Ki-67 expression in primary breast carcinomas and their axillary lymph node metastases: clinical implications

Investigating the role of tumour-to-skin proximity in predicting nodal metastasis in breast cancer

BACKGROUND

Understanding the factors influencing nodal status in breast cancer is vital for axillary staging, therapy, and patient survival. The nodal stage remains a crucial factor in prognostication indices. This study investigates the relationship between tumour-to-skin distance (in T1-T3 tumours where the skin is not clinically involved) and the risk of nodal metastasis.

METHODS

We retrospectively reviewed data from 100 patients who underwent neoadjuvant chemotherapy (NACT). Besides patient demographics and tumour variables, a radiologist retrospectively reviewed pre-operative MRI to measure tumour-to-skin distance. R core packages were used for univariate (χ2 and T-Wilcoxon tests) and bivariate logistic regression statistical analysis.

RESULTS

Of 95 analysable datasets, patients' median age was 51 years (IQR: 42-61), 97% were symptomatic (rest screen detected), and the median tumour size was 43 mm (IQR, 26-52). On multivariate analysis, increasing invasive tumour size (p = 0.02), ER positivity (p = 0.007) and shorter tumour-to-skin distance (p = 0.05) correlated with nodal metastasis.  HER2 was not included in multivariate analysis as there was no association with nodal status on univariate analysis. In node-positive tumours, as tumour size increased, the tumour-to-skin distance decreased (r = - 0.34, p = 0.026). In node-negative tumours, there was no correlation (r = + 0.18, p = 0.23).

CONCLUSION

This study shows that non-locally advanced cancers closer to the skin (and consequent proximity to subdermal lymphatics) are associated with a greater risk of nodal metastasis. Pre-operative identification of those more likely to be node positive may suggest the need for a second-look USS since a higher nodal stage may lead to a change in therapeutic strategies, such as upfront systemic therapy, node marking, and axillary clearance without the need to return to theatre following sentinel node biopsy.

Ki-67 Testing in Breast Cancer: Assessing Variability With Scoring Methods and Specimen Types and the Potential Subsequent Impact on Therapy Eligibility

Abemaciclib was originally FDA approved for patients with ER-positive/HER2-negative breast cancer with Ki-67 expression ≥20%. However, there were no guidelines provided on which specimen to test or which scoring method to use. We performed a comprehensive study evaluating the variation in Ki-67 expression in breast specimens from 50 consecutive patients who could have been eligible for abemaciclib therapy. Three pathologists with breast expertise each performed a blinded review with 3 different manual scoring methods [estimated (EST), unweighted (UNW), and weighted (WT) (WT recommended by the International Ki-67 in Breast Cancer Working Group)]. Quantitative image analysis (QIA) using the HALO platform was also performed. Three different specimen types [core needle biopsy (CNB) (n=63), resection (RES) (n=52), and axillary lymph node metastasis (ALN) (n=50)] were evaluated for each patient. The average Ki-67 for all specimens was 14.68% for EST, 14.46% for UNW, 14.15% for WT, and 11.15% for QIA. For the manual methods, the range between the lowest and highest Ki-67 for each specimen between the 3 pathologists was 8.44 for EST, 5.94 for WT, and 5.93 for UNW. The WT method limited interobserver variability with ICC1=0.959 (EST ICC1=0.922 and UNW=0.949). Using the aforementioned cutoff of Ki-67 ≥20% versus <20% to determine treatment eligibility, the averaged EST method yields 20 of 50 patients (40%) who would have been treatment-eligible, versus 15 (30%) for the UNW, 17 (34%) for the WT, and 12 (24%) for the QIA. There was no statistically significant difference in Ki-67 among the 3 specimen types. The average Ki-67 difference was 4.36 for CNB vs RES, 6.95 for CNB versus ALN, and RES versus ALN (P=0.93, 0.99, and 0.94, respectively). Our study concludes that further refinement in Ki-67 scoring is advisable to reduce clinically significant variation.

Discordance of Biomarker Expression Profile between Primary Breast Cancer and Synchronous Axillary Lymph Node Metastasis in Preoperative Core Needle Biopsy

Background: Breast cancer (BC) is a heterogeneous disease made up of clones with different metastatic potential. Intratumoral heterogeneity may cause metastases to show divergent biomarker expression, potentially affecting chemotherapy response. Methods: We investigated the immunohistochemical (IHC) and FISH profile of estrogen receptors (ER), progesterone (PR) receptors, Ki67, and HER2 in a series of BC-matched primary tumors (PTs) and axillary lymph node (ALN) metastases in pre-operative core needle biopsies (CNBs). Phenotypical findings were correlated to morphological features and their clinical implications. Results: Divergent expression between PTs and ALNs was found in 10% of the tumors, often involving multiple biomarkers (12/31, 39%). Most (52%) displayed significant differences in ER and PR staining. HER2 divergences were observed in almost three-quarters of the cases (23/31, 74%), with five (16%) switching from negativity to overexpression/amplification in ALNs. Roughly 90% of disparities reflected significant morphological differences between PTs and ALN metastases. Less than half of the discrepancies (12/31, 39%) modified pre/post-operative treatment options. Conclusions: We observed relevant discrepancies in biomarker expression between PTs and metastatic ALNs in a noteworthy proportion (10%) of preoperative BC CNBs, which were often able to influence therapies. Hence, our data suggest routine preoperative assessment of biomarkers in both PTs and ALNs in cases showing significant morphological differences.

Association of Proliferative Indices With Various Grades of Breast Carcinoma

AIMS AND OBJECTIVES

Various grades of breast carcinoma and proliferative indices used as nuclear protein Ki-67 and argyrophilic nucleolar organizer regions (AgNOR) are being compared to each other.

MATERIALS AND METHOD

In this observational cross-sectional investigation, 42 breast biopsies from questionable breast areas were collected and preserved in formalin and paraffin before the tissue blocks were made. A thorough medical history regarding the breast tumor and thorough physical examination results were recorded. Two sections were produced, one stained with an immunohistochemical marker called Ki-67 and the other with a unique stain called AgNOR.

RESULTS

Grade I in Nottingham was found to be highest in subjects with Ki-67 1%, grade II in subjects with Ki-67 1-10%, and grade III in subjects with Ki-67>10%. Therefore, a higher Ki-67 score and a higher Nottingham grade were more closely associated. The mean AgNOR score was determined to be highest in Nottingham grade III and lowest in Nottingham grade I. In contrast to grade I and grade II of carcinoma (CA) breast, where there was no statistically significant association between Ki-67 and AgNOR, grade III of CA breast showed a statistically significant link between Ki-67 and AgNOR.

CONCLUSION

Proliferation has been identified as a distinctive feature of cancer and as a key factor in the prognosis of the disease.

Clinical relevance of biomarker discordance between primary breast cancers and synchronous axillary lymph node metastases

Clinical decision-making for patients with breast cancer (BC) is still primarily based on biomarker characteristics of the primary tumor, together with the evaluation of synchronous axillary lymph node metastasis (LNM). In this study, we investigated the prevalence of discordance in the biomarkers and surrogate subtyping between the primary BC and the LNM, and whether subsequent changes would have altered clinical treatment recommendations. In this retrospective study, 94 patients treated for unifocal primary BC and synchronous LNM at Sahlgrenska UniversityHospital during 2018 were included. Estrogen (ER) and progesterone (PR) receptor, Ki67, and HER2 status were assessed in the primary tumor and LNM using immunohistochemistry. Discordances between the primary tumor and the LNM were analyzed for each individual biomarker and surrogate subtyping. The concordance between the primary tumor and the LNM for ER, PR, Ki67, and HER2 status was 98.9%, 89.4%, 72.3%, and 95.8%, respectively. Discordance in surrogate subtyping was found in 28.7% of the tumors and matched LNMs, the majority (81.5%) of which changed to a more favorable subtype in the LNM; most commonly from Luminal B to Luminal A (48.6%). No changes in surrogate subtyping were detected where ER or HER2 status changed from negativity in the BC to positivity in the LNM, thereby showing no additional value in performing immunohistochemistry on the LNM from a treatment decision-making perspective. However, large studies need to be performed that test both the primary BCs and synchronous LNMs for more accurate diagnostics.

A Preliminary Analysis of Ki-67 Expression in Breast Cancer in the Caribbean

OBJECTIVE

There has been a void of data regarding Ki-67 expression in breast cancer in the Caribbean. Ki-67 is a widely used marker to determine the grade and prognosis of breast cancer. Ki-67 has been shown to be a valuable tool in predicting the response to chemotherapy and hormonal therapy in breast cancer patients. The objective of this preliminary study aims to describe the Ki-67 (Ki) status in this population and its correlations with other parameters in breast cancer histology. This study also aims to lay the groundwork for Ki-67 analysis in this population so that future studies may better describe it.

METHOD

The methodology involved gathering data from histology reports for all breast cancer-related biopsies from the 1st of January 2018 to the 12th of July 2021. This data was retrospectively analyzed.

RESULTS

Twenty-three Ki-67 cases were obtained, 19 of which had Ki expression >10%. This >10% group was mostly staged from T1c up (one T1, three T1c cases, two T2 cases, four T3 cases while nine were not T staged). Two were N2/M1 while 9 were N0 and two were M0, the rest were not staged. The mean age was 65.6 years with a range of 54 and a standard deviation of 12.5. Lymphovascular invasion was confirmed in four cases and suspected in three. Axillary lymph node dissection (ALND) yielded >10 nodes involved in two cases while <5 nodes in the remaining. The most common receptor status was hormone positive/ human epidermal growth factor receptor-2 (HER) negative (eight). Invasive Ductal Carcinoma (IDC) occurred in 10 cases while intermediate grade was in 14 cases. The Ki 6-10 % group consisted of two cases, one staged at T1aN0Mx while the other T2NxMx. Lymphovascular invasion was suspected in one. The average age was 67.5 years. ALND yielded less than five nodes in one case and 5-10 nodes in the other. Grades were high and intermediate. Histology was invasive ductal carcinoma/ductal carcinoma in situ (IDC/DCIS), and ductal carcinoma in situ ( DCIS) respectively. The Ki <6% group comprised two cases, staged at T1NxMx and T3N2M1. Lymphovascular invasion was absent in both. The mean age was 58.5 years. ALND yielded >10 nodes in one case and <5 in the other. Grades were high and intermediate. Histology was IDC/DCIS in both. There were no sentinel nodes involved in all but two cases belonging to the Ki >10% group.

CONCLUSION

This preliminary study was the first to describe the Ki-67 marker in the Caribbean population. The vast majority of this population has a Ki-67 level of>10%. Higher Ki-67 expression is associated with larger tumors, lymphovascular invasion, metastases, and higher tumor grades. There is a need for consistent Ki-67 reporting in histology samples before follow-up studies are conducted.

A Prospective Multi-Institutional Observational Study on ER, PR, HER2/NEU, and Ki-67 Expression and Discordance Pattern in Primary and Metastatic and Recurrent Carcinoma Breast and Its Therapeutic Implications and Prognostic Outcome

Only few studies reported in literature that has elucidated in detail the implications of molecular typing in metastatic and recurrent breast cancer. In this prospective study, we have analysed in depth the pattern of expression, discordances of molecular markers in various metastatic sites, and recurrent cases and their response to chemotherapy/targeted agents and the prognostic outcome. The primary aim of the study was to determine ER, PR, HER2/NEU, and Ki-67 from recurrent and metastatic carcinoma breast to study the expression pattern and discordance and also to study the degree of discordance in relation to the site of metastasis and pattern of metastasis (synchronous vs metachronous) and discordance pattern with the response to chemotherapy and median overall survival rates in months in available subset of patients. Prospective open-label study done at the Government Rajaji Hospital, Madurai Medical College, and Government Royapettah Hospital, Kilpauk Medical College, India, from November 2014 to August 2021. All breast carcinoma patients with recurrence or oligo metastasis (defined as one organ with less than 5 metastases in our study) with known receptor status were eligible and 110 patients were enrolled in the study. ER (ER + to ER -) discordance was seen in 19 (26.38%) cases. PR (PR + to PR -Ve) discordance was seen in 14 (19.17%) cases. HER2/NEU (HER2/NEU + Ve to -Ve) discordance was seen in 3 (16.6%) cases. Ki-67 discordance was seen in 54 (49.09%) cases. High Ki-67 as a proliferative marker has increased response to chemotherapy but earlier relapse and disease progression especially in Luminal B type. In further subset analysis, ER, PR, and HER2/NEU discordance is higher for lung metastasis (ER, PR 61.1%, p value .001, HER2/NEU 5.5%), followed by liver metastasis (ER, PR 50%, p value .0023, 1 case turning ER -ve to + ve, HER2/NEU 1 (10%)). In lung, discordance is more for metachronous metastasis. In liver, discordance is 100% for synchronous metastasis. Synchronous metastasis with discordance in ER and PR is associated with rapid disease progression. High Ki-67 subset of Luminal B-like tumors progressed rapidly than triple negative and HER2/NEU positive subset. Complete clinical response rate in contralateral axillary node metastasis group was 87.8%, followed by local only recurrence with high Ki-67 where chemotherapy had response rate of 81% and 2 years DFS of 93.12% after excision. Certain subsets like contralateral axillary nodes and supraclavicular nodes which present as oligo metastatic disease with discordance and high Ki-67 respond well to chemotherapeutics and targeted agents improving the OS in this subset of patients. Molecular markers and their expression and discordance pattern determine the therapeutic outcome and prognosis of the disease. Early identification and targeting the discordance would go a long way in improving the outcome and DFS and OS of breast cancer patients.

Prediction model of axillary lymph node status using automated breast ultrasound (ABUS) and ki-67 status in early-stage breast cancer

Background

Automated breast ultrasound (ABUS) is a useful choice in breast disease diagnosis. The axillary lymph node (ALN) status is crucial for predicting the clinical classification and deciding on the treatment of early-stage breast cancer (EBC) and could be the primary indicator of locoregional recurrence. We aimed to establish a prediction model using ABUS features of primary breast cancer to predict ALN status.

Methods

A total of 469 lesions were divided into the axillary lymph node metastasis (ALNM) group and the no ALNM (NALNM) group. Univariate analysis and multivariate analysis were used to analyze the difference of clinical factors and ABUS features between the two groups, and a predictive model of ALNM was established. Pathological results were as the gold standard.

Results

Ki-67, maximum diameter (MD), posterior feature shadowing or enhancement and hyperechoic halo were significant risk factors for ALNM in multivariate logistic regression analysis (P < 0.05). The four risk factors were used to build the predictive model, and it achieved an area under the receiver operating characteristic (ROC) curve (AUC) of 0.791 (95% CI: 0.751, 0.831). The accuracy, sensitivity and specificity of the prediction model were 72.5%, 69.1% and 75.26%. The positive predictive value (PPV) and negative predictive value (NPV) were 66.08% and 79.93%, respectively. Distance to skin, MD, margin, shape, internal echo pattern, orientation, posterior features, and hyperechoic halo showed significant differences between stage I and stage II (P < 0.001).

Conclusion

ABUS features and Ki-67 can meaningfully predict ALNM in EBC and the prediction model may facilitate a more effective therapeutic schedule.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10034-3.

Current Biomarkers for Precision Medicine in Breast Cancer

Breast cancer has become the prototypical solid tumor where targets have been identified within the tumor allowing for personalized approach for systemic therapy. Biomarkers are beginning to play an important role in preparing the way for precision treatment. Mandatory biomarkers for every newly diagnosed case of breast cancer are estrogen receptors and progesterone receptors in selecting patients for endocrine treatment and HER2 for identifying patients likely to benefit from antiHER2 therapy. Although methodological problems exist in the determination of Ki67, because of its clearly established clinical value, wide availability, and low costs relative to the available multianalyte signatures, Ki67 may be used for determining prognosis, especially if values are low or high. Also, the androgen receptor (AR) pathway is emerging as a potential therapeutic target in breast cancer. AR-targeted treatments for breast cancer are in development and have shown promising preliminary results. While, most established biomarkers in breast cancer require tissue samples, serum tumor markers are easily accessible and require a less invasive procedure. Among them, tissue polypeptide-specific antigen (TPS), a specific epitope structure of a peptide in serum associated with human cytokeratin 18, is linked to the proliferative activity of tumors. TPS may be a valuable and independent prognostic biomarker for breast cancer.In order to accelerate progress towards precision treatment for women with breast cancer, we need additional predictive biomarker, especially for enhancing the positive predictive value for endocrine and antiHER2 therapies, as well as biomarkers for predicting response to specific forms of chemotherapy.

Correlation of Conventional Ultrasound Characteristics of Breast Tumors With Axillary Lymph Node Metastasis and Ki-67 Expression in Patients With Breast Cancer

OBJECTIVES

To explore the association between the ultrasound (US) characteristics of breast tumors with axillary lymph node metastasis (ALNM) and Ki-67 expression in patients with breast cancer.

METHODS

In total, 527 consecutive patients with breast cancer who had undergone US examinations and curative surgery with axillary lymph node evaluations were included. The size, shape, aspect ratio, margin, internal echo, internal calcification, posterior echo attenuation, lymphatic hilar structure, cortical thickness, and blood flow of the axillary lymph nodes or primary breast lesions were observed with conventional US. Pathologic prognostic factors, including the histologic type of the tumor, histologic grade, estrogen and progesterone receptor status, lymph node status, and Ki-67 expression were determined. A logistic regression model was used to evaluate whether the US characteristics of primary breast lesions were associated with ALNM and Ki-67 expression.

RESULTS

The maximum tumor diameter (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.05-2.27; P = .028), tumor margin (OR, 2.89; 95% CI, 1.69-4.94; P < .001), internal echo (OR, 2.17; 95% CI, 1.47-3.20; P < .001), and Ki-67 status (OR, 3.57; 95% CI, 2.29-5.58; P < .001) had significant value as independent predictors of ALNM. Only the internal echo (OR, 1.95; 95% CI, 1.28-2.95; P = .002) of breast cancer was an independent predictor of the Ki-67 status. The heterogeneity in the internal echo indicated faster cancer cell proliferation and was associated with a worse prognosis in patients with breast carcinoma.

CONCLUSIONS

Certain conventional US characteristics may be useful predictors of ALNM and the Ki-67 status in patients with breast cancer.

Hormone receptor, human epidermal growth factor receptor-2, and Ki-67 status in primary breast cancer and corresponding recurrences or synchronous axillary lymph node metastases

The therapeutic strategy for breast cancer is determined by the surrogate subtype, which is defined by biomarkers, such as estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor-2 (HER2), and Ki-67. In previous reports, the rate of discordance in ER, PgR, and HER2 between primary breast cancer and recurrent lesions or synchronous axillary lymph node metastasis was 15-25, 25-40, and 5-25 or 7-50, 10-50, and 3-30%, respectively. Overall, hormone receptors tended to weaken during the metastatic process, while patterns of HER2 were not uniform. Regarding the Ki-67 labeling index, an increase in metastatic lesions compared with primary lesions was the dominant pattern, suggesting that aggressive subclones with high proliferative potential form metastases. The loss of expression of hormone receptor or an increase in the Ki-67 labeling index in metastasis seemed to be associated with a poor prognosis. However, most previous studies did not report the background characteristics of patients, or they included subjects with varied characteristics, including those on systemic therapy, and were based on relatively small populations; therefore, definitive conclusions could not be drawn. Future studies should explore how to select therapies according to the biomarkers in primary breast cancer and/or its metastasis.

Changes in the Ki-67 labeling index between primary breast cancer and metachronous metastatic axillary lymph node: A retrospective observational study

BACKGROUND

The Ki-67 labeling index (LI) is a well-known prognostic factor for primary breast cancer, but its clinical significance for metachronous axillary lymph node (ALN) recurrence has not been well documented.

METHODS

Ki-67 expression in primary tumors (PTs) and ALN metastases (ALNMs) was evaluated in 21 patients and quantified to investigate the relationship between Ki-67 LIs in PTs and metachronous ALNMs.

RESULTS

The median Ki-67 LIs in the PTs and ALNMs were 25.2% (range: 2.3-80.2%) and 70% (range: 10.4-97.4%), respectively. A majority of patients had higher Ki-67 LIs in ALNMs than in PTs (76.2%, 16/21). Disease-specific survival was significantly better in patients with a lower-than-median ALNM Ki-67 LI (P = 0.019, log-rank test). Receiver operating characteristic curves showed a PT Ki-67 LI of 62.8% as the optimal cutoff value and an ALNM Ki-67 LI of 65.1%. Accordingly, we divided the patients into four groups: PT Ki-67 LI lower than 62.8%/ALNM Ki-67 LI lower than 65.1%, PT Ki-67 LI lower/ALNM Ki-67 LI higher, PT Ki-67 LI higher/ALNM Ki-67 LI higher, and PT Ki-67 LI higher/ALNM Ki-67 LI lower. Disease-specific survival was significantly better in patients with Ki-67 LI lower/ALNM Ki-67 LI lower than in the other groups.

CONCLUSION

This is the first study to show that the Ki-67 LI in metachronous ALNM is a prognostic factor for patients with metachronous ALN recurrence of breast cancer.

Differential Expression of RAGE, EGFR and Ki-67 in Primary Tumors and Lymph Node Deposits of Breast Carcinoma

Background:

Breast cancer is a complex disease that results from the inheritance of a number of susceptible genes. Intensive search wok was conducted world-wide on molecular bases of breast cancer in order to achieve the best therapeutic modalities; however, breast cancer still remains a challengeable task. It is very important to determine if the biological parameters in metastatic regional lymph nodes are similar to that in the primary breast cancer because therapy is indicated for patients with synchronous metastatic regional lymph nodes of breast cancer. Difference in therapeutic response in cases of breast cancer may be assumed partially to variability in the biological behavior of tumor tissue in primary breast cancer and lymph node metastasis.

Aim:

Our aim is to evaluate any variability in the expression of three types of tissue markers in both the primary breast tumors and corresponding axillary lymph nodes in order to expect the targeted therapeutic effect on both sites.

Material and Methods:

Three markers from different categories; RAGE, EGFR and Ki-67 were immunohistochemicalyl studied for their expression in biopsy specimens from primary breast tumors and their corresponding axillary lymph nodes.

Results:

There was a statistically significant difference in the expression of these markers between benign and malignant breast lesions. Although we found some differences in the expression of the three studied markers between primary breast cancer and corresponding axillary lymph nodes, yet these variations were mostly not statistically significant.

Conclusion:

Our findings support the validity of anti-RAGE and anti-EGFR therapy for treatment of both primary and nodal metastatic breast cancer in immunopositive cases.

Silymarin nanoformulation as potential anticancer agent in experimental Ehrlich ascites carcinoma-bearing animals

Aim: This study aimed to evaluate, for the first time the potential use of a safe biocompatible nanoformulation of silymarin (SM) as antitumor agent and to provide its mechanism of action compared with native SM. Materials & methods: SM was loaded into pluronic nanomicelles and Ehrlich ascites carcinoma-tumor-bearing mice were used as experimental model. Biochemical parameters including SOD, CAT and GSH, lipid peroxidation biomarkers (MDA), histopathological, ultrastructural and immunohistochemical studies were applied on the Ehrlich ascites carcinoma cells. Furthermore, the cell cycle as well as caspase-3 were examined. Results & conclusion: Nanoformulated SM (SMnp) destroyed tumors via increasing SOD, CAT and GSH concomitant with decreasing MDA. Moreover, SMnp-induced apoptosis through decreasing Ki-67 and Bcl2 expression, along with the activation of caspase-3, leads to inhibition of proliferation and the arrest of ceel cycle progression at the G1/S phase. Electron microscopy studies presented the superiority of SMnp over native SM in causing mitochondrial and nuclear degeneration in cancer cells.

Investigating Various Thresholds as Immunohistochemistry Cutoffs for Observer Agreement

BACKGROUND

Clinical translation of immunohistochemistry (IHC) biomarkers requires reliable and reproducible cutoffs or thresholds for interpretation of immunostaining. Most IHC biomarker research focuses on the clinical relevance (diagnostic, prognostic, or predictive utility) of cutoffs, with less emphasis on observer agreement using these cutoffs. From the literature, we identified 3 commonly used cutoffs of 10% positive epithelial cells, 20% positive epithelial cells, and moderate to strong staining intensity (+2/+3 hereafter) to use for investigating observer agreement.

MATERIALS AND METHODS

A series of 36 images of microarray cores stained for 4 different IHC biomarkers, with variable staining intensity and percentage of positive cells, was used for investigating interobserver and intraobserver agreement. Seven pathologists scored the immunostaining in each image using the 3 cutoffs for positive and negative staining. Kappa (κ) statistic was used to assess the strength of agreement for each cutoff.

RESULTS

The interobserver agreement between all 7 pathologists using the 3 cutoffs was reasonably good, with mean κ scores of 0.64, 0.59, and 0.62, respectively, for 10%, 20%, and +2/+3 cutoffs. A good agreement was observed for experienced pathologists using the 10% cutoff, and their agreement was statistically higher than for junior pathologists (P=0.02). In addition, the mean intraobserver agreement for all 7 pathologists using the 3 cutoffs was reasonably good, with mean κ scores of 0.71, 0.60, and 0.73, respectively, for 10%, 20%, and +2/+3 cutoffs. For all 3 cutoffs, a positive correlation was observed with perceived ease of interpretation (P<0.003). Finally, cytoplasmic-only staining achieved higher agreement using all 3 cutoffs than mixed staining patterns.

CONCLUSIONS

All 3 cutoffs investigated achieve reasonable strength of agreement, modestly decreasing interobserver and intraobserver variability in IHC interpretation. These cutoffs have previously been used in cancer pathology, and this study provides evidence that these cutoffs can be reproducible between practicing pathologists.

Heparanase augments insulin receptor signaling in breast carcinoma

Recently, growing interest in the potential link between metabolic disorders (i.e., diabetes, obesity, metabolic syndrome) and breast cancer has mounted, including studies which indicate that diabetic/hyperinsulinemic women have a significantly higher risk of bearing breast tumors that are more aggressive and associated with higher death rates. Insulin signaling is regarded as a major contributor to this phenomenon; much less is known about the role of heparan sulfate-degrading enzyme heparanase in the link between metabolic disorders and cancer.In the present study we analyzed clinical samples of breast carcinoma derived from diabetic/non-diabetic patients, and investigated effects of heparanase on insulin signaling in breast carcinoma cell lines, as well as insulin-driven growth of breast tumor cells.We demonstrate that heparanase activity leads to enhanced insulin signaling and activation of downstream tumor-promoting pathways in breast carcinoma cells. In agreement, heparanase enhances insulin-induced proliferation of breast tumor cells in vitro. Moreover, analyzing clinical data from diabetic breast carcinoma patients, we found that concurrent presence of both diabetic state and heparanase in tumor tissue (as opposed to either condition alone) was associated with more aggressive phenotype of breast tumors in the patient cohort analyzed in our study (two-sided Fisher's exact test; p=0.04). Our findings highlight the emerging role of heparanase in powering effect of hyperinsulinemic state on breast tumorigenesis and imply that heparanase targeting, which is now under intensive development/clinical testing, could be particularly efficient in a growing fraction of breast carcinoma patients suffering from metabolic disorders.

DNA ploidy and cell cycle protein expression in oral squamous cell carcinomas with and without lymph node metastases

BACKGROUND

Oral squamous cell carcinoma (OSCC) is the most frequently occurring malignant tumour in the oral cavity. OSCC arises because of multiple genetic alterations. Cell cycle aberrations and aneuploidy are reportedly among the main characteristics of cancer cells and are associated with aggressive growth and poor prognosis.

METHODS

The study sample included 47 non-metastasised and 39 metastasised primary OSCC, with matched positive cervical lymph nodes and 17 normal oral mucosa samples. Tissue microarrays (TMAs) were prepared with a minimum of three cores from each case. TMA sections were cut and immunostained with MCM2, Ki-67, geminin and cyclin D1 antibodies. DNA image analysis was performed on the whole tissue section before TMAs were created.

RESULTS

The results revealed that there were no differences in cell cycle protein expression in different areas of the tumours or between the metastatic and non-metastatic carcinomas. None of the cell cycle proteins showed significant differences between the lymph node metastasis and the primary OSCC, except for Ki-67. Geminin/Ki-67 ratio showed significant difference between metastatic and non-metastatic tumours. Aneuploidy was detected in all (100%) cases of OSCC. Similarly, all lymph node samples (39 cases) were aneuploid.

CONCLUSION

The results suggest that although there was dysregulation of cell cycle regulatory proteins, only Ki-67 and the MCM2/Ki-67 and geminin/Ki-67 ratios may have prognostic significance in oral cancer. DNA ploidy alone was not specific and may not be a good tool to evaluate prognosis or metastatic progression in oral cavity carcinomas.

Impact of intratumoural heterogeneity on the assessment of Ki67 expression in breast cancer

In breast cancer (BC), the prognostic value of Ki67 expression is well-documented. Intratumoural heterogeneity (ITH) of Ki67 expression is amongst the several technical issues behind the lag of its inclusion into BC prognostic work-up. The immunohistochemical (IHC) expression of anti-Ki67 antibody (MIB1 clone) was assessed in four full-face (FF) sections from different primary tumour blocks and their matched axillary nodal (LN) metastases in a series of 55 BC. Assessment was made using the highest expression hot spots (HS), lowest expression (LS), and overall/average expression scores (AS) in each section. Heterogeneity score (Hes), co-efficient of variation, and correlation co-efficient were used to assess the levels of Ki67 ITH. Ki67 HS, LS, and AS scores were highly variable within the same section and between different sections of the primary tumour, with maximal variation observed in the LS (P < 0.001). The least variability between the different slides was observed with HS scoring. Although the associations between Ki67 and clinicopathological and molecular variables were similar when using HS or AS, the best correlation between AS and HS was observed in tumours with high Ki67 expression only. Ki67 expression in LN deposits was less heterogeneous than in the primary tumours and was perfectly correlated with the HS Ki67 expression in the primary tumour sections (r = 0.98, P < 0.001). In conclusion, assessment of Ki67 expression using HS scoring method on a full-face BC tissue section can represent the primary tumour growth fraction that is likely to metastasise. The association between Ki67 expression pattern in the LN metastasis and the HS in the primary tumour may reflect the temporal heterogeneity through clonal expansion.

Ki67, PCNA, and MCM proteins: Markers of proliferation in the diagnosis of breast cancer

The proliferative activity of tumour cells represents an important prognostic marker in the diagnosis of cancer. One of the methods for assessing the proliferative activity of cells is the immunohistochemical detection of cell cycle-specific antigens. For example, Ki67, proliferating cell nuclear antigen (PCNA), and minichromosome maintenance (MCM) proteins are standard markers of proliferation that are commonly used to assess the growth fraction of a cell population. The function of Ki67, the widely used marker of proliferation, still remains unclear. In contrast, PCNA and MCM proteins have been identified as important participants of DNA replication. All three proteins only manifest their expression during the cell division of normal and neoplastic cells. Since the expression of these proliferative markers was confirmed in several malignant tumours, their prognostic and predictive values have been evaluated to determine their significance in the diagnosis of cancer. This review offers insight into the discovery of the abovementioned proteins, as well as their current molecular and biological importance. In addition, the functions and properties of all three proteins and their use as markers of proliferation in the diagnosis of breast cancer are described. This work also reveals new findings about the role of Ki67 during the mitotic phase of the cell cycle. Finally, information is provided about the advantages and disadvantages of using all three antigens in the diagnosis of cancer.

The correlation between Ki-67 with other prognostic factors in breast cancer: A study in Iranian patients

Context:

Despite the fact that breast cancer (BC) is a major health issue, very few studies describe its characteristics in the Middle East.

Aim:

The aim of this study was to evaluate the use and value of Ki-67 as a prognostic marker in BC and associations between Ki-67, clinical, and histopathological parameters were evaluated.

Subjects and Methods:

In a retrospective study, 260 BC women and invasive ductal carcinoma were included to our study in Kermanshah city, Iran. Age, tumor size, lymph node involvement, histological grade, nuclear grade, and vascular invasion were other factors that determined in a lot of patients.

Results:

The mean age at diagnosis was 47.6 years (range, 24-84 years) with 100% female. Of 243 patients that tumor size was determined for them, 207 patients (85.2%) had tumor size ≥2 cm, and 36 patients (14.8%) had size <2 cm and also of 237 patients, 47 patients (19.8%), 140 (59.1%), and 50 (21.1%) had histological grades I, II, and III, respectively. There is significant correlation between Ki-67 with nuclear grade, human epidermal growth factor receptor 2 (HER2), and p53 (P < 0.05). Based on this result, more patients with Ki-67 ≥20% have higher nuclear grade, p53-positive, and HER2-positive. There was correlation between Ki-67 with type of tumor (P = 0.009).

Conclusions:

The higher Ki-67 has a direct significant correlation with higher nuclear grade, p53-positive, and HER2-positive. Furthermore, triple negative patients have higher Ki-67 compared to other subtypes.

Ki-67 Expression in CRC Lymph Node Metastasis Does Not Predict Survival

Colorectal cancer is one of the most common malignancies and a leading cause of cancer death worldwide. Molecular markers may improve clinicopathologic staging and provide a basis to guide novel therapeutic strategies which target specific tumour-associated molecules according to individual tumour biology; however, so far, no ideal molecular marker has been found to predict disease progression. We tested Ki-67 proliferation marker in primary and lymph node metastasis of CRC. We observed a statistical significant difference between the positive rates of neoplastic cells positively stained by Ki-67 in both sites, with remarkable increased number of Ki-67 positive cells in primary tumor cells compared to cancer cells that invaded lymph nodes. We can speculate that the metastatic CRC in lymph node can be more resistant to the drugs that target cellular division.

In stage II/III lymph node-positive breast cancer patients less than 55 years of age, keratin 8 expression in lymph node metastases but not in the primary tumour is an indicator of better survival

Axillary lymph node status is one of the most important prognostic variables for breast cancer (BC). To investigate and understand the clinical, histopathological and biological factors that affect prognosis in node-positive young breast cancer patients, we compared the phenotype of 100 primary tumours with their corresponding loco-regional lymph node (LN) metastases using conventional immunohistochemistry (IHC) markers currently in use for molecular classification of breast cancer. By comparing the expression of ER, PR, HER-2, Ki67, K8, K5/6 and vimentin, we found that expression of HER-2, Ki67, K8 and vimentin is frequently lost in lymph node metastases. Between the primary tumour and corresponding lymph node metastases, expression of keratins K8 and K5/6 significantly changed. Expression of K8 in lymph node metastases, but not in primary tumours, segregates patients in two sub-groups with different outcomes. Survival of patients with K8-positive LN metastases at 5 years in comparison with patients with K8-negative LN metastases was 75 vs 48 %, at 10 years 62 vs 22 % and at 20 years 53 vs 14 % (p < 0.001). K8 immunostaining of tissue from the lymph node metastasis allows defining a sub-group of lymph node-positive BC patients with a highly unfavourable outcome, for whom therapeutic options might have to be reconsidered.

Expression of proliferation markers Ki67, cyclin A, geminin and aurora-kinase A in primary breast carcinomas and corresponding distant metastases

Aims

To assess the expression of the following cell cycle regulatory proteins in primary metastatic breast carcinomas (MBCs) and on availability in matched distant metastases (DMs): Ki67, cyclin A, geminin and aurora-kinase A (aurkA); and to compare the expression of these markers in early MBC (EMBC) and late MBC separated into groups according to median time point on metastatic event occurred (28 months).

Methods

The expression of the above mentioned markers was analysed in a total of 47 primary MBCs and 59 DMs (out of which 37 were pairs) by immunohistochemistry. Fourteen breast carcinomas with no relapse over a 10-year follow-up period were utilised as control cases (CBC).

Results

Among the MBCs, 22 metastasised to the bone, 4 to the lung and 21 to the central nervous system (CNS). Geminin (p<0.001) and Ki67 (p=0.001) were increased in the MBCs while aurkA and cyclin A showed no difference when compared with CBCs. There were no differences between aurkA, cyclin A and geminin expression in MBCs and DMs in general. Expression of Ki67 was, however, elevated (p=0.027) in DMs. In CNS metastases all markers showed elevated expression as compared to MBCs. In bone metastases, geminin was lower (p<0.001) compared with primary MBCs. In the metastases of the lung, the evaluated markers did not show different expression. According to the median follow-up until the metastatic event, Ki67 was found to be significantly elevated in EMBC (p=0.018).

Conclusions

Ki67 index and geminin distinguish a fraction of MBC with worse prognosis, showing increased levels in the latter in comparison to CBC being tumour-free over a 10-year follow-up period. Ki67 could possibly identify a group of MBCs that develop early DMs.

The diagnostic importance of matrix metalloproteinase-7 and nestin in gastrointestinal stromal tumors

BACKGROUND

The importance of the matrix metalloproteinase-7 (MMP-7) and nestin immunomarkers, C-kit proto-oncogene (CD117), and the efficiency of the Ki-67 proliferation index for gastrointestinal stromal tumors were evaluated.

MATERIAL AND METHODS

This study was conducted by examining the microscope slides of 72 patients with gastrointestinal stromal tumors that were sent to the pathology laboratory between 2007 and 2012. Immunohistochemical staining for CD117, MMP-7, nestin, and marker of proliferation Ki-67 was performed. The correlations between the positive results for Ki-67, CD117, MMP-7, and nestin were evaluated relative to the tumor characteristics of size, localization, grade, cellular type, cellularity, cytology type, growth pattern, ulceration, necrosis, hemorrhage, invasion depth, and lymph node metastasis.

RESULTS

The tumor was localized in the stomach in 42 of the patients, the intestines in 19, the colon in 7, and the rectum in 4. Comparisons among the groups showed that MMP-7 was correlated with the tumor grade (p<0.001), cellularity (p<0.009), cytologic atypia (p<0.001), ulceration (p=0.002), necrosis (p<0.001), and tumor size (p=0.001). Nestin was correlated with the tumor grade (p=0.013), and tumor size (p=0.024). Correlations among CD117, MMP-7, nestin, and Ki-67 were examined. Nestin and Ki-67 were both significantly correlated with CD117 and MMP-7 [(r=0.279, p=0.018), (r=0.322, p=0.006), (r=0.386, p=0.001), (r=0.386, p=0.002)], respectively.

CONCLUSIONS

MMP-7 and nestin may be beneficial as markers, given their sensitivity to gastrointestinal stromal tumors.

Prognostic value of Ki-67 in breast cancer patients with positive axillary lymph nodes: a retrospective cohort study

Introduction

Ki-67 expression is a biomarker for proliferation. Its prognostic value is recognized in breast cancer (BC) patients with negative axillary nodes, but is less clear in BC patients with positive axillary lymph nodes.

Methods

We retrospectively reviewed the medical records of 1131 Chinese BC patients treated from January 2002 to June 2007 and 450 patients met the inclusion criteria: positive nodes, adjuvant therapy, and complete biomarker profile (estrogen receptor (ER), progesterone receptor (PR), HER2, p53, Ki-67). Univariate and multivariate regression analysis were used to correlate biomarkers and tumor characteristics with metastasis free survival (MFS) and overall survival (OS).

Results

Median follow-up time was 46 months (range 5–76 months). The Ki-67 expression was associated significantly with histological grade, ER, PR, HER2, and P53 status (P<0.05). Tumor stage, nodal stage, and ER status were independent prognostic factors for MFS. Ki-67 status was associated significantly with OS but not MFS. To determine whether the extent of LN involvement in the BC patients influenced the role of Ki-67 in survival rates, we compared these variables in patients with 1–3 positive lymph nodes (N1) to those of patients with ≥4 positive lymph nodes. Ki-67 status was an independent prognostic factor for MFS (Hazard Ratio, 3.27, P = 0.026) and overall survival (HR, 10.64, P = 0.007) in patients with 1–3 positive nodes (N1).

Conclusions

The possibility that Ki-67 expression together with clinical factors can improve prediction of the prognosis of BC patients with 1∼3 positive axillary lymph nodes warrants further studies.

Semi-automated evaluation of Ki-67 index in invasive ductal carcinoma of the breast

A significant factor that affects the value of the Ki-67 proliferation index (IK) is the interpretation and implementation approach. This method is based on visual or automated methods to count tumor nuclei labeled with Ki-67 antigen, and is prone to errors. Detection of Ki-67 is a useful tool in breast cancer and contributes to its molecular classification. The current study proposes a method for the quantification of Ki-67-positive tumor nuclei, which allows for the determination of the exact IK value that is required for tumor stratification based on the proliferation rate. The IK was assessed in 81 successive cases of diagnosed invasive ductal breast carcinoma using a semi-automated method that accurately identifies positive tumor cell nuclei. This method prevents the inclusion of other possible positive cells, including lymphoid, normal epithelia and hyperplastic. In small specimens with increased cell density, where the nucleus/cytoplasm ratio is markedly in favor of the nucleus and the distance between nuclei is small, the method allows precise quantification of the nuclei, even when the limits between nuclei are difficult to identify. In addition, images may be stored in a database, including the assessments, and easily accessed when required. We hypothesize that the semi-automated method for counting nuclei offers the most accurate method of assessing the IK and avoids counting errors that may occur through other methods.

Molecular classification of breast carcinomas with particular emphasis on "basal-like" carcinoma: a critical review

During the last 11 years, 5 molecular subtypes of breast carcinoma (luminal A, luminal B, Her2-positive, basal-like, and normal breast-like) have been characterized and intensively studied. As genomic research evolves, further subtypes of breast cancers into new "molecular entities" are expected to occur. For example, a new and rare breast cancer subtype, known as claudin-low, has been recently found in human carcinomas and in breast cancer cell lines. There is no doubt that global gene expression analyses using high-throughput biotechnologies have drastically improved our understanding of breast cancer as a heterogeneous disease. The main question is, however, whether new molecular techniques such as gene expression profiling (or signature) should be regarded as the gold standard for identifying breast cancer subtypes. A critical review of the literature clearly shows major problems with current molecular techniques and classification including poor definitions, lack of reproducibility, and lack of quality control. Therefore, the current molecular approaches cannot be incorporated into routine clinical practice and treatment decision making as they are immature or even can be misleading. This review particularly focuses on the "basal-like" breast cancer subtype that represents one of the most popular breast cancer "entities". It critically shows major problems and misconceptions with and about this subtype and challenges the common claim that it represents a "distinct entity". It concludes that the term "basal-like" is misleading and states that there is no evidence that expression of basal-type cytokeratins in a given breast cancer, regardless of other established prognostic factors, does have any impact on clinical outcome.

Prevalence and Classification of Spontaneous Mammary Intraepithelial Lesions in Dogs Without Clinical Mammary Disease

Mammary intraepithelial lesions (IELs) are noninvasive epithelial proliferations that include ductal hyperplasia (DH), atypical DH (ADH), and ductal carcinoma in situ (DCIS). In women, IELs are associated with increased risk of invasive breast cancer and form a basis for therapeutic decisions. Similarly, in female dogs, IELs are common in tumor-bearing glands and in non-tumor-bearing glands. To determine the prevalence and types of spontaneous IELs, mammary glands from 108 female dogs without clinical mammary disease were evaluated histologically and immunohistochemically. Within this population, 56 dogs (52%) had at least one type of spontaneous IEL, including DH (49 dogs), ADH (14 dogs), low-grade DCIS (19 dogs), intermediate-grade DCIS (12 dogs), and high-grade DCIS (1 dog). Twenty-one dogs had two or more different IEL types. In 23 of 24 dogs with atypical IELs (ADH or DCIS), immunohistochemical expression was determined for estrogen receptor α (ER-α), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER-2/neu), and Ki-67. For all markers examined, low-grade DCIS had significantly lower scores than did adjacent nonlesional gland; PR expression was significantly decreased in low-grade DCIS compared to other atypical lesions. Sixty-one lesions were ER-α negative (12 ADH, 36 low-grade DCIS, 13 intermediate-grade DCIS), and no lesions overexpressed HER-2/neu. Based on the dog’s prevalence of spontaneous mammary IELs that precede clinical mammary disease, the remarkable histologic similarity between canine and human IELs, and the loss of ER expression in certain IELs in both species, the dog shows promise as a model for human breast preneoplasia.

The expression of p53, bcl-2, bax, fas and fasL in the primary tumour and lymph node metastases of breast cancer

PURPOSE. It is unknown to what extent lymph node metastases differ from primary tumours of breast cancer. Our aim was to investigate the similarity between primary breast tumours and the matching lymph node metastases in 59 breast cancer patients. EXPERIMENTAL DESIGN. Immunohistochemical stainings of p53, bax, bc-l2, fas and fasL were performed in primary tumours and the parallel lymph node metastases. RESULTS. When using a cut point of 10%, the concordance between primary tumours and parallel lymph node metastases in the expression of p53 was 85%, bcl-2 79%, bax 69%, fas 59% and fasL 43%. In most tumours the staining status of p53, bcl-2 and bax in the primary tumour and the corresponding lymph node did not change more than 20%. However, these variables could fluctuate in both directions. In 15-25% of the cases, nodal expression was more than 20% lower than in the primary tumours, while in 10-17% of the cases, nodal expression was more than 20% higher than in the primary tumours. In half of the tumours, fas status did not change. Most fasL positive tumours lost positivity in the lymph node metastases or showed positively staining cancer cells only in the peripheral region of the node. A phenotype analysis of combined information of tumour fas/tumour fasL/nodal fas/nodal fasL expression (+/ - ) was assessed. The most frequently observed phenotype was tumour fas - /tumour fasL + /nodal fas - /nodal fasL- (22% of the tumours), although almost all combinations were seen. CONCLUSIONS. The expression of p53, bax, bcl - 2, fas and fasL is not maintained in the matching lymph node metastases of breast cancer. Large studies comparing the expression of relevant tumour biology factors in primary tumours and parallel lymph node metastases and their impact on therapy outcome, especially in the adjuvant setting, are warranted.

Growth factor receptors and apoptosis regulators: signaling pathways, prognosis, chemosensitivity and treatment outcomes of breast cancer

Biomarkers of breast cancer are necessary for prognosis and prediction to chemotherapy. Prognostic biomarkers provide information regarding outcome irrespective of therapy, while predictive biomarkers provide information regarding response to therapy. Candidate prognostic biomarkers for breast cancers are growth factor receptors, steroid receptors, Ki-67, cyclins, urokinase plasminogen activator, p53, p21, pro- and anti-apoptotic factors, BRCA1 and BRCA2. But currently, the predictive markers are Estrogen and Progesterone receptors responding to endocrine therapy, and HER-2 responding to herceptin. But there are numerous breast cancer cases, where tamoxifen is ineffective even after estrogen receptor positivity. This lead to search of new prognostic and predictive markers and the number of potential markers is constantly increasing due to proteomics and genomics studies. However, most biomarkers individually have poor sensitivity or specificity, or other clinical value. It can be resolved by studying various biomarkers simultaneously, which will help in better prognosis and increasing sensitivity for chemotherapeutic agents. This review is focusing on growth factor receptors, apoptosis markers, signaling cascades, and their correlation with other associated biomarkers in breast cancers. As our knowledge regarding molecular biomarkers for breast cancer increases, prognostic indices will be developed that combine the predictive power of individual molecular biomarkers with specific clinical and pathologic factors. Rigorous comparison of these existing as well as emerging markers with current treatment selection is likely to see an escalation in an era of personalized medicines to ensure the breast cancer patients receive optimal treatment. This will also solve the treatment modalities and complications related to chemotherapeutic regimens.