Die chirurgische Axilladissektion

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

Literatur

• 1 Adair F, Berg J, Joubert L, Robbins G F. Long-term follow-up of breast cancer patients: the 30-year report.  Cancer. 1974;  33 1145-1150
• 2 Adler L P, Faulhaber P F, Schnur K C, Al Kasi N L, Shenk R R. Axillary lymph node metastases: screening with [F-18]2-deoxy-2-fluoro-D-glucose (FDG) PET.  Radiology. 1997;  203 323-327
• 3 Albertini J J, Lyman G H, Cox C, Yeatman T, Balducci L, Ku N, Shivers S, Berman C, Wells K, Rapaport D, Shons A, Horton J, Greenberg H, Nicosia S, Clark R, Cantor A, Reintgen D S. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer.  JAMA. 1996;  276 1818-1822
• 4 Barth A, Craig P H, Silverstein M J. Predictors of axillary lymph node metastases in patients with T1 breast carcinoma.  Cancer. 1997;  79 1918-1922
• 5 Berg J W. The significance of axillary node levels in the study of breast carcinoma.  Cancer. 1955;  8 776-778
• 6 Bohler F K, Eiter H, Rhomberg W. Is axillary dissection in clinically lymph node-negative breast carcinoma further indicated.  Strahlenther Onkol. 1998;  174 605-612
• 7 Borup Christensen S, Lundgren E. Sequelae of axillary dissection vs. axillary sampling with or without irradiation for breast cancer. A randomized trial.  Acta Chir Scand. 1989;  155 515-519
• 8 Budd D C, Cochran R C, Sturtz D L, Fouty W J. Surgical morbidity after mastectomy operations.  Am J Surg. 1978;  135 218-220
• 9 Carter C L, Allen C, Henson D E. Relation of tumor size, lymph node status, and survival in 24 740 breast cancer cases.  Cancer. 1989;  63 181-187
• 10 Danforth D N, Findlay P A, McDonald H D, Lippman M E, Reichert C M, d'Angelo T, Gorrell C R, Gerber N L, Lichter A S, Rosenberg S A. Complete axillary lymph node dissection for stage I-II carcinoma of the breast.  J Clin Oncol. 1986;  4 655-662
• 11 de Freitas R, Costa M V, Schneider S V, Nicolau M A, Marussi E. Accuracy of ultrasound and clinical examination in the diagnosis of axillary lymph node metastases in breast cancer.  Eur J Surg Oncol. 1991;  17 240-244
• 12 Dessureault S, Koven I, Reilly R M, Couture J, Schmocker B, Damani M, Kirsh J, Ichise M, Sidlofsky S, McEwan A JB, Boniface G, Stern H, Gallinger S. Pre-operative assessment of axillary lymph node status in patients with breast adenocarcinoma using intravenous ^99mtechnetium mAb-170H.82 (TruScint® AD™).  Breast Cancer Res Treat. 1997;  45 29-37
• 13 Fisher B, Redmond C, Fisher E R, Bauer M, Wolmark N, Wickerham D L, Deutsch M, Montague E, Margolese R, Foster R. Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation.  N Engl J Med. 1985;  312 674-681
• 14 Fisher B, Wolmark N, Bauer M, Redmond C, Gebhardt M. The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histologic nodal status in carcinoma of the breast.  Surg Gynecol Obstet. 1981;  152 765-772
• 15 Gaglia P, Bussone R, Caldarola B, Lai M, Jayme A, Caldarola L. The correlation between the spread of metastases by level in the axillary nodes and disease-free survival in breast cancer. A multifactorial analysis.  Eur J Cancer Clin Oncol. 1987;  23 849-854
• 16 Giuliano A E, Kirgan D M, Guenther J M, Morton D L. Lymphatic mapping and sentinel lymphadenectomy for breast cancer.  Ann Surg. 1994;  220 391-401
• 17 Harder F, Zuber M, Kocher T, Torhorst J. Endoscopic surgery to the axilla - a substitute for conventional axillary clearance.  Recent Results Cancer Res. 1998;  152 180-189
• 18 Hoe A L, Iven D, Royle G T, Taylor I. Incidence of arm swelling following axillary clearance for breast cancer.  Br J Surg. 1992;  79 261-262
• 19 Hoh C K, Schiepers C. 18-FDG imaging in breast cancer.  Sem Nucl Med. 1999;  29 49-56
• 20 Kissin M W, Thompson E M, Price A B, Slavin G, Kark A E. The inadequacy of axillary sampling in breast cancer.  Lancet. 1982;  I (8283) 1210-1212
• 21 Lloyd L R, Waits R K, Schroder D, Hawasli A. Axillary dissection for breast carcinoma. The myth of skip metastasis.  Am Surg. 1989;  55 381-384
• 22 Lohe K J, Strigl R. Operative Behandlung des Karzinoms der Brust.  In: Zander J, Graeff H (Hrsg): Kirschnersche allgemeine und spezielle Operationslehre. Gynäkologische Operationen. 3. Aufl, Springer, Berlin, Heidelberg 1991; S 577-596
• 23 Mackarem G, Barbarisi L, Hughes K. The role of axillary dissection in early stage breast cancer.  Cancer Invest. 1992;  10 461-470
• 24 March D E, Wechsler R J, Kurtz A B, Rosenberg A L, Needleman L. CT-pathologic correlation of axillary lymph nodes in breast carcinoma.  J Comput Assist Tomogr. 1991;  15 440-444
• 25 Noguchi M, Katev N, Miyazaki I. Diagnosis of axillary lymph node metastases in patients with breast cancer.  Breast Cancer Res Treat. 1996;  40 283-293
• 26 Nwariaku F E, Euhus D M, Beitsch P D, Clifford E, Erdman W, Mathews D, Albores-Saavedra J, Leitch M A, Peters G N. Sentinel lymph node biopsy, an alternative to elective axillary dissection for breast cancer.  Am J Surg. 1998;  176 529-531
• 27 Pendas S, Dauway E, Cox C E, Giuliano R, Schreiber R H, Reintgen D S. Sentinel node biopsy and cytokeratin staining for the accurate staging of 478 breast cancer patients.  Am Surg. 1999;  65 500-505
• 28 Petrek J A, Blackwood M M. Axillary dissection: current practice and technique.  Curr Probl Surg. 1995;  32 257-323
• 29 Pezner R D, Patterson M P, Hill L R, Lipsett J A, Desai K, Vora N, Wong J Y, Luk K H. Arm lymphedema in patients treated conservatively for breast cancer: relationship to patient age and axillary node dissection technique.  Int J Radiat Oncol Biol Phys. 1986;  12 2079-2083
• 30 Recht A, Houlihan M J. Axillary lymph nodes and breast cancer: a review.  Cancer. 1995;  76 1491-1512
• 31 Robinson D S, Senofsky G M, Ketcham A S. Role and extent of lymphadenectomy for early breast cancer.  Semin Surg Oncol. 1992;  8 78-82
• 32 Rose C M, Botnick L E, Weinstein M, Harris J R, Koufman C, Silen W, Hellman S. Axillary sampling in the definitive treatment of breast cancer by radiation therapy and lumpectomy.  Int J Radiat Oncol Biol Phys. 1983;  9 339-344
• 33 Schildberg F W, Lohe F. Basic principles and value of lymphadenectomy in breast carcinoma.  Chirurg. 1996;  67 771-778
• 34 Shoup M, Malinzak L, Weisenberger J, Aranha G V. Predictors of axillary lymph node metastasis in T1 breast carcinoma.  Am Surg. 1999;  65 748-752
• 35 Smith I C, Ogston K N, Whitford P, Smith F W, Sharp P, Norton M, Miller I D, Ah See A K, Heys S D, Jibril J A, Eremin O. Staging of the axilla in breast cancer: accurate in vivo assessment using positron emission tomography with 2-(fluorine-18)-fluoro-2-deoxy-D-glucose.  Ann Surg. 1998;  228 220-227
• 36 Veronesi U, Cascinelli N, Greco M, Bufalino R, Morabito A, Galluzzo D, Conti R, De Lellis R, Delle Donne V, Piotti P. Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes.  Ann Surg. 1985;  202 702-707
• 37 Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, Gallus G, Greco M, Luini A, Marubini E, Muscolino G, Rilke F, Salvadori B, Zecchini A, Zucali R. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast.  N Engl J Med. 1981;  305 6-11
• 38 Werner R S, McCormick B, Petrek J, Cox L, Cirrincione C, Gray J R, Yahalom J. Arm edema in conservatively managed breast cancer: obesity is a major predictive factor.  Radiology. 1991;  180 177-184
• 39 Wilking N, Rutqvist L E, Carstensen J, Mattsson A, Skoog L.. Stockholm Breast Cancer Study Group . Prognostic significance of axillary nodal status in primary breast cancer in relation to the number of resected nodes.  Acta Oncol. 1992;  31 29-35
• 40 Wilson R E, Donegan W L, Mettlin C, Natarajan N, Smart C R, Murphy G P. The 1982 national survey of carcinoma of the breast in the United States by the American College of Surgeons.  Surg Gynecol Obstet. 1984;  159 309-318
• 41 Woodward A H, Ivins J C, Soule E H. Lymphangiosarcoma arising in chronic lymphedematous extremities.  Cancer. 1972;  30 562-572