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Management der Axilla 2022: Wann und wie operieren wir noch?

Management of the axilla in 2022: when and how is surgery still carried out?

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Der Gynäkologe Aims and scope

Zusammenfassung

Der Lymphknotenstatus ist noch heute der wichtigste Prognosefaktor beim Mammakarzinom. Daher ist das axilläre Staging (axilläre Dissektion [ALND], Sentinellymphknotenbiopsie [SLNB]) integraler Bestandteil der operativen Therapie jedes invasiven Mammakarzinoms. Adjuvante systemische Therapieentscheidungen orientieren sich aber zunehmend an der Tumorbiologie und der Ansprechwahrscheinlichkeit auf eine spezifische Therapie. Dies gilt v. a. für triple-negative oder HER 2-positive Tumoren, bei denen unabhängig vom Nodalstatus eine Chemotherapie indiziert ist. Bei Luminal-B-Tumoren werden zunehmend Gensignaturen eingesetzt, sodass in einigen Kollektiven auch bei positivem Nodalstatus auf eine Chemotherapie verzichtet werden kann. Wenngleich die Erfassung des pN-Stadiums für die systemische Therapieentscheidung für weniger Patientinnen erforderlich ist, basieren viele systemische Behandlungsempfehlungen, z. B. bei luminalen Tumoren prämenopausaler Patientinnen, weiterhin auf dem Nodalstatus. Für die Indikationsstellung zu einer adjuvanten Radiotherapie (RT) hat das ypN-Stadium aktuell noch eine hohe Bedeutung. Dies gilt für das Zielvolumen bei der brusterhaltenden Therapie sowie die Indikation zu einer Radiotherapie (RT) der Thoraxwand nach Mastektomie oder der extraaxillären Lymphabflussgebiete. Nach einer neoadjuvanten Chemotherapie (NACT) spielt das axilläre Staging eine untergeordnete Rolle für die Planung der postneoadjuvanten Systemtherapie ist aber für die lokoregionäre Therapie von erheblicher Bedeutung. Daher erscheint ein Verzicht auf die Bestimmung des ppN-Stadiums aktuell nur in sehr kleinen Subgruppen möglich. Angesichts der abnehmenden Bedeutung des Nodalstatus bei primär operierten Patientinnen scheint eine selektive, zielgerichtet an den nachfolgenden Therapieentscheidungen orientierte Indikationsstellung sinnvoll.

Abstract

The lymph node status is still the most important prognostic factor in breast cancer. Therefore, axillary staging (axillary lymph node dissection, ANLD and sentinel lymph node biopsy, SLNB) is therefore an integral component of the surgical treatment for every invasive breast cancer; however, adjuvant systemic treatment decisions are increasingly based on tumor biology and the probability of response to a specific treatment. This is particularly true for triple negative or HER2 positive tumors for which chemotherapy is indicated independent of the lymph node status. For luminal B tumors gene signatures are increasingly being used, so that in some collectives chemotherapy can be omitted even if the lymph node status is positive. Although documentation of the pN stage is necessary for systemic treatment decisions for only a few patients, many systemic treatment recommendations, such as for luminal tumors in premenopausal patients, are still based on the lymph node status. The ypN stage is currently still of great importance for the indications for adjuvant radiotherapy (RT) of the thoracic wall after mastectomy or the extra-axillary lymph drainage area. After neoadjuvant chemotherapy (NACT) the axillary staging only plays a subordinate role in the planning of postneoadjuvant systemic treatment but is of substantial importance for locoregional treatment. Therefore, omission of the determination of the ppN stage currently only appears to be feasible in a small subset of patients. In view of the declining role of the lymph node status in patients who undergo upfront surgery, a selective staging that anticipates potential subsequent treatment decisions appears to be meaningful.

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Literatur

  1. Fisher B et al (2002) 25-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy and total mastectomy followed by irradiation. N Engl J Med 347:567575

    Google Scholar 

  2. Ditsch N, Kolberg-Liedtke C, Friedrich M et al (2021) AGO recommendations for the diagnosis and treatment of patients with early breast cancer: update 2021. Breast Care 16:214–217

    Article  Google Scholar 

  3. Nitz U et al (2017) Reducing chemotherapy use in clinically high-risk genomically low-risk pN0 and pN1 early breast cancer patients: five-year data from the prospective, randomized phase 3 west German study group (WSG) plan B trial. Breast Cancer Res Treat 165(3):573–583

    Article  CAS  Google Scholar 

  4. Kalinsky K et al (2020) First results from a phase 3 randomized clinical trial of standard adjuvant endocrine therapy (ET) +/− chemotherapy (CT) in patients (pts) with 1–3positive nodes (hormone receptor positive (HR+)and HER2 negative (HER2 −) breast cancer (BC) with recurrence score (RS) 〈 25: SWOG S1007 (RxPonder): SABCS 2020, GS3–00)

    Google Scholar 

  5. Giuliano AE et al (2011) Axillary dissection versus no axillary dissection in women with invasive breast cancer and sentinel lymph node metastases: a randomized clinical trial. JAMA 305(6):569–575

    Article  CAS  Google Scholar 

  6. Donker M et al (2014) Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981–22023 AMAROS): a randomized, multicenter, open-label, phase 3 non-inferiority trial. Lancet Oncol 15:1303–1310

    Article  Google Scholar 

  7. Mahaveer S et al (2021) Axillary dissection versus axillary observation for low risk, clinically node-negative invasive breast cancer: a systematic review and meta-analysis. Breast Cancer. https://doi.org/10.1007/s12282-021-01273-6

    Article  Google Scholar 

  8. Gentilini O, Veronesi U (2012) Abandoning sentinel lymph node biopsy in early breast cancer ? A new trial in progress at the European institute of oncology of Milan (SOUND: sentinel node versus observation after axillary ultrasound. Breast 21(5):678–681

    Article  Google Scholar 

  9. Reimer T et al (2017) Restricted axillary staging in clinically and sonographically node-negative early invasive breast cancer (c/I T1–2) in the context of breast conserving therapy: first results following commencement of the intergroup-sentinel mamma (INSEMA trial. Geburtshilfe Frauenheilkd 77(2):149–157

    Article  CAS  Google Scholar 

  10. Senkus E, Cardoso MJ, Kaidar-Person O, Łacko A, Meattini I, Poortmans P (2021) De-escalation of axillary irradiation for ealrly breast cancer—has the time come. Cancer Treat Rev 101:102297. https://doi.org/10.1016/j.ctrv.2021.102297

    Article  PubMed  Google Scholar 

  11. Galimberti V, Cole BF, Viale G, Veronesi P, Vicini E, Intra M et al (2018) Axillary dissection versus no axillary dissection in patients with breast cancer and sentinelnode micrometastases (IBCSG 23–01): 10-year follow-up of a randomised, controlled phase 3 trial. Lancet Oncol 19(10):1385–1393. https://doi.org/10.1016/S1470-2045(18)30380-2

    Article  PubMed  Google Scholar 

  12. Sola M, Alberro JA, Fraile M, Santesteban P, Ramos M, Fabregas R et al (2013) Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastasis: final results from the multicenter clinical trial AATRM 048/13/2000. Ann Surg Oncol. https://doi.org/10.1245/s10434-012-2569-y

    Article  PubMed  Google Scholar 

  13. Tinterri C, Marrazzo E, Anghelone C, Barbieri E, Sagona A, Bottini A et al (2021) Abstract PD4-01: preservation of axillary lymph nodes compared to complete dissection in T1–T2 breast cancer patients presenting 1–2 metastatic sentinel lymph nodes : a multicenter randomized clinical trial. Sinodar one. Cancer Res. https://doi.org/10.1158/1538-7445.sabcs20-pd4-01

    Article  Google Scholar 

  14. Rutgers E, Donker M, Poncet C, Straver M, Meijnen P, van de Velde C et al (2019) Abstract GS4-01: radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer patients: 10 year follow up results of the EORTC AMAROS trial (EORTC 10981/22023) https://doi.org/10.1158/1538-7445.sabcs18-gs4-01

    Book  Google Scholar 

  15. Savolt-Peley G, Polgar C, Udvarhelyi N, Rubovszky G, Kovacs E et al (2017) Eight-year follow up result of the OTOASOR trial: the optimal treatment of the axilla—surgery or radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: a randomized, single centre, phase III, non-inferiority Eur. J Surg Oncol 43(4):672–679. https://doi.org/10.1016/j.ejso.2016.12.011

    Article  Google Scholar 

  16. Early Breast Cancer Trialists Collaboration Group (2014) Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: metaanalysis of individual patient data for 8135 women in 22 randomized trials. Lancet 383(9935):2127–2135

    Article  Google Scholar 

  17. Early Breast Cancer Trialists Collaborative Group (2018) Regional lymph node irradiation in early breast cancer an EBCTCG metaanalysis of 13.000 women in 14 trials (Abstract GS4-02 AQ24 presented at the San Antonio Breast Cancer Meeting 2018)

    Google Scholar 

  18. AGO e. V. (2021) Adjuvante Strahlentherapie. https://www.ago-online.de/fileadmin/ago-online/downloads/_leitlinien/kommission_mamma/2021/Einzeldateien/2021D_13__Adjuvante_Strahlentherapie_MASTER_final_20210301.pdf. Zugegriffen: 21.03.2022

  19. Classe JM et al (2019) Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study. Breast Cancer Res Treat 173(2):343–352

    Article  Google Scholar 

  20. Kuehn T, Bauerfeind I, Fehm T et al (2013) Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicenter cohort study. Lancet Oncol 14:609–618

    Article  Google Scholar 

  21. Boughey JC, Suman VJ, Mittendorf EA et al (2013) Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA 310(14):1455–1461

    Article  CAS  Google Scholar 

  22. Boileau JF, Poirier B, Basik M et al (2015) Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol 33(3):258–264

    Article  Google Scholar 

  23. Banys-Paluchowski M et al (2021) Surgical management of the axilla in clinically node-positive breast cancer patients converting to clinical node negativity through neoadjuvant chemotherapy: current status, knowledge gaps and and rationale for the EUBREAST 03 AXSANA study. Cancers (Basel) 13(7):1565. https://doi.org/10.3390/cancers13071565

    Article  Google Scholar 

  24. Tadros AB, Yeng WT, Krishnamurthy S et al (2017) Identification of patients with pathologic complete response in the breast after neoadjuvant chemotherapy for omission of axillary surgery. JAMA Surg 152(7):665–670

    Article  Google Scholar 

  25. Samiei S, van Nijnatten TJA, Munck L et al (2018) Correlation between pathologic complete response in the breast and absence of axillary lymph node metastases after neoadjuvant systemic treatment. Ann Surg. https://doi.org/10.1097/SLA.0000000000003126

    Article  Google Scholar 

  26. Barron AU, Hoskin TL, Day CN et al (2018) Association of low nodal positivity rate among patients with HER2-positive or triple negative breast cancer and breast pathologic complete response to neoadjuvant chemotherapy. JAMA Surg 153(12):1120–1126

    Article  Google Scholar 

  27. Reimer T et al (2020) Avoiding axillary sentinel lymph node biopsy after neoadjuvant systemic therapy in breast cancer: rationale for the prospective, multicentric EUBREAST 01 trial. Cancers (Basel) 12(12):3698. https://doi.org/10.3390/cancers12123698

    Article  CAS  Google Scholar 

  28. Kahler-Ribeiro-Fontana S, Pagan E, Magnoni F et al (2021) Long-term standard sentinel node biopsy after neoadjuvant treatment in breast cancer: a single institution ten-year follow-up. Eur J Surg Oncol 47(4):804–812

    Article  Google Scholar 

  29. Martelli G, Barretta F, Miceli R et al (2020) Sentinel node biopsy alone or with axillary dissection in breast cancer patients after primary chemotherapy: long-term results of a prospective interventional study. Ann Surg. https://doi.org/10.1097/SLA.0000000000004562

    Article  PubMed  Google Scholar 

  30. Piltin M, Hoskin T, Day C et al (2020) Oncologic outcomes of sentinel lymph node surgery after neoadjuvant chemotherapy for node-positive breast cancer. Ann Surg Oncol 27(12):4795–4801

    Article  Google Scholar 

  31. Wong SM, Basik M, Florianova L et al (2021) Oncologic safety of sentinel lymph node biopsy alone after neoadjuvant chemotherapy for breast cancer. Ann Surg Oncol 28(5):2621–2629

    Article  Google Scholar 

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Authors and Affiliations

  1. Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Esslingen, Hirschlandstr. 97, 73730, Esslingen, Deutschland

    Thorsten Kühn

  2. Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Landshut, Robert-Koch-Str. 1, 84036, Landshut, Deutschland

    Ingo Bauerfeind

Authors
  1. Thorsten Kühn
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  2. Ingo Bauerfeind
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Correspondence to Thorsten Kühn or Ingo Bauerfeind.

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Interessenkonflikt

T. Kühn und I. Bauerfeind geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Tanja Fehm, Düsseldorf

Nicolai Maass, Kiel

Die Autoren Thorsten Kühn und Ingo Bauerfeind haben zu gleichen Teilen zum Manuskript beigetragen.

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Kühn, T., Bauerfeind, I. Management der Axilla 2022: Wann und wie operieren wir noch?. Gynäkologe 55, 306–314 (2022). https://doi.org/10.1007/s00129-022-04927-4

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