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Tumoren des oberen Gastrointestinaltrakts

Indikation und Ausmaß der Lymphknotendissektion

Tumors of the upper gastro-intestinal tract

Indications and extent of lymph node dissection

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Zusammenfassung

Der Stellenwert der Lymphadenektomie (LA) als grundlegender Baustein der operativen Therapie der Tumoren des oberen Gastrointestinaltrakts wird derzeit in Frage gestellt. Es wird die Frage aufgeworfen, ob es überhaupt eine lineare Metastasierung gibt oder ob nicht die Fernmetastasierung parallel zur Tumorigenese erfolgt. Nach letzterem Konzept hätte die LA keine therapeutische Bedeutung.

Eine erweiterte LA führt zu einem deutlich verbesserten Staging in der pN-Kategorie. Nach erweiterter LA wird die lokoregionäre Tumorkontrolle beim Ösophagus- und Magenkarzinom signifikant verbessert. Zumindest beim Magenkarzinom wird deutlich, dass sich mit der erweiterten D2-LA ein Prognosegewinn für Patienten erreichen lässt, deren lymphogene Metastasierung nicht oder nur wenig fortgeschritten ist. Für beide Tumorentitäten gilt, dass der Prognosegewinn bei lokal fortgeschrittener Erkrankung nicht bewiesen werden kann. Die erweiterte radikale LA hat keine Bedeutung beim Pankreaskarzinom, es resultiert kein verlängertes Überleben. Wichtig ist bei allen 3 Tumorentitäten, dass die LA mit hoher chirurgischer Expertise durchgeführt wird. Da Patienten, die von der LA profitieren, im präoperativen Staging nicht zu definieren sind, wird beim Ösophagus- und Magenkarzinom empfohlen, die Indikation zur erweiterten LA eher großzügig zu stellen.

Abstract

The appropriate extent of lymph node dissection in tumors of the upper gastro-intestinal tract continues to be debated. The basic tenet of surgical oncology that cancerous lymph nodes are indicators not governors of survival is under question and derives from the different theories of metastasis. Is the metastatic flow linear (indicators) or does it occur in parallel to tumorigenesis (governor)? If the latter theory is true there would be only a limited indication for lymphadenectomy (LA).

Extended LA leads to an ameliorated staging of the N category. Following LA locoregional tumor control is significantly improved for esophageal and gastric cancer. In case of gastric cancer it is evident that there is a group of patients in which extended LA lead to improved long-term survival. This gain in prognosis affects patients in which lymph node metastasis is not or only slightly advanced. In locally advanced tumors there is no prognostic benefit. Patients who might benefit from the extended procedure cannot be assessed during preoperative staging. Therefore, the indications for the procedure should be liberally carried out by experienced hands and in experienced centers. According to randomized studies there is no indication for extended radical LA in pancreatic cancer.

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  1. Isar Medizin Zentrum, Sonnenstraße 24–26, 80331, München, Deutschland

    A. Sendler

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Sendler, A. Tumoren des oberen Gastrointestinaltrakts. Chirurg 81, 103–110 (2010). https://doi.org/10.1007/s00104-009-1813-x

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