What fractionation would you recommend in a patient with recurrent early stage breast cancer who has had prior lumpectomy and IORT and refuses mastectomy?

While there is no standard of care, several options exist. It is important to delineate where recurrence is (true recurrence vs. elsewhere failure in breast). Also, IORT technique is important a low energy IORT (50 kv) has limited dose deposition beyond a few mm (5-6 Gy at 1 cm) and as such much of the irradiated tissue may be removed in a true recurrence.

1. As IORT has been used as boost, in patients refusing mastectomy and undergoing repeat lumpectomy, whole breast irradiation can used. I will offer hypofractionated WBI or standard WBI based on factors independent of IORT.

2. Repeat partial breast irradiation- this can be considered for elsewhere failures and I use RTOG 1014 as a guide. For true recurrences, I tend to favor whole breast ...