Classification of Ductal Carcinoma In Situ (DCIS)

• DCIS is generally classified as one of five subtypes:
  • Based on differences in the architectural pattern of the cancer cells and nuclear features:
    • Comedo
    • Solid
    • Cribriform
    • Micropapillary
    • Papillary
  • Cribriform, comedo, and micropapillary:
    • Are the most common subtypes:
      • Although two or more patterns coexist:
        • In up to 50% of cases
• The classification of noninvasive breast cancer:
  • Stratifies lesions based on their:
    • Likelihood of recurrence and incorporates prognostic factors
• Lagios et al. (1989):
  • Identified high nuclear grade and comedonecrosis:
    • As factors predictive of local recurrence
  • Patients whose tumors had a high nuclear grade and comedonecrosis:
    • Had a 19% local recurrence rate after lumpectomy alone at an average interval of 26 months:
      • Compared with 5% for those patients:
        • Whose tumors did not have necrosis and were a lower nuclear grade
• Silverstein et al. (1995):
  • Developed the Van Nuys algorithm:
    • To stratify patients into three risk groups using three established predictors of local recurrence:
      • Tumor size
      • Margin width
      • Pathologic classification:
        • The presence or absence of comedonecrosis and / or high tumor grade
    • Now updated to include:
      • Age
• The University of Southern California / Van Nuys Prognostic Index Scoring System:
  • Can be used to determine which patients with DCIS are at greatest risk for recurrence:
    • And would therefore benefit from particular forms of locoregional therapy
  • With the goal being a local recurrence rate:
    • Of less than 20% at 12 years
  • Surgical excision alone:
    • Is recommended for a patient with a:
      • Score of 4 to 6
      • Score of 7:
        • But have margins ≥ 3 mm
  • Excision plus radiation therapy:
    • Is recommended for patients with a:
      • Score of 7 and margins < 3 mm
      • Score of 8 and margins ≥ 3 mm
      • Score of 9 and margins ≥ 5 mm
  • Mastectomy:
    • Is recommended for a:
      • Score of 8 and margins < 3 mm
      • Score of 9 and margins < 5 mm
      • Score of 10 to 12
  • The USC/VNPI score may be a useful adjunct in therapeutic decision making:
    • But multiple attempts at independently validating the utility of this risk stratification scheme have not been consistent
• Currently, there is no universally accepted classification system for DCIS

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