Endoskopische Submukosa-Dissektion bei mukosalen Low-Risk-Magenfrühkarzinomen – eine retrospektive, unizentrische Studie

Zusammenfassung

Hintergrund Die endoskopische Submukosa-Dissektion (ESD) ist in Asien Standard zur Behandlung von Magenfrühkarzinomen (MFK) im Rahmen von definierten Kriterien. Auch in Europa wird sie immer häufiger benutzt. Bei Risikokonstellationen (z. B. Submukosa-Invasion, Lymphangio-Invasion, schlecht differenziertes Karzinom) ist das Auftreten von Lymphknotenmetastasen möglich. Wir definierten eine „Low-Risk-Gruppe“ (differenzierte, nur mukosal gelegene MFK ohne Ulzeration und Gefäßinfiltration, größenunabhängig) um das endoskopische Ergebnis und den Langzeitverlauf dieser prognostisch günstigen Gruppe zu untersuchen.

Patienten und Methoden Patienten mit nicht vorbehandelten Low-Risk-MFK wurden in die retrospektive Auswertung aufgenommen. Ausgewertet wurden Patientendaten (Alter, Geschlechterverteilung), Karzinomparameter (Anzahl, Größen, Lokalisation, Paris-Klassifikation), histologische Parameter, Resektionsdaten (u. a. En-bloc-Resektion, R-Status), Nachsorgen (u. a. Lokalrezidive, Überleben) und Komplikationsdaten.

Ergebnisse Durch ESD wurden bei 55 Patienten 61 Low-Risk-MFK entfernt. In 93,4 % gelang die En-bloc-, in 91,8 % die R0-Resektion. In 8 Fällen (13,1 %) kam es zu interventionsabhängigen Komplikationen: 5 verzögerte Nachblutungen (8,2 %), 2 Mikroperforationen (3,3 %, keine Operation notwendig) und ein Nicht-ST-Hebungsinfarkt (1,6 %).Während der Nachbeobachtungszeit (Mittelwert: 54,3 Monate) kam es in 4 Fällen (6,6 %) zu Lokalrezidiven, von welchen zumindest zwei erfolgreich endoskopisch behandelt werden konnten. Die anderen beiden Patienten verstarben nach endoskopischer Re-Therapie vor der ersten Kontrolle. Insgesamt verstarben 4 Patienten (7,8 %) während des Follow-ups, jeweils nicht tumorassoziiert. Bei 9 Patienten (16,4 %) wurden syn- oder metachrone Läsionen nachgewiesen, welche alle endoskopisch behandelt werden konnten. Lymphknotenmetastasen traten nicht auf.

Fazit In der von uns definierten Low-Risk-Gruppe von mukosalen MFK wurde mittels ESD eine hohe Rate von En-bloc- und R0-Resektionen erreicht. Die festgestellten Lokalrezidive konnten endoskopisch beherrscht werden. Metastasen wurden nicht festgestellt, kein Patient verstarb tumorassoziiert. ESD ist für diese Gruppe daher als Standard-Therapie zu empfehlen. Hinsichtlich des klinisch-endoskopischen Verlaufs bei Vorhandensein von Risikofaktoren sowohl bei Mukosakarzinomen als auch der übrigen MFK aus der sogenannten Expanded-Group (u. a. Lymphangio-Invasion, submukosainvasive MFK, schlecht differenzierte G3-Karzinome) liefert die Studie keine Daten.

Abstract

Background Endoscopic submucosal dissection (ESD) is the standard-procedure in Asia for the treatment of early gastric cancer (EGC) within defined criteria. In Europe, this technique is being used more and more frequently. In the context of risk constellations (submucosal invasion, lymphangioinvasion, poorly differentiated carcinoma), the occurrence of lymph node metastases is possible. We defined a low-risk group (differentiated, mucosal EGC without ulceration and vascular infiltration, size independent) to investigate the endoscopic outcome and the long-term course of this special group with excellent prognosis.

Patients and methods Patients with untreated low-risk EGC were included in this retrospective evaluation. Patient data (age, gender distribution), carcinoma parameters (number, size, location, Paris-Classification), histological parameters, resection data (including en bloc resection, R-status), follow-up (including local recurrence, survival) and complication data were evaluated.

Results In 55 patients, ESD was used to remove 61 low-risk EGC. In 93.4 %, the En-bloc resection succeeded, in 91.8 % of cases, an R0 status was documented. In 8 cases (13.1 %), intervention-dependent complications occurred: 5 delayed bleeding (8.2 %), two microperforations (3.3 %, no surgery required) and one non-ST-elevated myocardial infarciation (1.6 %). During the follow-up (mean: 54.3 months) there were 4 cases (6.6 %) of local recurrences, of which at least 2 could be successfully treated endoscopically. The other 2 patients died after repeated endoscopy before the first control. Overall, 4 patients (7.8 %) died during the follow up, none of them tumor-associated. In 9 patients (16.4 %) syn- or metachronous lesions were detected, all of which could be treated endoscopically. Lymphnode metastases did not occur.

Conclusion In the low-risk group that we defined, a high rate of en bloc and R0 resections were achieved with ESD; the detected local recurrences could be treated endoscopically. Metastases were not detected, no tumor-associated patient deaths occured. ESD is, therefore, recommended for this group as a standard therapy. The study provides no data on the endoscopic and clinical follow up in the presence of risk factors of both mucosal and other EGCs from the so-called Expanded Group (including lymphangio-invasion, submucosal invasive EGC, poorly differentiated G3 carcinomas).

Schlüsselwörter

Magenkarzinom - ESD - Lokalrezidive - Magenfrühkarzinom

Key words

Gastric carcinoma - ESD - local recurrence - early gastric cancer

^* Von den Co-Autoren Herrn Dr. Dollhopf zu seinem Beginn als neuem Chefarzt der Abteilung gewidmet.

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