Zusammenfassung
In den aktuell gültigen deutschen S3-Leitlinien wird bei metastasierten Magenkarzinomen und metastasierten Adenokarzinomen des ösophagogastralen Übergangs eine chirurgische Therapie in der Regel nicht empfohlen. In der täglichen Praxis findet jedoch schon heute in Einzelfällen eine Erweiterung der Indikation statt, sodass auch solche Patienten in kurativer Zielsetzung im Rahmen eines multimodalen Therapiekonzepts ausgedehnt und radikal operiert werden. Diese Arbeit stellt die wissenschaftliche Rationale eines solchen Vorgehens anhand der vorliegenden Literatur und unter Einbeziehung moderner, multimodaler Konzepte dar und verweist auf Kriterien, die für eine Erweiterung der Indikation gegeben sein sollten. Bislang existieren lediglich retrospektive Untersuchungen und wenige aktuelle Metaanalysen, die eine chirurgische Behandlung bei metastasierten Adenokarzinomen rechtfertigen. Es liegen zudem erste Ergebnisse der als Abstract publizierten FLOT-3-Studie vor, die eine Patientensubgruppe identifizieren konnte, die von einer Resektion im metastasierten Stadium profitiert. Ob die chirurgische Therapie zukünftig ein fester Bestandteil in der Behandlung des begrenzt metastasierten Adenokarzinoms des Magens und des Ösophagus wird, müssen große prospektiv randomisierte Studien wie die RENAISSANCE/FLOT-5-Studie zeigen.
Abstract
In the current German S3 guidelines surgical treatment is not recommended for metastatic gastric cancer or metastatic adenocarcinoma of the esophagogastric junction; however, in routine practice the indications can be extended so that there may be occasions in which radical surgical intervention for specific individuals may be appropriate as part of a multimodal therapy with curative intent. This article presents the scientific rationale of such an approach based on the available literature considering modern, multimodal therapy concepts including criteria to be met for radical surgery. Currently only retrospective trials and limited current meta-analysis data are available for justifying surgical treatment for metastatic adenocarcinoma. The recently published initial results of the FLOT-3 study identified a patient subgroup that benefits from a resection even though metastasis has occurred. Whether surgical therapy will become an integral part of the treatment of limited metastatic adenocarcinoma of the stomach and esophagus in the future, has to be demonstrated by large prospective randomized studies, such as the RENAISSANCE/FLOT-5 study.
Literatur
Ajani JA, Bentrem DJ, Besh S et al (2013) Gastric cancer, version 2.2013 featured updates to the NCCN guidelines. J Natl Compr Cancer Netw 11:531–546
Al-Batran S‑E, Hofheinz R, Homann N et al (2012) A prospective trial for defining a subset of patients with limited metastatic gastric cancer who may be candidates for bimodal treatment strategies: FLOT3. J Clin Oncol 30 (suppl–abstr 4090)
Al-Batran SE, Hartmann JT, Probst S et al (2008) Phase III trial in metastatic gastroesophageal adenocarcinoma with Fluorouracil, eucovorin plus either Oxaliplatin or Cisplatin: A study of the AIO. J Clin Oncol 26:1435–1442
Al-Batran SE, Pauligk C, Homann N (2013) The feasibility of triple-drug chemotherapy combination in older adult patients with oesophagogastric cancer: a randomised trial of the AIO. Eur J Cancer 49:835–842
Andreou A, Viganò L, Zimmitti G et al (2014) Response to preoperative chemotherapy predicts survival in patients undergoing Hepatectomy for liver metastases from gastric and esophageal cancer. J Gastrointest Surg 18:1974–1986
Becker K, Langer R, Reim D et al (2011) Significance of histopathological tumor regression after neoadjuvant chemotherapy in gastric adenocarcinomas. Ann Surg 253:934–939
Biffi R, Fazio N, Luca F et al (2010) Surgical outcome after docetaxel-based neoadjuvant chemotherapy in locally-advanced gastric cancer. World J Gastroenterol 16:868–874
Chang YR, Han DS, Kong SH et al (2012) The value of palliative gastrectomy in gastric cancer with distant metastasis. Ann Surg Oncol 19:1231–1239
Chen L, Song MQ, Lin HZ, Hao LH (2013) Chemotherapy and resection for gastric cancer with synchronous liver metastases. World J Gastroenterol 19:2097–2103
Chen S, Li Y‑F, Feng X‑Y et al (2012) Significance of palliative gastrectomy for late-stage gastric cancer patients. J Surg Oncol 106:862–871
Cheon SH, Rha SY, Jeung HC et al (2008) Survival benefit of combined curative resection of the stomach [D2 resection] and liver in gastric cancer patients with liver metastases. Ann Oncol 19:1146–1153
Dittmar Y, Altendorf-Hofmann A, Rauchfuss F et al (2011) Resection of liver metastases is beneficial in patients with gastric cancer: report on 15 cases and review of literature. Gastric Cancer 15:131–136
Dittmar Y, Rauchfuss F, Goetz M, Jandt K (2012) Non-curative gastric resection for patients with stage 4 gastric cancer–a single center experience and current review of literature – Springer. Langenbeck’s Arch Surg 397:745–753
Fitzgerald TL, Brinkley J, Banks S et al (2014) The benefits of liver resection for non-colorectal, non-neuroendocrine liver metastases: a systematic review. Langenbeck’s Arch Surg 399:989–1000
Gadde R, Tamariz L, Hanna M et al (2015) Metastatic gastric cancer [MGC] patients: Can we improve survival by metastasectomy? A systematic review and meta-analysis. J Surg Oncol 112:38–45
Geh JI, Glynne-Jones R, Kwok QSK et al (2000) Preoperative ECF chemotherapy in gastro-oesophageal adenocarcinoma. Clin Oncol 12:182–187
Glehen O, Gilly FN, Arvieux C et al (2010) Peritoneal carcinomatosis from gastric cancer: A multi-institutional study of 159 patients treated by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Ann Surg Oncol 17:2370–2377
Hartgrink HH, Putter H (2002) Value of palliative resection in gastric cancer. Br J Surg 89:1438–1443
Homann N, Pauligk C, Luley K et al (2011) Pathological complete remission in patients with oesophagogastric cancer receiving preoperative 5‑fluorouracil, oxaliplatin and docetaxel. Int J Cancer 130:1706–1713
Ikeguchi M, Oka A, Tsujitani S et al (1994) Relationship between area of serosal invasion and intraperitoneal free cancer cells in patients with gastric cancer. Anticancer Res 14:2131–2134
Zhai J, Li JH, Zhai RJ (2012) Predictive factors improving survival after gastric and hepatic surgical treatment in gastric cancer patients with synchronous liver metastases. Chin Med J 125:165–171
Kim KH, Lee KW, Baek SK et al (2011) Survival benefit of gastrectomy±metastasectomy in patients with metastatic gastric cancer receiving chemotherapy. Gastric Cancer 14:130–138
Kunieda K, Saji S, Sugiyama Y et al (2002) Evaluation of treatment for synchronous hepatic metastases from gastric cancer with special reference to long-term survivors. Surg Today 32:587–593
Lee JH, Paik YH, Lee JS et al (2006) Candidates for curative resection in advanced gastric cancer patients who had equivocal para-aortic lymph node metastasis on computed tomographic scan. Ann Surg Oncol 13:1163–1167
Lordick F (2012) To resect or not resect in metastatic gastric cancer: that is the question! Gastric Cancer 15:229–231
Lorenzen S, Brücher B, Zimmermann F et al (2008) Neoadjuvant continuous infusion of weekly 5‑fluorouracil and escalating doses of oxaliplatin plus concurrent radiation in locally advanced oesophageal squamous cell carcinoma: results of a phase I/II trial. Br J Cancer 99:1020–1026
Lorenzen S, Pauligk C, Homann N (2013) Feasibility of perioperative chemotherapy with infusional 5‑FU, leucovorin, and oxaliplatin with [FLOT] or without [FLO] docetaxel in elderly patients with locally advanced esophagogastric cancer. Br J Cancer 108:519–526
Makino H, Kunisaki C, Izumisawa Y et al (2010) Indication for hepatic resection in the treatment of liver metastasis from gastric cancer. Anticancer Res 30:2367–2376
Martella L, Bertozzi S, Londero AP et al (2015) Surgery for liver metastases from gastric cancer. Medicine (Baltimore) 94:1–9
Miki Y, Fujitani K, Hirao M et al (2012) Significance of surgical treatment of liver metastases from gastric cancer. Anticancer Res 32:665–670
Moehler M, Al-Batran SE, Andus T et al (2011) S3-Leitlinie „Magenkarzinom“ – Diagnostik und Therapie der Adenokarzinome des Magens und ösophagogastralen Übergangs. Z Gastroenterol 49:461–531
Mohri Y, Tanaka K, Ohi M et al (2014) Identification of prognostic factors and surgical indications for metastatic gastric cancer. Cancer 14:1–10
Okuyama K, Isono K, Juan I‑K et al (1985) Evaluation of treatment for gastric cancer with liver metastasis. Cancer 55:2498–2505
Oyama K, Fushida S, Kinoshita J et al (2011) Efficacy of pre-operative chemotherapy with docetaxel, cisplatin, and S‑1 [DCS therapy] and curative resection for gastric cancer with pathologically positive para-aortic lymph nodes. J Surg Oncol 105:535–541
Pauligk C, Meiler J et al (2013) Interim safety analysis of a phase III trial with 5‑FU, oxaliplatin, and docetaxel [FLOT] versus epirubicin, cisplatin, and 5‑FU [ECF] in patients with locally advanced, resectable gastric/oesophagogastric junction [OGJ] cancer: The AIO-sto-0210 FLOT4 study. J Clin Oncol 31: (suppl–abstr 4079)
Pauligk C, Tannapfel A, Meiler J et al (2015) Pathological response to neoadjuvant 5‑FU, oxaliplatin, and docetaxel [FLOT] versus epirubicin, cisplatin, and 5‑FU [ECF] in patients with locally advanced, resectable gastric/esophagogastric junction [EGJ] cancer: Data from the phase II part of the FLOT4 phase III study of the AIO. Am Soc Clin Oncol Meet Abstr 33:4016
Petrelli F, Coinu A, Cabiddu M et al (2015) Hepatic resection for gastric cancer liver metastases: A systematic review and meta-analysis. J Surg Oncol 111:1021–1027
Porschen R, Buck A, Fischbach W et al (2015) S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. Z Gastroenterol 53:1288–1347
Sadeghi B, Arvieux C, Glehen O et al (2000) Peritoneal carcinomatosis from non-gynecologic malignancies. Cancer 88:358–363
Scaringi S, Kianmanesh R, Sabate JM et al (2008) Advanced gastric cancer with or without peritoneal carcinomatosis treated with hyperthermic intraperitoneal chemotherapy: A single western center experience. Eur J Surg Oncol 34:1246–1252
Schulz C, Kullmann F, Kunzmann V et al (2012) Multicenter phase II study of perioperative chemotherapy in resectable adenocarcinoma of the gastroesophageal junction or gastric adenocarcinoma. J Clin Oncol 30: (suppl–abstr 4072)
Schulz C, Kullmann F, Kunzmann V et al (2015) NeoFLOT: Multicenter phase II study of perioperative chemotherapy in resectable adenocarcinoma of the gastroesophageal junction or gastric adenocarcinoma-very good response predominantly in patients with intestinal type tumors. Int J Cancer 137:678–685
Sougioultzis S, Syrios J, Xynos ID et al (2011) Palliative gastrectomy and other factors affecting overall survival in stage IV gastric adenocarcinoma patients receiving chemotherapy: A retrospective analysis. Eur J Surg Oncol 37:312–318
Starling N, Okines A, Cunningham D et al (2009) A phase II trial of preoperative chemotherapy with epirubicin, cisplatin and capecitabine for patients with localised gastro-oesophageal junctional adenocarcinoma. Br J Cancer 100:1725–1730
Takeda J, Yasumoto K, Yano S (1990) Retrospective studies of gastric cancer with hepatic metastases. Kurume Med J 37:271–276
Thuss-Patience PC, Hofheinz RD, Arnold D et al (2012) Perioperative chemotherapy with docetaxel, cisplatin and capecitabine [DCX] in gastro-oesophageal adenocarcinoma: a phase II study of the Arbeitsgemeinschaft Internistische Onkologie [AIO]. Ann Oncol 23:2827–2834
Tiberio G, Coniglio A, Marchet A, Marrelli D (2009) Metachronous hepatic metastases from gastric carcinoma: a multicentric survey. Eur J Cancer Surg 35:486–491
Tiberio GAM, Baiocchi GL, Morgagni P et al (2014) Gastric cancer and synchronous hepatic metastases: is it possible to recognize candidates to R0 resection? Ann Surg Oncol 22:589–596
Ueda K, Iwahashi M, Nakamori M, Nakamura M (2009) Analysis of the prognostic factors and evaluation of surgical treatment for synchronous liver metastases from gastric cancer. Langenbeck’s Arch Surg 394:647–653
Yang SW, Kim MG, Lee JH (2013) Role of Metastasectomy on overall survival of patients with metastatic gastric cancer. J Gastric Cancer 13:227–231
Yang X‑J, Huang C‑Q, Suo T et al (2011) Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy improves survival of patients with peritoneal carcinomatosis from gastric cancer: final results of a phase III randomized clinical trial. Ann Surg Oncol 18:1575–1581
Yonemura Y, Kawamura T, Bandou E et al (2005) Treatment of peritoneal dissemination from gastric cancer by peritonectomy and chemohyperthermic peritoneal perfusion. Br J Surg 92:370–375
Yoshida M, Ohtsu A, Boku N et al (2004) Long-term survival and prognostic factors in patients with metastatic gastric cancers treated with chemotherapy in the japan clinical oncology group [JCOG] study. Jpn J Clin Oncol 34:654–659
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
S.P. Mönig und L.M. Schiffmann geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
Rights and permissions
About this article
Cite this article
Mönig, S.P., Schiffmann, L.M. Resektion beim fortgeschrittenen Adenokarzinom des Magens und des Ösophagus. Chirurg 87, 398–405 (2016). https://doi.org/10.1007/s00104-016-0183-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00104-016-0183-4