Lungenmetastasenchirurgie beim pulmonal metastasierten kolorektalen Karzinom

Zusammenfassung

Hintergrund Patienten mit kolorektalem Karzinom sind häufig von Leber- und Lungenmetastasen betroffen. Neben Systemtherapien eignet sich für Patienten nach vollständiger Primärtumor- und potenzieller Lebermetastasenresektion die Lungenmetastasenchirurgie als therapeutisches Konzept.

Material und Methoden Es erfolgte eine systematische Literaturrecherche unter Berücksichtigung aller Studien, die ab dem 01. 01. 2010 publiziert worden sind. In die deskriptive Analyse wurden Studien eingeschlossen, die über mindestens 100 Patienten mit Lungenmetastasektomie berichteten und deren Operationszeitraum frühestens am 01. 01. 2000 begann. Aus den Studien wurden operative Daten, Überlebensdaten und Prognosefaktoren extrahiert.

Ergebnisse Elf Studienkohorten mit insgesamt 2891 Patienten konnten in die Analyse eingeschlossen werden. In den meisten Fällen wurde eine vollständige Resektion aller Metastasen erreicht und dabei subsegmentale den anatomischen Resektionsverfahren vorgezogen. Bei 2,3 – 18,2% der Patienten zeigten sich intrathorakale Lymphknotenmetastasen. Die postoperative Mortalität bewegte sich zwischen 0 und 0,5%. Der mediane Nachbeobachtungszeitraum erstreckte sich in den Fallserien von 27,5 bis zu 65,1 Monaten. Die Lungenmetastasenchirurgie war in den Studienkohorten mit 5-Jahres-Überlebensraten von 53 – 75,5% verbunden. Das 5-Jahres-Progressionsfreie-Überleben variierte zwischen 33 und 50,9%. Intrathorakale Rezidive traten in 25,2 – 42,9% der Patienten auf. Die Remetastasektomie resultierte in 5-Jahres-Überlebensraten von 49 – 75,5%. Die Analyse von Prognosemodellen offenbarte, dass die Metastasenanzahl, -größe und -verteilung eine untergeordnete prognostische Relevanz zu besitzen scheinen. Ein erhöhter CEA-Serumspiegel vor Metastasektomie und intrathorakale Lymphknotenmetastasen bedeuteten in mehreren Studien einen prognostischen Nachteil, nichtsdestotrotz können auch diese Patienten von der Lungenmetastasenchirurgie profitieren.

Schlussfolgerungen Für Patienten mit kolorektalem Karzinom und isolierter Lungen- oder kombinierter Leber- und Lungenmetastasierung sollte bei gewährleisteter Resektabilität die Metastasektomie die Therapie der Wahl sein. Die Lungenmetastasenchirurgie sollte durch eine Lymphknotenresektion ergänzt werden, um potenzielle Lymphknotenmetastasen zu entfernen. Patienten mit isolierten intrathorakalen Rezidiven sollte eine Remetastasektomie angeboten werden.

Abstract

Background Patients with colorectal cancer are often affected by liver and lung metastases. Besides systemic therapies, lung metastasectomy is a suitable treatment option after complete resection of primary colorectal carcinoma and even concomitant liver metastases.

Material and Methods We have performed a systematical literature research of all studies published after 01. 01. 2010. Studies reporting on at least 100 patients undergoing lung metastasectomy after 01. 01. 2000 have been included in our final analysis. Operative data, survival data and prognostic factors have been extracted.

Results Eleven study cohorts reporting on 2,891 patients could be included in the final analysis. Complete resection could be achieved in most cases and thoracic surgeons preferred subsegmental resections. Pathological examination revealed thoracic lymph node involvement in 2.3 to 18.2% of patients. The postoperative mortality varied from 0 to 0.5%. The median follow up ranged between 27.5 and 65.1 months. Pulmonary metastasectomy resulted in 5-year survival rates of 53 to 75.5% and 5-year progression-free survival rates of 33 to 50.9%. Intrathoracic recurrence occurred in 25.2 to 42.9% of patients with complete resection and five-year survival rates ranged from 49 to 75.5% after repeat pulmonary metastasectomy. Analysis of prognostic factors revealed that number, size and distribution of lung metastases are minor important prognostic factors. Moreover, current data suggest disadvantageous post-metastasectomy survival for patients with elevated pre-metastasectomy serum CEA level or intrathoracic lymph node metastases in comparison with the control groups. Nevertheless, even in these patients, lung metastasectomy might be a beneficial procedure.

Conclusions In patients with colorectal cancer and resectable isolated lung or combined liver and lung metastases pulmonary resection should be the treatment of choice. Pulmonary metastasectomy should be combined with thoracic lymph node resection to remove potential lymph node metastases. Repeat metastasectomy should be offered to patients suffering from isolated intrathoracic recurrence.

Schlüsselwörter

Lungenmetastasektomie - kolorektales Karzinom - Lungenmetastasen - VATS - thorakale Lymphknotenmetastasen

Key words

lung metastasectomy - colorectal cancer - lung metastases - VATS - thoracic lymph node metastases

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