Stellenwert der Chirurgie in der palliativen Behandlung des Rektumkarzinoms

Zusammenfassung

Die Behandlung des fortgeschrittenen Rektumkarzinoms ist eine komplexe Aufgabe, die sich auf die einfache Frage „Operieren oder nicht?“ kaum reduzieren lässt. Vielmehr müssen folgende Faktoren berücksichtigt werden: Symptomatischer vs. nicht-symptomatischer Patient, Notfalleingriff vs. elektive Operation, proximales vs. distales Rektumkarzinom, lokale fortgeschrittene vs. metastasierende Krankheit, Ersttumor vs. Rekurrenz, nicht resektable vs. potenziell resektable Metastasen, resezierende vs. ableitende chirurgische Verfahren, usw.. Auch innerhalb der konservativen Gruppe muss zwischen interventioneller Therapie (Kombinationschemotherapie, Stentanlage, Strahlentherapie, usw.) und reiner palliativer Therapie unterschieden werden. Die Studienlage ist ungenügend, um allgemeine Empfehlungen zu formulieren. Es gibt allerdings wenig Argumente gegen ein operatives Vorgehen in der symptomatischen Situation, wenn der Primärtumor im Vordergrund steht. Beim metastasierenden kolorektalen Karzinom können moderne Chemotherapieverfahren und neue Antikörpertherapien das Überleben deutlich verlängern. Diese Ergebnisse können durch die Chirurgie allein nicht erzielt werden. In dieser Situation sollte geprüft werden, ob aufgrund der längeren Lebenserwartung doch mit dem späteren Auftreten von Symptomen zu rechnen ist, was wiederum eine chirurgische Indikation im Rahmen der multimodalen Therapie rechtfertigen würde. Aus den unterschiedlichen Ausgangssituationen ergeben sich also verschiedene therapeutische Ansätze, sodass die individuelle Indikationsstellung im Rahmen eines Tumorboards gestellt werden soll.

Abstract

The treatment of advanced rectal cancer is a complicated task that can only poorly be reduced to the simple question “to operate or not to operate?” Instead the following factors must be taken into consideration: symptomatic versus non-symptomatic patients, emergency surgery versus elective surgery, proximal versus distal rectal cancer, local advanced versus metastatic disease, primary tumour versus recurrence, unresectable versus potentially resectable metastases, resection versus diversionary surgical procedures, etc. Also within the conservative group one must decide between interventional therapy (combined chemotherapy, stent placement, radiotherapy, etc.) and purely palliative therapy. Results from studies are not sufficient for the formulation of general recommendations. However, there are only few arguments against a surgical procedure in a symptomatic situation when the primary tumour dominates. In cases of metastatising colorectal cancer modern chemotherapeutic procedures and new antibody therapies can markedly prolong survival. These results cannot be achieved by surgery alone. In this situation, it should be considered whether the longer life expectancy will be accompanied by the later occurrence of symptoms, which again justifies a surgical indication within the framework of multimodality therapy. The widely differing starting situations lead to different therapeutic approaches so that an individual indication can be made in the course of a tumour board discussion.

Schlüsselwörter

Rektumkarzinom - Lebermetastase - Chemotherapie - Rektumresektion - Stent

Key words

rectal carcinoma / cancer - liver metastasis - chemotherapy - rectum resection - stent

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