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The specificity of IHC is limited if tumour tissue has physiological TRK protein expression, particularly in the nervous system and smooth muscle, as well as when there is variable basal expression in other tissues [1].

While two studies reported 98%–100% specificity for IHC [2, 3], studies with a larger number of negative controls have reported higher false positive rates if NGS was not performed for confirmation. For instance, diffuse pan-TRK staining was found to be a sensitive diagnostic IHC marker for infantile fibrosarcoma (NTRK3 fusion; 14/15, 93% sensitivity) and lipofibromatosis-like neural tumour (NTRK1 fusion; 5/5, 100% sensitivity), but non-specific staining was noted in 8% (16/190) of other paediatric spindle-cell tumours [4]. In addition, specificity of IHC was 96% in adults with common solid tumours (4,136 cases analysed, including 28 with confirmed NTRK gene fusion) [5]. However, in uterine leiomyosarcoma, TRKA and/or pan-TRK staining did not correlate with NTRK gene rearrangement. Specifically, TRK staining by IHC was observed in 6 of 97 leiomyosarcomas (which are tumours with smooth muscle differentiation), but these tumours lacked NTRK gene fusions as determined by FISH or whole transcriptome sequencing [6]. This illustrates the importance of a confirmatory second analysis following IHC screening in soft tissue tumours/sarcomas especially.

The disadvantages of IHC are summarised in the following table.

Table 20: Disadvantages of IHC for Testing for NTRK Gene Fusions


  • Confirmation of fusion by a second assay is recommended, particularly when cytoplasmic staining is present without nuclear, peri-nuclear, or membranous staining
  • Similarly, confirmation of fusion by a second assay is recommended if there is a possibility of smooth muscle or neurologic differentiation
  • Only detects the TRK protein expression without distinction between wild-type TRK and TRK fusion protein. As a result, a confirmatory test is needed to confirm the presence of a NTRK gene fusion if IHC used


  1. Murphy DA, Ely HA, Shoemaker R et al. Detecting Gene Rearrangements in Patient Populations Through a 2-Step Diagnostic Test Comprised of Rapid IHC Enrichment Followed by Sensitive Next-Generation Sequencing. Appl Immunohistochem Mol Morphol 2017; 25: 513-523.
  2. Hechtman JF, Benayed R, Hyman DM et al. Pan-Trk Immunohistochemistry Is an Efficient and Reliable Screen for the Detection of NTRK Fusions. Am J Surg Pathol 2017; 41: 1547-1551.
  3. Rudzinski ER, Lockwood CM, Stohr BA et al. Pan-Trk Immunohistochemistry Identifies NTRK Rearrangements in Pediatric Mesenchymal Tumors. Am J Surg Pathol 2018; 42: 927-935.
  4. Hung YP, Fletcher CDM, Hornick JL. Evaluation of pan-TRK immunohistochemistry in infantile fibrosarcoma, lipofibromatosis-like neural tumour and histological mimics. Histopathology 2018; 73: 634-644.
  5. Gatalica Z, Xiu J, Swensen J, Vranic S. Molecular characterization of cancers with NTRK gene fusions. Mod Pathol 2019; 32.
  6. Chiang S, Cotzia P, Hyman DM et al. NTRK Fusions Define a Novel Uterine Sarcoma Subtype With Features of Fibrosarcoma. The American Journal of Surgical Pathology 2018; 42: 791-798.

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