Die operative Behandlung des Lungenkarzinoms im lokal begrenzten Stadium

 

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Zusammenfassung

Etwa 30 % der Patienten mit einem nicht-kleinzelligen (NSCLC) und 5 % mit einem kleinzelligen (SCLC) Lungenkarzinom befinden sich bei Diagnosestellung in einem operablen Stadium. Die primäre Resektion mit kurativer Intention kann diesen Patienten jedoch eine echte Verlängerung des Langzeitüberlebens ermöglichen. Bevorzugt wird sie als standardisiertes Therapieverfahren der Wahl in den eher begrenzten Tumorstadien I und II eingesetzt. In Abhängigkeit von einer korrekten Indikationsstellung lassen sich mit den klassischen offenen Resektionsverfahren Lobektomie, Bilobektomie und Pneumonektomie 5-Jahres-Überlebensraten (5-JÜR) über 70 % im Frühstadium IA und 48 % im Stadium II erzielen. Zunehmend wird die videoassisstierte Thorakoskopie (VATS) als minimalinvasives Verfahren im Stadium I erfolgreich eingesetzt. Unabhängig ob offen oder minimalinvasiv ist es obligat, alle tumortragenden Abschnitte en bloc und komplett mit tumorfreien Resektionsrändern zu entfernen und zusätzlich eine systematische mediastinale Lymphadenektomie durchzuführen. Im Stadium IIIA mit befallenen mediastinalen Lymphknoten (N2) setzen sich zunehmend präoperative und/oder postoperative multimodale Therapieverfahren wie die Induktionsradiochemotherapie mit anschließender Resektion durch. Bei richtiger Indikationsstellung und korrekter operativer Verfahrenswahl lassen sich akzeptable perioperative Morbiditäts- und Mortalitätsraten erzielen. Die seit 2005 zusätzlich empfohlene postoperative adjuvante Chemotherapie in den lokal-begrenzten Stadien IB und II lässt aufgrund abgeschlossener Phase III-Studien ein bis zu 15 % verbessertes 5-JÜR erwarten und sollte in ein interdisziplinäres Therapiekonzept miteingebunden werden.

Abstract

Only 30 % of patients with non-small-cell lung cancer (NSCLC) and 5 % with small-cell lung cancer (SCLC) are eligible for curative operative resection at time of diagnosis. Surgical treatment, however, remains the only treatment modality which permits long-term survival in these patients. Usually, the locally contained stage I and II tumours are suitable for rountine complete primary resection. Following proper preoperative tumour staging and functional assessment of the patient standard open operative procedures such as lobectomy, bilobectomy and pneumonectomy show 5-year survival rates ranging from 70 % in early cancer stage IA to 48 % in stage II disease. Videothoracoscopic surgery (VATS) has been increasingly employed with success to resect early IA tumours. Nevertheless, basic surgical principle must be to resect enbloc all tumour ridden tissue with systematic mediastinal lymph node dissection whether open or minimal-invasive techniques are used. In stage IIIA disease with mediastinal lymph node infiltration (N2) preoperative treatment regimens such as radiochemotherapy followed by resection are being evaluated in controlled clinical studies. In any case an interdisciplinary treatment concept is always indicated at this stage. Given proper preoperative evaluation of the patient and use of the correct surgical technique acceptable perioperative morbidity and mortality rates may be achieved. Recent recommendations (2005) concerning the use of standard chemotherapeutic regimens in an adjuvant setting following surgery for stage IB and II disease suggest up to 15 % improved 5-year survival rates based on large-scale phase III clinical trials. Therefore, adjuvant chemotherapy should be considered as standard treatment in these selected patients.

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PD Dr. med. Rudolf A. HatzFACS 

Chirurgische Klinik und Poliklinik · Klinikum Großhadern · Ludwig-Maximilians-Universität München

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Email: rudolf.hatz@med.uni-muenchen.de