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
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.