Rhabdomyosarcoma is a rare soft tissue sarcoma that typically affects children, adolescents, and young adults. Despite treatment via a multidisciplinary approach, the prognosis of advance-stage rhabdomyosarcomas remains poor, and a new treatment strategy is needed. Anaplastic lymphoma kinase (ALK) is a receptor tyrosine kinase that is a potential target for specific inhibitors. In this study, we investigated 116 rhabdomyosarcomas using a polymer-based ALK immunostaining method and correlated the results with clinicopathological parameters. In addition, we examined ALK status using dual-color fluorescence in situ hybridization, PCR, and sequencing. In immunohistochemical analysis, ALK was detected in 2 (6%) of 33 embryonal rhabdomyosarcomas, 42 (69%) of 61 alveolar rhabdomyosarcomas, and 0 (0%) of 22 other subtypes, including pleomorphic, adult-spindle-cell/sclerosing, and epithelioid variants. Compared with ALK-negative alveolar rhabdomyosarcomas, ALK-positive ones are presented with metastatic spread more frequently and showed a greater extent of myogenin reactivity. Overall survival was not associated with ALK expression. FOXO1 rearrangement was significantly associated with ALK immunoreactivity. The median ALK copy number was greater in ALK-positive tumors than in ALK-negative tumors. Most (93%) cases tested showed no selective increase in the ALK gene dosage. ALK selective amplification and low-level selective gain were noted in one and three cases, respectively. Further, a high-polysomy pattern (Z4 ALK copies in Z40% of cells) was observed in seven cases. A significant increase in the ALK copy number was exclusive to the ALK-immunopositive cohort, but it was uncommon, accounting for only 30% of the 37 ALK-positive rhabdomyosarcomas. ALK gene rearrangement was not observed in either cohort, while an ALK somatic mutation (I1277T) was found in one ALK-negative embryonal case. Although it remains controversial whether ALK expression without gene rearrangement is therapeutically relevant, this comprehensive analysis may help future studies on the utility of ALK-targeted therapy for patients with rhabdomyosarcoma. Modern Pathology (2013) 26, 772-781; doi:10.1038/modpathol.2012 published online 11 January 2013 Keywords: anaplastic lymphoma kinase; fluorescence in situ hybridization; immunohistochemistry; rhabdomyosarcoma Rhabdomyosarcoma is a rare sarcoma with skeletal muscle differentiation that typically affects children, adolescents, and young adults. It is histologically classified into the embryonal, alveolar, and pleomorphic subtypes, 1-3 although other rare variants like sclerosing, adult-spindle-cell, and epithelioid rhabdomyosarcomas have also been proposed. [4][5][6][7] Each subtype is characterized by a distinct epidemiology, clinical behavior, and genetic background. 1-3 For example, alveolar rhabdomyosarcoma affects older patients compared with the embryonal subtype, is associated with poor survival, and in most cases, is characterized by a specific t(2;13) or t(1;13) translocation, which results i...