Background: Although Ki-67 is not included among the grading criteria in the current WHO Classification of Tumours of the Central Nervous System (CNS), it provides valuable, albeit limited, prognostic information. Immunohistochemistry for Ki-67 can reveal uneven proliferation patterns and assist in the assessment of mitotic counts. Several studies indicate that meningiomas with a proliferation index > 4% show recurrence rates comparable to CNS WHO grade 2 (atypical) tumors, while tumors with an index > 20% are associated with mortality rates similar to CNS WHO grade 3 (anaplastic) meningiomas. Issues related to Ki-67 assessment include interobserver variability, the use of different cut-off values among pathologists, and the presence of a complex inflammatory tumour microenvironment, which may lead to an overestimation of the proliferative index (PI). Methods: In this study, we describe how Double Staining Immunohistochemistry (dIHC) with EMA/Ki-67 better highlights neoplastic meningothelial cells compared with single-stain evaluation. Furthermore, the application of Digital Pathology provides quantitative digital data that allow a more accurate assessment of proliferation. Results: Ki-67 expression varied by grade, with digital image analysis (dIHC) showing high agreement with manual assessments. dIHC improved accuracy in evaluating diagnostic and proliferative markers within tumor samples. Conclusions: dIHC combined with DP can support and standardize the evaluation of the proliferative index in meningiomas in routine diagnostic practice.

Background Although several studies showed that high immunohistochemical Ki-67 index negatively influences the clinical course of meningiomas, especially in grade 1 and 2 neoplasm, the 5th edition of the World Health Organi-zation (WHO) Classification of Tumours of the Central Nervous System does not recognize it as a prognostic crite-rion. Issues related to Ki-67 assessment include interobserver variability, different cut-off values used by pathologists and the presence of a complex inflammatory tumour microenvironment, that may overestimate the proliferative index (PI). Methods In this paper, we described as Double Staining Immunohistochemistry (dIHC) EMA/Ki-67 highlights only neoplastic meningocytes better tha single slices evcaluation; then the application of Dig-ital Pathology (DP) can provide digital information for a more accurate count. Results and Future prospective dIHC and DP can support and standardize the evaluation of PI in meningiomas in daily routine.