NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

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

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