Zusammenfassung
Das duktale Pankreasadenokarzinom ist aktuell das vierthäufigste zu Tode führende
Krebsleiden mit einer Überlebensrate von weniger als 5 %, wenn alle Stadien einbezogen
werden. Andere maligne Pankreastumore haben eine deutlich bessere Prognose. Selbst
nach vollständiger Resektion und adjuvanter Chemotherapie beträgt die 5-Jahres-Überlebensrate
nur 20 – 25%. Gründe dafür sind neben einer hohen Chemotherapieresistenz und einer
frühen lympho- und hämatogenen Metastasierung auch häufig eine Tumorausdehnung über
die medialen und dorsalen Resektionsgrenzen hinaus. Bei standardisierter, pathologischer
Untersuchung können noch in ca. 75 % Krebszellen an den Resektionsrändern nachgewiesen
werden, was Zeugnis des aggressiven und infiltrierenden Tumorwachstums ist und wahrscheinlich
die hohe Lokalrezidivrate erklärt. Die Standardoperationen zur kurativen Tumorresektion
sind die pyloruserhaltende Pankreatikoduodenektomie (PPPD) sowie die Pankreaslinksresektion
mit Splenektomie bei Pankreasschwanztumoren. In High-volume-Zentren konnte bei einer
Steigerung der Resektionsrate die Mortalität unter 3 % reduziert und das Langzeitüberleben
nach Resektion verbessert werden. Bei den chirurgischen Komplikationen spielt die
Pankreasfistel mit einer Prävalenz von bis zu 10 % eine entscheidende Rolle. Die Technik
der Pankreasanastomose sowie der Verschluss des Pankreasschwanzes stellen daher die
größten chirurgischen Herausforderungen dar. Im Hinblick auf die hohe Rezidivrate
des Pankreaskarzinoms wurden die erweiterten Operationsverfahren in zahlreichen Studien
untersucht. Während eine Infiltration der Pfortader keine Kontraindikation zur kurativen
Resektion mit Gefäßrekonstruktion darstellt und in vergleichbaren Überlebensdaten
resultiert, erscheint eine radikale, erweiterte Lymphadenektomie aufgrund der Datenlage
nicht sinnvoll. In ausgewählten Einzelfällen können Patienten aber von einer neoadjuvanten
Radiochemotherapie zum Downstaging eines irresektablen Tumors und anschließender Resektion,
einer Metastasenresektion oder der Resektion eines Lokalrezidivs profitieren. Die
R0-Resektion und tumorfreie Lymphknoten (N0-Stadium) sind die beiden Faktoren, die
die beste Prognose für Patienten mit Pankreaskarzinom in Aussicht stellen und dann
ein medianes Überleben von 2 Jahren mit guter Lebensqualität bieten können. Die Pankreaschirurgie
orientiert sich zunehmend an evidenzbasierten Daten aufgrund randomisiert kontrollierter
Studien. Um in Zukunft eine weitere und dringend notwendige Verbesserung der Behandlungsergebnisse
zu erreichen, sollten wenn möglich alle geeigneten Patienten für den Einschluss in
aktuelle klinische Studien zur neoadjuvanten, operativen oder adjuvanten Therapie
berücksichtig werden.
Abstract
Ductal pancreatic carcinomas are currently the fourth most common fatal cancer disease
with a survival rate of less than 5 % when all stages are considered. Other malignant
pancreatic tumours have markedly better prognoses. Even after complete resection and
adjuvant chemotherapy, the 5-year survival rate amounts to merely 20 – 25%. Besides
a high resistance to chemotherapy and early lympho- and haematogenic metastases, the
reason for this is often tumour extension beyond the medial and dorsal resection margins.
In standardised pathological examinations cancer cells can be detected in the resection
margins in about 75 % of the cases, which reflect the aggressive and infiltrative
tumour growth and probably explains the high rate of local recurrence. Standard operations
for curative tumour resection are the pylorus-preserving pancreatoduodenectomy (PPPD)
and the left pancreatic resection with splenectomy in cases of pancreas tail tumours.
In high-volume centres the mortality can be reduced to under 3 % and the long-term
survival improved with an increase of the resection rate. Considering surgical complications,
pancreatic fistulas with a prevalence of up to 10 % play a decisive role. The technique
of the pancreatic anastomosis as well as closure of the pancreatic tail thus represents
major surgical challenges. In view of the high recurrence rate of pancreatic carcinomas,
extended surgical procedures have been examined in numerous studies. Although infiltration
of the portal vein is not a contraindication for curative resection with vascular
reconstruction which gives comparable survival rates, a radical, extended lymphadenectomy
does not seem reasonable on the basis the available data. In selected, individual
cases, patients may benefit from neoadjuvant radiochemotherapy to down-stage an unresectable
tumour with subsequent tumour resection, a metastasis resection, or a resection of
a local recurrence. An R0 resection and tumour-free lymph nodes (N0 stage) are the
two factors that can provide the best prognosis for the patient with a median survival
of 2 years and a good quality of life. Pancreas surgery is being increasingly oriented
to the evidence-based data from randomised, controlled studies. In order to achieve
a further and urgently needed improvement in treatment results, one should consider,
if possible, all suitable patients for enrolment in current clinical studies on neoadjuvant,
surgical, or adjuvant therapy.
Schlüsselwörter
Gastro-entero-pankreatische Tumoren - Chirurgie - Pankreaskarzinom - High-volume-Zentren
Key words
gastro-entero-pancreatic tumours - surgery - pancreatic cancer - high-volume centres
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Prof. Dr. Jan Schmidt
Klinik für Allgemein-, Viszeral- u. Transplantationschirurgie
Im Neuenheimer Feld 110
69120 Heidelberg
Phone: ++ 49/62 21/56 62 05
Fax: ++ 49/62 21/56 57 81
Email: jan.schmidt@med.uni-heidelberg.de
