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-62

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Endocrine therapy and radiation therapy are contraindicated during

pregnancy. Endocrine therapy and radiation therapy, if indicated, should

thus not be initiated until the postpartum period.

Communication between the oncologist and maternal fetal medicine

specialist is essential at every visit and for every treatment decision

point for the patient.

Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is a rare, aggressive form of breast

cancer estimated to account for 1% to 6% of breast cancer cases in the

United States.

566,567

IBC is a clinical diagnosis that requires erythema

and dermal edema (peau d’orange) of a third or more of the skin of the

breast with a palpable border to the erythema.

IBC is usually hormone receptor-negative and is more frequently

HER2-positive than the usual ductal breast cancers. Studies on gene

expression profiling of IBC have demonstrated that all the subtypes of

IBC exist, but basal and HER2 overexpressed are more frequent.

568-571

According to the 7

edition of the

AJCC Cancer Staging Manual

, IBC is

classified as stage IIIB, stage IIIC, or stage IV breast cancer, depending

on the degree of nodal involvement and whether distant metastases are

present. The primary tumor of IBC is classified as T4d by definition,

even when no mass is specifically apparent in the breast. On

radiographic

imaging, findings of skin thickening and, in some cases, an

underlying mass are observed. Despite use of the term “inflammatory,”

the characteristic clinical features of IBC are due to blockage of dermal

lymphatics by tumor emboli. Although a biopsy is required to evaluate

for the presence of cancer in breast tissue and the dermal lymphatics, a

diagnosis of IBC is based on clinical findings, and dermal lymphatic

involvement is neither required, nor sufficient by itself, to assign a

diagnosis of IBC.

9,572

The differential diagnosis includes cellulitis of the

breast and mastitis.

In the past, IBC has often been placed under the general heading of

locally advanced breast cancer. There is a growing body of evidence

that IBC patients, when compared with noninflammatory forms of locally

advanced breast cancer, are more likely to have a less favorable

prognosis

573-575

and to be younger at the time of disease presentation.

576

Hormone receptor-positive IBC is associated with a slightly more

favorable prognosis,

570,577

whereas HER2 overexpression in IBC is

associated with a poor prognosis.

570,578

The NCCN Panel acknowledges that studies focusing on genetic

characterization of IBC are needed to more clearly define IBC as a

disease entity and to optimize treatment.

579,580

Nevertheless, current

evidence provides justification for a separate guideline for the workup

and treatment of patients diagnosed with IBC.

StageT4d, N0- N3, M0

Workup

Women with a clinical/pathologic diagnosis of IBC without distant

metastasis (stage T4d, N0-N3, M0) should undergo a thorough staging

evaluation by a multidisciplinary team.

Recommendations for workup include a complete history and physical

examination involving a CBC and platelet count.

A pathology review and pre-chemotherapy determinations of tumor

hormone receptor and HER2 receptor status should be performed.

HER2 has a predictive role in determining which patients with IBC will

benefit from HER2 targeted therapy. The NCCN Panel endorses the

CAP protocol for pathology reporting

( www.cap.org )

and endorses the