Original articleAmerican College of Radiology Appropriateness Criteria® on Conservative Surgery and Radiation: Stages I and II Breast Carcinoma
Section snippets
Summary of Literature Review
Invasive breast cancer is the most common malignancy in women in the United States [1]. Breast conservation therapy (BCT) has become firmly established as a standard therapeutic approach for eligible women with early-stage breast cancer during the past 2 decades, replacing mastectomy as the predominant treatment. BCT is defined as excision of the primary breast tumor with a rim of adjacent normal breast tissue sufficient to achieve negative resection margins, with or without axillary sentinel
National Institutes of Health Consensus Conference
The Office of Medical Applications of Research of the National Institutes of Health and the National Cancer Institute convened a consensus development conference on the treatment of early-stage breast cancer in June of 1990. The panel concluded that “breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable to mastectomy because it provides survival rates equivalent to those of total mastectomy and
Results of Prospective Randomized Clinical Trials
Six modern prospective randomized trials have compared mastectomy and BCT for stages I and II invasive breast cancer [6, 7, 8, 9, 10, 11]. These data are mature, with 10 to 20-year overall and disease-free survivals reported. They all have demonstrated no significant differences in distant metastases, cause-specific survival, or overall survival between the 2 treatment approaches. Three of these trials reported equivalent local regional control when BCT was compared with mastectomy. In all of
Patient Selection
BCT is now accepted as standard treatment for the majority of women with stage I or II breast cancer. The rate of medical contraindications to BCT has been estimated to be low, approximately 10% for stage I and 30% for stage II [23], although more women with stage II breast cancer might be good candidates for BCT after neoadjuvant chemotherapy.
Approximately 50% of women with stage I or II breast carcinoma have BCT despite the aforementioned prospective randomized clinical trials. A joint study
Breast Imaging
Preoperative mammographic evaluation is necessary to determine a patient's eligibility for BCT. Mammography aids in defining the extent of a lesion and in determining whether the lesion is a unifocal or multicentric process; it also evaluates the contralateral breast. If the mass is associated with microcalcifications, the extent of microcalcifications, both within and outside of any tumor mass, should be noted. Magnification views and spot compressions should be performed to better delineate
Pregnancy
Pregnancy, unless terminated, is an absolute contraindication to treatment with RT. Late in the third trimester, it may be possible to perform breast-conserving surgery and treat the patient with irradiation after delivery.
Previous Radiation Therapy
A history of RT (eg, for the treatment of Hodgkin's disease or lung cancer) that delivered a significant dose to the breast and for which retreatment would result in an excessively high total radiation dose to the breast tissue is a contraindication for a breast-conserving
Margins
The pathologic specimen must be appropriately sampled to document the presence or absence of gross or microscopic carcinoma in the margins of excision. Microscopic status of the resection margins is the most commonly used method for estimating the residual tumor burden in the breast remaining after conservative surgery. The goal of breast-conserving surgery is to achieve negative margins of excision. When margins are microscopically involved, a reexcision should be performed. Reexcision may not
Patient Preference
Each patient must have a thorough discussion of options, addressing their fears and expectations. For patients who meet the selection criteria, choosing mastectomy does not increase survival. Psychologic adaptation is equivalent for women who choose mastectomy or BCT. Patients who undergo BCT, however, have a more positive body image.
Radiation Therapy Techniques
Computed tomography-based treatment planning for megavoltage beam irradiation is recommended by consensus of the panel for optimal RT after excision of the primary tumor and axillary sentinel node biopsy or dissection. RT should be designed to treat the entire breast to a total dose of 45 to 50 Gy in 1.8 to 2 Gy fractions for 4.5 to 5.5 weeks. In a randomized trial of 1234 patients with stage I breast cancer, a shorter course of breast radiation delivering 4250 cGy in 16 fractions for 22 days
Accelerated Partial Breast Irradiation
Accelerated PBI delivers hypofractionated radiation to the 1 to 2 cm of breast tissue around the lumpectomy cavity where the majority of in-breast recurrences occur. It is commonly delivered in twice-daily treatments (minimal 6-hour interfraction time interval) for 5 to 8 days. The smaller target volume allows for hypofractionated radiation. A growing body of data have demonstrated that PBI with multicatheter brachytherapy after lumpectomy in selected cases yields local control and cosmetic
Integration of Radiation Therapy and Adjuvant Systemic Therapy
In most series, the addition of adjuvant chemotherapy to RT results in a decreased incidence of breast recurrence when compared with conservative surgery and RT alone. Early adjuvant systemic chemotherapy in patients at substantial risk of metastases is believed to be important. Concurrent regimens have the theoretic advantage of initiating both local and regional treatments with systemic therapy at the same time without delay in either modality, although there is concern about potential
Neoadjuvant Chemotherapy
Patients with large tumors relative to their breast size, in whom resection would result in a cosmetically unacceptable breast appearance, should be considered for neoadjuvant chemotherapy to reduce the tumor size. An approximately 20% relative increase in BCT is achieved with neoadjuvant chemotherapy, and overall breast cancer recurrence is equivalent to the adjuvant setting [53]. There is equivalent overall survival from neoadjuvant compared with adjuvant chemotherapy. However, a small but
Follow-Up
Women treated for breast cancer should have a history and physical examination performed every 3 to 6 months for the first 3 years after treatment and then every 6 to 12 months; examination should be coordinated among specialties. A new baseline mammogram should be obtained approximately 6 months after completion of RT, when postsurgical and radiation changes have peaked. Annual mammograms should be obtained after mammographic stability. There are insufficient data to recommend the routine use
Management Guidelines
The majority of women with stage I or II breast cancer are good candidates for BCT. Whole-breast irradiation with or without boost is the standard of care after lumpectomy. Contraindications to BCT include patients with extensive malignant-appearing calcifications on the mammogram. Postbiopsy mammograms should be obtained to assess the completeness of resection in patients whose tumors demonstrate microcalcifications on mammograms.
Two nonadjacent primary tumors in the same breast is a relative
Disclaimer
The American College of Radiology Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for the diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection
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