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
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.