) defined only 15 CDs, a number that
expanded to 130 CDs after the fifth Workshop in Boston ten
years later (1993). Interestingly, also the CD classification
eventually subtyped in, for instance, CD11a, CD11b and CD11c.
The question is if the consensus allows extension to many
more patterns because they can be distinguished by the real
experts, or if the consensus is to be more conservative and
monitor the need in clinical practice. Personally, I do favor the
latter in order to keep all current users on board.
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