NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

fully optimized diagnostic CT scans, while the PET or PET/CT scans refer to scans primarily directed towards the PET component, not necessarily using diagnostic-quality CT. It is important for referring physicians to understand the differences between PET/CT performed primarily for PET imaging and fully optimized CT performed as a stand-alone diagnostic CT examination. 370 It may be convenient to perform PET/CT and diagnostic CT at the same time. Operable Locally Advanced Breast Cancer (Clinical stage T3N1M0) Locally advanced breast cancer describes a subset of invasive breast cancer where the initial clinical and radiographic evaluation documents advanced disease confined to the breast and regional lymph nodes. The AJCC clinical staging system used in these guidelines and for the determination of operability is recommended, and locally advanced disease is represented by the stage III category. Patients with stage III disease may be further divided into: 1) those where an initial surgical approach is unlikely to successfully remove all disease or to provide long-term local control; and 2) those with disease where a reasonable initial surgical approach is likely to achieve pathologically negative margins and provide long-term local control. Thus, stage IIIA patients are divided into those who have clinical T3N1M0 disease versus those who have clinical TanyN2M0 disease, based on evaluation by a multidisciplinary team. Postsurgical systemic adjuvant therapy for patients with stage IIIA breast cancer who do not receive neoadjuvant chemotherapy is similar to that for patients with stage II disease.

Inoperable Locally Advanced Breast Cancer (Clinical stage IIIA [except for T3N1M0], clinical stage IIIB, or clinical stage IIIC) For patients with inoperable, non-inflammatory, locally advanced disease at presentation, the initial use of anthracycline-based preoperative systemic therapy with or without a taxane is standard therapy. 371 Patients with locally advanced breast cancer that is HER2-positive should receive an initial chemotherapy program that incorporates preoperative trastuzumab. Local therapy following a clinical response to preoperative systemic therapy usually consists of: 1) total mastectomy with level I/II ALN dissection, with or without delayed breast reconstruction; or 2) lumpectomy and level I/II axillary dissection. Both local treatment groups are considered to have sufficient risk of local recurrence to warrant the use of chest wall (or breast) and supraclavicular node irradiation. If internal mammary lymph nodes are involved, they should also be irradiated. Without detected internal mammary node involvement, consideration may be given to include the internal mammary lymph nodes in the radiation field (category 2B). Adjuvant therapy may involve completion of planned chemotherapy regimen course if not completed preoperatively, followed by endocrine therapy in patients with hormone receptor-positive disease. Up to one year of total trastuzumab therapy should be completed if the tumor is HER2-positive (category 1). Endocrine therapy and trastuzumab can be administered concurrently with radiation therapy if indicated. Patients with an inoperable stage III tumor with disease progression during preoperative systemic therapy should be considered for palliative breast irradiation in an attempt to enhance local control. In all subsets of patients, further systemic adjuvant chemotherapy after local therapy is

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-42