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Lymphknotenmetastasen beim ypT1/2-Rektumkarzinom nach neoadjuvanter Radiochemotherapie

Die Achillesferse organerhaltender Operationsverfahren?

Lymph node metastases in ypT1/2 rectal cancer after neoadjuvant chemoradiotherapy

The Achilles heel of organ-preserving operative procedures?

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Zusammenfassung

Hintergrund

Für Patienten mit Rektumkarzinom und kompletter Remission (ypT0) oder guter Response mit intramuralem Residualtumor (ypT1–2) nach neoadjuvanter Radiochemotherapie (RCT) wurden – zur Reduktion postoperativer Funktionseinschränkungen – wiederholt lokale Operationsverfahren als Alternative zur totalen mesorektalen Exzision (TME) vorgeschlagen. Ziel dieser Untersuchung war eine vergleichende Analyse von Frequenz und tumorabhängiger Lokalisation mesorektaler Lymphknotenmetastasen bei Patienten mit kompletter Remission (ypT0), intramuralem (ypT1–2) und wandüberschreitendem Residualtumor (ypT3–4).

Patienten und Methoden

Patienten mit cUICC-II/III-Rektumkarzinom (n = 81), die innerhalb der CAO/ARO/AIO-04-Studie behandelt wurden, wurden prospektiv evaluiert. Es erfolgte eine intensivierte histopathologische Aufarbeitung mit vollständiger mikroskopischer Untersuchung des mesorektalen Fettgewebskompartimentes. Die stadienabhängige Inzidenz und die intramesorektale Verteilung lymphogener Metastasen in Abhängigkeit vom Primärtumor wurden erhoben.

Ergebnisse

Ein wandüberschreitendes Tumorwachstum (ypT3–4) zeigten 62 % der Patienten, 25 % hatten eine deutliche partielle Remission des Primarius mit intramuralen Residuen (ypT1–2) und 14 % wiesen eine komplette Remission (ypT0) auf. Insgesamt wurden 28 ± 13,7 Lymphknoten (LK) pro TME-Präparat detektiert. Zwar war die Inzidenz von LK-Metastasen in der ypT3–4-Gruppe mit 40 % höher, jedoch wiesen immerhin 25 % der Patienten mit intramuralem Residualtumor (ypT1–2) im Mittel 2,2 LK-Metastasen auf, von denen 55 % distanziert zum Primarius im proximalen Mesorektum lokalisiert waren. Patienten mit Komplettresponse (ypT0) wiesen keine residuellen LK-Metastasen auf.

Diskussion

Patienten mit guter Response (ypT1–2) nach neoadjuvanter RCT haben in bis zu 25 % der Fälle residuelle mesorektale LK-Metastasen. Lokale Operationsverfahren wären im Vergleich zur TME mit einem erhöhten Risiko für ein lokales Tumorrezidiv vergesellschaftet. Bisher fehlen valide Selektionskriterien dafür, welche Patienten onkologisch sicher mit organerhaltenden Verfahren operiert werden könnten.

Abstract

Background

For patients with rectal cancer and complete remission (ypT0) or with good response and residual tumor restricted only to the bowel wall (ypT1–2) after neoadjuvant chemoradiotherapy (CRT), local excision has been suggested as an alternative to avoid the significant morbidity and functional deficits associated with total mesorectal excision (TME). The aim of this investigation was to investigate the incidence, distribution and tumor-related localization of mesorectal lymph node (LN) metastases in TME specimens with complete remission (ypT0), intramural (ypT1–2) and extramural (ypT3–4) residual tumor tissue.

Patients and methods

Specimens of TME from 81 patients with locally advanced rectal cancer (UICC II-III) undergoing neoadjuvant CRT within the phase III German rectal cancer trial CAO/ARO/AIO-04 were prospectively evaluated. The entire mesorectal compartment was microscopically screened after complete paraffin embedding. The number and localization of all detectable LN metastases were documented in relation to the primary tumor.

Results

Whereas 50 patients (62 %) had ypT3–4 rectal cancer after neoadjuvant CRT, 20 patients (25 %) presented with residual tumor within the bowel wall (ypT1–2), 11 patients (14 %) had pathological complete remission (ypT0), an average of 28 ± 13.7 LN were detected per specimen and 25 patients (31 %) had residual LN metastases after CRT. Although the incidence of LN metastases was higher in the ypT3–4 group (40 %), 25 % of patients in the ypT1–2 group with intramural residual tumor had a mean number of 2.2 residual LN metastases of which 55 % were located far from the primary lesion in the proximal mesorectum. None of the patients with ypT0 status (complete response) had residual LN metastases.

Conclusion

Even in patients with good response and post-CRT tumor tissue restricted only to the bowel wall (ypT1–2), there is still a considerable risk for residual LN metastases. Local excision of residual rectal cancer was accompanied by a higher rate of local failure and radical surgery with TME should remain the standard treatment in these patients. To date, valid selection criteria for patients eligible for organ-sparing surgery are still lacking.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland

    T. Sprenger, L.-C. Conradi, A. Kauffels, K. Homayounfar, T. Liersch & M. Ghadimi

  2. Medizinisches Versorgungszentrum Göttingen (MVZ), 37081, Göttingen, Deutschland

    H. Rothe

  3. Institut für Medizinische Statistik, Universitätsmedizin Göttingen, 37099, Göttingen, Deutschland

    T. Beissbarth

  4. Institut für Pathologie, Universitätsmedizin Göttingen, 37099, Göttingen, Deutschland

    C. L. Behnes

  5. Klinik für Strahlentherapie und Onkologie, Universitätsklinikum Frankfurt, 60590, Frankfurt/Main, Deutschland

    C. Rödel

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Correspondence to T. Sprenger.

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Interessenkonflikt

T. Sprenger, H. Rothe, T. Beissbarth, L.-C. Conradi, A. Kauffels, K. Homayounfar, C. L. Behnes, C. Rödel, T. Liersch und M. Ghadimi geben an, dass kein Interessenkonflikt besteht.

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

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Diese Studie wurde von der Deutschen Forschungsgemeinschaft (KFO 179) unterstützt.

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Sprenger, T., Rothe, H., Beissbarth, T. et al. Lymphknotenmetastasen beim ypT1/2-Rektumkarzinom nach neoadjuvanter Radiochemotherapie. Chirurg 87, 593–601 (2016). https://doi.org/10.1007/s00104-016-0170-9

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