Journal Article
. 2016 Mar; 468(6):675-86.
doi: 10.1007/s00428-016-1925-x.

Expression of cell cycle markers is predictive of the response to primary systemic therapy of locally advanced breast cancer

Tímea Tőkés 1 Anna-Mária Tőkés 2 Gyöngyvér Szentmártoni 1 Gergő Kiszner 3 Lilla Madaras 4 Janina Kulka 4 Tibor Krenács 2 Magdolna Dank 5 
Affiliations
  • PMID: 27026269
  •     60 References
  •     3 citations

Abstract

We aimed to analyze to what extent expression of four cell cycle regulation markers-minichromosome maintenance protein (MCM2), Ki-67, cyclin A, and phosphohistone-H3 (PHH3)-predict response to primary systemic therapy in terms of pathological complete remission (pCR). In search of an accurate and reproducible scoring method, we compared computer-assisted (CA) and routine visual assessment (VA) of immunoreactivity. We included 57 patients with breast cancer in the study. The cell cycle markers were detected using immunohistochemistry on pre-therapy core biopsy samples. Parallel CA (validated by manual labeling) and standard VA were performed and compared for diagnostic agreement and predictive value for pCR. CA and VA results were dichotomized based on receiver operating characteristic analysis defined optimal cut-off values. "High" was defined by staining scores above the optimal cut-off, while "low" had staining scores below the optimal cut-off. The CA method resulted in significantly lower values for Ki-67 and MCM2 compared to VA (mean difference, -3.939 and -4.323). Diagnostic agreement was highest for cyclin A and PHH3 (-0.586 and -0.666, respectively). Regardless of the method (CA/VA) used, all tested markers were predictive of pCR. Optimal cut-off-based dichotomization improved diagnostic agreement between the CA and VA methods for every marker, in particular for MCM2 (κ = 1, p < 0.000). Cyclin A displayed excellent agreement (κ = 0.925; p < 0.000), while Ki-67 and PHH3 showed good agreement (κ = 0.789, p < 0.000 and κ = 0.794, p < 0.000, respectively). We found all cell cycle markers (Ki-67, MCM2, cyclin A, and PHH3) predictive of pCR. Diagnostic agreement between CA and VA was better at lower staining scores but improved after optimal cut-off-based dichotomization.

Keywords: Breast cancer; Cell cycle; Digital pathology; Primary systemic therapy; Proliferation.

The effect of random measurement error on receiver operating characteristic (ROC) curves.
D Faraggi.
Stat Med, 2000 Jan 07; 19(1). PMID: 10623913
Proliferative activity in human breast cancer: Ki-67 automated evaluation and the influence of different Ki-67 equivalent antibodies.
S Fasanella, E Leonardi, +11 authors, M Barbareschi.
Diagn Pathol, 2011 Apr 22; 6 Suppl 1. PMID: 21489202    Free PMC article.
Cell-cycle-phase progression analysis identifies unique phenotypes of major prognostic and predictive significance in breast cancer.
M Loddo, S R Kingsbury, +10 authors, G H Williams.
Br J Cancer, 2009 Feb 26; 100(6). PMID: 19240714    Free PMC article.
Applying the right statistics: analyses of measurement studies.
J M Bland, D G Altman.
Ultrasound Obstet Gynecol, 2003 Jul 15; 22(1). PMID: 12858311
Highly Cited. Review.
DNA replication licensing and cell cycle kinetics of normal and neoplastic breast.
A Shetty, M Loddo, +4 authors, K Stoeber.
Br J Cancer, 2005 Nov 10; 93(11). PMID: 16278669    Free PMC article.
Primary chemotherapy in breast invasive carcinoma: predictive value of the immunohistochemical detection of hormonal receptors, p53, c-erbB-2, MiB1, pS2 and GST pi.
G MacGrogan, L Mauriac, +4 authors, J M Coindre.
Br J Cancer, 1996 Nov 01; 74(9). PMID: 8912545    Free PMC article.
The cell cycle and cancer.
Gareth H Williams, Kai Stoeber.
J Pathol, 2011 Oct 13; 226(2). PMID: 21990031
Highly Cited. Review.
Digital immunohistochemistry wizard: image analysis-assisted stereology tool to produce reference data set for calibration and quality control.
Benoît Plancoulaine, Aida Laurinaviciene, +4 authors, Arvydas Laurinavicius.
Diagn Pathol, 2015 Jan 08; 9 Suppl 1. PMID: 25565221    Free PMC article.
Comparison of the effect of different techniques for measurement of Ki67 proliferation on reproducibility and prognosis prediction accuracy in breast cancer.
Einar Gudlaugsson, Ivar Skaland, +5 authors, Jan P A Baak.
Histopathology, 2012 Sep 12; 61(6). PMID: 22963617
Combination of the proliferation marker cyclin A, histological grade, and estrogen receptor status in a new variable with high prognostic impact in breast cancer.
Carina Strand, Cecilia Ahlin, +4 authors, Mårten Fernö.
Breast Cancer Res Treat, 2011 Feb 19; 131(1). PMID: 21331623
Pathological non-response to chemotherapy in a neoadjuvant setting of breast cancer: an inter-institutional study.
D Balmativola, C Marchiò, +26 authors, A Sapino.
Breast Cancer Res Treat, 2014 Nov 15; 148(3). PMID: 25395316    Free PMC article.
Proliferation is the strongest prognosticator in node-negative breast cancer: significance, error sources, alternatives and comparison with molecular prognostic markers.
Jan P A Baak, Einar Gudlaugsson, +6 authors, Axel Zur Hausen.
Breast Cancer Res Treat, 2008 Jul 31; 115(2). PMID: 18665447
Review.
The MCM complex: its role in DNA replication and implications for cancer therapy.
Ming Lei.
Curr Cancer Drug Targets, 2005 Aug 17; 5(5). PMID: 16101384
Review.
Aurora kinase A outperforms Ki67 as a prognostic marker in ER-positive breast cancer.
H R Ali, S-J Dawson, +3 authors, C Caldas.
Br J Cancer, 2012 Apr 28; 106(11). PMID: 22538974    Free PMC article.
Pathological complete response and residual DCIS following neoadjuvant chemotherapy for breast carcinoma.
R L Jones, S R Lakhani, +3 authors, I E Smith.
Br J Cancer, 2006 Jan 20; 94(3). PMID: 16421590    Free PMC article.
Relationship between tumour shrinkage and reduction in Ki67 expression after primary chemotherapy in human breast cancer.
A Bottini, A Berruti, +11 authors, L Dogliotti.
Br J Cancer, 2001 Nov 17; 85(8). PMID: 11710821    Free PMC article.
Cell-cycle-dependent regulation of DNA replication and its relevance to cancer pathology.
Kiku-E K Tachibana, Michael A Gonzalez, Nicholas Coleman.
J Pathol, 2005 Jan 12; 205(2). PMID: 15643673
Review.
Statistical methods for assessing agreement between two methods of clinical measurement.
J M Bland, D G Altman.
Lancet, 1986 Feb 08; 1(8476). PMID: 2868172
Highly Cited.
Ki-67 is a prognostic parameter in breast cancer patients: results of a large population-based cohort of a cancer registry.
E C Inwald, M Klinkhammer-Schalke, +4 authors, O Ortmann.
Breast Cancer Res Treat, 2013 May 16; 139(2). PMID: 23674192    Free PMC article.
Highly Cited.
Ki-67 as prognostic marker in early breast cancer: a meta-analysis of published studies involving 12,155 patients.
E de Azambuja, F Cardoso, +7 authors, M Paesmans.
Br J Cancer, 2007 Apr 25; 96(10). PMID: 17453008    Free PMC article.
Highly Cited.
Personalizing the treatment of women with early breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013.
A Goldhirsch, E P Winer, +5 authors, Panel members.
Ann Oncol, 2013 Aug 07; 24(9). PMID: 23917950    Free PMC article.
Highly Cited.
Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18.
N Wolmark, J Wang, +2 authors, B Fisher.
J Natl Cancer Inst Monogr, 2002 Jan 05; (30). PMID: 11773300
Highly Cited.
Expression of proliferation markers Ki67, cyclin A, geminin and aurora-kinase A in primary breast carcinomas and corresponding distant metastases.
Anna-Mária Tökés, A Marcell Szász, +12 authors, Janina Kulka.
J Clin Pathol, 2015 Jan 18; 68(4). PMID: 25595275
Comparative validation of the SP6 antibody to Ki67 in breast cancer.
Lila Zabaglo, Janine Salter, +5 authors, Mitch Dowsett.
J Clin Pathol, 2010 Jul 31; 63(9). PMID: 20671052
Assessment of Ki67 in breast cancer: recommendations from the International Ki67 in Breast Cancer working group.
Mitch Dowsett, Torsten O Nielsen, +19 authors, International Ki-67 in Breast Cancer Working Group.
J Natl Cancer Inst, 2011 Oct 01; 103(22). PMID: 21960707    Free PMC article.
Highly Cited.
Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine.
M H Zweig, G Campbell.
Clin Chem, 1993 Apr 01; 39(4). PMID: 8472349
Highly Cited. Review.
Comparing methods of measurement: why plotting difference against standard method is misleading.
J M Bland, D G Altman.
Lancet, 1995 Oct 21; 346(8982). PMID: 7564793
Highly Cited.
Recommendations from an international expert panel on the use of neoadjuvant (primary) systemic treatment of operable breast cancer: new perspectives 2006.
M Kaufmann, G von Minckwitz, +16 authors, S Loibl.
Ann Oncol, 2007 Nov 14; 18(12). PMID: 17998286
Review.
Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis.
Patricia Cortazar, Lijun Zhang, +34 authors, Gunter von Minckwitz.
Lancet, 2014 Feb 18; 384(9938). PMID: 24529560
Highly Cited. Review.
An international Ki67 reproducibility study.
Mei-Yin C Polley, Samuel C Y Leung, +16 authors, International Ki67 in Breast Cancer Working Group of the Breast International Group and North American Breast Cancer Group.
J Natl Cancer Inst, 2013 Nov 10; 105(24). PMID: 24203987    Free PMC article.
Highly Cited.
[Pharmaceutical therapy of breast cancer].
István Láng, Zsuzsanna Kahán, +7 authors, Zsolt Horváth.
Magy Onkol, 2010 Sep 28; 54(3). PMID: 20870601
Comparison of visual and automated assessment of Ki-67 proliferative activity and their impact on outcome in primary operable invasive ductal breast cancer.
Z M A Mohammed, D C McMillan, +5 authors, J Edwards.
Br J Cancer, 2012 Jan 19; 106(2). PMID: 22251968    Free PMC article.
Cyclin A as a marker for prognosis and chemotherapy response in advanced breast cancer.
P Poikonen, J Sjöström, +3 authors, C Blomqvist.
Br J Cancer, 2005 Aug 11; 93(5). PMID: 16091759    Free PMC article.
Detection and segmentation of cell nuclei in virtual microscopy images: a minimum-model approach.
Stephan Wienert, Daniel Heim, +6 authors, Frederick Klauschen.
Sci Rep, 2012 Jul 13; 2. PMID: 22787560    Free PMC article.
Ki67 and cyclin A as prognostic factors in early breast cancer. What are the optimal cut-off values?
C Ahlin, K Aaltonen, +3 authors, C Blomqvist.
Histopathology, 2007 Aug 23; 51(4). PMID: 17711446
Statistical techniques for comparing measurers and methods of measurement: a critical review.
John Ludbrook.
Clin Exp Pharmacol Physiol, 2002 Jun 13; 29(7). PMID: 12060093
Review.
The prognostic value of the proliferation marker phosphohistone H3 (PPH3) in luminal, basal-like and triple negative phenotype invasive lymph node-negative breast cancer.
Ivar Skaland, Emiel A M Janssen, +2 authors, Jan P A Baak.
Cell Oncol, 2009 Jul 28; 31(4). PMID: 19633363    Free PMC article.
The cell cycle: a review of regulation, deregulation and therapeutic targets in cancer.
Katrien Vermeulen, Dirk R Van Bockstaele, Zwi N Berneman.
Cell Prolif, 2003 Jun 20; 36(3). PMID: 12814430    Free PMC article.
Highly Cited. Review.
Laboratory handling and histology reporting of breast specimens from patients who have received neoadjuvant chemotherapy.
S E Pinder, E Provenzano, H Earl, I O Ellis.
Histopathology, 2007 Apr 24; 50(4). PMID: 17448015
Review.
Standardized Ki67 Diagnostics Using Automated Scoring--Clinical Validation in the GeparTrio Breast Cancer Study.
Frederick Klauschen, Stephan Wienert, +11 authors, Gunter von Minckwitz.
Clin Cancer Res, 2014 Dec 17; 21(16). PMID: 25501130
Digital image analysis in pathology: benefits and obligation.
Arvydas Laurinavicius, Aida Laurinaviciene, +4 authors, Paulette Herlin.
Anal Cell Pathol (Amst), 2011 Oct 06; 35(2). PMID: 21971321    Free PMC article.
Review.
Cyclin A is a proliferative marker with good prognostic value in node-negative breast cancer.
Cecilia Ahlin, Wenjing Zhou, +6 authors, Marie-Louise Fjällskog.
Cancer Epidemiol Biomarkers Prev, 2009 Aug 27; 18(9). PMID: 19706846
A methodology to ensure and improve accuracy of Ki67 labelling index estimation by automated digital image analysis in breast cancer tissue.
Arvydas Laurinavicius, Benoit Plancoulaine, +8 authors, Catherine Bor.
Breast Cancer Res, 2014 Apr 09; 16(2). PMID: 24708745    Free PMC article.
Clinical significance of Ki-67 in neoadjuvant chemotherapy for primary breast cancer as a predictor for chemosensitivity and for prognosis.
Reiki Nishimura, Tomofumi Osako, +2 authors, Nobuyuki Arima.
Breast Cancer, 2009 Sep 05; 17(4). PMID: 19730975
Common markers of proliferation.
Michael L Whitfield, Lacy K George, Gavin D Grant, Charles M Perou.
Nat Rev Cancer, 2006 Feb 24; 6(2). PMID: 16491069
Highly Cited. Review.
The potential of digital microscopy in breast pathology.
T Krenacs, I Zsakovics, +3 authors, B Molnar.
Pathol Oncol Res, 2008 Aug 30; 15(1). PMID: 18752051
Phosphohistone H3 labelling for histoprognostic grading of breast adenocarcinomas and computer-assisted determination of mitotic index.
C Bossard, A Jarry, +5 authors, C L Laboisse.
J Clin Pathol, 2006 Feb 08; 59(7). PMID: 16461563    Free PMC article.
Ki67 and proliferation in breast cancer.
Nirmala Pathmanathan, Rosemary L Balleine.
J Clin Pathol, 2013 Feb 26; 66(6). PMID: 23436927
Highly Cited. Review.
Optimal cut-point and its corresponding Youden Index to discriminate individuals using pooled blood samples.
Enrique F Schisterman, Neil J Perkins, Aiyi Liu, Howard Bondell.
Epidemiology, 2004 Dec 23; 16(1). PMID: 15613948
Highly Cited.
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.
Ivar Skaland, Emiel A M Janssen, +4 authors, Jan P A Baak.
Breast Cancer Res Treat, 2008 Apr 01; 114(1). PMID: 18373192
Development and evaluation of a virtual microscopy application for automated assessment of Ki-67 expression in breast cancer.
Juho Konsti, Mikael Lundin, +8 authors, Johan Lundin.
BMC Clin Pathol, 2011 Jan 26; 11. PMID: 21262004    Free PMC article.
Prognostic significance of pathological response of primary tumor and metastatic axillary lymph nodes after neoadjuvant chemotherapy for locally advanced breast carcinoma.
M R Machiavelli, A O Romero, +11 authors, B A Leone.
Cancer J Sci Am, 1998 Apr 29; 4(2). PMID: 9554929
A novel model for Ki67 assessment in breast cancer.
Quinci Romero, Pär-Ola Bendahl, +2 authors, Signe Borgquist.
Diagn Pathol, 2014 Jun 18; 9. PMID: 24934660    Free PMC article.
Different methods of pretreatment Ki-67 labeling index evaluation in core biopsies of breast cancer patients treated with neoadjuvant chemotherapy and their relation to response to therapy.
András Vörös, Erika Csörgő, +5 authors, Gábor Cserni.
Pathol Oncol Res, 2014 May 27; 21(1). PMID: 24859973
Ki67, chemotherapy response, and prognosis in breast cancer patients receiving neoadjuvant treatment.
Peter A Fasching, Katharina Heusinger, +14 authors, David L Wachter.
BMC Cancer, 2011 Nov 16; 11. PMID: 22081974    Free PMC article.
Highly Cited.
Proliferative markers as prognostic and predictive tools in early breast cancer: where are we now?
M Colozza, E Azambuja, +3 authors, M J Piccart.
Ann Oncol, 2005 Jun 28; 16(11). PMID: 15980158
Review.
Cell cycle analysis can differentiate thin melanomas from dysplastic nevi and reveals accelerated replication in thick melanomas.
Gergo Kiszner, Barnabas Wichmann, +7 authors, Tibor Krenacs.
Virchows Arch, 2014 Apr 01; 464(5). PMID: 24682564
Control of DNA replication and its potential clinical exploitation.
Michael A Gonzalez, Kiku-e K Tachibana, Ronald A Laskey, Nicholas Coleman.
Nat Rev Cancer, 2005 Jan 22; 5(2). PMID: 15660109
Review.
Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007.
A Goldhirsch, W C Wood, +4 authors, 10th St. Gallen conference.
Ann Oncol, 2007 Aug 07; 18(7). PMID: 17675394
Highly Cited. Review.
The Ki-67 protein: fascinating forms and an unknown function.
E Endl, J Gerdes.
Exp Cell Res, 2000 Jun 06; 257(2). PMID: 10837136
Review.
Minichromosome maintenance protein 2 correlates with the malignant status and regulates proliferation and cell cycle in lung squamous cell carcinoma.
Wei Wu, Xianwei Wang, +2 authors, Fengzhu Li.
Onco Targets Ther, 2018 Sep 04; 11. PMID: 30174440    Free PMC article.
Prognostic and Clinicopathological Correlations of Cell Cycle Marker Expressions before and after the Primary Systemic Therapy of Breast Cancer.
Tímea Tőkés, Anna-Mária Tőkés, +6 authors, Magdolna Dank.
Pathol Oncol Res, 2019 Aug 26; 26(3). PMID: 31446607    Free PMC article.
Artificial intelligence in digital breast pathology: Techniques and applications.
Asmaa Ibrahim, Paul Gamble, +4 authors, Emad A Rakha.
Breast, 2020 Jan 15; 49. PMID: 31935669    Free PMC article.
Review.