Stellenwert endoskopischer Diagnostik und Resektionstechniken bei benignen und malignen kolorektalen Neoplasien

Zusammenfassung

Diagnostik und Therapie von benignen und malignen kolorektalen Neoplasien basieren auf morphologischen (Paris-Klassifikation, Kyoto-Konferenz) und histopathologischen Einteilungen (WHO- und Wien-Klassifikation). Prinzipiell werden vorgewölbte (0–I), flache (0–II) und ulzerierte (0–III) Poly­pen unterschieden. Flache Polypen machen ca. ein Drittel aller Kolonpolypen aus. Global ist die Karzinomrate von Kolonpolypen größenabhängig und steigt mit zunehmender Polypengröße. Eine Sondergruppe stellen hier die 0–II c-Läsionen dar: bereits Läsionen < 1 cm weisen hier eine deutlich erhöhte Karzinomrate auf, sind bei Diagnosestellung nicht mehr frühinvasiv und sollten operiert werden. Dies gilt in geringerem Ausmaß auch für die LST-NG-Polypen. Kolonfrühkarzinome sind durch die ausschließliche bzw. alleinige Invasion der Submukosa charakterisiert. Die Therapie kolorektaler Frühkarzinome basiert auf dem Low-Risk- und High-Risk-Konzept. Dieses beinhaltet G-Klassifikation, L-Klassifikation, Tumorzell-Budding und Messung der Submukosainvasionstiefe. T1-Karzinome werden anhand der Invasionstiefe in sm1-, sm2- und sm3-Stadien eingeteilt. Alter­nativ wird beim Polypektomiepräparat die Sub­mukosainvasionstiefe gemessen und auf maximal 1000 µm festgelegt (gilt nur für den nicht gestielten Polypen!). Low-Risk-Frühkarzinome haben eine niedrige Lymphknotenmetastasierungsrate (0 ± 2 %). Deshalb ist bei belegter Entfernung im Gesunden (R0) die lokale endoskopische Therapie ausreichend und keine nachfolgende onkologische Resektion erforderlich. Benigne Neoplasien sind unabhängig von ihrer Größe in der Regel sicher und effektiv endoskopisch therapierbar. Die Langzeit­ergebnisse sind befriedigend. Die ESD ist indiziert, wenn eine En-Bloc-Resektion intendiert ist (z. B. bei „fortgeschrittener“ Histologie) und die polypoide Läsion im Rektum unterhalb der peritonealen Umschlagsfalte liegt. 

Abstract

Diagnosis and therapy of benign and malign colorectal neoplasias are based on morphological and histopathological classifications (Paris-Classification, Kyoto-Conference). In principle polyps are, according to their appearance, divided in pro­truding (0–I), flat (0–II) and ulcerated (0–III) forms. Flat polyps account for about one-third of the entirety of all colorectal polyps. Overall ­frequency of malign degeneration of colorec­tal polyps positively correlates with polyp size. In this context 0–II c lesions are an exception: ­al­ready 0–II c lesions < 1 cm show considerable ­increased carcinoma rates, are no longer early ­invasive and should be transferred for oncologi­cal resection. This applies for a lower extent also to LST-NG-polyps. Early colorectal cancer is de­fined by sole and exclusively invasion of the submucosal layer. Therapy of early colorectal cancer is based on low-risk- / high-risk-concept. This concept includes tumor-grading, lymphangioinva­sion, tumorcell-budding and depth of submucosal invasion. According to the depth of submcosal invasion stages are divided in sm1-, sm2- and sm3-invasion respectively. Alternatively for polyp­ectomy specimen measurement of submucosal invasion depth is used and the maximal acceptable extent is assessed to 1000 µm (does not apply to pedunculated polyps!). Low-risk-early-cancers show low rates of lymphnode metastasis (0 ± 2 %). Hence for proven complete resection (R0-status), local endoscopic therapy is sufficient and sub­sequent oncological resection is needless. Gen­er­ally benign neoplasias are safely and effectively treatable by endoscopy regardless to their size. Long-term-results of endoscopic treatment are satisfactory. ESD is indicated if en-bloc-resection is intended (i. e. for “advanced” histology) and the polypoid lesion is located in the rectum below the peritoneal fold. 

Schlüsselwörter

kolorektale Neoplasie - Polypektomie - Kolonfrühkarzinom - Low-Risk- / High-Risk-Konzept

Key words

colorectal neoplasia - polypectomy - early colorectal cancer - low-risk- / high-risk-concept

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