The validity of the labelling index in tumour studies

Colorectal cell kinetics

The assessment of cell proliferation in colorectal tissue may provide information with both prognostic and therapeutic implications. A variety of methods are available, including flow cytometric estimations of S phase fraction, immunohistochemical and autoradiographic visualization of exogenous and endogenous proliferation proteins, and morphological and stathmokinetic techniques. There is some correlation between Dukes stage and proliferation state features, and there is increased proliferative activity throughout the adenoma-carcinoma sequence. Data on cell proliferation rates are difficult to obtain. When correctly applied, the metaphase arrest technique remains the 'gold standard' of measuring proliferation, but its usefulness in clinical practice is limited. Recent studies have employed dual measurement flow cytometry and double labelling techniques to produce rate data.

In vitro BrdUrd incorporation of colorectal tumour tissue

This study describes a novel in vitro method for the incorporation of the thymidine analogue, bromodeoxyuridine (BrdUrd), in fresh colorectal tumour tissue. Disaggregation by pronase, collagenase and DNAse resulted in high cell yields of viable single cell suspensions, representative of the original tumour, which could be infiltrated with BrdUrd. A modified ELISA identified optimal incubation times and BrdUrd concentrations. This technique has been used in preliminary studies to investigate two important areas intrinsic in the analysis of BrdUrd colorectal cell proliferation data: 1) to determine the effects of the individual constituents of the cell culture media, in particular glutamine, on BrdUrd incorporation in suspensions of colorectal cells and 2) to examine the denaturation step. This method will have wide applicability in investigations of cell proliferation status in both normal and diseased tissue.

Ki-67-determined growth fraction versus standard staging and grading parameters in colorectal carcinoma. A multivariate analysis

BACKGROUND

The antibody Ki-67 binds to nuclei in all cell cycle phases except GO and can be used to measure growth fraction. Because proliferative activity has been linked to prognosis in neoplasia, the authors analyzed 100 cases of colorectal carcinoma, each with 3 or more years of follow-up, using Ki-67 immunostaining.

METHODS

The Ki-67-positive nuclear area and total nuclear area of carcinoma cells in 20 microscopic fields were measured by computed morphometry. A Ki-67 score (percent positive nuclear area x 100) was calculated. The following characteristics also were recorded for each case: patient age and sex, tumor site and size, modified Dukes' stage, spread beyond bowel wall, lymph node status, tumor grade, histologic type, extramural venous spread, tumor growth pattern, fibrosis, lymphocytic infiltration, and mitotic rate.

RESULTS

Ki-67 scores ranged from 1 to 90 (mean, 34.6). Ki-67 scores were higher in Stage A disease (versus Stage B, C, and D disease) but were not associated with survival. Survival curves differed by stage, lymph node metastases, infiltrative growth pattern, lymphocytic infiltration, fibrosis, extramural venous spread, and tumor grade in a univariate analysis. The infiltrative growth pattern (P = 0.04) and lymphocytic infiltration (P = 0.003) were features associated independently with survival after adjusting for modified Dukes' stage. Furthermore, the lack of a significant lymphocytic infiltrate was associated with a death rate 3.4 times greater than that occurring in patients with Stage B disease with a significant infiltrate.

CONCLUSIONS

The authors conclude that proliferative activity in colorectal carcinoma as measured by Ki-67 immunostaining was not associated with prognosis.

Cell cycle parameters and DNA ploidy in colorectal carcinomas

Seven patients with colorectal adenocarcinoma and one with squamous cell carcinoma of anorectal region were infused preoperatively with iododeoxyuridine (IUdR) and bromodeoxyuridine (BrdU) in sequence (100 mg/m2 x 1 hr each with 1-hr interval in between) to label S-phase cells. The tumor biopsy specimens were embedded in glycol-methacrylate and 2-microns thick sections were treated with two monoclonal antibodies which permitted the identification of cells which incorporated IUdR only, BrdU only, both IUdR and BrdU, or neither IUdR or BrdU. The labeling index of tumors varied from 17.3 to 35.6% (mean = 25.78 +/- 6.162), duration of S-phase ranged from 14.0 to 23.9 hr (mean = 18.73 +/- 3.712), and total cell cycle time ranged from 39.4 to 123.4 hr (mean = 76.78 +/- 24.165). The architecture of the tumor was well preserved and a variable number of DNA synthesizing mononuclear cells were identified within and around the tumor. Image analysis of Feulgen-stained smears of the tumors was done to measure the DNA content of seven tumor samples. Each tumor was found to be hyperdiploid with multiple modal values. The studies described here demonstrate the feasibility of performing cell cycle kinetic measurements on gastrointestinal tumors which have been labeled in vivo. The ability to perform these measurements on tumor biopsies allows the avoidance of artifacts introduced when solid tumors are disaggregated in vitro for study.

Assessment of proliferative activity in carcinomas of the human alimentary tract by Ki-67 immunostaining

The monoclonal antibody (MAb) Ki-67, which is directed against a proliferation-associated nuclear antigen, was used to measure tumor proliferation in 165 carcinomas of the esophagus, stomach, colon and rectum with an indirect immunoperoxidase technique. The percentage of Ki-67-positive tumor cells (Ki-67 index) was evaluated with the point-counting method. The Ki-67 index in gastric cancers (mean, 24.8%; standard deviation, 11.1%) was significantly lower than in tumors of the esophagus (35.7 +/- 12.6%), colon (37.6 +/- 15.2%), and rectum (34.3 +/- 16.4%). A wide range of the Ki-67 index (5.9-75.3%) could be observed within the various tumor types. In recurrent colorectal carcinomas, the Ki-67 index significantly increased to 51.9%. The Ki-67 index was independent of pathologic (e.g., TNM-stage, grading, tumor volume, tumor site) and clinical variables (age and gender of the patients). A marked heterogeneity of Ki-67 expression within different tumor stages was noted. Statistically significant regional variations in tumor proliferation existed between different areas within the same tumor.

Assessment of cell proliferation in colorectal carcinomas using the monoclonal antibody Ki-67. Correlation with pathohistologic criteria and influence of irradiation

Cell proliferation was measured by a three-step immunoperoxidase technique on cryostat sections of 61 resected colorectal adenocarcinomas using the monoclonal antibody Ki-67 that is directed against a proliferation-associated nuclear antigen. The percentage of Ki-67-positive cells was quantified with the point-counting method. The frequency distribution of the percentage of Ki-67-positive tumor cells in 52 unirradiated carcinomas was gaussian with a mean of 38.7% (range, 7.7% to 75.3%). Analysis of the unirradiated tumors showed no relation between Ki-67 staining and various clinicopathologic features including age, sex, tumor volume, tumor differentiation, location, and tumor stage. Although some tumors demonstrated intratumor heterogeneity of immunoreactivity, there was no significant difference in proliferative activity among peripheral, intermediate, and central tumor areas. Whereas the Ki-67 index increased to 47.1% in recurrent carcinomas, it decreased significantly to 24.7% in rectal carcinomas given radiotherapy before surgery. Therefore, Ki-67 immunostaining might be used as a tool to select and monitor patients with colorectal cancers who might benefit from radiotherapy. The marked differences of Ki-67 expression among different tumors may relate to heterogeneity in growth kinetics and may therefore carry prognostic implications.

The growth and cell kinetics of a secondary tumor after radiation or surgical treatment of the primary tumor

Early transplants of a spontaneous mouse fibrosarcoma (FSa II) were used to investigate whether radiation or surgical treatment of a tumor in the leg altered the growth or cell kinetics of a second tumor in the axilla. The volume doubling times and in vivo Bromodeoxyuridine labeling indices of the axillary tumors were the same in the control group and in the groups which received 70 Gy to the leg tumor or normal leg. After surgical removal of the leg tumor, there was small reduction in the time to reach 1500 mm3 (4.0 vs 4.6 days) and an increase in Bromo-deoxyuridine labeling index at Day 3 (18% to 24%) in the axillary tumors. In all groups, there was a fall in labeling index with time reflecting increasing tumor size.

Cell proliferation kinetics in human solid tumors: relation to probability of metastatic dissemination and long-term survival

A large number of studies have investigated the relationship between the long-term survival and the percentage of tumor cells in S phase assessed by autoradiography after tritiated thymidine labelling, image cytometry, flow cytometry or labelling with an halogenated analog of thymidine, in various types of human solid tumors. The survey of the results clearly shows that the S-phase fraction (SPF) is of high prognostic significance in several types of cancers, in particular in breast cancers, non-Hodgkin lymphomas, ovarian cancers, neuroblastoma, bladder cancers and lung cancers. SPF was found of high independent significance in 10 of the 11 studies in which multivariate analyses of prognostic factors had been carried out. Proliferation appears generally to be of higher prognostic significance than ploidy. In view of the wide differences in the biological characteristics of the tumors studied, it is likely that the association between a high proliferation rate and the degree of tumor aggressiveness is a general feature of human solid tumors. However, high proliferative rate of tumor cells is probably not the cause of tumor biological aggressiveness but a variable associated with it. The extent to which cells escape from the regulatory systems which control their proliferation appears to be a good index of tumor progression.

Stimulating effect of pentagastrin on cancer cell proliferation kinetics in chemically induced colon cancer in rats

Pharmacological doses of pentagastrin or gastrin are known to stimulate cell proliferation in normal colonic epithelium but the growth-promoting effect of gastrin on colon carcinoma is still controversial. In this study morphological parameters were measured to study the effect of pentagastrin (240 micrograms/kg) on the cell proliferation kinetics in experimental tumours. Colon cancer was produced in rats by weekly injections (20 mg/kg b.wt.) of 1.2-dimethylhydrazine for 24 weeks. Tritiated thymidine was given after administration of pentagastrin or the control solution to the animals. 75% of the animals from the pentagastrin group and 66% of the controls had at least one colon cancer. Autoradiographs of the colonic tumors were performed and the percentage of labeled cells in the cancer cell population was determined after counting 4000 to 16,000 cancer cells per tumor. The labeling index for cancer cells in the pentagastrin-treated group (21.49 +/- 1.76%) was higher (P less than 0.01) than in the control group (14.76 +/- 0.66%). In a second study vincristine sulphate (1 mg/kg) was given to the animals 20 h after administering pentagastrin or the control solution. The percentage of arrested metaphases in the tumours was determined after counting 10,000 to 24,000 cancer cells per histological section. Pentagastrin increased (P less than 0.01) the mean metaphase index by 108% (4.9 +/- 0.44% vs 2.35 +/- 0.32%). These data indicate that cell cycle manipulation of colon cancer is possible with hormonal peptides.

The monoclonal antibody Ki-67 as a marker for proliferating cells in stereotactic biopsies of brain tumours

The monoclonal antibody Ki-67 has been tested as a marker of proliferating cells in 52 stereotactic brain tumour biopsies. The antibody reacts with a nuclear protein expressed in G1,S, G2n and M-phases of the cell cycle. Using the immunoperoxidase technique on squash preparations the percentage of Ki-67 positive cells was determined as a fraction of the total number of tumour cells present. This Ki-67 index was in close correlation with the histological grade. Highest values were found in a pineal germinoma (46.3%) and in 3 primary cerebral non-Hodgkin lymphomas (mean 39.5%). Among the gliomas, the highest fraction of proliferating cells was seen in 2 anaplastic paediatric brain stem gliomas (mean 17.4%) and in an anaplastic ependymoma (12.5%). Anaplastic astrocytomas and glioblastomas varied considerably with mean values of 9.5% and 8%, respectively. To some extent this variability may reflect tumour heterogeneity which is more likely to manifest in small stereotactic samples than in large tissue specimens obtained during open surgery. Pilocytic astrocytomas, mixed gliomas and fibrillary astrocytomas had moderate to low percentages. Ki-67 staining of squash preparations can easily be performed on a routine basis and is, in our experience, superior to frozen sections. This method allows the determination of the growth fraction of an individual tumour and could become an important additional criterion for the decision among alternative and potentially harmful therapeutic regimens.

Evaluation of the mitotic index of human colonic mucosa; results of two different observers

The mitotic index (M.I.) of the colonic mucosa was evaluated in 67 biopsies and divided into 6 groups. The M.I. was evaluated by one author twice at magnification X 1000 and by the other author once at magnification X 1000 and once at X 400, in order to assess the degree of intra- and interobserver agreement and the most suitable magnification for the evaluation of the M.I. of human colonic mucosa. The results indicate that the mean M.I. of a group of biopsies was similar between the two authors and may therefore be proposed as a valuable estimate of the mitotic activity of a group of patients during scientific investigations, provided that it is evaluated at sufficiently high magnification (X 1000, to our experience). On the contrary, there was only partial agreement (though highly significant) on the M.I. of each individual biopsy between the two authors and between different counts of the same author as well, thus indicating that the M.I. cannot be proposed as an accurate estimate of the mitotic activity of individual patients.

The labelling index of human and mouse tumours assessed by bromodeoxyuridine staining in vitro and in vivo and flow cytometry

Bromodeoxyuridine (BrdUrd) incorporation and flow cytometry were used to measure human tumour kinetic parameters in vitro and in vivo. The technique was validated by comparison of labelling index estimates of mouse tumours in vivo and in vitro using BrdUrd and flow cytometry with tritiated thymidine (3HdThd) autoradiography. Similar labelling indices were obtained with both in vivo and in vitro incorporation into DNA of the two different precursors. Measurements of human tumour labelling indices were similar following in vitro incubation with either BrdUrd or 3HdThd. The use of BrdUrd allowed the visualization of a population of S-phase cells that did not appear to incorporate BrdUrd or 3HdThd. The human tumour labelling indices obtained with BrdUrd incorporation were similar to previously reported values using autoradiography studies. Preliminary studies demonstrated that significant human tumour labelling could be achieved with an intravenous injection of 500 mg BrdUrd.