Inoperable Genitaltumoren der Frau: Therapeutische Optionen bei Darmstenose und -blutung

 

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Zusammenfassung

Hintergrund: Tumoren der weiblichen Genitale werden nicht selten erst im fortgeschrittenen Stadium diagnostiziert oder rezidivieren nach zunächst kurativer Therapie. Insbesondere Ovarialkarzinome gehen im Verlauf häufig mit einer Peritonealkarzinose oder lokalem Tumorprogress einher, was zu einer Reihe behandlungsbedürftiger intestinaler Komplikationen führen kann. Material und Methoden: Basierend auf eigenen Ergebnissen und einer systematischen PubMed-Recherche erfolgte die Definition unterschied­licher intestinaler Komplikationen nicht kurabler Genitaltumoren der Frau sowie die Analyse unterschiedlicher chirurgischer und konservativer Therapieoptionen. Ergebnisse: Häufig treten Dünndarmstenosen aufgrund einer direkten Tumorinfiltration, Peritonealkarzinose oder postoperativen Verwachsungen auf, die zu einem akuten und häufig auch chronisch rezidivierenden Ileusbild führen können. Im kleinen Becken sind insbesondere das Rektum und das Sigma von extraluminalen Tumorstenosen, von Fisteln oder von einer direkten Tumorinfiltration betroffen, die unter Umstän­den mit ernsthaften Blutungen oder einem Dick­darmileus vergesellschaftet sind. Eine zusätzliche Form der intestinalen Komplikationen stellen postradiogene Verwachsungen und Stenosen im Bereich des Dünndarms sowie die chronische Strahlenproktitis nach vorangegangener Radiatio dar. In der palliativen Behandlungssituation ist ein spezielles Augenmerk auf eine abwägende Indi­kationsstellung zur chirurgischen, onkologischen und konservativen Therapie zu richten. Schlussfolgerung: Das Diktum des „primum nihil nocere“ ist unter Berücksichtigung des Patientenwillens, der anzunehmenden Prognose, des All­gemeinzustands und des Leidensdrucks sowie der zu erwartenden Komplikationen in besonderem Maße zu beachten. 

Abstract

Background: Tumours of the female genital tract are often diagnosed at an advanced stage or re­lapse after initial curative therapy. Ovarian cancer is in particular associated with peritoneal carcinomatosis or local tumour progression entailing different intestinal complications. Material and Methods: Based on our own results and a systemic PubMed search, different intes­tinal complications in non-curable tumours of the female genital tract were defined and dif­fer­ent surgical and non-surgical therapeutic options were analysed. Results: Stenosis of the small bowel is often ­caused by direct infiltration of the tumour. Peritoneal carcinomatosis or postoperative abdominal adhesions may lead to an acute or even more ­often chronic recurrent obstruction. The rectum or sigmoid colon is in particular affected by stenosis caused by tumour masses within the pelvis, ­occurring fistulas or direct tumour infiltration which may lead to bleeding complications or a large bowel obstruction. Radiation-induced ab­dominal adhesions or stenosis of the small bowel as well as radiation-induced chronic proctocolitis are further common abdominal complications. Special attention with regard to a well balanced indication towards surgical, oncological or conservative management must be given in the palliative setting of the genital tract. Conclusion: In particular the dictum of “primum nihil nocere” has to be followed in consideration of the patient's declared intention, the patient’s prognosis, general condition, psychological strain as well as the expected complications. 

Literatur

• 1 Hodgkinson K, Butow P, Fuchs A et al. Long-term survival from gynecologic cancer: psychosocial outcomes, supportive care needs and positive outcomes.  Gynecol Oncol. 2007;  104 381-389
  CrossrefPubMedGoogle Scholar
• 2 Ozols R F, Bundy B N, Greer B E et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study.  J Clin Oncol. 2003;  21 3194-3200
  CrossrefPubMedGoogle Scholar
• 3 Bookman M A, McGuire W P, Kilpatrick D et al. Carboplatin and pacli­taxel in ovarian carcinoma: a phase I study of the Gynecologic Oncology Group.  J Clin Oncol. 1996;  14 1895-1902
  PubMedGoogle Scholar
• 4 McGuire W P, Hoskins W J, Brady M F et al. Cyclophosphamide and cis­platin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer.  N Engl J Med. 1996;  334 1-6
  CrossrefPubMedGoogle Scholar
• 5 Chase D M, Monk B J, Wenzel L B et al. Supportive care for women with gynecologic cancers.  Exp Rev Anticancer Ther. 2008;  8 227-241
  CrossrefPubMedGoogle Scholar
• 6 Mangili G, Aletti G, Frigerio L et al. Palliative care for intestinal obstruction in recurrent ovarian cancer: a multivariate analysis.  Int J Gynecol Cancer. 2005;  15 830-835
  CrossrefPubMedGoogle Scholar
• 7 Bryan D N, Radbod R, Berek J S. An analysis of surgical versus chemotherapeutic intervention for the management of intestinal obstruction in advanced ovarian cancer.  Int J Gynecol Cancer. 2006;  16 125-134
  CrossrefPubMedGoogle Scholar
• 8 Meyer L, Pothuri B. Decompressive percutaneous gastrostomy tube use in gynecologic malignancies.  Curr Treat Options Oncol. 2006;  7 111-120
  CrossrefPubMedGoogle Scholar
• 9 Clarke-Pearson D L, Chin N O, DeLong E R et al. Surgical management of intestinal obstruction in ovarian cancer. I. Clinical features, postoperative complications, and survival.  Gynecol Oncol. 1987;  26 11-18
  CrossrefPubMedGoogle Scholar
• 10 Krebs H B, Goplerud D R. Surgical management of bowel obstruction in advanced ovarian carcinoma.  Obstet Gynecol. 1983;  61 327-330
  PubMedGoogle Scholar
• 11 Pothuri B, Meyer L, Gerardi M et al. Reoperation for palliation of recurrent malignant bowel obstruction in ovarian carcinoma.  Gynecol Oncol. 2004;  95 193-195
  CrossrefPubMedGoogle Scholar
• 12 Solomon H J, Atkinson K H, Coppleson J V et al. Bowel complications in the management of ovarian cancer.  Aust N Z J Obstet Gynaecol. 1983;  23 65-68
  CrossrefPubMedGoogle Scholar
• 13 Redman C W, Shafi M I, Ambrose S et al. Survival following intestinal ­obstruction in ovarian cancer.  Eur J Surg Oncol. 1988;  14 383-386
  PubMedGoogle Scholar
• 14 Pothuri B, Vaidya A, Aghajanian C et al. Palliative surgery for bowel ­obstruction in recurrent ovarian cancer: an updated series.  Gynecol Oncol. 2003;  89 306-313
  CrossrefPubMedGoogle Scholar
• 15 Dvoretsky P M, Richards K A, Angel C et al. Survival time, causes of death, and tumor / treatment-related morbidity in 100 women with ovarian cancer.  Hum Pathol. 1988;  19 1273-1279
  CrossrefPubMedGoogle Scholar
• 16 Antos F, Serclova Z, Gilbert Z. Pelvic exenteration in the treatment of ­locally advanced tumors of surgical, gynaecological and urological origin.  Zentralbl Chir. 2001;  126 777-779
  Article in Thieme ConnectPubMedGoogle Scholar
• 17 Rubin S C, Hoskins W J, Benjamin I et al. Palliative surgery for intestinal obstruction in advanced ovarian cancer.  Gynecol Oncol. 1989;  34 16-19
  CrossrefPubMedGoogle Scholar
• 18 Chalas E, Mann WJ J r, Westermann C P et al. Morbidity and mortality of stapled anastomoses on a gynecologic oncology service: a retrospective review.  Gynecol Oncol. 1990;  37 82-86
  CrossrefPubMedGoogle Scholar
• 19 Pothuri B, Guirguis A, Gerdes H et al. The use of colorectal stents for palliation of large-bowel obstruction due to recurrent gynecologic cancer.  Gynecol Oncol. 2004;  95 513-517
  CrossrefPubMedGoogle Scholar
• 20 Tomiki Y, Watanabe T, Ishibiki Y et al. Comparison of stent placement and colostomy as palliative treatment for inoperable malignant colorectal obstruction.  Surg Endosc. 2004;  18 1572-1577
  PubMedGoogle Scholar
• 21 Caceres A, Zhou Q, Iasonos A et al. Colorectal stents for palliation of large-bowel obstructions in recurrent gynecologic cancer: an updated series.  Gynecol Oncol. 2008;  108 482-485
  CrossrefPubMedGoogle Scholar
• 22 Tilney H S, Lovegrove R E, Purkayastha S et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction.  Surg Endosc. 2007;  21 225-233
  CrossrefPubMedGoogle Scholar
• 23 Vaz A F, Pinto-Neto A M, Conde D M et al. Quality of life and acute toxicity of radiotherapy in women with gynecologic cancer: a prospective longitudinal study.  Arch Gynecol Obstet. 2008;  278 215-223
  CrossrefPubMedGoogle Scholar
• 24 Andreyev H J, Vlavianos P, Blake P et al. Gastrointestinal symptoms after pelvic radiotherapy: role for the gastroenterologist?.  Int J Radiat Oncol Biol Phys. 2005;  62 1464-1471
  CrossrefPubMedGoogle Scholar
• 25 Béchade D, Desramé J, Raynaud J J et al. Hemorrhagic gastric metastasis of an ovarian carcinoma.  Gastroenterol Clin Biol. 2005;  29 1065-1066
  CrossrefPubMedGoogle Scholar
• 26 Taylor R R, Phillips W S, O'Connor D M et al. Unusual intramural gastric metastasis of recurrent epithelial ovarian carcinoma.  Gynecol Oncol. 1994;  55 152-155
  CrossrefPubMedGoogle Scholar
• 27 Martín G, Rodriguez C A, Fonseca E et al. Duodenal ulcer with bleeding as the sole symptom of relapse in ovarian carcinoma.  Am J Med. 1999;  106 380
  CrossrefPubMedGoogle Scholar
• 28 Dittmar Y, Voigt R, Heise M et al. Indications and results of palliative gastric resection in advanced gastric carcinoma.  Zentralbl Chir. 2009;  134 77-82
  Article in Thieme ConnectPubMedGoogle Scholar
• 29 Hamilton W, Peters T J, Bankhead C et al. Risk of ovarian cancer in ­women with symptoms in primary care: population based case-control study.  Br Med J. 2009;  339 b2998
  CrossrefPubMedGoogle Scholar
• 30 Gittleman A M, Glanz S, Hon M et al. Lower gastrointestinal bleeding from the internal iliac artery: angiographic demonstration of an iliac arteriocolic fistula.  Cardiovasc Intervent Radiol. 2004;  27 262-263
  PubMedGoogle Scholar
• 31 Leary C J, Sussman S K, Ohki S K. Life-threatening gastrointestinal hemorrhage secondary to nonmesenteric sources.  J Vasc Interv Radiol. 1997;  8 1025-1028
  CrossrefPubMedGoogle Scholar
• 32 Pisco J M, Martins J M, Correia M G. Internal iliac artery: embolization to control hemorrhage from pelvic neoplasms.  Radiology. 1989;  172 337-339
  PubMedGoogle Scholar
• 33 Kube R, Meyer F, Bien N et al. Surgical management of bevacizumab-associated peritonitis due to perforation.  Zentralbl Chir. 2009;  134 462-467
  Article in Thieme ConnectPubMedGoogle Scholar
• 34 Iraha S, Ogawa K, Moromizato H et al. Radiation enterocolitis requiring surgery in patients with gynecological malignancies.  Int J Radiat Oncol Biol Phys. 2007;  68 1088-1093
  CrossrefPubMedGoogle Scholar
• 35 Regimbeau J M, Panis Y, Gouzi J L et al. Operative and long term results after surgery for chronic radiation enteritis.  Am J Surg. 2001;  182 237-242
  CrossrefPubMedGoogle Scholar
• 36 Stein E. Entzündliche Erkrankungen des Dickdarms, Anorektums und Perinealbereichs. In: Stein E, ed. Proktologie, 4th Ed. Kap. 14.10: Strahlenproktitis. Heidelberg: Springer; 2003
  Google Scholar
• 37 Weidenhagen R, Gruetzner K U, Wiecken T et al. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method.  Surg Endosc. 2008;  22 1818-1825
  Google Scholar

Dr. A. Kleespies

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