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-65

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Radiation

After mastectomy, radiation therapy is recommended after the

completion of the planned chemotherapy.

The probability of locoregional lymph node involvement is high for

women with IBC. To reduce the risk of local recurrence, the panel

recommends radiation therapy to the chest wall and the supraclavicular

region. If the internal mammary lymph node(s) is clinically or

pathologically involved, radiation therapy should include the internal

mammary nodes. If the internal mammary nodes are not clinically or

pathologically involved, then including the internal mammary nodes in

the radiation therapy field is at the discretion of the treating radiation

oncologist (category 3). For HER2-positive disease, trastuzumab may

be administered concomitantly with radiation therapy.

Stage IV or Recurrent IBC

Patients with stage IV or recurrent IBC should be treated according to

the guidelines for recurrence/stage IV breast cancer (See

NCCN

Guidelines for Breast Cancer

Axillary Breast Cancer

Occult breast cancer presenting with axillary metastases is an unusual

presentation that can be a diagnostic and therapeutic challenge.

Evidence to support recommendations on the management of patients

presenting with axillary breast cancer comes from a limited number of

retrospective studies involving small numbers of patients

597-599

(see also

references therein). Although treatment of women with axillary

metastases from an unknown primary tumor has typically involved

mastectomy and axillary nodal dissection, some of these patients have

also been successfully treated with axillary nodal dissection followed by

radiation therapy.

598,599

Patients with a suspected occult primary breast cancer will typically

present to the oncologist after undergoing an initial biopsy: core needle

biopsy (preferred), and/or FNA. Accurate pathologic assessment of the

biopsied material is most important. Therefore, the pathologist must be

consulted to determine whether the available biopsy material is

adequate, or if additional biopsy material is necessary (eg, core needle,

incisional, or excisional biopsy) to provide an accurate and complete

diagnosis.

Workup for Possible Primary Breast Cancer

MRI of the breast can facilitate the identification of occult breast cancer,

and can help select those patients most likely to benefit from

mastectomy.

600

For example, in a study of 40 patients with

biopsy-proven breast cancer in the axilla, and a negative or

indeterminate mammogram, MRI identified the primary breast lesion in

70% of the patients.

598

In addition, of the 7 patients with a negative MRI

who subsequently underwent ALN dissection and radiation therapy to

the whole breast, no evidence of local recurrence was evident at a

median follow-up of 19 months.

The

NCCN Guidelines for Occult Primary Cancer

provide guidance on

the diagnosis and initial workup of patients with a suspicious axillary

mass without any signs of a primary tumor. A small subset of these

patients may have a primary cancer in the axillary tail of the breast.

Adenocarcinoma with positive axillary nodes and mediastinal nodes in a

woman is highly suggestive of a breast primary. Adenocarcinoma in the

supraclavicular nodes, chest, peritoneum, retroperitoneum, liver, bone,

or brain could also indicate primary breast cancer in women. The

guidelines suggest the use of a mammogram and breast ultrasound for

such patients.