Neoadjuvan Kemoterapi Sonrası Cerrahi Tedavi
Özet
Lokal ileri evre meme kanserli hastalarda neoadjuvan tedavi (NAT), cerrahi müdahalenin boyutunu küçülterek meme koruyucu cerrahi (MKC) imkanını artırmakta ve aksiller lenf nodu diseksiyonu (ALND) zorunluluğunu azaltarak lenfödem riskini minimize etmektedir. Erken evre agresif alt tiplerde (triple negatif ve HER2 pozitif) ise tedaviye verilen patolojik tam yanıt (pCR) oranları, sağkalım öngörüsü ve tedavi modifikasyonu açısından kritik bir kılavuzdur. Cerrahi planlamada doğruluk sağlamak adına, NAT öncesinde tespit edilen metastatik lenf nodlarının görüntüleme eşliğinde kliple işaretlenmesi, tedavi sonrasında ise hedeflenmiş aksilla cerrahisi (TAD) veya sentinel lenf nodu biyopsisi (SLNB) ile kombine yöntemlerin kullanılması yanlış negatiflik oranlarını belirgin şekilde düşürmektedir. NSABP ve EORTC gibi geniş ölçekli klinik çalışmalar, NAT’ın uzun dönem genel sağkalım oranlarında adjuvan tedavilere göre olumsuz bir fark yaratmadığını, ancak hasta konforu ve kozmetik sonuçlarda üstünlük sağladığını kanıtlamıştır. Günümüzde, aksillanın ışınlanmasıyla cerrahi agresyonun deeskale edilmesini araştıran çok merkezli uluslararası ve ulusal protokoller (ALLIANCE, TAXIS ve NEOSENTİTÜRK), aksiller diseksiyon yapılmaksızın sağ kalım ve bölgesel nüks yönetimine odaklanarak klinik pratiği şekillendirmektedir.
In locally advanced breast cancer, neoadjuvant therapy (NAT) downstages tumor volume, increasing the rates of breast-conserving surgery (BCS) and reducing the necessity of axillary lymph node dissection (ALND), thereby minimizing lymphedema risk. In early-stage aggressive subtypes (triple-negative and HER2-positive), achieving a pathological complete response (pCR) serves as a critical surrogate marker for survival outcomes and guides post-neoadjuvant systemic treatment adjustments. To ensure surgical precision, marking metastatic lymph nodes with clips under imaging guidance prior to NAT, and implementing targeted axillary dissection (TAD) or sentinel lymph node biopsy (SLNB) using dual tracers post-treatment significantly reduces false-negative rates. Large-scale clinical trials, including NSABP and EORTC, demonstrate that NAT yields equivalent long-term overall survival compared to adjuvant therapy while offering superior cosmetic outcomes and lower surgical morbidity. Currently, ongoing multicenter international and national protocols (such as ALLIANCE, TAXIS, and NEOSENTİTÜRK) evaluate whether regional radiotherapy can safely replace radical axillary dissection, focusing on optimizing regional recurrence and quality of life.
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