Background: Ki-67 proliferation index was recently incorporated in the grading of neuroendocrine neoplasms (NENs) of the gastrointestinal tract (GIT) and pancreas. These are now divided into well-differentiated neuroendocrine tumors (WDNETs, grades 1 and 2) and poorly differentiated neuroendocrine carcinomas (grade 3). While Ki-67 is an established proliferation marker in NENs, phosphohistone H3 (PHH3), a newer marker of mitotic activity, is not. Methods: We determined Ki-67 and PHH3 indices on cytologic samples from WDNETs of the GIT and pancreas using an automated cellular imaging system (ACIS®). Results: There was a strong correlation between Ki-67 and PHH3 indices generated by ACIS on cytologic samples. However, in some cases the two stains caused conflicting grades within the same tumor. Conclusion: Both antibodies stain cells in different phases of the cell cycle which may cause discordant grades, thus affecting patient management and prognostication. Ki-67 staining is stronger than PHH3, making ‘hot spots' easier to identify on ACIS. Ki-67 is more ideal than PHH3 for staining NENs, especially in tumors with borderline grades. Because PHH3 generates lower mitotic indices it should not be used as a proliferation marker in NENs until its expression has been further characterized.

Keywords:
Phosphohistone H3, Ki-67 labeling index, Well-differentiated neuroendocrine tumors, Gastrointestinal tract, Pancreas, Automated cellular imaging system
1.
Tornos C, Silva EG, el-Naggar A, Burke TW: Aggressive stage I grade 1 endometrial carcinoma. Cancer 1992;70:790-798.
2.
de Azambuja E, Cardoso F, de Castro G Jr, Colozza M, Mano MS, Durbecq V, Sotiriou C, Larsimont D, Piccart-Gebhart MJ, Paesmans M: Ki-67 as prognostic marker in early breast cancer: a meta-analysis of published studies involving 12,155 patients. Br J Cancer 2007;96:1504-1513.
3.
Ladstein RG, Bachmann IM, Straume O, Akslen LA: Ki-67 expression is superior to mitotic count and novel proliferation markers PHH3, MCM4 and mitosin as a prognostic factor in thick cutaneous melanoma. BMC Cancer 2010;10:140.
4.
La Rosa S, Klersy C, Uccella S, Dainese L, Albarello L, Sonzogni A, Doglioni C, Capella C, Solcia E: Improved histologic and clinicopathologic criteria for prognostic evaluation of pancreatic endocrine tumors. Hum Pathol 2009;40:30-40.
5.
Pelosi G, Bresaola E, Bogina G, Pasini F, Rodella S, Castelli P, Iacono C, Serio G, Zamboni G: Endocrine tumors of the pancreas: Ki-67 immunoreactivity on paraffin sections is an independent predictor for malignancy: a comparative study with proliferating-cell nuclear antigen and progesterone receptor protein immunostaining, mitotic index, and other clinicopathologic variables. Hum Pathol 1996;27:1124-1134.
6.
Scarpa A, Mantovani W, Capelli P, Beghelli S, Boninsegna L, Bettini R, Panzuto F, Pederzoli P, delle Fave G, Falconi M: Pancreatic endocrine tumors: improved TNM staging and histopathological grading permit a clinically efficient prognostic stratification of patients. Mod Pathol 2010;23:824-833.
7.
Rindi G, Arnold R, Bosman FT, Capella C, Klimstra DS, Kloppel G, Komminoth P, Solcia E: Nomenclature and classification of neuroendocrine neoplasms of the digestive system; in Bosman FT, Carneiro F, Hruban RH, Theise ND (eds): Who Classification of Tumours of the Digestive System. Lyon, IARC, 2010, pp 13-14.
8.
Scholzen T, Gerdes J: The Ki-67 protein: from the known and the unknown. J Cell Physiol 2000;182:311-322.
9.
Martin B, Paesmans M, Mascaux C, Berghmans T, Lothaire P, Meert AP, Lafitte JJ, Sculier JP: Ki-67 expression and patient survival in lung cancer: systematic review of the literature with meta-analysis. Br J Cancer 2004;91:2018-2025.
10.
Lin O, Olgac S, Green I, Zakowski MF, Klimstra DS: Immunohistochemical staining of cytologic smears with MIB-1 helps distinguish low-grade from high-grade neuroendocrine neoplasms. Am J Clin Pathol 2003;120:209-216.
11.
Hendzel MJ, Wei Y, Mancini MA, Van Hooser A, Ranalli T, Brinkley BR, Bazett-Jones DP, Allis CD: Mitosis-specific phosphorylation of histone H3 initiates primarily within pericentromeric heterochromatin during G2 and spreads in an ordered fashion coincident with mitotic chromosome condensation. Chromosoma 1997;106:348-360.
12.
Sun A, Zhou W, Lunceford J, Strack P, Dauffenbach LM, Kerfoot CA: Level of phosphohistone H3 among various types of human cancers. BMJ Open 2012;2:e001071.
13.
Williams DJ, Cohen C, Darrow M, Page AJ, Chastain B, Adams AL: Proliferation (Ki-67 and phosphohistone H3) and oncotype DX recurrence score in estrogen receptor-positive breast cancer. Appl Immunohistochem Mol Morphol 2011;19:431-436.
14.
Zbytek B, Cohen C, Wang J, Page A, Williams DJ, Adams AL: Nottingham-defined mitotic score: comparison with visual and image cytometric phosphohistone H3 labeling indices and correlation with oncotype DX recurrence score. Appl Immunohistochem Mol Morphol 2013;21:48-53.
15.
Skaland I, Janssen EA, Gudlaugsson E, Klos J, Kjellevold KH, Soiland H, Baak JP: Validating the prognostic value of proliferation measured by phosphohistone H3 (PPH3) in invasive lymph node-negative breast cancer patients less than 71 years of age. Breast Cancer Res Treat 2009;114:39-45.
16.
Scott IS, Heath TM, Morris LS, Rushbrook SM, Bird K, Vowler SL, Arends MJ, Coleman N: A novel immunohistochemical method for estimating cell cycle phase distribution in ovarian serous neoplasms: implications for the histopathological assessment of paraffin-embedded specimens. Br J Cancer 2004;90:1583-1590.
17.
Scott IS, Morris LS, Bird K, Davies RJ, Vowler SL, Rushbrook SM, Marshall AE, Laskey RA, Miller R, Arends MJ, Coleman N: A novel immunohistochemical method to estimate cell-cycle phase distribution in archival tissue: implications for the prediction of outcome in colorectal cancer. J Pathol 2003;201:187-197.
18.
Chatrath P, Scott IS, Morris LS, Davies RJ, Bird K, Vowler SL, Coleman N: Immunohistochemical estimation of cell cycle phase in laryngeal neoplasia. Br J Cancer 2006;95:314-321.
19.
Kim YJ, Ketter R, Steudel WI, Feiden W: Prognostic significance of the mitotic index using the mitosis marker anti-phosphohistone H3 in meningiomas. Am J Clin Pathol 2007;128:118-125.
20.
Nielsen PS, Riber-Hansen R, Jensen TO, Schmidt H, Steiniche T: Proliferation indices of phosphohistone H3 and Ki-67: strong prognostic markers in a consecutive cohort with stage I/II melanoma. Mod Pathol 2013;26:404-413.
21.
Brunner A, Riss P, Heinze G, Brustmann H: PHH3 and survivin are co-expressed in high-risk endometrial cancer and are prognostic relevant. Br J Cancer 2012;107:84-90.
22.
Klimstra DS, Modlin IR, Coppola D, Lloyd RV, Suster S: The pathologic classification of neuroendocrine tumors: a review of nomenclature, grading, and staging systems. Pancreas 2010;39:707-712.
23.
Cho CS, Labow DM, Tang L, Klimstra DS, Loeffler AG, Leverson GE, Fong Y, Jarnagin WR, D'Angelica MI, Weber SM, Blumgart LH, Dematteo RP: Histologic grade is correlated with outcome after resection of hepatic neuroendocrine neoplasms. Cancer 2008;113:126-134.
24.
Adsay V: Ki67 labeling index in neuroendocrine tumors of the gastrointestinal and pancreatobiliary tract: to count or not to count is not the question, but rather how to count. Am J Surg Pathol 2012;36:1743-1746.
25.
Tang LH, Gonen M, Hedvat C, Modlin IM, Klimstra DS: Objective quantification of the Ki67 proliferative index in neuroendocrine tumors of the gastroenteropancreatic system: a comparison of digital image analysis with manual methods. Am J Surg Pathol 2012;36:1761-1770.
26.
Pett M (ed): Nonparametric Statistics for Health Care Research. Statistics for Small Samples and Unusual Distributions, ed 1. Thousand Oaks, Sage, 1997.
27.
Ikenberg K, Pfaltz M, Rakozy C, Kempf W: Immunohistochemical dual staining as an adjunct in assessment of mitotic activity in melanoma. J Cutan Pathol 2012;39:324-330.
28.
Puri PK, Valdes CL, Burchette JL, Grichnik JM, Turner JW, Selim MA: Accurate identification of proliferative index in melanocytic neoplasms with Melan-A/Ki-67 double stain. J Cutan Pathol 2010;37:1010-1012.
© 2013 S. Karger AG, Basel
2013
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.