Typing of Amyloid for Routine Use on Formalin-Fixed Paraffin Sections of 626 Patients by Applying Amyloid type-Specific Immunohistochemistry: A Review

  • Reinhold P. LinkeEmail author
Part of the Current Clinical Pathology book series (CCPATH)


After establishing a diagnosis of amyloid by the Congo red procedure (see Chap.  14), it is now considered mandatory, for therapeutic reasons, to identify the chemical nature (i.e., “type”) of the amyloidotic protein causing the disease. In this review, it is shown how adequate and reliable immunohistochemical typing of amyloid can be achieved using formalin-fixed, paraffin-embedded tissue sections and a panel of amyloid type-specific antibodies. In this technique, antibodies are raised against the amyloidotic proteins themselves and, thereby, avoid the pitfalls and deficiencies associated with antibodies prepared against native, soluble, precursor proteins, which often lead to suboptimal results, typically reported as “unreliable immunohistochemistry.” These amyloid type-specific antibodies, prepared and evaluated with appropriate controls, therefore constitute the key to high-quality immunohistochemical amyloid typing.

In preparing these antibodies as reagents, only a strong and consistent reaction against a single amyloid protein type is considered diagnostic, and needs to be distinguished from other reactions, which are weaker and inconsistent, and therefore deemed nonspecific. These latter types of reactions are predictable considering that amyloid deposits represent a complex composite of many different constituents that are present in addition to the amyloid protein itself. In fact, these other constituents have hindered amyloid typing efforts, regardless of the method used, for decades.

The sensitivity and specificity of immunohistochemistry (IHC) can be further increased by double staining, using Congo red as the first step, followed by an immunohistochemical (CRIC) stain as an overlay. This overlay stain allows concomitant evaluation of the spatial relationship between Congo red-positive and immune stain-positive areas. All 19 different types of amyloid can be diagnosed by using a set of different amyloid type-specific antibodies and comparing their reactivities. Thus, the amyloid protein type is diagnosed based on the most dominant and consistent stain, while the weaker, nondiagnostic stains exclude all other amyloid types; this type of “comparative” approach to the interpretation of IHC stains thus provides support for its reliability through the inclusion of internal controls. In the author’s experience, based on more than 626 submitted samples, and using this comparative approach, the sensitivity of IHC is >97 %, and the specificity even higher; there were no major cross-reacting stains. Other laboratories have also achieved similar reliable results, on a routine basis, using amyloid-specific antibodies. Finally, the reliability of the typing results obtained usingamyoid type-specific antibodies was confirmed by mass spectrometric analysis of isolated amyloid proteins in two collaborative international blind-comparison studies.


Amyloid type prototypes Formalin-fixed paraffin sections Amyloid type-specific Immunohistochemistry (IHC) Double staining: Congo red with immunohistochemical overlay (CRIC) Amyloid typing Pitfalls in typing of amyloid Isolated amyloid fibrils Native proteins Nonnative proteins Amyloidotic proteins Conformational change Variable and unpredictable immunoreactivity Sensitivity Specificity 



This work was only possible as a result of contributions by many colleagues over several decades. Full acknowledgement of some of these contributions can be found in an in-depth review [13]. Here, I would like to thank Prof. Dr. R. Huber, director emeritus of the Max-Planck-Institute of Biochemistry in Martinsried, who provided laboratory space, and supported some of the technicians and coworkers involved in the laboratory work. They include Mrs. A. Rail, Mrs. A. Kerling, Mrs. R. Oos, Mrs. A. Meinel, and Dr. N. Wiegel. For secretarial work, I thank Mrs. A. Feix, Martinsried, Germany, and for the artwork Ms. A. K. M. Linke, Essen/Germany.


  1. 1.
    Sipe JD, Benson MD, Buxbaum JN, Ikeda S, Merlini G, Saraiva MJ, Westermark P. Nomenclature 2014: amyloid fibril proteins and clinical classification of the amyloidosis. Amyloid. 2014;21(4):221–4. 2014 Sep 29.CrossRefPubMedGoogle Scholar
  2. 2.
    Merlini G, Westermark P. The systemic amyloidosis: clearer understanding of the molecular mechanisms offer hope for more effective therapies. J Intern Med. 2004;255:159–78.CrossRefPubMedGoogle Scholar
  3. 3.
    Lavatelli F, Perlman DH, Spencer B, et al. Amyloidogenic and associated proteins in systemic amyloidosis proteome of adipose tissue. Mol Cell Proteomics. 2008;7:1570–83.PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Linke RP. Congo red staining of amyloid. Improvements and practical guide for a more precise diagnosis of amyloid and the different amyloidosis. Chapter 11.1. In: Uversky VN, Fink AL, editors. Protein misfolding, aggregation and conformational diseases, Protein Reviews, vol. 4. New York: Springer; 2006. p. 239–76.CrossRefGoogle Scholar
  5. 5.
    Schroeder R, Deckert M, Linke RP. Novel isolated cerebral ALλ (lambda) amyloid angiopathy with widespread subcortical distribution and leukoencephalopathy due to atypical monoclonal plasma cell proliferation, and terminal systemic gammopathy. J Neuropathol Exp Neurol. 2009;68(3):286–99.CrossRefGoogle Scholar
  6. 6.
    Murphy CL, Wang S, Williams T, et al. Characterization of systemic amyloid deposits by mass spectrometry. Methods Enzymol. 2006;412:48–62.CrossRefPubMedGoogle Scholar
  7. 7.
    Vrana JA, Gamez JD, Madden BJ, Theis JD, Bergen 3rd HR, Dogan A. Classification of amyloidosis by laser micro dissection and mass spectrometry based proteomic analysis in clinical biopsy specimens. Blood. 2009;114(24):4957–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Linke RP, Oos R, Wiegel NM, Nathrath WBJ. Classification of amyloidosis: misdiagnosing by way of incomplete immunohistochemistry and how to prevent it. Acta Histochem. 2006;108:197–208.CrossRefPubMedGoogle Scholar
  9. 9.
    Picken MM, Herrera GA. The burden of “sticky” amyloid: typing challenges. Arch Pathol Lab Med. 2007;131(6):850–1.PubMedGoogle Scholar
  10. 10.
    Linke RP. Classifying of amyloid on fixed tissue sections for routine use by validated immunohistochemistry. Amyloid. 2011;18 Suppl 1:67–70.CrossRefPubMedGoogle Scholar
  11. 11.
    Linke RP, Joswig R, Murphy CL, et al. Seminogelin I is the amyloidogenic protein in senile seminal vesicles. In: Grateau G, Kyle RA, Skinner M, editors. Amyloid and amyloidosis. Boca Raton, FL: CRC Press; 2004. p. 471–3.Google Scholar
  12. 12.
    Wiegel NM, Mentele R, Kellermann J, Meyer L, Riess H, Linke RP. ALkappa(I) (UNK)—primary structure of an AL-amyloid protein presenting an organ-limited subcutaneous nodular amyloid syndrome of long duration. Case report and review. Amyloid. 2010;17(1):10–23.CrossRefPubMedGoogle Scholar
  13. 13.
    Linke RP. On typing of amyloidosis using immunohistochemstry. Detailed illustrations, review and a note on mass spectrometry. Progr Histochem Cytochem. 2012;47:61–132.Google Scholar

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© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Reference Center of Amyloid Diseases amYmed. Innovation Center of BiotechnologyMartinsriedGermany

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