The gold standard for diagnosis of astrocytic tumors is the histological examination of abundantly sampled tissue. Therefore, histopathology should be used in combination with patient’s clinical history, the neurosurgical suggestions and neuroradiologic findings to ensure the greatest accuracy in the diagnosis of such tumors . Histological grading is well accepted for evaluating the prognosis of astrocytoma patients. It is important to differentiate between different grades of astrocytomas, because their clinical management differs. A number of studies have shown that high histological grade (based on increased cellularity, nuclear atypia, mitotic activity and necrosis and/or microvascular proliferation) is highly correlated with decreased survival [17, 18]. Our results also revealed that high histological grade was associated with decreased overall survival and proved its independent prognostic significance.
However, the morphologic criteria are not always accurate prognostic indicators. In some instances, the histopathology diagnoses a certain grade of astrocytoma, whereas other parameters such as the clinical and neuroimaging features indicate a more advanced grade.
Therefore, recent researches investigated the expression of novel prognostic biomarkers in astrocytic tumors that could lead to an accurate classification and effective treatment. For instance, the hypermethylation status of the epidermal growth factor receptor (EGFR) and methyl-guanine-DNA methyltransferase (MGMT) could play a role in glioma progression . In addition, Gulati et al.  indicated the adverse prognostic effect of C-erbB2 (a member of EGFR family) overexpression in anaplastic astrocytomas. Other relevant markers are the proliferation markers as minichromosome maintenance protein2 (Mcm2), survivin, mitosin and Ki67/MIB-1 [21, 22].
MIB-1 LI is one of the cell proliferation markers that had been extensively employed by the histopathologists in conjunction with the traditional morphologic variables. It supports better determination of the histological grade and consequently the prognosis of astrocytoma patients [23, 24].
Most of the studies have found significant differences in MIB-1 labeling indices between low and high grade astrocytomas [5, 25, 26]. In support to the previous studies, our results showed a significant direct correlation between MIB-1 LI and the histological grade. A significant difference was detected between the diffuse and the anaplastic astrocytomas, and the anaplastic astrocytomas and GBMs. However, Hsu et al.  and Rodriguez-Pereira et al.  could not find a significant difference between the anaplastic astrocytomas and GBMs as regards MIB-1 LI.
The majority of the previous studies proposed several prognostic MIB-1 cut off values that ranged from 1.5% to 15.3% [4, 28–30]. This wide range makes the interpretation and comparisons between the different results difficult. Nevertheless, a MIB-1 LI greater than 10 may serve as a commonly used value to express a more aggressive phenotype of astrocytomas.
The results of our study succeeded in identifying a MIB-1 cut off value of 10.1 for distinguishing astrocytomas with good prognosis from cases with poor prognosis. The univariate analysis revealed a significant reduction in the overall survival of astrocytoma patients with MIB-1 LI ≥10.1. However this significant association with survival was lost in multivariate analysis after adjustment of other possible prognostic factors as age, gender, histological grade and DJ-1 protein expression.
Though some studies claimed that MIB-1 LI is an independent prognostic variable [5, 31–33], others found it significant only in univariate analysis in concordance with our results [4, 27, 34].
The present study shows that MIB-1 LI could not also provide an independent role for predicting survival when Cox regression analysis was carried out for each grade of astrocytoma. This finding agreed with the results of McKeever et al. , Korshunov et al.  and Moskowitz et al.  which could not establish any prognostic role for MIB-1 LI on Cox regression analysis in diffuse, anaplastic astrocytoma and GBMs respectively. On the other hand, Giannini et al.  and Hsu et al.  found that MIB-1 LI was an independent prognostic indicator in the diffuse and anaplastic astrocytomas. Also Wakimoto et al.  confirmed the independent adverse effect of MIB-1 LI on survival in high-grade astrocytomas only.
There are many factors responsible for such a variation in MIB-1 labeling indices in many studies. The variability in tissue processing, immunohistochemical procedures and the different quantitation methods, make it difficult to determine a certain cut off value for clinical use. Also, the degree of inter-observer variability affects the clinical usefulness of such cut off values.
In the view of seeking additional prognostic markers in different grades of astrocytomas and owing to the well established anti-apoptotic and cell survival function of DJ-1 protein, we studied the applicability of using DJ-1 as a survival predictor marker in the studied cases of astrocytomas.
Similar to our study, Junn et al.  demonstrated that DJ-1 is present mostly in the cytoplasm of the tumor cells and to a lesser extent in the nucleus. They reported that on oxidative stress, DJ-1 translocates to the nucleus and mitochondria, and that mitochondrial DJ-1 appears to be primarily responsible for protection against oxidative stress.
The current results revealed a strong positive correlation between the cytoplasmic staining intensity of DJ-1 and the histological grade of astrocytomas.
Hinkle et al.  was the first to show that DJ-1 cytoplasmic immunoreactivity was strong in GBMs, while Miyajima et al.  conducted the leading study which confirmed that DJ-1 is localized in the cytoplasm in addition to the nucleus of tumor cells of astrocytomas and that the nuclear DJ-1 was inversely correlated with WHO grading.
In addition to the direct correlation between DJ-1 and grading, our results also demonstrated a strong association between DJ-1 and MIB-1 LI in the studied cases of astrocytomas. This supports the role of DJ-1 in neoplastic transformation and tumor proliferation, which is evident in several human cancers. This also reveals the molecular mechanisms by which DJ-1 is involved in cancer cell survival and aggressiveness of tumors .
In our set of 111 astrocytoma cases, increased cytoplasmic staining intensity of DJ-1 was associated with shortened overall survival upon univariate analysis. Furthermore, high DJ-1 expression was the only independent prognostic factor affecting survival in combination with histological grade. This was contradicted by Miyajima et al.  who concluded that reduced nuclear DJ-1 expression was associated with shorter survival, whereas there was no correlation between the level of DJ-1 cytoplasmic expression and the prognosis of their cohort of astrocytoma patients. This controversy may result from the variation in the subcellular localization of DJ-1 and consequently DJ-1 might have different functions in the different cellular compartments.
When the astrocytoma cases were stratified according to WHO grading system, a significant association between DJ-1 staining intensity and the patient’s overall survival was observed in high-grade astrocytomas (anaplastic astrocytomas and GBMs). In anaplastic astrocytomas, strong DJ-1 staining (score 3) was able to identify patients with shorter survival than those exhibiting moderate DJ-1 staining (score 2). Also the variation in DJ-1 staining intensity stratified the GBM patients into a group with better survival (score 2 DJ-1) and a group with worse survival (score 3 DJ-1). However, DJ-1 was not significantly associated with survival in the cohort of diffuse astrocytoma patients.
The differential expression of DJ-1 particularly in anaplastic astrocytomas may have a future significance in identifying subclasses that are more aggressive or more likely associated with worse prognosis. This could be particularly important in cases where histopathology reveals lower grades of astrocytoma, while other factors indicate more malignant phenotypes. The effect on patient’s overall survival in high grade astrocytomas was restricted to DJ-1 rendering it a poor prognostic indicator independent of other factors including MIB-1 LI.
Therefore, this study emphasizes the adverse prognostic role of high DJ-1 expression in astrocytoma patients. It was the first, to the best of our knowledge, to set up a statistical survival analysis in which DJ-1 has a more valuable role in predicting survival when compared to MIB-1 especially in high grade astrocytomas.
MIB-1 is an important clinical marker in astrocytomas. Nevertheless, several shortcomings make it difficult to standardize a proliferation index for prognostic purposes. Therefore future studies, on a larger scale, are recommended in a trial to apply DJ-1 protein as a possible adjunct or even an alternative to MIB-1 immunohistochemistry especially in the histological borderline cases such as those at the grade II-III border and grade III-IV border.
In conclusion, though the histological grade still appears to be the best guideline to prognosis in astrocytoma patients, in many instances, there is dissociation between the morphologic criteria and clinical parameters. Therefore, immunohistochemical procedures using DJ-1 might serve as a very useful supporting tool to the histopathological diagnosis.
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.