Diagnostisches Vorgehen und Ergebnisse in der chirurgischen Therapie von Gallenwegstumoren

Zusammenfassung

Hintergrund: Cholangiokarzinome (CCC) gehören bei weltweit steigender Inzidenz zu den seltenen Tumoren des Gastrointestinaltrakts. Therapieoptionen hängen von der Lokalisation des Tumors ab.

Patienten und Methodik: Seit 1995 wurden 425 konsekutive Patienten mit Cholangiokarzinomen in unserer Klinik vorgestellt und prospektiv in unserem Tumorregister erfasst. Die tumorbezogenen Daten wurden nun retrospektiv im Hinblick auf prognostische Kriterien ausgewertet.

Ergebnisse: Von 425 Patienten konnten 183 in primär kurativer Intention reseziert werden; die Resektionsrate lag dabei für intrahepatische Cholangiokarzinome (66 Patienten) bei 36 %, für perihiläre Karzinome (69 Patienten) bei 44 % und für distale Gallengangskarzinome (48 Patienten) bei 56 %. Eine R0-Resektion gelang bei 152 Patienten (83 %); sie stellt den wichtigsten Faktor für das Überleben dar. Als prognostisch ungünstige Parameter ließen sich für die intrahepatischen Cholangiokarzinome eine klinische T3- oder T4-Kategorie, Lymphknotenbefall sowie ein UICC-Stadium III oder IV herausarbeiten; bei den perihilären Karzinomen war dies lediglich für die beiden letztgenannten Faktoren darstellbar. Bei den distalen Gallengangskarzinomen korrelierte ein geringer Differenzierungsgrad mit einer schlechteren Prognose. Keine Unterschiede waren für die Perineuralscheideninfiltration, die Veneninvasion oder den Tumormarker CA 19-9 erkennbar. Hinsichtlich der Operationsmethode zeigt sich bei den intrahepatischen Cholangiokarzinomen ein Überlebensvorteil für kleine Leberresektionen, was in diesen Fällen den frühen Tumorstadien geschuldet ist, und bei den perihilären Cholangiokarzinomen für die Trisektorektomie und die Lebertransplantation.

Schlussfolgerung: Die Radikalität der Operation stellt auch bei den Cholangiokarzinomen den wesentlichsten Faktor für eine günstige Prognose dar; bei den perihilären Tumoren lässt sich für ausgedehnte Resektionen wie die Trisektorektomie und die Lebertransplantation ein Überlebensvorteil gegenüber limitierteren Resektionen darstellen. Insgesamt ist jedoch die Resektionsrate gering, da die Mehrzahl der Patienten erst in einem inkurablen Stadium in chirurgische Behandlung gelangt.

Abstract

Introduction: Despite a rising incidence worldwide, cholangiocarcinoma (CCC) is one of the infrequent malignancies of the gastrointestinal tract. The surgical approach depends largely on the location of the tumour.

Patients and Methods: Since 1995, 425 consecutive patients with cholangiocarcinoma were seen at our hospital; their data were prospectively entered in our cancer registry. Tumour-specific data were now retrospectively analysed for prognostic value.

Results: Resection with primarily curative intent was performed in 183 of the 425 patients; resection rates were 36 % for intrahepatic (66 patients), 44 % for hilar (69 patients) and 56 % for distal cholangiocarcinoma (48 patients). R0-resection was achieved in 152 patients (83 %) and was found to be the most important factor determining survival. With respect to intrahepatic cholangiocarcinoma, clinical T3- and T4-categories, lymph node metastases as well as UICC stages III and IV had negative predictive value; in hilar carcinomas, this was only seen for the last two factors. In distal cholangiocarcinoma, a low degree of differentiation was associated with a poor prognosis. No differences in survival were seen in the presence of perineural infiltration, angioinvasion or elevation of tumour marker CA 19 – 9. Regarding the surgical techniques, we found a survival benefit for limited liver resection in intrahepatic cholangiocarcinomas, which is explained by earlier tumour stages seen in these cases, as well as the performance of trisectionectomy or liver transplantation in hilar carcinomas.

Conclusions: Comparable to other malignant gastrointestinal tumours, radical surgery represents the most important prognostic factor in cholangiocarcinomas; for hilar tumours, a survival advantage is seen after extended resections (trisectionectomy or liver transplantation) if compared to more limited resections. At the time of presentation, however, the stage of disease was incurable in most patients, thus accounting for the low overall resection rates.

Schlüsselwörter

Cholangiokarzinom - Trisektorektomie - Lebertransplantation - CA 19-9 - Prognose

Key words

cholangiocarcinoma - trisectionectomy - liver transplantation - CA 19-9 - prognosis

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