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Version 2.2008 01/28/08 © 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

NCCN Clinical Practice Guidelines in Oncology™

Breast Cancer
V.2.2008

These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of
any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These
guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be
reproduced in any form without the express written permission of NCCN. ©2008.

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Practice Guidelines
in Oncology – v.2.2008NCCN

® Breast Cancer TOC

Staging, MS, References

National Comprehensive Cancer Network, Inc.

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Version 2.2008 01/28/08 © 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

Practice Guidelines
in Oncology – v.2.2008NCCN

® Breast Cancer TOC

Staging, MS, References

CLINICAL PRESENTATIONa

Inflammatory Breast Cancer

Clinical
pathologic
diagnosis
of IBC
Stage T4d,
N0-N3, M0

WORKUP















History and physical
exam
CBC, platelets
Liver function tests
Pathology review
Determination of tumor
ER/PR status and
HER2

Bone scan (category 2B)
CT scan chest/abd/pelvis
(category 2B)
Chest imaging (if
pulmonary symptoms are
present)

status
Bilateral diagnostic
mammogram, ultrasound
as necessary
Breast MRI (optional)�

Preoperative
chemotherapy,
anthracycline ± taxane
If tumor HER2 positive,
trastuzumab containing
regimen but not
concurrent with
anthracycline

b

Response

No
response

Total mastectomy + level
l/ll axillary dissection +
radiation therapy to
chest wall and
supraclavicular nodes

) ± delayed
breast reconstruction

(plus internal mammary
nodes if involved,
consider internal
mammary nodes if not
clinically involved
[category 3]

Consider additional
systemic chemotherapy
and/or preoperative
radiation

Response - See
above pathway

No
response

Individualized
treatment

Complete planned
chemotherapy regimen
course if not completed
preoperatively plus
endocrine treatment if
estrogen receptor
positive (sequential
chemotherapy followed
by endocrine therapy).
Complete 1 year of
trastuzumab if tumor
HER2-positive

TREATMENT

Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

IBC-1

aInflammatory breast cancer is a clinical syndrome in women with invasive breast cancer that is characterized by erythema and edema (peau d'orange) of a third or
more of the skin of the breast and with a palpable border to the erythema. The differential diagnosis includes cellulitis of the breast or mastitis. Pathologically, tumor
is typically present in the dermal lymphatics of the involved skin, but dermal lymphatic involvement is neither required for, nor sufficient for by itself, a diagnosis of
inflammatory breast cancer.

Patients with HER2-positive tumors should be considered for chemotherapy incorporating trastuzumab ( ).b

c
See BINV-J

See Principles of Reconstruction Following Mastectomy (BINV-G).

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Version 2.2008 01/28/08 © 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

Practice Guidelines
in Oncology – v.2.2008NCCN

® Breast Cancer TOC

Staging, MS, References

Table 1

American Joint Committee on Cancer (AJCC)
TNM Staging System For Breast Cancer

Primary Tumor (T)

TX

T0

Tis

Tis (DCIS)

Tis (LCIS)

Tis (Paget's)

T1

T2

T3

T4

Regional Lymph Nodes (N)

Clinical

NX

N0

N1

N2

N3

Definitions for classifying the primary tumor (T) are the same for clinical
and for pathologic classification. If the measurement is made by the
physical examination, the examiner will use the major headings (T1, T2, or
T3). If other measurements, such as mammographic or pathologic
measurements, are used, the subsets of T1 can be used. Tumors should
be measured to the nearest 0.1 cm increment.

Primary tumor cannot be assessed

No evidence of primary tumor

Carcinoma in situ

Ductal carcinoma in situ

Lobular carcinoma in situ

Paget's disease of the nipple with no tumor

Note: Paget's disease associated with a tumor is classified according to the
size of the tumor.

Tumor 2 cm or less in greatest dimension

T1mic Microinvasion 0.1 cm or less in greatest dimension

T1a Tumor more than 0.1 cm but not more than 0.5 cm in
greatest dimension

T1b Tumor more than 0.5 cm but not more than 1 cm in greatest
dimension

T1c Tumor more than 1 cm but not more than 2 cm in greatest
dimension

Tumor more than 2 cm but not more than 5 cm in greatest
dimension

Tumor more than 5 cm in greatest dimension

Tumor of any size with direct extension to (a) chest wall or
(b) skin, only as described below

T4a Extension to chest wall, not including pectoralis muscle

T4b Edema (including peau d'orange) or ulceration of the skin of
the breast, or satellite skin nodules confined to the same
breast

T4c Both T4a and T4b

T4d Inflammatory carcinoma

Regional lymph nodes cannot be assessed (e.g., previously
removed)

No regional lymph node metastasis

Metastasis to movable ipsilateral axillary lymph node(s)

Metastases in ipsilateral axillary lymph nodes fixed or
matted, or in * ipsilateral internal
mammary nodes in the of clinically evident axillary
lymph node metastasis

N2a Metastases in ipsilateral axillary lymph nodes fixed to one
another (matted) or to other structures

N2b Metastasis only in * ipsilateral internal
mammary nodes and in the of clinically evident
axillary lymph node metastasis

Metastasis in ipsilateral infraclavicular lymph node(s) with
or without axillary lymph node involvement, or in

* ipsilateral internal mammary lymph node(s) and
in the of clinically evident axillary lymph node
metastasis; or metastasis in ipsilateral supraclavicular
lymph node(s) with or without axillary or internal mammary
lymph node involvement

N3a Metastasis in ipsilateral infraclavicular lymph node(s)

N3b Metastasis in ipsilateral internal mammary lymph node(s)
and axillary lymph node(s)

N3c Metastasis in ipsilateral supraclavicular lymph node(s)

* is defined as detected by imaging studies (excluding
lymphoscintigraphy) or by clinical examination or grossly visible
pathologically.

clinically apparent
absence

clinically apparent
absence

clinically
apparent

presence

Clinically apparent

Staging

ST-1

Staging continued on next page (ST-2)

Breast Cancer

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Breast Cancer
Breast Cancer TOC

Staging, MS, References
Practice Guidelines
in Oncolo gy – v.2.2008 NCCN

®

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Breast Cancer
Breast Cancer TOC

Staging, MS, References
Practice Guidelines
in Oncolo gy – v.2.2008 NCCN

®

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