Aktuelles chirurgisches Vorgehen bei kolorektalen Lebermetastasen

Zusammenfassung

Das kolorektale Karzinom steht sowohl bei der Inzidenz als auch der tumorbedingten Sterblichkeit an zweiter Stelle der soliden Karzinome in der westlichen Welt. Bei etwa der Hälfte der Patienten mit einem kolorektalen Karzinom muss im Verlauf der Erkrankung mit Lebermetastasen gerechnet werden, wobei ein Drittel dieser Patienten eine isoliert hepatische Metastasierung aufweist. Die einzige potenziell kurative Therapie kolorektaler Lebermetastasen ist derzeit die Leberresektion. Voraussetzung für die Indikationsstellung zur Leberresektion ist die Möglichkeit, eine R0-Resektion unter Erhalt eines ausreichenden funktionellen Restlebervolumens erreichen zu können. Nur etwa 20–25%  der Patienten mit kolorektalen Lebermetastasen qualifizieren sich für eine primäre Leberresektion. Durch die Kombination verschiedener Verfahren und multimodaler Therapiekonzepte, wie z. B. 2-zeitige Leberresektionen oder neoadjuvante Chemotherapie zum ‚Downsizing’, kann der Anteil sekundär resezierbarer Metastasen um etwa 10–20%  erweitert werden. Die chirurgische Morbidität und Mortalität werden in aktuellen Studien mit 30–40%  und 1–2%  angegeben. Nach R0-Resektion kann, je nach Patientenselektion, mit einer tumorfreien 3-Jahres-Überlebensrate von ~35%  und einer 5- und 10-Jahres-Überlebensrate von ~45%  und ~25%  gerechnet werden. Dabei ist der wichtigste Prognosefaktor für das Langzeitüberleben ein tumorfreier Resektionsrand. Die Etablierung multimodaler Therapiekonzepte hat bis heute zu einer stetigen Zunahme des Anteils resezierbarer Metastasen und somit zu einer signifikanten Verbesserung der Prognose von Patienten mit kolorektalen Lebermetastasen geführt. Durch neue, Antikörper-basierte systemische Therapien ist für die nächsten Jahre eine Fortsetzung dieses Trends zu erwarten.

Abstract

Colorectal Cancer is the second most common cancer in the western world and about half of patients will develop liver metastases (CRLM) in the course of the disease. Complete liver resection is the only potentially curative therapy available to date. In first line, only 20%  of patients with colorectal liver metastases qualify for surgery. Surgery is indicated in cases when complete resection with tumor free resection margins can be achieved under preservation of a functionally sufficient remnant liver volume with undisturbed perfusion and biliary drainage. By modern multimodality treatment, another 10–20%  of metastases can be converted to a ‘secondary resectable’ stage, e. g. by 2 stage hepatectomy or downsizing of the metastases by neoadjuvant chemotherapy. Surgical morbidity and mortality in recent literature is 30–40%  and 1–2% , respectively. Depending on selection criteria, the progression-free 3-year survival rate is about 35% , and the 5- and 10-years overall survival rate is about 45%  und 25% , respectively. The most important prognostic factor for patients with CRLM is a tumor free resection margin. The evolvement of multimodality treatment algorithms led to a continuously increasing number of resectable metastases with subsequently improving prognosis for liver metastatic colorectal cancer. Due to the availability of new antibody based systemic therapies, further prognostic improvements can be expected for patients with CRLM.

Schlüsselwörter

Leberresektion - neoadjuvante Chemotherapie - Down-sizing - laparoskopische Leberresektion

Key words

liver resection - neoadjuvant chemotherapy - down-sizing - laproscopic liver resection

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