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

References:


 * 2003 Updated USC/VNPI PMID 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: PMID 10320383 Full text, 1999 (1979-1998) &mdash; "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 PMID 8635094 &mdash; "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
 * PMID 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:


 * Low risk: 0
 * Intermediate risk: 1-2
 * High risk: 3-6