• White JR, Halberg FE, Rabinovitch R, Green S, Haffty BG, Solin LJ, Strom EA, Taylor ME, Edge SB, Expert Panel on Radiation Oncology-Breast. ACR Appropriateness Criteria® conservative surgery and radiation--stage I and II breast carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 14 p. [55 references]

This is the current release of the guideline.

This guideline updates a previous version: Expert Panel on Radiation Oncology–Breast Work Group: Francine E. Halberg, MD; Brenda M. Shank, MD, PhD; Bruce G. Haffty, MD; Alvaro A. Martinez, MD; Beryl McCormick, MD; Marsha D. McNeese, MD; Nancy P. Mendenhall, MD; Sandra E. Mitchell, MD; Rachel Abrams Rabinovitch, MD; Lawrence J. Solin, MD; Marie E. Taylor, MD; Sonja Eva Singletary, MD; Steven Leibel, MD. ACR Appropriateness Criteria® conservative surgery and radiation in the treatment of stage I and II carcinoma of the breast. [online publication]. Reston (VA): American College of Radiology (ACR); 2000.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

ACR Appropriateness Criteria®

Clinical Condition: Conservative Surgery and Radiation—Stage I and II Breast Carcinoma

Variant 1: Premenopausal 45-year-old woman, left breast 1.9 cm upper inner quadrant (UIQ), primary with lumpectomy, margins (–), GIII infiltrating ductal carcinoma (IDC), estrogen receptor/progesterone receptor (ER/PR) (–), Her2 (–), sentinel lymph node (SN) 1/3 (+) micro metastases; chemotherapy planned.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 2: 74-year-old woman, 1.2 cm well differentiated IDC, ER/PR (+) Her2 (–) upper outer quadrant (UOQ), primary excised with lumpectomy, margins (–), clinically negative axilla; anti-endocrine therapy planned; Karnofsky performance status (KPS)=90.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 3: Postmenopausal 56-year-old woman, 1.7 cm UOQ primary excised with lumpectomy–infiltrating lobular carcinoma associated with scattered lobular cancer in situ (LCIS), LCIS at margins, SN biopsy (–); ER/PR (+), Her2 (–); chemotherapy and anti-endocrine therapy planned.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 4: Premenopausal 42-year-old woman, 1.8 cm UOQ, IDC, no ductal carcinoma in situ (DCIS), SN biopsy negative, primary excised with lumpectomy, 1 focus of microscopic margin involvement, ER/PR (+), Her2 (–); chemotherapy and anti-endocrine therapy planned.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 5: Premenopausal 41-year-old woman, 1.1 cm GII IDC, UOQ, ER/PR (+), Her2 (–) primary excised with lumpectomy, margins (–), SN biopsy negative, BRCA 1 mutation positive.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 6: Postmenopausal 56-year-old woman, 2.5 cm UOQ moderately differentiated, extensive intraductal component (EIC) present, SN (–), ER/PR (+), Her2 (–), primary excised with lumpectomy, 1 focus of margin involvement; chemotherapy and anti-endocrine therapy planned.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 7: Premenopausal 46-year-old women, 2.6 cm UOQ IDC, primary excised with lumpectomy, margins (–), little DCIS, 2/10 LNs (+), level I-II axillary node dissection, ER/PR (–), Her2 (–), chemotherapy planned, patient desires breast conservation.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 8: Healthy 67-year-old woman, 0.5 cm well-differentiated IDC, ER/PR (+), Her2 (‒), primary excised with lumpectomy, margins (–); anti-endocrine therapy planned.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Variant 9: Postmenopausal 55-year-old woman, clinical T2N1, core biopsy shows poorly differentiated IDC, palpable LN FNA (+), ER (–), Her2 (3+), treated with neoadjuvant chemotherapy with excellent clinical response; primary excised with lumpectomy, 1.0 cm pathologic residual, margins (–), 1/20 LNs (+), planning trastuzumab (Herceptin) for 12 months; patient desires breast conservation.

Note: Abbreviations used in the table are listed at the end of the "Major Recommendations" field.

Management Guidelines

The vast majority of women with stage I or II breast cancer are good candidates for breast-conserving therapy (BCT). Whole-breast irradiation with or without boost is the standard of care following lumpectomy. Contraindications to BCT include patients with very extensive malignant-appearing calcifications on the mammogram. Postbiopsy mammograms should be obtained to assess the completeness of resection in patients whose tumors demonstrate microcalcifications on mammograms.

Two nonadjacent primary tumors in the same breast is a relative contraindication to RT. Pregnancy is an absolute contraindication. A history of well-documented collagen vascular disease and a history of prior RT to a high total dose, or significant volume, or both are considered relative contraindications to a breast-conserving approach. Any other patient who desires a breast-conserving approach and in whom negative margins of excision around the primary tumor can be obtained, (e.g., in patients with extensive intraductal component [EIC]-positive tumors), is a good candidate for BCT.

RT to the entire breast, to a total dose of 45‒50 Gy in 1.8‒2 Gy fractions for 4.5‒5.5 weeks, generally followed by a supplemental boost dose of radiation to the surgical tumor bed, is recommended. Regional nodal irradiation is not recommended for patients with negative axillary nodes. The role of regional nodal irradiation in patients with one to three positive nodes is uncertain.

Abbreviations

• 2D, 2-dimensional
• 3D, 3-dimensional
• BRCA, breast cancer
• CT, computed tomography
• DCIS, ductal carcinoma in situ
• EIC, extensive intraductal component
• ER, estrogen receptor
• FNA, fine needle aspiration
• IDC, infiltrating ductal carcinoma
• IMN, internal mammary (lymph) node
• KPS, Karnofsky performance status
• LCIS, lobular cancer in situ
• LN, lymph node
• LND, lymph node dissection
• PBI, partial breast irradiation
• PR, progesterone receptor
• RT, radiation therapy
• SCL, supraclavicular node
• SN, sentinel lymph node
• UIQ, upper inner quadrant
• UOQ, upper outer quadrant

None provided

The recommendations are based on analysis of the current literature and expert panel consensus.

• White JR, Halberg FE, Rabinovitch R, Green S, Haffty BG, Solin LJ, Strom EA, Taylor ME, Edge SB, Expert Panel on Radiation Oncology-Breast. ACR Appropriateness Criteria® conservative surgery and radiation--stage I and II breast carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 14 p. [55 references]

Not applicable: The guideline was not adapted from another source.

1996 (revised 2008)

American College of Radiology - Medical Specialty Society

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Committee on Appropriateness Criteria, Expert Panel on Radiation Oncology–Breast

Panel Members: Julia R. White, MD; Francine E. Halberg, MD; Rachel Rabinovitch, MD; Sheryl Green, MB, ChB; Bruce G. Haffty, MD; Lawrence J. Solin, MD; Eric A. Strom, MD; Marie E. Taylor, MD; Stephen B. Edge, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Expert Panel on Radiation Oncology–Breast Work Group: Francine E. Halberg, MD; Brenda M. Shank, MD, PhD; Bruce G. Haffty, MD; Alvaro A. Martinez, MD; Beryl McCormick, MD; Marsha D. McNeese, MD; Nancy P. Mendenhall, MD; Sandra E. Mitchell, MD; Rachel Abrams Rabinovitch, MD; Lawrence J. Solin, MD; Marie E. Taylor, MD; Sonja Eva Singletary, MD; Steven Leibel, MD. ACR Appropriateness Criteria® conservative surgery and radiation in the treatment of stage I and II carcinoma of the breast. [online publication]. Reston (VA): American College of Radiology (ACR); 2000.

The appropriateness criteria are reviewed annually and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

None available

This NGC summary was completed by ECRI Institute on September 10, 2009.