Tumorchirurgie – Aspekte zur Behandlung gastrointestinaler Malignome

Die Chirurgie ist und bleibt auch in einer Zeit multimodaler Therapieoptionen der wesentliche Bestandteil in der Behandlung gastrointestinaler Malignome. In der Ösophagus-Chirurgie verbreitet sich in neuerer Zeit zur Reduktion der Morbidität ein minimalinvasives Operieren. Dabei werden unterschiedliche Konzepte verfolgt: Das komplette thorakoskopische und laparoskopische Vorgehen sowie Hybridverfahren. Beim Plattenepithelkarzinom des Ösophagus zeichnet sich ein Trend in Richtung einer definitiven Radiochemotherapie in kurativer Intention ab, obwohl die Evidenzlage nicht konklusiv ist. Die lokale Operabilität des Pankreaskarzinoms wird anhand radiologischer Kriterien in resektabel, grenzwertig-borderline resektabel und nicht resektabel klassifiziert. Die wesentlichen Bezugsgrößen dabei sind das Tumorwachstum zu den intestinalen Gefäßen. Dies hat insofern an erheblicher Bedeutung gewonnen, nachdem Patienten mit borderline operablen Tumoren einer Induktionschemotherapie mit dem Plan einer sekundären Resektion zugeführt werden können. Beim asymptomatischen Primärtumor kann im Stadium IV eines kolorektalen Karzinoms primär eine Chemotherapie durchgeführt werden. Dabei bleibt die Frage der Tumorresektion im Intervall oder nach Ende der Chemotherapie unbeantwortet.

Even in the era of multimodal therapeutic options, surgery is and remains the major cornerstone in the treatment of gastrointestinal malignancies. Recently minimally invasive operations have become widespread in esophagus surgery to reduce morbidity. Various different concepts are employed for this purpose: completely thoracoscopic and laparoscopic interventions as well as hybrid procedures. In cases of squamous cell carcinoma of the esophagus there is a trend in the direction of defined radiotherapy a treatment with a curative intention, although the evidence-basis is not yet conclusive. The local operability of pancreatic cancers is classified into resectable, borderline resectable and not resectable on the basis of radiological criteria. The major reference parameter for this ia tumor growth to the intestinal vessels. This has attained considerable importance since patients with borderline operable tumors can undergo an induction chemotherapy leading to a planned secondary resection. The S3 guidelines on the treatment of colorectal cancers recommend the performance of a primary chemotherapy without resection for asymptomatic tumors. The question as to resection of the tumor during an interval or at the end of the chemotherapy still remains unanswered.

Key words

Tumor surgery - gastrointestinal malignancies - esophagus surgery - minimally invasive operations - hybrid procedures - pancreatic cancer - colorectal cancer

• Literatur

• 1 Stahl M, Walz MK, Stuschke M et al. Phase III comparison of preoperative chemotherapy compared with chemoradiotherapy in patients with locally advanced adenocarcinoma of the esophagogastric junction. J Clin Oncol 2009; 27: 851-856
• 2 van Hagen P, Hulshof MC, van Lanschot JJ et al. CROSS Group. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012; 366: 2074-2084
• 3 Luketich JD, Pennathur A, Awais O et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012; 256: 95-103
• 4 Putora PM, Bedenne L, Budach W et al. Oesophageal cancer: exploring controversies overview of experts' opinions of Austria, Germany, France, Netherlands and Switzerland. Radiat Oncol 2015; 10: 116-116
• 5 Kato K, Muro K, Manashi K et al. Phase II study of chemoradiotherapy with 5-fluorouracil and cisplatin for stage II-III esophageal squamous cell carcinoma: JCOG trial (JCOG 9906). Int J Radiat Oncol Biol Phys 2011; 81: 684-690
• 6 Watanabe M, Mine S, Nishida K et al. Salvage Esophagectomy After Definitive Chemoradiotherapy for Patients with Esophageal Squamous Cell Carcinoma: Who Really Benefits from this High-Risk Surgery?. Ann Surg Oncol Apr 11 (online) 2015;
• 7 Callery MP, Chang KJ, Fishman EK et al. Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement. Ann Surg Oncol 2009; 16: 1727-1733
• 8 Katz MH, Crane CH, Varadhachary G. Management of borderline resectable pancreatic cancer. Semin Radiat Oncol 2014; 24: 105-112
• 9 Conroy T, Desseigne F, Ychou M et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 2011; 364: 1817-1825
• 10 Faris JE, Blaszkowsky LS, McDermott S et al. FOLFIRINOX in locally advanced pancreatic cancer: the Massachusetts General Hospital Cancer Center experience. Oncologist 2013; 18: 543-548
• 11 Ferrone CR, Marchegiani G, Hong TS et al. Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg 2015; 261: 12-17
• 12 Poultsides GA, Servais EL, Saltz LB et al. Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment. J Clin Oncol 2009; 27: 3379-3384
• 13 Hu CY, Bailey CE, You YN et al. Time trend analysis of primary tumor resection for stage IV colorectal cancer: less surgery, improved survival. JAMA Surg 2015; 150: 245-251
• 14 Ahmed S, Leis A, Fields A et al. Survival impact of surgical resection of primary tumor in patients with stage IV colorectal cancer: results from a large population-based cohort study. Cancer 2014; 120: 683-691
• 15 Rahbari NN, Lordick F, Fink C et al. SYNCHRONOUS trial group. Resection of the primary tumour versus no resection prior to systemic therapy in patients with colon cancer and synchronous unresectable metastases (UICC stage IV): SYNCHRONOUS – a randomised controlled multicentre trial (ISRCTN30964555). BMC Cancer 2012; 12: 142-142