Radiation Oncology/Breast/DCIS/Van Nuys

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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


Van Nuys Prognostic Index (VNPI) Scoring Index
Parameter 1 Point 2 Points 3 Points
Van Nuys Classification Group 1 Group 2 Group 3
Clear Margin > or = 10 mm 1-9 mm <1 mm
Lesion Size < or = 15 mm 16-40 mm > 41 mm


Final Score
Group 1 3 - 4 points 3.8% Recurrence 93% 8 year disease free
Group 2 5 - 7 points 11.1% Recurrence 84% 8 year disease free
Group 3 8 - 9 points 26.5% Recurrence 61 % 8 year disease free

References:

  • 1999 Subsequent report on margins: PMID 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 PMID 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

  • 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:


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
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