Zusammenfassung
Das Mammakarzinom gilt als systemische Erkrankung mit für den Krankheitsverlauf bedeutsamer
lokoregionaler Komponente. Während es für die brusterhaltende Therapie (BET) beim
primären Mammakarzinom allgemein akzeptierten Leitlinien für das operative und strahlentherapeutische
Vorgehen gibt, werden Rezidive nach BET unterschiedlich behandelt. Der Hauptgrund
für das unterschiedliche Vorgehen ist das Fehlen großer, randomisierter Studien zur
Operation, erneuter Bestrahlung und systemischer Therapie. Lokalrezidive treten in
5-15 % bzw. 20-25 % der Fälle 5 bzw. 10 Jahre nach einer BET auf und sind häufiger
bei jüngeren Patientinnen, wenn eine extensive intraduktale Komponente vorhanden ist,
bei positiven Tumorabsetzungsrändern, axillären Lymphknotenmetastasen, negativen Steroidhormon-Rezeptoren
und bei Tumoren mit hoher proliferativer Aktivität. Fernmetastasen nach Lokalrezidiven
treten häufiger auf, wenn die Zeit zwischen Primärtherapie (BET) und Lokalrezidiv
kürzer ist. Die Diagnose eines Lokalrezidivs nach BET wird wie beim primären Mammakarzinom
klinisch, mammografisch und sonographisch gestellt, wobei hier die Kernspintomographie
eine sinnvolle Ergänzung darstellt. Die Standardoperation eines Lokalrezidivs ist
die einfache Mastektomie, wenn eine Tumorektomie nicht durch eine erneute Bestrahlung
ergänzt werden kann. Eine Bestrahlung der Brust nach Exzision eines Lokalrezidives
kann im Einzelfall durchgeführt werden, wobei es sich aber stets um eine individualisierte
Entscheidung unter Berücksichtigung zahlreicher Faktoren handelt. Die systemische
Therapie nach einem Lokalrezdiv wird ebenfalls individuell indiziert. Studien zur
Chemotherapie nach einem Lokalrezidiv fehlen, in Bezug auf antihormonelle Therapie
gibt es lediglich Hinweise, dass sie sinnvoll sein könnte. Die Durchführung von Therapiestudien
bei Patientinnen mit Lokalrezidiven nach BET ist eine der wichtigen Aufgaben bei der
Behandlung des Mammakarzinoms insgesamt.
Abstract
In spite of the fact that breast cancer is a systemic disease, local control plays
an important role in its management. While surgical, radiotherapeutic and systemic
therapy of primary breast cancer are performed according to widely accepted guidelines,
the management of ispilateral breast tumor relapse (IBTR) is still a matter of individualised
concepts because of the lack of randomised studies. IBTR represents a significant
medical problem, since the recurrence rate is 5-15 % after 5 years and 20-25 % after
10 years. Incidence is higher in younger patients, in tumors with an extensive intraductal
component, positive tumor margins, axillary lymph node metastases, negative steroid
hormone receptors and high proliferative activity. Distant metastases after IBTR occur
more often if the interval between primary diagnosis and IBTR is short (e. g. less
than 4 years). Diagnosis of IBTR include breast palpation, mammography and breast
ultrasound. In addition breast MRI can be used to further differentiate between benign
and malignant lesions after breast conservation. Standard therapy in this setting
remains mastectomy. Breast-conserving surgery may be considered in the context of
clinical trials for patients with certain favorable features. Breast irradiation after
secondary breast-conservation can be carried out in some cases. Some local relapses
after breast-conserving surgery have a poorer prognosis, and the addition of adjuvant
systemic therapy should be considered in addition to mastectomy. The heterogenous
nature of locoregional relapses has made it difficult to conduct prospective randomized
clinical trials. However, many retrospective data exist, making it possible to recommend
rational treatment approaches for these patients.
Schlüsselwörter
Mammakarzinom - Brusterhaltung - Lokalrezidiv - Diagnose - Therapie
Key words
Breast cancer - ipsilateral breast tumor recurrence - diagnosis - therapy
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PD Dr. Dr. Serban D. Costa, Ärztlicher Direktor
Klinik Bad Trissl · Fachklinik für Onkologie
Bad-Trissl-Straße 73
83080 Oberaudorf
eMail: s.costa@klinik-bad-trissl.de
