Acta Neurochir (Wien) (2004) 146: 37–44

DOI 10.1007/s00701-003-0173-4

Clinico-Pathological Study
The Ki-67 proliferation antigen in meningiomas. Experience
in 600 cases

F. Roser1, M. Samii1;2 , H. Ostertag3 , and M. Bellinzona1

1
Department of Neurosurgery, Klinikum Hannover Nordstadt, Hannover, Germany
2
International Neuroscience Institute, Klinikum Hannover Nordstadt, Hannover, Germany
3
Institute of Pathology, Klinikum Hannover Nordstadt, Hannover, Germany

Published online December 22, 2003

# Springer-Verlag 2003

Summary Introduction

Background. Meningiomas are mostly benign tumours that can be
cured by surgical resection. Because meningiomas tend to recur, long
term management in patients with subtotal tumour resection remains
controversial. Previous studies have shown that the proliferation poten-
tial of meningiomas by Ki-67 labelling indices (LI) might predict their
natural history. The purpose of this study was to analyse the reliability of
Ki-67-labelling index in predicting the behaviour of meningiomas, and
to help the neurosurgeon in establishing better follow up criteria and
long term management strategies for these patients.
Method. From 1990 to 2000 1328 meningiomas have been operated
in our Neurosurgical Department. A total of 600 tumours were examined
immunohistochemically using the Mib-1 monoclonal antibody. Clinical
charts of the patients including surgical, histological and follow up
records, as well as imaging studies were analysed retrospectively. Ki-
67 LI were correlated with neuroradiological findings, 3D volumetric
studies, histological subtype, recurrence-free survival, grade of resection,
consistency of tumour tissue, location, osseous involvement, en plaque
appearance, vascularity and progesterone-receptor status.
Findings. Among the 600 patients analysed, there were 66% females
(mean LI 3.8%) and 34% males (mean LI 5.7%), including 20 neurofi-
bromatosis-type-2 (NF-II) patients with a mean LI of 5.2%. Histological
grading revealed 91% WHO
I meningiomas (mean LI 3.28%), 7%
WHO
II (mean LI 9.95%) and 2% WHO
III (mean LI 12.18%). Label-
ling indices in recurrent meningiomas increased from initial resection to
a fourth local resection. A significant correlation between negative
progesteron-receptor status and high tumour vascularity with high Ki-
67 LI was seen. Ki67 was not a statistically significant predictor of
survival time in totally excised WHO
I meningiomas.
Interpretation. Mib-1 is one important tool in addition to routine
histological evaluation, but a combination of clinical factors and parti-
cularly the extent of surgical resection, along with the biological features
of the tumour, should influence the decision of the neurosurgeon to the
patient follow up.
Keywords: Meningioma; Mib-1; Ki-67; recurrence; proliferation.
Although generally considered benign, the biological
behaviour of meningiomas varies considerably. Not only
histopathological criteria but also the surgical grade of
resection determines the recurrence free-survival in
patients with histologically comparable meningiomas
[3, 18, 34, 48]. Between 7 and 32% of benign menin-
giomas recur after total resection, and between 19 and
50% after subtotal removal [11, 20]. Because of
their clinical behaviour with a tendency to recur and
unfavourable outcome after repeated operations, menin-
giomas cannot be classified as a benign entity despite
their pathological classification. Decisions regarding
patient management therefore rely on a variety of clin-
ical, radiological and pathological prognosticators.
Growth potential of meningioma is variable and even
the microscopic morphological classification of the
World Health Organization (WHO) cannot predict the
clinical behaviour of these tumours [25]. Quantifying
their proliferative potential may help to predict the bio-
logical behaviour of individual tumours of comparable
histology. The prognostic significance of various pro-
liferative indices in meningiomas has already been
assessed by other authors, and it has been suggested that
the tumour proliferative potential can predict the
patient’s clinical course [1, 2, 11, 16, 20, 23, 28, 32,
33, 35, 40, 42, 44]. The nuclear antigen Ki-67 expressed
by proliferating cells has become available for routinely
38 F. Roser et al.

processed paraffin section [8, 15]. The Mib-1 antibody considered significant at P-value < 0.05. The distribution of the re-
currence-free survival times were estimated using the Kaplan-Meier
detects an epitope on the Ki-67 antigen, a nuclear pro- method. Pearson’s regression analysis was performed to determine the
tein present only during active phases of the cell cycle correlation between mean Ki-67 LI and other influencing factors. Multi-
(G1, S, G2 and M). Several studies were done to inves- variate analysis (ANOVA) was also performed. Volume measurements
were performed with the Image J program (Scion Image, based on NIH
tigate how Ki-67 labelling indices could help to predict
Image. Beta Release 4.0.2) scanning adjacent axial, coronal and sagittal
recurrences. However, a lack of adequate case numbers, slices of post contrast CT=MRI scans throughout the tumour. The growth
inconsistent statistical methods and clinical considera- rates were determined according to the absolute growth rate (cm3=year)
calculation [dV (latest-initial)=t]. Recurrence was defined as radiologi-
tions precludes a comparison of these studies. The aim
cally detected evidence of regrowth regardless of symptoms.
of the present study was to assess if and how the neu-
rosurgeon can rely on the Ki-67 labelling index to use
the best follow-up criteria and therapeutic options. Results
Therefore we compared selected histopathological and
The mean Mib-1 SI in the 184 male patients was
macroscopical features as well as survival times in me-
5.78% (SD 6.31), whereas that of the 370 female pa-
ningioma patients. Further comparisons were made for
tients was 3.87% (SD 6.314). Taking the WHO classifi-
each patient in the recurrent group between the initi-
cation into consideration, this sex-related difference was
ally resected tumour and all local recurrences to deter-
not significant (Table 1). There were no higher Mib-1
mine whether recurrent meningioma tends to become
scores observed in younger patients ( < 37 years mean
histologically more aggressive.
Ki-67 LI 4.2%, SD 4.19) whereas patients with NF-II
show significantly higher mean Ki-67 LI (6.2%, SD
Materials and methods 3.95). All NF-II cases were excluded from the following
statistical evaluations due to their different tumori-
Between 1990 and 2000, 1328 meningiomas have been removed in
our Neurosurgical Department. Six hundred paraffin blocks of 554 genesis. In this series of 600 retrospectively evaluated
patients were selected and the paraffin blocks retrieved from the meningiomas no tumour was embolized pre-operatively.
archives. Among our patients there were 184 males and 370 females After classifying 580 tumours into 6 typical cate-
(ratio 1:2), ranging in age from 15 to 94 (mean age of 64). All patients
were followed for a median of 74 months (ranging from 3–228 months)
gories of meningioma appearance, we found no statis-
or until death. The material included 20 patients with NF-II disease tically significant relationship between the proliferation
(for a total of 28 tumours), with a mean age of 32.3 years at presentation index and tumour location (P ¼ 0.273) (Table 2).
(16–60) and a male to female ratio of 1:1. Clinical information of each
patient was obtained through review of medical records, as well as
follow-up examinations with clinical and neuroradiological evaluation
or through detailed questionnaires with radiological reports of the latest Table 1. Mean Ki-67 LI in meningiomas
MRI findings.
Paraffin sections were stained with hematoxylin-eosin, and neoplastic No. of cases Ki-67 (range) Ki-67
areas were delineated. They were categorized into meningioma subtypes (mean þ SD)
according to the new WHO classification [25]. Immunohistochemistry
WHO
I 526 0–58 3.54  4.97
was performed using 2 mm thick paraffin sections. In short, paraffin sec-
– Female 370 3.30  4.44
tions were dewaxed and stained with Anti-Mib-1 purchased from DAKO
– Male 156 4.37  4.80
[Copenhagen, Denmark], according to standard protocols using the
ChemMate Detection Kit Alkaline Phospatase from DAKO [Copenhagen, WHO
II 45 3–30 11.9  8.25
Denmark] and NeoFuchsin as chromogen. Sections were counterstained – Female 18 12.27  8.51
with Hemalaun and coverslipped with KP tape [KliniPath BV, Nether- – Male 27 11.67  8.07
lands]. Positive control specimens were run in every essay using glioblas- WHO
III 9 5–30 18.2  9.53
toma tissue. Also, negative controls were run in every staining session. – Female 3 19.0  10.53
In each case, the entire section was systematically examined using an – Male 6 15.8  9.17
optical grid on high power fields (400  , ZEISS microscope) for the
presence of immunoreactivity. In every slide the area of densest staining
(‘hot spot’), was searched for and counting was performed in 10 contig-
uous fields. The average of the results in these fields determined the Table 2. Mean Ki-67 LI in different locations (n ¼ 580)
proliferative index (LI). Only unquestionably stained nuclei were accepted
Region Number of cases Mean Ki-67 SD
as positively stained. All slides were routinely examined by one patholo-
gist (HO). Randomly chosen stains were also counted by independent Convexity 178 5.02 5.36
researchers to check the interindividual difference of interpretation of the CPA 144 4.78 6.75
mean Ki-67 LI, and revealed no statistically significant differences. Sphenoid wing 105 4.27 6.13
Statistical analysis was performed using the SPSS 10.0 (SPSS Inc.) Frontobasal 67 3.57 3.84
software program for windows. Several parameters shown in the result Petroclival 54 3.84 3.15
section were analysed with Student’s t-test or log-rank tests. Mean value, Spinal 32 4.65 6.62
standard deviation (SD) and P-value were calculated. Differences were
The Ki-67 proliferation antigen in meningiomas 39

WHO
I meningiomas had a 3.54% Ki-67 LI (range We then looked at correlations of these significant
0–58%, SD 4.97). Ki-67 LI in WHO
I tumours was variables to see which ones might be redundant in any
significantly lower than in WHO
II (atypical) and model to account for these parameters. Increased vascu-
WHO
III (anaplastic), (P < 0.0001). Data are summa- larity was associated with significant increases in pro-
rized in Table 1. gesterone staining and decreases in WHO index and
When subdividing WHO
I meningiomas according to Ki67 labelling. In addition, increased WHO index was
the WHO histological classification we did not find a associated with decreased PR-Status and increased
significant Ki-67 LI difference in 379 meningothelioma- Ki-67 LI. Finally, decreased progesterone staining was
tous (mean Ki-67 LI 3.28%), 80 fibrous (mean Ki-67 LI associated with increased Ki-67 LI.
3.95%), 54 transitional (mean Ki-67 LI 2.88%), 11 In 38 patients we saw a significant correlation
psammomatous (mean Ki-67 LI 1.1%), 7 angiomatous between the neuroradiologically assessed tumour growth
(mean Ki-67 LI 3.0%), 7 clear cell (mean Ki-67 LI and the proliferative activity of the tumour (Fig. 2).
0.7%) or 5 microcystic meningiomas (mean Ki-67 LI Analysis of the dependence of time-to-recurrence and
4.4%) (P ¼ 0.087). Patients with first time treated grade of resection was performed. Separation of all
meningiomas (n ¼ 463) were compared with patients WHO
I meningiomas with recurrences (n ¼ 120) in
with local recurrence of a previous surgically treated four different resection grades according to the Simpson
meningioma (n ¼ 117). First time treated meningiomas classification (S
) showed that time-to-recurrence
had a mean Ki-67 LI of 3.9% vs. 6.91% in recurrent me- in completely resected meningiomas depend on the
ningiomas [P < 0.0001]). In 25 patients with WHO
I,
6 patients with WHO
II and 3 patients WHO
III we
measured the mean Ki-67 LI from the initial tumour
operation to its second, third and in 5 cases to its fourth
local recurrence and we saw a progression of the Ki-67
LI in local recurrences in each patient (Fig. 1). There
was a transformation from benign to atypical menin-
gioma from second to third local recurrence in 16% of
the cases, whereas no dedifferentiation from WHO
I to


III or WHO
II to WHO
III was seen.
Tumour size had a mean value of 43.65 cm3 ranging
from 3–372 cm3 ; progesterone receptors showed a mean
index of 23.8%, ranging from 0–85%); intra-osseous Fig. 2. Correlation of mean Ki-67 LI and neuroradiological growth
involvement was seen in 167 cases. rate in WHO
I meningiomas (n ¼ 38; r ¼ 0.34; p ¼ 0.0001)
Male gender (increased time-to-recurrence), vas-
cularity (increased vascularity – increased time-to-
recurrence) and progesterone-receptor status (high
PR-Status – increased time-to-recurrence) have been
found to be significantly related to time-to-recurrence
(ANOVA, p< 0.0005).

Fig. 1. Individual proliferation in local recurrence of meningioma Fig. 3. Recurrence free survival for WHO
I and S
I resected
patients meningiomas
40
resection grade (S
I 67.3 month, S
II 50.0 month, S
III
46.3 month and S
IV 40.3 month). The mean Ki-67 LI
was independent of the resection grade (S
I 5.75%, S
II
4.2%, S
III 6.76% and S
IV 7.99%).
For survival analysis WHO
II and
III meningiomas,
as well as partially resected meningiomas, were
excluded. In WHO
I and S
I resected meningiomas we
did not find any significant difference in survival accord-
ing to different mean Ki-67 LI (n ¼ 169, Pearson corre-
lation R ¼ 0.176, P ¼ 0.36). A cut-off point of 4% was
set as the mean value of the mean Ki-67 indices in the
analysed group (Fig. 3).
Conclusion
Meningiomas are mostly benign tumours that usually
do not invade the brain parenchyma. The WHO grading
system aiming to describe different types of tumours,
frequently fails to determine the clinical behaviour of
meningiomas. Even in cases of complete removal
according to the Simpson classification the chance of
recurrence is high [48]. Pathological specimens in those
cases do not show either atypical features or histopatho-
logical signs of increased biological activity. Prolifera-
tion markers like BrdU or AgNOR have been used to
describe the clinical course in meningioma patients
[5, 27, 45]. New biochemical markers like Topo-isomer-
ase II-
, telomerase or apoptotic fragmentation [13, 29,
31, 50] reflect meningioma behaviour in conjunction
with morphological grading, but they all describe the
biological activity in atypical and anaplastic meningio-
mas better than predicting the recurrence potential in
benign meningiomas. The Mib-1 monoclonal antibody,
staining the Ki-67 antigen, can be used on paraffin
embedded specimens. Its reliability in analysing menin-
gioma growth and recurrence has been shown by several
authors [2, 33, 39, 40, 44]. The purpose of this study was
to evaluate the value of the Ki-67 antigen in predicting
the behaviour of meningiomas.
Our data suggest that there is no statistically signifi-
cant correlation between mean Ki-67 LI and recurrence
free survival in patients harbouring a benign menin-
gioma and who underwent radical tumour resection
(Fig. 3). We excluded atypical and anaplastic meningio-
mas from survival analysis because aggressive behaviour
of these meningiomas with dedifferentiation at time of
recurrence is well described through morphological stud-
ies. In terms of true recurrence, incompletely resected
meningiomas with infiltrated dura left in place or sub-
totally removed tumour tissue, which will certainly
F. Roser et al.
regrow over time, would not fit into the concept of recur-
rence after radical resection and had been excluded from
the analysis as well. Even with these stringent selection
criteria a large sample could be meaningfully analysed
as we disposed of a very large number of cases from the
outset.
Møller separated different resection grades and histolo-
gy before survival analysis in 25 cases and could not
give any significant prediction with Ki-67 immunohisto-
chemistry as well [35]. Abramovich reported the
absence of a significant difference in proliferation in
59 meningioma patients who had been radically opera-
ted upon. He documented higher indices in the recurrent
group and recognized a clear overlap of the index range
between the groups [2].
These and our results differ from most of the other
studies showing a strong correlation between mean Ki-
67 LI and recurrence free survival. Ohta et al. showed a
correlation with recurrence free interval in 42 patients,
but the follow-up time was 60 month and the statistics
were performed without dividing the meningiomas
according to the WHO classification [42]. Perry et al.
showed values for interpretation of borderline atypical
meningiomas in 425 meningiomas through multivariate
analysis. Brain invasion, mitosis count > 3=10 and a mean
Ki-67 LI > 4.2% correlated to decreased recurrent free
survival. Based on ‘‘gross total resection’’ the statistics
summarize all grades of surgical excision, comparing a
disproportionate group of 389 patients with Ki-67
LI < 4.2% versus 33 patients with Ki-67 LI > 4.2%.
WHO
I meningiomas alone show an even more dispro-
portionate ratio of 325 vs. 15 patients [44]. Perry et al.
states that the Ki-67 LI influences survival, but he takes
all WHO grades together and makes no mention of Ki-67
LI influence on survival with WHO
I alone.
Our statistically more homogenous group has 169
patients with Ki-67 LI < 4.2% versus 23 patients with
Ki-67 LI > 4.2%, all with WHO
I and S
I resection
grade in survival analysis. Matsuno et al. and Nakasu
et al. reported a 3.2% and 3% cut-off point for higher
recurrence tendency. However 20% to 50% of the recur-
rent meningioma group were atypical, and all non-recur-
rent meningiomas were WHO
I. Survival analysis was
performed taking all patients together without dividing
for surgical resection or histological grade [32, 40]. The
small number of patients in each group and the uneven
distribution of histological grades might have addition-
ally influenced the mean LI and the survival analysis.
Failing to separate different histopathological and
resection grades expose these studies to the criticism
The Ki-67 proliferation antigen in meningiomas
that Ki67 may simply describe a well known phenom-
enon, in other words that more aggressive histology and
less aggressive regression correlate to shorter disease
free survival times.
The strength of our data lies furthermore in the fact,
that all meningiomas were treated surgically by one
experienced neurosurgeon (MS), morphologically diag-
nosed by one pathologist (HO) and stained by the same
method over a period of ten years. Definition of radical
tumour removal and interpretation of positive tissue
staining are therefore easier to achieve.
The proliferation index did not show any differences
concerning sex or age analysis, but in NF-II patients
showed significant higher levels. This may reflect differ-
ences in molecular biology between sporadic and NF-II
meningiomas and may be related to an earlier onset,
multiplicity or more aggressive behaviour of NF-II
tumours [4]. The proliferation index in 45 atypical and
12 anaplastic meningiomas in our series was higher than
in benign meningiomas and reflects the aggressive
histopathology described as increased vascularity and
mitosis, a loss of architectural pattern, prominent
nucleoli, nuclear polymorphism and necrosis [1, 12,
19, 25] (Table 1).
Although embolisation of meningiomas has been per-
formed for many years as a preoperative adjunct to
reduce tumour vascularity and facilitate surgical exci-
sion, it may potentially cause an erroneous diagnosis
of a high-grade lesion due to the fact that it may produce
tumour necrosis. Increase in MIB-1 labelling indices in
those tumours exhibiting necrotic foci has been demon-
strated, but it did not have any prognostic significance
[36, 41, 43].
Genetic alterations can explain biological progression.
Next to chromosome 22 anomalies, deletions of the short
arm of chromosome 1 have previously been described as
the most frequent alterations detected by cytogenetic
analysis of meningiomas [6]. Deletion of 1p and there-
fore enzyme activity loss of tissue non-specific alkaline
phosphatase (ALPL) has been proposed to be associated
with the development of atypical and anaplastic menin-
giomas [38]. The frequency of loss of heterogeneity on
chromosomes 1p, 10q and 22 increases with tumour
grade, which would support the concept that aggressive
meningiomas develop through tumour progression
[47, 51]. Attempts were also made to predict recurrence
in benign meningiomas, combining cytogenetics and
histology through a multimodal approach [24].
Some investigators reported a higher recurrence of
meningiomas at distinct locations (parasagittal, sphenoid
41
ridge) while others did not. [10, 19, 34]. In our study
there was no correlation between tumour location and
mean Ki-67 LI. The recurrence appears to be influenced
by accurate microsurgical removal, and this may be
location dependent.
Literature data support the view that tumour doubling
time and mean Ki-67 LI in subtotal resected meningio-
mas correlate [21, 39]. In these studies initial and recur-
rent tumour were not necessarily from the same patient,
therefore no conclusion about increased growth fraction
in the individual patient could be made [33]. We found a
strong correlation between neuroradiologically mea-
sured growth rates and mean Ki-67 LI, and for the first
time increased growth rates and mean Ki-67 LI in local
recurrencies in the individual patient. Even though we
analysed a higher number of cases for this purpose, case
numbers were still too small to statistically separate dif-
ferent stages of surgical resection [39].
The definition of tumour recurrence in a meningioma
is controversial throughout the literature. The term
‘‘radical removal’’ is a surgical definition, therefore sub-
jective so that tumour recurrence may in fact be a
regrowth. Post-operative MRI studies with contrast med-
ium can minimise this error and show the actual extent
of tumour removal.
Regrowth after surgical intervention can be silent for
a long period of time until the tumour reaches a sub-
stantial size while others will be brought to attention
sooner after compressing important structures like brain
stem, optic chiasm or sagittal sinus in parasagittal
meningiomas [46]. Besides the present study, we found
another series where recurrence is defined based on
radiological evidence of regrowth [40]. Other investiga-
tors have stated that a radiologically detected regrowth
that does not require intervention does not count as true
recurrence [13]. This is correct in terms of clinical
follow-up, but statistical analysis of morphological
features needs an accurate definition of recurrence.
The significant correlation of high vascularity and
high Ki-67 LI suggests the neo-angeogenetic capability
of meningiomas and might account for higher prolifera-
tion in these tumours as reflected by Ki-67 [7, 17]. It has
been shown that high progesterone receptor status in be-
nign meningiomas is associated with lower recurrence
rate and vice versa [9, 14]. Our data support this negative
correlation of high proliferation index in meningiomas and
low progesterone receptor level showing ‘‘protection’’
against recurrence.
In our series we observed elevated proliferative activ-
ity in recurrent meningiomas throughout the histological
42 F. Roser et al.

Table 3. Meningioma recurrence determined by mean Ki-67 LI. Review of the literature

Literature No. of F=U time Mean Ki-67 LI (%) Mean Ki-67 LI (%)
patients (month) initial recurrence

Present study 2002 600 73.5 3.9 6.9

Nakasu et al., Am J Surg Pathol 2001 139 81 2.06 4.37
Abramovich et al., Arch Path Lab Med 1999 59 109 1.5 4.7
Nakaguchi et al., Cancer 1999 22 64 1.8 3.0
Karamitopolou et al., Human Pathology 1998 60 96 1.06 3.12
Abramovich et al., Human Pathology 1998 37 120 3.8 7.1
Madsen et al., Clin Neuropathology 1997 66 – 7.9 7.42
Møller et al., J Neuro-Oncol 1997 85 50.4 0.6 1.1
Perry et al., Cancer 1997 425 106.8 1.5 4.2
Matsuno et al., Acta Neuropath 1996 127 38 1.6 3.6
Kolles et al., Acta Neurochir 1995 160 36 1.12 4.04

grouping, like most other studies had shown [1, 2, 32, 33,
35, 40, 42]. A decrease of the LI has only been reported
by Madsen et al. [30] (Table 3). Caution is recommended
when using the proliferation index as the sole prognostic
indicator or as a substitute for morphological diagnosis
due to the overlap in each group (WHO
I mean Ki-67 LI
0–30%, WHO
II mean Ki-67 LI 3–35% or WHO
III
mean Ki-67 LI 5–58%) [1, 22, 26, 28]. This might
be due to the heterogeneity of biological activity
within the tumour tissue [2, 46]. Proliferating cells in
all histological grades were found to be distributed het-
erogeneously throughout the tumour, especially in recur-
rences [42]. It is debatable that the focal accumulation
of proliferation may affect tumour recurrence for the
‘‘highest area’’ counting method [40]. We used the
‘‘highest area’’ counting method to minimize missing of
focal accumulation of biological activity within the me-
ningioma tissue, as it is recommended by Nakasu et al.
[40]. This is an important issue when considering modern
neurosurgical techniques, where only small parts of tu-
mour with unknown precise location of the tissue reaches
the pathologist. Indeed it is debatable whether recognized
areas of high mitotic activity in meningiomas determined
with either counting method, reflect the proliferation
status of the whole tumour.
Studies assessed the expression of leucocyte integrins
and macrophage-associated antigens in meningiomas to
detect any influence on proliferation capability. Evi-
dence of a correlation between the Ki-67 proliferation
index and macrophage infiltration could not be provided,
although it has been suggested that the expression of
leucocyte antigens could play a role in the attraction
of immunocompetent cells in the stroma of meningio-
mas. As proliferation cells in meningiomas are spread
heterogeneously within the tumour and macrophage=
lymphocyte infiltration has been reported to be mainly
at the tumour margins, only double labelling methods
could give insight into this phenomenon and exclude
errors in statistical evaluation [37].
In our series more than 80 patients have a mean Ki-67
LI of 1% with recurrence times ranging from 11 to 148
month. Therefore a cut-off value over which a tumour
becomes suspicious cannot be given. Precise values from
different laboratories are not applicable to other institu-
tions because of differences in methodology, counting
procedures and interpretation of the results as reflected
by the relatively wide range of initial and recurrent
Ki-67 LI determined by several investigators (Table 3).
Despite our single center study individual set cut-off
points even for our Neurosurgical Department would
be questionable due to the heterogeneity of meningio-
mas in the different groups (resection grade, histology,
Ki-67).
In histopathological borderline cases, with some but
not convincing aspects of atypia, the Ki-67 LI, combined
with the routine histopathological workup can provide
more insight in to the behaviour of a meningioma, par-
ticularly in the presence of high vascularity, low PR-
status, subtotal resection and recurrence [44]. High
scores are worrisome and should lead to a more close
follow up for evidence of recurrent tumour, but the con-
fidence in high LI should not interfere with the decisions
for treatment plans as some authors recommend [32, 40,
49]. Further studies are needed to establish new indica-
tors that can describe meningioma behaviour in a reli-
able and predictive way.
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Comment
This work on a large series of patients confirms the value of the Ki-67
labelling index for the classification of meningiomas. However, it can
not serve as a predictive factor on its own.
N. de Tribolet
Correspondence: Florian Roser M.D., Department of Neurosurgery,
Klinikum Hannover Nordstadt, Haltenhoffstr. 41, 30167 Hannover,
Germany. e-mail: f.roser@gmx.de