What is a contraindication to breast-conserving therapy?

Collagen Vascular Disease is a Contraindication to Breast-Conserving Therapy

Among the options presented, collagen vascular disease is a contraindication to breast-conserving therapy. 1

Contraindications to Breast-Conserving Therapy

Absolute Contraindications

1. Pregnancy (first and second trimester) - Radiation therapy cannot be administered during pregnancy due to fetal risks, though surgery in the third trimester with delayed radiation is sometimes possible 1
2. Multiple primary tumors in separate quadrants of the breast 1
3. Diffuse malignant-appearing microcalcifications 1
4. Prior therapeutic irradiation to the breast region that would require retreatment 1
5. Persistent positive margins after reasonable surgical attempts 1

Relative Contraindications

1. Collagen vascular disease - Particularly scleroderma and active lupus erythematosus 1

   • Patients with collagen vascular disease tolerate radiation poorly 1
   • Scleroderma specifically is considered an absolute contraindication by most radiation oncologists 1
   • Patients with scleroderma have shown significantly increased incidence of radiation complications after breast-conserving therapy 2
   • These complications can include severe fibrosis, chest wall necrosis, and osteoradionecrosis 3

2. Multiple gross tumors in the same quadrant 1

3. Large tumor in a small breast (cosmetic concerns) 1

4. Large or pendulous breasts (technical concerns) 1

Non-Contraindications (Factors that do NOT prevent breast conservation)

The following factors are NOT contraindications to breast-conserving therapy:

• Age more than 70 years 1
• Coronary artery disease 1
• Family history of breast cancer 1
• Clinically suspicious or positive axillary lymph nodes 1
• Tumor location (though subareolar tumors may require nipple-areolar complex resection) 1

Clinical Implications

For patients with collagen vascular disease, particularly scleroderma:

• Increased risk of severe acute and late complications of radiation therapy 4
• Marked breast fibrosis may develop, making mammographic, sonographic, and clinical surveillance ineffective 5
• Alternative surveillance methods like MRI may be necessary 5
• Patients with rheumatoid arthritis may still be candidates for breast conservation as this condition is not considered a contraindication 1

Evidence Analysis

The evidence strongly supports that collagen vascular disease is a contraindication to breast-conserving therapy. While some studies suggest that certain collagen vascular diseases may not significantly increase complications 2, scleroderma consistently shows severe adverse outcomes including chest wall necrosis and osteoradionecrosis 3. The guidelines clearly state that most radiation oncologists consider active scleroderma and lupus erythematosus as absolute contraindications 1.

Therefore, among the options presented (age >70, coronary artery disease, family history of breast cancer, and collagen vascular disease), only collagen vascular disease represents a contraindication to breast-conserving therapy.