Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Reducing Radiation Doses to Adjacent Organs

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • During a breath-hold:
  • The distance between the tangential radiation beam edge and heart typically increases:
    • Reducing cardiac dose
  • Intensity modulated radiation therapy (IMRT):
    • Utilizes a computerized multi-leaf collimator to control the dose distribution throughout the radiation beam:
      • This helps conform the dose to the target breast (and lymph node regions, as appropriate) and away from organs at risk, such as the heart and lung
  • Treatment in the prone position:
    • Is generally less useful for small breasts, because large, pendulous breasts fall away from the chest wall, thus increasing the distance between the majority of the target breast tissue and the heart and lungs
    • Treatment planning studies suggest that heart doses are reduced when treating women with large breasts but not reduced (and even increased) when treating women with small breasts
    • Additionally, axillary lymph node coverage may be compromised when treating in the prone position
  • Accelerated partial breast irradiation targets the tumor bed with a limited margin of surrounding breast tissue and may decrease integral dose to the heart and lungs in select women, but is not suitable for women with node-positive breast cancer
  • References
    • Shah C, Badiyan S, Berry S, et al. Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy. Radiother Oncol. 2014;112(1):9-16.
    • Mulliez T, Veldeman L, Speleers B, et al. Heart dose reduction by prone deep inspiration breath hold in left-sided breast irradiation. Radiother Oncol.2015;114(1):79-84.
    • Osa EO, DeWyngaert K, Roses D, et al. Prone breast intensity modulated radiation therapy: 5-year results. Int J Radiat Oncol Biol Phys. 2014;89(4):899-906.
    • Mulliez T, Speleers B, Mahjoubi K, et al. Prone left-sided whole-breast irradiation: significant heart dose reduction using end-inspiratory versus end-expiratory gating. Cancer Radiother. 2014;18(7):672-677.

Indication for Postmastectomy Radiation Therapy (PMRT)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The American Society of Clinical Oncology (ASCO) and American Society for Radiation Oncology (ASTRO):
    • Recommend PMRT for:
      • Tumor size greater than 5 cm with any number of involved axillary nodes
      • Smaller cancers with four or more involved
      • Locally advanced breast cancer
  • Locally advanced breast cancer:
    • Is defined as:
      • A tumor greater than 5 cm in size
      • Tumor extending to chest wall:
        • Not including pectoralis major muscle
      • Tumor extending to skin in the form of:
        • Nodules
        • Ulcerations
        • Edema
    • These patient populations have a risk of local recurrence greater than 20%:
      • After mastectomy, irradiation of the chest wall and regional lymph node basins improves local-regional control in these patient populations
  • PMTR in T1 to T2 tumors and 1 to 3 positive nodes:
    • Remains much more controversial
    • Many authors suggest that looking at the total number of risk factors in an individual patient:
      • Would be useful to determine if PMRT may be clinically beneficial
    • In addition to tumor size and the degree of nodal involvement, such factors include:
      • Ages less than 35 to 40
      • Lymphovascular invasion
      • High tumor grade
      • Close or positive surgical margins
      • Hormone receptor status
      • Lymph node ratio
      • Lack of receipt of systemic therapy
        • The data in the literature on these variables are conflicting however, and there is no consensus on how to integrate these factors.
  • ASCO, ASTRO, and SSO recently released an updated consensus statement regarding the role of PMRT in women with 1 to 3 positive lymph nodes:
    • The consensus panel unanimously agreed that PMRT in this subset of patients reduces local-regional failure, any recurrence, and breast cancer mortality:
      • In patients with T1 to T2 breast cancer with 1 to 3 positive lymph nodes
    • They agreed that the decision for PMRT should be made in a multidisciplinary setting and with the involvement of the patient after she is presented with all available data
    • The panel went on to acknowledge that in some subsets of patients, the risk of local-regional failure may be so low that the absolute benefit of PMRT is outweighed by its toxicities
    • Further, even if axillary lymph node dissection (ALND) is omitted in the setting of positive lymph nodes:
      • PMRT should only be used if there is already significant evidence justifying the benefit of PMRT without knowing the status of any additional axillary nodes
  • When given, PMRT should include:
    • The internal mammary, supraclavicular, and apical axillary nodes, and the chest wall or reconstructed breast
  • All patients with a positive axillary node after receipt of neoadjuvant chemotherapy should receive PMRT
  • References
    • Recht A, Comen EA, Fine RE, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. Ann Surg Oncol. 2017;24(1):38-51.
    • EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383(9935):2127-2135.
    • Khan AJ, Haffty BG. Postmastectomy radiation therapy. In: Kuerer HM, ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-Hill; 2010:995-1008.
    • McBride A, Allen P, Woodward W, et al. Locoregional recurrence risk for patients with T1,2 breast cancer with 1-3 positive lymph nodes treated with mastectomy and systemic treatment. Int J Radiat Oncol Biol Phys. 2014;89(2):392-398.
    • Offersen BV, Brodersen HJ, Nielsen MM, Overgaard J, Overgaard M. Should postmastectomy radiotherapy to the chest wall and regional lymph nodes be standard for patients with 1-3 positive lymph nodes? Breast Care. 2011;6(5):347-351.
    • Sharma R, Bedrosian I, Lucci A, et al. Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 2010;17(11):2899-2908.

Accelerated Partial Breast Irradiation

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Accelerated partial breast irradiation includes multiple techniques, including:
    • Interstitial brachytherapy
    • Applicator brachytherapy
    • External beam radiation therapy
  • The Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) trial:
    • Randomized 1,184 patients with low-risk invasive carcinoma or ductal carcinoma in situ (DCIS) treated with breast-conserving surgery to either whole-breast irradiation (WBI) or APBI using multicatheter brachytherapy
    • The cumulative incidence of local recurrence at 5 years was 1.44% with APBI and 0.92% with WBI
  • The Florence trial:
    • Randomized 520 patients to either WBI or APBI with intensity-modulated radiation therapy
    • With a mean followup of 5 years
    • The rate of local recurrence was 1.5% in both arms
  • Similarly, long-term outcomes from the American Society of Breast Surgeons’ Mammosite Registry:
    • Found that 5-year rates were less than 4%
  • An older randomized trial from Hungary:
    • Using interstitial APBI and electrons had a 5-year local recurrence rate of 4.7%
  • Current ASTRO APBI guidelines:
    • Suitable:
      • Any patient > 50 years, with T1 (margins at least 2 mm) or Tis (if screen-detected, < 2.5cm, low-intermediate grade, margins > 3 mm)
    • Cautionary:
      • 40‒49 years old or > 50 years old with at least one pathological higher risk factor
    • Unsuitable:
      • Less than 40 years old, positive margins, tumor > 3 cm, and N+
  • American Brachytherapy Society guidelines:
    • Consider candidates appropriate if age > 45, invasive or DCIS, tumors < 3 cm, N0, ER+ or ER–, no lymph-vascular space invasion, and negative margins
  • References
    • Livi L, Meattini I, Marrazzo L, et al. Accelerated partial breast irradiation using intensity modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. Eur J Cancer. 2015;51(4):451-463.
    • Polgár C, Fodor J, Major T, Sulyok Z, Kásler M. Breast-conserving therapy with partial or whole breast irradiation: ten-year results of the Budapest randomized trial. Radiother Oncol. 2013;108(3):197-202.
    • Shah C, Badiyan S, Ben Wilkinson J, et al. Treatment efficacy with accelerated partial breast irradiation (APBI): final analysis of the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. Ann Surg Oncol.2013;20(10):3279-3285.
    • Strnad V, Ott OJ, Hildebrandt G, et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 2016;16(10015);387:229-238.
    • Correa C, Harris EE, Leonardi MC, et al. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73-79.
    • Shah C, Vicini F, Shaitelman SF, et al. The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy.2018;17(1):154-170.

Radiation Therapy for Bone Metastasis

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Radiation therapy represents an effective treatment for painful bone metastases:
    • With pain control rates around 60%:
      • Radiation would be a good option for pain relief for the rib and humeral lesions
  • Lytic metastases in weight-bearing bones:
    • Portend impending fracture and should have surgical stabilization to prevent fracture
  • Whole brain radiation or stereotactic radiosurgery:
    • Can be considered for brain metastases
  • If there are symptoms of mass effect that may be improved with surgical resection:
    • Then the resection should precede radiation therapy
  • References
    • Chow E, Wu JS, Hoskin P, Coia LR, Bentzen SM, Blitzer PH. International consensus on palliative endpoints for future clinical trials in bone metastases. Radiother Oncol.2002;64(3):275-280.
    • Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res. 1989;249:256-264.
    • Morris PG, Reiner AS, Szenberg OR, et al. Leptomeningeal metastasis from non-small cell lung cancer: survival and the impact of whole brain radiotherapy. J Thorac Oncol. 2012;7(2):382-385.
    • Leal T, Chang JE, Mehta M, Robins HI. Leptomeningeal metastasis: challenges in diagnosis and treatment. Curr Cancer Ther Rev. 2011;7(4):319-327.
    • Linskey ME, Andrews DW, Asher AL, et al. The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol. 2010;96(1):45-68.

Radiation Therapy in Older Patients After Breast Conserving Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Increasing data are available evaluating the role of adjuvant radiation therapy in older patients undergoing breast-conserving surgery with small, ER positive tumors
  • CALGB 9343 trial:
    • Enrolled 636 women over the age of 70 with T1, N0, ER positive tumors
    • Randomizing patients to adjuvant endocrine therapy (tamoxifen) with or without radiation therapy
    • At 12 years, the risk of local-regional recurrence was 9% without radiation and 2% with radiation, confirming the initial 5-year results
    • No differences in breast cancer-specific survival or overall survival were noted
  • More recently, results from the PRIME II trial were published:
    • The trial enrolled 1,326 patients 65 years or older with T1 to T2 (< 3 cm), node negative tumors and clear margins
    • Following breast-conserving surgery, patients received endocrine therapy, and were randomized to adjuvant radiation therapy or no further treatment
    • At 5 years, those undergoing radiation demonstrated a reduction in local recurrence (4.1% vs. 1.3%) with no difference in survival noted
  • References
    • Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382-2387.
    • Kunkler IH, William LJ, Jack WJ, et al. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 2015;16(3):266-273.

Indications for Postoperative Radiotherapy in Head and Neck Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The definitive indications for postoperative radiotherapy are:
  1. Positive margins
  2. Multiple positive nodes with metastatic disease
  3. Extra capsular nodal extension
  • Less certain indications include:
  1. Lymphovascular space invasion
  2. Perineural spread
  3. Single encapsulated positive lymph node greater than 3 cm
  4. Thick tumors
  • Tumors with a thickness between 3 mm to 9 mm have 44% subclinical node positivity and a 7% local recurrence rate
  • Tumors with a thickness greater than 9 mm thickness have 53% subclinical node positivity and a 24% local recurrence rate
  • Postoperative radiotherapy (60 to 70 Gy in 6 to 7 weeks) reduces the rate of local and regional recurrence from 50% to 15% for tumors with pathologic features that predict a high local and regional failure rates
  • The indications for postoperative radiotherapy are well established:
  1. Close or positive margins
  2. An affected lymph node greater than 3 cm
  3. Multiple lymph nodes involved
  4. Extra capsular extension (ECE)
  5. Patients who had an open biopsy of a suspicious neck node and did not undergo neck dissection at the time
  6. Perineural invasion
  7. Lymphovascular space invasion
  8. Invasion of cartilage, bone or deep soft tissues
  9. Recommendation of the surgeon due to intraoperative findings

Radiation-Related Toxicities in Patients with Connective Tissue Disorders

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Not all connective tissue disorders:
    • Are contraindications to radiation therapy or breast conservation
  • A history of certain collagen vascular disorders, particularly scleroderma:
    • Has been associated with increased radiation-related toxicities, including fibrosis:
      • Which may impact the cosmetic outcome or cause pain
  • Chen et al. evaluated a cohort of patients with collagen vascular disease treated with breast radiotherapy:
    • They found an increase in chronic toxicity (17% vs. 3%):
      • With the increase limited to patients with scleroderma
  • Insufficient data prevent conclusive determination that treating scleroderma with systemic therapy will mitigate this toxicity risk
  • References
    • Giaj-Levra N, Sciascia S, Fiorentino A, et al. Radiotherapy in patients with connective tissue diseases. Lancet Oncol. 2016;17(3):e109-e117.
    • Lin A, Abu-Isa E, Griffith KA, Ben-Josef E. Toxicity of radiotherapy in patients with collagen vascular disease. Cancer. 2008;113(3);648-653.
    • Chen AM, Obedian E, Haffty BG. Breast-conserving therapy in the setting of collagen vascular disease. Cancer J. 2001;7(6):480-491.

Occult Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Occult breast cancer:
    • Which manifests as axillary lymph node metastasis:
      • Without the evidence of a primary breast tumor on clinical examination or mammography
    • It accounts for 0.3% to 1.0% of all breast cancers
  • The American College of Radiology:
    • Recommends the use of MRI for occult breast cancer patients:
      • Who do not have evidence of a breast primary on traditional radiological examination (mammogram and ultrasound) and clinical examination
    • Level I evidence has shown MRI is significantly more sensitive in detecting a primary lesion than mammography or ultrasound:
      • Identifying a primary tumor in 72% of cases that were originally deemed occult
  • Patients with occult breast cancer who have abnormalities demonstrated on MRI should then undergo evaluation with:
    • Targeted ultrasound plus ultrasound-guided needle biopsy or MRI-guided needle biopsy and receive treatment according to the clinical stage of the breast cancer
  • Treatment recommendations for those with negative MRI results and occult breast cancer presenting as isolated axillary metastases:
    • Are based on nodal status and breast cancer subtype
  • Most patients with axillary metastasis from an unknown breast primary:
    • Are candidates for neoadjuvant therapy
  • A meta-analysis reported outcomes for occult breast cancer in patients undergoing axillary lymph node dissection (ALND) (with or without radiation therapy [RT]) versus mastectomy:
    • It included 7 international studies, with 241 patients presenting between 1973 and 2011
    • The mean follow up was 62 months
    • There was no difference in survival, locoregional recurrence rate, or distant metastatic rate between those occult breast cancer patients who underwent mastectomy versus those who underwent ALND + breast RT (without breast surgery)
    • Radiotherapy improves locoregional recurrence and possibly mortality rates of patients undergoing ALND
    • Based on this meta-analysis, combined ALND and RT is an acceptable approach
  • The current National Comprehensive Cancer Network guidelines:
    • Recommend that patients with negative MRI results should be treated with mastectomy plus axillary lymph node dissection (modified radical mastectomy) OR ALND plus whole-breast irradiation
  • Approximately 40% of patients undergoing neoadjuvant chemotherapy for clinically node-positive disease:
    • Are successfully down staged in the axilla, and may be able to avoid ALND
    • Although this may prove to be safe for patients with primary occult breast cancer, there are no studies that have specifically addressed the safety of sentinel lymph node biopsy with targeted axillary dissection in this highly select subset
  • Treatment gold standard for occult breast cancer presenting with axillary metastases which remain clinically positive after neoadjvuant chemotherapy, remains ALND
  • References
    1. Ge L-P, Liu X-Y, Xiao Y, et al. Clinicopathological characteristics and treatment outcomes of occult breast cancer: a SEER population-based study. Cancer Manag Res. 2018;10:4381-4391. doi: 10.2147/CMAR.S169019
    2. Ofri A, Moore K. Occult breast cancer: where are we at? Breast. 2020;54:211-215. doi: 10.1016/j.breast.2020.10.012
    3. American College of Radiology. ACR practice parameter for the performance of contrast-enhanced magnetic resonance imaging (MRI) of the breast. Accessed April 7, 2023. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/MR-Contrast-Breast.pdf?la1⁄4en.
    4. de Bresser J, de Vos B, van der Ent F, Hulsewé K. Breast MRI in clinically and mammographically occult breast cancer presenting with an axillary metastasis: a systematic review. Eur J Surg Oncol. 2010;36(2):114-119. doi: 10.1016/j.ejso.2009.09.007
    5. Macedo FIB, Eid JJ, Flynn J, Jacobs MJ, Mittal VK. Optimal surgical management for occult breast carcinoma: a meta-analysis. Ann Surg Oncol. 2016;23(6):1838-1844. doi: 10.1245/s10434-016-5104-8
    6. National Comprehensive Cancer Network. Breast Cancer. Version: 3.2023. Accessed April 7, 2023. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf
    7. American Society of Breast Surgeons. Consensus Statement on Axillary Management for Patients With In-Situ and Invasive Breast Cancer: a concise overview. Accessed April 17, 2023. https://www.breastsurgeons.org/docs/statements/management-of-the-axilla.pdf

Breast Radiation and Pregnancy

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Whole-breast irradiation:
    • Can be administered following delivery
  • Uterine shielding can reduce dose:
    • But in non-life-threatening situation:
      • Radiation should be held until after delivery
  • Risks of radiation while pregnant can include:
    • Toxicity to the fetus, as well as potential increased risk of second malignancy in the child
  • Hypofractionated WBI:
    • Has been studied and found to be comparable to standard WBI:
      • Patients younger than 50 years-old were included in both the:
        • START B and Whelan studies
    • Updated 2018 ASTRO consensus guidelines:
      • Recommend hypofractionated WBI for any age and any stage assuming no additional fields will be used for regional nodal targeting
  • With 5 to 10 years’ follow-up:
    • APBI has equivalent rates of local recurrence compared to standard WBI:
      • The typical techniques utilized include intracavitary brachytherapy, interstitial brachytherapy, or external beam radiation
      • However, due to a paucity of young patients enrolled in such trials:
        • APBI is currently considered cautionary for patients 40 to 49, and unsuitable for patients younger than 40
  • References
    • Luis SA, Christie DR, Kaminski A, Kenny L, Peres MH. Pregnancy and radiotherapy: management options for minimizing risk, case series, and comprehensive literature review. J Med Imaging Radiat Oncol. 2009;53:559-568.
    • Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362(6):513-520.
    • Haviland JS, Owen JR, Dewar JA, et al; START Trialists’ Group. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early stage breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14(11):1086-1094.
    • Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018;8(3):145-152
    • Correa C, Harris EE, Leonardi MC, et al. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73-79.
    • Strnad V, Ott OJ, Hildebrandt G, et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 2016;387(10015):229-238.

Guidelines for Partial Breast Irradiation

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Several guidelines have been published to guide decision making for treating select patients with partial breast irradiation off protocol
  • The American Society for Radiation Oncology (ASTRO) consensus statement (Table) considers patients to be:
    • Suitable if the following characteristics are met:
      • Age greater than 50 years
      • BRCA 1 / BRCA 2 wild-type
      • Tumor size less than 2 cm:
        • Multifocality is allowed:
          • Provided the total size is less than 2 cm
      • ER positive
      • Invasive ductal (or other favorable) histology
      • Surgical margins greater than 2 mm
      • Absence of lymphovascular invasion (LVI)
      • Pure ductal carcinoma in situ (DCIS) meeting trial criteria
      • Absence of an extensive intraductal component
      • Absence of lymph node involvement
    • Unsuitable characteristics included:
      • Age less than 40 years
      • Presence of a BRCA1 / BRCA 2 deleterious mutation
      • Tumor size > 3 cm (including multiple foci)
      • Multicentricity
      • Positive surgical margins
      • Extensive LVI
      • Lymph node involvement (or not assessed)
    • Cautionary characteristics fall between suitable and unsuitable
  • The recent American Brachytherapy Society:
    • Defined acceptable criteria for partial breast irradiation as:
      • Age greater than 45 years
      • Tumor size ≤ 3 cm
      • All invasive subtypes and pure DCIS
      • ER + / –
      • Negative surgical margins (“on ink”)
      • Negative lymph nodes
      • The absence of LVI
  • The Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) consensus statement also classifies patients:
    • As good candidates for partial breast irradiation
      • Greater than 50 years
      • ER– (or +) disease
      • Tumors less than 3 cm as “low risk”
  • The American Society of Breast Surgeons current guidelines include:
    • Age greater than 45 years for invasive tumors
    • Age greater 50 years for DCIS
    • IDC or DCIS tumor size less than 3 cm
    • Negative margins
    • Negative lymph nodes
  • References
    • Correa C, Harris EE, Leonardi MC, et al. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73-79.
    • Shah C, Vicini F, Shaitelman SF, et al. The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy.2018;17(1):154-170.
    • Polgár C, Van Limbergen E, Potter R, et al; GEC-ESTRO breast cancer working group. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) Breast Cancer Working Group based on clinical evidence (2009). Radiother Oncol.2010;94(3):264-273.
    • Consensus statement for accelerated partial breast irradiation. American Society of Breast Surgeons website. https://www.breastsurgeons.org/docs/statements/Consensus-Statement-for-Accelerated-Partial-Breast-Irradiation.pdf. Accessed August 22, 2019.