Exploration of Digital Image Analysis for Ki67 Quantification in the Grading of Medullary Thyroid Carcinoma: A Pilot Study with 85 Cases

Background Although uncommon, medullary thyroid carcinoma (MTC) accounts for a significant proportion of thyroid cancer deaths. Recent studies have validated the two-tier International Medullary Thyroid Carcinoma Grading System (IMTCGS) to predict clinical outcomes. A 5% Ki67 proliferative index (Ki67PI) cut-off separates low-grade from high-grade MTC. In this study, we compared digital image analysis (DIA) to manual counting (MC) for determining the Ki67PI in a MTC cohort, and explored the challenges encountered. Methods Available slides from 85 MTCs were reviewed by two pathologists. The Ki67PI was documented by immunohistochemistry for each case, scanned with the Aperio® slide scanner at 40× magnification, and quantified using the QuPath® DIA platform. The same hotspots were screenshot, printed in color, and blindly counted. For each case, over 500 MTC cells were counted. Each MTC was graded using IMTCGS criteria. Results In our MTC cohort ( n = 85), 84.7 and 15.3% were low- and high-grade with the IMTCGS. In the entire cohort, QuPath® DIA performed well ( R 2 = 0.9891) but appeared to undercall compared to MC. QuPath® performed better in high-grade cases ( R 2 = 0.99) compared to low-grade cases ( R 2 = 0.7071). Overall, Ki67PI determined with either MC or DIA did not affect IMTCGS grade. Encountered DIA challenges include optimizing cell detection, overlapping nuclei, and tissue artifacts. Encountered MC challenges include background staining, morphologic overlap with normal elements, and counting time. Conclusion Our study highlights the utility of DIA in quantifying Ki67PI for MTC and can serve as an adjunct for grading in conjunction with the other criteria of mitotic activity and necrosis.