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Chirurgische Therapie beim peritoneal metastasierten Magenkarzinom

Surgical treatment of peritoneal metastases of gastric cancer

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Zusammenfassung

Hintergrund

Magenkarzinome weisen bei Diagnosestellung bei bis zu 17 % der Patienten eine peritoneale Metastasierung auf, die mit einer schlechten Prognose verbunden ist. Die multimodale Therapie besteht aus systemischer Chemotherapie und zytoreduktiver Chirurgie (CRS), welche die Entfernung des Magenkarzinoms und des befallenen Peritoneums beinhaltet. Die anschließende hypertherme intraperitoneale Chemotherapie (HIPEC) hat möglicherweise einen positiven Effekt und steht daher auf dem Prüfstand.

Fragestellung

Welchen Stellenwert nimmt die chirurgische Therapie beim peritoneal metastasierten Magenkarzinom ein und welche Patienten profitieren von diesem intensiven multimodalen Therapiekonzept?

Material und Methode

Es erfolgte eine ausführliche Literaturrecherche, um die bestehende Datenlage in dieser Übersichtsarbeit darzustellen.

Ergebnisse

CRS und HIPEC können in ausgewählten Fällen zu einer Verlängerung des medianen Überlebens auf 11 Monate beitragen. Patienten mit geringer und lediglich lokaler peritonealer Metastasierung sowie einem Peritonealkarzinoseindex ≤6 profitieren am meisten. Diese intensive Therapie geht jedoch mit einer Morbidität von 15–50 % und einer Mortalität von 1–10 % einher. Der wichtigste prognostische Faktor ist die komplette Zytoreduktion, d. h. eine komplette makroskopische Tumorfreiheit nach Resektion.

Schlussfolgerung

CRS und HIPEC kann bei ausgewählten Patienten zu einer deutlichen Verlängerung des Gesamtüberlebens beitragen. Aufgrund der relativ hohen Morbidität und Mortalität sollte die Evaluation durch ein erfahrenes Team, bestehend aus Chirurg, Onkologe und Intensivmediziner, erfolgen, um eine möglichst hohe Rate an kompletter Zytoreduktion verbunden mit einer geringen Komplikationsrate zu gewährleisten. Im Rahmen der GASTRIPEC-Studie wird derzeit geklärt, ob die HIPEC einen zusätzlichen positiven Effekt zeigen wird.

Abstract

Background

Up to 17% of all patients with gastric cancer are diagnosed with the presence of peritoneal metastases, which is associated with a poor prognosis. The most promising results were shown with multimodal treatment regimens including systemic chemotherapy and cytoreductive surgery (CRS). A subsequent hyperthermic intraperitoneal chemotherapy (HIPEC).possibly has a positive effect and is currently being tested.

Objectives

This manuscript highlights the key role of CRS and HIPEC in patients with peritoneal metastases of gastric cancer and illustrates which patients benefit from this intensive therapy.

Methods

We performed a comprehensive review of the literature to demonstrate relevant aspects in the treatment of peritoneal metastases in gastric cancer.

Results

The use of CRS and HIPEC improves the overall survival to 11 months compared to best supportive care in selected patients. Patients who present with low volume peritoneal disease (peritoneal cancer index ≤6) have the best prognosis. This intensive treatment is associated with a relatively high morbidity (15–50%) and mortality (1–10%). Complete cytoreduction, i.e. a complete macroscopic absence of tumor tissue after resection is the most important prognostic factor.

Conclusion

The CRS and HIPEC procedures have a proven survival benefit in selected patients. Due to the relatively high morbidity and mortality, the evaluation should be performed by an experienced team including a surgical oncologist, medical oncologist and intensive care physician, to achieve the highest rate of complete cytoreduction in combination with low morbidity; however, the effect of HIPEC has to be proven and the results of the randomized GASTRIPEC trial are awaited.

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Author information

Authors and Affiliations

  1. Chirurgische Klinik, Campus Virchow-Klinikum und Charité Campus Mitte, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland

    A. Brandl, E. Pachmayr, S. Gül-Klein, M. Alberto &  B. Rau MBA

  2. Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité – Universitätsmedizin Berlin, Berlin, Deutschland

    P. Thuss-Patience

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  1. A. Brandl
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  6. B. Rau MBA
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Corresponding author

Correspondence to B. Rau MBA.

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Interessenkonflikt

B. Rau ist PI bei der GASTRIPEC (gefördert durch die DKH). A. Brandl, E. Pachmayr, S. Gül-Klein, M. Alberto und P. Thuss-Patience geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Brandl, A., Pachmayr, E., Gül-Klein, S. et al. Chirurgische Therapie beim peritoneal metastasierten Magenkarzinom. Chirurg 89, 669–677 (2018). https://doi.org/10.1007/s00104-018-0625-2

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