Der Chirurg

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Chirurgische Therapie der Peritonealkarzinose kolorektaler Karzinome

Leitthema
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Zusammenfassung

Die chirurgische Zytoreduktion (CRS) mit hyperthermer intraperitonealer Chemotherapie (HIPEC) kann bei geeigneten Patienten mit peritonealen Metastasen kolorektaler Karzinome das Gesamtüberleben im Vergleich zu reiner systemischer Chemotherapie signifikant verlängern. Entscheidend für ein gutes onkologisches Ergebnis ist einerseits die makroskopisch komplette Zytoreduktion, andererseits aber auch eine möglichst frühe chirurgische Therapie, da eine lineare Korrelation zwischen der peritonealen Tumorlast und dem Gesamtüberleben besteht. Eine synchrone Resektion von Lebermetastasen ist mit guten Ergebnissen möglich und hat keinen Einfluss auf die Morbidität. Für die intraperitoneale Chemotherapie sind die Substanzen Mitomycin C und Oxaliplatin derzeit als gleichwertig zu betrachten. Diskrepante Ergebnisse liegen zur perioperativen systemischen Chemotherapie vor, da einzelne Studien ein schlechteres Gesamtüberleben nach neoadjuvanter Therapie zeigten. Im Hinblick auf die adjuvante Therapie gibt es Hinweise auf einen Überlebensvorteil, sofern mindestens 6 Zyklen verabreicht werden. Die derzeit noch schwierige Früherkennung peritonealer Metastasen wird möglicherweise zukünftig durch den Einsatz von „liquid biopsies“ mit Nachweis freier Tumor-DNA oder -RNA sicherer und einfacher, bis dahin kommt für Risikopatienten eine geplante Second-look-Laparotomie infrage. Ergänzend hierzu wird in mehreren Studien derzeit der Stellenwert einer adjuvanten oder prophylaktischen HIPEC geprüft. Im Falle eines Rezidivs nach HIPEC sollte ein erneutes chirurgisches Vorgehen erwogen werden, wobei zur Indikationsstellung dieselben Kriterien anzuwenden sind wie für den Primäreingriff. Ein rezidivfreies Intervall >2 Jahre ist prognostisch günstig.

Schlüsselwörter

Chirurgische Zytoreduktion Hypertherme intraperitoneale Chemotherapie Systemische Chemotherapie Lebermetastasen Rezidiv 

Surgical treatment of peritoneal metastases of colorectal cancer

Abstract

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may significantly improve overall survival in selected patients with peritoneal metastases of colorectal cancer. For good oncological results complete macroscopic cytoreduction is crucial; furthermore, a linear correlation between peritoneal tumor load, as determined by the peritoneal cancer index (PCI) and overall survival has been demonstrated; therefore, surgical treatment should be initiated as early as possible. Synchronous resection of up to three liver metastases may be performed safely and with good results and no influence on the morbidity. With respect to intraperitoneal chemotherapy, mitomycin C and oxaliplatin are most commonly used and may be regarded as equal; however, for perioperative chemotherapy study results are so far inconclusive with some trials hinting at decreased overall survival following neoadjuvant chemotherapy. Adjuvant therapy is likely to improve overall survival if at least 6 cycles are applied. Early detection of peritoneal metastases is difficult at present but might be facilitated in the future by the use of liquid biopsies, which may detect circulating free tumor-specific DNA or RNA. In the meantime, planned second-look laparotomy should be considered for patients at high risk of peritoneal recurrence. In addition, several international studies are currently evaluating the concept of adjuvant or prophylactic HIPEC. The CRS and HIPEC may be repeated in cases of recurrence and should be considered in suitable patients, applying the same criteria as for primary CRS and HIPEC. A recurrence-free interval of >2 years is associated with a significantly better prognosis.

Keywords

Cytoreductive surgery Hyperthermic intraperitoneal chemotherapy Systemic chemotherapy Liver metastases Recurrence 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

S. Schüle, H. Mothes, U. Settmacher und J. Zanow geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  • S. Schüle
    • 1
  • H. Mothes
    • 1
  • U. Settmacher
    • 1
  • J. Zanow
    • 1
  1. 1.Klinik für Allgemein‑, Viszeral- und GefäßchirurgieUniversitätsklinikum JenaJenaDeutschland

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