Ductal carcinoma in-situ: treatment decision breakpoints

reference: Silverstein MJ, Lagios MD, Craig PH, et al: A prognostic index for ductal carcinoma in situ of the breast. Cancer 77(11): 2267-2274, 1996. There has been an update so that some call the index the USC/VNPI (Silverstein MJ, "The University of Southern California/Van Nuys prognostic index for ductal carcinoma in situ of the breast", Am. J. Surg. 186(4): 337-43, 2003.

Update 2016: the biology of the DCIS is considered and CBS is much more aggressively used as promoted by the NAPBC and many other authorities as of 2016.

Update note as of 2010: in our program, conservative breast surgery for non-invasive breast cancer has become quite complex as it almost always results in additionally using radiation and medical hormonal blockade when ER and/or PR positive. Cases are reviewed at a multidisciplinary conference at every step in surgical treatment decisions until satisfactory surgery is accomplished. Whether to re-excise and how much depends on patient compliance issues, breast texture & need for possible MRI based on pathological circumscription or lack there-of, breast texture for mammographic follow-up and whether the case is suitable for hormonal blockade. So, our program does not officially use this calculation.

BACKGROUND: There is controversy and confusion regarding therapy for patients with the non-invasive cancer known as "ductal carcinoma in situ (DCIS) of the breast". The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment-choice selection process...with an eye toward statistically characterizing a patient's situation relative to the issue of conservative breast cancer surgery (CBS): how safe is lumpectomy only vs. lumpectomy PLUS radiation (XRT) vs. identification of those cases in which mastectomy may be the only advisable option. It is an index which is not really easy to calculate; therefore, I don't know that treating doctors actually use the VNPI (ours do not). Rather, they more likely use the general lessons from the study. Nevertheless, for those who want possibly more precise info., here is how it is done. A link to a "worksheet" for your use is at the bottom of this page, and it includes the numerical calculation coefficients for each parameter. Be aware, nevertheless, that mastectomy will be strongly considered in a "rule-of-thumb" manner for cases in which the:
 

• DCIS tumor is larger than 4 cm. 
• DCIS tumor location in breast is such that it is surgically technically difficult to get negative lumpectomy margins. 
• DCIS is multicentric (tumors in more than one breast quadrant) cancer.
   other factors about your breast are not OK for CBS. 

METHODS: The USC/VNPI combines four significant predictors of local recurrence: overall tumor size [largest single-direction size measure], closest clear surgical margin width [thinnest width],  pathologic nuclear grade classification, and patient age. Scores of 1 (best) to 3 (worst) are assigned for each of the 4 predictor parameters and then summed/totaled to give an overall VNPI score ranging from 4 to 12.

Three hundred thirty-three patients with pure, [non-invasive] DCIS treated with breast preservation/CBS (195 by excision only [lumpectomy] and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point. The later analysis was of a total of 583 cases.
 
calculate DCIS tumor SIZE

 
calculate DCIS tumor NUCLEAR GRADE

 
calculate DCIS tumor CLOSEST SURGICAL MARGIN

Original CONCLUSIONS: DCIS patients with VNPI scores of 4-6 can be considered for treatment with excision/lumpectomy only. Patients with intermediate scores (7-9) show a 17% decrease in their worse (than 3 and 4) local recurrence rates with the addition of radiation therapy (XRT) and are candidates for surgery PLUS radiation therapy. Patients with VNPI scores of 9-12 exhibit extremely high local recurrence rates, regardless of lumpectomy only or lumpectomy plus irradiation, and should be strongly considered for mastectomy.

Calculate the non-beta-weighted VNPI score
AND
chose VNPI Group, below

VNPI SCORE= tumor-size [_____pts] plus nuclear [_____pts]
plus margin [_____pts] plus age [___pts]=_____total VNPI points

Your VNPI calculation Worksheet

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(posted 17 Dec. 2000; latest update 10 October 2016)