Changes in Ki-67 in Residual Tumor and

Outcome of Primary Inflammatory Breast Cancer

Treated With Trimodality Therapy
Zheng Song,1,2,3,4 Chunyan Li,2,3,4,5 Dongdong Zhou,2,3,4,5 Jingjing Liu,2,3,4,5
Xiaolong Qian,2,3,4,6 Jin Zhang, MD2,3,4,5
Abstract
Inflammatory breast cancer (IBC) is an aggressive form of breast cancer. A total of 210 IBC patients were
included in current study for assessing the prognostic role of Ki-67 changes in residual tumors after neoadju-
vant chemotherapy. The decrease of Ki-67 significantly correlated with long-term survival outcomes compared
with no decrease, particularly in the luminal B-like and HER2-positive subgroups.
Background: Limited data are available on the prognostic role of Ki-67 changes in residual tumors after neoadjuvant
chemotherapy in primary inflammatory breast cancer (IBC) patients treated with trimodality therapy. This study aims to
evaluate changes in Ki-67 associated with disease-free survival (DFS) and overall survival (OS) in IBC patients without
pathological complete response. Patients and Methods: We identified a cohort of primary IBC patients with matched
pre- and posttreatment samples treated with anthracycline and taxane-based regimen. All patients had a pathological
evaluation, including ER, PR, HER2 status, and Ki-67 expression performed both at diagnostic core biopsy and at
final surgery. Kaplan–Meier and Cox proportional hazards methods were used to assess DFS and OS rates and their
relationship with clinicopathological features. Results: Two hundred and ten patients with stage III IBC were included.
Sixty-three percent of residual tumors showed a decrease in Ki-67 positivity by at least 1%. The decrease of Ki-67
significantly correlated with better DFS (p = .001) and OS (P = .010) compared with no decrease, particularly in the
luminal B-like and HER2-positive subgroups. The multivariate analysis showed that the decrease in Ki-67 level had
a significant positive predictive value on DFS (HR = 0.47, 95% CI: 0.33-0.67; P< .001) and OS (HR = 0.59, 95% CI:
0.36-0.82; P= .004) in all IBC patients. Conclusion: The decrease of Ki-67 expression after neoadjuvant chemotherapy
has a prognostic significance in IBC patients with residual disease. Evaluation of Ki-67 changes may help to identify
subgroups of patients with worse outcome to receive novel treatment in this setting.

Clinical Breast Cancer, Vol. 22, No. 5, e655–e663 © 2022 Elsevier Inc. All rights reserved.
Keywords: Breast cancer, Neoadjuvant threpy, Residual tumor, Prognosis

Introduction of breast cancers.1-3 It is characterized clinically by rapid progres-

Inflammatory breast cancer (IBC) is a rare and aggressive form sion and early distant metastasis.1 , 4 Furthermore, the molecular
of breast cancer, representing approximately 1% to 5% of all cases subtypes based on hormonal receptor (HR) and human epidermal
growth factor receptor 2 (HER2) status have limited predictive and
prognostic influence in IBC patients.3 , 5-7 Current treatment recom-
1
Department of Lymphoma, Tianjin Medical University Cancer Institute and mendation of primary IBC remains trimodality therapy, includ-
Hospital, National Clinical Research Center of Cancer, The Sino-US Center for
Lymphoma and Leukemia Research, Tianjin, China
ing neoadjuvant chemotherapy (NAC) followed by modified radical
2
Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical mastectomy and postmastectomy radiation therapy (PMRT) to the
University, Ministry of Education, Tianjin, China
3
Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
chest wall and draining lymphatics. Recent literatures suggest that
4
Tianjin’s Clinical Research Center for Cancer, Tianjin, China outcomes for patients with IBC treated with trimodality therapy
5
Third Department of Breast Cancer, Tianjin Medical University Cancer Institute and have improved significantly, and the 5-year overall survival (OS) rate
Hospital, National Clinical Research Center of Cancer, Tianjin, China
6
Department of Breast Cancer Pathology and Research Laboratory, Tianjin Medical now approximates 69% to 71%.7-8
University Cancer Institute and Hospital, National Clinical Research Center of Neoadjuvant chemotherapy is the mainstay of IBC treatment.
Cancer, Tianjin, China
Not only can it facilitate subsequent surgery, but also the clinical and
Submitted: Jun 8, 2021; Revised: Jan 21, 2022; Accepted: Feb 1, 2022; Epub: 6 Febru-
ary 2022 pathologic response to therapy can provide prognostic information
Address for correspondence: Jin Zhang, Third Department of Breast Cancer, Tianjin to guide therapy.3 , 9-12 In general, pathological complete response
Medical University Cancer Institute and Hospital, National Clinical Research Center (pCR) can be used as a surrogate efficacy endpoint correlated with
of Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical
University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, favorable long-term outcome.3 , 9-11 However, the pCR can only be
Tianjin’s Clinical Research Center for Cancer, Tianjin, 300060, China. achieved in 13.5% to 35% cases,3 , 9-12 while the vast majority of
E-mail contact: zhangjin@tjmuch.com

1526-8209/$ - see front matter © 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.clbc.2022.02.001 Clinical Breast Cancer July 2022 e655
 patients have residual tumor in the breast or axilla at final surgery.
Therefore, for IBC patients who do not achieve a pCR, the practical
prognostic markers should be identified to establish better prognos-
tic groups and to differentiate patients at great risk of recurrence and
death.
As a proliferation marker, immunohistochemistry of Ki-67
protein is widely used in routine clinical practice to distinguish
breast cancer subtypes, predict responsiveness to treatment and
long-term survival outcomes. In the NAC setting, Ki-67 levels
as a continuous dynamic biomarker of treatment efficacy in pre-
and posttreatment paired samples are often evaluated for non-IBC
patients.13 , 14 The changes of Ki-67 between primary and residual
tumors may have a prognostic significance of survival outcomes.15 , 16
Due to the invasive biological behavior of IBC, patients with IBC
generally had higher levels of Ki-67 tumor cells than patients with
non-IBC.17 A recent study showed that IBC patients with high Ki-
67 expression in prechemotherapy tumors tended to have worse
OS.18 However, for IBC patients completed trimodality therapy, it
is not clear whether the change of Ki-67 before and after neoadju-
vant chemotherapy may have a prognostic implication, especially in
various molecular subtypes.
In this study, we mainly focused on the primary IBC patients
whose information on ER, PR, HER2, and Ki-67 status was avail-
able and who received trimodality therapy. The primary aim of our
study was to evaluate the change in Ki-67 between the diagnostic
core biopsy and final surgery as a prognostic factor for disease-free
survival (DFS) and OS in IBC patients with residual disease after
neoadjuvant chemotherapy.
Materials and Methods
Patients and Treatments
We performed a retrospective review of patients with primary
IBC from the institutional database at Tianjin Medical University
Cancer Hospital and Institute between 2010 and 2018. A clinical
diagnosis of IBC was defined as the presence of diffuse erythema,
heat ridging, or peau d, o range in the breast with skin or chest
wall involvement. A total of 406 patients with clinical stage III
(T4d, N0-3, M0) disease were identified in the primary IBC registry
during this period, whose records were evaluated for documenta-
tion of receiving trimodality therapy of NCT and modified radical
mastectomy followed by radiotherapy. We excluded the following
patients from the current analysis: patients who developed distant
metastatic disease before surgery (n = 14), patients who did not
complete trimodality therapy (n = 81), patients who had missing
information of Ki-67 status (n = 58), and patients with pCR
(defined as no residual invasive cancer in the breast and axilla) after
preoperative chemotherapy (n = 43). Overall, 210 patients were
included in this analysis. The case selection process is shown in
Figure 1.
Age, menopausal status, axillary lymph node status, histology
subtype, histologic grade, lymphatic invasion, estrogen receptor
(ER) status, progesterone receptor (PR) status, and HER2 status
extracted from the initial medical records. The documentation
of the percentage of Ki-67 positivity before and after NAC was
compulsory. NAC therapy was administered as anthracycline and
e656 Clinical Breast Cancer July 2022
taxane-based treatment (4-6 cycles) and with trastuzumab for
HER2-positive patients.
Immunohistochemical Staining and Molecular Subtypes
All of the patients’ pathology materials (actual slides from the
initial diagnostic biopsy and from definitive surgery) were reviewed
at our institution. Each sample was analyzed using standardized
procedures and assays. Hormone receptor positivity was defined as
more than 1% of cells staining positive for the ER or PR, and the
HER2 receptor was considered positive with immunohistochemical
staining of 3+ or fluorescence in situ hybridization.
The immunohistochemical analysis for Ki-67 value was quanti-
fied using a visual scoring system according to international recom-
mendations.19 The primary antibody used was the MIB-1 mAb
(dilution 1:100; Code M7240, Dako, Glostrup, Denmark). All
staining was scored independently by 2 observers (interobserver
reproducibility) or dual scored by the same observer (intra-observer
reproducibility), and divergent scores were then discussed and
decided on a multi-headed microscope. The results for Ki-67 were
recorded as the percentage of immunoreactive cells over at least 1000
neoplastic cells. If the staining was homogenous, the total number of
invasive neoplastic cells were counted at least ten randomly selected
high-power magnification (× 400) fields. In the presence of hot
spots, defined as areas in which Ki-67 staining was particularly
prevalent, pathologists evaluated the whole section and recorded the
overall average score.
The value of 20% for Ki-67 labeling index (LI) was used as a cut-
off in distinguishing tumors with low (<20%) and high (≥20%)
proliferative fraction.20 The categories of Ki-67 change after NAC
were defined as follows: Decrease group (the absolute value of Ki-67
was reduced at least 1% less in residual tumor than in the initial
core biopsy), and no-decrease group (the absolute value of Ki-67
was increased or stable between the breast core biopsy and residual
disease).16
According to St. Gallen Consensus 2013, the molecular subtypes
were defined by IHC of core needle biopsy samples as follows:
luminal A-like (ER-positive and PR-positive, HER2-negative, and
Ki-67-low), luminal B-like (ER-positive, PR-negative, HER2-
negative, and Ki-67-high; ER-positive, any PR, any Ki-67, and
HER2-positive), HER2-positive (ER-negative, PR-negative, and
HER2-positive), and triple-negative (ER-negative, PR-negative, and
HER2-negative).20
Statistical Analysis
We calculated the descriptive statistics for the continuous
variables, including the means, medians, and ranges. Chi-square
or Fisher’s exact tests were used to analyze the association between
categorical variables. The paired t-test was presented to investigate
differences in Ki-67 LI from biopsy to surgery. The mean absolute
changes, along with the 95% confidence interval (CI) were reported.
Disease-free survival was defined as the length of time from
the date of completion of trimodality therapy to any relapse, the
appearance of a second primary cancer or death, whichever occurred
first. Overall survival was determined as the time from the date
of completion of trimodality therapy until the date of death from
any cause or loss to follow-up. DFS and OS were assessed with the

Figure 1 Flow chart of patient population.
Abbreviations: IBC: inflammatory breast cancer; pCR: pathological complete response; NAC: neoadjuvant chemotherapy.
Kaplan-Meier method, and the comparisons between groups used
the log-rank test. The variables that were identified as showing statis-
tical significance in univariate analysis were included in the multi-
variate Cox proportional hazards regression model. We estimated
the hazard ratio for each potential prognostic factor with a 95% CI.
The level of significance was defined as p<0.05. Statistical analyses
were performed using SPSS 23.0 software (IBM, Chicago, IL).
Results
Study Population Characteristics
We identified a total of 210 patients who met the inclusion crite-
ria for the present analysis at Tianjin Medical University Cancer
Hospital and Institute from 2010 to 2018. Baseline characteris-
tics of patients at the time of diagnostic core biopsy are listed in
Table 1. The Ki-67 LI was high (≥20% of the cells) in 67.6%
of patients. The most commonly used chemotherapy regimen was
doxorubicin and taxane–based chemotherapy, which was received
by 81.9% of the patients. Adjuvant chemotherapy was received
by 64 patients (30.5% of the study cohort). Among patients with
HR-positive disease, 90% received adjuvant hormonal therapy.
In HER2-positive disease, but only 30% of patients received
trastuzumab in (neo)adjuvant setting.
Change in Ki-67 Status
After NAC, the median residual tumor size was 3 cm (range 0-
8cm), and the pathological nodal status was ypN0 in 73 (34.8%)
patients. The median percentage for Ki-67-positive tumor cells
before NAC was 30.0% (mean 32.1%, rang 1.0%-90.0%), which
decreased to 20.0% (mean 23.7%, range 1.0%-80.0%) after NAC
(P < .001). Ki-67 LI expression decreased at final surgery with a
Zheng Song et al
mean value of 8.4 points (95% CI 5.8-10.9). Sixty-three percent of
residual tumors showed a decrease in Ki-67 positivity by at least 1%.
The decrease in Ki-67 in surgical excision specimens compared with
core needle samples was observed in 48.9, 70.4, 75.9, and 58.5% of
patients in the luminal A-like, luminal B-like, HER2-positive, and
triple-negative subtypes, respectively. The distribution of patients
according to subtype and Ki-67 changes after NAC is presented in
Table 2.
Univariate Analyses for Predictors of Survival
At a median follow-up of 59 months (range 13-96 months), 131
(62%) DFS events and 94 (45%) deaths were observed. The global
median DFS was 42 months (95% CI 34.3-49.7), and median OS
was 65.0 months (95% CI 49.9-80.1). Figure 2 shows the Kaplan-
Meier curves of DFS and OS for each IBC subtype. Patients with
triple-negative IBC showed a significantly worse DFS compared
with those with the other 3 subtypes (P < .001, for all comparisons,
Figure 2). And the luminal A-like subtype had more favorable DFS
than the luminal B-like subtype (P = .009, Figure 2) and HER2-
positive subtype (P < .001, Figure 2). There was no significant
difference between luminal B-like and HER2-positive IBC patients
in DFS (P = .174, Figure 2). We also observed that OS differed
significantly between the subtypes (P < .001, for all comparisons,
Figure 2), with the best OS for luminal A-like IBC. Triple-negative
disease still was associated with a significantly worse OS, compared
to luminal B-like disease (P = .009, Figure 2).
Figure 3 reports the outcome according to type of qualitative Ki-
67 changes. Patients who had decreased Ki-67 levels had a longer
median DFS than those without a decrease in Ki-67: 56.0 months
(95% CI 43.6-68.4) versus 32.0 months (95% CI 27.6-36.4),
Clinical Breast Cancer July 2022 e657
 Figure 2 Disease-free survival and overall survival of patients according to molecular subtypes.

Figure 3 Disease-free survival and overall survival of patients with decreased Ki-67 and those with no decrease in Ki-67 after
neoadjuvant chemotherapy, in patients with all tumor types (A), in patients with luminal B-like phenotype tumors (B),
and in patients with HER2-positive phenotype tumors (C).

e658 Clinical Breast Cancer July 2022

 Zheng Song et al
Table 1 Baseline Characteristics of Study Population

Triple
Negative
Luminal A (n = 45) Luminal B HER2+ (n = 65)
Characteristics Total (n = 210) (%) (%) (n = 71) (%) (n = 29) (%) (%) p
Median age 49(28-78) 47(34-72) 45(29-76) 51(28-78) 48(31-76) .124
Menopausal status
Pre 116(55.2) 28(62.2) 39(54.9) 16(55.2) 33(50.8) .702
Post 94(44.8) 17(37.8) 32(45.1) 13(44.8) 32(49.2)
Median tumor size(rang), cm 6.0(0-16) 5.5(0-15) 6.0(1-16) 6.0(2-14) 6.0(3-16)
Nodal status
Positive 175(83.3) 38(84.4) 56(78.9) 24(82.8) 57(87.7) .582
Negative 35(16.7) 7(15.6) 15(21.1) 5(17.2) 8(12.3)
Histology subtype
Invasive ductal carcinoma 175(83.3) 38(84.4) 63(88.7) 24(82.8) 50(76.9) .326
Others 35(16.7) 7(15.6) 8(11.3) 5(17.2) 15(23.1)
Histologic grade
I/II 51(24.3) 14(31.1) 23(32.4) 6(20.7) 8(12.3) .03
III 159(75.7) 31(68.9) 48(67.6) 23(79.3) 57(87.7)
Lymphatic invasion
Yes 145(69.0) 28(62.2) 47(66.2) 22(75.9) 48(73.8) .461
No 65(31.0) 17(37.8) 24(33.8) 7(24.1) 17(26.2)
ER
Positive 104(49.5) 45(100) 59(83.1) 0 0 <.001
Negative 106(50.5) 0 12(16.9) 29(100) 65(100)
PR
Positive 101(48.1) 45(100) 71 (100) 0 0 <.001
Negative 109(51.9) 0 0 29(100) 65(100)
HER2
Positive 77(36.7) 0 32(45.1) 29(100) 0 <.001
Negative 133(63.3) 45(100) 39(54.9) 0 65(100)
Ki-67
≥20% 142(67.6) 0 60(84.5) 25(86.2) 57(87.7) <.001
<20% 68(32.4) 45(100) 11(15.5) 4(13.8) 8(12.3)
NAC regimen
Doxorubicin and 172(81.9) 35(77.8) 57(80.3) 25(86.2) 55(84.6) .942
taxane–based
26(12.4) 7(15.6) 10(14.1) 3(10.3) 6(9.2)
Docetaxel/cyclophosphamide
Other 12(5.7) 3(16.7) 4(5.6) 1(3.4) 4(6.2)
Adjuvant chemotherapy
Yes 64(30.5) 11(24.4) 18(25.4) 10(34.5) 25(38.5) .281
No 146(69.5) 34(75.6) 53(74.6) 19(65.5) 40(61.5)

Abbreviations: ER = estrogen receptor; PR = progesterone receptor; HER2 = human epidermal growth factor receptor 2; NAC = neoadjuvant chemotherapy.

respectively (P = .001). Moreover, 5-year DFS in patients with a
decrease in Ki-67 levels was 43.2% (95% CI 33.6-52.5), compared
with 25.3% (95% CI 15.6-36.2) in patients without decreased Ki-
67 (Figure 3A). Median OS was 82.0 months in patients with a
decrease in Ki-67, and 53.0 months (95% CI 46.0-60.0) in patients
without a decrease (P = .010). Five-year OS was 63.9% (95% CI
54.0-72.8) in decrease group, and 39.6% (27.6-51.3) in no-decrease
group (Figure 3A).
In the luminal A-like and triple-negative subtypes, no statistically
significant differences were found between the patients with ki-67
decrease and those without Ki-67 decrease both DFS and OS. In
contrast, the differences in the 5-year DFS between decrease group

Clinical Breast Cancer July 2022 e659

 Table 2 Patient Distribution by Phenotype and Ki67 Changes After Neoadjuvant Chemotherapy
Total Luminal A
(%)n = 210 (%)n = 45
Median Ki-67 pre-chemo 30.0(1.0-90.0) 10.0(1.0-15.0)
(range)
Median Ki-67 20.0(1.0-80.0) 5.0(1.0-30.0)
post-chemo (range)
Ki-67 change
Decrease 132(62.9) 22(48.9)
No decrease or increase 78(37.1) 23(51.1)
Abbreviations: HER2 = human epidermal growth factor receptor 2.
and no-decrease group were statistically significant for luminal B-
like (52.0% [95% CI 35.6-66.1] vs. 21.8% [95% CI 7.1-41.6], P
= .002, Figure 3B), and HER2-positive (31.8% [95% CI 10.955.3]
vs. 0%, P = .009, Figure 3C) subtypes. Meanwhile, patients who
presented a decrease at final surgery had a better OS in luminal B-
like (69.8% [95% CI 54.2-81.0] vs. 40.4% [95% CI 19.2-60.8],
P = .023, Figure 3B), and HER2-positive (64.0% [95% CI 35.1-
82.7] vs. 14.3% [95% CI 0.7-46.5], P = .011, Figure 3C) subtypes.
Multivariate Analyses for Predictors of Survival
Multivariate analysis confirmed the prognostic role of classical
clinical and biological features correlated with higher risk of worse
outcome, such as lymphatic invasion, larger tumor size, ER negativ-
ity, pathological positive nodal, and no decrease in Ki-67 in residual
disease (Table 3). The decrease of Ki-67 at final surgery was associ-
ated with better outcome in terms of DFS (HR = 0.47, 95% CI:
0.33-0.67; P < .001) and OS (HR = 0.59, 95% CI: 0.36-0.82; P
= .004), when compared with patients without decrease in Ki-67
expression. No significant differences were showed on DFS and OS
when we analyzed the effect of the absolute value of pretreatment
Ki-67.
Discussion
Despite sophisticated advances in the treatment of non-IBC, the
aggressive treatment guidelines for IBC patients, including neoad-
juvant chemotherapy, modified radical mastectomy, and PMRT,
have remained largely unchanged. However, with the approach of
trimodality treatment, the locoregional control has been improved
and DFS has been prolonged.8 , 21 From 406 IBC patients enrolled
in our institutional database at Tianjin Medical University Cancer
Hospital and Institute, we isolated a cohort of 210 primary IBC
patients with matched pre- and posttreatment samples uniformly
received NAT, mastectomy, and PMRT.
In the last decade, there was no consensus in clinical practice
to define the optimal cutoff point of the high Ki-67 proliferative
index. We used a cutoff value of 20% as a means to differentiate
between luminal-A like and luminal-B like IBCs on initial diagnos-
tic core biopsy, according to the recommendation at the Thirteenth
St. Gallen Conference.20 Interestingly, our study revealed that triple-
negative IBC was associated with worse survival, which is in accor-
dance with other studies from IBC populations.3 , 5-7 , 21 However, our
results suggested for the first time that the luminal-A like subtype
e660 Clinical Breast Cancer July 2022
Luminal B HER2+ Triple negative
(%)n = 71 (%)n = 29 (%)n = 65 P
30.0(1.0-80.0) 35.0(5.0-80.0) 45.0(5.0-90.0) <.001
20.0(1.0-70.0) 20.0(5.0-65.0) 20..0(5.0-80.0) <.001
50(70.4) 22(75.9) 38(58.5) .043
21(29.6) 7(24.1) 27(41.5%)
had more favorable outcome than all other subtypes, contrast-
ing with other reports in which patients with HR positive/HER2
negative tumors had poor prognosis that did not differ from that
of the HR negative/HER2 positive subgroup.3 , 5-7 , 21 Therefore, the
value of Ki-67 as a tool to discriminate breast cancer subtypes could
provide additional useful prognostic information in IBC patients.
We also used the cutoff value of 20% as high expression in pre-and
posttreatment samples. Furthermore, evaluation of Ki-67 changes
was dichotomized into the decrease or non-decrease group in resid-
ual disease after NAC, compared with initial biopsy.
In this study, we observed that patients having a decrease of Ki-67
from biopsy had a better prognosis than patients remaining stable or
increasing at the level of Ki-67 expression regardless of their breast
cancer subtypes, both in terms of DFS (HR = 0.47, P < .001) and
OS (HR = 0.59, P = .004). This result indicated that Ki-67 change
can be used to separate different subgroups of IBC patients who
completed trimodality therapy with different prognostic outcomes.
To the best of our knowledge, our study is the first analysis to
investigate the prognostic impact of changes in Ki-67 status after
neoadjuvant chemotherapy in IBC patients treated with trimodal-
ity treatment. Ning Jing et al. reported that the association between
Ki-67 status for IBC patients and OS was marginally significant,
after adjusting for the receiving trimodality treatment and tumor
subtypes as defined by HR and HER2 status.18 Unlike the present
study, however, only pretreatment Ki-67 status was evaluated. The
potential prognostic value of Ki-67 after NAC in IBC is still not
well known.
Ki-67 labeling index has been reported as a predictive factor of
the response to neoadjuvant chemotherapy in non-IBC. The major-
ity of previous studies focused mostly on the patients achieved
pCR. Only a few studies investigated the role of Ki-67 in non-pCR
after NAC.15 , 16 , 22-29 Some studies confirmed that low Ki-67 expres-
sion in posttreatment tumors was associated with better DFS and
OS, regardless of tumor subtype.24-27 Contradicting the findings,
another study showed that the decrease of at least 1% of the absolute
value of Ki-67 index after NAC compared with the baseline level was
related to better DFS and OS.16 The data was consistent with the
studies previously demonstrated by other research groups.15 , 22 , 23 , 29
However, it should be noted that the evaluation methods were
different in the studies. Our results indicated that the no-decrease
of Ki-67 expression after preoperative chemotherapy had a negative
influence on the survival of IBC patients treated with trimodality
 Zheng Song et al
Table 3 Univariate and Multivariate Analysis by Cox Proportional Hazard Model for DFS and OS

DFS OS
Univariate Multivariate Univariate Multivariate
Variables HR (95% CI) P HR (95% CI) P HR (95% CI) P P
Age
≥49 versus <49 1.17(0.81-1.69) .398 1.13(0.73-1.75) .584
Menopausal status
Pre versus Post 0.87(0.61-1.23) .416 0.89(0.58-1.31) .499
Tumor size (at biopsy)
≤6cm versus >6cm 0.70(0.49-1.02) .044 0.61(0.43-0.88) .008 0.64(0.42-0.99) .032 0.60(0.40-0.92) .016
Nodal status (at biopsy)
negative versus positive 0.70(0.46-1.06) .123 0.62(0.38-1.02) .102
Lymphatic invasion
No versus Yes 0.69(0.48-0.98) .049 0.68(0.46-0.98) .047 0.66(0.44-1.01) .083
Tumor size (at surgery)
≤3cm versus >3cm 0.97(0.67-1.40) .869 0.85(0.56-1.31) .475
ypN
negative versus positive 0.51(0.37-0.77) .001 0.46(0.29-0.69) <.001 0.41(0.27-0.62) <.001 0.40(0.23-0.68) .001
Grade (at biopsy)
I/II versus III 0.77(0.52-1.13) .208 0.76(0.48-1.21) .279
ER (at biopsy)
positive versus negative 0.37(0.23-0.47) <.001 0.46(0.24-0.89) .020 0.39(0.26-0.59) <.001 0.47(0.21-1.08) .076
PR (at biopsy)
positive versus negative 0.44(0.31-0.62) <.001 0.76(0.40-1.44) .396 0.46(0.31-0.70) <.001 0.93(0.41-2.07) .850
HER2 (at biopsy)
positive versus negative 0.99(0.68-1.46) .99 1.28(0.81-2.01) .266
Ki-67 (at biopsy)
<20% versus ≥20% 0.61(0.43-0.88) .013 0.73(0.47-1.15) .173 0.62(0.41-0.94) .040 0.69(0.41-1.19) .183
Ki-67 change
decrease versus no decrease 0.58(0.40-0.84) .002 0.47(0.33-0.67) <.001 0.59(0.39-0.91) .010 0.55(0.36-0.82) .004

Abbreviations: DFS = disease-free survival; OS = overall survival; ER = estrogen receptor; PR = progesterone receptor; HR = hazard ratio; ypN = pathological node status.

treatment. In this setting, low expression of Ki-67 level in resid-
ual tumors did not show the same prognostic implications as the
decrease of Ki-67 expression. Ning Jing, s study also suggested that
the overall effect of trimodality therapy was attenuated among IBC
patients with low proliferative tumors in pretreatment.18
In recent years, several studies revealed that Ki-67 changes
between primary and residual tumors can predict different
long-term outcomes in various molecular subtypes of breast
cancer.15 , 16 , 30 , 31 Among IBC patients completed trimodality
therapy, a decrease in Ki-67 had been found in most patients
of almost all molecular subtypes after NAC in our study.
However, the reduction of Ki-67 value in residual disease was
associated with longer DFS and OS in the luminal-B like and
HER2-positive subgroups, but not the luminal-A like and triple-
negative subtypes. This result was consistent with other reports
in which the IBC patients with HR-positive/HER2-positive and
HR-negative/HER2-positive tumors achieved higher pCR rates
than those with HR-positive/HER2-negative and triple-negative
disease.21 , 32 , 33 Meanwhile, this finding also demonstrated that
the significance of Ki-67 change differed among subtypes, which
depended on the tumor heterogeneity.
IBC is a heterogeneous disease in which clinical management
depends on all the available information on both patient and
tumor characteristics. Our study suggested that the Ki-67 change
responded to NAC can be used to better stratify the prognosis
for IBC patients who did not achieve a pCR. Accordingly, the
patients without decrease of Ki-67 level are candidates for innovative
postneoadjuvant treatment concepts, such as extension of postop-
erative chemotherapy, development of novel targeted therapies, and
administration of Capecitabine, which was recently demonstrated to
prolong the survival of breast cancer patients with residual tumors.34
Compared with other studies based on a single institution, our
study cohort had a large sample size, long median follow-up time
to evaluate survival outcomes, and included all patients treated with
trimodality treatment. On the other hand, there were some limita-
tions to this study. First, the number of patients was dispropor-
tionate distribution within various immunophenotypic subtypes;
therefore, the possibility of introduction of bias can’t be excluded.

Clinical Breast Cancer July 2022 e661

 Second, this study has inherent limitations due to its retrospective
nature and was conducted in a single-center cohort that may not
reflect the results in the general population. Finally, a low propor-
tion of HER2-positive patients received trastuzumab as neoadjuvant
and/or adjuvant treatment, which might influence Ki-67 change
and survival results.
Conclusions
The current study suggested that a decreased expression Ki-67
LI in residual tumors after preoperative chemotherapy has predic-
tive and prognostic value in IBC patients treated with trimodality
treatment, especially in patients with luminal-B like and HER2-
positive cancers. Evaluation of Ki-67 changes may contribute to
identify subsets of patients with worse outcome and to optimize
treatment strategy for the prevention of disease relapse after neoad-
juvant chemotherapy.
Clinical Practice Points
• Current treatment of primary IBC includes NAC, modified
radical mastectomy, and PMRT. pCR can be used as a surrogate
efficacy endpoint correlated with favorable long-term outcome in
IBC patients.
• However, for patients who do not achieve a pCR, the practi-
cal prognostic markers should be identified to establish better
prognostic groups and to distinguish patients at great risk of recur-
rence and death. Information regarding the prognostic role of Ki-
67 in residual disease after NAC is scarce.
• To the best of our knowledge, our study is the first analysis to
investigate the prognostic impact of changes in Ki-67 status after
neoadjuvant chemotherapy in IBC patients with residual tumor
treated with trimodality treatment.
• The decrease of Ki-67 significantly correlated with better disease-
free survival and overall survival compared with no decrease,
particularly in the luminal B-like and HER2-positive subgroups.
• Evaluation of Ki-67 changes may contribute to identify subgroups
of patients with worse outcome to receive innovative treatment.
Ethical Approval
This research was authorized by The Ethics Committee of Tianjin
Medical University Cancer Institute and Hospital.
Disclosure
The authors declare that they have no competing financial inter-
ests.
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