Mammakarzinom pp 107-123 | Cite as

Das Management der AxilläRen Lymphknoten

  • S. Roka
  • R. Jakesz


In der modernen interdisziplinären Behandlung des Mammakarzinoms kommt dem korrekten Staging der Axilla eine besondere Bedeutung zu. Der Status der Axilla ist der wichtigste prognostische Faktor und hat Auswirkungen auf die Operation und die Planung von Strahlen- und adjuvanter Therapie. Die axilläre Lymphknotendissektion der Kompartimente I–II (mit Einschränkung auch Level III) gilt als verlässliche Stagingmethode und ist nach wie vor Goldstandard. Neben ihrer diagnostischen hat die Axilladissektion auch therapeutische Bedeutung bei Patienten mit positivem Lymphknotenstatus. Die postoperative Morbidität bei der Chirurgie des Mammakarzinoms wird allerdings nahezu ausschliesslich von den Komplikationen der Axilladissektion bestimmt. Im Zeitalter des Mammographiescreenings hat die Mehrzahl der Patienten zum Zeitpunkt der Diagnose einen negativen Lymphknotenstatus. Diese Patienten müssten ohne therapeutischen Nutzen die Komplikationen der Axilladissektion zur Diagnose des Lymphknotenstatus in Kauf nehmen.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Carter CL, Allen C and Henson DE (1989) Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 63: 181–188PubMedCrossRefGoogle Scholar
  2. Mustafa IA and Bland KI (1998) Indications for axillary dissection in T1 breast cancer. Ann Surg Oncol 5: 4–8PubMedCrossRefGoogle Scholar
  3. Port ER, Tan LK, Borgen PI and Van Zee KJ (1998) Incidence of axillary lymph node metastases in T1a and T1b breast carcinoma. Ann Surg Oncol 5: 23–27PubMedCrossRefGoogle Scholar
  4. Silverstein MJ, Skinner KA and Lomis TJ (2001) Predicting axillary nodal positivity in 2282 patients with breast carcinoma. World J Surg 25: 767–772PubMedCrossRefGoogle Scholar
  5. Axelsson CK, Rank F, Blichert-Toft M, Mouridsen HT and Jensen MB (2000) Impact of axillary dissection on staging and regional control in breast tumors ≤ 10 mm — the DBCG experience. The Danish Breast Cancer Cooperative Group (DBCG), Rigshisoutalet, Copenhagen, Denmark. Acta Oncol 39: 283–289PubMedCrossRefGoogle Scholar
  6. Veronesi U, Luini A, Galimberti V, Marchini S, Sacchini V and Rilke F (1990) Extent of metastatic axillary involvement in 1446 cases of breast cancer. Eur J Surg Oncol 16: 127–133PubMedGoogle Scholar
  7. Gaglia P, Bussone R, Caldarola B, Lai M, Jayme A and Caldarola L (1987) The correlation between the spread of metastases by level in the axillary nodes and disease-free survival in breast cancer. A multifactorial analysis. Eur J Cancer Clin Oncol 23: 849–854PubMedCrossRefGoogle Scholar
  8. Fisher B, Bauer M, Wickerham DL, Redmond CK, Fisher ER, Cruz AB, Foster R, Gardner B, Lerner H, Margolese R and et al. (1983) Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update. Cancer 52: 1551–1557PubMedCrossRefGoogle Scholar
  9. Fisher ER, Palekar A, Rockette H, Redmond C and Fisher B (1978) Pathologic findings from the National Surgical Adjuvant Breast Project (Protocol No. 4). V. Significance of axillary nodal micro-and macrometastases. Cancer 42: 2032–2038PubMedCrossRefGoogle Scholar
  10. Rosen PP, Saigo PE, Braun DW, Weathers E, Fracchia AA and Kinne DW (1981) Axillary micro-and macrometastases in breast cancer: prognostic significance of tumor size. Ann Surg 194: 585–591PubMedCrossRefGoogle Scholar
  11. Cote RJ, Peterson HF, Chaiwun B, Gelber RD, Goldhirsch A, Castiglione-Gertsch M, Gusterson B and Neville AM (1999) Role of immunohistochemical detection of lymph-node metastases in management of breast cancer. International Breast Cancer Study Group. Lancet 354: 896–900PubMedCrossRefGoogle Scholar
  12. Cody HS, 3rd and Urban JA (1995) Internal mammary node status: a major prognosticator in axillary node-negative breast cancer. Ann Surg Oncol 2: 32–37PubMedCrossRefGoogle Scholar
  13. Bevilacqua JL, Gucciardo G, Cody HS, MacDonald KA, Sacchini V, Borgen PI and Van Zee KJ (2002) A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer. Eur J Surg Oncol 28: 603–614PubMedCrossRefGoogle Scholar
  14. Veronesi U, Cascinelli N, Greco M, Bufalino R, Morabito A, Galluzzo D, Conti R, De Lellis R, Delle Donne V, Piotti P et al. (1985) Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes. Ann Surg 202: 702–707PubMedCrossRefGoogle Scholar
  15. Sugg SL, Ferguson DJ, Posner MC and Heimann R (2000) Should internal mammary nodes be sampled in the sentinel lymph node era? Ann Surg Oncol 7: 188–192PubMedCrossRefGoogle Scholar
  16. Arriagada R, Guinebretiere JM and Le MG (2000) Do internal mammary chain nodes matter in the prognosis of axillary node-negative breast cancer? Acta Oncol 39: 307–308PubMedCrossRefGoogle Scholar
  17. Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg VS, Shriver C, Feldman S, Kusminsky R, Gadd M, Kuhn J, Harlow S and Beitsch P (1998) The sentinel node in breast cancer — a multicenter validation study. N Engl J Med 339: 941–946PubMedCrossRefGoogle Scholar
  18. Paganelli G, Galimberti V, Trifiro G, Travaini L, De Cicco C, Mazzarol G, Intra M, Rocca P, Prisco G and Veronesi U (2002) Internal mammary node lymphoscintigraphy and biopsy in breast cancer. Q J Nucl Med 46: 138–144PubMedGoogle Scholar
  19. Galimberti V, Veronesi P, Arnone P, De Cicco C, Renne G, Intra M, Zurrida S, Sacchini V, Gennari R, Vento A, Luini A and Veronesi U (2002) Stage migration after biopsy of internal mammary chain lymph nodes in breast cancer patients. Ann Surg Oncol 9: 924–928PubMedCrossRefGoogle Scholar
  20. Podkrajsek M, Music MM, Kadivec M, Zgajnar J, Besic N, Pogacnik A and Hocevar M (2005) Role of ultrasound in the preoperative staging of patients with breast cancer. Eur Radiol 15: 1044–1050PubMedCrossRefGoogle Scholar
  21. Vaidya JS, Vyas JJ, Thakur MH, Khandelwal KC and Mittra I (1996) Role of ultrasonography to detect axillary node involvement in operable breast cancer. Eur J Surg Oncol 22: 140–143PubMedCrossRefGoogle Scholar
  22. de Freitas R, Jr., Costa MV, Schneider SV, Nicolau MA and Marussi E (1991) Accuracy of ultrasound and clinical examination in the diagnosis of axillary lymph node metastases in breast cancer. Eur J Surg Oncol 17: 240–244PubMedGoogle Scholar
  23. Lemos S, Dias M, Goncalo M, Pinto E, Fernandes G and Oliveira C (2005) Detection of axillary metastases in breast cancer patients using ultrasound and colour Doppler combined with fine needle aspiration cytology. Eur J Gynaecol Oncol 26: 165–166PubMedGoogle Scholar
  24. Mogavero GT, Fishman EK and Kuhlman JE (1992) Inflammatory breast cancer: CT evaluation. Clin Imaging 16: 183–186PubMedCrossRefGoogle Scholar
  25. Yamagami T, Yuen S, Sawai K and Nishimura T (2004) MR imaging-guided axillary node biopsy for breast cancer: initial findings. Eur Radiol 14: 151–156PubMedCrossRefGoogle Scholar
  26. Miyauchi M, Yamamoto N, N IM and Matsumoto M (1999) Computed tomography for preoperative evaluation of axillary nodal status in breast cancer. Breast Cancer 6: 243–248PubMedCrossRefGoogle Scholar
  27. Byrne AM, Hill AD, Skehan SJ, McDermott EW and O’Higgins NJ (2004) Positron emission tomography in the staging and management of breast cancer. Br J Surg 91: 1398–1409PubMedCrossRefGoogle Scholar
  28. van der Hoeven JJ, Hoekstra OS, Comans EF, Pijpers R, Boom RP, van Geldere D, Meijer S, Lammertsma AA and Teule GJ (2002) Determinants of diagnostic performance of [F-18]fluorodeoxyglucose positron emission tomography for axillary staging in breast cancer. Ann Surg 236: 619–624PubMedCrossRefGoogle Scholar
  29. Axelsson CK, Mouridsen HT and Zedeler K (1992) Axillary dissection of level I and II lymph nodes is important in breast cancer classification. The Danish Breast Cancer Cooperative Group (DBCG). Eur J Cancer 28A: 1415–1418PubMedCrossRefGoogle Scholar
  30. Kiricuta CI and Tausch J (1992) A mathematical model of axillary lymph node involvement based on 1446 complete axillary dissections in patients with breast carcinoma. Cancer 69: 2496–2501PubMedCrossRefGoogle Scholar
  31. Fisher B, Wolmark N, Bauer M, Redmond C and Gebhardt M (1981) The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histologic nodal status in carcinoma of the breast. Surg Gynecol Obstet 152: 765–772PubMedGoogle Scholar
  32. Orr RK (1999) The impact of prophylactic axillary node dissection on breast cancer survival — a Bayesian meta-analysis. Ann Surg Oncol 6: 109–116PubMedCrossRefGoogle Scholar
  33. Fisher B, Redmond C, Fisher ER, Bauer M, Wolmark N, Wickerham DL, Deutsch M, Montague E, Margolese R and Foster R (1985) Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312: 674–681PubMedCrossRefGoogle Scholar
  34. Graversen HP, Blichert-Toft M, Andersen JA and Zedeler K (1988) Breast cancer: risk of axillary recurrence in nodenegative patients following partial dissection of the axilla. Eur J Surg Oncol 14: 407–412PubMedGoogle Scholar
  35. Robinson DS, Senofsky GM and Ketcham AS (1992) Role and extent of lymphadenectomy for early breast cancer. Semin Surg Oncol 8: 78–82PubMedCrossRefGoogle Scholar
  36. Rose CM, Botnick LE, Weinstein M, Harris JR, Koufman C, Silen W and Hellman S (1983) Axillary sampling in the definitive treatment of breast cancer by radiation therapy and lumpectomy. Int J Radiat Oncol Biol Phys 9: 339–344PubMedGoogle Scholar
  37. Budd DC, Cochran RC, Sturtz DL and Fouty WJ, Jr. (1978) Surgical morbidity after mastectomy operations. Am J Surg 135: 218–220PubMedCrossRefGoogle Scholar
  38. Lin PP, Allison DC, Wainstock J, Miller KD, Dooley WC, Friedman N and Baker RR (1993) Impact of axillary lymph node dissection on the therapy of breast cancer patients. J Clin Oncol 11: 1536–1544PubMedGoogle Scholar
  39. Warmuth MA, Bowen G, Prosnitz LR, Chu L, Broadwater G, Peterson B, Leight G and Winer EP (1998) Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 83: 1362–68PubMedCrossRefGoogle Scholar
  40. Recht A and Houlihan MJ (1995) Axillary lymph nodes and breast cancer: a review. Cancer 76: 1491–1512PubMedCrossRefGoogle Scholar
  41. Kuehn T, Santjohanser C, Grab D, Klauss W, Koretz K and Kreienberg R (2001) Endoscopic axillary surgery in breast cancer. Br J Surg 88: 698–703PubMedCrossRefGoogle Scholar
  42. Langer I, Kocher T, Guller U, Torhorst J, Oertli D, Harder F and Zuber M (2005) Long-term outcomes of breast cancer patients after endoscopic axillary lymph node dissection: a prospective analysis of 52 patients. Breast Cancer Res Treat 90: 85–91PubMedCrossRefGoogle Scholar
  43. Cant EL, Shivas AA and Forrest AP (1975) Lymph-node biopsy during simple mastectomy. Lancet 1: 995–997PubMedCrossRefGoogle Scholar
  44. Du Toit RS, Locker AP, Ellis IO, Elston CW and Blamey RW (1990) Evaluation of the prognostic value of triple node biopsy in early breast cancer. Br J Surg 77: 163–167PubMedCrossRefGoogle Scholar
  45. Forrest AP, Everington D, McDonald CC, Steele RJ, Chetty U and Stewart HJ (1995) The Edinburgh randomized trial of axillary sampling or clearance after mastectomy. Br J Surg 82: 1504–1508PubMedCrossRefGoogle Scholar
  46. Chetty U, Jack W, Prescott RJ, Tyler C and Rodger A (2000) Management of the axilla in operable breast cancer treated by breast conservation: a randomized clinical trial. Edinburgh Breast Unit. Br J Surg 87: 163–169PubMedCrossRefGoogle Scholar
  47. Macmillan RD, Barbera D, Hadjiminas DJ, Rampaul RS, Lee AH, Pinder SE, Ellis IO, Blamey RW and Geraghty JG (2001) Sentinel node biopsy for breast cancer may have little to offer four-node-samplers. results of a prospective comparison study. Eur J Cancer 37: 1076–1080PubMedCrossRefGoogle Scholar
  48. Krag DN, Weaver DL, Alex JC and Fairbank JT (1993) Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol 2: 335–339; discussion 340PubMedCrossRefGoogle Scholar
  49. Giuliano AE, Kirgan DM, Guenther JM and Morton DL (1994) Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 220: 391–8; discussion 398–401PubMedCrossRefGoogle Scholar
  50. Gallowitsch H, Konstantiniuk P, Jörg L, Urbania A, Kugler F, Peschina W, Hatzl-Griesenhofer M and Zettinig G (2002) Identification of sentinel lymph nodes in breast cancer by lymphoscintigraphy and gamma probe guidance: dependence on route of injection and tumour location. Eur Surg 34: 267–271CrossRefGoogle Scholar
  51. Blessing WD, Stolier AJ, Teng SC, Bolton JS and Fuhrman GM (2002) A comparison of methylene blue and lymphazurin in breast cancer sentinel node mapping. Am J Surg 184: 341–345PubMedCrossRefGoogle Scholar
  52. Pichler-Gebhard B, Konstantiniuk P, Tausch C, Joerg L, Haid A, Schrenk P, Peters-Engl C and Roka S (2002) Factors affecting identification rate and positivity of the sentinel node in breast cancer in 1567 patients, using Blue-Dye and 99 m Tc-labelled Colloid, based on a multicentre database project in Austria. Eur Surg 34: 272–276CrossRefGoogle Scholar
  53. Veronesi U, Zurrida S, Mazzarol G and Viale G (2001) Extensive frozen section examination of axillary sentinel nodes to determine selective axillary dissection. World J Surg 25: 806–808PubMedCrossRefGoogle Scholar
  54. Rudas M, Konstantiniuk P, Horvat R, Niedermoser P, Bogner S, Pichler-Gebhard B, Hoffmann B and Offner F (2002) Sentinel lymph node examination: balancing between high workload and low metastasis detection rate. Eur Surg 34: 277–279CrossRefGoogle Scholar
  55. Mamounas EP, Brown A, Anderson S, Smith R, Julian T, Miller B, Bear HD, Caldwell CB, Walker AP, Mikkelson WM, Stauffer JS, Robidoux A, Theoret H, Soran A, Fisher B, Wickerham DL and Wolmark N (2005) Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol 23: 2694–2702PubMedCrossRefGoogle Scholar
  56. Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, Shivers S, Berman C, Wells K, Rapaport D, Shons A, Horton J, Greenberg H, Nicosia S, Clark R, Cantor A and Reintgen DS (1996) Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. Jama 276: 1818–1822PubMedCrossRefGoogle Scholar
  57. McMasters KM, Tuttle TM, Carlson DJ, Brown CM, Noyes RD, Glaser RL, Vennekotter DJ, Turk PS, Tate PS, Sardi A, Cerrito PB and Edwards MJ (2000) Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used. J Clin Oncol 18: 2560–2566PubMedGoogle Scholar
  58. Derossis AM, Fey J, Yeung H, Yeh SD, Heerdt AS, Petrek J, VanZee KJ, Montgomery LL, Borgen PI and Cody HS, 3rd (2001) 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 193: 473–478PubMedCrossRefGoogle Scholar
  59. Rageth CJ, Scholl B, Sarasin E and Saurenmann E (2005) Sentinel lymphonodectomy — new surgical standard for the evaluation of the axilla: an overview. Part 1. Gynakol Geburtshilfliche Rundsch 45: 28–38PubMedCrossRefGoogle Scholar
  60. Cox CE, Pendas S, Cox JM, Joseph E, Shons AR, Yeatman T, Ku NN, Lyman GH, Berman C, Haddad F and Reintgen DS (1998) Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer. Ann Surg 227: 645–51; discussion 651–653PubMedCrossRefGoogle Scholar
  61. Haid A, Kuehn T, Konstantiniuk P, Koberle-Wuhrer R, Knauer M, Kreienberg R and Zimmermann G (2002) Shoulderarm morbidity following axillary dissection and sentinel node only biopsy for breast cancer. Eur J Surg Oncol 28: 705–710PubMedCrossRefGoogle Scholar
  62. Haid A, Koberle-Wuhrer R, Knauer M, Burtscher J, Fritzsche H, Peschina W, Jasarevic Z, Ammann M, Hergan K, Sturn H and Zimmermann G (2002) Morbidity of breast cancer patients following complete axillary dissection or sentinel node biopsy only: a comparative evaluation. Breast Cancer Res Treat 73: 31–36PubMedCrossRefGoogle Scholar
  63. Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, Intra M, Veronesi P, Robertson C, Maisonneuve P, Renne G, De Cicco C, De Lucia F and Gennari R (2003) A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 349: 546–553PubMedCrossRefGoogle Scholar
  64. Giuliano AE, Jones RC, Brennan M and Statman R (1997) Sentinel lymphadenectomy in breast cancer. J Clin Oncol 15: 2345–2350PubMedGoogle Scholar
  65. Guenther JM, Krishnamoorthy M and Tan LR (1997) Sentinel lymphadenectomy for breast cancer in a community managed care setting. Cancer J Sci Am 3: 336–340PubMedGoogle Scholar
  66. Veronesi U, Paganelli G, Galimberti V, Viale G, Zurrida S, Bedoni M, Costa A, de Cicco C, Geraghty JG, Luini A, Sacchini V and Veronesi P (1997) Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet 349: 1864–1867PubMedCrossRefGoogle Scholar
  67. Borgstein PJ, Pijpers R, Comans EF, van Diest PJ, Boom RP and Meijer S (1998) Sentinel lymph node biopsy in breast cancer: guidelines and pitfalls of lymphoscintigraphy and gamma probe detection. J Am Coll Surg 186: 275–283PubMedCrossRefGoogle Scholar
  68. Crossin JA, Johnson AC, Stewart PB and Turner WW, Jr. (1998) Gamma-probe-guided resection of the sentinel lymph node in breast cancer. Am Surg 64: 666–668; discussion 669PubMedGoogle Scholar
  69. McMasters KM, Wong SL, Martin RC, 2nd, Chao C, Tuttle TM, Noyes RD, Carlson DJ, Laidley AL, McGlothin TQ, Ley PB, Brown CM, Glaser RL, Pennington RE, Turk PS, Simpson D, Cerrito PB and Edwards MJ (2001) Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multiinstitutional study. Ann Surg 233: 676–687PubMedCrossRefGoogle Scholar
  70. Linehan DC, Hill AD, Akhurst T, Yeung H, Yeh SD, Tran KN, Borgen PI and Cody HS 3rd (1999) Intradermal radiocolloid and intraparenchymal blue dye injection optimize sentinel node identification in breast cancer patients. Ann Surg Oncol 6: 450–454PubMedCrossRefGoogle Scholar
  71. Martin RC, Derossis AM, Fey J, Yeung H, Yeh SD, Akhurst T, Heerdt AS, Petrek J, VanZee KJ, Montgomery LL, Borgen PI and Cody HS, 3rd (2001) Intradermal isotope injection is superior to intramammary in sentinel node biopsy for breast cancer. Surgery 130: 432–438PubMedCrossRefGoogle Scholar
  72. Klimberg VS, Rubio IT, Henry R, Cowan C, Colvert M and Korourian S (1999) Subareolar versus peritumoral injection for location of the sentinel lymph node. Ann Surg 229: 860–864; discussion 864–865PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag / Wien 2007

Authors and Affiliations

  • S. Roka
    • 1
  • R. Jakesz
    • 2
  1. 1.Brustambulanz AKH Wien, Universitätsklinik für ChirurgieMedizinische Universität WienWien
  2. 2.Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für ChirurgieMedizinische Universität WienWien

Personalised recommendations