American College of Radiology
ACR Appropriateness Criteria®

Local Regional Recurrence and Salvage Surgery — Breast Cancer

Variant 1: 52-year-old woman, 0.5 cm LRR in breast, 15 years after BCT with lumpectomy and axillary node dissection + RT for T1bN0 lesion. Biopsy showed invasive ductal carcinoma. ER/PR (+). HER-2 negative/nonamplified. EOD workup negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hormone therapy May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Trastuzumab Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Simple mastectomy (SM) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
SM + sentinel lymph node biopsy (SLNB) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
SM + LND or modified radical mastectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Quadrantectomy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + RT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Whole breast +/- boost Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Partial breast RT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Chest wall (after mastectomy) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular (adequate LND) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 42-year-old woman, 3.0-cm LRR in breast 6 years after BCT + chemotherapy for T1cN0 lesion. Biopsy showed invasive ductal carcinoma. ER/PR (–). HER-2 negative/nonamplified. EOD workup positive: liver and multiple bone metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemotherapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Simple mastectomy (SM) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SM + LND or modified radical mastectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Quadrantectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Hormone therapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Whole breast +/- boost Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Partial breast RT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Chest wall (after mastectomy) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular (adequate LND) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 55-year-old woman, 1.5 cm LRR in breast 7 years after BCT with lumpectomy only + RT for original diagnosis of DCIS, not otherwise specified. Biopsy: invasive ductal carcinoma. ER/PR (–). HER-2 normal. EOD workup negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemotherapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
SM + LND or modified radical mastectomy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
SM + sentinel lymph node biopsy (SLNB) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Simple mastectomy (SM) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Quadrantectomy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Lumpectomy + RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Hormone therapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Whole breast +/- boost Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Partial breast RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Chest wall (after mastectomy) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular (adequate LND) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 55-year-old woman, 7 nodules (1-2 cm in diameter) along MRM scar 3 years after MRM + chemotherapy + adjuvant chest wall/SCL RT (50 Gy). Primary and LR both ER/PR (–), HER-2 normal.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Complete excision of recurrence Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Radiation therapy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Hormone therapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 60-year-old woman, 2-cm nodule on MRM scar 4 years after MRM + chemotherapy without hormonal therapy for T1N1 [3 lymph nodes (LN) (+)]. Fine-needle aspiration (+). Primary ER/PR (+). Biopsy nodule ER/PR (+) by immunohistochemistry and HER-2 3+. Asymptomatic EOD workup negative.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Complete excision of recurrence Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Radiation therapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Hormone therapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Trastuzumab May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Chest wall Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular fossa Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Axilla Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Internal mammary nodes (IMN) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 6: 65-year-old woman, 2-cm isolated axillary nodal recurrence detected on PE, confirmed on CT. Initial treatment MRM, chemotherapy, no adjuvant RT for T2N1MO invasive ductal carcinoma, grade 2. LN biopsy (+), invasive ductal carcinoma, ER/PR (+), HER-2 nonamplified. Metastatic workup negative for distant metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Complete excision of recurrence Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Radiation therapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Hormone therapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Trastuzumab Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Chest wall Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Supraclavicular fossa Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Axilla Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Internal mammary nodes (IMN) May be appropriate TBD TBD 5 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.