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DOI: 10.1055/s-2005-872572
© Georg Thieme Verlag Stuttgart · New York
Die operative Behandlung des Lungenkarzinoms im lokal begrenzten Stadium
Surgical Management of Lung Cancer in Stages I-IIIAPublication History
Publication Date:
14 December 2005 (online)
![](https://www.thieme-connect.de/media/viszeralchirurgie/200506/lookinside/thumbnails/10.1055-s-2005-872572-1.jpg)
Zusammenfassung
Etwa 30 % der Patienten mit einem nicht-kleinzelligen (NSCLC) und 5 % mit einem kleinzelligen (SCLC) Lungenkarzinom befinden sich bei Diagnosestellung in einem operablen Stadium. Die primäre Resektion mit kurativer Intention kann diesen Patienten jedoch eine echte Verlängerung des Langzeitüberlebens ermöglichen. Bevorzugt wird sie als standardisiertes Therapieverfahren der Wahl in den eher begrenzten Tumorstadien I und II eingesetzt. In Abhängigkeit von einer korrekten Indikationsstellung lassen sich mit den klassischen offenen Resektionsverfahren Lobektomie, Bilobektomie und Pneumonektomie 5-Jahres-Überlebensraten (5-JÜR) über 70 % im Frühstadium IA und 48 % im Stadium II erzielen. Zunehmend wird die videoassisstierte Thorakoskopie (VATS) als minimalinvasives Verfahren im Stadium I erfolgreich eingesetzt. Unabhängig ob offen oder minimalinvasiv ist es obligat, alle tumortragenden Abschnitte en bloc und komplett mit tumorfreien Resektionsrändern zu entfernen und zusätzlich eine systematische mediastinale Lymphadenektomie durchzuführen. Im Stadium IIIA mit befallenen mediastinalen Lymphknoten (N2) setzen sich zunehmend präoperative und/oder postoperative multimodale Therapieverfahren wie die Induktionsradiochemotherapie mit anschließender Resektion durch. Bei richtiger Indikationsstellung und korrekter operativer Verfahrenswahl lassen sich akzeptable perioperative Morbiditäts- und Mortalitätsraten erzielen. Die seit 2005 zusätzlich empfohlene postoperative adjuvante Chemotherapie in den lokal-begrenzten Stadien IB und II lässt aufgrund abgeschlossener Phase III-Studien ein bis zu 15 % verbessertes 5-JÜR erwarten und sollte in ein interdisziplinäres Therapiekonzept miteingebunden werden.
Abstract
Only 30 % of patients with non-small-cell lung cancer (NSCLC) and 5 % with small-cell lung cancer (SCLC) are eligible for curative operative resection at time of diagnosis. Surgical treatment, however, remains the only treatment modality which permits long-term survival in these patients. Usually, the locally contained stage I and II tumours are suitable for rountine complete primary resection. Following proper preoperative tumour staging and functional assessment of the patient standard open operative procedures such as lobectomy, bilobectomy and pneumonectomy show 5-year survival rates ranging from 70 % in early cancer stage IA to 48 % in stage II disease. Videothoracoscopic surgery (VATS) has been increasingly employed with success to resect early IA tumours. Nevertheless, basic surgical principle must be to resect enbloc all tumour ridden tissue with systematic mediastinal lymph node dissection whether open or minimal-invasive techniques are used. In stage IIIA disease with mediastinal lymph node infiltration (N2) preoperative treatment regimens such as radiochemotherapy followed by resection are being evaluated in controlled clinical studies. In any case an interdisciplinary treatment concept is always indicated at this stage. Given proper preoperative evaluation of the patient and use of the correct surgical technique acceptable perioperative morbidity and mortality rates may be achieved. Recent recommendations (2005) concerning the use of standard chemotherapeutic regimens in an adjuvant setting following surgery for stage IB and II disease suggest up to 15 % improved 5-year survival rates based on large-scale phase III clinical trials. Therefore, adjuvant chemotherapy should be considered as standard treatment in these selected patients.
Schlüsselwörter
Lungenkarzinom - NSCLC - SCLC - Tumorstadien - VATS - Überleben
Key words
lung cancer - NSCLC - SCLC - tumor stage - VATS - survival
Literatur
- 1 Travis W D, Brambilla E, Müller-Hermelink H K, Harris C C. World Health Organization Classification of Tumors. Pathology and Genetics of Tumors of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004
- 2 Samet J M. The epidemiology of lung cancer. Chest. 1993; 103 20
- 3 Nowack D, Magnussen H, Rüdiger H W. Exposition und Disposition in der Genese des Bronchialkarzinoms. Pneumol. 1989; 43 135-146
- 4 Rogot E, Murray J L. Smoking and causes of death among U.S. veterans: 16 years of observation. Public Health Rep. 1980; 95 213
- 5 Mountain C F. The new international staging system for lung cancer. Surg Clin North Am. 1987; 67 925
- 6 Mountain C F. The international system for staging lung cancer. Semin Surg Oncol. 2000; 18 106-115
- 7 Martini N, Bains M S, Burt M E. et al . Incidence of local recurrence and second primary tumours in resected stage I lung cancer. J Thorac Cardiovasc Surg. 1995; 109 120
- 8 Rens M TM van, de la Rivere A B, Elbers H RJ, den Bosch J MM van. Prognostic assessment of 2 361 patients who underwent pulmonary resection for non-small cell lung cancer, stage I, II and IIIA. Chest. 2000; 117 374-379
- 9 Williams D E, Pairolero P C, Davis C S, Bernatz P E. et al . Survival of patients surgically treated for stage I lung cancer. J Thorac Cardiovasc Surg. 1981; 82 70
- 10 Thomas C F, Tazelaar H D, Jett J R. Typical and atypical pulmonary carcinoids: outcome in patients presenting with regional lymph node involvement. Chest. 2001; 119 1143-1150
- 11 Terasaki H, Niki T, Matsuno Y. et al . Lung adenocarcinoma with mixed bronchioloalveolar and invasive components: clinicopathological features, subclassification by extent of invasive foci, and immunohistochemical characterization. Am J Surg Pathol. 2003; 27 937-951
- 12 Holden D A, Rice T W, Stelmach K, Meeker D P. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest. 1992; 102 1774-1779
- 13 Ferguson M K, Reeder L B, Mick R. Optimising selection of patients for major lung resection. J Thorac Cardiovasc Surg. 1995; 109 275-281
- 14 Beckles M A, Spiro S G, Colice G L, Rudd R M. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest. 2003; 123 105 S-114 S
- 15 Olsen G N, Bolton J W, Weiman D S, Hornung C A. Stair climbing as an exercise test to predict the postoperative complications of lung resection. Two years' experience. Chest. 1991; 99 587-590
- 16 Abrams J, Doyle L A, Aisner J. Staging, prognostic features and special considerations in small cell lung cancer. Semin Oncol. 1988; 15 261
- 17 Dwamena B A, Sonnad S S, Angobaldo J O, Wahl R L. Metastases from non-small cell lung cancer : mediastinal staging in the 1990s - Meta-analytic comparison of PET and CT. Radiology. 1999; 213 530-536
- 18 Tinteren H Van, Hoekstra O S, Smit E F. et al . Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: The PLUS multicentre randomised trial. Lancet. 2002; 359 1388-1393
- 19 Bültzingslöwen F, Emslander H P, Gallenberger S. et al .Diagnostik des Bronchialkarzinoms. In: Schalhorn A (Hrsg). Manual Tumorzentrum München Empfehlungen zur Diagnostik, Therapie und Nachsorge, Tumoren der Lunge und des Mediastinums. W. Zuckschwerdt Verlag, München 2000; 5-17
- 20 Semik M, Netz B, Schmidt C, Scheld H. Surgical exploration of the mediastinum: mediastinoscopy and intraoperative staging. Lung Cancer. 2004; 45 (Suppl 2) 555-561
- 21 Hoffmann H. Invasive staging of lung cancer by mediastinoscopy and video-assisted thorascopy. Lung Cancer. 2001; 34 S 3-S 5
- 22 British Thoracic Society and Society of Cardiothoracic surgeons of Great Britain and Ireland working Party . Guidelines on the selection of patients with lung cancer for surgery. Thorax. 2001; 56 89-108
- 23 Pfister D G, Johnson D H, Azzoli C G. et al . American Society of Clinical Oncology. American Society of Clinical Oncology treatment of unresectable non-small-cell lung cancer guideline: update. J Clin Oncol. 2004; 22 330-353
- 24 Belani C P. Adjuvant and neoadjuvant therapy in non-small cell lung cancer. Semin Oncol. 2005; 32 (Suppl 2) S 9-S 15
- 25 Smythe W R. Treatment of stage I non-small cell lung carcinom. Chest. 2003; 123 181 S-187 S
- 26 Inoue K, Sato M, Fujimura S. et al . Prognostic assessment of 1 310 patients with non-small cell lung cancer who underwent complete resection from 1980-1993. J Thorac Cardiovasc Surg. 1998; 116 407-411
- 27 Sakurada A, Sagawa M, Usuda K. et al . The significance of surgical treatment for T4 lung cancer. Kyobu Geka. 1997; 50 95-100
- 28 Rendina E A, Venuta F, De Giacomo T. et al . Inductiontherapy for T4 centrally located non-small cell lung cancer. J Thorac Cardiovasc Surg. 1999; 117 225-233
- 29 Deslauriers J, Gregoire J, Jacques L F, Piraux M, Guojin L, Lacasse Y. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and site of recurrences. Ann Thorac Surg. 2004; 77 1152-1156
- 30 Tan B B, Flaherty K R, Kazerooni E A, Iannettoni M D. American College of Chest Physicians . The solitary pulmonary nodule. Chest. 2003; 123 89 S-96 S
- 31 Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg. 2000; 24 27-31
- 32 Smythe W R. American College of Chest Physicians . Treatment of stage I non-small cell lung carcinoma. Chest. 2003; 123 181 S-187 S
- 33 Manser R, Wright G, Hart D, Byrnes G, Campbell D A. Surgery for early stage non-small cell lung cancer. The Cochrane Database of Systematic Reviews 2005; Issue 1. Art.No.: CD004699
- 34 Jaklitsch M T, Pappas-Estocin A, Bueno R. Thoracoscopic surgery in elderly lung cancer patients. Crit Rev Oncol/Hematol. 2004; 49 165-171
- 35 Ginsberg R J, Rubinstein L V. Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Ann Thorac Surg. 1995; 60 615-623
- 36 The International Adjuvant Lung Cancer Trial Collaborative Group . Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small cell lung cancer. N Engl J Med. 2004; 350 351-360
- 37 Izbicki J R, Passlick B, Pantel K. et al . Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non-small cell lung cancer: results of a prospective randomized trial. Ann Surg. 1998; 227 138-144
- 38 Spira A, Ettinger D S. Multidisciplinary management of lung cancer. N Engl J Med. 2004; 350 379-392
- 39 Depierre A, Milleron B, Moro-Sibilot D. et al . Preoperative chemotherapy followed by surgery compared with primary surgery in resectable stage I (except T1N0), II and IIIA non-small-cell lung cancer. J Clin Oncol. 2002; 20 247-253
- 40 Farray D, Mirkovic N, Albain K S. Multimodality therapy for stage III non-small cell lung cancer. J Clin Oncol. 2005; 23 3257-3269
- 41 Rusch V W, Giroux D J, Kraut M J. et al . Induction chemoradiation and surgical resection for non-small cell carcinomas of the superior sulcus: Initial results of Southwest Oncology Group Trial 9916 (Intergroup Trial 0160). J Thorac Cardiovasc Surg. 2001; 121 472
- 42 Dt. Krebsgesellschaft (Hrsg) .Qualitätssicherung in der Onkologie - Interdiszplinäre Leitlinien 1999: Diagnose und Therapie maligner Erkrankungen. München, Bern, Wien, New York 1999; 59-66
- 43 Adej A A, Marks R S, Bonner J A. Current guidelines for the management of small cell lung cancer. Mayo Clin Proc. 1999; 74 809-816
- 44 Dusmet M, Goldstraw P. Surgery for small cell lung cancer. Hematol Oncol Clin N Am. 2004; 18 323-341
- 45 Simon G R, Wagner H. American College of Chest Physicians . Small cell lung cancer. Chest. 2003; 123 259 S-271 S
- 46 Riedel R F, Crawford J. Small-cell lung cancer: a review of clinical trials. Semin Thorac Cardiovasc Surg. 2003; 15 448-456
- 47 Shepard F A, Ginsberg R J, Evans W K. et al . Reduction in local recurrence and improved survival treated patients with small cell lung cancer. J Thorac Cardiovasc Surg. 1983; 86 498-506
- 48 Damhuis R AM, Schütte P R. Resection rates and postoperative mortality in 7 899 patients with lung cancer. Eur Respir J. 1996; 9 7-10
- 49 Licker M, de Perrot M, Höhn L. et al . A Perioperative mortality and major cardio-pulmonary complications after lung cancer surgery for non-small cell carcinoma. Eur J Cardio-Thorac Surg. 1999; 15 314-319
- 50 Rens M T van, de la Riviere A B, Elbers H RJ, den Bosch J MM van. Prognostic assessment of 2 366 patients who underwent pulmonary resection for non-small cell lung cancer, stage I, II and IIIA. Chest. 2000; 117 374-379
- 51 Roxburgh J C, Thompson J, Goldstraw P. Hospital mortality and long-term survival after pulmonary resection in the elderly. Ann Thorac Surg. 1991; 51 800-803
- 52 Asamura H, Haruhiko K, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures. Eur J Cardio-Thorac Surg. 2000; 17 106-110
- 53 Winton T, Livingston R, Johnson D. et al . National Cancer Institute of the United States Intergroup JBR.10 Trial Investigators. Vinorelbine plus cisplatin vs. observation in resected non-small-cell lung cancer. N Engl J Med. 2005; 352 2589-2597
- 54 Alam N, Sheperd F A, Winton T. et al . Compliance with post-operative adjuvant chemotherapy in non-small-cell lung cancer. An analysis of the National Cancer Institute of Canada and Intergroup Trial JBR.10 and a review of the literature. Lung Cancer. 2005; 47 385-394
PD Dr. med. Rudolf A. HatzFACS
Chirurgische Klinik und Poliklinik · Klinikum Großhadern · Ludwig-Maximilians-Universität München
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