Chirurgische Behandlung von peritoneal disseminierten gastrointestinalen Tumoren

 

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Zusammenfassung

Die Peritonealkarzinose gastrointestinaler Malignome ist mit einer schlechten Prognose verbunden. Bis zu 15 % der Patienten mit kolorektalen Karzinomen erleiden im Verlauf der Erkrankung eine Peritonealkarzinose. Dieser Prozentsatz liegt bei Patienten mit Magenkarzinom höher. In den letzten Jahren konnte durch eine zytoreduktive Chirurgie, bestehend aus einer parietalen und viszeralen Peritonektomie in Kombination mit einer hyperthermen intraperitonealen Chemotherapie, eine 5-Jahres-Überlebensrate von 30 - 40 % für peritoneal metastasierte kolorektale Karzinome erreicht werden. Dieses konnte durch eine prospektiv, randomisierte Studie sowie mehrere Phase-II-Studien belegt werden. Wichtig ist eine sorgfältige Auswahl der Patienten und das Erreichen einer kompletten makroskopischen Zytoreduktion. Weniger erfolgreich war bisher die Durchführung des Konzeptes beim Magenkarzinom mit Peritonealkarzinose, wobei hier der adjuvante Ansatz nach Gastrektomie ohne Peritonealkarzinose attraktiver erscheint. Für Patienten mit Karzinomen der Leber, Gallenwege und Pankreas kommt das Konzept nicht infrage. Um die Patienten, bei denen eine Prognoseverbesserung durch die Therapie möglich ist, besser identifizieren zu können, sind weitere prospektive, randomisierte Studien zur Rolle der hyperthermen intraperitonealen Chemotherapie notwendig. Diese müssen interdisziplinär und multizentrisch mit der Unterstützung der zuständigen Fachgesellschaften geplant werden.

Abstract

Peritoneal carcinomatosis is found in approximately 15 % of patients with colorectal cancer during the course of their disease, and is associated with a poor prognosis. Even more patients with gastric cancer develop peritoneal seeding. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) have been introduced in the past decade and have led to 5-year survival rates of 30 to 40 % for selected patients with colorectal cancer and peritoneal carcinomatosis. These numbers have been demonstrated by many retrospective analyses and by prospective Phase II studies. The clinical assessment to select patients who will benefit from the combined therapy and achievement of complete macroscopic cytoreduction both play a crucial role. Less favourabale results have been achieved for patients suffering from stage IV gastric cancer with peritoneal seeding. Promising results were demonstrated for postoperative intraperitoneal chemotherapy following curative gastrectomy. Patients with hepatic, biliary and pancreatic cancers and peritoneal carcinomatosis do not benefit from cytoreductive surgery. There is a need for further multicentre, prospective trials analysing the use of hyperthermic intraperitoneal chemotherapy. They should be conducted in the specialised centres by interdisciplinary teams.

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Igors Iesalnieks

Surgery, University of Regensburg

Franz-Josef-Strauß-Allee 11

93053 Regensburg

Email: igors.iesalnieks@klinik.uni-regensburg.de