• Taylor ME, Haffty BG, Rabinovitch R, Arthur DW, Halberg FE, Strom EA, White JR, Cobleigh MA, Edge SB, Expert Panel on Radiation Oncology-Breast. ACR Appropriateness Criteria® postmastectomy radiotherapy. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 17 p. [96 references]

This is the current release of the guideline.

This guideline updates a previous version: Expert Panel on Radiation Oncology–Breast Work Group: Marie E. Taylor, MD; Bruce G. Haffty, MD; Brenda M. Shank, MD, PhD; Francine E. Halberg, 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; Sonja Eva Singletary, MD; Steven Leibel, MD; Abram Recht, MD. ACR Appropriateness Criteria® postmastectormy radiotherapy. [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: Postmastectomy Radiotherapy

Variant 1: 50 years of age, infiltrating ductal carcinoma, status post (S/P) modified radical mastectomy, 1.5 cm upper outer quadrant (UOQ), margins (–), 4/15 lymph nodes (LNs) (+). No blood vessel invasion (BVI) or lymphovascular invasion (LVI), no metastasis, systemic treatment planned (type undecided). Estrogen receptor/progesterone receptor (ER/PR), Her2, and menopause status will not alter treatment options.

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

Variant 2: 50 years of age, grade 3 infiltrating ductal carcinoma, S/P modified radical mastectomy, tumor is 3.5 cm UOQ, margins (–), 0/15 LNs (+). No BVI or LVI, no metastasis, systemic treatment planned (type undecided). ER/PR, Her2, and menopause status will not alter treatment options.

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

Variant 3: 50 years of age, postmenopausal woman with infiltrating ductal carcinoma, S/P modified radical mastectomy, 6.5 cm UOQ, margins (-), 0/15 LNs (+), ER/PR (+), Her2 (–). No BVI or LVI, no metastasis, systemic treatment planned (type undecided).

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

Variant 4: 54 years of age, postmenopausal woman, infiltrating ductal carcinoma, S/P modified radical mastectomy, 1.5 cm UOQ, margins (-), 2/15 LNs (+), ER/PR (+), Her2 (–). No BVI or LVI, no metastasis, systemic treatment planned (type undecided).

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

Variant 5: 50 years of age, postmenopausal woman, infiltrating ductal carcinoma, S/P modified radical mastectomy, 6.5 cm UOQ, margins (-), 2/15 LNs (+), ER/PR (+), Her2 (–). No BVI or LVI, no metastasis, systemic treatment planned (type undecided).

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

Variant 6: 40 years of age, premenopausal woman with infiltrating ductal carcinoma, S/P modified radical mastectomy, 3.5 cm UOQ, positive deep margins (tumor at ink), 0/15 LNs (+). No BVI or LVI, no metastasis, systemic treatment planned (type undecided).

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

Variant 7: 50 years of age, infiltrating ductal carcinoma, S/P modified radical mastectomy, with immediate reconstruction, no BVI or LVI, no metastasis, systemic treatment planned (type undecided), 3.5 cm left UOQ, margins (-), 4/15 LNs (+), post level I-II dissection. ER, PR, Her2 and menopausal status will not alter treatment recommendations.

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

Variant 8: 45 years of age, with diffuse suspicious calcifications, positive for DCIS, S/P simple mastectomy, no invasive carcinoma, but diffuse high-grade comedo DCIS with a positive deep margin (tumor at ink). Sentinel node at the time of mastectomy was negative.

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

Variant 9: 40 years of age, S/P mastectomy and sentinel node for multifocal invasive breast cancer, no focus greater than 1.0 cm. Sentinel node frozen section was negative, but the permanent section shows a focus of metastasis (˃2 mm). Completion level I/II axillary dissection demonstrates no further tumor in nine lymph nodes. Cytotoxic chemotherapy is planned. ER/PR (–), IHC only (+).

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

Conclusions

There is clear evidence from large randomized studies and meta-analyses that giving radiation therapy following modified radical mastectomy in high risk patients not only reduces local-regional failure rates but also yields clinically relevant improvements in disease-free and overall survival rates, even when adjuvant systemic therapy is also given. However, as stated in the American College of Radiology (ACR) position paper on postmastectomy radiation therapy, questions remain in generalizing from these results because of differences in surgical techniques, radiotherapy techniques, and treatment volumes, as well as differing systemic treatments.

Management Guidelines

Postmastectomy radiotherapy (PMR) is indicated in patients with T3N1 and T4N1&2 primary tumors as well as T1-2 disease with 4 or more positive nodes. The panel acknowledges that some controversy remains regarding the benefit of PMR for patients with T1-2N1 disease (i.e., one to three positive lymph nodes [LNs]), and the importance of the consultation process to review the risks and benefits of this therapy cannot be overemphasized. Chest-wall and regional lymphatic radiation therapy for premenopausal node-positive patients or node-positive postmenopausal women receiving tamoxifen therapy only is worthy of consideration, given the potential survival benefit. A radiation oncologist should be consulted for node-positive patients treated with mastectomy to help them assess the risk and benefits of postmastectomy radiotherapy. All postmastectomy patients with primary tumors larger than 5 cm with involved axillary nodes, or locally advanced (T4, N2) tumors should be irradiated. Patients with invasive tumor at the deep resection margin (including patients with negative axillary nodes) should also undergo radiotherapy.

Other treatment issues also need further attention if postmastectomy radiotherapy is to be used with maximum effectiveness and minimum toxicity. These include the interactions of doxorubicin or taxanes with radiotherapy, particularly when administered in high doses, the timing of chemotherapy and radiotherapy with regard to each other, and the best way to give radiotherapy to patients undergoing reconstruction surgery. Studies suggest that concurrent paclitaxel and irradiation are safe.

The chest wall should be treated in all irradiated patients. At simulation the radiation oncologist should check that the radiologic field borders to adequately ensure coverage of the clinical target volume, including scars. The panel's preferred total dose is approximately 50 Gy in 1.8-2 Gy daily fractions, five times weekly. Bolus should be applied to the entire chest wall in patients treated with 6 MV or higher energy photons. Use of a mastectomy scar electron boost is reasonable, and application of boost is based on risk assessment for residual microscopic disease.

Axillary radiotherapy should not be given after removal of level I or II nodes when the nodes are negative. For patients with one to three positive nodes, treatment of the supraclavicular fossa and axilla is optional. Patients with four or more positive nodes, or those with tumors larger than 5 cm, should be treated to the supraclavicular field. The panel did not strongly recommend treatment of the level I axilla after level I/II dissection when four or more lymph nodes are positive. Treatment of the axilla should be considered whenever there is a question of extensive nodal involvement, as defined by numbers of lymph nodes involved, size (bulk) of nodal disease, or extent of soft-tissue involvement in the axilla, or if there is limited dissection. The panel considered routine doses of 45-50.4 Gy reasonable. Treatment of the internal mammary chain remains controversial. The panel generally supports use of internal mammary treatment for patients having positive axillary nodes with medial or centrally located tumors.

Abbreviations

• BVI, blood vessel invasion
• DCIS, ductal carcinoma in situ
• ER, estrogen receptor
• IHC, immunohistochemistry
• IMN, internal mammary (lymph) node
• LN, lymph node
• LVI, lymphovascular invasion
• PR, progesterone receptor
• RT, radiation therapy
• S/P, status post
• UOQ, upper outer quadrant

None provided

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

• Taylor ME, Haffty BG, Rabinovitch R, Arthur DW, Halberg FE, Strom EA, White JR, Cobleigh MA, Edge SB, Expert Panel on Radiation Oncology-Breast. ACR Appropriateness Criteria® postmastectomy radiotherapy. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 17 p. [96 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: Marie E. Taylor, MD; Bruce G. Haffty, MD; Rachel Rabinovitch, MD; Douglas W Arthur, MD; Francine E. Halberg, MD; Eric A. Strom, MD; Julia R. White, MD; Melody A. Cobleigh, 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: Marie E. Taylor, MD; Bruce G. Haffty, MD; Brenda M. Shank, MD, PhD; Francine E. Halberg, 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; Sonja Eva Singletary, MD; Steven Leibel, MD; Abram Recht, MD. ACR Appropriateness Criteria® postmastectormy radiotherapy. [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.