NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

chest wall following resection of a local recurrence, but this recommendation is controversial (category 2B). 534

provides tissue for histologic confirmation of invasive disease as well as adequate tissue for hormone receptor and HER2 analyses. Staging assessment of the pregnant patient with breast cancer may be guided by clinical disease stage. The staging studies should be tailored to minimize fetal exposure to radiation. For clinically node-negative T1-T2 tumors, a chest x-ray (with shielding), liver function and renal function assessment, and CBC with differential are appropriate. In patients who have clinically node-positive or T3 breast lesions, in addition to the aforementioned, an ultrasound of the liver and consideration of a screening MRI of the thoracic and lumbar spine without contrast may be employed. The documentation of the presence of metastases may alter the treatment plan and influence the patient’s decision regarding maintenance of the pregnancy. Assessment of the pregnancy should include a maternal fetal medicine consultation and review of antecedent maternal risks such as hypertension, diabetes, and complications with prior pregnancies. Documentation of fetal growth and development and fetal age by means of ultrasonographic assessment is appropriate. Estimation of the date of the delivery will help with systemic chemotherapy planning. In addition, maternal fetal medicine consultation should include counseling regarding maintaining or terminating pregnancy. Counseling of the pregnant patient with breast cancer should include a review of the treatment options, which include mastectomy or breast-conserving surgery as well as the use of systemic therapy. The most common surgical procedure has been modified radical mastectomy. However, breast-conserving surgery is possible if radiation therapy can be delayed to the postpartum period, 540 and breast-conserving therapy during pregnancy does not appear to have a negative impact on survival. 540,541 When surgery is performed at 25 weeks of gestation or later, obstetrical and prenatal specialists must

While the epithelial component of most phyllodes tumors contains ER (58%) and/or PR (75%), 535 endocrine therapy has no proven role in the treatment of phyllodes tumors. Similarly, there is no evidence that adjuvant cytotoxic chemotherapy provides benefit in reduction of recurrences or death. In the rare patient who experiences a systemic recurrence (usually in the lung), treatment should be as recommended in the NCCN Guidelines for Soft Tissue Sarcoma. Breast Cancer During Pregnancy Breast cancer occurring concurrently with pregnancy is an infrequent clinical event. In a California registry study, there were 1.3 breast cancers diagnosed per 10,000 live births. 536 Unfortunately, breast cancer during pregnancy is most often ALN-positive and with larger primary tumor size. Histologically the tumors are poorly differentiated, are more frequently ER/PR-negative, and approximately 30% are HER2-positive. 537,538 The diagnosis is often delayed because neither the patient nor the physician suspects malignancy. Evaluation of the pregnant patient with suspected breast cancer should include a physical examination with particular attention to the breast and regional lymph nodes. Mammogram of the breast with shielding can be done safely and the accuracy is reported to be greater than 80%. 539 Ultrasound of the breast and regional lymph nodes can be used to assess the extent of disease and also to guide biopsy. Ultrasound has been reported to be abnormal in up to 100% of breast cancers occurring during pregnancy. 539 Biopsies for cytologic evaluation of a suspicious breast mass may be done with FNA of the breast and suspicious lymph nodes. However, the preferred technique is core needle biopsy. This

Version 2.2015, 03/11/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. MS-60