Article Text

Download PDFPDF
Positivity for SATB2 distinguishes Islet1 positive rectal neuroendocrine tumours from pancreaticoduodenal neuroendocrine tumours
  1. Sambit Kumar Mohanty1,2,
  2. Ankit Tiwari1,
  3. Nitin Bhardwaj1,
  4. Fai Chuang2,
  5. Evelyn Kim2,
  6. Hector Lugo2,
  7. Xiaopu Yuan2,
  8. Sameer Al Diffalha3,
  9. Mariza Peralta-Venturina2,
  10. Bonnie Balzer2,
  11. Deepti Dhall3
  1. 1 Pathology and Laboratory Medicine, Advanced Medical Research Institute, Bhubaneswar, Odisha, India
  2. 2 Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
  3. 3 Pathology, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
  1. Correspondence to Dr Deepti Dhall, Pathology, The University of Alabama at Birmingham School of Medicine, Birmingham, AL 35233, USA; ddhall{at}


Aims Determining the site of origin of a metastatic neuroendocrine tumour (NET) can be challenging and has important prognostic and therapeutic implications. An immunohistochemical (IHC) panel consisting of TTF1, CDX2, PAX8/PAX6 and Islet1 is often employed. However, there can be a significant IHC overlap among different primary sites. Herein, we sought to determine the utility of including Special AT-rich sequence binding protein-2 (SATB2) in the IHC panel that is used for determining the site of origin of a metastatic NET.

Methods Paraffin tissue microarrays consisting of 137 primary NETs (26 lung, 22 jejunoileal, 8 appendix, 5 stomach, 4 duodenum, 17 rectum and 55 pancreas) were stained for SATB2, in addition to the well-described lineage-associated markers, such as TTF1, CDX2, PAX6 and Islet1. Additionally, a tissue microarray consisting of 21 metastatic NETs (1 lung, 1 stomach, 8 jejunoileal and 11 pancreas) was stained for TTF1, CDX2, SATB2 and Islet1. The results were recorded as no staining, weak staining and moderate to strong staining.

Results All appendiceal NETs and majority (88%) of the rectal NETs were positive for SATB2. All primary foregut NETs (stomach, pancreas, duodenum and lung) were negative for SATB2, except for one pulmonary NET with weak staining. However, among the metastatic tumours, 5 of 11 pancreatic NETs, 1 stomach NET, 1 lung NET and 2 of 8 jejunoileal NETs showed weak staining. Receiver operating characteristic analysis incorporating sensitivity and specificity data of IHC panel, considering moderate to strong staining as truly positive cases, showed that inclusion of SATB2 to the previously described NET IHC panel outperformed the panel without SATB2, raising the specificity for pancreaticoduodenal NETs from 81.2% to 100%, with a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 82.22% (p<0.0001); for appendiceal NETs the specificity changed from 99.1% to 98.5% and sensitivity increased from 11.8% to 80%, with a PPV and NPV of 66.67% and 99.26%, respectively (p<0.0001); and for rectal NETs the specificity increased from 97.6% to 99.3% and sensitivity raised from 7.1% to 66.7%, with a PPV and NPV of 80% and 98.53%, respectively (p<0.0001).

Conclusions SATB2 stain is useful in differentiatingIslet1/PAX6 positive pancreatic and rectal NETs, as rectal NETs are typically moderately to strongly positive for SATB2 and pancreatic NETs are usually negative or weakly positive for SATB2. Moderate to strong staining for SATB2 is suggestive of an appendiceal or a rectal primary. SATB2 may complement the panel of CDX2, TTF1 and Islet1 in determining the site of origin of an NET in a metastatic setting.

  • neuroendocrine tumours
  • pancreatic neoplasms
  • rectal neoplasms
  • immunohistochemistry

Data availability statement

All data relevant to the study are included in the article. SATB2 in NET.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

All data relevant to the study are included in the article. SATB2 in NET.

View Full Text


  • SKM and AT are joint first authors.

  • Handling editor Dhirendra Govender.

  • Contributors Conception and design: SKM and DD. Development of methodology: SKM, AT, NB and DD. Acquisition of data: SKM, XY, SAD, MP-V and DD. Analysis of data: SKM, AT, NB and DD. Interpretation of data: SKM, AT and DD. Writing and review/revision of the manuscript: SKM, NB, AT, DD and BB. Technical support: EK and FC. Study supervision: DD, SKM and BB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.