Chirurgische Therapie des Ösophaguskarzinoms: Eine prospektive 20-Jahres-Analyse

 

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Zusammenfassung

Hintergrund: Ziel unserer Studie war die Analyse von Langzeitentwicklungen der chirurgischen Therapie des Ösophaguskarzinoms in unserer Klinik über einen Zeitraum von 20 Jahren mit differenzierter Betrachtung der beiden vorherrschenden histologischen Tumortypen. Patienten und Methodik: Zwischen September 1985 und September 2005 wurden in unserer Klinik 470 Patienten wegen eines malignen Tumors der Speiseröhre ösophagusreseziert. Die abdomino-thorakale Ösophagusresektion mit abdomineller und erweiterter mediastinaler Lymphknotendissektion sowie intrathorakaler Anastomose war der Standardeingriff beim Plattenepithelkarzinom, während beim Adenokarzinom eine transhiatale Resektion mit abdomineller und hinterer mediastinaler Lymphadenektomie und zervikaler Ösophagogastrostomie erfolgte. Der Beobachtungszeitraum von 20 Jahren wurde zur Analyse von Entwicklungen in 2 Intervalle eingeteilt: Intervall 1 von 9 / 1985 bis 9 / 1995 und Intervall 2 von 10 / 1995 bis 9 / 2005. Ergebnisse: Beide Tumorentitäten wiesen im letzten Intervall (10 / 1995-9 / 2005) signifikant frühere Tumorstadien auf. Bei in beiden Intervallen proportional identischem Anteil an transthorakalen Resektionen beim Plattenepithelkarzinom zeigte sich ein signifikanter Trend zum transhiatalen Vorgehen beim Adenokarzinom in der letzten Dekade (3,6 % im Zeitraum zwischen 9 / 1985 und 9 / 1995 im Vergleich zu 23,6 % zwischen 10 / 1995 und 9 / 2005) (p < 0,05). Während die Gesamtprognose beim Plattenepithelkarzinom in beiden Dekaden nicht signifikant verschieden war (p = 0,2040), fand sich bei Patienten mit Adenokarzinom in der letzten Dekade ein signifikant besseres Langzeitüberleben (Log-Rank-Test: p = 0,0365). Die Prognose beim Adenokarzinom konnte somit im zeitlichen Verlauf mit einer 3-Jahres-Überlebensrate von zuletzt 40 % (verglichen mit 17,5 % in der ersten Dekade) und einer 5-Jahres-Überlebensrate von 25 % (verglichen mit 15 %) verbessert werden. Folgerung: Die chirurgische Therapie des Ösophaguskarzinoms hat in den letzten 20 Jahren deutliche Veränderungen erfahren. Diese sind überwiegend durch epidemiologische und diagnostische Aspekte, eine verbesserte Patientenselektion durch ein dem Tumorstadium und dem individuellen operativen Risiko des Patienten angepasstes operatives Vorgehen bedingt und haben insbesondere beim Adenokarzinom des Ösophagus zu einer signifikant günstigeren Langzeitprognose geführt.

Abstract

Background: The aim of our study was the analysis of long-term developments in the surgical therapy for esophageal carcinoma at our hospital over a period of 20 years with a differentiated view on the two predominant histological tumour types. Patients and Methods: Between September 1985 and September 2005, esophageal resections were performed in 470 patients at our clinic on account of a malignant tumour of the esophagus. The abdomino-thoracic resection with abdominal and extended mediastinal lymph node dissection as well as intrathoracic anastomosis was the standard treatment in the case of squamous cell carcinoma, whereas in adenocarcinoma a transhiatal resection with abdominal and dorsal mediastinal lymphadenectomy and cervical esophagogastrostomy was carried out. For analysis of the development, the study period of 20 years was divided into two intervals: interval 1 from 9 / 1985 to 9 / 1995, and interval 2 from 10 / 1995 to 9 / 2005. Results: Both tumour entities displayed in the last interval (10 / 1995 to 9 / 2005) significantly earlier tumour stages. A proportionally identical amount of transhiatal resections for squamous cell carcinoma was found in both intervals, whereas the transhiatal procedures for adenocarcinoma increased in the last decade (3.6 % in the period between 9 / 1985 and 9 / 1995, as compared with 23.6 % between 10 / 1995 and 9 / 2005) (p < 0.05). While the overall prognosis for squamous cell carcinoma did not significantly differ in the two decades (p = 0.2040), patients with adenocarcinoma were found to have a significantly improved long-term survival (log-rank test: p = 0.0365) in the second decade. The prognosis for adenocarcinoma, therefore, could be improved in the course of time with a 3-year survival rate of finally 40 % (as compared with 17.5 % in the first decade), and a 5-year survival rate of 25 % (as compared with 15 %). Conclusion: Surgical therapy for esophageal carcinoma has undergone distinct changes over the past 20 years. These are mainly due to epidemiological and diagnostic aspects, an improved selection of patients, whereby the operative procedure is adapted to the tumour stage and the operative risk for the patient. Especially with adenocarcinoma of the esophagus, these changes have led to a significantly more favourable long-term prognosis.

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Dr. med. habil. I. Gockel

Klinik für Allgemein- und Abdominalchirurgie · Johannes-Gutenberg-Universität

Langenbeckstr. 1

55131 Mainz

Phone: 0 61 31 / 17 72 91

Fax: 0 61 31 / 17 66 30

Email: gockel@ach.klinik.uni-mainz.de