Aksilārā sargātājlimfmezgla biopsijas nozīme agrīnās stadijas krūts vēža orgānsaudzējošā operācijā
Date
2010
Authors
Januškevičs, Sergejs
Journal Title
Journal ISSN
Volume Title
Publisher
Latvijas Universitāte
Abstract
ANOTĀCIJA
Ievads. Ķirurģijai kompleksajā krūts vēža (KV) ārstēšanā joprojām ir galvenā nozīme. Neraugoties
uz onkoloģiski pamatotu krūts audu apjoma samazināšanu – krūts saudzējoša operācija (KSO), vēl
arvien tiek veikta plaša aksilāro limfmezglu (LM) disekcija (ALMD), kas izraisa samērā daudz
pēcoperācijas komplikāciju, kuri varētu radīt pacientes invaliditāti. Mazu, dažkārt subklīnisku
karcinomu konstatēšana, kuras slimības procesā minimāli iesaista reģionālos LM, izraisa šaubas par
nepieciešamību veikt ALMD pilnā apjomā. Vispiemērotākā šim nolūkam izrādījās
sargātājlimfmezgla (SLM) atklāšanas un biopsijas (SLMB) metode.
Darba mērķis. Pētīt orgānsaudzējošās ķirurģiskās ārstēšanas iespējas dažādas lokalizācijas agrīna
KV pacientēm, balstoties uz SLMB rezultātiem un galvenajiem prognostiskiem faktoriem.
Darba uzdevumi. Primārais: novērtēt KSO rezultātus – recidīvu biežuma, dzīvildzes un
pēcoperācijas komplikāciju analīze. Sekundārais: noskaidrot SLM diagnostiskās metodes vērtību
salīdzinājumā ar citu aksilāro LM datiem.
Materiāls un metodes. 176 pacientes ar KV I–II stadijā tika sadalītas divās grupās: pamatgrupā
bija 89 slimnieces, kam veikta KSO kopā ar SLMB un kontroles grupā – 87 sievietes, kurām tika
izdarītas KSO ar standartvarianta ALMD. Lai noteiktu SLM, izmantojām dubultās kontrastēšanas
(radioizotopiskās un vizuālās) metodi. Pie tam 86 (96,6%) slimniecēm SLM uzkrāja radioizotopu,
bet 85 (95,5%) – krāsvielu. Pēc SLMB tika veikta rezultātu analīze apakšgrupās: slimniecēm ar
negatīviem SLM (N0sn) un ALMD (n=33); ar metastāzēm SLM (N1sn) un ALMD (n=11); ar N0sn bez
papildu ALMD (n=45). Kontrolgrupas analīze tika veikta atkarā no aksilāro LM stāvokļa – N0
(n=61) vai N1 (n=26).
Rezultāti. Apkopojot datus par 44 (49,4%) slimniecēm, kam bija veikta aksilārā ALMD
kombinācija ar SLMB, noskaidroti SLMB diagnostiskā testa vērtības kritēriji: jutība – 91,7%,
specifiskums – 100%, viltus negatīvs rezultāts – 8,3% un testa pareizums – 96,9% (p<0,001).
Metastazēšanās (N1sn) SLM (n=11) atkarība prognostiskiem faktoriem netika konstatēta, kas
iespējams, saistīts ar nelielo novērojumu skaitu. Analīze apakšgrupā (n=45) parādīja, ka atšķiras
procesa lokalizācija krūts kvadrantos un audzēja histologiskā struktūra, kas ietekmēja turpmākās
ārstēšanas taktikas izvēli. Salīdzinot kontroles grupas slimnieces ar N1 un N0, atzīmēta statistiski
ticama (p<0,05) atšķirība starp prognostiskiem faktoriem, kuri ietekmē reģionārās metastazēšanas
procesu. Pēcoperācijas komplikācijas abās pētījuma grupās slimniecēm ar ALMD bija 31,8%
(n=44) un 31,0% (n=87) bet, slimniecēm (n=45) tikai ar SLMB – 4,8% (p<0,001). Lokāli recidīvi
konstatēti 18,2% un 15,4% slimniecēm ar N1 sn un N1, bet bez metastāzēm LM (N0 sn un N0) – 4,4%
un 4,9% attiecīgi. Bezrecidīvu un kopējā piecu gadu dzīvildze pamatgrupā bija 81,8 % un 84,8%
slimniecēm ar N1 sn (n=11) pret 80,8% un 84,6% kontroles slimnieču grupā N1 (n=26). Pamatgrupas
dzīvildzes rādītāji slimniecēm ar N0 sn un ALMD (n=33) bija 90,3% un 97,0% pret 91,7% un 95,0%
attiecīgi kontroles grupā (n=61), bet slimniecēm ar N0 sn bez papildu ALMD (n=45) – 93,2% un
95,5%. Tas apstiprina un arī pamato koncepciju par SLM disekciju arī tad, kad LM metastāzes
nekonstatē.
Secinājumi. Noteiktu indikāciju gadījumā SLMB var aizstāt ALMD. To var izmantot kā standartu,
nosakot krūts vēža stadiju un ārstēšanu slimniecēm ar klīniski negatīviem limfmezgliem.
ABSTRACT Background. Surgery plays a major role in breast cancer multidisciplinary management. Although the oncological safety after breast conserving surgery (BCS) is accepted, axillary lymph node dissection (ALND) with frequent arm morbidity is still fequently performed. The detection of small nonpalpable BC with minimally regional lymph nodes (LN) involvement raises questions about the volume of ALND. The sentinel lymph node (SLN) biopsy (SLNB) is the best method to solve these problems. Aim of the study. To investigate the possibilities of BCS for various located BC according to the results of SLNB and the main important prognostic factors. The objectives of the study were: primary, to examine whether BCS influences local recurrence rate, survival and surgical complications. The secondary target of the study was to evaluate axillary LN status and SLNB in the aspect of diagnostic test power. Material and Methods. 176 consecutive I-II stage BC patients enrolled and divided into two groups: 89 patients (cases) underwent SLNB, but 87 patients (controls) were treated with BCS and ALND. For SLN verification radiolabled and colored methods or both methods were used. Moreover, SLN(s) were radiopositive in 86 (96.6%) and colored in 85 (95.5%) cases. Results in subgroups were analyzed: patients with tumor-free SLN (N0sn) plus ALND (n=33); with positive SLN (N1sn) and complete ALND (n=11); with negative N0sn without ALND (n=45). The analysis was performed comparing axillary status N0 (n=61) and N1 (n=26) of the patients in the control group. Results. According to results in the 44 (49.4%) patient subgroup with ALND after SLNB, the criteria of diagnostic test were: sensitivity – 91.7%, specificity – 100%, false-negativerate – 8.3% and accuracy – 96.9% (p<0.001). There was no evidence between (N1sn) SLN (n=11) and prognostic factors due to the small sample size. The analysis in the subgroup (n=45) of patients with only SLNB showed differences of tumor location in breast quadrants and histology that had influence on adjuvant therapy planning. Comparing the control group with N1 and N0, statistically significant (p<0,05) difference among prognostic factors had influence on metastatic tumor spread. Postoperative surgical complications in both groups with ALND were marked: 31.8% (n=44) and 31.0% (n=87); however, there were only 4.8% (p<0,001) in the group with SLNB. Tumor local relapse was detected in the groups with positive LN (N1 sn and N1) – 18.2% and 15.4%, respectively, but for patients with tumor-free LN (N0 sn and N0) – 4.4% and 4.9%, respectively. There were no differences in disease-free survival (DFS) and 5-year overall survival (OS) in patients with positive LN (N1 sn – 80.8% versus 84.6% in the control group). DFS and 5-year OS were 90.3% and 97.0% in the case group with N0 sn and ALND (n=33) versus 91.7% and 95.0% in the same patients (n=61) in the control group, but in patients in the case group with negative SLN (N0 sn) and without ALND (n=45) – 93.2% and 95.5%, respectively. All this provides evidence that the concept of SLNB is the best option when axillary LN are tumor-free. Conclusions. With strong indications, SLNB is a powerful alternative to ALND. For forthcoming treatment planning, SLNB can be accepted as a standard staging procedure for early BC patients with clinical negative axilla.
ABSTRACT Background. Surgery plays a major role in breast cancer multidisciplinary management. Although the oncological safety after breast conserving surgery (BCS) is accepted, axillary lymph node dissection (ALND) with frequent arm morbidity is still fequently performed. The detection of small nonpalpable BC with minimally regional lymph nodes (LN) involvement raises questions about the volume of ALND. The sentinel lymph node (SLN) biopsy (SLNB) is the best method to solve these problems. Aim of the study. To investigate the possibilities of BCS for various located BC according to the results of SLNB and the main important prognostic factors. The objectives of the study were: primary, to examine whether BCS influences local recurrence rate, survival and surgical complications. The secondary target of the study was to evaluate axillary LN status and SLNB in the aspect of diagnostic test power. Material and Methods. 176 consecutive I-II stage BC patients enrolled and divided into two groups: 89 patients (cases) underwent SLNB, but 87 patients (controls) were treated with BCS and ALND. For SLN verification radiolabled and colored methods or both methods were used. Moreover, SLN(s) were radiopositive in 86 (96.6%) and colored in 85 (95.5%) cases. Results in subgroups were analyzed: patients with tumor-free SLN (N0sn) plus ALND (n=33); with positive SLN (N1sn) and complete ALND (n=11); with negative N0sn without ALND (n=45). The analysis was performed comparing axillary status N0 (n=61) and N1 (n=26) of the patients in the control group. Results. According to results in the 44 (49.4%) patient subgroup with ALND after SLNB, the criteria of diagnostic test were: sensitivity – 91.7%, specificity – 100%, false-negativerate – 8.3% and accuracy – 96.9% (p<0.001). There was no evidence between (N1sn) SLN (n=11) and prognostic factors due to the small sample size. The analysis in the subgroup (n=45) of patients with only SLNB showed differences of tumor location in breast quadrants and histology that had influence on adjuvant therapy planning. Comparing the control group with N1 and N0, statistically significant (p<0,05) difference among prognostic factors had influence on metastatic tumor spread. Postoperative surgical complications in both groups with ALND were marked: 31.8% (n=44) and 31.0% (n=87); however, there were only 4.8% (p<0,001) in the group with SLNB. Tumor local relapse was detected in the groups with positive LN (N1 sn and N1) – 18.2% and 15.4%, respectively, but for patients with tumor-free LN (N0 sn and N0) – 4.4% and 4.9%, respectively. There were no differences in disease-free survival (DFS) and 5-year overall survival (OS) in patients with positive LN (N1 sn – 80.8% versus 84.6% in the control group). DFS and 5-year OS were 90.3% and 97.0% in the case group with N0 sn and ALND (n=33) versus 91.7% and 95.0% in the same patients (n=61) in the control group, but in patients in the case group with negative SLN (N0 sn) and without ALND (n=45) – 93.2% and 95.5%, respectively. All this provides evidence that the concept of SLNB is the best option when axillary LN are tumor-free. Conclusions. With strong indications, SLNB is a powerful alternative to ALND. For forthcoming treatment planning, SLNB can be accepted as a standard staging procedure for early BC patients with clinical negative axilla.
Description
Elektroniskā versija nesatur pielikumus
Keywords
Medicīna un farmācija , Medicīna , Veselības aprūpe