乳腺癌NCCN指南2016年第1版更新

NCCN Guidelines Version 1.2016 Breast Cancer Updates 乳腺癌NCCN指南2016年第1版更新

Updates in Version 1.2016 of the NCCN Guidelines for Breast Cancer from Version 2.2015 include:山东省肿瘤医院呼吸肿瘤内科张品良
2016年第1版乳腺癌NCCN指南从2015年第2版的更新包括：

DCIS-1 " Modified the first sentence in footnote "h": Complete axillary lymph node dissection should not be performed in the absence of evidence of invasive cancer or proven axillary metastatic disease in women with apparent pure DCIS or mammographically detected DCIS with microcalcifications."
DCIS-1修改脚注“H”中的第一句：在明显单纯性DCIS或乳房摄影发现DCIS有微小钙化女性中，在没有侵袭性肿瘤证据或证实腋窝转移的情况下不应施行腋窝淋巴结清扫。”

DCIS-2
* Under "Risk reduction therapy for ipsilateral breast following breast- conserving surgery" replaced "tamoxifen" with "endocrine therapy" in the following bullets: Consider endocrine therapy for 5 years for:
＊“在保乳手术后降低同侧乳腺风险治疗”下面下列内容中的“他莫昔芬”用“内分泌治疗”替换：考虑内分泌治疗5年对于：

Patients treated with breast-conserving therapy (lumpectomy) and radiation therapy (category 1), especially for those with ER- positive DCIS.
保乳和放射治疗的患者（乳房肿瘤切除术）（1类），特别是那些ER阳性的DCIS。

The benefit of endocrine therapy for ER-negative DCIS is uncertain BINV-3 Added new bullets for "Endocrine therapy:"
对雌激素受体阴性的DCIS内分泌治疗的收益不确定BINV-3“内分泌治疗：”增加了新内容

Tamoxifen for premenopausal patients
他莫昔芬用于绝经前患者

Tamoxifen or aromatase inhibitor for postmenopausal patients with some advantage for aromatase inhibitor therapy in patients<60 years old or with concerns for thromboembolism
他莫昔芬或芳香化酶抑制剂用于绝经后患者在年龄<60< span="">岁或担心血栓栓塞的患者中芳香化酶抑制剂治疗具有一些优势

* Modified footnote "o" for consistency with NCCN Guidelines for Breast Cancer Risk Reduction. The footnote states "CYP2D6 genotype testing is not recommended in women who are considering tamoxifen."
*为了与NCCN降低乳腺癌风险指南一致修改脚注“o”。脚注指出“在考虑他莫昔芬的女性中不建议CYP2D6基因型检测。”

* Footnote "p", changed "tamoxifen" to "endocrine therapy."
*脚注“P”，“他莫昔芬”更改为“内分泌治疗。”

BINV-1
* CBC includes platelets, deleted "platelets"
* CBC包括血小板，删除了“血小板”

* "Assess for distress" - moved the link to the NCCN Guidelines for Distress Management from the algorithm to a footnote.
＊“窘迫评估”-窘迫管理NCCN指南链接从工作规则移动到脚注。

* Listed CBC, liver function tests and alkaline phosphatase as optional based on signs and symptoms and clinical stage I-IIB, and IIIA (T3,N1,M0).
*当基于症状和体征、临床I-IIB期和IIIA（T3N1M0）时的可选择列出的血常规、肝功能检查以及碱性磷酸酶。

* Footnote "k" is new, "See NCCN Guidelines for Older Adult Oncology for special treatment considerations."
*脚注“k"是新的，”见老年肿瘤治疗特别注意事项NCCN指南。”

BINV-2
* Following ≥4 positive axillary nodes, added "internal mammary nodes, and any part of the axillary bed at risk (category 1). Removed "Strongly consider radiation therapy to internal mammary nodes (category 2B)
*在≥4个阳性腋窝淋巴结之后，增加了“内乳淋巴结以及任何腋床部位有风险时（1类）。删除“强烈考虑内乳淋巴结放疗（2B类）

* Footnote "q" was deleted. "Radiation therapy should be given to the internal mammary lymph nodes that are clinically or pathologically positive; otherwise the treatment to the internal mammary nodes is at the discretion of the treating radiation oncologist. CT treatment planning should be utilized in all cases where radiation therapy is delivered to the internal mammary lymph nodes."
*脚注“q”被删除。“对临床或病理学阳性的内乳淋巴结应该给予放射治疗；否则按照肿瘤放疗学家的判断对内乳淋巴结治疗。在所有对内乳淋巴结给予放疗的患者中均应利用CT治疗计划。

* Following 1-3 positive axillary nodes, removed category 2B from radiation therapy to internal mammary nodes. "Strongly consider radiation therapy to infraclavicular, supraclavicular area, internal mammary nodes" added "and any part of the axillary bed at risk."
*在1-3个阳性腋窝淋巴结之后，从内乳淋巴结放疗中去除了2B类。“强烈考虑对锁骨下区、锁骨上区、内乳淋巴结放射治疗”增加了“以及腋床任何部分有风险时。”

* Following ≥4 positive axillary nodes, "Postchemotherapy radiation therapy to chest wall + infraclavicular region, supraclavicular area" added "internal mammary nodes, and any part of the axillary bed at risk (category 1)." Removed "Strongly consider radiation therapy to internal mammary nodes (category 2B)
*在≥4个阳性腋窝淋巴结之后，“化疗后对胸壁+锁骨下区、锁骨上区放疗”增加了“内乳淋巴结以及腋床任何部分有风险时(1类)。”删除“强烈考虑内乳淋巴结放疗（2B类）

* Following 1-3 positive axillary nodes, "Strongly consider postchemotherapy radiation therapy to chest wall + infraclavicular region, supraclavicular area, internal mammary nodes" added "and any part of the axillary bed at risk." Removed "if radiation therapy is given, strongly consider internal mammary node radiation therapy (category 2B)."
*在1-3阳性腋窝淋巴结之后，“强烈考虑化疗后对胸壁+锁骨下区、锁骨上区、内乳淋巴结放疗”增加了“以及腋床任何部分有风险时。”去除了"如果给予放射治疗，强烈考虑内乳淋巴结放疗（2B类）。”

* Following Negative axillary nodes and tumor >5 cm or margins positive, "Consider postchemotherapy radiation therapy to chest wall ± infraclavicular region, ± supraclavicular area" added "± internal mammary nodes, and any part of the axillary bed at risk.". Removed "Strongly consider radiation therapy to internal mammary nodes (category 2B)."
*在腋窝淋巴结阴性且肿瘤＞125px或切缘阳性之后，“考虑化疗后对胸壁±锁骨下区±锁骨上区放疗”增加了“±内乳淋巴结以及任何有风险的腋床部分。”。删除“强烈考虑内乳淋巴结放疗（2B类）。”

BINV-6
* Added a footnote to "Consider 21-gene RT-PCR assay" stating "Other prognostic multigene assays may be considered to help assess risk of recurrence but have not been validated to predict response to chemotherapy."
*增加了一个脚注“考虑21基因RT-PCR检测”分析“其他预后性多基因检测可以考虑以帮助评估复发风险但对预测化疗应答尚未验证。”

BINV-10
* Modified the workup for consistency with BINV-1.
*为了与BINV-1一致修改了检查。

* CBC includes platelets, deleted "platelets"
* CBC包括血小板，删除了“血小板”

* "Assess for distress" - moved the link to the NCCN Guidelines for Distress Management from the algorithm to a footnote.
＊“窘迫评估”-窘迫管理NCCN指南链接从工作规则移动到脚注。

* Additional studies consider: CBC, liver function tests and alkaline phosphatase as optional based on signs and symptoms and clinical stage I-IIB, and IIIA (T3,N1,M0).
*其他研究考虑：当基于症状和体征、临床I-IIB和IIIA（T3N1M0）期时血常规、肝功能检查以及碱性磷酸酶不是必需的。

* If lymph node FNA or core biopsy positive, axilla may be restaged after preoperative systemic therapy, added "(category 2B)."
*如果淋巴结FNA或空心针活检阳性，可以在术前系统治疗后重新腋窝分期，增加了“（2B类）。”

* Removed bottom branch for "Surgical resection."
*删除了底部分支“手术切除”。

BINV-11
* Clinically negative axillary lymph node, changed "should have" to "consider."
*临床腋窝淋巴结阴性，“应该”更改为“考虑”。

* Clinically positive axillary lymph node, added (category 2B) to "SLNB or ALND can be performed if axilla is clinically negative."
*临床腋淋巴结阳性，“如果腋窝临床阴性可以实施SLNB或ALND。”增加了（2B类）

BINV-12
* Preoperative systemic therapy, modified the statement " [Endocrine therapy alone with an aromatase inhibitor (preferred option for postmenopausal women; given along with ovarian suppression for premenopausal women) or tamoxifen may be considered for patients with hormone-receptor positive disease]."
*术前全身治疗,修改了叙述“[对于激素受体阳性的患者可考虑单纯芳香酶抑制剂（绝经后女性首选；绝经前女性同时给予卵巢抑制）或他莫昔芬内分泌治疗]。”

* Added a footnote "See Principles of Preoperative Systemic Therapy (BINV-L)."
*增加了一个脚注“见术前全身治疗原则（BINV-L）。”

BINV-13
* Mastectomy and surgical axillary staging ± reconstruction - Added a footnote. "See Principles of Breast Reconstruction Following Surgery (BINV-H)."
*乳腺切除术联合腋淋巴结手术分期±重建——增加了一个脚注。“见术后乳房重塑原则（BINV-H）。”

* Revised footnote "qq": "Axilla may be restaged after preoperative systemic therapy (category 2B); ALND should be performed if axilla is clinically positive; SLNB or ALND can be performed if axilla is clinically negative."
*修订了脚注“qq”：“在术前系统治疗后可以重新腋窝分期（2B类）；如果腋窝临床阳性应该进行ALND；如果腋窝临床阴性可以进行SLNB或ALND。”

BINV-14
* Listed CBC, liver function tests and alkaline phosphatase under Additional studies.
*在其他研究下面列出了CBC、肝功能及碱性磷酸酶检查。

* CBC includes platelets, deleted "platelets"
* CBC包括血小板，删除了“血小板”

* "Assess for distress" - moved the link to the NCCN Guidelines for Distress Management from the algorithm to a footnote.
＊“窘迫评估”-窘迫管理NCCN指南链接从工作规则移动到注脚。

BINV-15
* "Preoperative systemic therapy, modified the statement [Endocrine therapy alone with an aromatase inhibitor (preferred option for postmenopausal women; given along with ovarian suppression for premenopausal women) or tamoxifen may be considered for patients with hormone-receptor positive disease]."
*“术前全身治疗，修改了说明[对于激素受体阳性的患者可考虑用一种芳香化酶抑制剂（绝经后女性首选；绝经前女性同时给予卵巢抑制）或他莫昔芬单独内分泌治疗]。”

* Added a footnote "See Principles of Preoperative Systemic Therapy (BINV-L)."
*增加了一个脚注“见术前全身治疗原则（BINV-L）。”

* Removed the following footnotes from page BINV-12 and BINV-15, they have been incorporated into Principles of Preoperative Systemic Therapy (BINV-L):
*从BINV-12和BINV-15页删除了以下脚注，她们已加入到术前全身治疗原则（BINV-L）中：

A number of chemotherapy regimens have activity in the preoperative setting. In general, those chemotherapy regimens recommended in the adjuvant setting may be considered in the preoperative setting. See Preoperative/Adjuvant Chemotherapy (BINV-K). If treated with endocrine therapy, an aromatase inhibitor is preferred for postmenopausal women.
在术前情况下许多化疗方案均有效。通常情况下，在术前情况下可以考虑那些在辅助治疗中推荐的化疗方案。见术前/辅助化疗(BINV-K)。如果使用内分泌治疗，对于绝经后女性首选一种芳香化酶抑制剂。

Patients with HER2-positive tumors should be treated with preoperative systemic incorporating trastuzumab for at least 9 weeks of preoperative therapy See Preoperative/Adjuvant Chemotherapy (BINV-K).
HER2阳性肿瘤患者应该用包含至少9周曲妥珠单抗的术前系统治疗见术前/辅助化疗（BINV-K）。

A pertuzumab-containing regimen may be administered preoperatively to patients with greater than or equal to T2 or greater than or equal to N1, HER2-positive breast cancer.
对于≥T2或≥N1、HER2阳性的乳腺癌患者可术前给予一种包含帕妥珠单抗的方案。

Administration of all chemotherapy prior to surgery is preferred.
首选术前给予的所有化疗。

* Removed "(plus internal mammary nodes if involved, strongly consider internal mammary nodes if not clinically involved (category 2B)."
*删除“（如果受累加内乳淋巴结，如果内乳淋巴结临床未受累强烈考虑（2B类）”。

* Removed "delayed" from breast reconstruction.
*从乳房重建中删除“延迟”。

* Removed "consider" from the mastectomy/lumpectomy choice.
*从乳房切除术/乳房肿瘤切除术选择中删除“考虑”。

* Added "and internal mammary nodes and any part of the axillary bed at risk."
*增加了“和内乳淋巴结以及腋床任何部分有风险时。”

BINV-16
* Added a new bullet; "Periodic screening for changes in family history and referral to genetic counseling as necessary."
*增加了一个新项目；“定期筛查家族史的变化，必要时转诊到遗传咨询。”

* Added a footnote to "Mammography every 12 mo." The new footnote states "Studies indicate that annual mammograms are the appropriate frequency for surveillance of breast cancer patients who have had breast-conserving surgery and radiation therapy with no clear advantage to shorter interval imaging. Patients should wait 6 to 12 months after the completion of radiation therapy to begin their annual mammogram surveillance. Suspicious findings on physical examination or surveillance imaging might warrant a shorter interval between mammograms."
*对“每12个月1次乳房摄影术。”增加了一个脚注新脚注指出“研究表明对于保乳术加放疗的乳腺癌患者的监测每年1次乳房摄影是合理的频度，更短的成像间隔时间没有明确的优势。在放疗结束后患者应该等6到12个月再开始他们每年1次的乳房X线照相监测。在体检或影像监测时可疑的发现可能有正当理由缩短乳房X线检查的间隔时间。”

* Added a new bullet "Routine imaging of reconstructed breast is not indicated."
*增加了一个新的项目“常规乳腺影像重建是不适宜的。”

* Added a new bullet "In the absence of clinical signs and symptoms suggestive of recurrent disease, there is no indication for laboratory or imaging studies for metastases screening."
*增加了一个新的项目“在临床症状和体征没有提示疾病复发的情况下，没有指征进行转移筛检的实验室或影像检查。”

* Added healthy diet and limited alcohol intake to the following bullet "Evidence suggests that active lifestyle, healthy diet, limited alcohol intake, and achieving and maintaining an ideal body weight (20–25 BMI) may lead to optimal breast cancer outcomes."
*在下面的项目“证据表明，积极的生活方式、健康饮食、限制酒精摄入、达到并维持一个理想的体重（BMI 20-25）可能会带来最佳的乳腺癌结局。”增加了健康饮食和限制酒精摄入

* Revised footnote "tt": "The use of estrogen, progesterone, or selective estrogen receptor modulators to treat osteoporosis or osteopenia in women with breast cancer is discouraged. The use of a bisphosphonate or denosumab is acceptable to maintain or to improve bone mineral density. Optimal duration of either therapy has not been established. Duration beyond 3 y is not known. Factors to consider for duration of anti-osteoporosis therapy include bone mineral density, response to therapy, and risk factors for continued bone loss or fracture. Women treated with a bisphosphonate or denosumab should undergo a dental examination with preventive dentistry prior to the initiation of therapy, and should take supplemental calcium and vitamin D."
*修订了脚注“tt”：“在乳腺癌女性中使用雌激素、黄体酮或者选择性雌激素受体调节剂治疗骨质疏松症或骨量减少令人沮丧。使用双膦酸盐或地诺单抗维持或提高骨矿物质密度是可以接受的。两种治疗的任何一种最佳持续时间尚未确定。持续时间超过3年尚不清楚。抗骨质疏松治疗持续时间考虑的因素包括骨矿物质密度、治疗应答以及持续的骨丢失或者骨折的危险因素。接受一种双磷酸盐或地诺单抗治疗的女性在治疗开始之前应该接受预防性牙科检查，并且应该补充钙和维生素D。”

BINV-17
* CBC includes platelets, deleted "platelets" BINV-18
* CBC包括血小板，删除了“血小板”BINV-18

* Changed page header to "Treatment of Recurrence."
* 页眉更改为“复发的治疗。”

* Simplified the recommendations for "Radiation therapy", by removing the following text: "to chest wall and supraclavicular and infraclavicular nodes."
*简化“放射治疗”的建议，去除下列文本：“对胸壁与锁骨上及锁骨下淋巴结。”

* Added the following footnote "Multidisciplinary approach is especially important in the management of breast cancer recurrence to consider all potential treatment options for optimal outcomes."
*增加了以下脚注：“在乳腺癌复发的管理中，为了获得最佳的结果考虑所有可能的治疗方案，多学科方法尤其重要。”

BINV-19
* Changed page header to "Treatment of Stage IV Disease."
*页眉更改为“Ⅳ期疾病的治疗。”

BINV-22
* Bottom branch: Added Ado-trastuzumab emtansine (T-DM1) to first line therapy. Changed "trastuzumab ± chemotherapy" to "trastuzumab + chemotherapy."
*底部的分支：一线治疗增加了抗体耦连曲妥珠单抗（T-DM1）。“曲妥珠单抗±化疗”更改为“曲妥珠单抗+化疗。”

Simplified second line therapy to state "HER2-targeted therapy."

二线治疗简化为陈述“HER2靶向治疗。”

BINV-B

* Modified the first bullet: "Breast MRI examinations are performed with IV contrast and should be performed and interpreted by an expert breast imaging team working in concert with the multidisciplinary treatment team."
*修改了第一个项目：“应该进行静脉注射对比剂的乳腺MRI检查并由一个专门的乳腺影像工作组配合多学科治疗组判断。”

* Second bullet, replaced "wire" with "image-guided. "The imaging center should have the ability to perform MRI-guided needle sampling and/or image-guided localization of MRI-detected findings."
*第二个项目，用“ 影像导引”代替“金属丝”。“影像中心应该具有施行MRI引导的针吸取样和/或MRI能检测发现影像引导定位的能力。”

BINV-C
* Fertility and birth control modified the first bullet: "All premenopausal patients should be informed about the potential impact of chemotherapy on fertility and asked about their desire for potential future pregnancies. Patients who may desire future pregnancies should be referred to fertility specialists before chemotherapy and/or endocrine therapy, to discuss the options based on patient specifics, disease stage and biology, (which determine the urgency and type and sequence of treatment). Timing and duration allowed for fertility preservation, options inclusive of oocyte and embryo cryopreservation as well as evolving technologies, and the probability of successful pregnancies subsequent to completion of breast cancer therapy are also to be discussed."
*生育节育修改了第一项："所有的绝经前患者均应该被告知有关化疗对生育力的潜在影响并询问其将来可能妊娠的意愿。可能希望将来怀孕的患者在化疗和/或内分泌治疗前应咨询生育专家，讨论患者基于具体病情、疾病分期和生物学的选择，（确定治疗的紧迫性、类型和顺序）。至于生育能力保护的时机和持续时间，允许的方案包括卵母细胞和胚胎冷冻保存，而且随着技术的不断开展，也讨论在完成乳腺癌治疗之后成功怀孕的概率。

BINV-D
* Footnote 2: Removed the last sentence "However, only peritumoral injections map to the internal mammary lymph node(s).
*脚注2：删除了最后一句“然而，癌周注射仅仅显示内乳淋巴结。

BINV-E
* Replaced "Sentinel lymph node biopsy is the preferred method of axillary lymph node staging if there is an experienced sentinel node team and the patient is an appropriate sentinel lymph node biopsy candidate (See BINV-D)." with "Sentinel lymph node biopsy should be performed and is the preferred method of axillary lymph node staging if the patient is an appropriate sentinel lymph node biopsy candidate."
*用“如果患者适合前哨淋巴结活检，应该进行哨淋巴结活检并且是腋淋巴结分期的首选方法。”替换“如果有哨淋巴结组经验并且该患者是合适的前哨淋巴结活检候选者前哨淋巴结活检是腋淋巴结分期的首选方法(见BINV-D)。” 

BINV-F
* Second paragraph, modified the last sentence "A boost to the tumor bed is recommended in patients at higher risk for recurrence."
*第二段，修改了最后一句“在更高危复发的患者中推荐瘤床推量照射。”

BINV-G

* Absolute contraindications: added "Diffusely positive pathologic margins" and removed "Positive pathologic margin."
*绝对禁忌症：增加了“切缘病理学弥漫阳性”并去除“切缘病理学阳性。”

* Relative contraindications: added "Positive pathologic margin" and removed "Diffusely positive pathologic margins."
*相对禁忌症：增加了“切缘病理学阳性”并去除“切缘病理学弥漫阳性。”

* Added a link to NCCN Guidelines for Genetic/Familial High-Risk Assessment Breast and Ovarian.
*增加了一个链接：遗传性/家族性高危评估乳腺与卵巢NCCN指南。BINV-H(1/2)

* First paragraph, added the following "However, breast reconstruction should not interfere with the appropriate surgical management of the cancer or the scope of appropriate surgical treatment for this disease. Coordinating consultation and surgical treatment with a reconstructive surgeon should be executed within a reasonable time frame."
*第一段，增加了以下“然而，乳房再造不应妨碍恰当癌症手术治疗或适当的手术治疗范围。在一个合理的时间框架内，应与重建外科医生协商重建与外科治疗。”

* Modified "Oncoplastic techniques for breast conservation can extend breast-conserving surgical options in situations where the resection by itself would likely yield an unacceptable cosmetic outcome."

*修改了“在切除本身可能不能获得可接受的美容结果的情况下保乳肿瘤整形技术可以扩大保乳手术方案。”

BINV-H (2/2)

* Modified the statement "Evidence of nipple involvement such as Paget’s disease or other nipple discharge associated with malignancy, and/or imaging findings suggesting malignant involvement of the nipple or subareolar tissues is a contraindicates nipple preservation."
*修改了说明“乳头受累如佩吉特病或其他与恶性肿瘤相关的乳头溢液和/或影像学检查提示乳头或乳晕下组织恶性受累的证据，是保留乳头的一个禁忌症。”

BINV-I
* This page has been reorganized and updated.
*此页已重新整理并更新。

BINV-J

* Changed tamoxifen for 5 y (category 1) ± ovarian suppression or ablation (category 2B) to a (category 1).
*他莫昔芬5年（1类）±卵巢抑制或消融治疗（2B类）更改为（1类）。

* Adjuvant endocrine therapy - premenopausal at diagnosis, added "or aromatase inhibitor for 5y + ovarian suppression or ablation (category 1)." With a new footnote " Aromatase inhibitor or tamoxifen for 5 y plus ovarian suppression should be considered, based on SOFT and TEXT clinical trial outcomes, for premenopausal women at higher risk of recurrence (i.e. young age, high grade tumor, lymph node involvement, Pagani, NEJM 2014, Prudence, NEJM 2014).Survival data still pending."
*辅助内分泌治疗—在诊断时绝经前期者，增加了“或芳香化酶抑制剂5年 +卵巢抑制或切除（1类）”。用一个新脚注“基于SOFT与TEXT临床试验结果，应考虑芳香化酶抑制剂或他莫昔芬5年加卵巢抑制，对于更高复发风险的绝经前妇女（即年轻、高级别肿瘤、淋巴结转移，帕加尼，NEJM 2014，Prudence，NEJM 2014）。生存数据仍然悬而未决。”

BINV-K (1 of 7)
* Footnote 5 is new to the page. "The regimens listed for HER2-negative disease are all category 1 (except where indicated) when used in the adjuvant setting."
*该页脚注5是新的。“对于HER2阴性疾病列出的方案当用于辅助情况时全部是1级（已注明者除外）。”

* Removed FAC/CAF (fluorouracil/doxorubicin/cyclophosphamide) and FEC/CEF (cyclophosphamide/ epirubicin/fluorouracil) from the list of regimens for preoperative/ adjuvant chemotherapy.
*对于术前/辅助化疗，FAC/CAF（氟尿嘧啶/阿霉素/环磷酰胺）和FEC/CEF（环磷酰胺/表阿霉素/氟尿嘧啶）从方案列表中删除。

BINV-K (3 of 7)
* Under the regimen "FAC followed by weekly paclitaxel, changed 6 to 4 cycles. BINV-K (4, 5, and 6 of 7)
*在“FAC序贯每周1次紫杉醇”方案下，6周期更改为4周期。BINV-K(4、5、6/7)

* Replaced cardiac monitoring at baseline, 3, 6, and 9 mo with "Evaluate left ventricular ejection fraction (LVEF) prior to and during treatment."
*在基线、3、6、9个月时心脏监测，替换为“在治疗前和治疗期间评估左室射血分数（LVEF）。”

* Added the following footnote " The optimal frequency of LVEF assessment during adjuvant trastuzumab therapy is not known. The FDA label recommends LVEF measurements prior to initiation of trastuzumab and every 3 mo during therapy."
*增加了下列脚注“在曲妥珠单抗辅助治疗期间LVEF评估的最佳频率尚不清楚。FDA标注的建议是在曲妥珠单抗开始之前以及在治疗期间每3个月测定LVEF。”

BINV-L
* New page - Principles of Preoperative Systemic Therapy.
*新页——术前系统治疗的原则。

BINV-N
* Modified first statement, "Premenopausal patients with hormone receptor- positive disease should have ovarian ablation/suppression and follow
*修改了第一句说明，“激素受体阳性的绝经前患者应该进行卵巢去势/抑制序贯

* Endocrine therapy for recurrent or stage IV disease, added Palbociclib + fulvestrant (category 1) with the following footnote: "For postmenopausal women or for premenopausal women receiving ovarian suppression with an LHRH agonist, with hormone-receptor positive and HER2-negative metastatic breast cancer that has progressed on endocrine therapy."
*复发或IV期患者的内分泌治疗，下列脚注增加了帕博西尼+氟维司群（1类）：“对于绝经后妇女或接受LHRH激动剂卵巢抑制、激素受体阳性、HER2阴性的转移性乳腺癌的绝经前妇女内分泌治疗已取得了进展。”

* Footnote 4 is new to the page. "A single study (S0226) in women with hormone receptor-positive breast cancer and no prior chemotherapy, biological therapy, or endocrine therapy for metastatic disease demonstrated that the addition of fulvestrant to anastrozole resulted in prolongation of time to progression. Subset analysis suggested that patients without prior adjuvant tamoxifen and more than 10 years since diagnosis experienced the greatest benefit. Two studies with similar design (FACT and SOFEA) demonstrated no advantage in time to progression with the addition of fulvestrant to anastrozole."
*该页脚注4是新的。“在激素受体阳性、既往未针对转移性疾病接受过化疗、生物治疗或内分泌治疗的乳腺癌女性中的一项单中心研究（S0226）证明氟维司群加入到阿那曲唑中延长至疾病进展时间。亚组分析表明，既往没有辅助他莫昔芬以及自诊断超过10年的患者获益最大。两项设计类似的研究（FACT和SOFEA）证明阿那曲唑外加氟维司群在至进展时间方面没有优势。”

BINV-O
* Other first-line agents for HER2-positive disease: Trastuzumab alone has been removed. * Footnote 4 is new to the page: Trastuzumab may be safely combined with all non-anthracycline containing preferred and other single agents listed above for recurrent or metastatic breast cancer.
*HER2阳性疾病其他的一线药物：去掉了曲妥珠单抗单药。*该页脚注4是新的：对于复发或转移性乳腺癌，曲妥珠单抗可以安全地首选联合所有不含蒽环类的方案以及上述列出的其他单药。

* Updated reference list. BINV-P (3 of 3)
*更新了参考目录。BINV-P(3/3)

* Suggested intervals of follow-up for patients with metastatic disease, changed the interval for endocrine therapy follow-up from "2-3 mo" to "1-3 mo."
*对于转移性疾病患者建议的随访时间间隔，内分泌治疗的随访间隔时间从“2-3个月”更改为“1-3个月。”

PHYLL-1
* Revised footnote "a": "FNA or core biopsy may not distinguish a fibroadenoma from a phyllodes tumor in some cases. The sensitivity of core biopsy for the diagnosis of phyllodes tumor is greater than that of FNA biopsy, but neither core biopsy or FNA biopsy can always differentiate phyllodes tumors from fibroadenoma. In cases with clinical suspicion for phyllodes tumor, excision of the lesion may be needed for definitive pathologic classification."
*修订了脚注“a”：“在某些情况下细针穿刺或空芯针活检可能无法区分纤维腺瘤与叶状囊肉瘤。对于叶状囊肉瘤的诊断空芯针活检的敏感性高于FNA活检，但是空芯针活检或细针穿刺活检都不能总是从纤维腺瘤中辨别出叶状囊肉瘤。在临床怀疑为叶状囊肉瘤的病例中，为了明确病理类型可能需要切除病变组织。”

PHYLL-2
* Added footnote "a" to "Tissue sampling"
*“组织标本”增加了脚注“a”

PREG-1
* Changed: Pregnant patient with confirmed breast cancer diagnosis (core biopsy preferred) To: Pregnant patient with confirmed breast cancer diagnosis by FNA or core biopsy; No distant metastases on staging.
*确认为乳腺癌诊断（推荐芯针活检）的妊娠患者更改为：FNA或芯针活检确诊为乳腺癌的妊娠患者；分期时无远处转移。