Zusammenfassung
Diagnostik und Therapie von benignen und malignen kolorektalen Neoplasien basieren auf morphologischen (Paris-Klassifikation, Kyoto-Konferenz) und histopathologischen Einteilungen (WHO- und Wien-Klassifikation). Prinzipiell werden vorgewölbte (0–I), flache (0–II) und ulzerierte (0–III) Polypen unterschieden. Flache Polypen machen ca. ein Drittel aller Kolonpolypen aus. Global ist die Karzinomrate von Kolonpolypen größenabhängig und steigt mit zunehmender Polypengröße. Eine Sondergruppe stellen hier die 0–II c-Läsionen dar: bereits Läsionen < 1 cm weisen hier eine deutlich erhöhte Karzinomrate auf, sind bei Diagnosestellung nicht mehr frühinvasiv und sollten operiert werden. Dies gilt in geringerem Ausmaß auch für die LST-NG-Polypen. Kolonfrühkarzinome sind durch die ausschließliche bzw. alleinige Invasion der Submukosa charakterisiert. Die Therapie kolorektaler Frühkarzinome basiert auf dem Low-Risk- und High-Risk-Konzept. Dieses beinhaltet G-Klassifikation, L-Klassifikation, Tumorzell-Budding und Messung der Submukosainvasionstiefe. T1-Karzinome werden anhand der Invasionstiefe in sm1-, sm2- und sm3-Stadien eingeteilt. Alternativ wird beim Polypektomiepräparat die Submukosainvasionstiefe gemessen und auf maximal 1000 µm festgelegt (gilt nur für den nicht gestielten Polypen!). Low-Risk-Frühkarzinome haben eine niedrige Lymphknotenmetastasierungsrate (0 ± 2 %). Deshalb ist bei belegter Entfernung im Gesunden (R0) die lokale endoskopische Therapie ausreichend und keine nachfolgende onkologische Resektion erforderlich. Benigne Neoplasien sind unabhängig von ihrer Größe in der Regel sicher und effektiv endoskopisch therapierbar. Die Langzeitergebnisse sind befriedigend. Die ESD ist indiziert, wenn eine En-Bloc-Resektion intendiert ist (z. B. bei „fortgeschrittener“ Histologie) und die polypoide Läsion im Rektum unterhalb der peritonealen Umschlagsfalte liegt.
Abstract
Diagnosis and therapy of benign and malign colorectal neoplasias are based on morphological and histopathological classifications (Paris-Classification, Kyoto-Conference). In principle polyps are, according to their appearance, divided in protruding (0–I), flat (0–II) and ulcerated (0–III) forms. Flat polyps account for about one-third of the entirety of all colorectal polyps. Overall frequency of malign degeneration of colorectal polyps positively correlates with polyp size. In this context 0–II c lesions are an exception: already 0–II c lesions < 1 cm show considerable increased carcinoma rates, are no longer early invasive and should be transferred for oncological resection. This applies for a lower extent also to LST-NG-polyps. Early colorectal cancer is defined by sole and exclusively invasion of the submucosal layer. Therapy of early colorectal cancer is based on low-risk- / high-risk-concept. This concept includes tumor-grading, lymphangioinvasion, tumorcell-budding and depth of submucosal invasion. According to the depth of submcosal invasion stages are divided in sm1-, sm2- and sm3-invasion respectively. Alternatively for polypectomy specimen measurement of submucosal invasion depth is used and the maximal acceptable extent is assessed to 1000 µm (does not apply to pedunculated polyps!). Low-risk-early-cancers show low rates of lymphnode metastasis (0 ± 2 %). Hence for proven complete resection (R0-status), local endoscopic therapy is sufficient and subsequent oncological resection is needless. Generally benign neoplasias are safely and effectively treatable by endoscopy regardless to their size. Long-term-results of endoscopic treatment are satisfactory. ESD is indicated if en-bloc-resection is intended (i. e. for “advanced” histology) and the polypoid lesion is located in the rectum below the peritoneal fold.
Schlüsselwörter
kolorektale Neoplasie - Polypektomie - Kolonfrühkarzinom - Low-Risk- / High-Risk-Konzept
Key words
colorectal neoplasia - polypectomy - early colorectal cancer - low-risk- / high-risk-concept
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Dr. M. Dollhopf
Klinik für Gastroenterologie und Hepatologie · Klinikum Neuperlach
Oskar-Maria-Graf-Ring 51
81737 München
Email: markus.dollhopf@klinikum-muenchen.de
