Dopolnilne radiološke metode za oceno prizadetosti pazdušnih bezgavk pri raku dojke

Novak, Jerica (avtor), Bešić, Nikola (mentor)

Uvod Rak dojke je najpogostejši rak, zaradi katerega zbolevajo ženske v Sloveniji. Ultrazvočna ocena obsega bolezni v pazdušnih bezgavkah je pomembna za ustrezno načrtovanje kirurškega zdravljenja. Standardna slikovna metoda za oceno obsega bolezni v pazdušnih bezgavkah je pregled pazduhe z B-mode ultrazvokom. S standardno ultrazvočno metodo včasih ne uspemo zaznati zasevkov v pazdušnih bezgavkah. Z dopolnilnimi radiološkimi metodami želimo natančneje oceniti obseg bolezni v pazdušnih bezgavkah. Natančnejša ocena obsega bolezni v pazdušnih bezgavkah bi nam pomagala pri boljšem načrtovanju kirurškega zdravljenja. Namen doktorske naloge je ugotoviti, kako uspešno določimo obseg bolezni v pazdušnih bezgavkah pri bolnicah z rakom dojke s predoperativnim ultrazvočnim pregledom pazdušne lože. Cilj raziskave je izboljšanje predoperativne diagnostike za zaznavanje zasevkov raka dojke v pazdušnih bezgavkah ter zmanjšanje števila reoperacij v pazduhi pri bolnicah z rakom dojke. Hipoteze V naši raziskavi smo preverili naslednje hipoteze: (1.) Standardna ultrazvočna preiskava pazdušnih bezgavk bolj zanesljivo opredeli zasevke duktalnega raka dojke kot lobularnega raka dojke; (2.) S standardno ultrazvočno preiskavo pazdušnih bezgavk pri bolnicah z lobularnim rakom dojke pravilno ocenimo prisotnost zasevkov v pazdušnih bezgavkah v manj kot 60%; (3.) Pri bolnicah z rakom dojke obseg bolezni v pazdušnih bezgavkah bolj uspešno ugotavljamo s kombinacijo standardne ultrazvočne preiskave pazduhe in ultrazvočne preiskave z elastografijo ter ultrazvočnim kontrastom kot s standardno ultrazvočno preiskavo pazdušnih bezgavk. Metode Izvedli smo retrospektivno kohortno študijo in pilotno prospektivno študijo. V retrospektivno študijo smo vključili 102 bolnici z invazivnim lobularnim rakom (ILC) in 106 bolnic z invazivnim duktalnim rakom (IDC) dojke, ki so bile od leta 2002 naprej zdravljene na Onkološkem inštitutu Ljubljana (OIL) in pri katerih je bil opravljen predoperativni pregled pazdušnih bezgavk s standardno ultrazvočno preiskavo in so imele opravljeno mastektomijo. Ocenjevali smo, kako uspešna je standardna ultrazvočna preiskava pazduhe pri napovedi prisotnosti zasevkov v pazdušnih bezgavkah. V prospektivno študijo smo vključili 43 bolnic z rakom dojke, in sicer 10 bolnic z ILC in 33 bolnic z IDC, ki so v letu 2017 in 2018 začele z zdravljenjem na OIL. Vse vključene bolnice so imele opravljen UZ pregled pazduhe. Pri 30 bolnicah je bil opravljen pregled pazdušnih bezgavk z elastografijo in pri 18 pregled pazdušnih bezgavk z ultrazvočnim kontrastom. Ocenjevali smo, kako uspešna je kombinacija standardne ultrazvočne preiskave pazduhe z dopolnilnimi radiološkimi metodami pri napovedi obsega bolezni v pazdušnih bezgavkah. Rezultati V retrospektivno študijo sta bili vključeni 102 bolnici z ILC (mediana starost 52 let ± 8,7), pri katerih je bilo opravljenih 108 mastektomij, in 106 bolnic z IDC (mediana starost 50 let ± 10,2), pri katerih je bilo opravljenih 108 mastektomij. Zasevki so bili v pazdušnih bezgavkah prisotni pri 42,5% žensk z ILC in pri 63% žensk z IDC. Z UZ smo pravilno napovedali bolezen v pazdušnih bezgavkah pri 48% bolnic z ILC in pri 60% bolnic z IDC. Senzitivnost UZ preiskave je pri ILC znašala 49%, pri IDC pa 60% (p = 0,147). Pri bolnicah z IDC smo zaradi uspešnejše predoperativne diagnostike večkrat opravili aksilarno limfadenektomijo (p = 0,06) oziroma enostopenjski kirurški poseg v pazduhi (p = 0,05). V prospektivno študijo je bilo vključenih 10 bolnic z ILC (mediana starost 60 let ± 10,1) in 33 bolnic z IDC (mediana starost 65 let ± 13,3). Zasevki so bili v pazdušnih bezgavkah prisotni v 70%. Z UZ preiskavo smo bolezen v pazdušnih bezgavkah pravilno napovedali v 77%. Elastografija je bila narejena v 30 primerih. Senzitivnost UZ preiskave, elastografije in kombinacije UZ in elastografije je v prospektivni študiji znašala 77%, 60% oziroma 86%. Kombinacija UZ preiskave in elastografije se ni statistično značilno razlikovala glede uspešnosti zaznavanja zasevkov v pazdušnih bezgavkah od standardne UZ preiskave (p=0,058). Ultrazvočni kontrast smo uporabili pri 18 bolnicah. Kriterijev, s katerimi bi dovolj dobro opredelili status tarčne bezgavke, nismo uspeli opredeliti. Zaključek Ultrazvočne predoperativne preiskave so zelo uporabne za planiranje kirurškega zdravljenja pazdušnih bezgavk pri bolnicah z ILC in IDC. Njihova uporaba omogoči zvečanje deleža bolnic, pri katerih opravimo v pazduhi zgolj enostopenjski kirurški poseg. Elastografija je uporabna preiskava za zaznavanje zasevkov v pazdušnih bezgavkah. V primerjavi s standardno UZ preiskavo s kombinacijo UZ in elastografije bolj uspešno zaznavamo zasevke raka dojke v pazdušnih bezgavkah. Preiskava z ultrazvočnim kontrastom ni uporabna za diagnostiko zasevkov v pazdušnih bezgavkah.

• Jezik: Slovenski jezik
• Ključne besede: Invazivni lobularni rak dojke, zasevki v pazdušnih bezgavkah, ultrazvok pazdušnih bezgavk, elastografija, ultrazvok s kontrastnim sredstvom
• Vrsta gradiva: Doktorsko delo/naloga
• Organizacija: MF - Medicinska fakulteta
• Leto izida: 2018
• PID: 20.500.12556/RUL-105821
• COBISS.SI-ID: 3097467
• Datum objave v RUL: 19.12.2018

Sekundarni jezik

• Jezik: Angleški jezik
• Naslov: Additional imaging modalities for axillary staging in breast cancer

Izvleček

Background Breast cancer is the most common form of cancer among Slovenian women. Ultrasound pre-operative evaluation of the axilla is important in planning of surgical therapy. The standard method for preoperative axillary evaluation is grey-scale ultrasound. Preoperative detection of the lymph node metastases sometimes may not detect metastases. Additional imaging modalities for axillary staging may possibly improve detection rate of lymph node metastases in patients with breast cancer. The purpose of this study was to examine the success rate of the preoperative axillary ultrasound in predicting lymph node metastases in patients with breast cancer. The aim of this study was to improve the success rate of preoperative diagnostics in detecting lymph node metastases in order to avoid two-stage axillary surgery. Hypotheses In our study, we verified the following hypotheses: (1.) A standard ultrasound investigation of axillary lymph nodes is more reliable in detection of metastases in invasive ductal carcinoma than in invasive lobular carcinoma. (2.) A standard axillary ultrasound investigation accurately detects lymph node metastases of invasive lobular carcinoma in less than 60%. (3.) The combination of standard axillary ultrasound investigation and elastography and/or contrast-enhanced ultrasound can improve detection rate of axillary lymph node metastases in comparison to standard axillary ultrasound investigation in patients with breast carcinoma. Methods A retrospective cohort and a prospective pilot study were performed. The object of the retrospective study were 102 patients with invasive lobular cancer (ILC) and 106 patients with invasive ductal cancer (IDC) who were treated at Institute of Oncology Ljubljana (IOL) from 2002 and in whom mastectomies were performed after a preoperative axillary ultrasound investigation. The success rate of the standard axillary ultrasound in detecting lymph node metastases was analysed. The object of the prospective study were 43 patients with breast cancer (10 with ILC and 33 with IDC) who were treated at IOL in 2017 and 2018. A preoperative axillary ultrasound investigation was performed in all patients. Elastography was done in 30 patients, while 18 patients had contrast-enhanced ultrasound investigation. The success rate of the additional ultrasound modalities in combination with the standard axillary ultrasound in detecting lymph node metastases was evaluated. Results A total of 102 women (median age 52 years ± 8.7) with ILC in whom 108 mastectomies were performed and 106 women (median age 50 years ± 10.2) with IDC in whom 108 mastectomies were performed were included in the retrospective study. Lymph node metastases were confirmed in 42.5% patients with ILC and 63% patients with IDC. Axillary ultrasound correctly identified lymph node metastases in 48% of patients with ILC and in 60% of patients with IDC. Sensitivity of axillary ultrasound in patients with ILC and IDC was 49% and 60%, respectively (p = 0.147). Due to the superior detection rate of lymph node metastases in patients with IDC an axillary lymph node dissection (p = 0.06) and one stage axillary surgery (p = 0.05) were more often performed in this group of patients. A total of 10 women with ILC (median age 60 years ± 10.1) and 33 women with IDC (median age 65 years ± 13.3) were included in the prospective study. Lymph node metastases were confirmed in 70%. An axillary ultrasound correctly identified lymph node metastases in 77%. Elastography was performed in 30 patients. Sensitivity of the axillary ultrasound alone, elastography alone and the combination of ultrasound and elastography were 77%, 60% and 86%, respectively. Axillary lymph node metastases were not statisitically significanlly more successfully identified with the combination of axillary ultrasound and elastography than with axillary ultrasound alone (p = 0.058) Contrast-enhance ultrasound was performed in 18 patients. We were not able to specify the criteria for the identification of the target axillary lymph node. Conclusions Ultrasound preoperative axillary investigations are very useful in planning of axillary surgical procedures in patients with breast cancer. Use of ultrasound investigations enables increase of proportion of patients in whom only one stage surgical procedures of axilla is done. Elastography is useful investigation for detectin of metastases in axillary lymph nodes. Axillary lymph node metastases are more successfully identified with the combination of axillary ultrasound and elastography than with axillary ultrasound alone. A contrast-enhanced ultrasound is not useful for the diagnosis of metastases in the axillary lymph nodes.

• Ključne besede: Invasive lobular carcinoma, Axillary lymph node metastasis, Axillary ultrasound, Elastography, CEUS