Zusammenfassung
Hintergrund
Das Pankreaskarzinom hat nach wie vor eine sehr schlechte Prognose. Die chirurgische Resektion ist der einzige kurative Therapieansatz, womit heute zumindest für 25 % der Patienten ein 5‑Jahres-Überleben erreicht werden kann. In den letzten Jahren wurden zunehmend Fortschritte in der chirurgischen Technik gemacht, wodurch sich die Kriterien der Resektabilität wesentlich geändert haben. Diese sollen nachfolgend detailliert dargestellt werden.
Ziel der Arbeit
Darstellung aktueller Resektabilitätskriterien beim Pankreaskarzinom.
Material und Methoden
Selektive Literaturrecherche und Zusammenfassung der derzeitig gängigsten Kriterien zur Resektabilität beim Pankreaskarzinom.
Ergebnisse
Bei Patienten mit Pankreaskarzinom muss zwischen primär resektablen, Borderline-resektablen, lokal fortgeschrittenen (primär nicht resektablen) und metastasierten Befunden unterschieden werden. Während Tumorinfiltrationen von Gefäßen früher ein absolutes Ausschlusskriterium für eine Resektion darstellten, kann heute bei einer Tumorinfiltration benachbarter Venen (V. mesenterica superior, Pfortader und Konfluens/V. lienalis) eine chirurgische Resektion in aller Regel sicher vorgenommen werden. Ein persistierendes Problem stellen Tumorinfiltrationen in benachbarte arterielle Gefäße (A. hepatica, A. mesenterica superior und Truncus coeliacus) dar. Obwohl eine Resektion in diesen Fällen technisch häufig möglich wäre, ist diese aufgrund von erhöhter Morbidität und Mortalität der Eingriffe als auch eines schlechteren onkologischen Outcomes derzeit nur in Einzelfällen indiziert. Eine besondere Gruppe stellen die Borderline-resektablen Tumoren dar, bei denen zunehmend neoadjuvante Therapiekonzepte zur Anwendung kommen. Die Evaluation des Therapieansprechens stellt hier eine besondere Herausforderung dar, da dies in aller Regel nicht mit einer radiologisch nachweisbaren Reduktion des Tumorvolumens einhergeht.
Schlussfolgerungen
Aufgrund von Fortschritten in der chirurgischen Technik sind heute radikalere Pankreasoperationen sicher durchführbar, wodurch sich auch die Resektabilitätskriterien in den letzten Jahren insbesondere bzgl. venöser Tumorinfiltrationen deutlich verändert haben.
Abstract
Background
Pancreatic cancer is notoriously one of the most aggressive cancers and still has a poor prognosis. Surgical resection is the only chance for a curative therapy approach, with which at least a 5‑year survival can be achieved for 25 % of patients. Recent advances in surgical techniques have led to a change in the criteria for resectability.
Objective
This review summarizes the currently available evidence on the criteria for resectability of pancreatic cancer and discusses the treatment options.
Material and methods
The study was based on a selective literature search and a summary of the latest data on criteria for resectability is given.
Results
Patients with pancreatic cancer must be differentiated into those with primarily resectable disease, borderline resectable disease, locally advanced (primarily unresectable) and metastatic disease. While infiltration into the major surrounding venous vessels (e.g. superior mesenteric vein, portal vein and confluence of splenic vein) used to be a criterion for unresectable disease, these tumors can nowadays be safely resected in specialized centers. Tumor infiltration into adjacent arteries (e.g. hepatic artery, superior mesenteric artery and celiac artery) remains a clinical problem and surgical resection is often technically possible but associated with an increased morbidity and mortality and therefore not generally recommended. Borderline resectable tumors represent a special group for which neoadjuvant treatment concepts are increasingly being implemented. Radiological therapy response evaluation is challenging after neoadjuvant therapy as it is not usually associated with a radiologically detectable reduction in tumor volume.
Conclusion
Pancreatic resections can nowadays be more radically performed due to advances in surgical techniques. This has led to a change in the criteria for resectability, especially concerning venous tumor infiltration.
Literatur
Allema JH, Reinders ME, Van Gulik TM et al (1994) Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head. Br J Surg 81:1642–1646
Ammori JB, Colletti LM, Zalupski MM et al (2003) Surgical resection following radiation therapy with concurrent gemcitabine in patients with previously unresectable adenocarcinoma of the pancreas. J Gastrointest Surg 7:766–772
Bilimoria KY, Bentrem DJ, Ko CY et al (2007) National failure to operate on early stage pancreatic cancer. Ann Surg 246:173–180
Birkmeyer JD, Siewers AE, Finlayson EV et al (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128–1137
Birkmeyer JD, Sun Y, Wong SL et al (2007) Hospital volume and late survival after cancer surgery. Ann Surg 245:777–783
Burdelski CM, Reeh M, Bogoevski D et al (2011) Multivisceral resections in pancreatic cancer: identification of risk factors. World J Surg 35:2756–2763
Butturini G, Stocken DD, Wente MN et al (2008) Influence of resection margins and treatment on survival in patients with pancreatic cancer: meta-analysis of randomized controlled trials. Arch Surg 143:75–83
Callery MP, Chang KJ, Fishman EK et al (2009) Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement. Ann Surg Oncol 16:1727–1733
Chua TC, Saxena A (2010) Extended pancreaticoduodenectomy with vascular resection for pancreatic cancer: a systematic review. J Gastrointest Surg 14:1442–1452
Esposito I, Kleeff J, Bergmann F et al (2008) Most pancreatic cancer resections are R1 resections. Ann Surg Oncol 15:1651–1660
Ferrone CR, Marchegiani G, Hong TS et al (2015) Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg 261:12–17
Fuhrman GM, Leach SD, Staley CA et al (1996) Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg 223:154–162
Gillen S, Schuster T, Meyer Zum Buschenfelde C et al (2010) Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages. PLoS Med 7:e1000267
Hackert T, Werner J, Weitz J et al (2010) Uncinate process first–a novel approach for pancreatic head resection. Langenbecks Arch Surg 395:1161–1164
Hartwig W, Hackert T, Hinz U et al (2011) Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg 254:311–319
Hartwig W, Hackert T, Hinz U et al (2009) Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann Surg 250:81–87
Hidalgo M (2010) Pancreatic cancer. N Engl J Med 362:1605–1617
Imamura M, Doi R, Imaizumi T et al (2004) A randomized multicenter trial comparing resection and radiochemotherapy for resectable locally invasive pancreatic cancer. Surgery 136:1003–1011
Katz MH, Pisters PW, Evans DB et al (2008) Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg 206:833–846; discussion 846–848
Klauss M, Alt CD, Welzel T et al (2009) Multidetector CT evaluation of the course of nonresectable pancreatic carcinomas with neoadjuvant therapy. Pancreatology 9:621–630
Konstantinidis IT, Warshaw AL, Allen JN et al (2013) Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a „true“ R0 resection? Ann Surg 257:731–736
Mayo SC, Nathan H, Cameron JL et al (2012) Conditional survival in patients with pancreatic ductal adenocarcinoma resected with curative intent. Cancer 118:2674–2681
Mollberg N, Rahbari NN, Koch M et al (2011) Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 254:882–893
Morgan DE, Waggoner CN, Canon CL et al (2010) Resectability of pancreatic adenocarcinoma in patients with locally advanced disease downstaged by preoperative therapy: a challenge for MDCT. AJR. Am J Roentgenol 194:615–622
Neoptolemos JP, Stocken DD, Bassi C et al (2010) Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 304:1073–1081
Pessaux P, Rosso E, Panaro F et al (2009) Preliminary experience with the hanging maneuver for pancreaticoduodenectomy. Eur J Surg Oncol 35:1006–1010
Strobel O, Berens V, Hinz U et al (2012) Resection after neoadjuvant therapy for locally advanced, „unresectable“ pancreatic cancer. Surgery 152:S33–42
Varadhachary GR, Tamm EP, Abbruzzese JL et al (2006) Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol 13:1035–1046
Weitz J, Rahbari N, Koch M et al (2010) The „artery first“ approach for resection of pancreatic head cancer. J Am Coll Surg 210:e1–4
Werner J, Combs SE, Springfeld C et al (2013) Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 10:323–333
Zhou Y, Zhang Z, Liu Y et al (2012) Pancreatectomy combined with superior mesenteric vein-portal vein resection for pancreatic cancer: a meta-analysis. World J Surg 36:884–891
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J.G. D’Haese und J. Werner geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
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D’Haese, J.G., Werner, J. Resektabilität des Pankreaskarzinoms. Radiologe 56, 318–324 (2016). https://doi.org/10.1007/s00117-016-0092-z
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DOI: https://doi.org/10.1007/s00117-016-0092-z