Lungenmetastasenchirurgie: Indikationen und Technik

Zusammenfassung

Fernmetastasen solider maligner Tumore finden sich am häufigsten in der Lunge. Die meisten Patienten mit Lungenmetastasen weisen eine Vielzahl von Herden auf oder haben Metastasen in anderen Organen, sodass eine operative Therapie nicht in Frage kommt. Viele Untersuchungen belegen jedoch einen Überlebensvorteil für Patienten, bei denen eine vollständige chirurgische Entfernung aller Lungenmetastasen möglich ist. Bei einigen Patienten ist die pulmonale Metastasektomie die sogar einzige kurative Behandlungsoption. Bei V. a. Lungenmetastasen ist die kontrastmittelverstärkte Computertomografie des Thoraxes das diagnostische Verfahren der ersten Wahl. Die bei kurativer Intention geltenden Regeln bei der Indikationsstellung zur Metastasektomie sind die Kontrolle des Primärtumors, die technisch mögliche komplette Resektion aller Metastasen, der Ausschluss extrathorakaler Metastasen mit Ausnahme resektabler Lebermetastasen sowie die funktionelle Operabilität. Die wichtigsten Prognosefaktoren sind die vollständige Resektion, die Tumorentität, das krankheitsfreie Intervall und in beschränktem Maß auch die Anzahl der Metastasen. Bei bilateralen Metastasen kommen die Sternotomie und die sequenzielle oder simultane Thorakotomie als Zugangswege in Betracht, wobei die Thorakotomie bei zentralen Herden oder Herden im linken Unterlappen von Vorteil ist. Bei einseitigem Befall kann unter bestimmten Voraussetzungen auch eine videoassistierte Resektion in Betracht gezogen werden. Primäres Ziel muss immer eine R0-Resektion sein. Neben anatomischen Resektionen finden daher vor allem parenchymsparende lungendissezierende Techniken Anwendung. Insbesondere bei zentralen Metastasen oder multiplen Herden ist große thoraxchirurgische Expertise notwendig, um möglichst viel funktionsfähiges Lungenparenchym zu erhalten. Der sekundäre Befall von mediastinalen Lymphknoten ist mit einer ungünstigen Prognose assoziiert, sodass dieser präoperativ ausgeschlossen werden sollte.

Abstract

Distant metastases of solid tumours are most frequently located in the lung. Most patients with lung metastases suffer from multiple pulmonary lesions or metastases in other organs, which makes these patients unsuitable for surgical treatment. However, several studies suggest a survival benefit if complete resection of all pulmonary metastases is possible. In some patients pulmonary metastasectomy may even be the only curative treatment option. If pulmonary metastases are suspected contrast-enhanced computed tomography is the diagnostic procedure of first choice. Generally accepted rules for intended curative pulmonary metastasectomy are control of the primary tumour, technically completely resectable metastases, the exclusion of extrapulmonary metastases except for potentially completely resectable hepatic metastases and a functional operability. The most important prognostic factors are complete resection, the exact entity of the tumour, disease-free interval and, to a limited extent, also the number of metastases. In bilateral disease sternotomy and sequentially staged or one-stage thoracotomy are the standard surgical approaches to be considered, whereby thoracotomy is more advantageous in cases of centrally located lesions and left lower lobe metastases. In unilateral disease, video-assisted resection may be considered under certain circumstances. Primary aim must be R0 resection. Tissue-sparing pulmonary dissection techniques are proposed besides anatomic resections. In particular in cases of centrally located or multiple lesions an extensive expertise in thoracic surgery is necessary to preserve as much functional lung parenchyma as possible. Secondary mediastinal lymph node involvement is associated with an adverse prognosis and should therefore be ruled out preoperatively.

Schlüsselwörter

Lungenmetastasen - chirurgische Technik - Langzeitergebnis

Key words

pulmonary metastases - surgical technique - long-term results

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