Surgical axillary lymph node dissection.Still standard procedure or obsolete method?
Summary
Axillary lymph node status remains the single most important prognostic parameter
and has crucial therapeutic implications in patients with breast carcinoma. Surgical
dissection of the axilla is commonly regarded as the standard procedure of axillary
staging, its sensitivity and specificity being 99 % and 100 %, respectively. Apart
from giving reliable information on the individual prognosis axillary dissection also
contributes to efficient local tumor control in the axilla, as it reduces the risk
of local recurrence to less than 1.4 % if more than 10 lymph nodes are removed. Alternative,
less or non-invasive axillary staging methods have either not yet been sufficiently
standardized (immunoscintigraphy, PET-scan, prediction of axillary lymph node status
by means of individual risk factors) or are associated with a considerable risk of
false-negative staging (up to 50 % of patients with positive axillary lymph nodes
are not detected by palpation alone, ultrasonography or CT-scan). The basic principles
of axillary sampling and axilloscopic dissection are questionable because the number
of lymph nodes removed during these procedures is commonly less than 10. With its
sensitivity/specificity being comparable to that of standard axillary dissection sentinel
lymph node biopsy represents a highly promising approach which will in the future
potentially lead to significant optimization of the clinical management of patients
with breast cancer, especially those diagnosed in early stages (T1 a, T1 b and T1
c).
Zusammenfassung
Nach wie vor ist der axilläre Lymphknotenstatus entscheidender prognostischer Parameter
beim invasiven Mammakarzinom sowie weitgehend therapiebestimmend. Anerkanntes Standardverfahren
zur Evaluierung des axillären Lymphknotenstatus ist die chirurgische Axilladissektion,
deren Sensitivität sowie Spezifität bei 99 % bzw. 100 % liegen. Neben verläßlicher
Prognosestellung leistet das Verfahren einen wesentlichen Beitrag zur effizienten
lokalen Tumorkontrolle in der Axilla, da es die Wahrscheinlichkeit des axillären Tumorrezidivs
auf weniger als 1,4 % zu reduzieren vermag, falls mehr als 10 Lymphknoten entnommen
werden. Alternative, weniger bzw. nicht-invasive und somit belastungsärmere axilläre
Stagingverfahren sind entweder noch unzureichend standardisiert (Immunszintigraphie,
PET-Scan, Expertensysteme) oder mit einem nicht unbeträchtlichen Risiko falsch-negativer
Stagingergebnisse verbunden (bis zu 50 % der Patientinnen mit positiven axillären
Lymphknoten werden durch alleinige klinische Untersuchung, Ultraschalluntersuchung
der Axilla oder CT nicht erkannt). Andere Verfahren wie etwa das axilläre Sampling
oder die endoskopische Axilladissektion erscheinen aufgrund eines zweifelhaften Grundprinzips
(Entnahme von meist weit weniger als 10 Lymphknoten) ebenso fragwürdig wie unverläßlich
und kommen nicht als sinnvolle Alternativen zur Standarddissektion in Betracht. Derzeit
vielversprechendstes Alternativverfahren ist die Sentinel-Lymphknotendiagnostik, die
insbesondere bei Patientinnen im Frühstadium der Erkrankung (T1 a, T1 b, ev. T1 c)
aufgrund einer der Standarddissektion vergleichbaren Sensitivität/Spezifität in Zukunft
zu einer entscheidenden Optimierung des klinischen Mammakarzinom-Managements beitragen
könnte.
Key words
Axilla - lymph node dissection - breast cancer - sentinel lymph node - alternative
methods
Schlüsselwörter
Axilla - Lymphknotendissektion - Mammakarzinom - Sentinel-Lymphknoten - Alternative
Methoden
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