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Chirurgische Strategie bei Frühkarzinomen des Ösophagus

Surgical strategy for early stage carcinoma of the esophagus

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Zusammenfassung

Ösophagusfrühkarzinome werden histologisch in Adeno- und Plattenepithelkarzinome und abhängig von der Tiefeninfiltration in m1–3(Mukosa)-und sm1–3(Submukosa)-Karzinome unterteilt. Während die Prävalenz von Lymphknotenmetastasen bei Mukosakarzinomen sehr gering ist, steigt die Wahrscheinlichkeit von Lymphknotenmetastasen ab Infiltration der Submukosa mit zunehmender Tiefe an. Nach der aktuellen deutschen S3-Leitlinie wird bei intramukosalen Adenokarzinomen ohne histologische Risikofaktoren (Lymphgefäßinvasion [L1], Blutgefäßinvasion [V1], gering differenziert [>G2], mikroskopischer Residualtumor [R1] basal) eine endoskopische Resektion empfohlen. Bei oberflächlicher Submukosainfiltration (sm1) ohne histologische Risikofaktoren kann ebenfalls eine endoskopische Resektion erfolgen, wobei die Leitlinie in diesem Fall eine stärkere Empfehlung für eine Ösophagektomie gibt. Bei Plattenepithelkarzinomen ist bis zur Infiltrationstiefe m2 und ohne histologische Risikofaktoren eine endoskopische Resektion indiziert. Außerhalb dieser Kriterien sollte immer eine Ösophagusresektion erfolgen. Das chirurgische Standardverfahren ist eine subtotale abdominothorakale Ösophagektomie mit Zweifeldlymphadenektomie. Alternative Verfahren sind die totale Ösophagektomie bei proximalen Karzinomen und die transhiatal erweiterte Gastrektomie bei Kardiakarzinomen. Limitierte proximale oder distale Ösophagusresektionen können bei proximal oder distal gelegenen und endoskopisch nicht resezierbaren Mukosakarzinomen durchgeführt werden, sind aber der radikalen Resektion funktionell nicht überlegen und onkologisch aufgrund der eingeschränkten Lymphadenektomie nicht gleichwertig. Minimalinvasive Verfahren zeigen gute onkologische Ergebnisse und vermindern die Morbidität der radikalen Ösophagusresektion. Dies sollte in Zukunft bei der Entscheidungsfindung in Grenzfällen zwischen endoskopischer und chirurgischer Resektion berücksichtigt werden.

Abstract

Early stage carcinomas of the esophagus are histologically differentiated into adenocarcinomas and squamous cell carcinomas and subdivided into mucosal (m1–3) and submucosal (sm1–3) carcinomas depending on the infiltration depth. While the prevalence of lymph node metastases in mucosal carcinomas is very low, the probability of lymph node metastases increases from submucosal infiltration with increasing depth. According to the current German S3 guidelines endoscopic resection is the recommended treatment strategy for mucosal adenocarcinoma without histological risk factors (lymphatic invasion [L1], venous invasion [V1], poorly differentiated [>G2], microscopic residual disease [R1] at the deep resection margin). For superficial submucosal infiltration (sm1) without histological risk factors endoscopic resection can also be carried out, whereby in this case the guidelines make a stronger recommendation for esophagectomy. For squamous cell carcinoma endoscopic resection is indicated for an infiltration depth up to middle layer mucosal carcinoma (m2) without histological risk factors. Outside of these criteria an esophageal resection should always be carried out. The surgical gold standard is a subtotal abdominothoracic esophagectomy with two-field lymphadenectomy. Alternative procedures are total esophagectomy in proximal esophageal carcinoma and transhiatal extended gastrectomy for carcinoma of the cardia. Limited proximal or distal esophageal resections can be performed in proximal or distal mucosal carcinoma without the possibility of endoscopic resection; however, partial resections are not superior in terms of functional results and are not oncologically equivalent due to limited lymphadenectomy. Minimally invasive procedures show good oncological results and reduce the morbidity of radical esophagectomy. Reduced morbidity might be an argument for surgical resection in borderline cases between endoscopic and surgical resection.

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Authors and Affiliations

  1. Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Rue Gabrielle-Perret-Gentil 4, 1205, Genf, Schweiz

    N. Niclauss,  M. Chevallay &  S. P. Mönig

  2. Service de gastroentérologie et hépatologie, Hôpitaux Universitaires de Genève, Genf, Schweiz

    J. L. Frossard

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  1. N. Niclauss
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  2. M. Chevallay
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  3. J. L. Frossard
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  4. S. P. Mönig
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Correspondence to S. P. Mönig.

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Interessenkonflikt

N. Niclauss, M. Chevallay, J. L. Frossard und S. P. Mönig geben an, dass kein Interessenkonflikt besteht.

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

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Niclauss, N., Chevallay, M., Frossard, J.L. et al. Chirurgische Strategie bei Frühkarzinomen des Ösophagus. Chirurg 89, 339–346 (2018). https://doi.org/10.1007/s00104-018-0589-2

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