Ergebnisse des chirurgischen Vorgehens bei NSCLC und Infiltration der Vena cava superior

Zusammenfassung

Das therapeutische Vorgehen bei NSCLC und Infiltration der Vena cava superior (VCS) wird häufig kontrovers diskutiert. Der Ersatz oder die Rekonstruktion der VCS ist unter Einbeziehung multimodaler Therapieverfahren heute eine therapeutische, aber technisch anspruchsvolle Option. Unsere heutige Vorgehensweise, deren Änderung im Lauf der Zeit und die jeweiligen Ergebnisse werden präsentiert.

Zwischen 1998 und 2013 erfolgte bei 17 Patienten ein alloplastischer Ersatz oder die Rekonstruktion (n = 5) der VCS bei NSCLC im Rahmen einer Lobektomie (n = 8) oder Pneumonektomie (n = 14). Eine adjuvante Strahlentherapie erhielten 16, eine induktive Chemotherapie 3 Patienten. Retrospektiv ausgewertet wurden der klinische Verlauf und das Überleben.

Therapierelevante postoperative Komplikationen traten bei 13 Patienten auf. Ein Verschluss des Interponats fand sich bei keinem Patienten. Die 30-Tage-Letalität nach Pneumonektomie betrug 7 %, nach Lobektomie 0 %. Die Lokalrezidivrate betrug 4,5 %, das Auftreten von Fernmetastasen lag bei 54,5 % ( p = 0,0008). Die Überlebenskurve für das Gesamtkollektiv zeigte ein 1-Jahres-Überleben von 63,6 %, ein 5-Jahres-Überleben von 27,9 %. Patienten mit VCS-Rekonstruktion haben eine etwas bessere Prognose als Patienten mit VCS-Ersatz im 5-Jahres-Vergleich (33 % vs. 25 %, p = 0,22). Patienten mit einer Lobektomie zeigten ein 5-Jahres-Überleben von 37,5 % (n = 8), nach Pneumonektomie lag dieses bei 21,4 % (n = 14, p = 0,18).

Bei NSCLC und Infiltration der Vena cava superior kann man mit Resektion und adjuvanter Strahlentherapie eine gute lokale Kontrolle erzielen. Aufgrund der hohen Rate an Fernmetastasen sollten induktive und adjuvante chemotherapeutische Möglichkeiten sorgfältig erwogen werden.

Abstract

The benefits of surgical therapy of locally advanced non-small cell lung cancer (NSCLC) with infiltration of the superior vena cava (SVC) remains controversial. Here we describe our therapeutic approach and results of our intervention.

A retrospective analysis of 22 patients with NSCLC who underwent SVC replacement (n = 17) or reconstruction (n = 5) between 1998 and 2013 was performed. Pneumonectomy was necessary in 16 patients, lobectomy in 8. Preoperative chemotherapy was administered to 3 patients, 16 received postoperative radiation treatment. The clinical course and survival were analyzed.

Major postoperative morbidities were found in 13 patients. Graft thrombosis did not occur. Thirty-day mortality was 7 % in pneumonectomy patients and 0 % following lobectomy. Local recurrence was found in 4.5 %, distant metastases developed in 54.5 % of the patients (p = 0.0008). One- and five-year survival probabilities for all patients were 63.6 and 27.9 %. Five-year survival probability was 33 % for patients with SVC reconstruction and 25 % for patients with SVC replacement (p = 0.22). Five-year survival rates after pneumonectomy and lobectomy were 21.4 % and 37.5 %, respectively (p = 0.18).

Radical resection involving the SVC in carefully selected patients with NSCLC results in excellent local tumor control. Due to the high rate of distant metastases, application of induction and adjuvant chemotherapy should be carefully assessed.

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