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Der Gynäkologe

, Volume 51, Issue 9, pp 744–751 | Cite as

Axilläre Operationen im Wandel der Zeit

  • Thorsten Kühn
Leitthema
  • 104 Downloads

Zusammenfassung

Beim Mammakarzinom hat sich das operative Vorgehen im Bereich der axillären Lymphknoten in den vergangenen 20 Jahren dramatisch verändert. Wurden die Lymphknoten früher mit der Zielsetzung reseziert, potenziell tumorbefallenes Gewebe zu entfernen, entwickelte sich später der Lymphknotenstatus zu einem Prognoseparameter, an dem die adjuvante Therapie orientiert wurde. Die Lymphknotenentfernung bei klinisch unauffälligen Lymphknoten entwickelte sich daraufhin zu einem diagnostischen Eingriff. Die Axilladissektion (AD) war jahrzehntelang die einzige Option, um den Nodalstatus zu bestimmen. Die Sentinellymphknotenbiopsie (SLNB) ermöglichte es seit den späten 1990er-Jahren, den Nodalstatus zuverlässig durch die Entfernung weniger Lymphknoten zu bestimmen; so konnte die operative Radikalität vielfach erheblich reduziert werden. Zunehmend wurde auch der therapeutische Effekt einer AD bei klinisch okkultem Lymphknotenbefall hinterfragt. Nach randomisierten Studien kann bei vielen Patientinnen heute auch bei einem positiven Nodalstatus auf die AD verzichtet werden; Voraussetzung ist ein klar definiertes multimodales Therapiekonzept. Das operative Vorgehen im Bereich der Lymphknoten wird auch künftig einem erheblichen Wandel unterliegen. In ersten Studien wird die Frage untersucht, ob bei primär operierten Patientinnen gänzlich auf ein operatives Staging verzichtet werden kann. Auch das Vorgehen in der Axilla im Zusammenhang mit der neoadjuvanten Therapie (NACT) steht im Fokus von aktuellen Diskussionen und Studien. Dabei wird über die Durchführbarkeit und Verlässlichkeit der SLNB nach der Chemotherapie ebenso diskutiert wie über Möglichkeiten, die operative Radikalität in der Axilla durch die NACT weiter zu reduzieren.

Schlüsselwörter

Sentinellymphknotenbiopsie Neoadjuvante Therapie Mammakarzinom Lymphknotenexzision Rezidiv 

Trends in axillary surgery

Abstract

Axillary lymph node surgery in breast cancer patients has been subject to dramatic changes over the past 20 years. Originally, lymph nodes were removed in order to resect potentially involved tissue. When the axillary lymph node status was identified as the most important prognostic parameter to guide adjuvant treatment decisions, axillary surgery became a diagnostic procedure in patients with clinically uninvolved nodes. Axillary dissection (AD) was the only option to determine lymph node status for decades. In the late 1990s, sentinel lymph node biopsy (SLNB) was introduced as a minimally invasive procedure that reliably determines the lymph node status by removal of very few nodes. Thus, the postsurgical morbidity was significantly reduced in many women. In recent years, even the therapeutic effect of AD was increasingly questioned in patients with clinically occult axillary disease. According to the results of randomized trials, many patients with positive lymph nodes can be spared AD. An important precondition is a clearly defined multimodal treatment concept. The surgical approach to the axilla will undergo further evolution in the future. Preliminary data show that in patients who undergo primary surgery, axillary staging can eventually be omitted entirely. Surgical approaches in patients who undergo neoadjuvant chemotherapy (NACT) are currently intensively debated and investigated in clinical trials. The feasibility, reproducibility and safety of SLNB after NACT is discussed. Further options to reduce the extent of axillary surgery by the effect of NACT are being investigated in ongoing clinical trials.

Keywords

Sentinel lymph node biopsy Neoadjuvant therapy Breast cancer Lymph node excision Recurrent disease 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

T. Kühn gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Frauenklinik EsslingenEsslingenDeutschland

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