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-42

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

fully optimized diagnostic CT scans, while the PET or PET/CT scans

refer to scans primarily directed towards the PET component, not

necessarily using diagnostic-quality CT. It is important for referring

physicians to understand the differences between PET/CT performed

primarily for PET imaging and fully optimized CT performed as a

stand-alone diagnostic CT examination.

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It may be convenient to

perform PET/CT and diagnostic CT at the same time.

Operable Locally Advanced Breast Cancer

(Clinical stage T3N1M0)

Locally advanced breast cancer describes a subset of invasive breast

cancer where the initial clinical and radiographic evaluation documents

advanced disease confined to the breast and regional lymph nodes.

The AJCC clinical staging system used in these guidelines and for the

determination of operability is recommended, and locally advanced

disease is represented by the stage III category. Patients with stage III

disease may be further divided into: 1) those where an initial surgical

approach is unlikely to successfully remove all disease or to provide

long-term local control; and 2) those with disease where a reasonable

initial surgical approach is likely to achieve pathologically negative

margins and provide long-term local control. Thus, stage IIIA patients

are divided into those who have clinical T3N1M0 disease versus those

who have clinical TanyN2M0 disease, based on evaluation by a

multidisciplinary team.

Postsurgical systemic adjuvant therapy for patients with stage IIIA

breast cancer who do not receive neoadjuvant chemotherapy is similar

to that for patients with stage II disease.

Inoperable Locally Advanced Breast Cancer

(Clinical stage IIIA [except for T3N1M0], clinical stage IIIB, or clinical

stage IIIC)

For patients with inoperable, non-inflammatory, locally advanced

disease at presentation, the initial use of anthracycline-based

preoperative systemic therapy with or without a taxane is standard

therapy.

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Patients with locally advanced breast cancer that is

HER2-positive should receive an initial chemotherapy program that

incorporates preoperative trastuzumab. Local therapy following a

clinical response to preoperative systemic therapy usually consists of:

1) total mastectomy with level I/II ALN dissection, with or without

delayed breast reconstruction; or 2) lumpectomy and level I/II axillary

dissection.

Both local treatment groups are considered to have sufficient risk of

local recurrence to warrant the use of chest wall (or breast) and

supraclavicular node irradiation. If internal mammary lymph nodes are

involved, they should also be irradiated. Without detected internal

mammary node involvement, consideration may be given to include the

internal mammary lymph nodes in the radiation field (category 2B).

Adjuvant therapy may involve completion of planned chemotherapy

regimen course if not completed preoperatively, followed by endocrine

therapy in patients with hormone receptor-positive disease. Up to one

year of total trastuzumab therapy should be completed if the tumor is

HER2-positive (category 1). Endocrine therapy and trastuzumab can be

administered concurrently with radiation therapy if indicated.

Patients with an inoperable stage III tumor with disease progression

during preoperative systemic therapy should be considered for palliative

breast irradiation in an attempt to enhance local control. In all subsets of

patients, further systemic adjuvant chemotherapy after local therapy is