Ist eine Operation der Brust bei Komplettremission nach neoadjuvanter Chemotherapie des Mammakarzinoms notwendig?

Zusammenfassung

Die Wahrscheinlichkeit einer pathologischen Komplettremission (pCR) bei Brustkrebs nach neoadjuvanter Chemotherapie (NACT) nimmt zu; vor allem in den Subgruppen der tripel-negativen und HER-2-positiven Tumoren. Daher stellt sich die Frage, ob bei einer Komplettremission nach NACT eine operative Therapie der Brust notwendig ist, und ob es einen Vorteil für das onkologische Behandlungsergebnis hat, wenn kein Tumor mehr nachgewiesen werden kann. Ein Verzicht auf die Operation und gegebenenfalls auch auf die Radiotherapie ist jedoch nur auf der Basis einer verlässlichen pCR-Diagnose ohne Operation denkbar. Bildgebende Verfahren erreichen derzeit nicht die nötige Sensitivität und Spezifität, um die Diagnose einer pathologischen Komplettremission sicher zu stellen. Daher sind weitere Studien nötig, um herauszufinden, welche Methode die bestmögliche Evaluation des Tumoransprechens auf NACT erlaubt. Erste vielversprechende Ergebnisse zeigen sich in Studien zu bildgebungsgesteuerten, minimalinvasiven Biopsien nach NACT. Diese evaluieren die Möglichkeit einer pCR-Diagnose vor der Operation und könnten die Grundlage für weitere Studien zu einem möglichen Verzicht auf eine Operation in diesem ausgewählten Kollektiv sein.

Schlüsselwörter

neoadjuvante Chemotherapie - minimalinvasive Biopsie - Brustkrebs - Diagnose - Operation/Chirurgie

• References/Literatur

• 1 Ellis P, Smith I, Ashley S. et al. Clinical prognostic and predictive factors for primary chemotherapy in operable breast cancer. J Clin Oncol 1998; 16: 107-114
• 2 Ring A, Webb A, Ashley S. et al. Is surgery necessary after complete clinical remission following neoadjuvant chemotherapy for early breast cancer?. J Clin Oncol 2003; 21: 4540-4545
• 3 Heil J, Schaefgen B, Sinn P. et al. Can a pathological complete response of breast cancer after neoadjuvant chemotherapy be diagnosed by minimal invasive biopsy?. Eur J Cancer 2016; 69: 142-150
• 4 van la Parra RF, Kuerer HM. Selective elimination of breast cancer surgery in exceptional responders: historical perspective and current trials. Breast Cancer Res 2016; 18: 28
• 5 De Lena M, Varini M, Zucali R. et al. Multimodal treatment for locally advanced breast cancer. Result of chemotherapy-radiotherapy versus chemotherapy-surgery. Cancer Clin Trials 1981; 4: 229-236
• 6 Perloff M, Lesnick GJ, Korzun A. et al. Combination chemotherapy with mastectomy or radiotherapy for stage III breast carcinoma: a Cancer and Leukemia Group B study. J Clin Oncol 1988; 6: 261-269
• 7 Scholl SM, Pierga JY, Asselain B. et al. Breast tumour response to primary chemotherapy predicts local and distant control as well as survival. Eur J Cancer 1995; 31A: 1969-1975
• 8 Touboul E, Buffat L, Lefranc JP. et al. Possibility of conservative local treatment after combined chemotherapy and preoperative irradiation for locally advanced noninflammatory breast cancer. Int J Radiat Oncol Biol Phys 1996; 34: 1019-1028
• 9 Mauriac L, MacGrogan G, Avril A. et al. Neoadjuvant chemotherapy for operable breast carcinoma larger than 3 cm: a unicentre randomized trial with a 124-month median follow-up. Institut Bergonie Bordeaux Groupe Sein (IBBGS). Ann Oncol 1999; 10: 47-52
• 10 Daveau C, Savignoni A, Abrous-Anane S. et al. Is radiotherapy an option for early breast cancers with complete clinical response after neoadjuvant chemotherapy?. Int J Radiat Oncol Biol Phys 2011; 79: 1452-1459
• 11 Chagpar AB, Middleton LP, Sahin AA. et al. Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy. Ann Surg 2006; 243: 257-264
• 12 Shin HJ, Kim HH, Ahn JH. et al. Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy. Br J Radiol 2011; 84: 612-620
• 13 Marinovich ML, Houssami N, Macaskill P. et al. Meta-analysis of magnetic resonance imaging in detecting residual breast cancer after neoadjuvant therapy. J Natl Cancer Inst 2013; 105: 321-333
• 14 Marinovich ML, Houssami N, Macaskill P. et al. Accuracy of ultrasound for predicting pathologic response during neoadjuvant therapy for breast cancer. Int J Cancer 2015; 136: 2730-2737
• 15 Eisenhauer EA, Therasse P, Bogaerts J. et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 2009; 45: 228-247
• 16 De Los Santos JF, Cantor A, Amos KD. et al. Magnetic resonance imaging as a predictor of pathologic response in patients treated with neoadjuvant systemic treatment for operable breast cancer. Translational Breast Cancer Research Consortium trial 017. Cancer 2013; 119: 1776-1783
• 17 Schaefgen B, Mati M, Sinn HP. et al. Can routine imaging after neoadjuvant chemotherapy in breast cancer predict pathologic complete response?. Ann Surg Oncol 2016; 23: 789-795
• 18 Schott AF, Roubidoux MA, Helvie MA. et al. Clinical and radiologic assessments to predict breast cancer pathologic complete response to neoadjuvant chemotherapy. Breast Cancer Res Treat 2005; 92: 231-238
• 19 Peintinger F, Kuerer HM, Anderson K. et al. Accuracy of the combination of mammography and sonography in predicting tumor response in breast cancer patients after neoadjuvant chemotherapy. Ann Surg Oncol 2006; 13: 1443-1449
• 20 Chen JH, Feig B, Agrawal G. et al. MRI evaluation of pathologically complete response and residual tumors in breast cancer after neoadjuvant chemotherapy. Cancer 2008; 112: 17-26
• 21 Bhattacharyya M, Ryan D, Carpenter R. et al. Using MRI to plan breast-conserving surgery following neoadjuvant chemotherapy for early breast cancer. Br J Cancer 2008; 98: 289-293
• 22 Keune JD, Jeffe DB, Schootman M. et al. Accuracy of ultrasonography and mammography in predicting pathologic response after neoadjuvant chemotherapy for breast cancer. Am J Surg 2010; 199: 477-484
• 23 Croshaw R, Shapiro-Wright H, Svensson E. et al. Accuracy of clinical examination, digital mammogram, ultrasound, and MRI in determining postneoadjuvant pathologic tumor response in operable breast cancer patients. Ann Surg Oncol 2011; 18: 3160-3163
• 24 Adrada BE, Huo L, Lane DL. et al. Histopathologic correlation of residual mammographic microcalcifications after neoadjuvant chemotherapy for locally advanced breast cancer. Ann Surg Oncol 2015; 22: 1111-1117
• 25 Matsuo K, Fukutomi T, Watanabe T. et al. Concordance in pathological response to neoadjuvant chemotherapy between invasive and noninvasive components of primary breast carcinomas. Breast Cancer 2002; 9: 75-81
• 26 Vinnicombe SJ, MacVicar AD, Guy RL. et al. Primary breast cancer: mammographic changes after neoadjuvant chemotherapy, with pathologic correlation. Radiology 1996; 198: 333-340
• 27 Fadul D, Rapelyea J, Schwartz AM. et al. Development of malignant breast microcalcifications after neoadjuvant chemotherapy in advanced breast cancer. Breast J 2004; 10: 141-145
• 28 Bossuyt V, Provenzano E, Symmans WF. et al. Recommendations for standardized pathological characterization of residual disease for neoadjuvant clinical trials of breast cancer by the BIG-NABCG collaboration. Ann Oncol 2015; 26: 1280-1291
• 29 Loo CE, Straver ME, Rodenhuis S. et al. Magnetic resonance imaging response monitoring of breast cancer during neoadjuvant chemotherapy: relevance of breast cancer subtype. J Clin Oncol 2011; 29: 660-666
• 30 Wang Y, Zhang C, Liu J. et al. Is 18F-FDG PET accurate to predict neoadjuvant therapy response in breast cancer? A meta-analysis. Breast Cancer Res Treat 2012; 131: 357-369
• 31 Clouth B, Chandrasekharan S, Inwang R. et al. The surgical management of patients who achieve a complete pathological response after primary chemotherapy for locally advanced breast cancer. Eur J Surg Oncol 2007; 33: 961-966
• 32 Rea D, Tomlins A, Francis A. Time to stop operating on breast cancer patients with pathological complete response?. Eur J Surg Oncol 2013; 39: 924-930
• 33 Kuerer HM, Rauch GM, Krishnamurthy S. et al. A clinical feasibility trial for identification of exceptional responders in whom breast cancer surgery can be eliminated following neoadjuvant systemic therapy. Ann Surg 2017;
• 34 Heil J, Kummel S, Schaefgen B. et al. Diagnosis of pathological complete response to neoadjuvant chemotherapy in breast cancer by minimal invasive biopsy techniques. Br J Cancer 2015; 113: 1565-1570
• 35 Kuerer HM, Vrancken Peeters M, Rea DW. et al. Nonoperative management for invasive breast cancer after neoadjuvant systemic therapy: conceptual basis and fundamental international feasibility clinical trials. Ann Surg Oncol 2017;