Meme Kanserinin Preoperatif Değerlendirilmesinde Aksiller Ultrasonografinin Değeri ve Sentinel Nod ile Uyumu
Özet
Amaç:
T1-T2 evre, aksillası klinik olarak negatif, SLNB yapılacak olgularda, preoperatif aksiller ultrasonografinin patolojik lenf nodunu belirlemedeki etkinliğinin ölçülmesi amaçlandı. Bu sayede minimal tümör yükünün saptandığı radyoterapi alacak hastalarda aksilla cerrahisinden kaçınabilmeyi ve bu hastaları mamografi, meme ultrasonografisi, aksiller ultrasonografi ile takip edebilmeyi hedefledik.
Gereç ve Yöntem:
Ultrasonografi ile tümörün bulunduğu meme kadranı, boyutu ve aksiller lenf nodları değerlendirildi. Şüpheli lenf nodu mevcutsa, lenf nodunun kısa ve uzun çapı, kortikal kalınlığı, hiler ve periferal vaskülaritesi, santral yağlı hilusu, lenf nodunun tümöre uzaklığı belirlendi ve kayıt edildi. En şüpheli görünümlü (en kalın korteksli veya primer tümöre en yakın) lenf noduna bir makrokolloid olan Teknesyum 99-m ile işaretli makroagregat albumin ultrasonografi eşliğinde enjekte edildi, ameliyatta ve gama probla sentinel lenf nodu bulundu, eksize edildi. Sentinel lenf nodunu saptamak için mavi boya kullanıldı. Lenf nodları perop frozen ve parafinde histopatolojik olarak değerlendirildi.
Bulgular:
Yaş ortalaması 54 (36-92) olarak bulundu. Prospektif yapılan çalışmaya 57 hasta dahil edildi. 43 hastada (%75) ultrasonografiyle işaretlenen lenf nodu ve mavi boyalı lenf nodu aynıydı. 17 hastanın aksillasında metastaz saptandı. 12 hastada (%70) metastatik lenf nodu, radyonüklid madde ile de işaretlenmişti ve histopatolojik incelemede saptanan ortalama çap 1,60cm idi. 5 hastada (%30) ise radyonüklid maddeyle işaretlenmiş lenf nodu ve metastatik lenf nodu aynı değildi, ortalama çap 1,56cm idi. 5 hastanın 3’ünde tutulum mikrometastaz (ortalama çap 1,50cm), 2’sinde tutulum makrometastaz (ortalama çap 1,65cm) düzeyindeydi. Ultrasonografinin makrometastazı saptayamama oranı (yanlış negatiflik oranı) 2/14 (%14) olarak saptandı. Lenf nodunun korteks kalınlığı arttıkça metastaz oranı artmaktaydı.
Sonuç:
Sentinel lenf nodunu tahmin etmede preoperatif ultrasonografi etkindir. Makrometastazı saptamadaki yanlış negatiflik oranı %14 olarak saptanmıştır. Mavi boyanın ise tüm patolojik lenf nodlarını doğru olarak saptadığı görülmüştür. Düşük tutulumlu(mikrometastaz ve görece küçük makrometastazlar) sentinel lenf nodlarını belirlemede de mavi boya altın standarttır.
Aksillanın radyoterapi ile tedavisinin başarılı olduğu günümüzde düşük yanlış negatiflik oranıyla deneyimli ellerde ve uygun hasta seçimiyle ultrasonografi ile aksilla değerlendirilmesi yapılabilir. Cerrahisiz bir süreç oluşturulabilir.
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