American College of Radiology
ACR Appropriateness Criteria®

Locally Advanced Breast Cancer

Variant 1: 57-year-old woman, triple negative IDC, status postmastectomy: 3.5 cm inner quadrant primary, 7/12 LN (+). Focally positive deep margin. PET (+) IMN and supraclavicular nodes. Adjuvant anthracycline and taxane, with normalization of PET findings. Metastatic workup negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest wall only ± boost Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular + apical nodes (assumes chest wall RT also) Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Full axilla (assumes chest wall RT also) Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Internal mammary nodes (assumes chest wall RT) Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Boost to IMN Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Boost supraclavicular nodes Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Total dose to chest wall: 45-50 Gy (no boost) Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Total dose to chest wall: 60 Gy (no boost) May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Total dose to chest wall including boost to focally positive margin: 50-66 Gy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Total dose to supraclavicular fossa including boost: 45-50 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Total dose to pre-chemotherapy, PET (+), supraclavicular fossa: 60-66 Gy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Total dose to entire IMN chain: 45-50 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Total dose to pre-chemotherapy, PET (+) internal mammary node, 60-66 Gy Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 55-year-old woman with neglected primary. Large, fungating lesion and matted axilla. ER (–)/PR (+), Her2 (–). Metastatic workup negative. Not operable after three chemo regimens, including anthracyclines and taxanes.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Switch to endocrine therapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Preoperative RT (50-54 Gy) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Concurrent chemoradiation May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Definitive RT 60–64 Gy May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Switch to 4th line chemotherapy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Debulking surgery with anticipated + margins Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Palliative radiation (30-45 Gy) Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 40-year-old woman, 4 cm primary with diffuse suspicious microcalcifications in breast, direct skin invasion, satellite skin nodule, matted axilla (N2), ER (+)/PR (–), Her2 (–). Metastatic workup negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Initial chemotherapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Mastectomy if response to initial chemotherapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Initial endocrine therapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Initial surgery Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Initial breast and nodal RT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
BCT if response to initial chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Chest wall only ± boost (no nodal RT) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Chest wall, supraclavicular and apical nodes Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Chest wall, supraclavicular fossa + full axilla Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Internal mammary nodes (assumes chest wall RT) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Boost to chest wall Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Chest wall: 45-50 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Total dose to chest wall including boost: 60-66 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular and axilary nodes: 45-50 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Full axilla: 45-50 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
IMN: 45-50 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 80-year-old woman, 4 cm primary, direct skin invasion, satellite nodule, matted axilla (N2), strongly ER/PR (+), Her2 (–). Metastatic workup negative. Medically fit.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Initial endocrine therapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Initial chemotherapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Initial surgery Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Initial breast and nodal RT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 45-year-old premenopausal woman, 4.5 cm IDC left breast, ER/PR (–), Her2 amplified, PET (+) in breast, axilla, and medial infraclavicular fossa. Palpable nodes in high axilla. Metastatic workup negative. Patient desires breast conservation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Initial chemotherapy plus Her2-directed therapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
BCT if > or = PR to chemotherapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Initial mastectomy and axillary dissection Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Initial BCT and axillary dissection Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Whole breast only ± boost (no nodal RT) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Partial breast irradiation (no nodal RT) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Whole breast and supraclavicular + apical axillary nodes Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Whole breast and supraclavicular LNs and full axilla Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Internal mammary nodes (assumes breast RT given concurrently) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Boost infraclavicular region Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 42.5 Gy (16 fractions) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 45-50 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Total dose to breast tumor bed: 45-50 Gy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Total dose to breast tumor bed: 60-66 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Total dose to supraclavicular fossa and axillary apex: 45-50 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Total dose to supraclavicular fossa and axillary apex: 60 Gy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Total dose to medial infraclavicular nodes: > or = 60Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Full axilla: 45-50 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
IMN: 45-50 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Variant 6: 38-year-old woman, T4 inflammatory, N1 disease, no response post 3-cycle multidrug chemotherapy. ER/PR (–), Her2 (–). Metastatic workup negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Change chemotherapy; if no response or progressive disease, proceed to RT Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Change chemotherapy; if response, mastectomy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Change chemotherapy; if no response, pre-op chemoradiation (radiosensitizing chemotherapy) Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Immediate mastectomy/axillary dissection Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Standard fractionation (1.8-2.0 Gy) Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Accelerated fractionation (1.5 Gy BID) Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Dose to central chest wall: 45-50 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Total dose to chest wall including boost: 60-66 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Variant 7: 50-year-old woman, T3N2M0 disease, with clinical CR post 4-cycle multidrug chemotherapy. ER/PR (–), Her2 (–). Does not desire BCT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mastectomy and axillary dissection Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Additional chemotherapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Postmastectomy RT Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
No surgery: RT + chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 8: 50-year-old woman, stage T3N2M0 disease, with good clinical response following 4 cycles of multidrug neoadjuvant chemotherapy. She does not desire BCT and consents for mastectomy with reconstruction. Pathology from the mastectomy confirms ypT0N0M0 disease.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
No postmastectomy RT Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Postmastectomy RT with tissue expander in place Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Postmastectomy RT after implant exchange with tissue expander Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Postmastectomy RT after autologous flap Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Variant 9: 42-year-old woman with clinical stage T2N1M0 Her2 amplified left breast cancer. She undergoes a mastectomy with reconstruction and axillary dissection. Pathology notes 3.5-cm invasive cancer mastectomy margins are negative and 11/12 (+) nodes. Patient will receive chemotherapy and trastuzumab for 1 year.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest wall RT Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular RT Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Total RT dose delivery of 50 Gy or 50.4Gy without boost Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Total RT dose delivery of 60 Gy including boost Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Total RT dose delivery with bolus Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Total RT dose delivery without bolus May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Full axilla RT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
IMN RT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Discontinue trastuzimab during radiotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.