Zusammenfassung
Das operative Lymphknotenstaging beim Vulvakarzinom ist mit einer hohen postoperativen, lang andauernden Morbidität assoziiert. Die im Rahmen der präoperativen Diagnostik angewendeten bildgebenden Verfahren (Computertomographie, Magnetresonanztomographie, Positronenemissionstomographie-CT, Ultraschall) sind teils sehr kostenintensiv und noch nicht ausreichend gut evaluiert. Mit einer Spezifität von >90 % und einer Sensitivität von knapp 80 % ist der Leistenultraschall gut, jedoch nicht akkurat genug, um ein operatives Staging zu ersetzten. Die Ausdehnung des Lymphknotenstagings wird durch die Tumorgröße und Lokalisation bestimmt. Die publizierte Literatur unterstützt zunehmend die Anwendung des Sentinellymphknotenkonzepts bei den Frühstadien des Vulvakarzinoms. Die aktuellen Leitlinien empfehlen eine inguinale Lymphonodektomie für multifokale Tumore bzw. für Tumore ab einer Ausdehnung von 4 cm. Aufgrund der ansteigenden Metastasierungsraten kann nach derzeitiger Datenlage auch eine pelvine Lymphonodektomie bei ausgeprägter Leistenmetastasierung oder bekanntem Lymphknotenbefall entlang der pelvinen Lymphbahnen erwogen werden. Fragestellungen zu bestimmten Konstellationen, beispielsweise, ob auf eine radikale, kontralaterale Lymphonodektomie bei streng lateralem Sitz und einseitiger Lymphknotenmetastasierung verzichtet werden kann, bedürfen weiterer prospektiver Studien. Zusammenfassend ist derzeit keine Bildgebung mit ausreichender Sicherheit bekannt, um auf ein operatives Staging der LK bei einem Vulvakarzinom ab einem Tumorstadium pT1b verzichten zu können. Wesentliche Fortschritte zur Reduktion der postoperativen Morbidität hat die Etablierung des Sentinelkonzeptes in den Frühstadien des Vulvakarzinoms ermöglicht.
Abstract
Surgical lymph node staging of vulvar cancer is associated with a high perioperative and postoperative morbidity of long duration. Preoperative imaging studies (magnetic resonance imaging, computed tomography, positron emission tomography and ultrasound) can be very costly or the required case numbers are lacking. Inguinal ultrasound with a specificity of >90% and sensitivity of nearly 80% is the most promising method but is not yet accurate enough to replace surgical staging. Tumor size and location determine the extent of lymph node staging. An increasing number of publications support the sentinel lymph node concept in the early stages of vulvar cancer. The current national guidelines recommend an inguinal lymphadenectomy for multifocal tumors or a tumor diameter of 4 cm or larger. As a result of the increasing rate of metastasis and according to the current data situation pelvic lymphadenectomy can also can be considered for extensive inguinal metastases and known lymph node involvement along the pelvic lymphatic system; however, the impact on the clinical outcome has not yet been completely established. Special constellations, such as whether radical removal of contralateral inguinal lymph nodes is necessary in the case of lateral and unilateral lymph node metastases, still need to be answered by prospective trials. In summary, no imaging method with sufficient certainty is currently known, which can replace surgical lymph node staging in vulvar cancer for tumor stages pT1b and above. The establishment of the sentinel lymph node concept in the early stages of vulvar cancer has enabled substantial progress in the reduction of postoperative morbidity.
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Schochter, F., Ebner, F. Lymphknotenstaging beim Vulvakarzinom. Gynäkologe 50, 255–260 (2017). https://doi.org/10.1007/s00129-017-4041-3
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DOI: https://doi.org/10.1007/s00129-017-4041-3