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Senologie - Zeitschrift für Mammadiagnostik und -therapie 2024; 21(03): 208-218
DOI: 10.1055/a-2256-4201
Übersicht

Die Sentinel-Lymphknoten-Biopsie beim Mammakarzinom – was haben wir in den letzten 20 Jahren gelernt?

Sentinel lymph node biopsy in breast cancer – what have we learned in the last 20 years?
Thorsten Kühn
1   Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Ulm, Deutschland (Ringgold ID: RIN27197)
2   Gynäkologische Onkologie, Die Filderklinik, Filderstadt-Bonlanden, Deutschland
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Zusammenfassung

Vor gut 20 Jahren wurde die Sentinel-Lymphknoten-Biopsie (SLNB) als Standardverfahren für das axilläre Staging beim invasiven Mammakarzinom eingeführt und ersetzte die über Jahrzehnte etablierte Axilladissektion (ALND), bei der alle Lymphknoten aus den Leveln 1 und 2 aus diagnostischer und/oder therapeutischer Indikation entfernt wurden. Dabei stellte die Implementierung der SLNB lediglich den ersten Schritt zu einer kontinuierlichen Deeskalation der Lymphknoten-Chirurgie dar. Diese Entwicklung begründete sich mit dem zunehmenden Ersatz prognostischer Faktoren durch prädiktive Marker für adjuvante Therapieentscheidungen, die Möglichkeit, das Tumorstadium durch eine vorgeschaltete Chemotherapie (NACT) herabzustufen sowie die Bestätigung älterer Studien, die bereits sehr frühzeitig den therapeutischen Benefit einer ALND in Zweifel gezogen haben. Bei Patientinnen, die eine primäre Operation erhalten, werden zunehmend Kollektive identifiziert, bei denen gar keine SLNB mehr durchgeführt werden muss. Auch die therapeutische ALND ist bei Frauen mit einem positiven SLN nur noch in Ausnahmefällen erforderlich. Die Einführung der SLNB nach einer NACT bei Patientinnen mit primär unauffälligen Lymphknoten erlaubte nicht nur die verlässliche Beurteilung der Tumorresponse, sondern auch eine Reduktion der ALND-Rate durch die Konversion des Nodalstatus bei vielen Patientinnen. Bei nodalpositiven Frauen, die unter Chemotherapie zu einem klinisch unauffälligen Lymphknotenstatus konvertieren, setzt sich zunehmend die Targeted Axillary Dissection als neuer operativer Standard durch.

Abstract

Twenty years ago, Sentinel Node Biopsy (SLNB) was introduced as a standard procedure for surgical staging of the axilla in invasive breast cancer and replaced full axilla lymph node dissection (ALND) with complete removal of all lymph nodes from level 1 and 2 which was performed over decades as surgical standard for diagnostic and/or therapeutic purposes. The implementation of SLNB was a first step in a continuous process to deescalate axillary surgery in recent years. This evolution was based on the replacement of prognostic factors by predictive markers for the decision making of adjuvant treatment, the option to downgrade the tumor stage by neoadjuvant chemotherapy (NACT) and the confirmation of early trials that doubted the therapeutic effect of ALND. In patients who undergo primary surgery increasing cohorts are identified in whom SLNB can be omitted at all. In addition, therapeutic ALND in SLN positive patients is only required in few patients. The introduction of SLNB after NACT in primarily unsuspicious nodes not only allowed the assessment of tumor response but also a reduction of the ALND rate for many patients – due to the conversion of the lymph node status. For node-positive patients, who convert under NACT from node-positive to node-negative, targeted axillary dissection is increasingly established as a surgical standard.

Schlüsselwörter

Brustkrebs - Operation - Lymphknoten - Lymph Nodes

Keywords

Breast Cancer - Surgery


Publication History

Article published online:
13 September 2024

© 2024. Thieme. All rights reserved.

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