Zusammenfassung
Für Patienten mit einer isolierten Lungenmetastasierung stellt die chirurgische Therapie
die einzige Chance auf Kuration dar. Die Chemotherapie muss, trotz der aktuellen
Fortschritte in den Behandlungskonzepten, als palliative Maßnahme betrachtet werden.
Es ist von großer Bedeutung, durch ein sorgfältiges klinisches Staging und unter
Berücksichtigung definierter Prognosefaktoren Patienten zu selektionieren, die von
einer Operation profitieren könnten. Neben den etablierten Kriterien zur Metastasektomie
sind die Parameter: Anzahl Lungenmetastasen, krankheitsfreies Intervall (KFI), Serum-Tumormarkerspiegel
und die Frage einer hilären oder mediastinalen Lymphknotenmetastasierung für die Indikationsstellung
zur Operation bedeutsam. Ein potenzielles Langzeit-Überleben ist nur durch die radikale
Resektion mittels Thorakotomie und systematischer mediastinaler und hilärer Lymphknotendissektion
zu erreichen. Aktuelle Entwicklungen in der video-assistierten Thorakoskopie (VATS)
und radiologischen Diagnostik ermöglichen auch die Resektion kleiner pulmonaler Rundherde.
Als Operationsverfahren zur Resektion von Lungenmetastasen wird bei Verwendung der
VATS die zu fordernde onkologische Radikalität bezweifelt. Dennoch besitzt die VATS
einen hohen Stellenwert als diagnostisches Verfahren und sollte, möglichst nur innerhalb
klinischer Studien zur Metastasektomie, in einem selektionierten Patientenkollektiv
mit wenigen, peripher lokalisierten Metastasen evaluiert werden. Alle Ergebnisse zusammengenommen
zeigen, dass die Resektion von Lungenmetastasen und Rezidiv-Lungenmetastasen erfolgreich
und mit kurativem Ansatz durchgeführt werden kann. Dies setzt jedoch eine interdisziplinäre
Therapieentscheidung in einem Tumorboard, bestehend aus Thoraxchirurgen und internistischen
Onkologen, voraus.
Abstract
Surgical resection has been the first choice for the treatment of isolated pulmonary
metastases secondary to extrapulmonary malignancies. Despite recent advances, systemic
chemotherapy for metastatic disease without the use of surgery is considered to be
merely palliative, as there are rarely long-term survivors. Criteria for resection
and prognostic parameters help facilitate patient selection. In addition to the established
parameters the most significant factors in selecting patients for operation include
the number of pulmonary metastases, disease-free interval, serum tumour marker level,
and the question of mediastinal and hilar lymph node metastases. Complete surgical
resection is critical to achieving long-term survival and is best accomplished via
open thoracotomy accompanied by a systematic mediastinal and hilar lymph node dissection.
The recent development of video-assisted thoracoscopic surgery (VATS) and advances
in thoracic imaging technique has made the VATS approach more ammenable for resection
of small pulmonary nodules. However, the oncological radicality of VATS is questionable
for pulmonary metastasectomy, thus the VATS approach is mostly limited to diagnostic
purposes and in highly selected groups of patients with limited, peripherally located
lesions. These operations should be performed preferably within a prospective study
setting. All results together demonstrate that resection and re-resection of pulmonary
metastases can be benefical in patients, carefully selected by a multidiscipinary
tumour board of thoracic surgeons and medical oncologists.
Schlüsselwörter
Lungenmetastasen - Prognosefaktoren - Chirurgie
Key words
pulmonary metastases - prognostic factors - surgery
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Priv.-Doz. Dr. J. Pfannschmidt
Thoraxklinik am Universitätsklinikum · Chirurgie
Amalienstr. 5
69126 Heidelberg
Deutschland
Phone: 0 62 21 / 3 96 81 05
Fax: 0 62 21 / 3 96 11 02
Email: joachim.pfannschmidt@thoraxklinik-heidelberg.de
