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Allgemein- und Viszeralchirurgie up2date 2020; 14(04): 379-395
DOI: 10.1055/a-1030-8254
Leber, Galle, Pankreas, Milz

Interventionelle und chirurgische Therapie non-kolorektaler Lebermetastasen

Update: Interventional and Surgical Therapy of Non-colorectal Liver Metastases
Daniela Kniepeiss
,
Emina Talakić
,
Peter Schemmer
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In der Vergangenheit wurden Resektionen oder Transplantationen wegen non-kolorektaler Lebermetastasen durch die Abwägung von geringem Überlebensvorteil und Komplikationsrate eher zurückhaltend indiziert. Mittlerweile zählt die Leberchirurgie jedoch zu den komplikationsarmen Standardverfahren in der Tumortherapie, die unter Einbettung in multimodale Therapiekonzepte zu einer deutlichen Steigerung des Patientenüberlebens führen.
Kernaussagen

  • Die Entstehung von LM von kolorektalen Karzinomen erfolgt meist über den Pfortaderkreislauf oder über intestinale Lymphknotenbahnen. Daher sind diese im Vergleich zu non-kolorektalen LM, die über den Systemkreislauf entstehen, mit einer geringeren Tumorausbreitung assoziiert. Das ist ein möglicher Grund dafür, dass die Resektion kolorektaler LM einen deutlichen Vorteil für das Patientenüberleben bringt, die Ergebnisse bei Patienten mit non-kolorektalen LM aber deutlich schlechter sind (5-Jahres-Überleben 80 vs. 42%).

  • Karzinome, die über den Systemkreislauf in die Leber metastasieren, zeigen zudem häufig ein multilokuläres Metastasierungsmuster mit entsprechend schlechter Prognose.

  • Ein standardisiertes Therapiekonzept von non-kolorektalen LM gibt es aufgrund ihrer Heterogenität nicht. Randomisierte kontrollierte Studien sind hierzu nicht vorhanden. Nicht chirurgische Konzepte bringen keine zufriedenstellenden Therapieerfolge mit einem Überleben von nur wenigen Monaten.

  • Die Therapie von Tumorpatienten hat sich in den letzten Jahren durch zunehmendes Verständnis der Tumorbiologie, aber auch durch die Entwicklung von multimodalen Therapiekonzepten mit adaptierten Chemotherapie-Regimen verbessert. Interventionelle Verfahren wurden aufgrund der Gerätetechnik verfeinert und tragen zu einer lokalen Kontrolle von LM bei.

  • Sowohl die chirurgische Technik als auch die perioperative Versorgung haben die Morbidität und Letalität nach Leberresektion auf ca. 30% bzw. < 5% gesenkt bzw. ein 5-Jahres-Überleben nach LT von > 80% ermöglicht, was die chirurgische Therapie von non-kolorektalen LM rechtfertigt [62].

  • Selektionskriterien für eine Leberresektion oder LT beinhalten Prognosefaktoren, die nicht zuletzt vom ursprünglichen Tumor abhängig sind [63].

  • Mit entsprechender Patientenselektion gilt die chirurgische Therapie, eingebettet in teils individuellen und multimodalen Konzepten, als Standardverfahren bei non-kolorektalen LM.

Schlüsselwörter

Patientenselektion - Überleben - hochspezialisierte Zentren


Publikationsverlauf

Artikel online veröffentlicht:
04. August 2020

Georg Thieme Verlag KG
Stuttgart · New York

 

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