Barrett-Frühkarzinom/Hochgradige intraepitheliale Neoplasie (HG-IEN): pro endoskopische Therapie – pro chirurgische Therapie

Zusammenfassung

Wem gehört das Barrett-(Früh-)Karzinom? Das Adenokarzinom des Ösophagus, entstanden auf dem Boden einer Barrett-Schleimhaut, gehört zu den Tumoren, die in den letzten Jahren einen deutlichen Inzidenzanstieg aufweisen. Die Therapie der Tumorvorstufen und des Barrett-Frühkarzinoms wurde in den vergangen Jahren kontrovers diskutiert. Aus endoskopischer Sicht kommt bei hochgradigen intraepithelialen Neoplasien (HG-IEN) eine endoskopische Resektion, weniger die endoskopische Destruktion infrage, während bei einem gesicherten Frühkarzinom eine endoskopische Staging-Resektion sinnvoll erscheint. Gegen chirurgische Verfahren spricht die geringe Wahrscheinlichkeit von Lymphknotenmetastasen bei vorhandener, wenn auch geringer, Morbidität und Mortalität des operativen Eingriffs. Für eine (endoskopische oder operative) Resektion der Läsion spricht, dass kein Stagingverfahren das Ausmaß der Neoplasie sicher beurteilen kann und letztendlich die exakte Tiefeninfiltration des Karzinoms erst im Resektat bestimmbar ist. Vorteil eines operativen Vorgehens hierbei ist, dass eine vollständige Entfernung der Lymphknoten nur chirurgisch gewährleistet werden kann. Die Entfernung der präexistenten Barrett-Schleimhaut erfolgt chirurgisch in jedem Fall, während dies endoskopisch bisher nur unter größerem Aufwand (Einsatz multipler Behandlungssitzungen) möglich ist. Die Operation nach Merendino-Siewert bietet hier eine Option mit geringerer Morbidität und Letalität. Die neuen endoskopischen Resektionsverfahren sind bislang nicht gegen chirurgische Verfahren kontrolliert geprüft. Zusammenfassend sollten Patienten mit einer HG-IEN oder einem Barrett-Frühkarzinom in spezialisierten Zentren, vorzugsweise im Rahmen von Studien, behandelt werden.

Abstract

Who may treat early Barrett’s carcinoma of the oesophagus? The incidence of adenocarcinoma of the oesophagus developing within Barrett’s mucosa has substantially risen in the past few years. Furthermore, treatment of preneoplastic lesions or early carcinoma is controversial. From an endoscopist’s point of view high-grade intraepithelial neoplasia (HG-IEN) should be resected endoscopically rather than destroyed endoscopically while early Barrett’s carcinoma should undergo endoscopic staging resection. Surgical resection is rarely necessary because lymph node metastases are rare and there is some morbidity and mortality associated with the procedure. However, surgeons argue that complete surgical resection is required because no imaging technique reveals the exact extent of the lesion and, ultimately, the degree of infiltration can only be determined within the resected specimen. Also, only surgical procedures may remove all potentially involved regional lymph nodes. Furthermore, only within surgical resections we can eliminate all pre-existing Barrett’s mucosa easily while endoscopic clearance of Barrett’s mucosa is difficult and requires multiple sessions. The Merendino-Siewert procedure may be an option with very low morbidity and mortality. It is worthy of note that new endoscopic resection procedures have not been studied in a controlled fashion against conventional surgical procedures. Therefore, patients with HG-IEN or early Barrett’s carcinoma of the esophagus should be recruited into controlled studies and be treated in specialised high-volume centres.

Schlüsselwörter

Barrett-Ösophagus - Adenokarzinom - endoskopische Resektion - Argon-Plasma-Koagulation - Merendino-Siewert-Operation

Key words

Barrett’s oesophagus - adenocarcinoma - endoscopic resection - argon-plasma coagulation - Merendino-Siewert procedure

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