Relevance and Methods of Interventional Breast Sonography in Preoperative Axillary Lymph Node Staging

Zusammenfassung

Die Reduktion der therapieinduzierten Morbidität ist ein wichtiges Ziel für die Verbesserung der Behandlungsqualität beim Mammakarzinom. Die Einführung der Sentinellymphknotenbiopsie (SLNB) hat dazu beigetragen, die operationsbedingte Morbidität im Schulter-Arm-Bereich erheblich zu reduzieren. Allerdings gilt der klinisch positive Nodalstatus nach wie vor als eine Kontraindikation für die SLNB. Die aktuelle Datenlage macht aber deutlich, dass die klinische und auch sonografische Dignitätseinschätzung zur Evaluation nicht ausreichend ist, um den Nodalstatus mit der notwendigen Genauigkeit zu erfassen. Die alleinige klinische und/oder bildgebende Beurteilung des axillären Lymphknotenstatus würde zu einer Übertherapie von 40 % der Patientinnen führen. Um die Rate an unnötigen Axilladissektionen (AD) zu reduzieren, ist eine prätherapeutische interventionelle Abklärung notwendig, die genauere Information über den feingeweblichen Zustand des Lymphknotens liefert. Im Vergleich der aktuell verfügbaren Methoden erweist sich die Feinnadelaspiration (FNA) in Bezug auf den Kosten-, Zeitaufwand, Praktikabilität, Komplikationsrate als das beste Abklärungsverfahren, ist jedoch in Bezug auf die Sensitivität der sonografisch gesteuerten Stanzbiopsie unterlegen. Ein negatives Ergebnis der FNA erfordert daher eine weitere Abklärung, die gegebenenfalls durch die CNB vorgenommen werden kann. Bei einer Spezifität von nahezu 100 % kann bei einem positiven Ergebnis der FNA die Indikation zur kompletten Axilladissektion gestellt werden.

Abstract

Reduction of therapy-induced morbidity is an important goal for the improvement of the quality of breast cancer treatment. The introduction of sentinel lymph node biopsy (SLNB) significantly contributed to the reduction of surgery-induced morbidity in the shoulder-arm region. However, a clinically positive nodal status is still considered a contra-indication for SLNB. The current data constellation clearly shows that the clinical and also the sonographic malignancy assessment is insufficient for the accurate identification of the nodal status. A merely clinical and/or image-based appraisal of the axillary lymph node status would lead to overtreatment due to unnecessary axillary dissection in approximately 40 % of patients. In order to reduce the rate of unnecessary axillary dissection (AD), pretreatment interventional clarification is necessary to provide more detailed information about the histological condition of the lymph node. Comparing the currently available methods, fine needle aspiration (FNA) is the best in terms of cost and time requirement, practicability and complication rate. However, considering the sensitivity, it is inferior to ultrasound-guided core needle biopsy (CNB). Thus, a negative FNA outcome requires further clarification, which possibly can be performed with CNB. With a specificity of nearly 100 % and therefore a low rate of false positive cases for FNA, complete AD can be indicated by a positive FNA result. In the context of the interventional procedure, it must be stressed that FNA requires a high level of expertise on the part of both the examiner and the cytologist. The prerequisite for optimal interventional diagnostics of lymph nodes is an adequate sonographic assessment on the basis of standardized sonomorphological criteria.

Key words

axillary ultrasound - fine needle aspiration - core needle biopsy - axilary dissection - sentinel lymph node biopsy

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