Abnormal Nuclear Membranous Staining Pattern by MLH1 Immunohistochemistry in Endometrial Cancer: A Diagnostic Pitfall...

Immunohistochemistry (IHC) for mismatch repair (MMR) proteins is routinely performed for endometrial cancer (EC). Loss of nuclear staining for MLH1/PMS2 triggers reflex testing for MLH1 promoter hypermethylation, while loss of MSH2/MSH6 or isolated loss of MSH6 and PMS2 prompts germline testing for Lynch syndrome. We observed an unusual nuclear membranous staining pattern of MLH1 (clone G168-15). The goal of the study was to determine its significance and highlight this IHC interpretation pitfall. A total of 52 EC cases with abnormal IHC staining patterns were identified in our database from 2017 to 2020. Of these, 41 were reported as MLH1/PMS2 deficient, and 11 as MSH2/MSH6 deficient. On review, 6/41 (14.6%) showed nuclear membranous expression of MLH1 (focal in 1 and diffuse in 5) with complete loss of PMS2 in the same foci. These foci demonstrated mucinous morphology or squamous/morular metaplasia in 3 cases. One additional consultation case showed nuclear membranous staining of MLH1 in the carcinoma and complete loss in the associated endometrial intraepithelial neoplasia, with PMS2 loss in both. Three of 7 cases were FIGO grade 1, and 4 were FIGO grade 2 to 3. MLH1 promoter hypermethylation was detected in 6/7 cases (not performed for one case). Repeat staining with ES05 clone showed complete loss of nuclear MLH1 expression in all 6 in-house cases. Nuclear membranous expression of MLH1 represents an aberrant staining pattern, observed with complete loss of PMS2 and frequently associated with MLH1 promoter hypermethylation. Failure to recognize this aberrant MLH1 expression pattern can lead to misinterpreting isolated PMS2 loss.