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DOI: 10.1055/s-2006-942286
© Georg Thieme Verlag Stuttgart · New York
Chirurgische und pathologische Qualitätssicherung beim Rektumkarzinom - eine besondere Herausforderung mit Einfluss auf die Therapie?
Surgical and Pathological Quality Assurance in Rectal Cancer - A Particular Challenge with Impact on Therapy?Publication History
Publication Date:
27 October 2006 (online)
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Zusammenfassung
Der Chirurg wird in der Therapie des Rektumkarzinoms als ein entscheidender Prognosefaktor angesehen. Seine Verantwortlichkeit für einen langfristigen Therapieerfolg liegt nicht nur in der Gewährleistung einer komplikationsarmen Operation (geringe Morbidität und Letalität), sondern auch im Erlernen moderner Resektionstechniken (z. B. der totalen mesorektalen Exzision, TME), im Erwerb profunder onkologischer Kenntnisse und in seiner Fähigkeit aktiv an interdisziplinären, multimodalen Konzepten (prä- und postoperative Radiochemotherapie) zur Behandlung lokal fortgeschrittener Rektumkarzinome (UICC-II/III-Stadien) teil zu haben. Gegenwärtig besitzt der histologisch überprüfte tumorfreie Resektionsrand, die R0-Klassifikation, den größten Einfluss auf das Überleben von Rektumkarzinom-Patienten. Insbesondere durch eine sorgfältige Untersuchung der zirkumferentiellen Resektionsränder am tumortragenden TME-Resektat kann der Pathologen jene Patienten identifizieren, die im weiteren postoperativen Verlauf ein hohes Risiko für ein Lokalrezidiv haben. Dabei führt ein zirkumferentieller Resektionsrand von < 1-2 mm (formal eine R0-Resektion) zu einer erhöhten Rate an Karzinomrezidiven. Zudem ist die Prognose der Rektumkarzinom-Patienten signifikant verschlechtert, sofern eine lymphatische Metastasierung vorliegt. Folglich ist eine umfassende histologische Untersuchung von Lymphknoten im TME-Rektum-Resektat unumgänglich. Verschiedene Untersuchungen haben gezeigt, dass je mehr Lymphknoten im Präparat analysiert werden, desto präziser das histopathologische Staging erfolgen kann. Es ist z. B. bekannt, dass die Prognose bei pN0-klassifizierten Patienten, bei denen der Pathologe weniger als 12 bis 14 Lymphknoten im Rektumresektat untersucht, deutlich schlechter ist im Vergleich zu Patienten mit > 18 untersuchten Lymphknoten. Dabei hängt die Anzahl der für das histopathologische Staging auswertbaren Lymphknoten sowohl von dem Training und der Präzision des chirurgischen Eingriffes als auch der Akribie der histopathologischen Aufarbeitung ab.
Vor dem Hintergrund, dass das arterielle und venöse rektale Netzwerk innerhalb der mesorektalen Hüllfaszien verläuft und die Lymphbahnen parallel zu den Blutgefäßen verlaufen, liegt es nahe, dass eine lymphogene Tumorzell-Aussaat in die mesorektale Faszie ein frühzeitiges Lokalrezidiv nach TME-Resektion bedingen kann. Somit ist eine umfassende Aufarbeitung des Mesorektumresektates mitsamt der dort lokalisierten Lymphknoten unerlässlich. Zusammenfassend ist die Qualität des chirurgischen Vorgehens als auch der histopathologischen Aufarbeitung Grundlage für die weitere Therapieentscheidung und ausschlaggebend für die Prognose des Patienten.
Abstract
The surgeon remains a crucial prognostic factor in the treatment of rectal cancer. His responsibility goes beyond the actual surgery (morbidity and letality). It also requires his experience in colorectal surgery (including the technique of total mesorectal excision, TME), his oncological view of rectal cancer disease, and his skills in taking part at interdisciplinary multimodal treatment schedules (pre- or postoperative radiochemotherapy in locally advanced rectal cancer (UICC stage II/III)). Because of the risk of dissemination of cancer cells during surgery, the extent of resection, and the responsibility of performing a curative R0 resection the surgeon is a key player in the attempt to avoid cancer recurrence. At present, the R classification (histopathologically checked resection margin) has the greatest influence on the survival in patients with rectal cancer and requires special attention by the investigator. Especially the pathologist's very careful evaluation of the circumferential tumor margins in the TME specimens can identify those patients who are at a high risk for local cancer recurrence. A circumferential tumor free margin of less than 1-2 mm resulted in an enhanced rate of cancer relapse. Moreover, the prognosis of patients with rectal cancer is significantly lower if they carry a lymphogeneous metastatic disease. A thorough pathologic assessment of the lymph nodes in the resected specimen of rectal cancer is therefore mandatory in all cases. Several reports demonstrate that the more lymph nodes are analyzed, the more precise is the histopathological staging. It has been shown that for patients classified as pN0, the prognosis was far worse if less than 12 to 14 lymph nodes were analyzed by the pathologist. The number of lymph nodes available for histopathological staging depends on the training and the meticulousness on the part of the surgeon (using the “no touch technique” and TME) as well as on the attentiveness on the part of the pathologist. Furthermore, it is known that the arterial and venous rectal vascular network lies within the mesorectal fascia. Because the lymph ducts run in parallel to the blood vessels, it is likely that a lymphogenous tumor spread within the mesorectal fascia causes local cancer relapses after TME resection. A careful assessment of lymph nodes in the surgical specimens remains mandatory. In summary, the surgical procedure as well as the pathologic assessment of tumors is critical for the decision on further treatment and for the judgement on the prognosis of the patient.
Schlüsselwörter
lokal fortgeschrittenes Rektumkarzinom (UICC-II/III-Stadium) - totale mesorektale Exzision - der Chirurg und der Pathologe sind gemeinsam Prognosefaktoren
Key words
locally advanced rectal cancer (UICC-II/III) - total mesorectal excision - surgeons and pathologists are prognostic factors
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Dr. med. T. Liersch
Zentrum Chirurgie · Abteilung Allgemeinchirurgie · Bereich Humanmedizin der Georg-August-Universität Göttingen
Robert Koch Str. 40
37099 Göttingen
Deutschland
Email: tliersc@gwdg.de