Meme Kanserinde Neoadjuvan Tedavi
Synopsis
Sistemik tedavinin cerrahi öncesi dönemde uygulanmasını ifade eden neoadjuvan tedavi, özellikle lokal ileri evre (Evre II–III) veya operabilitesi sınırda meme kanseri olgularında standart yaklaşım haline gelmiştir. Başlangıçta meme koruyucu cerrahi olasılığını artırmak için kullanılan bu yaklaşım; günümüzde tümör biyolojisini, tedavi yanıtını ve sistemik risk profilini değerlendirme aracı olarak önemli bir rol oynamaktadır. En önemli avantajı tedavi yanıtının patolojik tam yanıt (pCR) gibi prognostik göstergelere yansıtılabilmesidir. pCR oranı ve bunun sağ kalıma olan etkisi moleküler alt tiplere göre değişkendir. Özellikle HER2 pozitif ve üçlü negatif meme kanserinde yüksek pCR oranları ile sağkalım avantajı olduğu bildirilmektedir. Buna karşılık HR+/HER2- olgularda pCR oranları düşük ve sağ kalım üzerinde etki sınırlıdır. HR+/HER2- alt tipte neoadjuvan endokrin tedaviler alternatif oluşturur. Aksiller hastalık yükünü azaltma ve aksiller lenf nodu diseksiyonundan kaçınma olanağı, önemli cerrahi kazanımlarındandır. AMAROS, AXSANA gibi büyük klinik çalışmalar, NAT sonrası aksiller yaklaşımın yeniden tanımlanmasında belirleyici olmuş ve olmaya devam etmektedir. Aksilla yönetiminde NAT sonrası nodal yanıtın güvenilir biçimde değerlendirilmesi amacıyla hedeflenmiş aksiller diseksiyon (TAD), dual yöntem ve en az üç sentinel lenf nodunun çıkarılması gibi teknik yaklaşımlar ile yanlış negatiflik oranının azaltılması hedeflenmektedir. Neoadjuvan tedavi sonrası rezidüel invaziv hastalık saptanan olgularda, biyolojik alt tipe özgü adjuvan tedavi intensifikasyonu güncel yaklaşımın temelini oluşturmaktadır. Üçlü negatif meme kanserinde adjuvan kapesitabin, germline BRCA mutasyonu taşıyan yüksek riskli hastalarda olaparib ve HER2 pozitif hastalıkta ado-trastuzumab emtansine (T-DM1) kullanımı, sağkalım sonuçlarını iyileştiren stratejiler olarak öne çıkmaktadır. Sonuç olarak güncel kılavuzlar (NCCN 2025) lokal ileri evre operabl hastalarda sıklıkla neoadjuvan tedaviyi önermektedir. Neoadjuvan tedavi; yalnızca tümör küçültücü bir strateji değil, bireyselleştirilmiş tedavi planına yön veren dinamik bir onkolojik araçtır.
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