Radiation Oncology/Breast/DCIS/Van Nuys
< Radiation Oncology < Breast < DCIS
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 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 |
Updated USC / Van Nuys Prognostic Index (VNPI)
| 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 |
| Age | 61 or older | 40 - 60 | 39 or younger |
Updated USC / Van Nuys - Total Score
| Score | Local recurrence | 5-yr and 10-yr local RFS |
| 4 - 6 points | 1% | 99% / 97% |
| 7 - 9 points | 20% | 84% / 73% |
| 10 - 12 points | 50% | 51% / 34% |
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) — "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