Zusammenfassung
Die Ergebnisse, die im Zusammenhang mit einer R1-Situation bei einem resezierten Magenkarzinom in der Literatur berichtet werden, sind nicht einheitlich. Eine R1-Situation verschlechtert die Prognose für das Langzeitüberleben der Patienten. Dies ist vor allem für niedrige T‑Stadien und einer Lymphknotenmetastasierung mit 0 bis ≤3 Lymphknotenmetastasen signifikant. In höheren Tumorstadien und bei ausgedehnter Lymphknotenmetastasierung ist der Überlebensunterschied zwischen R0- und R1-Resektion geringer bzw. nicht mehr signifikant. Die Häufigkeit einer R1-Resektion liegt bei ca. 5 % (1,8–9 %, AEG-Tumoren ≥10 %). Die Daten beziehen sich vor allem auf den oralen und aboralen Schnittrand, Angaben zum zirkumferenziellen Schnittrand finden sich selten. Das Risiko eines histologisch positiven Schnittrandes steigt mit der Größe des Tumors (≥5 cm), einem T3/4- und oder pN2/pN3-Stadium. Schlecht differenzierte, Siegelringzell- oder muzinöse Adenokarzinome und Karzinome vom Bormann-Typ 3+4 führen ebenfalls zu einer erhöhten R1-Rate. Zur Erzielung einer R0-Resektion stellt eine intraoperative histologische Schnellschnittuntersuchung den Standard dar. Bei einer Tumorinfiltration sollte die sofortige Nachresektion vorgenommen werden. Findet sich die R1-Diagnose erst in der definitiven Histologie, gilt die Nachresektion zur Erzielung einer R0-Resektion in Publikationen als Standard. Trotzdem erfolgt eine Reoperation nur selten. Nur eine Studie berichtet über 122 Patienten mit 100 % Reoperationen, die bei 50 Patienten (41 %) erfolgreich (R0) durchgeführt wurden. Für die R0-Gruppe konnte das mediane Überleben von 18 auf 23 Monate verlängert werden. Für postoperative additive Maßnahmen (Chemo‑, Strahlen- und Radiochemotherapie) finden sich nur sporadische Literaturdaten und keine Evidenz.
Abstract
The results reported in the literature in the context of an R1 situation for a resected gastric carcinoma are not uniform. An R1 situation worsens the prognosis for the long-term survival of patients. This is significant especially for low T stages and lymph node metastasis with 0–≤3 lymph node metastases. In higher tumor stages with extensive lymph node metastases, the survival difference between R0 and R1 resections is lower and frequently no longer significant. The frequency of R1 resection is approximately 5% (range 1.8–9%) and for adenocarcinoma of the esophagogastric junction (AEG tumors)> 10%. The data are mainly related to the oral and aboral resection line but there are only a few specifications on the circumferential margin. The risk of an infiltrated resection line increases with the size of the tumor (>5 cm), T3+4 and pN2/pN3 stages. Poorly differentiated signet ring cell or mucinous adenocarcinomas and carcinomas of the Bormann type 3+4 also lead to an increased R1 rate. In order to achieve an R0 resection, an intraoperative frozen section is the standard approach. Immediate reoperation should be performed in the case of tumor infiltration. If an R1 resection is detected only in the definitive histology, surgical re-excision to achieve an R0 resection is the standard approach in publications. Nevertheless, a reoperation is rare. Only 1 study showed 122 patients with 100% re-operations, which were successfully performed in 50 patients (41% R0). For the R0 group, median survival was extended from 18 months to 23 months. There are only sporadic literature data and no evidence for postoperative additive treatment (chemotherapy, radiotherapy and radiochemotherapy).
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K. Ridwelski, J. Fahlke, M. Huß, R. Otto und S. Wolff geben an, dass kein Interessenkonflikt besteht.
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Ridwelski, K., Fahlke, J., Huß, M. et al. R1-Resektion beim Magenkarzinom. Chirurg 88, 756–763 (2017). https://doi.org/10.1007/s00104-017-0460-x
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DOI: https://doi.org/10.1007/s00104-017-0460-x