editorial

editorial

Is the Ki-67 labelling index ready for

clinical use?

function [9, 10]. Ki-67 expression varies throughout the different

cell cycle phases. Cells express the antigen during G1, S, G2, and
M phases but not during the resting phase G0. Ki-67 levels are
low in the G1 and S phases and rise to their peak level in mitosis.
Later in the mitotic phase (anaphase and telophase), a sharp
decrease in Ki-67 levels occurs [11]. Since the description of Ki67, several antibodies, such as MM-1, Ki-S5, and SP6, have been
assessed on paraffin sections after antigen retrieval. Mostly, Ki-67
is measured on paraffin sections by an immunohistochemical
method, using the MIB-1 antibody. In general, the Ki-67 score is
defined as the percentage of total number of tumour cells with
nuclear staining.
The use of Ki-67 as a predictive and prognostic marker in
breast cancer has been widely investigated. Recent data suggest
that a Ki-67 level above 10%14% defines a high-risk group in
terms of prognosis, and according to Yerushalmi et al. [12],
acceptance of this definition might make comparisons of future
studies more reliable. Therefore, the panel of experts at the St
Gallen Consensus in 2009 considered the Ki-67 labelling index
important for selecting the addition of chemotherapy to
endocrine therapy in hormone receptor-positive breast cancers
and classified tumours as low, intermediate, and highly
proliferating according to the value of Ki-67 labelling index
of 15%, 16%30%, and >30%, respectively.
Neoadjuvant chemotherapy for breast cancer is considered to
be the most practical in vivo chemosensitivity test and is ideal for
the evaluation of the predictive factors for molecular markers, as
tumour tissue can be obtained before and after treatment.
Nishimura et al. [13] suggest that the Ki-67 value before
neoadjuvant chemotherapy is a strong predictive factor for the
effectiveness of the therapy. They found that the pathological
documented response was significantly associated with Ki-67
values using multivariate analysis. A higher Ki-67 reveals a higher
pathological complete response (pCR) rate. Patients with higher
cell proliferation (Ki-67 > 25%) may be better candidates for
neoadjuvant chemotherapy. After neoadjuvant chemotherapy,
lower Ki-67 values indicate a low chance for pathological
complete response but a better prognosis.
DeCensi et al. [14] in this issue of Annals of Oncology
analysed the follow-up of a previous study where the effects of
different doses of tamoxifen on breast cancer proliferation were
studied using Ki-67 expression as the main surrogate end point
marker. The change in Ki-67 expression induced by lower doses
of tamoxifen was comparable with that achieved with the
standard dose, implying that tamoxifen at low doses retains
antiproliferative activity [15]. The findings of Dowsett et al.
[16] that higher Ki-67 labelling index after 2 weeks of
neoadjuvant treatment with either tamoxifen or anastrozole or
their combination was associated with shorter recurrence-free
survival (RFS) after a median of 37 months in 158

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Cancer is one of the leading causes of death worldwide.

Identification of biomarkers that can detect cancer early,
monitor disease progression or serve as a surrogate marker for
prognosis and prediction will enable us to personalise medicine
and improve care of cancer patients. Up to now, the leading
parameters that define treatment recommendations in early
breast cancer are estrogen receptor (ER), progesterone receptor,
and human epidermal growth factor status. In the last years,
global gene expression analysis studies have demonstrated the
prime role of proliferation signatures in breast cancer prognosis
and prediction of response to therapy [13]. This could also be
shown in a recent meta-analysis of publicly available BC gene
expression studies that revealed that the key biological drivers
in nine prognostic signatures were proliferation-related genes,
in addition to ER signalling and Her2/neu amplification [4].
Using the information provided by expression data,
commercially available multigene assays like the Oncotype DX
gene test were developed in which 5 of the 16 genes, used in the
text, reflect the proliferative status of the tumour. These specific
genes, which include Ki-67, are heavily weighted in the formula
used to calculate the tests recurrence score [5]. Two large
randomised studies, one led by the Eastern Cooperative
Oncology Group called Tailorx study and the MINDACT
(microarray in node negative disease may avoid chemotherapy)
trial coordinated by the Breast International Group, are
assessing the role of different multigene assays in determining
the benefit of chemotherapy in addition to endocrine treatment
in node-negative hormone-positive tumours. The panel of the
St Gallen International Expert Consensus on the primary
therapy of early breast cancer recommends the use of
proliferation markers (e.g. Ki-67 index and mitosis) and
multigene assays when choosing the appropriate systemic
treatment in addition to traditional parameters, such as stage,
grade, and endocrine status [6]. A search on the Web site of the
American Society of Clinical Oncology revealed that the
guidelines for use of biological markers in breast cancer do not
include Ki-67 in the list of required routine markers [7].
The Ki-67 antigen was originally identified by a German group
[8] in the early 1980s, by use of a mouse mAb against a nuclear
antigen from a Hodgkins lymphoma-derived cell line. This nonhistone protein was named after the researchers location, Ki for
Kiel University, Germany, with the 67 label referring to the clone
number on the 96-well plate [8]. Studies have identified the
involvement of Ki-67 in the early steps of polymerase Idependent ribosomal RNA synthesis. Although it seems that the
protein has an important function in cell division, its exact role is
still obscure and there is little published work on its overall

Annals of Oncology 22: 500502, 2011

doi:10.1093/annonc/mdq732

editorial

Annals of Oncology

Volume 22 | No. 3 | March 2011

recognises a 100-kd proliferation-specific nuclear protein

expressed exclusively in the cell cycle phases S, G2, and M.
Therefore, actively proliferating cells that constitute a subset of
the population recognised by Ki-67 were specifically labelled.
The cycling ratio, defined as the ratio of the Ki-S2 (p100)
labelling index to the Ki-67 labelling index, represents the
relative fraction of cells in the S, G2, and M phases of the cell
cycle. This finding implies that alterations of cell cycle
regulation at the G1S transition strongly influence breast
cancer progression [19]. Prognosis is apparently best indicated
by the percentage of cells in S through M phases of the cell
cycle. Measurement of the Ki-S2 labelling index of a tumour
sample also may improve a clinicians ability to make an
accurate prognosis and to identify patients with a low risk of
recurrence who may not need adjuvant therapy [20].
Concerning Ki-67 antibodies, recently a comparative study has
been published revealing that the antibody SP6 might be better
suited for image analysis [21].
In summary, cellular proliferation is a major determinant
of the biologic behaviour of breast cancer and
a standardisation of the techniques to determine cellular
proliferation is needed.
W. Jonat* & N. Arnold
Department of Gynaecology and Obstetrics, University
Hospital Schleswig-Holstein, Christian-Albrechts-University,
Kiel, Germany
(*E-mail: jonat@email.uni-kiel.de)

disclosure
The authors declare no conflict of interest.

references
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postmenopausal women with operable or locally advanced

breast cancer participating in the IMPACT (Immediate
Preoperative Anastrozole Tamoxifen or Combined with
Tamoxifen) trial and of Ellis et al. [17] on postmenopausal
patients substantiated the correlation of Ki-67 values as
a reliable surrogate biomarker of disease outcome. According to
the authors, a substantial reduction of Ki-67 labelling index
after a short-term challenge test of a few weeks of hormonal
treatment might be a simple and inexpensive way to select
women with ER-positive breast cancer who may not benefit
from adjuvant chemotherapy. Compared with the costs of
various multigene assays, testing of Ki-67 would be cost saving
and economical at US$30 per test, especially because it can be
done in parallel with other immunohistochemical markers and
included in the initial pathology report of the core biopsy or
surgical specimen [12].
The comparison of baseline Ki-67 labelling index and posttreatment level will enhance the informative value of the test.
Baseline Ki-67 values were higher in patients with triplenegative tumours and on the other hand, patients with ER+
and/or PgR+ tumours had lower Ki-67 values. Nishimura et al.
[13] found that Ki-67 values before neoadjuvant chemotherapy
could predict the effectiveness of the treatment and those after
neoadjuvant treatment could predict the disease-free survival
(DFS) in patients. The authors of the accompanied paper find
the same correlation. They conclude that their findings indicate
that Ki-67 labelling index response after short-term presurgical
tamoxifen is a better predictor of invasive DFS and overall
survival than baseline Ki-67 labelling index in women with ERpositive breast cancer. This finding was also noted by the
IMPACT Trialists Group [16], which reported that the
continuous evaluation of the changes in Ki-67 values 2 weeks
after the initial endocrine treatment improved the prediction
for RFS. Therefore, in line with the reports of other groups,
the authors stated that the findings support the notion that
post-treatment Ki-67 labelling index is a reliable marker
of endocrine responsiveness that can allow selection of
endocrine-responsive patients who may not benefit from
additional chemotherapy.
One of the restrictions to the statement was also mentioned
by the authors. They note that given the limited number of
events, especially for overall death that was based on 10 events
only, their findings should be interpreted with caution. The
other limitations in the reported and other studies is the
relatively small number of cases analysed leading mostly to
higher confidence intervals and the lack of standardisation of
Ki-67 pathological assessment. We are in line with Colloza et al.
[18] that despite the absence of standardisation of Ki-67
pathological assessment, the acceptance of Ki-67 as a standard
marker requires much more research to be done. Further
analysis using validated methods is necessary before its
widespread adoption and only a complete standardisation of
tissue handling and processing will improve the value of Ki-67
as a clinically useful and widely accepted marker [18].
Nevertheless, the MIB1 labelling index assay is accepted to be
a low cost simple method, which is perfectly suitable for
standardisation in clinical laboratory practice.
Another possible marker to monitor proliferation in
a tumour tissue would be the Ki-S2 antibody. This antibody

editorial
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Annals of Oncology

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Volume 22 | No. 3 | March 2011