NCCN recommendations

1. Diagnostics

The NCCN recommends a three-pronged diagnostic approach including:

• Clinical examination
  
• Diagnostic imaging
  
  • Bilateral mammography
    
  • Ultrasound examination of the breasts and axilla
    
  • MRI - in selected cases (high risk, multifocality, unclear findings)
    
• Histological confirmation
  

Evaluation of axillary lymph nodes with ultrasound is mandatory in invasive carcinoma.

2. Biopsy

The NCCN clearly recommends core needle biopsy as the method of choice.

Basic principles:

• Biopsy should be performed before any surgical treatment
  
• Image-guided biopsy (US, stereotactic, MRI-guided) is preferred
  
• Fine needle aspiration (FNA) is not recommended for the primary diagnosis of tumor
  

Histological analysis should include:

• Type and grade of tumour
  
• ER, PR status
  
• HER2 status
  
• Ki-67 (if needed)
  

3. Surgical treatment of the primary tumor

The NCCN accepts organ-sparing surgery (BCS) as the standard in appropriate patients.

Options:

• Organ-sparing surgery + radiotherapy
  
• Mastectomy - for
  
  
  • contraindications to radiotherapy
    
  • patient preference
    
  • genetic risk (BRCA1/2)
    

Resection lines

• In invasive carcinoma: “no ink on tumor”
  
• For DCIS: recommended free edge ≥ 2 mm
  

Reconstructive surgery (immediate or delayed) is an integral part of the treatment plan.

4. Sentinel lymph node biopsy (SLNB)

SLNB is the standard for staging clinically negative axilla (cN0).

NCCN Recommendations:

• Indicated in:
  
  • T1-T2 invasive cancer
    
  • DCIS in planned mastectomy
    
• Not recommended for clinically proven metastases without neoadjuvant therapy
  

Technique:

• Radioisotope and/or blue dye
  
• ICG fluorescence
  

Behavior in positive SLN:

• With 1-2 positive nodes and BCS + radiotherapy → axillary dissection can be avoided
  
• Axillary dissection is reserved for selected cases
  

5. Multidisciplinary approach

NCCN emphasizes that any decision should be made within a multidisciplinary team including:

• surgeon
  
• medical oncologist
  
• Radiation Therapist
  
• image diagnostic
  
• pathologist
  
• geneticist (if needed)