Chirurgische Therapie der peritonealen Metastasierung in Abhängigkeit von Tumorentität, -stadium und -charakteristik(a)

Zusammenfassung

Eine Metastasierung in das viszerale oder parietale Peritoneum (Peritonealkarzinose) wird nach wie vor als terminales Krankheitsstadium angesehen. Stimuliert durch die Pionierarbeit von Prof. Dr. Paul Sugarbaker wurde das Konzept der Peritonektomie in Form einer maximalen Zytoreduktion (ZRS) mit intraoperativer hyperthermer Chemotherapie (HIPEC) entwickelt, wodurch sich die Überlebenszeit, verglichen mit alleiniger systemischer Chemotherapie, bei selektionierten Patienten nahezu verdoppeln ließ. Diese Therapieform hat sich in spezialisierten Zentren mit vertretbarer Mortalität und Morbidität etabliert, wobei die größte Herausforderung in einer adäquaten Patientenselektion liegt. Grundsätzlich ist die Peritonektomie und HIPEC sowohl bei primären peritonealen Tumoren wie dem Mesotheliom und dem Pseudomyxom sowie bei einem metastatischen Befall des Peritoneums durch gastrointestinale Tumoren oder das Ovarialkarzinom angezeigt. Die Rationale für diese Therapie liegt in der fehlenden systemischen Metastasierung, sodass der Befall des „Kompartments Abdomen“ als lokale Metastasierung verstanden werden kann. Ein Überlebensvorteil ergibt sich jedoch nur, wenn intraoperativ eine komplette (CC-0 oder CC-1) Zytoreduktion zu erzielen ist. Als Selektionskriterien gelten histopathologische Parameter, der Peritonealkarzinoseindex nach Sugarbaker (PCI) und der Allgemeinzustand des Patienten. Während bei den primär vom Peritoneum ausgehenden Tumoren die individuelle Tumorbiologie entscheidendes Prognose- und damit auch Selektionskriterium für die Peritonektomie und HIPEC ist, steht bei den gastrointestinalen Tumoren das Ausmaß des intraabdominellen Tumorbefalls im Vordergrund. Beim Magenkarzinom ist aufgrund des aggressiveren Wachstumsverhaltens die Peritonektomie und HIPEC nur bei synchroner und lokal begrenzter Peritonealkarzinose sinnvoll. Bei positiver Spülzytologie ohne makroskopischen Nachweis einer Peritonealkarzinose bleibt nach Ansprechen auf eine „neoadjuvante“ Chemotherapie durch eine Gastrektomie und HIPEC eine gewisse Option auf Kuration bestehen. Bisher hat die Therapieform der Peritonektomie und HIPEC leider noch keinen generellen Eingang in die jeweiligen Leitlinien gefunden. Lediglich in die aktuelle S3-Leitlinie kolorektales Karzinom ist sie als “Kann-Option“ aufgenommen worden.

Abstract

Peritoneal tumour dissemination is still considered as a terminal disease. For the last two decades, cytoreductive surgery (CRS) combined with intraoperative hyperthermic chemotherapy (HIPEC) has been popularised by Paul Sugarbaker almost doubling survival in selected patients compared with systemic chemotherapy alone. Nowadays, this particular treatment protocol is available in comprehensive cancer centres with reasonable mortality and morbidity. However, patient selection is still challenging. In general, CRS and HIPEC is indicated in primary peritoneal tumours such as mesothelioma and pseudomyxoma peritonei as well as in peritoneal metastases derived from gastrointestinal malignancies and ovarian cancers. Since systemic tumour spread is uncommon in patients with peritoneal metastases, peritoneal tumour dissemination was defined as localised disease within the „compartment abdomen“. However, CRS and HIPEC are only beneficial as long as complete cytoreduction is achieved (CC-0 or CC-1). Histopathological parameters, the Sugarbaker peritoneal carcinomatosis index (PCI) and general condition of the patient have been established as patient selection criteria. In primary peritoneal cancers, individual tumour biology is the predominant criterium for patient selection as opposed to intraabdominal tumour load in peritoneal metastases derived from gastrointestinal cancers. In gastric cancer, CRS and HIPEC should be restricted to synchronous limited disease because of its biological aggressiveness. In patients with free floating cancer cells without macroscopic signs of peritoneal spread, however, CRS and HIPEC following preoperative „neoadjuvant“ chemotherapy preserves chances for cure. So far, there is no general recommendation for CRS and HIPEC by clinical practice guidelines. In the recent S3 guideline for treatment of colorectal cancer, however, CRS and HIPEC have been included as possible treatment options.

Schlüsselwörter

Abdominalchirurgie - Peritonealkarzinose - Peritonektomie - metastatischer Befall des Peritoneums

Key words

abdominal surgery - peritoneal carcinomatosis - peritonectomy - peritoneal metastases

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