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-45

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

disease, except in those situations where other staging studies are

equivocal or suspicious

There is limited evidence (mostly from

retrospective studies) to support the use of PET/CT scanning to guide

treatment planning through determination of the extent of disease in

select patients with recurrent or metastatic disease.

95,96,393,394

The Panel

considers biopsy of equivocal or suspicious sites to be more likely than

PET/CT scanning to provide accurate staging information in this

population of patients.

The consensus of the Panel is that FDG PET/CT is optional (category

2B) and most helpful in situations where standard imaging results are

equivocal or suspicious. The NCCN Panel recommends bone scan or

sodium fluoride PET/CT to detect bone metastases (category 2B).

However, if the FDG PET results clearly indicate bone metastasis,

these scans can be omitted.

The NCCN Panel recommends that metastatic disease at presentation

or first recurrence of disease should be biopsied as a part of the workup

for patients with recurrent or stage IV disease. This ensures accurate

determination of metastatic/recurrent disease and tumor histology, and

allows for biomarker determination and selection of appropriate

treatment.

Determination of hormone receptor status (ER and PR) and HER2

status should be repeated in all cases when diagnostic tissue is

obtained. ER and PR assays may be falsely negative or falsely positive,

and there may be discordance between the primary and metastatic

tumors

395,396

The reasons for the discordance may relate to change in

biology of disease, differential effect of prior treatment on clonal

subsets, tumor heterogeneity, or imperfect accuracy and reproducibility

of assays.

396

Discordance between the receptor status of primary and

recurrent disease has been reported in a number of studies. The

discordance rates are in the range of 3.4% to 60% for ER negative to

ER positive; 7.2% to 31% for ER positive to ER negative; and 0.7% to

11% for HER2.

397-405

The NCCN Panel recommends that re-testing the receptor status of

recurrent disease be performed,

especially

in cases when it was

previously unknown, originally negative, or not overexpressed. For

patients with clinical courses consistent with hormone receptor–positive

breast cancer, or with prior positive hormone receptor results, the panel

has noted that a course of endocrine therapy is reasonable, regardless

of whether the receptor assay is repeated or the result of the most

recent hormone receptor assay.

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

Management of Local Disease Only

Patients with local recurrence only are divided into 3 groups: those who

had been treated initially by mastectomy alone, those who had been

treated initially by mastectomy with radiation therapy, and those who

had received breast-conserving therapy.

In one retrospective study of local recurrence patterns in women with

breast cancer who had undergone mastectomy and adjuvant

chemotherapy without radiation therapy, the most common sites of local

recurrence were at the chest wall and the supraclavicular lymph

nodes.

406

The recommendations for treatment of the population of

patients experiencing a local recurrence only are supported by analyses

of a combined database of patients from the EORTC 10801 and Danish

Breast Cancer Group 82TM trials. The analyses compared