Zusammenfassung
Die große Variationsbreite des klinischen Bildes beim metastasierten malignen Melanom erfordert ein sorgfältiges Staging und eine individuelle Behandlung der Patienten. Dabei stellt vor allem das häufige Auftreten von lokoregionären Metastasen bzw. Fernmetastasen ein relevantes Problem für den Patienten dar. Hierbei zielt das differenzierte chirurgische Vorgehen neben einem Therapieansatz in kurativer Intention (R0-Resektion) in einem nicht unerheblichen Teil der Patienten auch auf die Behandlung von Tumorkomplikationen in palliativer Intention ab, welche per se keine Verbesserung der Prognose aus onkologischer Sicht ermöglicht, jedoch die Patienten aus einer akuten, teilweise lebensbedrohlichen Situation befreien kann. Insofern besitzt die Indikation zur palliativen Metastasenchirurgie beim malignen Melanom einen gesicherten Stellenwert und bedarf in besonderem Maße der Beurteilung durch ein erfahrenes Expertenteam im Rahmen von interdisziplinären Tumorboards, welche sich in letzter Zeit zunehmend etablieren.
Abstract
Due to the broad variation of clinical presentation in metastasised malignant melanoma, a careful staging and individual treatment of these patients is required. Especially, the occurrence of locoregional or / and distant metastasis presents an important problem. Not only treatment with a curative intent but also sophisticated surgical procedures with a palliative intent are necessary in patients with tumour complications. These procedures do not improve the oncological prognosis. However, they may rescue patients from life-threatening situations. Therefore, palliative surgery of metastases plays an important role and requires assessment by an experienced oncological team.
Schlüsselwörter
malignes Melanom - lokoregionäre Metastasen - Fernmetastasen - palliative Therapie
Key words
malignant melanoma - locoregional metastases - distant metastases - palliative treatment
Literatur
-
1
Balch C M, Soong S J, Gershenwald J E et al.
Prognostic factors analysis of 17 600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system.
J Clin Oncol.
2001;
19
3622-3634
-
2
Balch C, Soong S, Murad T et al.
A multifactorial analysis of melanoma. IV. Prognostic factors in 200 melanoma patients with distant metastases.
J Clin Oncol.
1983;
1
126-134
-
3
Meyer T, Merkel S, Goehl J et al.
Surgical therapy for distant metastases of malignant melanoma.
Cancer.
2000;
89
1983-1991
-
4
Ollila D.
Complete metastasectomy in patients with stage IV metastastic melanoma.
Lancet Oncol.
2006;
7
919-924
-
5
Tomov T, Siegel R, Bembenek A.
Long-Term Survival in Stage IV Melanoma after repetitive surgical therapy.
Onkologie.
2008;
31
259-261
-
6
Barth A, Wanek L A, Morton D L.
Prognostic factors in 1 521 melanoma patients with distant metastases.
J Am Coll Surg.
1995;
181
193-201
-
7
Agrawal S, Yao T J, Coit D G.
Surgery for melanoma metastastic to the gastrointestinal tract.
Ann Surg Oncol.
1999;
6
336-344
-
8
Eton O, Legha S S, Moon T E et al.
Prognostic factors for survival of patients treated systemically for disseminated melanoma.
J Clin Oncol.
1998;
16
1103-1111
-
9
Essner R, Lee J H, Wanek L A et al.
Contemporary surgical treatment of advanced-stage melanoma.
Arch Surg.
2004;
139
961-966
-
10
Cadili A.
The role of debulking surgery in metastatic melanoma.
ANZ J Surg.
2009;
79
509-511
-
11
Knorr C, Meyer T, Janssen T et al.
Hyperthermic isolated limb perfusion (HILP) in malignant melanoma. Experience with 101 patients.
Eur J Surg Oncol.
2006;
32
224-227
-
12
Göhl J, Hohenberger W, Merkel S.
Malignes Melanom.
Der Chirurg.
2009;
80
559-568
-
13
Cornett W R, McCall L M, Petersen R P et al.
Randomized Multicenter Trial of Hyperthermic Isolated Limb Perfusion With Melphalan Alone Compared With Melphalan Plus Tumor Necrosis Factor: American College of Surgeons Oncology Group Trial Z0020.
J Clin Oncol.
2006;
24
4196-4201
-
14
Grunhagen D J, de Wilt J H, Graveland W J et al.
Outcome and prognostic factor analysis of 217 consecutive isolated limb perfusions with tumor necrosis factor-alpha and melphalan for limb-threatening soft tissue carcinoma.
Cancer.
2006;
106
1776-1785
-
15
Vaglini M, Ammatuna M, Nava M et al.
Regional perfusion at high temperature in treatment of stage III A–III AB melanoma patients.
Tumori.
1983;
69
585-588
-
16
Minor D R, Allen R E, Alberts D et al.
A clinical and pharmacokinetic study of isolated limb perfusion with heat and melphalan for melanoma.
Cancer.
1985;
55
2638-2644
-
17
Storm F K, Morton D L.
Value of therapeutic hyperthermic limb perfusion in advanced recurrent melanoma of the lower extremity.
Am J Surg.
1985;
150
32-35
-
18
Kroon B B, Van Geel A N, Benckhuijsen C et al.
Normothermic isolation perfusion with melphalan for advanced melanoma of the limbs.
Anticancer Res.
1987;
7
441-442
-
19
Santinami M, Belli F, Cascinelli N et al.
Seven years experience with hyperthermic perfusions in extracorporeal circulation for melanoma of the extremities.
J Surg Oncol.
1989;
42
201-208
-
20
Di Filippo F, Calabrò A, Giannarelli D et al.
Prognostic variables in recurrent limb melanoma treated with hyperthermic antiblastic perfusion.
Cancer.
1989;
63
2551-2561
-
21
Skene A I, Bulman A S, Williams T R et al.
Hyperthermic isolated perfusion with melphalan in the treatment of advanced malignant melanoma of the lower limb.
Br J Surg.
1990;
77
765-767
-
22
Lejeune F, Liénard D, Eggermont A et al.
Administration of high-dose tumor necrosis factor alpha by isolation perfusion of the limbs. Rationale and results.
J Infus Chemother.
1995;
5
73-81
-
23
Thompson J F, Hunt J A, Shannon K F et al.
Frequency and duration of remission after isolated limb perfusion for melanoma.
Arch Surg.
1997;
132
903-907
-
24
Beasley G M, Petersen R P, Yoo J et al.
Isolated limb infusion for in-transit malignant melanoma of the extremity: a well-tolerated but less effective alternative to hyperthermic isolated limb perfusion.
Ann Surg Oncol.
2008;
15
2195-2205
-
25
Noorda E M, von Kreij R HJ, Vrouenraets B C et al.
The health-related quality of life of long-term survivors of melanoma treated with isolated limb perfusion.
Eur J Surg Oncol.
2007;
33
776-782
-
26
Pace M, Gattai R, Matteini M et al.
Toxicity and morbility after isolated lower limb perfusion in 242 chemo-hyperthermal treatments for cutaneous melanoma: The experience of the Tuscan Reference Centre.
J Exp Clin Cancer Res.
2008;
27
67
-
27 Meyer T, Göhl J. Regionale Chemotherapie – Technik, Ergebnisse und Komplikationen der Extremitätenperfusion. In: Schönleben K, Hrsg. Παντα ρϵι. Umdenken in der Chirurgie. Sonderband zum Chirurgenkongress 2001. München: Hans Marseille Verlag; 2001: 161–175
-
28 Wittekind C, Meyer H J, Bootz F. TNM-Klassifikation maligner Tumoren. 7. Aufl. Berlin, Heidelberg, New York: Springer; 2009
-
29
Hohenberger W, Göhl J, Altendorf-Hofmann A et al.
Lymphknotendissektionen beim malignen Melanom.
Chirurg.
1996;
67
779-787
-
30
Meyer T, Merkel S, Göhl J et al.
Lymph node dissection for clinically evident lymph node metastases of malignant melanoma.
Eur J Surg Oncol.
2002;
28
424-430
-
31
Gadd M A, Coit D G.
Recurrence patterns and outcome in 1 019 patients undergoing axillary or inguinal lymphadenectomy for melanoma.
Arch Surg.
1992;
127
1412-1416
-
32
Karakousis C P, Velez A, Driscoll D L et al.
Metastasectomy in malignant melanoma.
Surgery.
1994;
115
295-302
-
33
Cascinelli N, Santinami M, Maurichi A et al.
World Health Organization experience in the treatment of melanoma.
Surg Clin North Am.
2003;
83
405-416
-
34
McCarthy W H, Shaw H M, Thompson J F et al.
Time and frequency of recurrence of stage I malignant melanoma with guidelines for follow up study.
Surg Gynecol Obstet.
1988;
166
497-502
-
35
Fuster D, Chiang S, Johnson G et al.
Is F-FDG PET more accurate than standard diagnostic procedures in the detection of suspected recurrent melanoma?.
J Nucl Med.
2004;
45
1323-1327
-
36
Göhl J, Driesch P VD, Meyer T.
Zeitgemäße Diagnostik beim malignen Melanom.
chir praxis.
2000;
57
391-402
-
37
Wood T F, DiFronzo L A, Rose D M et al.
Does complete resection of melanoma metastatic to solid intra-abdominal organs improve survival?.
Ann Surg Oncol.
2001;
8
658-662
-
38 Göhl J, Meyer T. Operative Therapie des metastasierten Melanoms. In: Garbe, Hrsg. Management des Melanoms. Heidelberg: Springer Medizin Verlag; 2006
-
39 Göhl J, Meyer T. Malignes Melanom der Haut. In: Berger M, Domschke W, Hohenberger W et al., Hrsg. Therapie-Handbuch 5. Aufl. München, Jena: Urban & Fischer; 2006
-
40
Sanki A, Scolyer R A, Thompson J F.
Surgery for melanoma metastases of the gastrointestinal tract: indications and results.
Eur J Surg Oncol.
2009;
35
313-319
-
41
Amersi F F, McElrath-Garza A, Ahmad A et al.
Long-term survival after radiofrequency ablation of complex unresectable liver tumors.
Arch Surg.
2006;
141
581-588
-
42
Chua T C, Glenn D, Morris D L.
Extending the survival of patients with melanoma lung metastases through radiofrequency ablation.
Acta Oncologica.
2010;
49
517-519
-
43
Rate W R, Solin L J, Turrisi A T.
Palliative radiotherapy for metastatic malignant melanoma: brain metastases, bone metastases, and spinal cord compression.
Int J Radiat Oncol Biol Phys.
1988;
15
859-864
-
44
Ollila D W, Essner R, Wanek L et al.
Surgical resection for melanoma metastatic to the gastrointestinal tract.
Arch Surg.
1996;
131
975-979
-
45
Ollila D W, Morton J H.
Surgical resection as the treatment of choice for melanoma metastastic to the lung.
Chest Surg Clin N Am.
1998;
8
183-196
-
46
Leo F, Cagini L, Rocmans P et al.
Lung metastases from melanoma: when is surgical treatment warranted?.
Br J Cancer.
2000;
83
569-572
-
47
Wong S L, Coit D G.
Role of surgery in patients with stage IV melanoma.
Curr Opin Oncol.
2004;
16
155-160
-
48
Yasui K, Shimizu Y.
Surgical treatment for metastatic malignancies: anatomical resection of liver metastasis – indications and outcomes.
Int J Clin Onocl.
2005;
10
86-96
-
49
Hodgson R, Fink M A, Jones R M.
The role of abdominal resectional surgery in metastatic melanoma.
ANZ J Surg.
2007;
77
885-889
-
50
Dengel L T, Slingluff Jr C L.
Short length of stay and rapid recovery to normal function after surgery for metastatic melanoma to abdominal and retroperitoneal viscera.
J Surg Oncol.
2009;
100
481-483
-
51
Markowitz J S, Cosimi L A, Carey R W et al.
Prognosis after initial recurrence of cutaneous melanoma.
Arch Surg.
1991;
126
703-707
Prof. J. Göhl
Chirurgische Klinik · Friedrich-Alexander-Universität
91054 Erlangen
Deutschland
Telefon: 0 91 31 / 8 53 35 88
Fax: 0 91 31 / 8 53 41 07
eMail: jonas.goehl@uk-erlangen.de
