3/22/2017. Disclosure of Relevant Financial Relationships. Ki-67 in Pancreatic Neuroendocrine Neoplasms According to WHO 2017.

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1 Disclosure of Relevant Financial Relationships Ki-67 in Pancreatic Neuroendocrine Neoplasms According to WHO USCAP requires that all planners (Education Committee) in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Günter Klöppel Dept of Pathology, Technical University München, Germany Dr. Günter Klöppel declares he has no conflict(s) of interest to disclose Znt. J. Cancer: 31, (1983) PRODUCTION OF A MOUSE MONOCLONAL ANTIBODY REACTIVE WITH A HUMAN NUCLEAR ANTIGEN ASSOCIATED WITH CELL PROLIFERATION Johannes GERDES, Ulrich SCHWAB, Hilmar LEMKE and Harald STEIN Institutes of Pathology and Biochemistry Christian Albrecht University, Kiel; Germany Gerdes J, Schwab U, Lemke H, Stein H. Int J Cancer. 1983;31(1): reported upon a new monoclonal antibody which was generated by immunizing mice with nuclei of the Hodgkin lymphoma line L428. The antibody labelled nuclei of proliferating s including tumor s. The authors concluded: Ki-67 may be a potent tool for easy and quick evaluation of the proportion of proliferating s in a tumor Ki-67 The name derived from the city of Kiel where the authors worked at the Dept of Pathology of the University Hospital, and it derived from the number 67 of the original clone position in the 96- well plate The monoclonal antibody Ki-67 identifies a 359-kD non-histone nuclear protein (encoded by MKI67), PRESENTATION which is TITLE not only expressed in the M-phase, but also in the G1, S and G2 phase. 1

2 Comparison between Ki67 and mitotic counts 26 counts 3 counts The function of the Ki-67 nuclear protein remains unclear The original Ki-67 antibody worked only on frozen material, but was soon replaced by monoclonal antibodies which worked on formalin-fixed and paraffin-embedded tissues. 25 counts Comparison between two staining protocols for Ki67/MIB1 -Kreipe H, Heidebrecht HJ, Hansen S, Rohlk W, Kubbies M, Wacker HH, et al. A new proliferation-associated nuclear antigen detectable in paraffin-embedded tissues by the monoclonal antibody Ki-S1. Am J Pathol. 1993;142(1):3-9. -Rudolph P, Kellner U, Chassevent A, Collin F, Bonichon F, Parwaresch R, et al. Prognostic relevance of a novel proliferation marker, Ki-S11, for soft-tissue sarcoma. A multivariate study. Am J Pathol. 1997;150(6): MIB-1 recognizes the Ki-67 antigen Without optimizer 34 counts With optimizer -von Herbay A, Sieg B, Schurmann G, Hofmann WJ, Betzler M, Otto HF. Proliferative activity of neuroendocrine tumours of the gastroenteropancreatic endocrine system: DNA flow cytometric and immunohistological investigations. Gut. 1991;32(8): Pelosi G, Bresaola E, Bogina G, Pasini F, Rodella S, Castelli P, et al. Endocrine tumors of the pancreas: Ki-67 immunoreactivity on paraffin sections is an independent predictor for malignancy: a comparative study with proliferating- nuclear antigen and progesterone receptor protein immunostaining, mitotic index, and other clinicopathologic variables. Hum Pathol. 1996;27(11): Why and when was Ki-67 included into the PanNEN classification? 2

3 The WHO 2000 classification of PanNENs The WHO classification of PanNENs Definition of grades Well differentiated NENs Ki67index* Mitotic index Neuroendocrine tumour (NET) G1 <3 2 % <2/10 HPF Neuroendocrine tumour (NET) G % 2-20/10 HPF Neuroendocrine tumour (NET) G3 >20 % >20/10 HPF well differentiated NEN -NET -low proliferative activity -hormone expression -hormonal syndromes -hereditary syndromes -long survival Poorly differentiated NENs Neuroendocrine carcinoma (NEC) G3 >20 % >20/10 HPF Small type Large type Mixed neuroendocrine-nonneuroendocrine neoplasm (MiNEN) poorly differentiated NEN -NEC -high proliferative activity -no hormone expression -no hormonal syndromes -short survival Grade of pancreatic NENs and Ki67- index related to prognosis and therapy Resection Bio-Responsemodifiers Temozolomide NET G1: < 2% Recommendations for counting Ki67 labeled s Chemo CIS-platinum NEC G3: > 20 % NET G2: 2%-20% Ki67 index is based on at least 500 s in areas of higher nuclear labeling ( hot spots ). For assessing Ki67,; manual counting of printed images is suggested (Reid et al 2015) ; eyeballing is not recommended Rindi et al, JNCI

4 What is new in the upcoming WHO 2017 PanNEN classification? Reid et al Mod Pathol 2015 New Features of the WHO 2017 classification of PanNENs Definition of grades Well differentiated NENs Ki67index* Mitotic index Neuroendocrine tumour (NET) G1 <3 % <2/10 HPF Neuroendocrine tumour (NET) G % 2-20/10 HPF Neuroendocrine tumour (NET) G3 >20 % >20/10 HPF Poorly differentiated NENs Neuroendocrine carcinoma (NEC) G3 >20 % >20/10 HPF Small type Large type Mixed neuroendocrine-nonneuroendocrine neoplasm (MiNEN) Sorbye, Nordic NEC study, Ann Oncol 2013; Baudin et al ERC 2013 Liver Met of PanNET - primary tumor was G2, 16% Ki-67: 37% Are both G3 PanNECs? PanNEC, G3? Ki-67: 25% Ki-67: 70% 4

5 NETs or NECs of the pancreas? NETs or NECs of the pancreas? Pancreatic neuroendocrine neoplasms Potential markers for PanNETs or PanNECs - ATRX / DAXX, MEN1, mtor genes - p53 / TP53 - Rb1 / rb1 NET G3 of the pancreas Ki-67: 25% p53 - SSTR2A - Islet 1 - Progesteron receptor Jiao et al Science 2011 Agaimy et al Modern Pathol 2013 Marinoni et al Gastroenterol 2014 Kaemmerer et al Oncotarget 2015 Yashida et al AJSP 2012 Tang et al CCR 2016 Tang et al AJSP 2016 Konukiewitz et al Modern Pathol 2017 NEC G3 of the pancreas Ki-67: 70% p53 rb1 Pancreatic neuroendocrine neoplasms Pancreatic neuroendocrine neoplasms NET G3 Small NEC Large NEC Small NEC NET G3 SSTR2A 3+ SSTR2A 2+ SSTR2A 0-1+ ATRX positive WT ATRX negative MUT 5

6 PanNENs and Ki-67 Markers distinguishing between PanNETs G3 and PanNECs, large and small NET G1 G2 NET G3 / NEC G3 NEC G3 2% 20% >50% 80% Organ Diagnosis n Ki67-range p53 TP53 Rb1 (loss) SSTR2A ATRX (loss) DAXX (loss) Pancreas NET G3 9 21% 36% 0% 0% 0% 78% 11% 33% Pancreas NEC 12 21%-90% 75% 67% 45% 8% 0% 0% Konukiewitz et al Modern Pathol 2017 Well differentiated NENs -NETs Poorly differentiated NENs -NECs Progenitor origin of GEP-NENs NET with poorly differentiated component Intestinal stem NGN3? endocrineprecursor duodenum NGN3 Somatostatin Gastrin CDX2 MATH1 Poorly differentiated - NEC Stem PDX1 p53, rb,. MEN1 ATRX/ DAXX, mtor Well differentiated - NET Ki-67: 60% Pancreas stem NGN3 endocrineprecursor pancreas, PDX1 Gastrin Somatostatin PP Glucagon Insulin These tumors showed no p53/rb1 abnormalities despite poor morphology and high proliferation. However,. Tang et al AJSP 2016 Take Home Message In PanNENs (as in many other tumors) the Ki-67 index strongly correlates with prognosis PanNENs are heterogeneous regarding morphology, proliferation and biology The new WHO classification therefore distinguishes among the PanNENs with Ki-67 >20% between well differentiated PanNENs (NETs) G3 and poorly differentiated PanNENs (NECs) G3 6