Radiation Oncology/Breast/DCIS/Van Nuys

Van Nuys Prognostic Classification: Group 1 Non-high nuclear grade without necrosis Group 2 Non-high nuclear grade with necrosis Group 3 High nuclear grade with or without necrosis +Original Van Nuys Prognostic Index (VNPI) Scoring IndexParameter 1 Point 2 Points 3 PointsVan Nuys Classification Group 1 Group 2 Group 3Clear Margin > or = 10 mm 1-9 mm <1 mmLesion Size < or = 15 mm 16-40 mm > 41 mm +Final ScoreGroup 1 3 - 4 points 3.8% Recurrence 93% 8 year disease freeGroup 2 5 - 7 points 11.1% Recurrence 84% 8 year disease freeGroup 3 8 - 9 points 26.5% Recurrence 61 % 8 year disease free +Updated USC / Van Nuys Prognostic Index (VNPI)Parameter 1 Point 2 Points 3 PointsVan Nuys Classification Group 1 Group 2 Group 3Clear Margin > or = 10 mm 1-9 mm <1 mmLesion Size < or = 15 mm 16-40 mm > 41 mmAge 61 or older 40 - 60 39 or younger +Updated USC / Van Nuys - Total ScoreScore Local recurrence 5-yr and 10-yr local RFS4 - 6 points 1% 99% / 97%7 - 9 points 20% 84% / 73%10 - 12 points 50% 51% / 34% References: 2003 Updated USC/VNPI 14553846 Full text -- "The University of Southern California/Van Nuys prognostic index for ductal carcinoma in situ of the breast." (Silverstein MJ, Am J Surg. 2003 Oct;186(4):337-43.) Added age Score 4-6 : no statistical difference in 12-yr local RFS for pts treated with vs without RT Score 7-9 : 12-15% improvement with RT Score 10-12 : benefit with RT, but very high risk of recurrence despite RT Conclusion: Recommend excision alone for scores 4-6. RT for scores 7-9. Consider mastectomy for scores 10-12 1999 Subsequent report on margins: 10320383 Full text, 1999 (1979-1998) — "The influence of margin width on local control of ductal carcinoma in situ of the breast." Silverstein MJ et al. N Engl J Med. 1999 May 13;340(19):1455-61. Retrospective. 469 pts. Pts treated until 1989 received post-op RT and those treated after 1989 did not. RT was 40-50 Gy to whole breast + 16-20 Gy boost. Tumors were assessed for histologic subtype, nuclear grade, comedonecrosis, maximal diameter, and margin width. Margins were classified as close or involved (<1 mm), intermediate (1 to <10 mm), or wide. RT decreased the recurrence rate for close or involved margins; for intermediate or wide margins, was not statistically different. Conclusion: RT is not necessary for margins > 10 mm. 1996 First report 8635094 — "A prognostic index for ductal carcinoma in situ of the breast." Silverstein MJ et al (and Lewinsky BS). Cancer. 1996 Jun 1;77(11):2267-74. Came up with Van Nuys Prognostic Index (VNPI). Combines tumor size, margin width, histologic classification. Score 1-3 for each to arrive at a total score of 3-9. Evaluated 333 pts treated with excision alone or excision + RT. For pts with VNPI score of 3-4, excellent recurrence free survival (100% vs 97%) whether or not RT was used. For VNPI scores of 5-7, there was a 17% decrease (85% vs 68%) in RFS when RT was used. For score of 8-9, recurrence rate > 60% despite RT. Conclusion: recommend excision alone for score of 3-4, excision + RT for score of 5-7, and mastectomy for 8-9. Alternative 16750316 -- "Rationalization and regionalization of treatment for ductal carcinoma in situ of the breast." (Smith GL, Int J Radiat Oncol Biol Phys. 2006 Aug 1;65(5):1397-403.) Used classification below for cohort study: +Alternative Parameter Age Size Histology 0 Points 61+ <=15 mm Grade I-II 1 Points 40-60 16-40 mm Grade I-II + Necrosis 2 Points <40 >40 mm Grade III Low risk: 0 Intermediate risk: 1-2 High risk: 3-6