Clinical practice guidelines for pre-operative evaluation of breast cancer: Chinese Society of Breast Surgery (CSBrS) practice guidelines 2021

Abstract

Breast cancer is the most common cancer in women in China. Since Halsted introduced radical mastectomy, surgery has remained the cornerstone of breast cancer treatment. The Chinese Society of Breast Surgery (CSBrS) has conducted a literature review and experts have discussed key clinical issues related to standardizing pre-operative evaluation of patients with breast cancer; evaluated the relevant evidence with reference to the grading of recommendations assessment, development, and evaluation system; combined the accessibility under China's national conditions; and formulated the following written Clinical Practice Guidelines for Pre-operative Evaluation of Breast Cancer (2021 Edition) with the aim of providing a reference for Chinese breast surgeons. Tumor-related evaluation Component Level of evidence Strength of recommendation 3.1 Evaluation of primary tumor  3.1.1 Breast ultrasound[10] I A  3.1.2 Mammography[11] I A  3.1.3 Breast MRI   a. Uncertain findings on mammography, ultrasound, or physical examination[11] II A   b. To define extent of cancer or presence of multifocal or multicentric cancer in the ipsilateral breast[11] II A   c. Occult (or unidentified) primary breast cancer with axillary lymph node metastases[11] II A  3.1.4 Determination of tumor estrogen/progesterone receptor and human epidermal growth factor receptor-2 status[11] I A 3.2 Evaluation of regional lymph nodes  3.2.1 Needle biopsy of suspicious lymph nodes[12] I A 3.3 Evaluation of distant metastasis  3.3.1 Bone scan if patient has localized bone pain or high serum alkaline phosphatase[11] II A  3.3.2 Chest diagnostic CT with contrast if patient has pulmonary symptoms[11] II A  3.3.3 Abdominal ± pelvic diagnostic CT or MRI with contrast if high serum alkaline phosphatase, abnormal liver function tests, abdominal symptoms, or abnormal findings on physical examination of the abdomen and pelvis[11] II A  3.3.4 PET/CT can be performed to further investigate suspicious or inconclusive findings in standard staging studies, locally advanced breast cancer (IIIA and above), and/or distant metastases[11] II B 3.4 Concomitant evaluation of patients with breast cancer  3.4.1 Genetic counseling if patient is at risk of hereditary breast cancer[10] II A  3.4.2 Pregnancy testing in all potentially pregnant women[11] II A  3.4.3 Assessment of mental health status[11] II A 3.5 Evaluation of neoadjuvant therapy  3.5.1 Marking of tumor before commencing neoadjuvant therapy[13] II A  3.5.2 Imaging evaluation every two cycles[13] II A  3.5.3 Primary tumor evaluation after neoadjuvant therapy   a. Breast ultrasound[13,14] I A   b. Breast MRI[14] II A   c. If the lesion was clearly shown on a pre-treatment mammogram, mammography can be repeated after neoadjuvant therapy[14] II A  3.5.4 Regional lymph node evaluation after neoadjuvant therapy   a. Breast ultrasound[14] I A   b. Breast MRI[14] II A CT: [17] The CSBrS panel stresses that the application value of breast MRI should be fully understood: it has high sensitivity and can show multi-focal, multi-centric, or occult tumors, the relationship between tumor and chest wall, and axillary lymph node metastasis, thus providing a reliable basis for development of a surgical plan. [...]decisions about surgery cannot be made purely on the basis of MRI findings.