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|Year : 2011 | Volume
| Issue : 6 | Page : 817-822
Detection of progesterone receptor and the correlation with Ki-67 labeling index in meningiomas
Sanghamitra Mukherjee1, Samarendra Nath Ghosh2, Uttara Chatterjee3, Sandip Chatterjee4
1 Postgraduate Trainee in Pathology, IPGME&R, Kolkata, India
2 Professor in Neurosurgery, BIN&P, Kolkata, India
3 Reader in Pathology, IPGME&R, Kolkata, India
4 Neurosurgeon, Park Clinic, Kolkata, India
|Date of Submission||18-May-2011|
|Date of Decision||05-Sep-2011|
|Date of Acceptance||11-Oct-2011|
|Date of Web Publication||2-Jan-2012|
57/11A, Ballygunje Circular Road, Kolkata - 700 019
Context: Although most of the meningiomas are benign, some of them are associated with a less favorable clinical outcome. The major prognostic question regarding meningiomas is the prediction of recurrence which is largely dependent on the histopathological type, grading, proliferation indices and progesterone receptor status. Aims: Our study was done to assess the expression of Ki-67 and progesterone receptor (PR) in different histological types, grades, recurrent and non-recurrent meningiomas. Materials and Methods: A total of 60 cases were collected over a period of 2.5 years. Hematoxylin and eosin staining was done for histological typing and grading of the tumors. Immunohistochemical staining was done for Ki-67 and PR using standard immunoperoxidase technique and Ki-67 Labeling Index (LI) and PR score was calculated. Results: Mean Ki-67 LI was significantly higher in males versus females, in Grade II versus Grade I, in recurrent versus non-recurrent and in PR-negative versus PR-positive meningiomas. Moreover, considering Grade I and Grade II-meningiomas separately, mean Ki-67 LI was significantly higher in recurrent cases. PR positivity was significantly higher in females versus males, in Grade I versus Grade II and in non-recurrent versus recurrent meningiomas. Correlation between Ki-67 LI and PR expression was also evaluated and a strong inverse correlation was found between Ki-67 LI and PR expression. A strong negative correlation was also established between the values of Ki-67 LI and recurrence-free survival. Conclusion: Our results establish that the immunodetection of Ki-67 LI and PR expression in meningiomas provides a practical tool for assessing the biological behavior of meningiomas.
Keywords: Ki-67, meningioma, progesterone receptor
|How to cite this article:|
Mukherjee S, Ghosh SN, Chatterjee U, Chatterjee S. Detection of progesterone receptor and the correlation with Ki-67 labeling index in meningiomas. Neurol India 2011;59:817-22
|How to cite this URL:|
Mukherjee S, Ghosh SN, Chatterjee U, Chatterjee S. Detection of progesterone receptor and the correlation with Ki-67 labeling index in meningiomas. Neurol India [serial online] 2011 [cited 2015 Feb 1];59:817-22. Available from: http://www.neurologyindia.com/text.asp?2011/59/6/817/91357
| » Introduction|| |
Meningiomas are slow-growing benign tumors attached to the dura mater and are composed of neoplastic meningothelial cells. Most of them are benign; however, certain histological types are associated with a less favorable clinical outcome. The major prognostic question regarding meningiomas is the prediction of recurrence. This is dependent on the extent of resection, its histopathological type, grading, proliferation indices and progesterone receptor status. There are many histological subtypes of meningioma and the common subtypes are meningothelial, fibroblastic, transitional, microcystic, secretory, etc.  Meningiomas with low risk of recurrence and aggressive growth are meningothelial, fibroblastic, transitional, psammomatous, angiomatous, microcystic, secretory, lymphoplasmacyte-rich and metaplastic meningioma.  Meningiomas with greater likelihood of recurrence are of the clear cell, chordoid, papillary and rhabdoid variety.  The new World Health Organization (WHO) 2007 classification for the grading of meningioma has introduced brain invasion as a new criterion for diagnosing Grade II or atypical meningioma.  Traditionally, the majority of the meningiomas are considered benign and slow-growing tumors, however, about 20%  of them can have a more aggressive course manifesting usually as local recurrences and it is difficult to predict which one is likely to do so. The prediction of clinical outcome, recurrence and discrimination of atypical from benign or anaplastic meningioma (at least in histological borderline cases) is often difficult with the help of histological criteria only. Several newer prognostic markers are increasingly being studied nowadays. Analysis of Ki-67 labeling indices, one of the most important proliferation markers, appears to have a correlation with clinical outcome. Since meningiomas are known to enlarge during periods when levels of circulating progestins are high, the presence of significant quantities of progesterone receptors in a high percentage of tumors may have therapeutic implications for recurrent, malignant or incompletely excised tumors or for medically fragile patients.  There are several reports suggesting that a positive progesterone receptor (PR) status is linked to later recurrence.  This study was done to assess the expression of Ki-67 and PR in different histological types, grades, recurrent and non-recurrent meningiomas.
| » Materials and Methods|| |
In this study, cases have been collected for a period of 2.5 years. It was noted whether the tumors at the time of presentation in our hospital outdoor were first-time tumors or recurrence. Since this was a retrospective study, it was not possible to obtain details of primary surgery in cases of recurrent tumors operated elsewhere. Subtotal resection was done in most of the cases. Hematoxylin and eosin (H and E) staining was done for histological typing and grading of the tumors. Tumors were graded according to the 2007 WHO grading system. Immunohistochemical staining was done for Ki-67 and PR using standard immunoperoxidase technique with pre-diluted monoclonal antibody of Bio-Genex (USA). Tissue sections are first dewaxed (as they are paraffin-embedded), treated with an antigen retrieval solution, blocked with a proteinaceous solution and then incubated with a primary antibody. The bound primary antibody is detected by the addition of secondary antibody conjugated with horseradish peroxidase polymer (HRP) and DAB (3 ' Diaminobenzidine Tetra Hydrochloride) substrate. When adequate color development is seen, the slides are washed in water to stop the reaction, counterstained and covered with a mounting medium.
Ki-67 Labeling Index (LI) was determined in each case by manual counting and was interpreted as number of nuclei showing positive staining (brown color) / total number of nuclei X 100%. PR expression was scored into Group I to III as follows: Group I - Moderate to strong nuclear staining, Group II - Weak nuclear staining and Group III - Absent nuclear staining. 
Regarding statistical analysis, two-group comparison was done using Mann-Whitney U test and Fisher ' s Exact test. Difference in Ki-67 expression between male-female, different histological types, different histological grades, recurrent and non-recurrent meningiomas and between PR-positive and PR-negative tumors was determined separately using Mann-Whitney U test. Correlation between Ki-67 expression and PR positivity was calculated using Point-biserial correlation coefficient. Comparison of PR status between male-female, different histological types, different histological grades and between recurrent and non-recurrent meningiomas was done by Fisher's Exact test. Two-tailed P value < 0.05 was considered statistically significant.
| » Results|| |
A total of 60 cases were studied. Age ranged from 32 years to 73 years (Mean: 49.15 years). There were 37 female patients and 23 male patients. According to location, 51 (85%) were cranial and nine (15%) were spinal meningiomas. Female: Male ratio among cranial meningiomas was 1.4:1 and among spinal meningiomas was 3.5:1. According to histological type, 22 were meningothelial (36.7%), 13 fibrous (21.6%), eight transitional (13.4%), five psammomatous (8.3%), three were angiomatous (5%) [Figure 1]a, three microcystic (5%) [Figure 1]b, there were five cases of atypical meningiomas (8.3%) and one case of anaplastic meningioma (1.7%). Five cases grossly presented as en-plaque meningiomas [Figure 1]c. According to the WHO 2007 grading system, 54 were Grade I (90%), five were Grade II (8.3%) and one was Grade III meningioma (1.7%). The patient of Grade III meingioma died within three months of presentation. Among 60 meningiomas, eight (13%) were recurrent at the time of presentation in our hospital and of these one was spinal and the rest cranial in location. Recurrence-free survival of Grade I recurrent meningiomas was between 48-62 months whereas that of Grade II cases was between 18-32 months [Table 1].
|Figure 1: a: Low-power view of angiomatous meningioma showing hyalinized blood vessels|
Figure 1: b: Low-power view of microcystic meningioma showing multiple small cysts
Figure 1: c: Low-power view of en-plaque meningioma showing muscle invasion
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We determined Ki-67 LIs of all the 60 cases [Figure 1]a, b, c. Mean LI in 23 male patients was 2.83% (SD = 2.86) whereas in 37 female cases, it was 1.24% (SD = 0.662) and this gender-related difference was statistically significant (P value = 0.000001). Difference in Ki-67 LIs among different histological types of meningomas was not significant. Mean Ki-67 LIs of 54 Grade I meningiomas (mean LI: 1.4%; SD = 0.642) were significantly lower (P value = 0.0002) than LIs of five Grade II meningiomas (mean LI: 4.08%; SD = 0.645). One case of Grade III meningioma showed Ki-67 LI of 15%. Mean Ki-67 LI in recurrent meningiomas (mean LI: 3.56%; SD = 0.819) was significantly higher (P value = 0.000017)) than that of non-recurrent meningiomas (mean LI: 1.32%; SD = 0.584). Five cases of Grade I recurrent meningiomas had a mean Ki-67 LI of 2.9% (SD = 0.178) whereas three cases of Grade II recurrent meningiomas had a mean value of 4.53% (SD = 0.819). Mean LI in recurrent Grade II meningiomas was significantly higher (P=0.009) than in non-recurrent Grade II meningiomas. Similarly, significantly high Ki-67 LI was also obtained in recurrent Grade I meningiomas than in non-recurrent cases. We also analyzed progesterone receptor (PR) expression in all the 60 cases [Figure 2]a, b, c. PR positivity was found in 39 meningiomas (65%) whereas PR staining was absent in the remaining 21 cases (35%). Among 37 female patients, 31 showed positive PR staining (83%) whereas only eight out of 15 male patients (34%) showed PR positivity and this gender-related difference in PR expression was statistically significant (P value = 0.000). PR staining was present in 23 out of 30 cases (76%) of meningothelial and transitional meningiomas whereas only eight out of 13 fibrous meningiomas (61%) showed PR positivity but this difference was not significant. A statistically significant difference in PR positivity (P value = 0.041) was found between Grade I (70% PR positivity) and Grade II meningiomas (20% PR positivity). The single Grade III meningioma was PR-negative [Figure 3] a-c. According to PR score, out of 38 PR-positive Grade I meningiomas, 28 were in Group I (moderate to strong PR positivity) and 10 cases showed weak nuclear staining (Group II). The single case of PR-positive Grade II meningioma also showed Group II positivity. Among 52 non-recurrent meningiomas, 37 were PR-positive (71%) whereas only two out of eight recurrent tumors showed PR positivity (25%) and this finding was also significant (P value = 0.014). Mean Ki-67 LI in 39 PR-positive cases (mean LI: 1.2%) was significantly lower (P value = 0.000) than that of 21 PR-negative meningiomas (mean LI: 3.06%). Correlation between mean Ki-67 LI and recurrencefree survival was evaluated among all the recurrent cases and a strong negative correlation was established with a correlation coefficient ratio of -0.87. This ratio was -0.49 amongst Grade I recurrent meningiomas [Table 1]. Correlation between Ki-67 LI and PR expression was also evaluated and a strong inverse correlation was found between Ki-67 LI and PR expression with a correlation coefficient ratio of -0.45 (P < 0.001). Moreover, among Grade I meningiomas, this negative correlation was found to be stronger (correlation coefficient ratio of -0.62). But it was not possible to establish this inverse correlation between the two markers among Grade II meningiomas as sample size was small. Similarly, among 52 non-recurrent meningiomas, mean Ki-67 LI in PR-negative tumors was higher (LI=1.75%) than in PR-positive tumors (LI=1.07%) and this inverse correlation was also strong (correlation coefficient ratio of -0.60) [Graph 1] and [Graph 2].
|Figure 2: a: Low-power view of Grade I meningioma showing very low Ki-67 expression|
Figure 2: b: High-power view of Grade II meningioma showing moderate Ki-67 expression
Figure 2: c: High-power view of Grade III meningioma showing high Ki-67 expression
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|Figure 3: a: High-power view showing strong PR expression in Grade I meningioma|
Figure 3: b: Low-power view showing weak PR expression in Grade II meningioma
Figure 3: c: Low-power view showing absence of PR expression in Grade III meningioma
Click here to view
| » Discussion|| |
Many studies have been undertaken so far to analyze the role of Ki-67 and PR in meningioma and also to assess their significance as prognostic factors in predicting the behavior of meningioma but different studies have given varied propositions regarding the correlation of Ki-67 and PR expression with the biological behavior of meningioma.
Out of the 60 evaluated cases, 22 were meningothelial (36.7%), 13 fibrous (21.6%), eight transitional (13.4%), five psammomatous (8.3%), three were angiomatous (5%), three microcystic (5%), there were five cases of atypical meningiomas (8.3%) and one case of anaplastic meningioma (1.7%). Our result differs from that of Gursan et al.,  who showed a somewhat higher percentage of transitional subtype and lower percentage of fibrous meningiomas in comparison to ours. Gursan et al., found 50% meningothelial, 16.3% fibrous, 29.2% transitional, 1.8% atypical and 2.7% anaplastic meningiomas. According to histological grade, we found 54 cases (90%) of Grade I meningiomas, five cases (8.3%) of Grade II or atypical meningiomas and one case (1.7%) of Grade III or anaplastic meningioma. So, atypical and anaplastic meningiomas constituted 10% of total cases and this finding is consistent with Nagashima et al.  We found significantly higher mean Ki-67 LIs in male patients (LI = 2.83%) in comparison to female patients (LI = 1.24%) and this finding is similar to Matsuno et al.  This gender difference may reflect the higher occurrence of non-benign meningiomas in males. In our study, Ki-67 LIs of 60 meningiomas varied between 0.6-15% which is quite similar to Nagashima et al., who found the range being 0.4-16.4%.  We have found significantly higher Ki-67 LIs in Grade II meningioma than Grade I and this finding is corroborative with Gursan et al., Abramovich et al.,  and Wolfsberger et al.  The difference in Ki-67 LIs between recurrent and non-recurrent meningiomas was also statistically significant and the result is in keeping with Miyagami et al., Matsuno et al.,  and Abramovich et al.  According to our study, mean Ki-67 LI in recurrent tumors was 3.56% whereas non-recurrent tumors showed LI of 1.32%. On the other hand, Abramovich et al., showed mean Ki-67 LIs for recurrent versus non-recurrent tumors as 7.1% versus 3.8%. 
We have found PR positivity in 65% of total cases whereas different other studies (Gursan et al., Nagashima et al., Wolfsberger et al.,  ) showed a little higher percentage of PR positivity (72%). According to our study, the presence of PR immunostaining was more abundant in females (83% versus 34% in males) and this gender-related difference was statistically significant. Other studies (Gursan et al., Halpern et al.,  and Perrot et al.,  ) also demonstrate a significant gender difference in the expression of the PR, in that a higher percentage of women with meningiomas have PR than do men. This gender difference is attributable to the higher occurrence of atypical and anaplastic meningomas in male patients. Although most of the studies show the same percentage of PR positivity in female patients as ours, PR positivity in male patients largely differs. In contrast to 34% PR positivity of male patients in our study, Gursan et al.,  showed 55% PR positivity and Perrot et al.,found 58% PR positivity.  Our study found PR expression more frequently in meningothelial and transitional subtypes than in the fibroblastic histological type and this finding is consistent with that of other studies (Gursan et al., Black et al.,  ). In our study, the positive immunostaining rate for PR in the Grade I meningiomas was significantly higher than in high-grade tumors which is similar to Nagashima et al.,  and Gursan et al. We found 70% PR positivity in Grade I meningiomas whereas Gursan et al., found 76% positivity in the same grade.  We found that six out of eight recurrent meningiomas (80%) were PR-negative and similar to Fewings et al.,  there is a significant association between tumor recurrence and PR negativity. According to their study, 11 out of 13 recurrent tumors were PR-negative (84%) and Grade I meningiomas that were PR-positive were less likely to recur (P = 0.013).  Moreover, in the present study, the Ki-67 LIs were significantly higher in the PR-negative meningiomas than in the PR-positive tumors and there was a "strong" inverse correlation between Ki-67 LI and PR expression. This finding is supported by several other studies by Gursan et al., Nagashima et al., Roser et al.,  and Kakinuma et al. This "strong" inverse correlation between Ki-67 LI and PR expression was more evident in case of Grade I meningiomas and also in non-recurrent tumors whereas five out of six high-grade meningiomas showed PR negativity and high mean Ki-67 LI (4.08%). This result is quite similar to Gursan et al.,  and Nagashima et al.,  who found negative PR staining and high Ki-67 LI (6.50% to 7.37%) in high-grade meningiomas.
So, in addition to H and E staining, combining Ki-67 LI and PR expression can help not only in distinguishing between grades of meningiomas but can also help to pick which cases within the group of Grade I meningiomas are likely to recur.
| » References|| |
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