Infiltration der herznahen Gefäße durch Lungenkarzinome: Inzidenz, Klassifikationen, operative Technik unter Einsatz der Herz-Lungen-Maschine und Ergebnisse

Zusammenfassung

Lungenkarzinome, welche die herznahen Gefäße (linker Vorhof, Pulmonalarterie und Aorta) infiltrieren und bei denen keine mediastinalen Lymphknoten – oder eine Fernmetastasierung – vorliegen, sind insgesamt selten. Häufig werden solche Situationen im interdisziplinären Tumorboard als primär inoperabel eingeschätzt. Dies gilt nur dann, wenn ein erfahrener Thoraxchirurg sich aus operationstechnischen Gründen nicht in der Lage sieht, eine Resektion im Gesunden durchzuführen. Je nach infiltrierter Struktur muss über das operationstaktische Vorgehen individuell entschieden werden. In jedem Falle sollte ein komplettes Tumorstaging durchgeführt werden, auch, um zu entscheiden, ob eine neoadjuvante Chemotherapie vor der Resektion durchgeführt werden sollte. Entstehen durch die Resektion der herznahen Gefäße größere Defekte, so muss in jedem Falle eine Herz-Lungen-Maschine eingesetzt werden. Der Einsatz einer Herz-Lungen-Maschine im Rahmen der Tumorresektion ist hinsichtlich einer Tumorzellaussaat unproblematisch. Dennoch sollte auch aufgrund der Antikoagulation die Einsatzdauer der Herz-Lungen-Maschine auf das Mindestmaß begrenzt bleiben. Mit den heutzutage verfügbaren bovinen Ersatzmaterialien lassen sich die kardialen Defekte sicher verschließen. Die postoperative Morbidität und Mortalität ist nach solchen Resektionen niedrig. Ein 5-Jahres-Überlebensrate von bis zu 50 % kann durch die kurative Resektion der herznahen, durch Lungenkarzinome infiltrierten Gefäße erreicht werden.

Abstract

Carcinomas of the lung that infiltrate the blood vessels close to the heart (left atrium, pulmonary artery and aorta) without spreading to mediastinal lymph nodes or developing distant metastases are rare overall. Such situations are often classified as primarily inoperable by interdisciplinary tumour boards. This is only the case if, for technical reasons, an experienced thoracic surgeon does not feel able to perform a resection with a surrounding margin of healthy tissue. The surgical strategy to be employed must be chosen individually depending on the infiltrated structure. Complete tumour staging should always be carried out. This also helps in deciding whether neoadjuvant chemotherapy should be given before resection. A heart-lung machine must always be used if larger defects occur due to the resection of blood vessels close to the heart. Using a heart-lung machine in the case of tumour resection does not lead to problems of tumour cell dissemination. Nevertheless, the duration of use of the heart-lung machine should be kept to a minimum, also because of the anticoagulation required. The cardiac defects can be closed securely with the bovine patching materials that are now available. Postoperative morbidity and mortality are low after such resections. Curative resection of blood vessels close to the heart infiltrated by carcinomas of the lung can lead to 5-year survival rates of up to 50 %.

Schlüsselwörter

Aorta thoracica - chirurgische Technik - Thoraxchirurgie

Key words

cancer - thoracic aorta - surgical technique - thoracic surgery

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