1. How to count, what to count and why to count Ki-67 immunoreactive cells Beppe Viale IEO & UNIMI

2. Ki-67: son of a lesser God

3. Can we do it better? Ki67 www.google.com

4. Mitsubishi Ki-67 Hiryu (Peggy) Though classified as a medium bomber by the Japanese, by Western standards, the Ki-67 Peggy was seen as a light bomber

11. STEPP Ki-67 LI by Treatment in the PACS01 trial

15. DFS by Ki-67 LI

16. STEPP Ki-67 LI by Treatment in the BIG1-98 trial

18. Contributions to Composite Risk Points: 0 ~0.25 ~0.5 ~0.75 ~1.5 Lymph nodes 0 1-3 4-9 10+ ER % 50+ 30-49 <30% PgR % 20+ <20 Ki-67 % <14 14-33 34+ HER2 Neg Pos PVI No Yes Grade 1 2 3 T size ≤ 2 2.1-4.9 5+

19. STEPP 5-year DFS by Composite Risk Increasing Composite Risk

20. Chemotherapy in ER+ve HER2-ve Relative Indications for chemotherapy: any of Factors not useful in decision* Relative Indications for endocrine therapy alone Grade 3 Grade 2 Grade 1 High proliferation Intermediate proliferation Low proliferation Lower ER and PgR level Higher ER and PgR level N 4+ N 1-3 Node negative Peritumoral vascular invasion (PVI) No PVI T size > 5cm T size >2 – 5 cm T size <= 2cm*** Patient preference to use all available treatments Patient preference to avoid side effects Multigene assays: High Intermediate Low score

22. Intrinsic Subtypes Clinicopathological correlates (1) Intrinsic Subtype Clinico-pathologic definition Notes Luminal A ‘ Luminal A’ ER and/or PgR positive HER2 negative Ki-67 low (<14%)* Optimal cut point for Ki-67 labelling index was established by comparison with PAM50 intrinsic subtyping. Local quality control of Ki-67 staining is important. Luminal B** ‘ Luminal B (HER2 negative)’ ER and/or PgR positive HER2 negative Ki-67 high ‘ Luminal B (HER2 positive)’ ER and/or PgR positive Any Ki-67, HER2 over-expressed or amplified [5] Genes indicative of higher proliferation are poor prognostic markers in multiple genetic assays [7]. Useful to distinguish ‘luminal B HER2 positive’ as both endocrine and anti-HER2 therapy indicated

23. Intrinsic Subtypes Clinicopathological correlates (2) Intrinsic Subtype Clinico-pathologic definition Notes Erb-B2 overexpression ‘ HER2 positive (non luminal)’ HER2 over-expressed or amplified ER and PgR absent The majority of HER2 positive tumours are endocrine-receptor negative ‘ Basal-like’ ‘ Triple negative (ductal)’ ER and PgR absent HER2 negative Approximately 80% overlap between ‘triple negative’ and intrinsic ‘basal-like’ subtype Staining for basal keratins although shown to aid selection of true basal-like tumours, is not considered insufficiently reproducible for general use.

25. ‘ Subtype’ Type of therapy Notes ‘ Luminal A’ Endocrine therapy alone Few require cytotoxics (e.g. high nodal status). ‘ Luminal B (HER2 negative)’ Cytotoxics + endocrine therapy Inclusion and type of cytotoxics may depend on perceived risk and patient preference. ‘ Luminal B (HER2 positive)’ Cytotoxics + anti-HER2 + endocrine therapy No data are available to support the omission of cytotoxics in this group. ‘ HER2 positive (non luminal)’ Cytotoxics + anti-HER2 ‘ Triple negative (ductal)’ Cytotoxics Consider DNA disrupting agents. ‘ Special histological types’* A. Endocrine responsive B. Endocrine non responsive Endocrine therapy Cytotoxics Medullary and adenoid cysctic carcinomas may not require any adjuvant cytotoxics).

27. Work in progress: Fostering standardisation Ki67 in breast cancer: recommendations from the International Ki67 in Breast Cancer Working Group Mitch Dowsett 1 , Torsten O Nielsen 2 , Roger A’Hern 3 , John Bartlett 4 , R Charles Coombes 5 , Jack Cuzick 6 , Matthew Ellis 7 , Lynn Henry 8 , Tracy Lively 9 , Lisa McShane 10 , Soon Paik 11 , Ljudmila Prudkin 12 , Meredith Regan 13 , Janine Salter 1 , Christos Sotiriou 14 , Ian Smith 15 , Giuseppe Viale 16 , Jo Anne Zujewski 17 , Daniel F Hayes 8 . Meeting in London, March 2010

29. Gradient of Ki67 labelling index

30. Gradient & hot spot

31. Gradient & hot spot ?