Ergebnisse nach Resektion kolorektaler Lebermetastasen

Zusammenfassung

Lebermetastasen bei Kolon- und Rektumkarzinomen sind ein häufiges Krankheitsbild und bestimmen ganz wesentlich die Prognose des Patienten. Die rasante Entwicklung der Leberchirurgie in den letzten 20 Jahren erlaubt heute auch erweiterte Resektionen mit einem Parenchymverlust von über 70 % mit einer perioperativen Letalität von weniger als 5 %. Die alleinige Leberresektion bei kolorektalen Metastasen ist in den meisten Zentren derzeit das Standardvorgehen und kann ein Fünf-Jahresüberleben zwischen 20 und 45 % erzielen. Um diese Ergebnisse weiter zu verbessern, müssen Risikofaktoren bei den Patientenkollektiven identifiziert werden, welche mit einer schlechten Prognose einhergehen. Wichtige prädiktive Faktoren sind ein fortgeschrittener Primärtumor, ein kurzes krankheitsfreies Intervall nach Primär-OP, Anzahl und Größe der Lebermetastasen und ein hoher CEA-Wert. Weiterhin ein positiver Resektionsrand und die intraoperative Detektion von extrahepatischem Tumor. Diese Hochrisikopatienten sind vermutlich mit einer alleinigen Leberresektion unzureichend behandelt. Obwohl die Ergebnisse für die adjuvante Chemotherapie nach kompletter Metastasenresektion derzeit noch kontrovers sind, scheint sich ein Vorteil bei der neoadjuvanten Vorbehandlung bei Hochrisikopatienten zu bestätigen, wenngleich Daten aus prospektiven Untersuchungen noch nicht vorliegen. Das Langzeitüberleben von Patienten mit kolorektalen Lebermetastasen wird wegen dem häufigen Auftreten eines intrahepatischen Tumorrezidivs nach Resektion die Einbindung in multimodale Therapiekonzepte und die Anwendung moderner Chemotherapeutika erfordern.

Abstract

The liver is the commonest site of distant metastasis of colorectal cancer and is the major cause of death in theses patients. Liver resection has rapidly developed during the past 20 years, yielding low mortality rates of less than 5 % even after extended surgery with parenchymal loss of 70 % and more. At present, surgery seems the only curative treatment for liver metastasis from colorectal cancer. Five-year survival has been 20-45 % after hepatic resection, as published in large series. To improve results it seems mandatory to identify poor prognostic factors which allow stratification of patients suitable for different therapeutic modalities. Positive resection margin, size of tumor greater than 5 cm, disease-free interval less than 12 months, multiple tumors, advanced stage of the primary, extrahepatic disease and CEA-levels were identified as independent predictors of poorer outcome by multivariate analysis. Liver resection as the sole treatment seems inadequate in these patients. However, the benefit of adjuvant chemotherapy has not been clearly proven. Retrospective studies suggest the efficacy of neo-adjuvant chemotherapy for downsizing and downstaging of liver tumors in high-risk patients, thus rendering resectable liver metastasis previously considered to be non-operable. These promising results have to be confirmed now by prospective series. Long-term survival of patients with colorectal liver metastasis should be improved in the future by multimodal therapy, including chemotherapy with oxaliplatin or irinotecan.

Kolorektales Karzinom - Lebermetastase - Leberresektion

Colorectal cancer - liver surgery - metastases

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