Kurative endoskopische Therapie: Welche Läsionen eignen sich?

Zusammenfassung

Durch die Einführung der flächendeckenden Vorsorgekoloskopie ist die Kolonkarzinominzidenz gesunken und die Diagnosestellung dieser Tumoren in frühen, endoskopisch resezierbaren und damit kurativ therapierbaren Stadien hat zugenommen. Auch Tumoren des oberen Gastrointestinaltrakts werden zunehmend im endoskopisch therapierbaren Stadium diagnostiziert, wobei hier auch verbesserte technische Möglichkeiten dazu beigetragen haben, dass zunehmend mehr Läsionen endoskopisch reseziert werden.

Die aktuellen Leitlinien zu Diagnostik und Therapie von Plattenepithelkarzinomen und Adenokarzinomen des Ösophagus, Magen- und Kolonkarzinom definieren genau, welche Tumore kurativ endoskopisch therapierbar sind. Dies hängt vom lymphogenen Metastasierungsrisiko ab, das durch bestimmte, von der Tumorlokalisation abhängige, histopathologische Charakteristika abgeschätzt werden kann. Im Wesentlichen handelt es sich um die am endoskopischen Resektat erfassbare Infiltrationstiefe und den Resektionsrandstatus nach endoskopischer Therapie sowie den Tumorsubtyp und das histologische Grading. Additiv ist eine Infiltration in Lymph- und Blutgefäße zu berücksichtigen.

Abstract

Since the implementation of a nationwide screening colonoscopy the incidence of colorectal adenocarcinoma is decreasing, while the amount of early endoscopically resectable tumours is increasing. Similarly malignant tumors of the upper gastrointestinal tract are diagnosed and resected endoscopically more often. In part, this also depends on improvements in technology.

The current guidelines of diagnosis and treatment of squamous carcinoma and adenocarcinoma of the esophagus, gastric cancer and colorectal cancer exactly define, which lesions can be endoscopically resected curatively. This mostly depends on the risc of metastases in regional lymph nodes. The risc of a lymphatic spread can be asessed by histopathological characteristics depending on the localisation of the lesion. Substantially, these characteristics comprise the depth of invasion in the resection specimen and the status at the resection margins after the endoscopic resection as well as the tumor subtype and the histological grading of the tumor. In addition, an infiltration in lymphatic or blood vessels has to be taken into account.

Schlüsselwörter

Endoskopie - Invasionstiefe - Grading - Lymphgefäßinfiltration - Lymphknotenmetastasen

Keywords

endoscopy - depth of invasion - grading - infiltration of lymphatic vessels - lymph node metastasis

• Literatur

• 1 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft DK, AWMF). S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus, Langversion 1.0. 2015 AWMF Registernummer: 021/023OL
• 2 Möhler M, Ebert M, Galle PR, Schmid R. S3-Leitlinie Magenkarzinom: Diagnostik und Therapie der Adenokarzinome des Magens und ösophagogastralen Übergangs. Z Gastroenterol 2011; 49: 461-531
• 3 Pox C, Aretz S, Bischoff SC et al. [S3-guideline colorectal cancer version 1.0]. Z Gastroenterol 2013; 51: 753-854
• 4 Koop H, Fuchs KH, Labenz J et al. [S2k guideline: gastroesophageal reflux disease guided by the German Society of Gastroenterology: AWMF register no. 021–013]. Z Gastroenterol 2014; 52: 1299-1346
• 5 Edgren G, Adami HO, Weiderpass E, Nyren O. A global assessment of the oesophageal adenocarcinoma epidemic. Gut 2013; 62: 1406-1414
• 6 Bollschweiler E, Knoppe K, Wolfgarten E, Holscher AH. [Prevalence of reflux symptoms in the general population of Cologne]. Z Gastroenterol 2007; 45: 177-181
• 7 Labenz J, Koop H, Tannapfel A et al. The epidemiology, diagnosis, and treatment of Barrett’s carcinoma. Dtsch Arztebl Int 2015; 112: 224-233 quiz 234
• 8 Bosman FT, Carneiro F, Hruban RH eds. WHO Classification of Tumours of the Digestive System. 4 ed: World Health Orgn; 2010
• 9 Wang GQ, Abnet CC, Shen Q et al. Histological precursors of oesophageal squamous cell carcinoma: results from a 13 year prospective follow up study in a high risk population. Gut 2005; 54: 187-192
• 10 Kodama M, Kakegawa T. Treatment of superficial cancer of the esophagus: a summary of responses to a questionnaire on superficial cancer of the esophagus in Japan. Surgery 1998; 123: 432-439
• 11 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 12 Kerkhof M, van Dekken H, Steyerberg EW et al. Grading of dysplasia in Barrett’s oesophagus: substantial interobserver variation between general and gastrointestinal pathologists. Histopathology 2007; 50: 920-927
• 13 Manner H, Pech O, Heldmann Y et al. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol 2013; 11: 630-635 quiz e645
• 14 Vieth M, Schubert B, Lang-Schwarz K, Stolte M. Frequency of Barrett’s neoplasia after initial negative endoscopy with biopsy: a long-term histopathological follow-up study. Endoscopy 2006; 38: 1201-1205
• 15 Westerterp M, Koppert LB, Buskens CJ et al. Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction. Virchows Arch 2005; 446: 497-504
• 16 Wittekind C, Meyer HJ. TNM Klassifikation maligner Tumore. Weinheim: Wiley-Blackwell; 2010
• 17 Holscher AH, Bollschweiler E, Schroder W et al. Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer. Ann Surg 2011; 254: 802-807 discussion 807–808
• 18 Gronnier C, Messager M, Robb WB et al. Is the negative prognostic impact of signet ring cell histology maintained in early gastric adenocarcinoma?. Surgery 2013; 154: 1093-1099
• 19 Kim YH, Kim JH, Kim H et al. Is the recent WHO histological classification for gastric cancer helpful for application to endoscopic resection?. Gastric Cancer 2015;
• 20 Huh CW, Jung da H, Kim JH et al. Signet ring cell mixed histology may show more aggressive behavior than other histologies in early gastric cancer. J Surg Oncol 2013; 107: 124-129
• 21 Kim JH, Kim YH, Jung da H et al. Follow-up outcomes of endoscopic resection for early gastric cancer with undifferentiated histology. Surg Endosc 2014; 28: 2627-2633
• 22 Wang Z, Zhang X, Hu J et al. Clinicopathological features and outcomes in patients undergoing radical resection for early gastric cancer with signet ring cell histology. J Visc Surg 2015; 152: 357-361
• 23 Guo CG, Zhao DB, Liu Q et al. Risk Factors for Lymph Node Metastasis in Early Gastric Cancer with Signet Ring Cell Carcinoma. J Gastrointest Surg 2015; 19: 1958-1965
• 24 Kakushima N, Kanemoto H, Tanaka M et al. Treatment for superficial non-ampullary duodenal epithelial tumors. World J Gastroenterol 2014; 20: 12501-12508
• 25 Brenner H, Chang-Claude J, Jansen L et al. Reduced risk of colorectal cancer up to 10 years after screening, surveillance, or diagnostic colonoscopy. Gastroenterology 2014; 146: 709-717
• 26 Wasif N, Etzioni D, Maggard MA et al. Trends, patterns, and outcomes in the management of malignant colonic polyps in the general population of the United States. Cancer 2011; 117: 931-937
• 27 Williams JG, Pullan RD, Hill J et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15 (Suppl 2) 1-38
• 28 Tanaka S, Asayama N, Shigita K et al. Towards safer and appropriate application of endoscopic submucosal dissection for T1 colorectal carcinoma as total excisional biopsy: future perspectives. Dig Endosc 2015; 27: 216-222
• 29 Toh EW, Brown P, Morris E at al. Area of submucosal invasion and width of invasion predicts lymph node metastasis in pT1 colorectal cancers. Dis Colon Rectum 2015; 58: 393-400
• 30 Delle Fave G, Kwekkeboom DJ, Van Cutsem E et al. ENETS Consensus Guidelines for the management of patients with gastroduodenal neoplasms. Neuroendocrinology 2012; 95: 74-87
• 31 Caplin M, Sundin A, Nillson O et al. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: colorectal neuroendocrine neoplasms. Neuroendocrinology 2012; 95: 88-97
• 32 Konishi T, Watanabe T, Kishimoto J et al. Prognosis and risk factors of metastasis in colorectal carcinoids: results of a nationwide registry over 15 years. Gut 2007; 56: 863-868