Rezidivlebermetastasen kolorektaler Karzinome: Wer profitiert von einer zweiten Leberresektion?

Zusammenfassung

Hintergrund: Rezidivlebermetastasen kolorektaler Karzinome treten bei ca. 40 % der Patienten nach schon vorangegangener Leberresektion auf. Ziel dieser Untersuchung war es, Prognosefaktoren für das Überleben und den Nutzen einer erneuten Leberresektion zu evaluieren. Patienten und Methoden: Bei 60 Patienten, bei denen eine 2. Leberresektion wegen kolorektaler Rezidivlebermetastasen durchgeführt wurde, wurden insgesamt 39 Parameter aus einer prospektiv geführten Datenbank identifiziert und in Hinblick auf das rezidivfreie und das Gesamtüberleben analysiert. Ergebnisse: Bei einem mittleren Follow-up von 26 Monaten (Range: 2–173 Monate) nach der 2. Lebermetastasenresektion war das rezidivfreie Überleben nach 3 und 5 Jahren 50 % und 37 %. Das Gesamtüberleben betrug 61 % bzw. 52 %. Ein erneutes Rezidiv trat bei 58 % der Patienten auf. Davon war das Rezidiv bei 19 Patienten (32 %) auf die Leber beschränkt. Mittels multivariater Analyse (Cox proportional hazard model) wurden ein Abstand von weniger als 24 Monaten zwischen der Diagnose der 1. Lebermetastase(n) und der Operation des Primärkarzinoms (HR: 6,47; p = 0,002), ein CEA-Level von 4,0 ng/ml oder mehr zum Zeitpunkt der 1. Lebermetastasenresektion (HR: 3,48; p = 0,004) und eine Größe einer Metastase von mehr als 80 mm (HR: 4,73; p = 0,007) als unabhängige Prognosefaktoren für ein reduziertes rezidivfreies Überleben identifiziert. Ein erneutes Rezidiv der Lebermetastasierung ohne Option einer kurativen Resektion war der einzige Prognosefaktor für eine Reduktion des Gesamtüberlebens nach der 2. Leberresektion (p = 0,009). Hierdurch erhöhte sich das Mortalitätsrisiko um den Faktor 4,51, bei der Möglichkeit einer Resektion des Metastasenrezidivs hingegen nur um den Faktor 1,40. Schlussfolgerung: Technisch resektable Rezidivlebermetastasen sollten wie die primäre Metastasierung einer Resektion zugeführt werden. Sowohl Charakteristika der 1. Lebermetastasierung als auch Parameter des hepatischen Rezidivs beeinflussen die Prognose der Patienten nach der Resektion der Rezidivlebermetastasen. Die neuerliche Resektion kolorektaler hepatischer Rezidive nach bereits erfolgter 2-maliger Entfernung von Lebermetastasen ermöglicht für die Patienten wiederum eine Verbesserung der Prognose.

Abstract

Background: Hepatic recurrence is seen in approximately 40 % of patients undergoing hepatectomy for colorectal metastases. The authors assessed the benefit and the main prognostic factors for a second liver resection of recurrent colorectal metastases. Methods: This study reports the experience with second liver resections for recurrent liver metastases at a German University Hospital. A total of 39 parameters from 60 patients were identified from a prospective database and analysed as to their influence on recurrence-free survival and overall survival. Results: At a median follow-up of 26 months (range: 2–173 months) after second hepatic resection, recurrence-free survival at 3 and 5 years were 50 % and 37 %, respectively. The overall survival at three and five years were 61 % and 52 %, respectively. Recurrence was identified in 58.3 % of the patients. Recurrences involved exclusively the liver in 19 patients (31.6 %). By multivariate analysis (Cox proportional hazard model), a time interval between diagnosis of the liver metastases of less than 24 months after operation for colorectal primary carcinoma (HR: 6.47, p = 0.002), a CEA level of 4.0 ng/mL or more (HR: 3.48, p = 0.004) at the time of first liver metastases and a size of second liver metastases of 80 mm or more (HR: 4.73, p = 0.007) were independent prognostic factors for a reduced recurrence-free survival. A repeat recurrence of liver metastases without the option of curative resection was the only risk factor for overall survival after second hepatic resection (p = 0.009). In these cases, mortality risk was 4.51-fold, however, when the second liver recurrence was resectable, the mortality risk increased only 1.4-fold. Conclusions: Technically resectable recurrent colorectal hepatic metastases should be resected the same as the first metastases. Characteristics of the primary metastasis as well as parameters of the hepatic recurrence are shown to influence the prognosis of patients after resection of recurrent liver metastases. Repeat resection of colorectal liver metastases allows for improved survival in patients even after two previous liver operations.

Schlüsselwörter

Leberchirurgie - Lebermetastasenresektion - kolorektales Karzinom - Resektabilität - Rezidiv

Key words

liver surgery - resection of liver metastases - colorectal carcinoma - resectability - recurrent tumour growth - tumour recurrence

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