American College of Radiology
ACR Appropriateness Criteria®

Ductal Carcinoma in Situ

Variant 1: 55-year-old woman with mammographically detected 2.0-cm comedo, high nuclear grade DCIS, ER-positive. Surgically excised, multiple foci of DCIS in lateral and medial specimen close to excision margin (≤1.0 mm).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Re-excision lumpectomy and RT if margins negative Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Mastectomy with LN staging Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Mastectomy without LN staging Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Breast MRI prior to additional surgery May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Re-excision lumpectomy alone, no RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
RT alone, no re-excision Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Boost to tumor bed Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
PBI (assuming re-excision with widely negative margins) May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 42.5 Gy/16 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 45–46.8 Gy/23–26 fractions Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 50–50.4 Gy/25–28 fractions Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Total cumulative dose: 40 Gy Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Boost dose 10 Gy in 2 Gy fractions after WBRT dose of 50 Gy (assume <1 mm margins, no re-excision) Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Boost dose 16 Gy in 2 Gy fractions after WBRT dose of 50 Gy (assume &lt;1 mm margins, no re-excision) Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Boost dose 10 Gy in 2 Gy fractions (assume re-excision, widely negative margin of >1.0 cm) Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Boost dose 16 Gy in 2 Gy fractions (assume re-excision, widely negative margin of &gt;1.0 cm) May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) after lumpectomy + RT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 50-year-old woman with extensive pleomorphic microcalcifications in more than one quadrant on mammography. Area too large to excise with cosmetically acceptable outcome. Core biopsies demonstrate DCIS involving more than one quadrant.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Mastectomy with SLNB Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Mastectomy without LN staging May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Mastectomy with ALND Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Attempt at lumpectomy with adjuvant RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Attempt at lumpectomy, LN staging, adjuvant RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Breast MRI prior to definitive surgery Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 78-year-old woman with mammographically detected 1-cm, low nuclear grade DCIS, ER-positive. Surgically excised with 5-mm negative margins. Excellent performance status, no comorbidities. Plans to take a hormonal agent for 5 years.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Adjuvant RT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
No RT (observation) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast without boost Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast with boost May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Regional nodes Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
PBI May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 42.5 Gy/16 fractions Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 45–49 Gy Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 50–50.4 Gy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Total cumulative dose, including any boost: 40 Gy Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Total cumulative dose, including any boost: 50–50.4 Gy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Boost dose 10 Gy in 2 Gy fractions after WBRT dose of 50 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Boost dose 16 Gy in 2 Gy fractions after WBRT dose of 50 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Aromatase Inhibitor (5 years) May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 41-year-old premenopausal woman with mammographically detected 0.9-cm, intermediate nuclear grade, comedo DCIS, ER negative. Surgically excised with widely negative margins.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
RT but no further surgery Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Breast MRI (after DCIS on biopsy and prior to definitive surgery) May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
LN staging and RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
No further surgery or RT (observation) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast without boost Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole breast with boost Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
PBI Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 42.5 Gy/16 fractions (without boost) Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 45 Gy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 50–50.4 Gy Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Total cumulative dose, including any boost: 40 Gy Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Boost dose 10 Gy in 2 Gy fractions (in addition to whole breast 50 Gy) Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Boost dose 16 Gy in 2 Gy fractions (in addition to whole breast 50 Gy) May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Trastuzumab for 2 cycles (if HER2/neu+) Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 49-year-old premenopausal woman with mammographically detected 1-cm high-grade, comedo DCIS with single focus microinvasion, ER-positive. Surgically excised with widely negative margins (>5 mm).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
LN staging + adjuvant RT Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Mastectomy with LN staging Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
No LN staging required, proceed with adjuvant RT alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Mastectomy without LN staging Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
No LN staging, no adjuvant RT (observation) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Postmastectomy chest wall Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Whole breast without boost Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole breast with boost Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Regional nodes Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
PBI Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 42.5 Gy/16 fractions Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast: 50–50.4 Gy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Total cumulative dose, including any boost: 40 Gy Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast 50 Gy + boost 10 Gy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Whole breast 50 Gy + boost 16 Gy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Variant 6: 60-year-old woman with new microcalcifications on screening mammography. Stereotactic core biopsy shows pure pleomorphic LCIS, ER/PR negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical excision for clear margins Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Mastectomy May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Whole-breast RT Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Observation (no surgical excision) Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Surgical excision with LN staging Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Variant 7: 41-year-old premenopausal woman with mammographically detected 0.9-cm, high nuclear grade DCIS, plus comedo necrosis, ER negative. Surgically excised. Assume final margins >1 cm, patient wants partial breast irradiation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PBI Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 8: 58-year-old postmenopausal woman with mammographically detected 1.9-cm, intermediate nuclear grade solid DCIS, ER positive. Surgically excised. Assume final margins >1 cm, patient wants partial breast irradiation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PBI May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Tamoxifen (5 years) Usually appropriate TBD TBD 8 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.