NCCN VERSION 2 2015

The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

MS-41

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

alkaline phosphatase tests, chest imaging, pathology review, and

pre-chemotherapy determination of tumor ER/PR receptor status and

HER2 status. Diagnostic bilateral mammogram and breast ultrasound

should be performed as clinically warranted. Genetic counseling is

recommended if the patient is considered to be at high risk for

hereditary breast cancer as defined by the

NCCN Guidelines for

Genetic/Familial High-Risk Assessment: Breast and Ovarian.

The performance of other studies, such as a breast MRI, a bone scan

(category 2B), and abdominal imaging with diagnostic CT (with or

without pelvic CT) or MRI (all category 2A) are optional unless directed

by symptoms or other abnormal study results. PET/CT scan is also

included as an optional additional study (category 2B). Ultrasound is an

alternative when diagnostic CT or MRI is unavailable.

The consensus of the panel is that FDG PET/CT is most helpful in

situations where standard imaging results are equivocal or suspicious.

However, limited studies

95,96,363-367

support a potential role for FDG

PET/CT to detect regional node involvement as well as distant

metastases in locally advanced breast cancer, including T3, N1, M0

disease.

A retrospective study comparing bone scan with integrated FDG

PET/CT, in women with stages I–III breast cancer with suspected

metastasis, observed a high concordance (81%) between the two

studies for reporting osseous metastases.

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The NCCN Panel suggests

that bone scan may be omitted if FDG PET/CT results are positive for

bone metastases.

Equivocal or suspicious sites identified by PET/CT scanning should be

biopsied for confirmation whenever possible and if the site of disease

would impact the course of treatment. In the past decade, the advent of

PET/CT scanners has significantly changed the approach to PET

imaging.

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However, the terminology has also created confusion

regarding the nature of the scans obtained from a PET/CT device.

PET/CT scanners have both a PET and CT scanner in the same gantry

that allows precise coregistration of molecular (PET) and anatomic (CT)

imaging. Almost all current clinical PET imaging is performed using

combined PET/CT devices.

In PET/CT tomographs, the CT scanner has a second important role

beyond diagnostic CT scanning.

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For PET applications, the CT scan is

also used for photon attenuation correction and for anatomic localization

of the PET imaging findings. For these tasks, the CT scan is usually

taken without breathholding, to match PET image acquisition, and

typically uses low-dose (non-diagnostic) CT. Radiation exposure for

these non-diagnostic CT scans is lower than for diagnostic CT.

Intravenous contrast is not needed for this task.

PET/CT scanners typically include a high-quality CT device that can

also be used for stand-alone, optimized, and fully diagnostic CT.

Diagnostic CT scans are acquired using breathholding for optimal chest

imaging, and are often performed with intravenous contrast. For fully

diagnostic CT, the CT beam current, and therefore patient radiation

exposure, is considerably higher than for the low-dose CT needed for

PET requirements. Radiation exposures for fully diagnostic CT are often

greater than for the emission (PET) component of the study.

Currently, the approach to clinical PET/CT imaging varies widely across

centers.

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Many centers perform low-dose CT as part of a PET/CT

scan, and perform optimized, fully diagnostic CT only when diagnostic

CT has also been requested in addition to PET/CT. Other centers

combine diagnostic CT scans with PET on all of their PET/CT images.

The CT scans described in the workup section of the guidelines refer to