Axilläres Staging – neue Konzepte

Axillary staging is an integral component of the surgical treatment of early stages of breast cancer. In patients with initially clinically and sonographically negative lymph nodes (cN0), sentinel lymph node excision (SLNE) represents the gold standard in cases of planned primary surgery and after neoadjuvant therapy. Following the publication of the ACOSOG Z011 study, cN0 patients undergoing breast-preserving surgery with planned irradiation therapy, with up to two postoperatively positive sentinel lymph nodes, no longer required a completing axillary lymph node excision (ALNE). According to the recently published SENOMAC study ALNE can also be omitted in this cohort after mastectomy, provided that axillary irradiation is performed. It remains to be seen to what extent this study will be incorporated into the German Working Group on Gynecological Oncology (AGO) recommendations. Another potential de-escalation in the cN0 group, which is currently being investigated in prospective studies, is the complete omission of axillary surgery. The first positive study results (SOUND study) have recently been published. In nodal positive patients (cN+) with a planned primary surgery, ALNE remains the surgical standard. In cN+ patients with a maximum of 1–3 suspicious lymph nodes and complete nodal remission (ycN0/ypN0) following neoadjuvant therapy, a de-escalation of axillary surgery is possible. In Germany, due to the low false negative rate the concept of targeted axillary dissection (TAD) is being pursued, which combines SLNE with removal of the target lymph node. Prospective data on the oncological safety of TAD are currently being collected in the multicenter AXSANA register study.