Diagnostik und Therapie von Lebermetastasen kolorektaler Karzinome - Workflow

R. T. Grundmann; P. Hermanek; S. Merkel; C.-T. Germer; J. Hauss; D. Henne-Bruns; K. Herfarth; U. T. Hopt; T. Junginger; E. Klar; J. Klempnauer; W. H. Knapp; M. Kraus; H. Lang; K.-H. Link; F. Löhe; K. J. Oldhafer; H.-R. Raab; H.-G. Rau; A. Reinacher-Schick; J. Ricke; J. Roder; A.-O. Schäfer; H. J. Schlitt; M. R. Schön; D. Stippel; A. Tannapfel; K. Tatsch; T. J. Vogl; null für die Arbeitsgruppe Workflow „Diagnostik und Therapie von Lebermetastasen kolorektaler Karz

doi:10.1055/s-2008-1076796

Zentralblatt für Chirurgie, Inhaltsverzeichnis

Zentralbl Chir 2008; 133(3): 267-284
DOI: 10.1055/s-2008-1076796

Übersicht

Diagnostik und Therapie von Lebermetastasen kolorektaler Karzinome - Workflow

Diagnosis and Treatment of Colorectal Liver Metastases - WorkflowR. T. Grundmann¹ , P. Hermanek² , S. Merkel² , für die Arbeitsgruppe Workflow „Diagnostik und Therapie von Lebermetastasen kolorektaler Karzinome”, C.-T. Germer³ , R. T. Grundmann¹ , J. Hauss⁴ , D. Henne-Bruns⁵ , K. Herfarth⁶ , P. Hermanek² , U. T. Hopt⁷ , T. Junginger⁸ , E. Klar⁹ , J. Klempnauer¹⁰ , W. H. Knapp¹⁰ , M. Kraus¹ , H. Lang⁸ , K.-H. Link¹¹ , F. Löhe¹² , S. Merkel² , K. J. Oldhafer¹³ , H.-R. Raab¹⁴ , H.-G. Rau¹⁵ , A. Reinacher-Schick¹⁶ , J. Ricke¹⁷ , J. Roder¹ , A.-O. Schäfer⁷ , H. J. Schlitt¹⁸ , M. R. Schön¹⁹ , D. Stippel²⁰ , A. Tannapfel²¹ , K. Tatsch¹² , T. J. Vogl²²

¹Kreiskliniken Altötting-Burghausen
²Universitätsklinik Erlangen
³Klinikum Nürnberg Nord
⁴Universität Leipzig
⁵Universitätsklinikum Ulm
⁶Universitätsklinikum Heidelberg
⁷Universitätsklinikum Freiburg
⁸Johannes Gutenberg Universität Mainz
⁹Universitätsklinikum Rostock
¹⁰Medizinische Hochschule Hannover
¹¹Asklepios Paulinen Klinik Wiesbaden
¹²Klinikum Großhadern - LMU München
¹³Allgemeines Krankenhaus Celle
¹⁴Klinikum Oldenburg
¹⁵Klinikum Dachau
¹⁶Medizinische Universitätsklinik Bochum-Langendreer
¹⁷Universitätsklinikum Magdeburg
¹⁸Klinikum der Universität Regensburg
¹⁹Städtisches Klinikum Karlsruhe
²⁰Uniklinik Köln
²¹Universitätsklinikum Bergmannsheil Bochum
²²Klinikum der Johann Wolfgang Goethe-Universitat Frankfurt am Main

Abstract

Zusammenfassung

In dieser Übersicht wird zu den Standards der Diagnostik und Therapie von Lebermetastasen kolorektaler Karzinome auf der Basis eines Workshops Stellung genommen. Es werden Algorithmen zum Vorgehen bei Patienten mit synchronen / metachronen kolorektalen Lebermetastasen sowie beim lokoregionären Rezidivtumor beschrieben. Die chirurgische Resektion ist die Methode der Wahl zur kurativen Behandlung von Lebermetastasen. Die Indikation hierzu sollte sich an folgenden Faktoren orientieren:
1. Generelle Operabilität des Patienten (Begleiterkrankung),
2. Erreichbarkeit einer R 0-Situation,
i. ggf. in Kombination mit ablativen Verfahren,
ii. ggf. neoadjuvante Chemotherapie,
iii. Sanierbarkeit extrahepatischer Tumormanifestation,
3. Ausreichende funktionelle Leberreserve nach Erreichen einer R 0-Situation,
i. ggf. Pfortaderembolisation oder zweizeitiges Vorgehen,
4. Zwei benachbarte Lebersegmente können mit vollständiger vaskulärer und biliärer Versorgung erhalten werden,
5. Tumorbiologische Aspekte („prognostische Parameter”),
6. Erfahrung des Chirurgen / Zentrums!
Extrahepatische Metastasen stellen keine absolute Kontraindikation zur Leberresektion dar, vorausgesetzt, eine komplette Resektion von intra- und extrahepatischem Tumor ist möglich. Lässt sich eine R 0-Resektion erreichen, wird selbst bei bilateralem Leberbefall und 5 und mehr Knoten eine sinnvolle Operationsindikation beschrieben. Die Art der Leberresektion (Wedge-Resektion vs. anatomische Resektion) hat keinen Einfluss auf die Rezidivrate. Die präoperative Volumetrie ist bei größeren Resektionen angezeigt. Mindestanforderungen an die Größe der Restleber sind: 25 % des gesunden Lebergewebes bei Patienten mit normaler Leber, bei Zustand nach Zytostatika, Fettleber, Fibrose und Diabetes 40 % und bei Zirrhose 50-60 %. Bei 15-30 % der Patienten, die initial als anatomisch irresektabel gelten, erlaubt die präoperative Chemotherapie eine komplette Resektion, jedoch ist der Nutzen einer neoadjuvanten Chemotherapie bei Patienten mit resektablen Metastasen noch nicht ausreichend belegt. Lokal destruierende Maßnahmen wie Radiofrequenzablation (RFA) oder Laserinduzierte interstitielle Thermotherapie (LITT) kommen vor allem bei zentralen Rezidivmetastasen, risikoreichen Leberresektionen einer Seite (wegen großer oder multipler Metastasen) und gleichzeitig tief liegender Metastase der anderen Seite in Betracht sowie für zwei bis drei kleine Metastasen bei eingeschränkter Operationsfähigkeit. Patienten mit Tumoren größer 3 cm zeigen bei der perkutanen RFA eine hohe lokale Rezidivrate und sind keine optimalen Kandidaten für dieses Verfahren. Sowohl für die operative Behandlung als auch die lokal destruierenden Maßnahmen muss ausreichende Erfahrung vorliegen, sodass diese Patienten nur in Zentren mit Erfahrung in der Leberchirurgie behandelt werden sollten.

Abstract

In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters:
1. General operability of the patient (comorbidity);
2. Achievability of an R 0 situation:
i. if necessary, in combination with ablative methods,
ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations;
3. Sufficient volume of the liver remaining after resection („future liver remnant = FLR):
i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy;
4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage;
5. Tumour biological aspects (“prognostic variables”);
6. Experience of the surgeon and centre!
Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.

Schlüsselwörter

Lebermetastasen - kolorektales Karzinom - Leberresektion - Radiofrequenzablation - Laser - Chemotherapie

Key words

liver metastasis - colorectal carcinoma - liver resection - radiofrequency ablation - laser - chemotherapy

Volltext

Referenzen

Literatur

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Prof. Dr. R. T. Grundmann

Kreiskliniken Altötting-Burghausen

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