Automated AI-based grading of neuroendocrine tumors using Ki-67 proliferation index: comparative evaluation and performance analysis

Early detection is critical for successfully diagnosing cancer, and timely analysis of diagnostic tests is increasingly important. In the context of neuroendocrine tumors, the Ki-67 proliferation index serves as a fundamental biomarker, aiding pathologists in grading and diagnosing these tumors based on histopathological images. The appropriate treatment plan for the patient is determined based on the tumor grade. An artificial intelligence-based method is proposed to aid pathologists in the automated calculation and grading of the Ki-67 proliferation index. The proposed system first performs preprocessing to enhance image quality. Then, segmentation process is performed using the U-Net architecture, which is a deep learning algorithm, to separate the nuclei from the background. The identified nuclei are then evaluated as Ki-67 positive or negative based on basic color space information and other features. The Ki-67 proliferation index is then calculated, and the neuroendocrine tumor is graded accordingly. The proposed system's performance was evaluated on a dataset obtained from the Department of Pathology at Meram Faculty of Medicine Hospital, Necmettin Erbakan University. The results of the pathologist and the proposed system were compared, and the proposed system was found to have an accuracy of 95% in tumor grading when compared to the pathologist's report.

Prognostic utility and characteristics of MIB-1 labeling index as a proliferative activity marker in childhood low-grade glioma: a retrospective observational study

PURPOSE

The prognostic utility of MIB-1 labeling index (LI) in pediatric low-grade glioma (PLGG) has not yet conclusively been described. We assess the correlation of MIB-1 LI and tumor growth velocity (TGV), aiming to contribute to the understanding of clinical implications and the predictive value of MIB-1 LI as an indicator of proliferative activity and progression-free survival (PFS) in PLGG.

METHODS

MIB-1 LI of a cohort of 172 nonependymal PLGGs were comprehensively characterized. Correlation to TGV, assessed by sequential MRI-based three-dimensional volumetry, and PFS was analyzed.

RESULTS

Mean MIB-1 LI accounted for 2.7% (range: < 1-10) and showed a significant decrease to 1.5% at secondary surgery (p = .0013). A significant difference of MIB-1 LI in different histopathological types and a correlation to tumor volume at diagnosis could be shown. Linear regression analysis showed a correlation between MIB-1 LI and preoperative TGV (R2 = .55, p < .0001), while correlation to TGV remarkably decreased after incomplete resection (R2 = .08, p = .013). Log-rank test showed no association of MIB-1 LI and 5-year PFS after incomplete (MIB-1 LI > 1 vs ≤ 1%: 48 vs 46%, p = .73) and gross-total resection (MIB-1 LI > 1 vs ≤ 1%: 89 vs 95%, p = .75).

CONCLUSION

These data confirm a correlation of MIB-1 LI and radiologically detectable TGV in PLGG for the first time. Compared with preoperative TGV, a crucially decreasing correlation of MIB-1 LI and TGV after surgery may result in limited prognostic capability of MIB-1 LI in PLGG.

Immunohistochemical double nuclear staining for cell-specific automated quantification of the proliferation index - A promising diagnostic aid for melanocytic lesions

AIMS

Pathologists often use immunohistochemical staining of the proliferation marker Ki67 in their diagnostic assessment of melanocytic lesions. However, the interpretation of Ki67 can be challenging. We propose a new workflow to improve the diagnostic utility of the Ki67-index. In this workflow, Ki67 is combined with the melanocytic tumour-cell marker SOX10 in a Ki67/SOX10 double nuclear stain. The Ki67-index is then quantified automatically using digital image analysis (DIA). The aim of this study was to optimise and test three different multiplexing methods for Ki67/SOX10 double nuclear staining.

METHODS

Multiplex immunofluorescence (mIF), multiplex immunohistochemistry (mIHC), and multiplexed immunohistochemical consecutive staining on single slide (MICSSS) were optimised for Ki67/SOX10 double nuclear staining. DIA applications were designed for automated quantification of the Ki67-index. The methods were tested on a pilot case-control cohort of benign and malignant melanocytic lesions (n = 23).

RESULTS

Using the Ki67/SOX10 double nuclear stain, malignant melanocytic lesions could be completely distinguished from benign lesions by the Ki67-index. The Ki67-index cut-offs were 1.8% (mIF) and 1.5% (mIHC and MICSSS). The AUC of the automatically quantified Ki67-index based on double nuclear staining was 1.0 (95% CI: 1.0;1.0), whereas the AUC of conventional Ki67 single-stains was 0.87 (95% CI: 0.71;1.00).

CONCLUSIONS

The novel Ki67/SOX10 double nuclear stain highly improved the diagnostic precision of Ki67 interpretation. Both mIHC and mIF were useful methods for Ki67/SOX10 double nuclear staining, whereas the MICSSS method had challenges in the current setting. The Ki67/SOX10 double nuclear stain shows potential as a valuable diagnostic aid for melanocytic lesions.

Apparent diffusion coefficient values effectively predict cell proliferation and determine oligodendroglioma grade

This study aims to evaluate the value of conventional magnetic resonance imaging (MRI) features and apparent diffusion coefficient (ADC) values in differentiating oligodendroglioma of various grades and explore the correlation between ADC and Ki-67. The preoperative MRI data of 99 patients with World Health Organization (WHO) grades 2 (n = 42) and 3 (n = 57) oligodendroglioma confirmed by surgery and pathology were retrospectively analyzed. Conventional MRI features, ADCmean, ADCmin, and normalized ADC (nADC) were compared between the two groups. A receiver operating characteristic curve was used to evaluate each parameter's diagnostic efficacy in differentiating the two tumor types. Each tumor's Ki-67 proliferation index was also measured to explore its relationship with the ADC value. Compared with WHO2 grade tumors, WHO3 grade tumors had a larger maximum diameter and more significant cystic degeneration/necrosis, edema, and moderate/severe enhancement (all P < 0.05). The ADCmin, ADCmean, and nADC values of the WHO3 and WHO2 grade tumors were significantly different, and the ADCmin value most accurately distinguished the two tumor types, yielding an area under the curve value of 0.980. When 0.96 × 10^-3 mm²/s was used as the differential diagnosis threshold, the sensitivity, specificity, and accuracy of the two groups were 100%, 93.00%, and 96.96%, respectively. The ADCmin (r = -0.596), ADCmean (r =  - 0.590), nADC (r =  - 0.577), and Ki-67 proliferation index values had significantly negative correlations (all P < 0.05). Conventional MRI features and ADC values are beneficial in the noninvasive prediction of the WHO grade and tumor proliferation rate of oligodendroglioma.

Expression of substance P, neurokinin 1 receptor, Ki-67 and pyruvate kinase M2 in hormone receptor negative breast cancer and evaluation of impact on overall survival

BACKGROUND

Chronic inflammation is a hallmark of cancer, and it can be stimulated by many factors. Substance P (SP), through binding to neurokinin 1 receptor (NK1R), and pyruvate kinase M2 (PKM2) play critical roles in cancer development and progression via modulating the tumor microenvironment. This study aimed to investigate the prognostic significance of SP and PKM2 in combination with NK1R and Ki-67 in hormone receptor negative (HR-ve) breast cancer.

METHODS

Immunohistochemical expression levels of SP, NK1R, PKM2, and Ki-67 were measured in 144 paraffin-embedded breast cancer tissues (77 h -ve and 67 h + ve). SP, NK1R, and PKM2 were scored semiquantitatively, while Ki-67 was obtained by the percentage of total number of tumor cells with nuclear staining. The optimal cutoff value for SP, NK1R, PKM2, and Ki-67 were assessed by Cutoff Finder.

RESULTS

High SP expression in HR -ve breast cancer was associated with TNM stage (p = 0.020), pT stage (p = 0.035), pN stage (p = 0.002), axillary lymph node metastasis (p = 0.003), and NK1R expression level (p = 0.010). In HR + ve breast cancer, SP expression was associated with HER2 status (p = 0.001) and PKM2 expression level (p = 0.012). Regarding PKM2 expression level, it significantly associated with HER2 status (p = 0.001) and history of DCIS (p = 0.046) in HR-ve tumors, and with HER2 status (p < 0.001) and SP expression level (p = 0.012) in HR + ve tumors. Survival analysis revealed that high SP level negatively impacted overall survival in HR-ve tumors that had low NK1R level (p = 0.021). Moreover, high SP negatively impacted overall survival in HR-ve tumors that had low Ki-67 level (p = 0.005). High PKM2 negatively impacted overall survival in HR-ve cases with low SP (p = 0.047).

CONCLUSION

Combined expression levels of SP with NK1R or Ki-67, and PKM2 with SP could be used to predict survival in breast cancer patients with HR-ve tumors. Our findings suggest a role of SP/NK1R pathway and PKM2 in HR-ve breast cancer pathogenesis which should be further investigated to unveil the underlying molecular mechanisms.

Metallothionein expression in feline injection site fibrosarcomas

BACKGROUND

Feline injection site fibrosarcoma is an aggressive and infiltrative tumour arising in the background of chronic inflammation. The aim of this study was to evaluate the expression of metallothionein (I-II) in feline injection site fibrosarcomas and to assess its possible relationships with Ki67 index, inflammation score and tumour grade. The study included 40 feline fibrosarcomas, located in the common injection sites (i.e., interscapular area, thigh, flank), constituting archival diagnostic specimens collected between 2019-2020. Tumours were graded histologically according to the newly proposed soft-tissue sarcoma grading system in cats. Immunohistochemistry was performed to evaluate the expression of Ki67 and metallothionein in tumour cells.

RESULTS

The cytoplasmic and sometimes nuclear expression of metallothionein was observed in all tumours grade I, 66.67% of tumours grade II and 55% of tumours grade III. The expression of metallothionein was negatively correlated with tumour grade and inflammation score, while the Ki67 index was positively correlated with tumour grade, inflammation score and necrosis score.

CONCLUSION

The downregulation of MT expression in feline injection site fibrosarcomas seems to be connected with an increase in the inflammatory infiltration, hence tumour progression. This is the first study describing metallothionein expression in feline injection site fibrosarcomas.

Ki67 as Proliferative Marker in Patients with Early Breast Cancer and Its Association with Clinicopathological Factors

INTRODUCTION

Ki67 as a proliferative marker has prognostic and therapeutic relevance in early breast cancer (EBC). However, standard cutoffs for distinguishing low and high Ki67 do not exist.

MATERIAL AND METHODS

Data from all patients treated at the University Hospital Ulm for EBC between January 2013 and December 2015 with documented results for internal Ki67 assessment of the primary (n = 917) tumor were retrospectively analyzed evaluating the associations between Ki67 and other clinicopathological factors.

RESULTS

595 (64.9%) patients had a Ki67 <20% and 322 (35.1%) a Ki67 ≥20%. The median Ki67 was 10% (range 1-90%). Median Ki67 values according to the hormone receptor (HR)/ human epidermal growth factor receptor 2 (HER2) subtypes were 10% for HR-positive/HER2 negative (HR+/HER2-) disease (n = 717), 20% for HR+/HER2+ (n = 76), 30% for HR-/HER2+ (n = 45), and 60% for HR-/HER2- (n = 75). 75.2% or 89.3% of all patients with HER2-positive or triple-negative disease had a Ki67 ≥20%, respectively. Using a multivariable logistic regression with Ki67 (<20% vs. ≥20%) as binary dependent variable, younger age, positive nodal status, higher grading, histological nonspecific type carcinoma, negative HR status, and positive HER2 status were shown to be significantly associated with a higher proliferative index (Ki67 ≥20%).

CONCLUSION

This analysis described Ki67 in different subtypes in EBC and its association with clinicopathological factors. According to more aggressive tumor biology, the respective subgroups also showed higher median Ki67 levels. However, definition of low and high proliferation index itself is difficult. It is essential to interpret Ki67 indices carefully with regard to the own institutional values and other clinicopathological factors.

A procedure for in vitro evaluation of the immunosuppressive effect of mouse mesenchymal stem cells on activated T cell proliferation

Background

Mesenchymal stem/stromal cells (MSC) represent adult cells with multipotent capacity. Besides their capacity to differentiate into multiple lineages in vitro and in vivo, increasing evidence points towards the immunomodulatory capacity of these cells, as an important feature for their therapeutic power. Although not included in the minimal criteria established by the International Society for Cellular Therapy as a defining MSC attribute, demonstration of the immunomodulatory capacity of MSC can be useful for the characterization of these cells before being considered MSC.

Methods

Here we present a simple and reliable protocol by which the immunosuppressive effect of mouse bone marrow-derived MSC can be evaluated in vitro. It is based on the measuring of the proliferation of activated T cells cultured in direct contact with irradiated MSC.

Results

Our results showed that mouse MSC have a dose-dependent inhibitory effect on activated T cell proliferation, which can be quantified as a percentage of maximum proliferation. Our data shows that batch-to-batch variability can be determined within one or multiple experiments, by extracting the area under curve of T cell proliferation plotted against the absolute number of MSC in co-culture.

Conclusions

The validation of the immunosupressive capacity of MSC could be added to the characterization of the cells before being used in various MSC-based approaches to treat immunological diseases. Our results showed that mouse MSC have a dose-dependent inhibitory effect on activated T cell proliferation. The immunosuppressive properties of MSC vary between batches, but not between different passages of the same batch.

A Clinicopathologic Study on the Role of Estrogen, Progesterone, and Their Classical and Nonclassical Receptors in Cutaneous Neurofibromas of Individuals With Neurofibromatosis 1

OBJECTIVES

To evaluate the expression of progesterone receptor (PR), estrogen receptor (ER), and G protein-coupled estrogen receptor 1 (GPER-1) in cutaneous neurofibromas (cNFs) and their correlation with demographic, clinical, and laboratory data of individuals with neurofibromatosis 1 (NF1). The association of PROGINS polymorphism and PR expression in cNFs, as well as the serum steroidal hormones and the number of cNFs, was investigated.

METHODS

The sample comprised 80 large and 80 small cNFs from 80 individuals with NF1. PR, ER, GPER-1, and Ki-67 expression were investigated by immunohistochemistry in tissue micro- and macroarrays and quantified using a digital computer-assisted method. The number of cNFs, the levels of serum 17β estradiol and progesterone, and the PROGINS polymorphism were identified.

RESULTS

Twelve (8.5%) small cNFs were weakly positive for ER, 131 (92.3%) cNFs expressed PR, and all (100%) cNFs expressed GPER-1. Large cNFs showed a higher expression of PR (P < .0001) and GPER-1 (P = .019) and had a higher intensity of staining for these receptors (P < .0001). The cell proliferation index was positively correlated with PR (P = .001). Persons with more cNFs had higher serum levels of progesterone (P = .001).

CONCLUSIONS

These findings emphasize the role of estrogen and progesterone in cNF development and suggest that these hormones may act on cNF cells via a noncanonical pathway through GPER-1.

Doxorubicin treatment modulates chemoresistance and affects the cell cycle in two canine mammary tumour cell lines

BACKGROUND

Doxorubicin (DOX) is widely used in both human and veterinary oncology although the onset of multidrug resistance (MDR) in neoplastic cells often leads to chemotherapy failure. Better understanding of the cellular mechanisms that circumvent chemotherapy efficacy is paramount. The aim of this study was to investigate the response of two canine mammary tumour cell lines, CIPp from a primary tumour and CIPm, from its lymph node metastasis, to exposure to EC50(20h) DOX at 12, 24 and 48 h of treatment. We assessed the uptake and subcellular distribution of DOX, the expression and function of P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP), two important MDR mediators. To better understand this phenomenon the effects of DOX on the cell cycle and Ki67 cell proliferation index and the expression of p53 and telomerase reverse transcriptase (TERT) were also evaluated by immunocytochemistry (ICC).

RESULTS

Both cell lines were able to uptake DOX within the nucleus at 3 h treatment while at 48 h DOX was absent from the intracellular compartment (assessed by fluorescence microscope) in all the surviving cells. CIPm, originated from the metastatic tumour, were more efficient in extruding P-gp substrates. By ICC and qRT-PCR an overall increase in both P-gp and BCRP were observed at 48 h of EC50(20h) DOX treatment in both cell lines and were associated with a striking increase in the percentage of p53 and TERT expressing cells by ICC. The cell proliferation fraction was decreased at 48 h in both cell lines and cell cycle analysis showed a DOX-induced arrest in the S phase for CIPp, while CIPm had an increase in cellular death without arrest. Both cells lines were therefore composed by a fraction of cells sensible to DOX that underwent apoptosis/necrosis.

CONCLUSIONS

DOX administration results in interlinked modifications in the cellular population including a substantial effect on the cell cycle, in particular arrest in the S phase for CIPp and the selection of a subpopulation of neoplastic cells bearing MDR phenotype characterized by P-gp and BCRP expression, TERT activation, p53 accumulation and decrease in the proliferating fraction. Important information is given for understanding the dynamic and mechanisms of the onset of drug resistance in a neoplastic cell population.

Clinical - pathological significance of leptin receptor (LEPR) expression in squamous cell carcinoma of the skin

Adipokine leptin functions through its transmembrane receptors (LEPR). In many malignant tumors it stimulates the growth, migration and invasion of malignant cells. The aim of our work is to examine the effect of LEPR expression on the clinical-morphological properties of squamous cell carcinoma of the skin (cSCC). The biopsy material obtained by excision of squamous cell skin cancer was used. The test group consisted of excision biopsies of squamous cell carcinoma of the skin (n = 62), and the control group (n = 62) consisted of excision biopsies of non-tumor tissue of the skin (from the tumor environment) from an operative preparation delivered to the Pathohistology Department. After routine processing and paraffin molding, histochemical Hematoxylin-Eosin and immunohistochemical ABC method with anti LEPR and Ki67 antibodies were applied at 4 μm sections. The statistical software package SPSS for Windows (26.0) was used to analyze obtained results. Intracytoplasmic and intramembranous LEPR expression was found in 100 % of examined cSCCs. LEPR expression was statistically significantly associated with proliferation index and histologic grade of tumors. Pronounced LEPR expression was associated with a high proliferation index in 66.7 % of cases and with poorly differentiated cSCC in 94.4 %. Multivariate regression analysis showed that cSCCs with pronounced LEPR expression were seven times more often poorly differentiated than tumors with moderate or LEPR expression in trace. Our results indicate that LEPR expression is a predictor of the malignant potential of cSCC, so that based on LEPR expression, it is possible to identify an aggressive cSCC phenotype, which provides the possibility of individualizing anti-tumor treatment using LEPR antagonists.

WHO grade, proliferation index, and progesterone receptor expression are different according to the location of meningioma

BACKGROUND

Meningiomas may show a different WHO grade and variable biological and clinical behaviors. The aim of the present study is to assess whether WHO grade, proliferation index, progesterone receptor (PR) expression, histological subtype, neuroradiological features, and the recurrence rate differ depending on the tumor location.

METHODS

Three hundred meningiomas operated on from 2006 to 2016 were reviewed. The WHO grade (2007 classification), Ki67-MIB1, progesterone receptor expression, and histological subtype were reexamined and correlated to the meningioma location, classified as medial skull base, lateral skull base, non-skull base, and spinal.

RESULTS

Non-skull base and lateral skull base meningiomas showed significantly higher rates of atypical WHO II forms (34% and 25.5% respectively) than medial skull base (12.5%) and spinal ones (7%) (p = 0.0003) and also higher rates of tumors with Ki67-Li > 4% (42% and 38% vs 22% and 14%) (p = 0.0031). The rate of meningiomas with PR expression ≤ 50% was significantly lower in medial skull base (25%) than in non-skull base (48%) (p = 0.009). Meningothelial and transitional meningiomas were more frequent at the skull base (68.5% and 54.5%, respectively), the fibroblastic subtype at the non-skull base (48.5%), and the psammomatous at the spinal canal (50%) (p < 0.00001). Medial skull base and spinal meningiomas showed significantly lower size (p < 0.00001), lower rates of cases with lost arachnoid interface (p = 0.0022), and significantly lower recurrence rates (p = 0.0035) than lateral skull base and non-skull base meningiomas.

CONCLUSION

Medial skull base meningiomas show lower size, lower rate of atypical forms, lower Ki67-Li values, and significantly higher PR expression than those at the lateral skull base and non-skull base. This corresponds to lesser aggressiveness and lower recurrence rates.

High minichromosome maintenance protein 7 proliferation indices: a powerful predictor of progression in pancreatic neuroendocrine neoplasms without distant metastasis at the time of surgery

Pancreatic neuroendocrine neoplasms (PanNENs) have an unpredictable clinical course that varies from indolent to highly malignant. No immunohistochemical markers are available for reliable prediction of the biological behavior of early stage PanNENs. Minichromosome maintenance protein 7 (MCM7) is a putative powerful marker of cell proliferation. Whether the expression of MCM7 is related to the risk of PanNENs progression remains unclear. We assessed the clinical behavior of 156 PanNENs with respect to stage, grade, Ki-67 index, MCM7 index, and other pathologic features. A high MCM7 index was significantly associated with larger tumor size (P < .001), nonfunctioning tumor (P < .001), increased grade (P < .0001), and later TNM stage (P < .001). In multivariate analysis, G2/G3 (hazard ratio [HR], 2.21; 95% confidence interval [CI], 1.35-3.62; P < .001), stage III/IV (HR, 2.11; 95% CI, 1.31-3.41; P < .001), and MCM7 labeling index >5% (HR, 3.81; 95% CI, 1.30-11.17; P = .02) were independent negative prognostic factors related to the risk of tumor progression in stage I-IV disease. MCM7 labeling index >5% was associated with an increased risk of progression in stages I-V, I-III, and I-II. Our study confirms that MCM7 is a valuable marker for assessing the progression of PanNENs, especially in patients with early stage disease and without distant metastasis.

Ki-67 and presence of liver metastases identify different progression-risk classes in pancreatic neuroendocrine neoplasms (pNEN) undergoing resection

In pancreatic neuroendocrine neoplasms (pNEN), size ≤2 cm and Ki-67 < 3% suggest indolent behavior, but no factor alone predicts prognosis. We investigated factors predictive of tumor progression in 80 pNENs surgically resected in a single Institution from 1995 to 2015. At multivariable analysis the only two independent variables related to PFS were Ki-67 (HR 2.97; 95%CI 1.26-7.02) and presence of synchronous liver metastases (HR 3.60; 95%CI 1.70-7.61). Using Ki-67 < 3% and M0 as reference, the HR for tumor progression was 3.21 (95%CI 1.18-8.74) for M0 patients with Ki-67 3-20%, 5.06 (2.29-11.2) for M1 patients with Ki-67 ≤ 20% and 24.3 (6.64-89.2) for those with Ki-67 > 20%. Tumor size (≤2 vs. >2 cm) was not a predictive factor at any analysis. Intra-class correlation of Ki-67 values on pre-surgical biopsies vs. surgical specimens was 0.99 and Ki-67 classes were correctly identified in 97% of biopsies. Ki-67 and presence of liver metastases are the major prognostic factors in pNEN and identify different progression risks regardless of tumor size. Pre-surgical pNEN biopsy for Ki-67 assessment should be included in the evaluation of patients with 1-2 cm tumors to help in the decision on whether to perform surgical resection.

Normal microscopic anatomy of equine body and limb skin: A morphological and immunohistochemical study

INTRODUCTION

Information on microscopic anatomy of equine skin is sparse. In horses, limb wounds often become chronic and/or non-healing whereas body wounds heal normally. These dissimilarities in healing patterns might be a product of different phenotypic characteristics of body and limb skin. The objective of this study was to investigate microscopic anatomy, epidermal thickness, keratinocyte proliferation and differentiation as well as the presence of mast cells in normal equine skin of body and limb.

MATERIALS AND METHODS

The study involved body and limb skin biopsies from six horses. Histological characteristics of the epidermis were assessed and epithelial thickness measured. Immunohistochemistry was performed to investigate epidermal differentiation patterns of cytokeratin (CK) 10, CK14, CK16, loricrin, and peroxisome proliferator-activated receptor alpha (PPAR-α), epidermal proliferation (Ki-67 immunostaining), and mast cells distribution in the skin.

RESULTS

The epidermis was significantly thicker in the limb skin compared to body skin (p<0.01). Epidermal proliferation and CK distribution did not show differences in the two anatomical areas. Loricrin presence was focally found in the spinous layer in four out of six limb skin samples but not in body skin samples. Tryptase positive mast cells were detected in the dermis and their density (cell/mm²) was not different between body and limb.

DISCUSSION AND CONCLUSION

Here we report for the first time about the normal distribution of CK10, CK14, CK16, PPAR-α, and loricrin in equine limb and body skin as well as about epidermal proliferation rate and mast cell count. It will be relevant to investigate the distribution of the investigated epithelial differentiation markers and the role of mast cells during equine wound healing and/or other skin diseases.

Diagnosis and Pathological Analysis of Patient Cancers by Detection of Proliferating Cells in Gelfoam® Histoculture

Patient tumors grew in Gelfoam^® histoculture with maintenance of tissue architecture, tumor-stromal interaction, and differentiated functions. In this chapter, we review the use of Gelfoam^® histoculture to demonstrate proliferation indices of major solid cancer types explanted directly from surgery. Cell proliferation was visualized by histological autoradiography within the cultured tissues after [³H]thymidine incorporation by the proliferating cells. Epilumination polarization microscopy enables high-resolution imaging of the autoradiography of each cell. The histological status of the cultured tissues can be assessed simultaneously with the proliferation status. Carcinomas were observed to have areas of high epithelial proliferation with quiescent stromal cells. Sarcomas have high proliferation of the cancer cells of mesenchymal organ. Normal tissues can also proliferate at high rates. Mean growth fraction index (GFI) was highest for patient tumors with the pure subtype of small-cell lung cancer than other types of lung cancer.

Ki67 Proliferative Index in Carcinoid Tumors Involving Ovary

Primary ovarian carcinoid tumors are rare neoplasms that constitute less than 0.1% of all ovarian carcinomas. However, carcinoid tumors metastatic to ovaries are more common. Cell proliferative rate is an important factor in the determination of neuroendocrine tumor prognosis. Limited data are available as regards Ki67 proliferation index in predicting the physiological features of carcinoid tumors involving the ovary. Pathology files of Mayo Clinic Rochester (1995-2014) were searched, and clinical information was collected from medical records. All cases were stained with an antibody against Ki67, and digital analysis was performed with digital imaging analysis. A total of 36 cases (median age 64 years, range 33-83 years), including 9 primary (median age 68 years, range 33-73 years) and 27 metastatic carcinoid cases (median age 64 years, range 36-83 years), were investigated in the current study. Seven out of nine (77.8%) primary ovarian carcinoids are associated with mature teratoma. Twenty two metastatic carcinoids (81.5%) were from the GI tract, four (14.8%) from the pancreas, and one (3.7%) from the posterior thorax location. There was significant difference of Ki67 index between primary (median 2.3%, range, 0.6-8.4%) and metastatic carcinoid tumors (median 9.7%, range, 1.3-46.7%) (p = 0.002). The survival time is much shorter among patients with metastatic carcinoid tumor (median survival 5.8 years) comparing to primary ovarian carcinoid tumor (median 14.2 years) (p = 0.0005). A strong association between Ki67 index and patient survival time was identified (Hazard ratio for 1-percentage point increase 1.11, p = 0.001). Comparing to primary ovarian carcinoid tumor, metastatic carcinoid usually exhibits a higher Ki67 index and a worse outcome.

Cervical clear cell adenocarcinoma with an exceptionally low proliferation index: Report of a case

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A histologically low-grade cervical clear cell lesion was observed.

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Proliferating cells were seen only at the periphery of this lesion.

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Due to its low proliferation index, this may represent a precursor of clear cell carcinoma.

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Further definition of such lesions may allow for more minimal management.

18F-FDG Uptake in Well-Differentiated Neuroendocrine Tumors Correlates with Both Ki-67 and VHL Pathway Inactivation

BACKGROUND

18F-FDG-PET scan positivity correlates with poor prognosis in neuroendocrine neoplasms (NEN). Glucose transporter 1 (GLUT1) and carbonic anhydrase 9 (CA9) are markers of aggressiveness in tumors. Together with von Hippel-Lindau protein (pVHL), they are involved in tumor cell metabolism via the hypoxia-inducible factor signaling pathway. The aim of this study was to compare, in a series of well-differentiated neuroendocrine tumors (NET), the 18F-FDG uptake and expression of the proliferation markers Ki-67, GLUT1, CA9, and pVHL.

PATIENTS AND METHODS

This retrospective study included 27 patients with well-differentiated NET. 18F-FDG-PET images were evaluated by the maximum standardized uptake value (SUVmax). GLUT1, CA9, and pVHL were analyzed by immunohistochemistry.

RESULTS

The NET were of pancreatic (n = 19), midgut (n = 4), duodenal (n = 1), esophageal (n = 1), rectal (n = 1), and pulmonary (n = 1) origin. Eight, 11, and 8 tumors were grade 1, 2, and 3, respectively. The mean/median Ki-67 index was 15/10% (1-60). The mean/median SUVmax was 6.2/5.2 (1.4-18.7). SUVmax correlated with greater tumor size (p = 0.03), higher expression of Ki-67 (p = 0.04), and lower expression of pVHL (p = 0.008). In the group of 16 NET with a low proliferative index (Ki-67 index <10%), 5/6 (83%) of the tumors with a high SUVmax had decreased pVHL expression (p = 0.0013).

CONCLUSION

This study confirms that 18F-FDG-PET uptake correlates with both tumor size and proliferation in well-differentiated NET, and it highlights a subset of low-grade but 18F-FDG-PET-positive NET related to sporadic inactivation of the VHL pathway.

Automated characterization and counting of Ki-67 protein for breast cancer prognosis: A quantitative immunohistochemistry approach

Ki-67 protein expression plays an important role in predicting the proliferative status of tumour cells and deciding the future course of therapy in breast cancer. Immunohistochemical (IHC) determination of Ki-67 score or labelling index, by estimating the fraction of Ki67 positively stained tumour cells, is the most widely practiced method to assess tumour proliferation (Dowsett et al. 2011). Accurate manual counting of these cells (specifically nuclei) due to complex and dense distribution of cells, therefore, becomes critical and presents a major challenge to pathologists. In this paper, we suggest a hybrid clustering algorithm to quantify the proliferative index of breast cancer cells based on automated counting of Ki-67 nuclei. The proposed methodology initially pre-processes the IHC images of Ki-67 stained slides of breast cancer. The RGB images are converted to grey, L*a*b*, HSI, YCbCr, YIQ and XYZ colour space. All the stained cells are then characterized by two stage segmentation process. Fuzzy C-means quantifies all the stained cells as one cluster. The blue channel of the first stage output is given as input to k-means algorithm, which provides separate cluster for Ki-67 positive and negative cells. The count of positive and negative nuclei is used to calculate the F-measure for each colour space. A comparative study of our work with the expert opinion is studied to evaluate the error rate. The positive and negative nuclei detection results for all colour spaces are compared with the ground truth for validation and F-measure is calculated. The F-measure for L*a*b* colour space (0.8847) provides the best statistical result as compared to grey, HSI, YCbCr, YIQ and XYZ colour space. Further, a study is carried out to count nuclei manually and automatically from the proposed algorithm with an average error rate of 6.84% which is significant. The study provides an automated count of positive and negative nuclei using L*a*b*colour space and hybrid segmentation technique. Computerized evaluation of proliferation index can aid pathologist in assessing breast cancer severity. The proposed methodology, further, has the potential advantage of saving time and assisting in decision making over the present manual procedure and could evolve as an assistive pathological decision support system.

Correlation between the Ki-67 proliferation index and response to radiation therapy in small cell lung cancer

Background

In the breast cancer, the decision whether to administer adjuvant therapy is increasingly influenced by the Ki-67 proliferation index. In the present retrospective study, we investigated if this index could predict the therapeutic response to radiation therapy in small cell lung cancer (SCLC).

Methods

Data from 19 SCLC patients who received thoracic radiation therapy were included. Clinical staging was assessed using the TNM classification system (UICC, 2009; cstage IIA/IIB/IIIA/IIIB = 3/1/7/8). Ki-67 was detected using immunostained tumour sections and the Ki-67 proliferation index was determined using e-Count software. Radiation therapy was administered at total doses of 45–60 Gy. A total of 16 of the 19 patients received chemotherapy.

Results

Patients were divided into two groups, one with a Ki-67 proliferation index ≥79.77% (group 1, 8 cases) and the other with a Ki-67 proliferation index <79.77% (group 2, 11 cases). Following radiation therapy, a complete response (CR) was observed in six cases from group 1 (75.0%) and three cases from group 2 (27.3%). The Ki-67 proliferation index was significantly correlated with the CR rate (P = 0.05), which was significantly higher in group 1 than in group 2 (P = 0.04). The median survival time was 516 days for all patients, and the survival rates did not differ significantly between groups 1 and 2.

Conclusions

Our study is the first to evaluate the correlation between the Ki-67 proliferation index and SCLC tumour response to radiation therapy. Our findings suggest that a high Ki-67 proliferation index might represent a predictive factor for increased tumour radiosensitivity.

Proliferation Index Evaluation in Breast Cancer Using ImageJ and ImmunoRatio Applications

BACKGROUND

Proliferation index (PI) plays a critical role in distinguishing surrogate biological subtypes of breast cancer and, thus, determining the optimal therapeutic scheme. The commonly applied method of determining PI is visual semiquantitative scoring. The most precise way of PI evaluation is formal counting of nuclei on a digital picture using software equipped with a pointer function. The less time-consuming solution may be using image analysis software enabling automatic counting of nuclei, such as the free web application ImmunoRatio.

MATERIALS AND METHODS

We analyzed a group of 98 patients diagnosed with invasive breast carcinoma. A digital image of the hot-spot was taken from each case. Cell Counter plug-in of ImageJ platform was employed to precisely count brown- and blue-stained nuclei. The same images were analyzed using ImmunoRatio. The results were compared using Pearson's and Spearman's coefficients. The agreement was assessed with Cohen's kappa.

RESULTS

Pearson's correlation coefficient was 0.84 (p<0.05), Spearman's correlation coefficient was 0.83 (p<0.05). Moderate agreement was shown by Cohen's kappa calculation (K= 0.47; p<0.05).

CONCLUSION

As many as 26 cases were classified to different biological subtypes depending on the method of PI assessment. Thus, ImmunoRatio needs further improvement to be a reliable diagnostic tool.

Automated quantification of proliferation with automated hot-spot selection in phosphohistone H3/MART1 dual-stained stage I/II melanoma

Background

Staging of melanoma includes quantification of a proliferation index, i.e., presumed melanocytic mitoses of H&E stains are counted manually in hot spots. Yet, its reproducibility and prognostic impact increases by immunohistochemical dual staining for phosphohistone H3 (PHH3) and MART1, which also may enable fully automated quantification by image analysis. To ensure manageable workloads and repeatable measurements in modern pathology, the study aimed to present an automated quantification of proliferation with automated hot-spot selection in PHH3/MART1-stained melanomas.

Methods

Formalin-fixed, paraffin-embedded tissue from 153 consecutive stage I/II melanoma patients was immunohistochemically dual-stained for PHH3 and MART1. Whole slide images were captured, and the number of PHH3/MART1-positive cells was manually and automatically counted in the global tumor area and in a manually and automatically selected hot spot, i.e., a fixed 1-mm² square. Bland-Altman plots and hypothesis tests compared manual and automated procedures, and the Cox proportional hazards model established their prognostic impact.

Results

The mean difference between manual and automated global counts was 2.9 cells/mm² (P = 0.0071) and 0.23 cells per hot spot (P = 0.96) for automated counts in manually and automatically selected hot spots. In 77 % of cases, manual and automated hot spots overlapped. Fully manual hot-spot counts yielded the highest prognostic performance with an adjusted hazard ratio of 5.5 (95 % CI, 1.3–24, P = 0.024) as opposed to 1.3 (95 % CI, 0.61–2.9, P = 0.47) for automated counts with automated hot spots.

Conclusions

The automated index and automated hot-spot selection were highly correlated to their manual counterpart, but altogether their prognostic impact was noticeably reduced. Because correct recognition of only one PHH3/MART1-positive cell seems important, extremely high sensitivity and specificity of the algorithm is required for prognostic purposes. Thus, automated analysis may still aid and improve the pathologists’ detection of mitoses in melanoma and possibly other malignancies.

Pulmonary metastasis of a meningioma presenting as a solitary pulmonary nodule: 2 case reports

Distant metastases of meningioma are rare, especially in grade 1 meningiomas. In a recent literature review, only 115 cases were found. In almost all published cases, the meningioma was treated several years before the metastasis was diagnosed. The lungs are the most frequent site of metastasis. We describe two patients treated for meningioma (one case grade 1, the other grade 3) who were referred to the Respiratory Oncology Unit because of the incidental finding of a pulmonary nodule on routine chest radiography. Both had undergone several neurosurgical procedures but the last operation was more than 7 years before in both cases. Positron emission tomography scan was suggestive of a malignant lung tumour. The lesions were surgically removed. Pathology confirmed meningioma in both cases with the same WHO grade, immunohistochemical and genetic profiles as the original meningioma. Both patients recovered well from thoracic surgery. The patient with grade 3 meningioma died three years later from intracranial recurrence. When a patient previously treated for meningioma develops a nodular lung lesion, metastasis of the meningioma should be in the differential diagnosis list. Because of the occurrence of distant metastasis even in grade I meningiomas, we suggest that the grading system should take into account genetic changes in the meningioma. Chromosome 1p and 14q losses possibly explain the aggressive behaviour of the grade 1 meningioma.

Giant Cell Tumour of the Tendon Sheath: Analysis of 35 Cases and their Ki-67 Proliferation Indexes

INTRODUCTION

A giant cell Tumour of the tendon sheath (GCTTS) is a slow-growing benign Tumour originating from the synovial cells of the tendon sheath. It is the second most common Tumour of the hand. The aim of this study was to perform a retrospective clinicopathological evaluation of GCTTS cases and determine whether the proliferative activity of giant cell tumour of tendon sheath is related to its recurrence rate and local aggressiveness.

MATERIALS AND METHODS

The age, gender, Tumour location and diameter, treatment mode, Ki-67 proliferation index, mitotic rate, and recurrence were retrospectively evaluated in 35 patients diagnosed with GCTTS in the Department of Pathology, School of Medicine, Recep Tayyip Erdogan University between 2009 and 2014.

RESULTS

Of the 35 GCTTS cases, 23 were female, and 12 were male. The mean age was 45 y (range 10-70). Sixteen tumours were located in the right hand and 14 in the left hand, and five were in the feet. The mean Tumour diameter was 2.3 cm (0.6-6 cm). All patients underwent marginal excision. The mean postoperative follow-up period was 4 y (range 28 months-5 y). Only six patients showed recurrence. In these cases, the site of GCTTS recurrence was the phalanx of the hand. The mean Ki-67 index in the recurrence cases was 6.5%, whereas it was 2.3% in those without recurrence.

CONCLUSION

The Ki-67 proliferation index and mitotic activity were increased in recurrent cases compared to nonrecurrent cases. Therefore, these parameters may be helpful in predicting recurrence of GCTTS. However, adequate surgical excision and complete removal of the Tumour are important steps to minimize the recurrence rate.

Automated quantification of MART1-verified Ki-67 indices: useful diagnostic aid in melanocytic lesions

The MART1-verified Ki-67 proliferation index is a valuable aid to distinguish melanomas from nevi. Because such indices are quantifiable by image analysis, they may provide a novel automated diagnostic aid. This study aimed to validate the diagnostic performance of automated dermal Ki-67 indices and to explore the diagnostic capability of epidermal Ki-67 in lesions both with and without a dermal component. In addition, we investigated the automated indices' ability to predict sentinel lymph node (SLN) status. Paraffin-embedded tissues from 84 primary cutaneous melanomas (35 with SLN biopsy), 22 melanoma in situ, and 270 nevi were included consecutively. Whole slide images were captured from Ki-67/MART1 double stains, and image analysis computed Ki-67 indices for epidermis and dermis. In lesions with a dermal component, the area under the receiver operating characteristic (ROC) curve was 0.79 (95% confidence interval [CI], 0.72-0.86) for dermal indices. By excluding lesions with few melanocytic cells, this area increased to 0.93 (95% CI, 0.88-0.98). A simultaneous analysis of epidermis and dermis yielded an ROC area of 0.94 (95% CI, 0.91-0.96) for lesions with a dermal component and 0.98 (95% CI, 0.97-1.0) for lesions with a considerable dermal component. For all lesions, the ROC area of the simultaneous analysis was 0.89 (95% CI, 0.85-0.92). SLN-positive patients generally had a higher index than SLN-negative patients (P ≤ .003). Conclusively, an automated diagnostic aid seems feasible in melanocytic pathology. The dermal Ki-67 index was inferior to a combined epidermal and dermal index in diagnosis but valuable for predicting the SLN status of our melanoma patients.

Software-automated counting of Ki-67 proliferation index correlates with pathologic grade and disease progression of follicular lymphomas

OBJECTIVES

To examine the accuracy of software-assisted measurement of the Ki-67 proliferation index (PI) and its correlation with the grade and clinical progression of follicular lymphoma (FL).

METHODS

High-power field equivalents were extracted from H&E- and Ki-67-immunostained slides of FL, and a nuclear quantitation algorithm was used to calculate a PI. Representative fields were manually counted for validation with close agreement.

RESULTS

The PI was significantly higher in World Health Organization grade 3 FL than grade 1 to 2 FL. Disease progression, as defined by subsequent treatment with radiation or cytotoxic chemotherapy, was also significantly associated with elevated PI but not pathologic grade.

CONCLUSIONS

These data show that software-automated quantitation of Ki-67 can provide both a useful adjunct to pathologic grade in FL and improved prognostic information for patients.

Relationship between Survivin expression and indexes of cell apoptosis and proliferation in pancreatic carcinoma

AIM: To investigate the relationship between survivin expression and the indexes of apoptosis and proliferation in pancreatic carcinoma tissues.

METHODS: Sixty-four pairs of pancreatic carcinoma and cancer-adjacent tissues were included in this study. TUNEL method was used to measure the cell apoptosis index, and immunohistochemistry was used to detect ki-67 expression (standing for the cell proliferation index) and Survivin expression. The relations of apoptosis index and proliferation index with Survivin expression and pathological features were analyzed.

RESULTS: The apoptosis index had no correlation with the age and gender of patients and tumor location, increased with the elevation of carcinoma differentiated degrees, and was markedly higher in cancer-adjacent tissues than that in cancer tissues (30.47% vs 1.64%, P < 0.001). The proliferation index had no correlation with the age and sex of patients, tumor location and lymphatic metastases, increased with the reduction of carcinoma differentiated degrees. From the view of differentiation, Survivin expression was negatively correlated with the apoptosis index (r = -0.85), but positively correlated with the proliferation index (r = 0.87) in pancreatic carcinoma tissues. From the view of metastases, the apoptosis index was negatively correlated with Survivin expression (r = -0.81).

CONCLUSION: Survivin gene plays an important role in the pathogenesis and development of pancreatic carcinoma.

Relationship between survivin expression and recurrence, and prognosis in hepatocellular carcinoma

AIM: To study the expression of the inhibitor of apoptosis protein survivin in hepatocellular carcinoma (HCC), and its correlation with clinicopathological factors, cell proliferation, recurrence and prognosis after hepatectomy.

METHODS: Immunohistochemical staining of survivin and Ki-67 was performed by the standard streptavidin-peroxidase technique on paraffin sections of 55 cases of HCC.

RESULTS: The positive rate of survivin in HCC was 52.7% (29/55). Significant correlation was found between survivin expression with portal vein thrombi and intrahepatic matastasistic nodes (P < 0.05). The recurrent rate in survivin-positive HCC was significantly higher than that in survivin-negative HCC after hepatectomy, the 1- and 3-year survival rate in patients with survivin-positive tumors was significantly lower than that in patients with survivin-negative tumors (58.62 and 10.34% vs 76.92 and 30.77%, P < 0.05, log-rank test). The proliferation index (Ki-67) in survivin-positive HCC (33.83% ± 18.90%) was significantly higher than that in survivin-negative HCC (19.60% ± 19.35%) (P < 0.05).

CONCLUSION: Survivin may play an important role in progression of HCC by promoting cell proliferation, and may be positively correlated with high risk of disease recurrence and poor prognosis in HCC. Its expression may serve as a prognostic factor for patients with HCC after hepatectomy.