Sind elektive Lymphknotendissektionen in der Karzinomchirurgie noch zeitgemäß?

 

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Zusammenfassung

Fragestellung: Die elektive radikale Operation der regionären Lymphknoten (LK) gehört seit mehr als einem Jahrhundert zum Standard der Tumorchirurgie bei Karzinomen. Ob dieser Standard noch zeitgemäß ist, wird diskutiert. Methodik: Die Diskussion wird durch bekannte, randomisierte Studien und Kohortenstudien sowie durch Ergebnisse des Tumorregisters München vorbereitet. Ergebnis: Unter Metastasierung (MET) wird ein Tumorwachstum verstanden, das extravasal entsteht und auf migrierte Tumorzellen des Primärherdes zurückzuführen ist. Damit gibt es 3 Formen von MET. Bei regionären LK-MET reicht die Behandlung von der radikalen operativen und adjuvanten Therapie bis zum Watchful Waiting. Obwohl die Anzahl positiver LK bei allen Karzinomen einer der wichtigsten Prognosefaktoren ist, hat die Art der Behandlung der LK keinen Einfluss auf das Langzeitüberleben. Die Anzahl positiver LK ist demnach Indikator, aber nicht Ursache für die Fernmetastasierung. Dies scheint allgemeingültig zu sein. Auch ein Teil der Lokalrezidive kann als Folge einer lokalen MET in Betracht kommen. Ihre Häufigkeit kann durch operative, adjuvante systemische und strahlentherapeutische Maßnahmen stark variieren, wirkt sich aber ebenfalls nicht auf das Überleben aus. Distante MET bestimmen in der Regel den Krankheitsverlauf. Ob hämatogene MET die Quelle neuer, klinisch relevanter, die Prognose beeinflussender Absiedelungen sind, ist aufgrund des statistisch erfassten zeitlichen Auftretens infrage zu stellen. Schlussfolgerung: Die genetische Steuerung der MET legt einen prinzipiell gleichartigen MET-Prozess für alle Karzinome nahe. Die Hypothese „Metastasen metastasieren nicht“ hat aufgrund epidemiologischer Daten eine hohe Plausibilität: Eine Reduktion der elektiven Lymphknoten-Dissektionen (LKD) auf das für prognoseadaptierte Therapieentscheidungen erforderliche Ausmaß wäre dann (bio)-logisch konsequent.

Abstract

Purpose: Since more than a century elective radical dissection of regional lymph nodes is a standard procedure in tumour surgery. We discuss whether or not this standard is still up to date. Methods: The discussion was based on evaluations from well known clinical trials and cohort studies as well as from the results of the Munich Cancer Registry (MCR). Results: Distant metastases develop extravasally from disseminated tumour cells that originate from the primary tumour. Therefore, three categories of metastases can be described: First, regional lymph node metastases treated by surgical and/or adjuvant therapy or by watchful waiting. Although the number of positive lymph nodes is one of the most important prognostic factor in all cancer sites, treatment of lymph nodes does not affect long-term survival. The number of positive lymph nodes is therefore simply a marker, but not a cause, of distant metastases. This seems to be generally valid. Also, the major part of local recurrences can be seen as “local metastases”. The frequency of local relapse can be influenced by surgery, adjuvant treatment or radiotherapy only with a small impact on survival. Distant metastases normally determine the course of disease. Whether metastases can be a source of new clinically relevant metastases that influence the prognosis has to be questioned by the presented analyses of tumour growth times. Conclusions: The gene-based control of metastases implies a principal process of metastatic spread for solid tumours. The hypothesis “metastases do not metastasise” has a high plausibility. Reduction of lymph node dissection and its performance only in those cases where it is necessary for treatment decisions seems to be (bio)-logically consequent.

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Prof. Dr. D. Hölzel

IBE / Klinikum Großhadern

Marchioninistr. 15

81377 München

Email: hoe@ibe.med.uni-muenchen.de