Annals of Surgical Oncology

, Volume 25, Issue 1, pp 290–298 | Cite as

Redefining the Ki-67 Index Stratification for Low-Grade Pancreatic Neuroendocrine Tumors: Improving Its Prognostic Value for Recurrence of Disease

  • Alexandra G. Lopez-Aguiar
  • Cecilia G. Ethun
  • Lauren M. Postlewait
  • Kristen Zhelnin
  • Alyssa Krasinskas
  • Bassel F. El-Rayes
  • Maria C. Russell
  • Juan M. Sarmiento
  • David A. Kooby
  • Charles A. Staley
  • Shishir K. Maithel
  • Kenneth CardonaEmail author
Pancreatic Tumors



The Ki-67 index is an established prognostic marker for recurrence after resection of pancreatic neuroendocrine tumors (PanNETs) that groups tumors into three categories: low grade (< 3%), intermediate grade (3–20%), and high grade (> 20%). Given that the majority of resected PanNETs have a Ki-67 less than 3%, this study aimed to stratify this group further to predict disease recurrence more accurately.


The Ki-67 index was pathologically re-reviewed and scored by a pathologist blinded to all other clinicopathologic variables using tissue microarray blocks made in triplicate. All patients who underwent curative-intent resection of non-metastatic PanNETs at a single institution from 2000 to 2013 were included in the study. The primary outcome was recurrence-free survival (RFS).


Of 113 patients with well-differentiated PanNETs resected, 83 had tissue available for pathologic re-review. The Ki-67 index was lower than 3% for 72 tumors (87%) and between 3 and 20% for 11 tumors (13%). Considering only Ki-67 less than 3%, the tumors were further stratified by Ki-67 into three groups: group A (< 1%, n = 43), group B (1–1.99%, n = 23), and group C (2–2.99%, n = 6). Compared with group A, groups B and C more frequently had advanced T stage (T3: 44% and 67% vs 12%; p = 0.003) and lymphovascular invasion (50% and 83% vs 23%; p = 0.007). Groups B and C had similar 1- and 3-year RFS, both less than group A. After combining groups B and C, a Ki-67 of 1–2.99% was associated with decreased RFS compared with group A (< 1%). This persisted in the multivariable analysis (hazard ratio [HR] 8.6; 95% confidence interval [CI] 1.0–70.7; p = 0.045), with control used for tumor size, margin-positivity, lymph node involvement, and advanced T stage.


PanNETs with a Ki-67 of 1–2.99% exhibit distinct biologic behavior and earlier disease recurrence than those with a Ki-67 lower than 1%. This new stratification scheme, if externally validated, should be incorporated into future grading systems to guide both surveillance protocols and treatment strategies.



Funding in part was provided by the Katz Foundation.


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Copyright information

© Society of Surgical Oncology 2017

Authors and Affiliations

  • Alexandra G. Lopez-Aguiar
    • 1
  • Cecilia G. Ethun
    • 1
  • Lauren M. Postlewait
    • 1
  • Kristen Zhelnin
    • 2
  • Alyssa Krasinskas
    • 2
  • Bassel F. El-Rayes
    • 3
  • Maria C. Russell
    • 1
  • Juan M. Sarmiento
    • 4
  • David A. Kooby
    • 1
  • Charles A. Staley
    • 1
  • Shishir K. Maithel
    • 1
  • Kenneth Cardona
    • 1
    Email author
  1. 1.Division of Surgical Oncology, Winship Cancer InstituteEmory UniversityAtlantaUSA
  2. 2.Department of Pathology, Winship Cancer InstituteEmory UniversityAtlantaUSA
  3. 3.Department of Hematology Oncology, Winship Cancer InstituteEmory UniversityAtlantaUSA
  4. 4.Department of General SurgeryEmory UniversityAtlantaUSA

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