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DOI: 10.1055/s-0028-1098881
© Georg Thieme Verlag Stuttgart ˙ New York
Leberresektion beim Hepatozellulären Karzinom – Eigene Ergebnisse und Literaturübersicht
Hepatic Resection for Hepatocellular Carcinoma – Results and Analysis of the Current LiteraturePublication History
Publication Date:
20 April 2009 (online)
Zusammenfassung
Hintergrund: Das hepatozelluläre Karzinom (HCC) ist weltweit die fünft häufigste Krebstodesursache. In Mitteleuropa ist seine Inzidenz zwar deutlich niedriger, aber stetig zunehmend. Hier spielen weniger virale Grunderkrankungen als nutritiv-toxische / metabolische Ursachen (Alkohol, Diabetes, Übergewicht) eine Rolle. Die Therapiemöglichkeiten des HCC sind stark abhängig vom Ausmaß der Erkrankung bei der Diagnosestellung und umfassen, neben lokal destruierenden Verfahren, die Lebertransplantation sowie die chirurgische Resektion. In dieser Arbeit sollen aktuelle Ergebnisse der Resektion des HCC vorgestellt und mit Ergebnissen sowohl der Resektion aber auch der lokalen Therapie und Transplantation verglichen werden. Patienten: Von 1999–2008 führten wir bei 93 Patienten (83 % männlich, medianes Alter 64 [Spanne 39–94] Jahre) eine Leberresektion wegen eines HCC durch. Die Datenerhebung erfolgte prospektiv. Die für 85 Patienten erhältliche Nachbeobachtungszeit lag im Median bei 1,2 Jahren (0,25–8 Jahre). Ergebnisse: Im Gegensatz zur weltweiten Epidemiologie des HCC wurde eine virale Hepatitis als Grunderkrankung nur bei 28 % aller Patienten nachgewiesen. Eine Zirrhose lag in 50 % vor. Die Anzahl der Tumore betrug im Median eins (1–11). Die mediane Tumorgröße lag bei 55 mm (5–250 mm). 58 % der Tumore wurden atypisch oder durch Segmentresektion, 42 % durch eine (ggf. erweiterte) Hemihepatektomie entfernt. In 95 % gelang die R0-Resektion. Die Gesamtkomplikationsrate lag bei 61 %. Eine operative Revision wurde in 10 % durchgeführt. Die Gesamtmortalität lag bei 8,6 % und nahm während des Studienzeitraumes stark ab (1999–2004: 14,9 %, 2005–2008: 2,2 %, p = 0,03). Das kumulative Überleben betrug 81 % nach 1 Jahr, 58 % nach 3 Jahren und 26 % nach 5 Jahren. Als tendenzieller prognostischer Faktor konnte das T-Stadium identifiziert werden. Schlussfolgerung: Die Resektion hepatozellulärer Karzinome ist neben lokal ablativen Verfahren und der Transplantation eine der Haupttherapieoptionen. Eine sorgfältige Patientenselektion lässt R0-Resektionsraten > 90 % zu. Trotz einer hohen Gesamtkomplikationsrate bleibt die Notwendigkeit einer Re-Operation eher die Ausnahme. Die perioperative Mortalität nahm in der zweiten Hälfte des Untersuchungszeitraumes zwar signifikant ab, lag aber insgesamt mit 8,6 % höher als nach Resektion anderer Lebertumore. Die Überlebensrate unserer Serie ist vergleichbar mit Berichten anderer europäischen Zentren.
Abstract
Background: Hepatocellular carcinoma (HCC) is the fifth-leading cause of cancer death worldwide. Although less frequent in Western Europe, its incidence is increasing in this region. Causes involved in the pathogenesis of HCC are, besides viral hepatitis, metabolic and nutritional factors (alcohol, diabetes, obesity). The therapeutic management depends strongly on the initial extent of disease and includes hepatic resection, liver transplantation and local ablation. In this context, we present our results on liver resection for HCC and a discussion of the current literature about (potentially curative) treatment for HCC. Patients: From 1999 until 2008 93 patients [83 % male, median age 64 (range: 39–94) years] underwent hepatic resection for HCC. Postoperative follow-up was available in 85 patients [median follow-up: 1.2 (0.25–8) years]. Results: In contrast to data, especially from Asia, a viral hepatitis as the origin of HCC was found in only 28 % of the patients in our series. Half of the patients had proven liver cirrhosis. The median number of intrahepatic tumours was one (1–11), median size of the largest tumour was 55 mm (5–250 mm). 58 % of the HCC were removed by atypical or segmental resection, 42 % of the patients underwent hemihepatectomy or extended hemihepatectomy. Tumor-free resection margins were achieved in 95 %. Total postoperative morbidity was 61 %. A reoperation for complications was necessary in 10 %. Hospital mortality was 8.6 % in the entire study period but decreased from 14.9 % in 1999–2004 to 2.2 % in 2005 to 2008 (p = 0.03). Actuarial survival was 81 % after 1 year, 58 % after 3 years and 26 % after 5 years. The T-stage could be identified tendentially as a prognostic factor influencing survival. Conclusion: With the proper selection of patients, liver resection for HCC may be performed with a curative intention (i. e., free resection margins) in over 90 %. Although it decreased during the study period perioperative mortality was higher than after resection of other hepatic tumours. Long-term survival in our series was comparable to reports from other European centres.
Schlüsselwörter
hepatozelluläres Karzinom - Leberresektion - Überleben - postoperative Komplikation
Key words
hepatocellular carcinoma - liver resection - survival - postoperative complication
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F. Makowiec
University of Freiburg · Department of Surgery · Freiburg · Germany
Phone: +49 / 7 61 / 2 70 28 06
Fax: +49 / 7 61 / 2 70 28 04
Email: Frank.Makowiec@uniklinik-freiburg.de