NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

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.

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

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-65