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Einsatz der Sentinellymphonodektomie in der Diagnostik und Therapie bei Karzinomen von Vulva und Vagina

  • Linn WölberEmail author
  • Hans-Georg Schnürch
Leitthema
  • 15 Downloads

Zusammenfassung

Hintergrund

Der Lymphknotenbefall der Leiste ist der zentrale Prognosefaktor für Rezidivrisiko und Überleben bei Patientinnen mit Vulva- und Vaginalkarzinom. Im letzten Jahrzehnt hat die Sentinellymphonodektomie (SNB, Wächterlymphknotenbiopsie) insbesondere beim Vulvakarzinom Einzug in die klinische Routine erhalten.

Ziel

Die aktuelle Datenlage und Empfehlungen zum Thema SNB bei Vulva- und Vaginalkarzinom werden dargestellt.

Methoden

Diese Arbeit basiert auf einer selektiven Literaturrecherche in der Datenbank PubMed zum Thema „sentinelnode biopsy“ und „vulva cancer“ sowie „vaginal cancer“.

Ergebnisse

Erst durch das operative Staging der Lymphknoten gelingt bei klinisch nodalnegativen Patientinnen eine Risikoabschätzung für die weitere Prognose und damit eine Stratifizierung hinsichtlich der adjuvanten Therapie. Seit Veröffentlichung der Ergebnisse der GROINSS-V-I Studie in 2008 gilt die SNB beim Vulvakarzinom als onkologisch sicher durchführbar bei Einhaltung klar definierter Kriterien: Unifokaler Primärtumor, Tumorgröße <4 cm, klinisch/sonographisch unauffällige Leistenlymphknoten. Mit Einführung der SNB konnte die operative Morbidität bei minimal erhöhtem Leistenrezidivrisiko deutlich reduziert werden. Anders als beim Vulvakarzinom ist die Durchführung einer alleinigen SNB beim Vaginalkarzinom als experimentell einzuordnen, denn wegen der Seltenheit dieser Tumoren sind prospektive Studien kaum durchführbar. Insbesondere beim Vaginalkarzinom mit seiner unsicheren Assoziationen zwischen Tumorsitz und Lymphabflussrichtung bietet der Einsatz des Verfahrens aber die Möglichkeit zur sinnvollen Individualisierung der Therapie: Aufgrund der unklaren Lymphabflusssituation werden bislang alle Lymphabflussgebiete in die Therapie mit einbezogen. Um die damit verbundene Morbidität einzugrenzen, könnten die Lymphabflussgebiete, die durch das Sentinelverfahren als tumorfrei beschrieben werden, bei der Therapie zukünftig ausgespart werden.

Schlussfolgerungen

Die SNB soll bei erfüllten Kriterien analog der GROINSS-V-I-Studie jeder Patientin mit primärem Vulvakarzinom angeboten werden. Beim Vaginalkarzinom handelt es sich um ein relevantes aber derzeit experimentelles Verfahren zur Individualisierung der Therapie.

Schlüsselwörter

Rezidivrisiko Lymphknotenbefall Lymphabflussgebiete Staging Lymphonodektomie 

Integration of sentinel lymph node biopsy in the diagnostics and treatment of vulvar and vaginal cancer

Abstract

Background

Inguinal lymph node involvement is the most important prognostic factor for disease-free and overall survival in patients with vulvar and vaginal cancer. Over the last decade the sentinel lymph node biopsy (SNB) has become part of the clinical routine especially for vulvar cancer.

Aim

Presentation of the currently available literature and discussion of the guideline recommendations regarding SNB in vulvar and vaginal cancer.

Methods

The Medline (PubMed) databank was searched for articles on SNB in vulvar and vaginal cancer. Search terms were “vulvar cancer” or “vaginal cancer” AND “sentinelnode biopsy”.

Results

A risk estimation for the prognosis and therefore a stratification with respect to the adjuvant treatment strategy is only possible after surgical staging of the lymph nodes in clinically node-negative patients with vulvar cancer. Since publication of the GROINSS-V-I study in 2008, SNB is considered to be a safe procedure in early stage vulvar cancer when the following criteria are met: unifocal primary tumor, tumor diameter <4 cm and clinically (and sonographically) inconspicuous inguinal lymph nodes. Implementation of the SNB procedure has led to a substantial decrease of surgical morbidity with only a minimally increased risk of inguinal recurrence. In contrast to vulvar cancer the performance of SNB alone is classified as experimental in vaginal cancer. The main reason is the rarity of these tumors resulting in an inability to perform prospective studies within a reasonable timeframe; however, especially in vaginal cancer where the association between tumor localization and lymphatic spread is variable and poorly understood, SNB may be the key to individualize treatment and minimize morbidity while taking reasonable oncological risks. Lymphatic drainage areas that are defined as tumor-free by the SNB procedure could be omitted from further treatment instead of bilateral inguinal and pelvic lymph nodes in each patient.

Conclusions

The SNB should be offered to all patients with primary vulvar cancer who fulfill the criteria of the GROINSS-V-I study. In vaginal cancer the procedure is still experimental but is a helpful tool to individualize treatment.

Keywords

Recurrence risk Lymph node involvement Lymphatic drainage areas Staging Lymphadenectomy 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

L. Wölber und H.-G. Schnürch geben an, dass kein Interessenkonflikt bezogen auf den Inhalt dieses Artikels 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 2019

Authors and Affiliations

  1. 1.Klinik und Poliklinik für GynäkologieUniversitätsklinikum Hamburg-EppendorfHamburgDeutschland
  2. 2.KaarstDeutschland

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