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-63

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

ASCO CAP recommendations for quality control performance of HER2

testing and interpretation of IHC and ISH results.

481

Imaging studies help facilitate image-guided biopsy, delineate

locoregional disease, and identify distant metastases. Evaluation of all

women suspected with IBC must include diagnostic bilateral

mammogram, with the addition of ultrasound as necessary. A breast

MRI scan is optional.

Evaluations for the presence of distant metastasis in the asymptomatic

patient include liver function testing, bone scan or sodium fluoride

PET/CT (category 2B), and diagnostic CT imaging of the chest,

abdomen, and pelvis (category 2B; category 2A for diagnostic CT

imaging of the chest when pulmonary symptoms are present).

FDG PET/CT may be most helpful in situations where standard imaging

results are equivocal or suspicious. However, there is limited evidence

suggesting that PET/CT may be a useful adjunct to standard imaging of

IBC due to the increased risk of regional lymph node involvement and

distant spread of disease in this group of patients.

95,96,581,582

Nevertheless, equivocal or suspicious sites identified by FDG PET/CT

scanning or other imaging methods should be biopsied for confirmation

of stage IV disease whenever possible. FDG PET/CT is a category 2B

recommendation. The consensus of the panel is that FDG PET/CT can

be performed at the same time as diagnostic CT. If FDG PET and

diagnostic CT are performed and both clearly indicate bone metastases,

bone scan or sodium fluoride PET/CT may not be needed.

Genetic counseling is recommended if the patient is considered to be at

high risk of hereditary breast cancer as defined by the

NCCN

Guidelines for Genetic/Familial High-Risk Assessment: Breast and

Ovarian

Treatment

The treatment of patients with IBC should involve a combined modality

approach

566

comprising preoperative systemic therapy followed by

surgery (mastectomy)

and

radiotherapy.

Preoperative Chemotherapy

There are no large randomized trials evaluating the optimal systemic

treatment of IBC, since it is a rare disease. The systemic therapy

recommendations are based on data from retrospective analyses, small

prospective studies, and data from non-IBC, locally advanced breast

cancer.

The benefit of preoperative systemic therapy followed by mastectomy

over preoperative systemic therapy alone in patients with IBC was

shown in a retrospective analysis in which lower local recurrence rates

and longer disease-specific survival were reported for the combined

modality approach.

583

Results from a large retrospective study of

patients with IBC performed over a 20-year period at The University of

Texas M.D. Anderson Cancer Center demonstrated that initial treatment

with doxorubicin-based chemotherapy followed by local therapy (ie,

radiation therapy or mastectomy, or both) and additional postoperative

chemotherapy resulted in a 15-year DFS rate of 28%.

584

A retrospective study demonstrated that addition of a taxane to an

anthracycline-based regimen improved PFS and OS in patients with

ER-negative IBC.

585

A systematic review found evidence for an

association between the intensity of preoperative therapy and the

likelihood of a pCR.

586

A study of IBC patients, with cytologically

confirmed ALN metastases, treated with anthracycline-based

chemotherapy with or without a taxane indicated that more patients

receiving the anthracycline-taxane combination achieved a pCR

compared with those who received only anthracycline-based therapy. In