Aktueller Stand in der chirurgischen Therapie von Lungenmetastasen

Zusammenfassung

Für Patienten mit einer isolierten Lungenmetastasierung stellt die chirurgische Therapie die ein­zige Chance auf Kuration dar. Die Chemothera­pie muss, trotz der aktuellen Fortschritte in den Behandlungskonzepten, als palliative Maßnahme betrachtet werden. Es ist von großer Bedeutung, durch ein sorgfältiges klinisches Staging und ­unter Berücksichtigung definierter Prognosefaktoren Patienten zu selektionieren, die von einer Operation profitieren könnten. Neben den etablierten Kriterien zur Metastasektomie sind die Parameter: Anzahl Lungenmetastasen, krankheitsfreies Intervall (KFI), Serum-Tumormarkerspiegel und die Frage einer hilären oder mediastinalen Lymphknotenmetastasierung für die Indikationsstellung zur Operation bedeutsam. Ein ­potenzielles Langzeit-Überleben ist nur durch die radikale Resektion mittels Thorakotomie und systematischer mediastinaler und hilärer Lymphknotendissektion zu erreichen. Aktuelle Entwicklungen in der video-assistierten Thorakoskopie (VATS) und radiologischen Diagnostik ermög­lichen auch die Resektion kleiner pulmonaler Rundherde. Als Operationsverfahren zur Resek­tion von Lungenmetastasen wird bei Verwendung der VATS die zu fordernde onkologische Radikalität bezweifelt. Dennoch besitzt die VATS einen hohen Stellenwert als diagnostisches Verfahren und sollte, möglichst nur innerhalb klinischer Studien zur Metastasektomie, in einem selektio­nierten Patientenkollektiv mit wenigen, peripher lokalisierten Metastasen evaluiert werden. Alle Ergebnisse zusammengenommen zeigen, dass die Resektion von Lungenmetastasen und Rezidiv-Lungenmetastasen erfolgreich und mit kurativem Ansatz durchgeführt werden kann. Dies setzt jedoch eine interdisziplinäre Therapieentscheidung in einem Tumorboard, bestehend aus Thoraxchirurgen und internistischen Onkologen, voraus.

Abstract

Surgical resection has been the first choice for the treatment of isolated pulmonary metastases ­sec­ondary to extrapulmonary malignancies. De­spite recent advances, systemic chemotherapy for metastatic disease without the use of surgery is considered to be merely palliative, as there are rarely long-term survivors. Criteria for resection and prognostic parameters help facilitate patient selection. In addition to the established param­eters the most significant factors in selecting ­patients for operation include the number of pulmonary metastases, disease-free interval, serum tumour marker level, and the question of medi­astinal and hilar lymph node metastases. Com­plete surgical resection is critical to achieving long-term survival and is best accomplished via open thoracotomy accompanied by a systematic mediastinal and hilar lymph node dissection. The recent development of video-assisted thoraco­scopic surgery (VATS) and advances in thoracic imaging technique has made the VATS approach more ammenable for resection of small pulmo­nary nodules. However, the oncological radicality of VATS is questionable for pulmonary metas­tasectomy, thus the VATS approach is mostly lim­ited to diagnostic purposes and in highly selected groups of patients with limited, peripherally locat­ed lesions. These operations should be performed preferably within a prospective study setting. All results together demonstrate that resection and re-resection of pulmonary metastases can be benefical in patients, carefully selected by a multidiscipinary tumour board of thoracic surgeons and medical oncologists.

Schlüsselwörter

Lungenmetastasen - Prognosefaktoren - Chirurgie

Key words

pulmonary metastases - prognostic factors - surgery

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