Marie Klintman

The prognostic value of Ki67 is dependent on estrogen receptor status and histological grade in premenopausal patients with node-negative breast cancer.

The aim of this study was to evaluate the prognostic value of Ki67 in relation to established prognostic factors in lymph node-negative breast cancer, and furthermore, whether the prognostic impact was dependent on estrogen receptor (ER) status and histological grade. In 200 premenopausal patients, with 5 years of follow-up, Ki67 was determined on tissue microarrays. In univariate analysis, Ki67 (≤20 vs >20%) was a prognostic factor for distant disease-free survival (hazard ratio: 2.7, 95% confidence interval: 1.3–5.4, P=0.005) and overall survival (hazard ratio: 4.9, 95% confidence interval: 1.7–14, P=0.003). When stratifying for ER status and histological grade, Ki67 was a significant prognostic factor for distant disease-free survival and overall survival only in the ER-positive group, and only in patients with histological grade 2, respectively. In multivariate analysis, human epidermal growth factor receptor 2 and age were independent prognostic factors for distant disease-free survival, whereas Ki67, histological grade, and tumor size were not. Ki67 was, however, an independent prognostic factor in the 87% of the patients who had not received adjuvant medical treatment. Agreement between the three readers was very good (κ-values: 0.83–0.88). Furthermore, Ki67 was a significant prognostic factor for all three investigators (hazard ratio: 2.7–3.2). This study shows that Ki67 is a prognostic factor in node-negative breast cancer. It is noteworthy that the prognostic information of Ki67 is restricted to ER-positive patients, and to patients with histological grade 2. Taken together, Ki67, as an easily assessed and reproducible proliferation factor, may be an alternative or complement to histological grade as a prognostic tool and for selection of adjuvant treatment.

The Prognostic Value of Mitotic Activity Index (MAI), Phosphohistone H3 (PPH3), Cyclin B1, Cyclin A, and Ki67, Alone and in Combinations, in Node-Negative Premenopausal Breast Cancer.

Proliferation, either as the main common denominator in genetic profiles, or in the form of single factors such as Ki67, is recommended for clinical use especially in estrogen receptor-positive (ER) patients. However, due to high costs of genetic profiles and lack of reproducibility for Ki67, studies on other proliferation factors are warranted. The aim of the present study was to evaluate the prognostic value of the proliferation factors mitotic activity index (MAI), phosphohistone H3 (PPH3), cyclin B1, cyclin A and Ki67, alone and in combinations. In 222 consecutive premenopausal node-negative breast cancer patients (87% without adjuvant medical treatment), MAI was assessed on whole tissue sections (predefined cut-off ≥10 mitoses), and PPH3, cyclin B1, cyclin A, and Ki67 on tissue microarray (predefined cut-offs 7th decile). In univariable analysis (high versus low) the strongest prognostic proliferation factor for 10-year distant disease-free survival was MAI (Hazard Ratio (HR)=3.3, 95% Confidence Interval (CI): 1.8-6.1), followed by PPH3, cyclin A, Ki67, and cyclin B1. A combination variable, with patients with MAI and/or cyclin A high defined as high-risk, had even stronger prognostic value (HR=4.2, 95%CI: 2.2-7). When stratifying for ER-status, MAI was a significant prognostic factor in ER-positive patients only (HR=7.0, 95%CI: 3.1-16). Stratified for histological grade, MAI added prognostic value in grade 2 (HR=7.2, 95%CI: 3.1-38) and grade 1 patients. In multivariable analysis including HER2, age, adjuvant medical treatment, ER, and one proliferation factor at a time, only MAI (HR=2.7, 95%CI: 1.1-6.7), and cyclin A (HR=2.7, 95%CI: 1.2-6.0) remained independently prognostic. In conclusion this study confirms the strong prognostic value of all proliferation factors, especially MAI and cyclin A, in all patients, and more specifically in ER-positive patients, and patients with histological grade 2 and 1. Additionally, by combining two proliferation factors, an even stronger prognostic value may be found.

The combination of Ki67, histological grade and estrogen receptor status identifies a low-risk group among 1,854 chemo-naïve women with N0/N1 primary breast cancer

BackgroundThe aim was to confirm a previously defined prognostic index, combining a proliferation marker, histological grade, and estrogen receptor (ER) in different subsets of primary N0/N1 chemo-naïve breast cancer patients.Methods/designIn the present study, including 1,854 patients, Ki67 was used in the index (KiGE), since it is the generally accepted proliferation marker in clinical routine. The low KiGE-group was defined as histological grade 1 patients and grade 2 patients which were ER-positive and had low Ki67 expression. All other patients made up the high KiGE-group. The KiGE-index separated patients into two groups with different prognosis. In multivariate analysis, KiGE was significantly associated with disease-free survival, when adjusted for age at diagnosis, tumor size and adjuvant endocrine treatment (hazard ratio: 3.5, 95% confidence interval: 2.6–4.7, P<0.0001).DiscussionWe have confirmed a prognostic index based on a proliferation marker (Ki67), histological grade, and ER for identification of a low-risk group of patients with N0/N1 primary breast cancer. For this low-risk group constituting 57% of the patients, with a five-year distant disease-free survival of 92%, adjuvant chemotherapy will have limited effect and may be avoided.

Significantly higher expression of vascular endothelial growth factor (VEGF) and shorter survival after recurrences in premenopausal node negative patients with triple negative breast cancer.

CTRC-AACR San Antonio Breast Cancer Symposium: 2008 Abstracts Abstract #1077 Background: Triple-negative breast cancer (TNBC) amounts to approximately 15% of all breast cancer and is defined as lacking expression of oestrogen- and progesterone receptors (ER and PgR) and HER2 leaving chemotherapy as the only treatment option. The aggressive nature of TNBC is reflected by high histological grade, early onset of relapses, and more commonly visceral metastases. Further exploration of biological features in this group could (would) help to find potential targeted therapies. Aim: To compare intratumoural levels of VEGF and survival in patients with TNBC compared with HER2 positive patients and ER and/or PgR positive but HER2 negative patients. Patients and methods: 210 premenopausal patients with lymph-node negative breast cancer included in a prospective clinical trial were studied. (Ref Malmstrom et al JCO 19:2010-2019, 2001). Levels of VEGF were determined by an enzyme-linked immuno-sorbent assay (ELISA) on lysates from freshly frozen breast tumor material. HER2 amplification was determined by in situ hybridization of tumor with Her2 + or 3+ reactivity with IHC (determined by IHC followed by confirmatory FISH in 2+ or 3+). Results : Thirty-six out of 210 (17%) patients were classified as having a TNBC. The median level of VEGF in the total patient population was 81 ng/mg total protein (range 2.0- 3610). Significantly higher VEGF levels were found in TNBC compared with HER2 pos. or HER2 neg. ER/PgR pos. patients; median levels 250, 157 and 53 ng/mg total protein respectively (p<0.001). Similarly, 84% of TNBC had VEGF above the median compared to 62% in HER2 pos and 41% in the HER2 neg. ER/PgR pos. group (p<0.001). TNBC was significantly associated to high histological grade (89% grade III) (p<0.001), and high S-phase fraction (p=0.001). The highest rate of distant metastases was (seen or) recorded for HER2 pos patients while TNBC and HER2 neg. ER/PgR pos. had similar relapse rates (p<0.001; three-group comparison). After adjustment for chemotherapy, patients with TNBC survived significantly shorter after relapse compared with ER/PgR pos/HER2 neg patients (HR=7.2;95%CI=2.1-25; p=0.002) but not compared to HER2 pos patients (HR=2.3;95%CI=0.73-7.0; p=0.16). Conclusion : We here for the first time show significant higher levels of an angiogenesis stimulating factor, VEGF in TNBC. Whether blockade of angiogenesis can be an effective new targeted treatment option for this poor prognosis group will be elucidated in ongoing trials. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1077.

A prospective, multicenter validation study of a prognostic index composed of S-phase fraction, progesterone receptor status, and tumour size predicts survival in node-negative breast cancer patients: NNBC, the node-negative breast cancer trial

BACKGROUND In a retrospective study on node-negative breast cancer, a prognostic index consisting of a proliferation factor, S-phase fraction (SPF), progesterone receptor status (PR), and tumour size identified one-third of patients as high risk, with a sixfold increased risk of breast cancer death. This prospective multicenter cohort study was set up to validate the index. PATIENTS AND METHODS In 576 T1-2N0 patients <60 years, prospective analyses of PR and SPF were carried out. High risk was defined as ≥2 of the following: size >20 mm, PR-negativity, and high SPF (in the absence of SPF, Bloom-Richardson grade 3). Median follow-up was 17.8 years. RESULTS Thirty-one percent were high risk. In univariate analysis, the index was prognostic for breast cancer-specific survival after 5 years [hazard ratio (HR) = 4.7, 95% confidence interval (95% CI) 2.5-8.9], 10 years (HR = 2.2, 95% CI 1.5-3.3), and 15 years (HR = 1.7, 95% CI 1.2-2.5), and remained significant after adjustment for adjuvant medical treatment and age. In the 37% of patients with no risk factors, only one patient died of breast cancer the first 5 years. CONCLUSIONS This prospective study validates a prognostic index consisting of a proliferation factor, PR-status, and tumour size. The index may be helpful for prognostic considerations and for selection of patients in need of adjuvant therapy.

Validation of the predictive value of tissue inhibitor of metalloproteinases-1 for the response to first-line chemotherapy in metastatic breast cancer.

CTRC-AACR San Antonio Breast Cancer Symposium: 2008 Abstracts Abstract #6057 *Wurtz SO and Klintman M contributed equally, Malstrom P and Brunner N shares the senior authorship. Background. Predictive markers are scarcely represented in breast cancer. TIMP-1 has in a previous study (n = 173) performed in our laboratory been shown to carry predictive information for the response to chemotherapy in metastatic breast cancer as high tumor tissue levels of TIMP-1 were significantly associated with a low objective response rate to treatment with the most frequently used chemotherapeutic drugs (CMF or anthracyclines). The purpose of the present study was to validate these previous results with a new independent patient population. Methods. The TIMP-1 level was measured using a validated ELISA in 168 primary tumor extracts from patients with metastatic breast cancer and levels were associated with the objective response to CMF and anthracyclines. Patients were included in the study provided that they had received chemotherapy for their metastatic disease and that frozen tumor tissue as well as data on their objective response to chemotherapy was available. Results. The median TIMP-1 level in responders was 17.3 (2.9 – 75.8) ng TIMP-1/mg protein and in non-responders it was 19.6 (0-190.3) ng TIMP-1/mg protein. When analysed as a continuous log-transformed variable, increasing tumor levels of TIMP-1 were associated with a decreasing probability of objective response to CMF or anthracyclines (OR = 1.59, 95% CI: 0.97 – 2.62, p = 0.07). This is very similar to the original study and thus supporting previous data. Next, we used a more clinically relevant approach for analysing the data from the validation study. For this analysis, objective response was scored as complete or partial response versus stable disease lasting at least six months (clinical benefit) versus progressive disease (non-response). This analysis showed that increasing levels of TIMP-1 were associated with a poor clinical benefit rate from chemotherapy (OR = 1.56, 95% CI: 0.98 - 2.51, p=0.06). The original study has not previously been analysed using this endpoint. When performing this analysis, similar results were found (OR = 1.62, 95% CI: 1.06 - 2.48, p = 0.02). Combining the new population and the original population in a pooled analysis (n = 341) using a random effects model showed that high levels of TIMP-1 were highly significantly associated with a poor clinical benefit rate from chemotherapy compared with patients with low levels (OR = 1.59, 95% CI: 1.16 - 2.18, p=0.003). Conclusion. The present validation study supports previous findings that primary tumor tissue levels of TIMP-1 carries predictive information in metastatic breast cancer treated with chemotherapy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6057.

Abstract P2-10-19: Are the mitotic factors Mitotic Activity Index (MAI) and Phosphohistone 3 (PPH3) stronger prognostic proliferation factors than Ki67 in node-negative breast cancer?

Background: The prognostic value of proliferation in node-negative breast cancer, either in the form of Ki67 or as the main common denominator in different gene expression profiles, has become clearer over the last years. The St Gallen guidelines recommend the use of Ki67 to distinguish between the luminal A and luminal B-like subtypes. Also, data have shown that Ki67 can separate patients with histological grade 2 into two groups with significant difference in prognosis. However, there is no consensus on the methodology for Ki67, and genetic profiling is still expensive. Previous studies have shown a strong prognostic value of the mitosis- and late G2-specific proliferation factors Phosphohistone H3 (PPH3) and mitotic activity index (MAI) in node-negative breast cancer. The present study was set up to study the value of these two factors compared to Ki67, alone and combined. Material and methods: In 221 consecutive premenopausal node-negative breast cancer patients, of whom 87% had received no adjuvant medical treatment, PPH3 was assessed on tissue microarray (TMA), and MAI on whole sections. TMA-data on Ki67 was already available. Cut-offs for MAI, PPH3, and Ki67 were predefined. Cox proportional hazards regression was used to model the impact of the prognostic factors on distant disease-free survival (DDFS). The follow-up was restricted to the first 5 years after diagnosis, a time period during which 34 patients developed distant recurrences. Results: In univariate analysis the strongest prognostic proliferation factor for DDFS was MAI (HR 5.1 95%CI 2.4–11, p Discussion: The present study on node-negative breast cancer patients confirms the strong prognostic value of the proliferation factors MAI and PPH3, in all patients, and more specifically in ER+ patients, and patients with histological grade 2. The study also suggests that by combining two proliferation factors, MAI and PPH3, an even stronger prognostic value is found. Ki67 however, did not add any prognostic value to MAI. Taken together, MAI and PPH3, alone and in combination may be helpful for prognostic considerations and for selection of adjuvant medical treatment. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-19.

Is the prognostic value of Ki-67 dependent on ER status and histological grade?.

Abstract #1076 Purpose: Histological grade, tumor size, age, hormone receptor, and HER2 are established prognostic indicators for distant recurrences in node negative breast cancer. However, the role of the proliferation marker Ki-67 as a prognostic factor is still under debate. The aim of this study is to evaluate the additional prognostic value of Ki-67 in lymph node negative breast cancer.
 Patients and methods: In 200 consecutive premenopausal women with lymph node negative breast cancer, Ki-67 was determined using the monoclonal MIB-1 antibody on tissue microarray. High Ki-67 proliferation index was defined as >20% positive tumor cells. Cox proportional hazards regression was used to model the impact of the prognostic factors on distant disease-free survival (DDFS). Due to non-proportional hazards, the analysis was restricted to the first 5 years after diagnosis, a time period during which 38 patients developed distant recurrences.
 Results: Strong positive correlations were observed between Ki-67, histological grade, S-phase, and HER-2. In univariate analysis, Ki-67 was a prognostic factor for DDFS (HR 2.9 95%CI: 1.5-5.7, p=0.002), as well as HER2, histological grade, age and ER. Tumor size was not a significant factor. In multivariate analysis, Ki-67 was an independent prognostic factor for DDFS (HR 2.3 95% CI: 1.0-5.0, p=0.044) together with HER2 and age, whereas tumor size and ER were not significant factors. Models including both Ki-67 and histological grade were not fitted due to colinearity. When stratifying for ER status Ki-67 was a significant prognostic factor in the ER positive group only (HR 5.1 95% CI: 2.0-13, p=0.001, univariate analysis) and significant interaction between the two markers was found (p=0.02). When stratifying for histological grade, Ki-67 could divide the patients with histological grade 2 (n=69; 10 distant recurrences) into two separate groups with significant difference in DDFS (HR 15 95% CI: 3.7-57, p=0.0001) . This remained significant after adjustment for age and HER2 status. In histological grade 1 and 3, Ki-67 provided no additional prognostic information.
 Conclusion: This study demonstrates that Ki-67 is an independent prognostic factor for premenopausal patients with lymph node negative breast cancer. It is noteworthy that Ki-67 adds prognostic information in ER positive patients, but not in ER negative, and in patients with histological grade 2, but not in patients with histological grade 1 and 3. Taken together, Ki-67 may be clinically helpful for prognostic considerations and for selection of adjuvant treatment. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1076.