NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

recommend routine cytokeratin IHC to define node involvement and believes that current treatment decisions should be made based solely on H&E staining. This recommendation is further supported by a randomized clinical trial (ACOSOG Z0010) for patients with H&E negative nodes where further examination by cytokeratin IHC was not associated with improved OS over a median of 6.3 years. 139 In the uncommon situation in which H&E staining is equivocal, reliance on the results of cytokeratin IHC is appropriate. Multiple attempts have been made to identify cohorts of women with involved SLNs who have a low enough risk for non-SLN involvement that complete axillary dissection might be avoided if the SLN is positive. None of the early studies identified a low-risk group of patients with positive SLN biopsies but consistently negative non-sentinel nodes. 140-146 Nonetheless, a randomized trial (ACOSOG Z0011) compared SLN resection alone with ALN dissection in women ≥18 years of age with T1/T2 tumors, fewer than 3 positive SLNs, and undergoing breast-conserving surgery and whole breast irradiation. In this study, there was no difference in local recurrence, DFS, or OS between the two treatment groups. Only ER-negative status, age <50, and lack of adjuvant systemic therapy were associated with decreased OS. 147 At a median follow-up of 6.3 years, locoregional recurrences were noted in 4.1% of the ALN dissection group (n = 420) and 2.8% of the SLN dissection patients (n = 436) ( P = .11). Median OS was approximately 92% in each group. 148 Therefore, based on these results after SLN mapping and excision, if a patient has a T1 or T2 tumor with 1 to 2 positive SLNs, did not receive neoadjuvant therapy, and is treated with lumpectomy and whole breast radiation, the panel recommends considering level I and II axillary dissection or no further axillary surgery. The panel recommends level I or II axillary dissection 1) when patients have clinically positive nodes at the time of diagnosis that is confirmed

by FNA or core biopsy; or 2) when sentinel nodes are not identified. Traditional level I and level II evaluation of ALN requires that at least 10 lymph nodes should be provided for pathologic evaluation to accurately stage the axilla. 149,150 ALN should be extended to include level III nodes only if gross disease is apparent in the level II nodes. In the absence of gross disease in level II nodes, lymph node dissection should include tissue inferior to the axillary vein from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle (level I/II). Furthermore, according to the panel, without definitive data demonstrating superior survival with ALN dissection or SLN resection, these procedures may be considered optional in patients who have particularly favorable tumors, patients for whom the selection of adjuvant systemic therapy will not be affected by the results of the procedure, elderly patients, and patients with serious comorbid conditions. Women who do not undergo ALN dissection or ALN irradiation are at increased risk for ipsilateral lymph node recurrence. 151 Women who undergo mastectomy are appropriate candidates for breast reconstruction. Breast reconstruction following mastectomy is discussed Preoperative chemotherapy should be considered for women with large clinical stage IIA, stage IIB, and T3N1M0 tumors who meet the criteria for breast-conserving therapy except for tumor size and who wish to undergo breast-conserving therapy. Preoperative chemotherapy is not indicated unless invasive breast cancer is confirmed. In the available data from clinical trials of preoperative systemic therapy, pretreatment biopsies have been limited to core needle biopsy or FNA cytology. Therefore, according to the NCCN Panel, in patients anticipated to receive preoperative systemic therapy, core biopsy of the breast tumor further under the section titled Breast Reconstruction . Preoperative Systemic Therapy for Large Tumors (Clinical stage IIA and IIB tumors and T3,N1,M0)

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