NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

alkaline phosphatase tests, chest imaging, pathology review, and pre-chemotherapy determination of tumor ER/PR receptor status and HER2 status. Diagnostic bilateral mammogram and breast ultrasound should be performed as clinically warranted. 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. The performance of other studies, such as a breast MRI, a bone scan (category 2B), and abdominal imaging with diagnostic CT (with or without pelvic CT) or MRI (all category 2A) are optional unless directed by symptoms or other abnormal study results. PET/CT scan is also included as an optional additional study (category 2B). Ultrasound is an alternative when diagnostic CT or MRI is unavailable. The consensus of the panel is that FDG PET/CT is most helpful in situations where standard imaging results are equivocal or suspicious. However, limited studies 95,96,363-367 support a potential role for FDG PET/CT to detect regional node involvement as well as distant metastases in locally advanced breast cancer, including T3, N1, M0 disease. A retrospective study comparing bone scan with integrated FDG PET/CT, in women with stages I–III breast cancer with suspected metastasis, observed a high concordance (81%) between the two studies for reporting osseous metastases. 368 The NCCN Panel suggests that bone scan may be omitted if FDG PET/CT results are positive for bone metastases. Equivocal or suspicious sites identified by PET/CT scanning should be biopsied for confirmation whenever possible and if the site of disease would impact the course of treatment. In the past decade, the advent of

PET/CT scanners has significantly changed the approach to PET imaging. 369 However, the terminology has also created confusion regarding the nature of the scans obtained from a PET/CT device. PET/CT scanners have both a PET and CT scanner in the same gantry that allows precise coregistration of molecular (PET) and anatomic (CT) imaging. Almost all current clinical PET imaging is performed using combined PET/CT devices. In PET/CT tomographs, the CT scanner has a second important role beyond diagnostic CT scanning. 369 For PET applications, the CT scan is also used for photon attenuation correction and for anatomic localization of the PET imaging findings. For these tasks, the CT scan is usually taken without breathholding, to match PET image acquisition, and typically uses low-dose (non-diagnostic) CT. Radiation exposure for these non-diagnostic CT scans is lower than for diagnostic CT. Intravenous contrast is not needed for this task. PET/CT scanners typically include a high-quality CT device that can also be used for stand-alone, optimized, and fully diagnostic CT. Diagnostic CT scans are acquired using breathholding for optimal chest imaging, and are often performed with intravenous contrast. For fully diagnostic CT, the CT beam current, and therefore patient radiation exposure, is considerably higher than for the low-dose CT needed for PET requirements. Radiation exposures for fully diagnostic CT are often greater than for the emission (PET) component of the study. Currently, the approach to clinical PET/CT imaging varies widely across centers. 370 Many centers perform low-dose CT as part of a PET/CT scan, and perform optimized, fully diagnostic CT only when diagnostic CT has also been requested in addition to PET/CT. Other centers combine diagnostic CT scans with PET on all of their PET/CT images. The CT scans described in the workup section of the guidelines refer to

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