
The mitotic index is a measure of cellular proliferation, defined as the percentage of cells undergoing mitosis in a given population of cells. Mitosis is the process of cell division, where somatic cells divide into two daughter cells. In the context of muscle tissue, such as skeletal and cardiac muscle cells, the mitotic activity is typically low after maturity. Muscle cells generally do not exhibit high rates of mitosis and have a lower capacity for regeneration compared to other tissues like skin. This is due to the spatial constraints and syncytial nature of muscle fibres, which hinder the process of cytokinesis. However, recent studies on skeletal muscle nuclei in mice have challenged the notion that muscle cells are completely post-mitotic, suggesting that there may be some capacity for DNA replication and growth.
| Characteristics | Values |
|---|---|
| Definition | The mitotic index is defined as the percentage of cells undergoing mitosis in a given population of cells. |
| Mitosis | Mitosis is the division of somatic cells into two daughter cells. |
| Durations of the cell cycle and mitosis | Durations of the cell cycle and mitosis vary in different cell types. |
| Elevated mitotic index | An elevated mitotic index indicates more cells are dividing. |
| Cancer cells | In cancer cells, the mitotic index may be elevated compared to normal growth of tissues or cellular repair of the site of an injury. |
| Prognostic factor | The mitotic index is an important prognostic factor predicting both overall survival and response to chemotherapy in most types of cancer. |
| Predictive value for elderly populations | The mitotic index may lose its predictive value for elderly populations. For example, a low mitotic index loses any prognostic value for women over 70 years old with breast cancer. |
| Muscle tissue | Muscle cells, such as skeletal and cardiac muscle cells, enter a phase of very low mitotic activity after maturity. They generally do not undergo mitosis; when they are damaged, they cannot divide to replace themselves effectively. |
| Skin tissue | Skin tissue would have the highest mitotic index compared to muscle, kidney, and lung tissue. Skin cells are constantly being shed and replaced. |
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What You'll Learn

Muscle cells rarely divide
The four main categories of muscle cells are skeletal muscle cells, heart (cardiac) muscle cells, smooth muscle cells, and myoepithelial cells. Once skeletal muscle fibres are formed, they generally survive for the entire lifetime of the animal. They cannot divide, and more of them can only be made by the fusion of myoblasts. This process of muscle cell formation occurs before birth in humans.
Cardiac muscle cells enter a phase of very low mitotic activity after maturity. They do not undergo mitosis and cannot effectively divide to replace themselves when damaged. Smooth muscle cells, on the other hand, exhibit variation in mitotic activity over the course of the menstrual cycle, with exogenous progesterone increasing the mitotic rate in leiomyomata.
The mitotic count (MC) is a biomarker that has been used for over 20 years. It is counted over at least 10 high-power fields and has been shown to have prognostic significance in various types of tumours. The Ki-67 index, which is present in cells undergoing all parts of the cell division cycle (G1, S, G2, and mitosis), is another marker of cell proliferation.
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Tumour grading systems
The mitotic index is a measure of how frequently cells undergo mitosis, or cell division. Muscle tissue, including skeletal and cardiac muscle cells, enters a phase of very low mitotic activity upon reaching maturity. As a result, muscle tissue generally has a low mitotic index, indicating that muscle cells do not replicate quickly or divide effectively to replace damaged cells.
Since then, various grading systems have been developed, including the French grading system and the National Cancer Institute (NCI) grading system. The French grading system is a 3-grade system based on tumour differentiation, mitotic index, and tumour necrosis. Scores are assigned to each parameter, with grade 1 being the least severe and grade 3 being the most severe.
The NCI system, on the other hand, is also a 3-grade system based on tumour histologic type and subtype, location, and the amount of tumour necrosis. However, for certain tumour types, cellularity, nuclear pleomorphism, and mitotic index are also considered. Tumours are then graded on a scale of 1 to 3, with higher grades indicating more abnormal and aggressive cancer cells.
In addition to these systems, the Ki-67 index, which measures the expression of a nuclear protein during the cell cycle, has been adopted into tumour grading systems. It is particularly prominent in gastroenteropancreatic neuroendocrine tumours (GEPNETS) and provides valuable information for management decisions.
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Prognostic factor for cancer
The mitotic index is a measure of how frequently cells undergo mitosis, or cell division. It is a valuable tool in oncology, providing information about the expected course of progression of a cancer, and can help with treatment decisions. Generally, cancerous tissues have a higher mitotic index than non-cancerous tissues as cancer cells divide faster than normal cells.
The mitotic index has been shown to be a good indicator of prognosis for some cancer types, including melanoma, soft tissue sarcoma, and mast cell tumours. Tumours with a mitotic index greater than 3 are usually more aggressive and have a poorer prognosis. Tumours with a mitotic index under 10 are usually classified as grade 1 and have a better prognosis. Tumours with an MI over 19 are generally classified as grade 3 and have a poorer prognosis.
In the context of specific cancers, a high mitotic index has been associated with larger tumour size, higher tumour grade, microvascular invasion, intrahepatic metastasis, and higher cancer stage. Patients with a high mitotic index tend to have shorter survival times. The mitotic index is used for tumour grading of breast and ovarian cancers, and has been incorporated into the American Joint Committee on Cancer's seventh tumour staging system for malignant melanoma, gastrointestinal tumours, and neuroendocrine tumours of the gastrointestinal tract.
The mitotic count (MC) has been used as a biomarker for over 20 years and has prognostic significance in several types of neuroendocrine tumours (NETs). The Ki-67 index, a marker of cell proliferation, is often used in conjunction with the mitotic count as it provides additional information that may affect management, particularly in gastroenteropancreatic NETs.
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Mitotic activity in muscle cells
The mitotic index is a measure of how frequently cells undergo mitosis, or cell division. Muscle cells, such as skeletal and cardiac muscle cells, enter a phase of very low mitotic activity after maturity. They generally do not undergo mitosis; when they are damaged, they cannot divide to replace themselves effectively.
However, there are some instances in which muscle cells have been observed to undergo mitosis. For example, in newts, skeletal muscle involves the de-differentiation of myocytes into myoblasts, which then re-enter the cell cycle and replicate. In mice, terminally differentiated C2C12 myotubes can de-differentiate and re-enter the cell cycle when induced by extracellular factors. Additionally, in humans, the regeneration of muscle fibers following damage requires the activation, proliferation, and differentiation of satellite cells, which then fuse into multinucleated myotubes to replace the damaged fiber.
Leiomyoma and leiomyosarcoma, which are smooth muscle tumors, have also been observed to exhibit mitotic activity. Some investigators have noted that exogenous progesterone increases the mitotic rate in leiomyomata. The detection of atypical mitoses in these tumors should prompt further investigation by pathologists.
While muscle cells generally have low mitotic activity, there are certain conditions and stimuli that can induce them to undergo mitosis. Further research and understanding of the mitotic activity in muscle cells may have implications for muscle regeneration and disease treatment.
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Mitotic count methods
The mitotic count (MC) has been used as a biomarker for over 20 years. It is a widely used criterion for assessing cancers in animals and humans. The mitotic index is defined as the number of cells undergoing mitosis divided by the number of cells not undergoing mitosis. It is expressed as a percentage or as mitoses per 1000 neoplastic cells. The mitotic rate is defined as the rate at which cells enter the mitotic (M) phase of the cell cycle, expressed as a percentage of the cells counted per hour.
Mitotic activity can be determined in a specified area or volume of a tumour. The mitotic count is most frequently determined in veterinary pathology, usually at 400x magnification, but the area counted can vary by more than 33% depending on the field number of the ocular. The recommended approach with the “hotspot” method is to first assess all slides from the tumour at low power to find the region containing more mitoses, then count the mitoses in the initial high-power field with the highest number of mitoses within the "hotspot". The count is then extended to adjacent non-overlapping fields until a specified area has been assessed.
The “average counting method” assesses mitoses in randomly selected high-power fields and expresses the average number of mitoses in a predefined area as a number per mm^2. Modern computational systems can calculate the mean or median number of mitoses across the whole slide. When using small biopsies, mitotic counts can be prone to error due to sampling bias and delayed fixation.
The mitotic count is conventionally counted over at least 10 high-power fields. It has been shown to have prognostic significance in pancreatic, upper gastrointestinal, and bronchial NETs. The Ki-67 index, which is present in cells undergoing all parts of the cell division cycle, often provides additional information that may affect management, especially in GEPNETs.
Automated systems can be used to report mitotic activity, and these have shown good correlation with manual counts. Computational pathology methods on digital images may increase the utility of the mitotic index in future studies.
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