Abstract
Identifying ductal carcinoma in situ (DCIS) patients at highest risk for recurrence after breast conserving surgery (BCS) remains a clinical concern. Subjecting all such patients to radiotherapy may be unnecessary. The Van Nuys Prognostic Index (VNPI) is a simple scoring system for predicting the risk of local recurrence in patients with DCIS. We reviewed patients with DCIS applying the VNPI score system. A total of 184 DCIS patients who underwent surgery at our institution between January 2003 and December 2011 were identified. Patients were not treated according to VNPI guidelines; rather, radiation therapy was applied at each surgeon’s discretion. All patients with hormonal receptor positive tumors were treated with hormonal therapy. Pathology reports were reviewed and VNPI scores of each DCIS calculated. Of the 184 patients, 52 (28.3%), 115 (62.5%) and 17 (9.2%) had low, intermediate and high VNPI scores, respectively. Six of the 184 patients (3.3%) developed ipsilateral local recurrence, five in the intermediate and one in the high VNPI score group. Of the five in the intermediate group, three (60%) were in patients with ER-negative tumors. VNPI score itself was not associated with recurrence (P = 0.145). Factors associated with recurrence included tumor size (hazard ratio [HR] 6.88), grade (HR 9.07) and hormone receptor status (HR 11.75). Radiotherapy did not significantly improve recurrence rates in patients with low and intermediate risk DCIS, especially in those with ER-positive tumors. Radiotherapy can be omitted in patients with ER-positive intermediate score DCIS and in patients with low score DCIS.
Highlights
ductal carcinoma in situ (DCIS) of the breast encompasses a heterogeneous spectrum of diseases, characterized by the proliferation of cancer cells within the ducts without invasion of the surrounding stromal tissue (Harris et al 1992)
breast conserving surgery (BCS) followed by RT has become the standard of management in DCIS, several retrospective series have suggested that adjuvant RT may be omitted for patients at lower risk for recurrence
Margin widths were determined after the final excision in the patients who underwent BCS, with 21 (11.4%) undergoing re-excision for safety
Summary
DCIS of the breast encompasses a heterogeneous spectrum of diseases, characterized by the proliferation of cancer cells within the ducts without invasion of the surrounding stromal tissue (Harris et al 1992). Little is known regarding the natural history of DCIS, patients with DCIS have a potential risk of invasive cancer (Robinson et al 2008); its management is similar to that for early invasive breast cancer (Masson and Bahl 2013). Due to the risk of recurrence following breast conserving surgery (BCS), patients with DCIS. At the time of those studies, pathologic factors related to local control were largely unknown, resulting in underestimation of invasiveness and margin status. BCS followed by RT has become the standard of management in DCIS, several retrospective series have suggested that adjuvant RT may be omitted for patients at lower risk for recurrence. Identifying patient subgroups likely to show local control without additional RT is important, since RT has various side effects, ranging from skin reactions to radiation pneumonitis. The benefits of RT with respect to local control must be compared with its risks of side effects
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