Wächterlymphknotendetektion und -Biopsie beim Mammakarzinom - Fakten und unbeantwortete Fragen

Zusammenfassung

Das Konzept der Wächterlymphknoten-Biopsie (Sentinel-Lymph-Node-Biopsie) bei Brustkrebspatientinnen entwickelt sich schnell zu einem diagnostischen Standard [1]. Die rasche Akzeptanz dieser Methode im klinischen Alltag ist das Ergebnis vieler Faktoren: Sicherheit, Verminderung der Morbidität und Verminderung der Lymphknotenanzahl, die dem Pathologen zugesandt werden mit einer dann mehr fokussierten und sensitiveren histopathologischen Auswertung. Die Wächterlymphknoten sind diejenigen Lymphknoten, die im Falle einer vom Tumor ausgehenden Metastasierung am wahrscheinlichsten Tumorzellen enthalten. Aufgrund dessen kann die histopathologische Auswertung dieser Wächterlymphknoten sehr genau andere Metastasen in der gleichen Lymphabflussregion vorhersagen und wesentliche Beiträge zur lokalen und systemischen Therapieentscheidung liefern. Die SLN-Biopsie beeinhaltet die Markierung sowie nachfolgende Resektion der Sentinel Lymph Node (SLN), die die Region des Primärtumors drainieren. Diese Lymphknoten können mittels Sondentechnik und Szintigraphie nach radioaktiver Markierung und/oder durch Visualisierung mit Patentblau-Farbe nachgewiesen werden. Die axilläre Lymphknotendissektion (ALND) und die damit verbundene hohe Morbidität kann bei Patientinnen mit einem negativen Befund der Wächterlymphknoten vermieden werden. Trotz des Erfolges und der Akzeptanz des SLN-Konzeptes bleiben einige Kontroversen und Fragen unbeantwortet. In dieser Übersicht werden einige dieser relevanten klinischen Aussagen diskutiert.

Abstract

The concept of sentinel lymph node (SLN) biopsy in breast cancer patients is rapidly becoming the standard of care [1]. The fast assent of this technique in clinical practise is the result of multiple factors, including accuracy of the technique, decreased morbidity, and supplying the pathologist with only few nodes which allows a more focused and sensitive histopathologic evaluation. The sentinel nodes are those most likely to contain tumour cells that have spread from the tumour. Histopathological evaluation of these nodes therefore can be an accurate predictor for metastases in the respective lymph node basin and can guide regional and systemic treatment. The SLN-biopsy concerns the identification and subsequent resection of the initial lymph nodes (SLN) which are draining the primary tumour. These nodes can be identified by radioguided lymphatic mapping and/or by visualisation of the nodes with vital blue dyes. Axillary lymph node dissection (ALND) and its morbidity can be avoided in patients with negative SLN. Despite the success and acceptance of lymphatic mapping, some controversies and questions remain unanswered. In this review, some of the most relevant clinical issues will be discussed.

Schlüsselwörter

Mammakarzinom - Wächterlymphknoten-Biopsie

Key words

breast carcinoma - sentinel lymph node biopsy

Literatur

• 1 Cody H S. Clinical aspects of sentinel node biopsy.  Breast Cancer Res. 2001;  3 104-108
• 2 Linehan D C, Hill A D, Akhurst T. et al . Intradermal radiocolloid and intraparenchymal blue dye injection optimize sentinel node identification in breast cancer patients.  Ann Surg Oncol. 1999;  6 450-454
• 3 McMasters K M, Wong S L, Martin R C. et al . Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multiinstitutional study.  Ann Surg. 2001;  233 676-687
• 4 Wong S L, Edwards M J, Chao C. et al . Sentinel lymph node biopsy for breast cancer: impact of the number of sentinel nodes removed on the false-negative rate.  J Am Coll Surg. 2001;  192 684-689
• 5 Derossis A M, Fey J, Yeung H. et al . A trend analysis of the relative value of blue dye and isotope localization in 2 000 consecutive cases of sentinel node biopsy for breast cancer.  J Am Coll Surg. 2001;  193 473-478
• 6 Tanis P J, Nieweg O E, Valdes Olmos R A, Kroon B B. Anatomy and physiology of lymphatic drainage of the breast from the perspective of sentinel node biopsy.  J Am Coll Surg. 2001;  192 399-409
• 7 Borgstein P J, Meijer S, Pijpers R J, Diest P J van. Functional lymphatic anatomy for sentinel node biopsy in breast cancer: echoes from the past and the periareolar blue method.  Ann Surg. 2000;  232 81-89
• 8 Borgstein P J, Meijer S, Pijpers R. Intradermal blue dye to identify sentinel lymph-node in breast cancer.  Lancet. 1997;  349 1668-1669
• 9 Mariani G, Moresco L, Viale G. et al . Radioguided sentinel lymph node biopsy in breast cancer surgery.  J Nucl Med. 2001;  42 1198-1215
• 10 Cody H S, Fey J, Akhurst T. et al . Complementarity of blue dye and isotope in sentinel node localization for breast cancer: univariate and multivariate analysis of 966 procedures.  Ann Surg Oncol. 2001;  8 13-19
• 11 Veronesi U, Paganelli G, Galimberti V. et al . Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes.  Lancet. 1997;  349 1864-1867
• 12 Sandrucci S, Mussa A. Sentinel lymph node biopsy and axillary staging of T1-T2 N0 breast cancer: a multicenter study.  Semin Surg Oncol. 1998;  15 278-283
• 13 Jansen L, Doting M H, Rutgers E J. et al . Clinical relevance of sentinel lymph nodes outside the axilla in patients with breast cancer.  Br J Surg. 2000;  87 920-925
• 14 Cserni G, Pap S J. Internal mammary lymph nodes and sentinel node biopsy in breast cancer.  Surg Oncol. 2001;  10 25-33
• 15 der Ent F W van, Kengen R A, der Pol H A van. et al . Halsted revisited: internal mammary sentinel lymph node biopsy in breast cancer.  Ann Surg. 2001;  234 79-84
• 16 Klauber-DeMore N, Bevilacqua J L, Zee K J Van. et al . Comprehensive review of the management of internal mammary lymph node metastases in breast cancer.  J Am Coll Surg. 2001;  193 547-555
• 17 McMasters K M, Wong S L, Tuttle T M. et al . Preoperative lymphoscintigraphy for breast cancer does not improve the ability to identify axillary sentinel lymph nodes.  Ann Surg. 2000;  231 724-731
• 18 Burak W E, Walker M J, Yee L D. et al . Routine preoperative lymphoscintigraphy is not necessary prior to sentinel node biopsy for breast cancer.  Am J Surg. 1999;  177 445-449
• 19 Tanis P J, Nieweg O E, Merkus J W. et al . False negative sentinel node procedure established through palpation of the biopsy wound.  Eur J Surg Oncol. 2000;  26 714-715
• 20 Bass S S, Cox C E, Ku N N. et al . The role of sentinel lymph node biopsy in breast cancer.  J Am Coll Surg. 1999;  189 183-194
• 21 McMasters K M, Wong S L, Chao C. et al . Defining the optimal surgeon experience for breast cancer sentinel lymph node biopsy: a model for implementation of new surgical techniques.  Ann Surg. 2001;  234 292-299
• 22 Krag D, Weaver D, Ashikaga T. et al . The sentinel node in breast cancer - a multicenter validation study.  N Engl J Med. 1998;  339 941-946
• 23 Cox C E, Pendas S, Cox J M. et al . Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer.  Ann Surg. 1998;  227 645-651
• 24 Cantin J, Scarth H, Levine M, Hugi M. Clinical practice guidelines for the care and treatment of breast cancer: 13. Sentinel lymph node biopsy.  CMAJ. 2001;  165 166-173
• 25 Lucci A, Kelemen P R, Miller C. et al . National practice patterns of sentinel lymph node dissection for breast carcinoma.  J Am Coll Surg. 2001;  192 453-458
• 26 Schijven M, Rutten H, Roumen R. Implementation of the sentinel node biopsy: a survey among surgeons in the Netherlands.  Eur J Surg Oncol. 2000;  26 431-432
• 27 Fraile M, Rull M, Julian F J. et al . Sentinel node biopsy as a practical alternative to axillary lymph node dissection in breast cancer patients: an approach to its validity.  Ann Oncol. 2000;  11 701-705
• 28 Roy P, Bobin J Y, Esteve J. Methodological questions in sentinel lymph node analysis in breast cancer patients.  Ann Oncol. 2000;  11 1381-1385
• 29 Giuliano A E, Haigh P I, Brennan M B. et al . Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer.  J Clin Oncol. 2000;  18 2553-2559
• 30 Veronesi U, Galimberti V, Zurrida S. et al . Sentinel lymph node biopsy as an indicator for axillary dissection in early breast cancer.  Eur J Cancer. 2001;  37 454-458
• 31 Roumen R M, Kuijt G P, Liem I H, Beek M W van. Treatment of 100 patients with sentinel node-negative breast cancer without further axillary dissection.  Br J Surg. 2001;  88 1639-1643
• 32 Schwartz G F, Giuliano A E, Veronesi U. Proceedings of the Consensus Conference on the role of Sentinel Lymph Node Biopsy in Carcinoma of the Breast. April 19-22, 2001, Philadelphia, Pennsylvania
• 33 Olson J A, Fey J, Winawer J. et al . Sentinel lymphadenectomy accurately predicts nodal status in T2 breast cancer.  J Am Coll Surg. 2000;  191 593-599
• 34 Bedrosian I, Reynolds C, Mick R. et al . Accuracy of sentinel lymph node biopsy in patients with large primary breast tumors.  Cancer. 2000;  88 2540-2545
• 35 Nason K S, Anderson B O, Byrd D R. et al . Increased false negative sentinel node biopsy rates after preoperative chemotherapy for invasive breast carcinoma.  Cancer. 2000;  89 2187-2194
• 36 Pendas S, Dauway E, Giuliano R. et al . Sentinel node biopsy in ductal carcinoma in situ patients.  Ann Surg Oncol. 2000;  7 15-20
• 37 Klauber-DeMore N, Tan L K, Liberman L. et al . Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion?.  Ann Surg Oncol. 2000;  7 636-642
• 38 Lagios M D, Silverstein M J. Sentinel node biopsy for patients with DCIS: a dangerous and unwarranted direction.  Ann Surg Oncol. 2001;  8 275-277
• 39 Finck S C, Villela R, Young S. et al . An evaluation of micrometastasis in ductal carcinoma in situ (DCIS).  Breast Cancer Res Treat. 2001;  69 250
• 40 Fernandez A, Cortes M, Benito E. et al . Gamma probe sentinel node localization and biopsy in breast cancer patients treated with a neoadjuvant chemotherapy scheme.  Nucl Med Commun. 2001;  22 361-366
• 41 Haid A, Tausch C, Lang A. et al . Is sentinel lymph node biopsy reliable and indicated after preoperative chemotherapy in patients with breast carcinoma?.  Cancer. 2001;  92 1080-1084
• 42 Julian T B, Patel N, Dusi D. et al . Sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer.  Am J Surg. 2001;  182 407-410
• 43 Breslin T M, Cohen L, Sahin A. et al . Sentinel lymph node biopsy is accurate after neoadjuvant chemotherapy for breast cancer.  J Clin Oncol. 2000;  18 3480-3486
• 44 Kuerer H M, Sahin A A, Hunt K K. et al . Incidence and impact of documented eradication of breast cancer axillary lymph node metastases before surgery in patients treated with neoadjuvant chemotherapy.  Ann Surg. 1999;  230 72-78
• 45 Liberman L, Cody H S. Percutaneous biopsy and sentinel lymphadenectomy: minimally invasive diagnosis and treatment of nonpalpable breast cancer.  AJR Am J Roentgenol. 2001;  177 887-891
• 46 Haigh P I, Hansen N M, Qi K, Giuliano A E. Biopsy method and excision volume do not affect success rate of subsequent sentinel lymph node dissection in breast cancer.  Ann Surg Oncol. 2000;  7 21-27
• 47 Schrenk P, Wayand W. Sentinel-node biopsy in axillary lymph-node staging for patients with multicentric breast cancer.  Lancet. 2001;  357 122
• 48 Port E R, Fey J V, Cody H S, Borgen P I. Sentinel lymph node biopsy in patients with male breast carcinoma.  Cancer. 2001;  91 319-323
• 49 Tafra L, Lannin D R, Swanson M S. et al . Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye.  Ann Surg. 2001;  233 51-59
• 50 Dupont E L, Kuhn M A, McCann C. et al . The role of sentinel lymph node biopsy in women undergoing prophylactic mastectomy.  Am J Surg. 2000;  180 274-277