NKX3-1 Is a Useful Immunohistochemical Marker of EWSR1-NFATC2 Sarcoma and Mesenchymal Chondrosarcoma

Am J Surg Pathol. 2020 Jun;44(6):719-728. doi: 10.1097/PAS.0000000000001441.


NK3 homeobox 1 (NKX3-1) is widely accepted as a highly sensitive and specific marker for prostatic adenocarcinoma. Prompted by published transcriptome data showing upregulation of NKX3-1 mRNA expression in EWSR1-NFATC2 sarcoma, we explored the utility of NKX3-1 immunohistochemistry in sarcoma diagnosis. We applied NKX3-1 immunohistochemistry to 11 EWSR1-NFATC2 sarcomas and 168 mimics using whole tissue sections. All EWSR1-NFATC2 sarcomas consisted of uniform small round or ovoid cells, all except 1 showing at least focally the typical growth pattern of nests, cords, or trabeculae within a fibrous/myxoid background. A variable eosinophilic infiltrate was common. NKX3-1 was expressed in 9 of 11 (82%) EWSR1-NFATC2 sarcomas, often diffuse and of moderate or strong intensity. All 12 mesenchymal chondrosarcomas tested were also positive for NKX3-1, with over half showing diffuse staining and moderate or strong intensity. The positive staining was seen only in the primitive small round cell component, whereas the cartilaginous component was mostly negative. Although 1 of 30 osteosarcomas showed focal NKX3-1 positivity, all the remaining 155 cases tested, including 20 Ewing sarcomas, 20 myoepithelial tumors, 11 ossifying fibromyxoid tumors, and 1 FUS-NFATC2 sarcoma were negative for NKX3-1. Our study provides the first evidence that EWSR1-NFATC2 sarcoma and Ewing sarcoma could be distinguished immunohistochemically, adding to the accumulating data that these tumors are phenotypically distinct. We suggest that NKX3-1 may have a diagnostic utility in the evaluation of sarcoma and we also call attention to potential pitfalls in the use of this well-known marker of prostatic adenocarcinoma.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Biomarkers, Tumor / analysis
  • Biomarkers, Tumor / metabolism*
  • Bone Neoplasms / diagnosis
  • Chondrosarcoma, Mesenchymal / diagnosis*
  • Female
  • Homeodomain Proteins / analysis
  • Homeodomain Proteins / metabolism*
  • Humans
  • Immunohistochemistry
  • Male
  • Middle Aged
  • NFATC Transcription Factors / genetics
  • Oncogene Proteins, Fusion
  • RNA-Binding Protein EWS / genetics
  • Sarcoma / diagnosis*
  • Sarcoma / genetics
  • Transcription Factors / analysis
  • Transcription Factors / metabolism*


  • Biomarkers, Tumor
  • EWSR1 protein, human
  • Homeodomain Proteins
  • NFATC Transcription Factors
  • NFATC2 protein, human
  • NKX3-1 protein, human
  • Oncogene Proteins, Fusion
  • RNA-Binding Protein EWS
  • Transcription Factors