American College of Radiology
ACR Appropriateness Criteria®

Conservative Surgery and Radiation—Stage I and II Breast Cancer

Variant 1: Healthy 70-year-old woman, 0.5-cm well-differentiated IDC, ER/PR (+), HER2 (–), left-sided primary excised with lumpectomy, margins (–) <2 mm; endocrine therapy planned.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mastectomy + sentinel lymph node biopsy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + sentinel lymph node biopsy + whole breast RT Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + sentinel lymph node biopsy + accelerated PBI Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + sentinel lymph node biopsy (no RT) Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + sentinel lymph node biopsy (no RT, no endocrine therapy) Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 40–42.5 Gy (15–16 fractions) Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 45–50 Gy (23–25 fractions) Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Total tumor bed dose: 50 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast + tumor bed boost: 60 Gy (30 fractions) Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Whole breast + tumor bed boost: 64–66 Gy (32–33 fractions) Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
PBI: 34–38.5 Gy (8–10 fractions over 5 days) Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Premenopausal 41-year-old woman, 1.1-cm GII IDC, upper outer quadrant (UOQ), ER/PR (+), HER2 (–), primary excised with lumpectomy, margins (–), SN biopsy negative, BRCA1 mutation positive.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Whole breast irradiation Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Completion mastectomy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Completion mastectomy + contralateral mastectomy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Partial breast irradiation Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Postmenopausal 56-year-old woman, 2.5-cm UOQ moderately differentiated, EIC present, SN (–), ER/PR (+), HER2 (–), primary excised with lumpectomy, 1 focus of margin involvement; chemotherapy and antiendocrine therapy planned.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Re-excision + whole breast RT if negative margins +/- boost Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Completion mastectomy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
No further surgery + RT to 66 Gy (33 fractions) May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
No further surgery + RT to 60 Gy (30 fractions) Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Premenopausal 46-year-old woman, 2.6-cm UOQ IDC, primary excised with lumpectomy, margins (–), minimal DCIS, 2/10 LNs (+), level I-II axillary node dissection, ER/PR (–), HER2 (–), BRCA (–), chemotherapy planned, 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
Whole breast RT alone Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Whole breast RT + nodal RT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Completion mastectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular + apical (level III) axillary nodes Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Full axilla (level I-III) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Internal mammary nodes (IMN) May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 40–42.6 Gy (15–16 fractions) + 10 Gy boost May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 40–42.6 Gy (15–16 fractions) (no boost) Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 45–50 Gy (23–25 fractions) (no boost) Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast + tumor bed dose: 60–66 Gy (30–33 fractions) Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular ± axillary apex: 45–50 Gy (23–25 fractions) Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
IMN: 45–50 Gy (23–25 fractions) Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.