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-6

NCCN Guidelines Index

Breast Cancer Table of Contents

Discussion

NCCN Guidelines Version 2.2015

Breast Cancer

Workup

Recommended workup includes history and physical examination,

diagnostic bilateral mammography, and pathology review.

Primary Treatment

Controversy exists regarding whether an open surgical excision should

be performed of the region of LCIS diagnosed by core biopsy and that is

not associated with a mammographic structural abnormality or residual

mammographic calcifications. Small retrospective studies have

concluded that excision following the diagnosis of LCIS on core needle

biopsy is not necessary.

30-32

Other studies have shown that 17% to 27%

of patients with LCIS diagnosed by core needle biopsy are upgraded to

having invasive cancer or DCIS after larger excisional biopsy.

33-37

Based

on core needle biopsies, it may be possible to identify subsets of

patients with LCIS who can be safely spared a surgical excision.

There are some data of small groups of patients suggesting that LCIS

subtypes, including pleomorphic LCIS and LCIS associated with

necrosis, carry a risk for associated invasive carcinoma similar to DCIS.

Therefore, according to the NCCN Panel, it is reasonable to perform

surgical excision of LCIS found in a core biopsy to exclude an

associated invasive cancer or DCIS. More than 4 foci of LCIS may also

increase the risk for upstaging on surgical biopsy.

The NCCN Panel

recommends that LCIS of the usual type (involving <4 terminal ductal

lobular units in a single core) found on core biopsy, as a result of routine

screening for calcifications and without imaging discordance, may be

managed by imaging follow-up.

There is evidence to support the existence of histologically aggressive

variants of LCIS (eg, “pleomorphic” LCIS), which may have a greater

potential than classic LCIS to develop into invasive lobular carcinoma.

Clinicians may consider complete excision with negative margins for

pleomorphic LCIS. However, outcome data regarding treatment of

patients with pleomorphic LCIS are lacking, due in part to a paucity of

histologic categorization of variants of LCIS. Therefore,

recommendations on the treatment of pleomorphic LCIS as a distinct

entity of LCIS have not been made by the panel.

Patients with a confirmed diagnosis of LCIS should be counseled

regarding reducing the risk of developing invasive cancer (see

NCCN

Guidelines for Breast Cancer Risk Reduction

Surveillance

Follow-up of patients with LCIS includes interval history and physical

examinations every 6 to 12 months. Annual diagnostic mammography is

recommended in patients being followed with clinical observation; see

also the

NCCN Guidelines for Breast Cancer Screening and Diagnosis

Patients receiving a risk reduction agent should be monitored as

described in the

NCCN Guidelines for Breast Cancer Risk Reduction

Ductal Carcinoma in Situ

(Stage 0, Tis, N0, M0)

Workup

The recommended workup and staging of DCIS includes: history and

physical examination; bilateral diagnostic mammography; pathology

review; and tumor ER determination. 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

Although HER2 status is of prognostic significance in invasive cancer,

its importance in DCIS has not been elucidated. To date studies have

either found unclear or weak evidence of HER2 status as a prognostic

indicator in DCIS.

40-43

The NCCN Panel concluded that knowing the