Stellenwert der lokalchirurgischen Therapie beim Rektumkarzinom

Zusammenfassung

Hintergrund: Die lokale Exzision ist als kurative Therapieform beim pT₁ Rektumkarzinom anerkannt, wohingegen die Indikation bei pT₂ Tumoren nicht geklärt ist. Ferner ist der Wert prognostisch histologischer Bewertungskriterien und der Einfluss adjuvanter und neoadjuvanter Maßnahmen offen.
Methodik: In unserer Literaturrecherche gingen Untersuchungen ab dem Erscheinungsdatum 1990 zur lokalen Exzision mit wenigstens 30 Patienten und einer Nachbeobachtungsdauer von mindestens 24 Monaten, mit und ohne adjuvanter oder neoadjuvanter Therapie, ein. Wir analysierten die Beurteilungskriterien Lokalrezidiv, Überlebensrate, Tumorgrading sowie die Beschaffenheit der Absetzungsränder.
Ergebnisse: Nach R0-Resektion sind bei „low grade” Tumoren der pT₁-Kategorie Lokalrezidivwerte im Mittel von 8 % und im Stadium pT₂ im Mittel von 22 % zu erwarten. Schlecht differenzierte pT₁-Tumore weisen nach R0-Resektion über 18 % und nach R1-Resektion, trotz adjuvanter Radio-(Chemo)-Therapie, bis zu 26 % Rezidive auf. Bei pT ₂ „high grade” Tumoren sind im Mittel 50 % und für pT₂ „low grade” Tumoren nach R0-Resektion und adjuvanter Radiatio im Mittel 6 % Lokalrezidive zu erwarten. Adjuvante Maßnahmen können bei pT₂-Tumoren nach R1-Resektion das Lokalrezidivrisiko nicht unter 20 % senken.
Diskussion: Die lokale R0-Exzision stellt bei pT ₁ „low grade” Tumoren eine adäquate Therapieform dar. Künftige prospektive Studien sind notwendig um zu klären, ob die adjuvante Radio-(Chemo)-Therapie bei pT₂ „low grade” Tumoren nach R0-Resektion eine kurative Therapieoption darstellt.

Abstract

Background: Local excision of pT₁ rectal cancer is recognized as curative treatment, whereas the indication is not clarified for pT₂-tumours. In addition the prognostic histological analysis criteria and the influence of adjuvant and neoadjuvant measures are open.
Method: Starting form the publication date 1990 investigations on the local excision, with and without adjuvant or neoadjuvant therapy, were included in our literature search and analysed if they comprised at least 30 patients and a follow up of at least 24 months. We studied the assessment criteria local recurrence, survival rate, histological grading, and the conditions of resection margins.
Results: After complete resection of “low grade” rectal cancers local recurrences are expected for the pT₁-category of mean 8 % and for pT₂-tumours of mean 22 %. Poor differentiated pT¹-tumours exhibit after complete resection over 18 % and after incomplete, despite adjuvant radio (chemo)-therapy, up to 26 % recurrences. For pT₂ “high grade” tumours in mean 50 % local recurrences and for pT₂ “low grade” tumours after complete resection and adjuvant irradiation in mean 6 % have to be expected. Adjuvant measures cannot lower the local recurrence rate for pT₂ tumours after incomplete resection under 20 %.
Conclusion: Local excision with clear margins represents for pT₁ “low grade” cancer an adequate therapy. Further prospective investigations are necessary to clarify whether adjuvant radio (chemo)-therapy represents a curative therapeutic option for pT ₂ “low grade” tumours after complete resection.

Rektumkarzinom - transanale Resektion - lokale Exzision - adjuvante Therapie - neoadjuvante Therapie

Rectal cancer - transanal resection - local excision - adjuvant therapy - neoadjuvant therapy

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