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Mammakarzinom

Stellenwert des axillaren Stagings

Breast cancer

Value of axillary staging

  • Gynäkologie aktuell
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Zusammenfassung

Der Stellenwert der Axilladissektion (ALD) im Rahmen der Primärtherapie des Mammakarzinoms wird zunehmend hinterfragt. Um Patientinnen mit negativem Nodalstatus zu identifizieren wurde die ALD im vergangenen Jahrzehnt durch die Sentinel-Lymphknotenexstirpation („sentinel lymph node biopsy“, SLNB) abgelöst. Bei positivem Sentinel-Lymphknoten (SLN) ist die ALD derzeit die einzige Methode, um Patientinnen mit hoch positivem Nodalstatus (pN2/3), die von einer intensivierten lokalen und systemischen Therapie profitieren, zu identifizieren. Mehrere Studien zeigten keinen Vorteil der ALD in Bezug auf krankheitsfreies und Gesamtüberleben. Neben methodischen Problemen zeigt sich in diesen Studien ein ungeplanter therapeutischer Überlappungseffekte der ALD mit der Strahlentherapie (Tangentialfeldbestrahlung nach BET), sodass diese Studien nicht die fehlende Notwendigkeit einer Therapie der Lymphabflussgebiete im Falle positiver Lymphknoten belegen können. Eine große randomisierten Studie und eine Metaanalyse zeigen die Notwendigkeit einer regionären Therapie bei positivem Nodalstatus. Der Verzicht auf eine ALD setzt daher eine definierte, zielgerichtete Alternativtherapie der Axilla voraus. Im Rahmen der Tangentialfeldbestrahlung der Brust erhält ein hoher Anteil an Patientinnen eine akzidentelle therapeutische Dosis (Level I und II). Da das Zielvolumen der Tangentialfeldbestrahlung ausschließlich auf den verbliebenen Brustdrüsenkörper ausgerichtet ist, unterliegt die Wahrscheinlichkeit für eine adäquate Therapie der Axilla damit der Form und Größe der verbliebenen Brust.

Abstract

The removal of axillary lymph nodes has been an important component of primary breast cancer surgery for more than a century. The clinical objective of lymph node surgery has, however, changed with the understanding of the biological behaviour of the disease and the modification of treatment strategies. Axillary lymph node dissection (ALD) was primarily regarded as a therapeutic procedure to remove all reachable tumour cells. ALD then changed to become a diagnostic tool when breast cancer was identified as a systemic disease and the lymph node status became the most important prognostic factor to determine systemic treatment decisions. For node-positive patients ALD remained the treatment of choice in order to ensure regional control. During the last decade the diagnostic role of ALD to identify node-positive patients was replaced by sentinel lymph node biopsy (SLNB), a targeted procedure that is associated with less morbidity compared to ALD. Recently the benefit of ALD has been questioned even for SLN-positive patients. However, ALD is still an important diagnostic tool for the cohort of node-positive patients. Women with pN2/3 disease derive benefit from a more intensive local and systemic treatment. Furthermore the data from a meta-analysis and a randomized trial indicate that patients with positive SLNs require regional treatment. Omission of SLNB requires new tools to define patients who derive a benefit from an intensified local and systemic treatment. Since local treatment is effective in node-positive patients, this treatment (radiotherapy vs surgery) must be clearly defined.

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  1. Klinikum Esslingen, Hirschlandstr. 97, 73730, Esslingen, Deutschland

    T. Kühn

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  1. T. Kühn
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Kühn, T. Mammakarzinom. Gynäkologe 44, 999–1004 (2011). https://doi.org/10.1007/s00129-011-2848-x

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