Breast Cancer Research and Treatment

, Volume 61, Issue 2, pp 151–159 | Cite as

Application of the Van Nuys prognostic index in a retrospective series of 367 ductal carcinomas in situ of the breast examinated by serial macroscopic sectioning: Practical considerations

  • Isabelle de Mascarel
  • Françoise Bonichon
  • Gäetan MacGrogan
  • Christine Tunon de Lara
  • Antoine Avril
  • Véronique Picot
  • Michel Durand
  • Louis Mauriac
  • Monique Trojani
  • Jean-Michel Coindre
Article

Abstract

The Van Nuys prognostic index (VNPI) was thought to be useful for predicting response to radiotherapy and local recurrence of ductal carcinoma in situ (DCIS). We applied the VNPI under the conditions defined by Silverstein et al., in 367 retrospective DCIS entirely sectioned into serial macroscopic 2 mm slices (155 patients had radiotherapy, median follow-up 71 months). The percentage of positive blocks with DCIS was also estimated for each specimen with cut-offs at 30% and 60% to obtain three scores. One hundred and ninety five lesions had a low VNPI, 152 an intermediate VNPI, and 20 a high VNPI. There were 9% of local recurrences (half invasive, all in the group without radiotherapy) in the low VNPI group. The local recurrence rate increased with size (p=0.001), with reduction of distance to margins (p=0.05), with histologic grade (p=0.02), with percentage of positive blocks (p=0.0003) and with VNPI score (p=0.03). The percentage of positive blocks was the only independent predictor for local recurrence (p=0.0001).

Conclusion: (1) The VNPI was a local recurrence rate predictor between the low and the intermediate groups but in our series the low VNPI group had a surprisingly high local recurrence rate. (2) Only prospective studies will assess the importance of margin width and the role of radiotherapy in maintaining local control. (3) Estimation of the percentage of positive blocks is simple, may be an alternative when measurement of DCIS is difficult and should be taken into account.

breast ductal carcinoma in situ (DCIS) local recurrence rate percentage of positive blocks prognostic index 

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References

  1. 1.
    Sunshine JA, Moseley HS, Fletcher WS, Krippaehne WW: Breast carcinoma in situ. A retrospective review of 112 cases with a minimum 10 year follow-up. Am J Surg 150: 44–51, 1985Google Scholar
  2. 2.
    Ernster VL, Barclay J, Kerlikowske K, Grady D, Henderson C: Incidence of and treatment for ductal carcinoma in situ of the breast [see comments]. JAMA 275: 913–918, 1996Google Scholar
  3. 3.
    Nemoto T, Vana J, Bedwani RN, Baker HW, McGregor FH, Murphy GP: Management and survival of female breast cancer: results of a national survey by the American College of Surgeons. Cancer 45: 2917–2924, 1980Google Scholar
  4. 4.
    Landis SH, Murray T, Bolden S, Wingo PA: Cancer statistics, 1998 [published erratum appears in CA Cancer J Clin 1998 May-Jun; 48(3): 192]. CA Cancer J Clin 48: 6–29, 1998Google Scholar
  5. 5.
    Silverstein MJ: Ductal carcinoma in situ of the breast. Williams and Wilkins, Baltimore, 1997Google Scholar
  6. 6.
    Stomper PC, Connolly JL, Meyer JE, Harris JR: Clinically occult ductal carcinoma in situ detected with mammography: analysis of 100 cases with radiologic- pathologic correlation. Radiology 172: 235–241, 1989Google Scholar
  7. 7.
    Silverstein MJ, Gamagami P, Colburn WJ: Coordinated biopsy team: surgical, pathologic and radiologic issues. In: Silverstein MJ (ed.) Ductal Carcinoma in situ of the Breast. Williams and Wilkins, Baltimore, 1997, pp. 333–342Google Scholar
  8. 8.
    Sloane JP, Ellman R, Anderson TJ, Brown CL, Coyne J, Dallimore NS, Davies JD, Eakins D, Ellis IO, Elston CW: Consistency of histopathological reporting of breast lesions detected by screening: findings of the UK National External Quality Assessment (EQA) Scheme. UK National Coordinating Group for Breast Screening Pathology. Eur J Cancer 30A: 1414–1419, 1994Google Scholar
  9. 9.
    Patchefsky AS, Schwartz GF, Finkelstein SD, Prestipino A, Sohn SE, Singer JS, Feig SA: Heterogeneity of intraductal carcinoma of the breast. Cancer 63: 731–741, 1989Google Scholar
  10. 10.
    Lennington WJ, Jensen RA, Dalton LW, Page DL: Ductal carcinoma in situ of the breast. Heterogeneity of individual lesions. Cancer 73: 118–124, 1994Google Scholar
  11. 11.
    Consensus Conference on the classification of ductal carcinoma in situ. The Consensus Conference Committee. Cancer 80: 1798–1802, 1997Google Scholar
  12. 12.
    Lagios MD: Ductal carcinoma in situ: controversies in diagnosis, biology, and treatment. Breast J 1: 68–78, 1995Google Scholar
  13. 13.
    Morrow M, Schnitt SJ, Harris JR: Ductal carcinoma in situ. In: Harris JR, Lippman ME, Morrow M, Hellman S (eds) Diseases of the breast. Lippincott-Raven, Philadelphia, 1996, pp. 355–368Google Scholar
  14. 14.
    Silverstein MJ, Barth A, Poller DN, Gierson ED, Colburn WJ, Waisman JR, Gamagami P: Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast. Eur J Cancer 31A: 1425–1427, 1995Google Scholar
  15. 15.
    Schwartz GF, Finkel GC, Garcia JC, Patchefsky AS: Subclinical ductal carcinoma in situ of the breast. Treatment by local excision and surveillance alone [see comments]. Cancer 70: 2468–2474, 1992Google Scholar
  16. 16.
    Silverstein MJ, Lagios MD: Use of predictors of recurrence to plan therapy for DCIS of the breast. Oncology (Huntingt) 11: 393–410, 1997Google Scholar
  17. 17.
    Silverstein MJ, Lagios MD, Craig PH, Waisman JR, Lewinsky BS, Colburn WJ, Poller DN: A prognostic index for ductal carcinoma in situ of the breast [see comments]. Cancer 77: 2267–2274, 1996Google Scholar
  18. 18.
    Silverstein MJ: Predicting local recurrences in patients with ductal carcinoma in situ. In: Anonymous Ductal carcinoma in situ of the Breast. Williams and Wilkins, Baltimore, 1997, pp. 271–283Google Scholar
  19. 19.
    Silverstein MJ, Poller DN, Waisman JR, Colburn WJ, Barth A, Gierson ED: Prognostic classification of breast ductal carcinoma in situ. Lancet 345: 1154–1157, 1995Google Scholar
  20. 20.
    Tavassoli FA: Intraductal carcinoma. In: Anonymous Pathology of the Breast. Appleton and Lange, New York, 1992, pp. 238–243Google Scholar
  21. 21.
    Solin LJ, Yeh IT, Kurtz J, Fourquet A, Recht A, Kuske R, McCormick B, Cross MA, Schultz DJ, Amalric R: Ductal carcinoma in situ (intraductal carcinoma) of the breast treated with breast-conserving surgery and definitive irradiation. Correlation of pathologic parameters with outcome of treatment. Cancer 71: 2532–2542, 1993Google Scholar
  22. 22.
    Bellamy CO, McDonald C, Salter DM, Chetty U, Anderson TJ: Noninvasive ductal carcinoma of the breast: the relevance of histologic categorization. Hum Pathol 24: 16–23, 1993Google Scholar
  23. 23.
    Schnitt SJ, Abner A, Gelman R, Connolly JL, Recht A, Duda RB, Eberlein TJ, Mayzel K, Silver B, Harris JR: The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy [see comments]. Cancer 74: 1746–1751, 1994Google Scholar
  24. 24.
    Lagios MD, Margolin FR, Westdahl PR, Rose MR: Mammographically detected duct carcinoma in situ. Frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence. Cancer 63: 618–624, 1989Google Scholar
  25. 25.
    Fisher ER, Costantino J, Fisher B, Palekar AS, Redmond C, Mamounas E: Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators [see comments]. Cancer 75: 1310–1319, 1995Google Scholar
  26. 26.
    Carty NJ, Carter C, Royle GT, Johnson CD: Management of ductal carcinoma in situ of the breast. Ann R Coll Surg Engl 77: 163–167, 1995Google Scholar
  27. 27.
    Schnitt SJ, Connolly JL, Tavassoli FA, Fechner RE, Kempson RL, Gelman R, Page DL: Interobserver reproducibility in the diagnosis of ductal proliferative breast lesions using standardized criteria [see comments]. Am J Surg Pathol 16: 1133- 1143, 1992Google Scholar
  28. 28.
    Holland R, Peterse JL, Millis RR, Eusebi V, Faverly D, van d, V, Zafrani B: Ductal carcinoma in situ: a proposal for a new classification. Semin Diagn Pathol 11: 167–180, 1994Google Scholar
  29. 29.
    Eusebi V, Feudale E, Foschini MP, Micheli A, Conti A, Riva C, Di Palma S, Rilke F: Long-term follow-up of in situ carcinoma of the breast. Semin Diagn Pathol 11: 223–235, 1994Google Scholar
  30. 30.
    Millis RR: Classification of ductal carcinoma in situ of the breast. Adv Anat Pathol 3: 114–129, 1996Google Scholar
  31. 31.
    Silverstein MJ, Craig PH, Lagios MD, Waisman JK, Lewinsky BS, Colburn WJ: Developing a prognostic index for ductal carcinoma in situ of the breast. Are we there yet? Cancer 78: 1138–1140, 1996Google Scholar
  32. 32.
    Douglas-Jones AG, Gupta SK, Attanoos RL, Morgan JM, Mansel RE: A critical appraisal of six modern classifications of ductal carcinoma in situ of the breast (DCIS): correlation with grade of associated invasive carcinoma. Histopathology 29: 397–409, 1996Google Scholar
  33. 33.
    Simon R, Altman DG: Statistical aspects of prognostic factor studies in oncology [editorial]. Br J Cancer 69: 979–985, 1994Google Scholar
  34. 34.
    Zafrani B, Leroyer A, Fourquet A, Laurent M, Trophilme D, Validire P, Sastre-Garau X: Mammographically-detected ductal in situ carcinoma of the breast analyzed with a new classification. A study of 127 cases: correlation with estrogen and progesterone receptors, p53 and c-erbB-2 proteins, and proliferative activity. Semin Diagn Pathol 11: 208–214, 1994Google Scholar
  35. 35.
    Badve S, A'Hern RP, Ward AM, Millis RR, Pinder SE, Ellis IO, Gusterson BA, Sloane JP: Prediction of local recurrence of ductal carcinoma in situ of the breast using five histological classifications: a comparative study with long follow-up. Hum Pathol 29: 915–923, 1998Google Scholar
  36. 36.
    Page DL, Dupont WD, Rogers LW, Jensen RA, Schuyler PA: Continued local recurrence of carcinoma 15- 25 years after a diagnosis of low grade ductal carcinoma in situ of the breast treated only by biopsy. Cancer 76: 1197–1200, 1995Google Scholar
  37. 37.
    Solin LJ, Kurtz J, Fourquet A, Amalric R, Recht A, Bornstein BA, Kuske R, Taylor M, Barrett W, Fowble B, Haffty B, Schultz DJ, Yeh IT, McCormick B, McNeese M: Fifteen-year results of breast-conserving surgery and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast. J Clin Oncol 14: 754–763, 1996Google Scholar
  38. 38.
    Silverstein MJ: Ductal carcinoma in situ of the breast. BMJ 317: 734–739, 1998Google Scholar
  39. 39.
    Schnitt SJ, Harris JR, Smith BL: Developing a prognostic index for ductal carcinoma in situ of the breast. Are we there yet? [editorial; comment] [see comments]. Cancer 77: 2189–2192, 1996Google Scholar
  40. 40.
    Silverstein MJ, Waisman JR, Gamagami P, Gierson ED, Colburn WJ, Rosser RJ, Gordon PS, Lewinsky BS, Fingerhut A: Intraductal carcinoma of the breast (208 cases). Clinical factors influencing treatment choice. Cancer 66: 102–108, 1990Google Scholar
  41. 41.
    Solin LJ, Fourquet A, McCormick B, Haffty B, Recht A, Schultz DJ, Barrett W, Fowble BL, Kuske R, Taylor M: Salvage treatment for local recurrence following breastconserving surgery and definitive irradiation for ductal carcinoma in situ (intraductal carcinoma) of the breast. Int J Radiat Oncol Biol Phys 30: 3–9, 1994Google Scholar
  42. 42.
    de Jong E, Peterse JL, van Dongen JA: Recurrence after breast ablation for ductal carcinoma in situ. Eur J Surg Oncol 18: 64–66, 1992Google Scholar
  43. 43.
    Silverstein MJ, Lagios MD, Martino S, Lewinsky BS, Craig PH, Beron PJ: Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast. J Clin Oncol 16: 1367–1373, 1998Google Scholar
  44. 44.
    Hiramatsu H, Bornstein BA, Recht A, Schnitt SJ, Baum JK, Connolly JL, Duda RB, Guidi AJ, Kaelin CM, Silver B, Harris JR: Local recurrence after conservative surgery and radiation therapy for ductal carcinoma in situ. Cancer J Sci Am 1: 55, 1995Google Scholar
  45. 45.
    Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, Fisher ER, Wickerham DL, Deutsch M, Margolese R, Dimitrov N, Kavanah M: Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol 16: 441–452, 1998Google Scholar
  46. 46.
    Lagios MD, Page DL: Radiation therapy for in situ or localized breast cancer [letter; comment]. N Engl J Med 329: 1577–1578, 1993Google Scholar
  47. 47.
    Page DL, Lagios MD: Pathologic analysis of the National Surgical Adjuvant Breast Project (NSABP) B-17 Trial. Unanswered questions remaining unanswered considering current concepts of ductal carcinoma in situ [editorial]. Cancer 75: 1219–1222, 1995Google Scholar
  48. 48.
    Arnesson LG, Smeds S, Fagerberg G, Grontoft O: Follow-up of two treatment modalities for ductal cancer in situ of the breast. Br J Surg 76: 672–675, 1989Google Scholar
  49. 49.
    Gallagher WJ, Koerner FC, Wood WC: Treatment of intraductal carcinoma with limited surgery: long-term follow-up. J Clin Oncol 7: 376–380, 1989Google Scholar
  50. 50.
    Carpenter R, Boulter PS, Cooke T, Gibbs NM: Management of screen detected ductal carcinoma in situ of the female breast. Br J Surg 76: 564–567, 1989Google Scholar
  51. 51.
    Temple WJ, Jenkins M, Alexander F, Hwang WS, Marx LH, Lees AW, Williams HT, Pambrun MG: Natural history of in situ breast cancer in a defined population. Ann Surg 210: 653–657, 1989Google Scholar
  52. 52.
    Baird RM, Worth A, Hislop G: Recurrence after lumpectomy for comedo-type intraductal carcinoma of the breast. Am J Surg 159: 479–481, 1990Google Scholar
  53. 53.
    Price P, Sinnett HD, Gusterson B, Walsh G, A'Hern RP, McKinna JA: Duct carcinoma in situ: predictors of local recurrence and progression in patients treated by surgery alone. Br J Cancer 61: 869–872, 1990Google Scholar
  54. 54.
    Ringberg A, Andersson I, Aspegren K, Linell F: Breast carcinoma in situ in 167 women, incidence, mode of presentation, therapy and follow-up. Eur J Surg Oncol 17: 466–476, 1991Google Scholar
  55. 55.
    Silverstein MJ, Cohlan BF, Gierson ED, Furmanski M, Gamagami P, Colburn WJ, Lewinsky BS, Waisman JR: Duct carcinoma in situ: 227 cases without microinvasion [see comments]. Eur J Cancer 28: 630–634, 1992Google Scholar
  56. 56.
    Fisher B, Costantino J, Redmond C, Fisher E, Margolese R, Dimitrov N, Wolmark N, Wickerham DL, Deutsch M, Ore L: Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer [see comments]. N Engl J Med 328: 1581–1586, 1993Google Scholar
  57. 57.
    Frykberg ER, Bland KI: Overview of the biology and management of ductal carcinoma in situ of the breast. Cancer 74: 350–361, 1994Google Scholar
  58. 58.
    Lagios MD, Westdahl PR, Margolin FR, Rose MR: Duct carcinoma in situ. tiRelationship of extent of noninvasive disease to the frequency of occult invasion, multicentricity, lymph node metastases, and short-term treatment failures. Cancer 50: 1309–1314, 1982Google Scholar
  59. 59.
    Holland PA, Gandhi A, Knox WF, Wilson M, Baildam AD, Bundred NJ: The importance of complete excision in the prevention of local recurrence of ductal carcinoma in situ. Br J Cancer 77: 110–114, 1998Google Scholar
  60. 60.
    Holland R, Faverly DRG: Whole organ studies. In: Silverstein MJ (ed.) Ductal Carcinoma In situ of the Breast. Williams and Wilkins, Baltimore, 1997, pp. 233–240Google Scholar
  61. 61.
    Silverstein MJ, Lagios MD, Lewinsky BS, Colburn WJ, Beron P, Craig PH, et al.: Breast irradiation is unnecessary for widely excised ductal carcinoma in situ (DCIS) (abst). Breast Cancer Res Treat 46: 23–23, 1997Google Scholar
  62. 62.
    Sibbering MD, Blamer RW: Nottingham experience. In: Silverstein MJ (ed.) Ductal carcinoma in situ of the Breast. Williams and Wilkins, Baltimore, 1997, pp. 367–372Google Scholar
  63. 63.
    Silverstein MJ, Lagios MD, Waisman JR, Martino S, Beron P, Lewinsky BS, et al.: Margin width: a critical determinant of local control in patients with ductal carcinoma in situ (DCIS) of the breast. (abst). Proc A Soc Clin Oncol 17: 120A- 120A, 1998Google Scholar
  64. 64.
    Silverstein MJ, Lagios MD, Groshen S, Waisman JR, Lewinsky BS, Martino S, Gamagami P, Colburn WJ: The influence of margin width on local control of ductal carcinoma in situ of the breast [see comments]. N Engl J Med 340: 1455–1461, 1999Google Scholar
  65. 65.
    Tavassoli FA: Ductal carcinoma in situ: introduction of the concept of ductal intraepithelial neoplasia. Mod Pathol 11: 140–154, 1998Google Scholar
  66. 66.
    Radford DM, Fair K, Thompson AM, Ritter JH, Holt M, Steinbrueck T, Wallace M, Wells SAJ, Donis-Keller HR: Allelic loss on a chromosome 17 in ductal carcinoma in situ of the breast. Cancer Res 53: 2947–2949, 1993Google Scholar
  67. 67.
    Noguchi S, Motomura K, Inaji H, Imaoka S, Koyama H: Clonal analysis of predominantly intraductal carcinoma and precancerous lesions of the breast by means of polymerase chain reaction. Cancer Res 54: 1849–1853, 1994Google Scholar
  68. 68.
    Radford DM, Phillips NJ, Fair KL, Ritter JH, Holt M, Donis-Keller H: Allelic loss and the progression of breast cancer [published erratum appears in Cancer Res 1996 Feb 15; 56(4): 935]. Cancer Res 55: 5180–5183, 1995Google Scholar
  69. 69.
    Stratton MR, Collins N, Lakhani SR, Sloane JP: Loss of heterozygosity in ductal carcinoma in situ of the breast. J Pathol 175: 195–201, 1995Google Scholar
  70. 70.
    Lakhani SR, Collins N, Stratton MR, Sloane JP: Atypical ductal hyperplasia of the breast: clonal proliferation with loss of heterozygosity on chromosomes 16q and 17p. J Clin Pathol 48: 611–615, 1995Google Scholar
  71. 71.
    Lakhani SR, Slack DN, Hamoudi RA, Collins N, Stratton MR, Sloane JP: Detection of allelic imbalance indicates that a proportion of mammary hyperplasia of usual type are clonal, neoplastic proliferations. Lab Invest 74: 129–135, 1996Google Scholar
  72. 72.
    Fujii H, Marsh C, Cairns P, Sidransky D, Gabrielson E: Genetic divergence in the clonal evolution of breast cancer. Cancer Res 56: 1493–1497, 1996Google Scholar
  73. 73.
    Fédération Nationale des Centres de Lutte Contre le Cancer: Cancers du sein non métastatiques. Standards, options et recommandations, vol. 3. Paris: Arnette-Blackwell, 1996Google Scholar
  74. 74.
    Winchester DP, Strom EA: Standards for diagnosis and management of ductal carcinoma in situ (DCIS) of the breast. American College of Radiology. American College of Surgeons. College of American Pathologists. Society of Surgical Oncology. CA Cancer J Clin 48: 108–128, 1998Google Scholar
  75. 75.
    Morrow M, Schnitt, SJ: Treatment selection in ductal carcinoma in situ. JAMA 283: 453–455, 2000Google Scholar

Copyright information

© Kluwer Academic Publishers 2000

Authors and Affiliations

  • Isabelle de Mascarel
    • 1
  • Françoise Bonichon
    • 2
  • Gäetan MacGrogan
    • 1
  • Christine Tunon de Lara
    • 3
  • Antoine Avril
    • 3
  • Véronique Picot
    • 2
  • Michel Durand
    • 4
  • Louis Mauriac
    • 4
  • Monique Trojani
    • 1
  • Jean-Michel Coindre
    • 1
  1. 1.Department of PathologyBordeauxFrance
  2. 2.Department of BiostatisticsBordeauxFrance
  3. 3.Department of SurgeryBordeauxFrance
  4. 4.Department of MedicineInstitut BergoniéBordeauxFrance

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