Neue Prinzipien und Techniken in der operativen Therapie des Zervixkarzinoms: Aktuelle systematische Übersicht

Zusammenfassung

Die operative Standardtherapie des Zervixkarzinoms in den FIGO-Stadien IB - IIA ist die abdominale radikale Hysterektomie („Wertheim-Operation“) mit pelviner und eventuell paraaortaler Lymphknotenentfernung. In Deutschland und Österreich wird dieser Eingriff traditionell auch beim Stadium IIB durchgeführt. Patientinnen mit histopathologischen Risikofaktoren - in der Regel etwa 50 % der Fälle - erhalten zusätzlich zur radikalen Operation eine adjuvante (Chemo-)Radiotherapie. Die operative Standardtherapie scheint im Vergleich zur primären Radiotherapie mit einer wesentlich höheren behandlungsbedingten Morbidität assoziiert zu sein, aber keine besseren Heilungsergebnisse zu erbringen. In jüngster Zeit erfolgten deshalb zahlreiche Neuentwicklungen mit dem Ziel, den therapeutischen Index der operativen Behandlung des Zervixkarzinoms zu verbessern. Dabei wurden sowohl neue Operationstechniken angewandt als auch neue Operationsprinzipien berücksichtigt. Das Spektrum neuer Verfahren reicht von minimalinvasiven über fertilitätserhaltende und autonome Nerven schonende bis zu supraradikalen Eingriffen. Ausgehend von einer embryologisch definierten chirurgischen Beckenanatomie wurde die Kompartimentresektion als ein neues Radikalitätsprinzip eingeführt, das die adjuvante Strahlentherapie entbehrlich macht. Obwohl bislang keines der neuen Verfahren in randomisierten prospektiven Studien gegenüber dem noch geltenden Standard geprüft wurde, kann aufgrund der bereits gewonnenen Ergebnisse ein signifikanter Fortschritt in der operativen Therapie des Zervixkarzinoms erwartet werden. In dieser Übersichtsarbeit werden die Neuerungen anhand einer systematischen Literaturrecherche in den Medline- und Cochrane-Datenbanken vorgestellt und vergleichend evaluiert. Insbesondere wurden die patienten- und tumorbezogenen Rahmenbedingungen ermittelt, die für die jeweiligen neuen Verfahren als Voraussetzungen für eine Verbesserung gegenüber dem Standard angesehen werden müssen. Die Arbeit wird durch die Einbeziehung neuer Entwicklungen der operativen Therapie des Mikrokarzinoms (FIGO-Stadium IA) einerseits und lokoregionär fortgeschrittener und rezidivierender Tumoren andererseits komplettiert.

Abstract

Abdominal radical hysterectomy (the “Wertheim operation“) combined with pelvic and periaortic lymph node dissection is still regarded as the standard surgical therapy for cervical carcinoma, FIGO stages IB - IIA. In Germany and Austria, this procedure is also carried out in selected patients with FIGO stage IIB cancer. Postoperative adjuvant (chemo-)radiation is recommended for all patients with histopathologically high risk factors detected in the surgical specimens - generally about 50 % of cases. This conventional surgical approach is obviously associated with a higher treatment-related morbidity compared to primary radiation as the therapeutic alternative, without achieving better tumor control. In consequence, various new surgical techniques have recently been developed with the aim of improving the therapeutic index of surgery for cervical cancer. The new surgical spectrum includes minimally invasive/robotic techniques, supraradical procedures as well as techniques which preserve fertility and the autonomic nerves. Compartment resection, a new excisional approach based on embryologically defined surgical pelvic anatomy, makes it possible to dispense with adjuvant radiation. Although none of the new procedures has been compared with the current standard in prospective randomized trials significant progress in the surgical therapy of cervical cancer can be expected from the results published to date. This systematic review examines and analyzes the new developments based on literature from the Medline and Cochrane databases with particular reference to the patient and tumor-related conditions which must be met to obtain (potential) benefits compared to the standard therapy. New surgical options for the treatment of microcarcinomas (FIGO stage IA) and locoregionally advanced and recurrent disease are reviewed as well.

Schlüsselwörter

Zervixkarzinom - minimalinvasive Chirurgie - Fertilitätserhalt - Nervenschonung - Kompartimentresektion

Key words

cervical cancer - minimally invasive surgery - preservation of fertility - autonomic nerve preservation - compartment resection

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