Das inoperable Pankreaskarzinom – palliative interventionelle und chirurgische Therapie

 

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Zusammenfassung

Das Pankreaskarzinom ist bei Diagnosestellung in der Mehrzahl der Fälle bereits nicht mehr kurativ resektabel, sodass palliative Therapiekonzepte bei diesen Patienten im Vordergrund stehen. Patienten ohne Fernmetastasen – aber mit grenzwertig resektablen bzw. lokal nicht resektablen Tumoren – sollten allerdings nicht primär palliativ therapiert, sondern in neoadjuvante Radiochemotherapie-Protokolle eingeschlossen werden. Nach abgeschlossener Therapie und Reevaluation ist eine potenziell kurative Resektion bei etwa einem Drittel dieser Patienten möglich. Im Rahmen bestmöglicher Palliation stellt auch die Metastasenresektion plus Primärtumorresektion in ausgewählten Fällen eine optionale Therapiemaßnahme dar. Bei definitiv lokal irresektablem oder fernmetastasiertem, fortgeschrittenem Pankreaskarzinom ist ein wesentlicher Bestandteil der Palliation die Therapie einer Gallengangs- und / oder Duodenalobstruktion. Sowohl endoskopische / perkutane Stentverfahren als auch operative Bypassanlagen sind sichere und mit hoher Erfolgsrate durchführbare Optionen. Bei operativer Anlage einer Gallengangsableitung wird die prophylaktische Anlage eines Magenbypasses (Doppelbypass) favorisiert. Die Entscheidung für ein operatives versus endoskopisches Verfahren zur Palliation hängt wesentlich vom Tumorbefund und der Prognoseabschätzung ab und muss interdisziplinär und individuell entschieden werden.

Abstract

In most cases pancreatic cancer appears in a non-curatively resectable stage at time the diagnosis is made. Thus, palliative treatment concepts come to the fore in these patients. Patients without metastases, but presenting with marginally resectable or locally non-resectable tumours should not be treated in a palliative therapeutic scheme. These patients should be enrolled in neoadjuvant radiochemotherapy trials. After finishing treatment and restaging, a potentially curative resection can be achieved in approximately one-third of these patients. Within the scope of the best possible palliative care, excision of metastases together with resection of the primary cancer represents a therapeutic option to be contemplated in selected cases. For distinct locally unresectable or metastasised advanced pancreatic cancer, treatment of bile duct or duodenal obstruction is an essential part of the comprehensive palliative therapy. However, both endoscopic / percutaneous stenting procedures and surgical bypass makeshifts constitute safe and highly effective therapeutic alternatives in this context. In the case of operative drainage of the biliary tract the prophylactic creation of a gastro-intestinal bypass (double bypass) is recommended. The decision on a surgical versus an endoscopic procedure for palliation depends considerably on the tumour stage and the estimated prognosis and has to be determined interdisciplinary and individually in each case.

Literatur

• 1 Sener S F, Fremgen A, Menck H R et al. Pancreatic cancer: a report of treatment and survival trends for 100 313 patients diagnosed from 1985–1995, using the National Cancer Database.  J Am Coll Surg. 1999;  189 1-7
  CrossrefPubMedGoogle Scholar
• 2 Bramhall S R, Allum W H, Jones A G et al. Treatment and survival in 13 560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study.  Br J Surg. 1995;  82 111-115
  CrossrefPubMedGoogle Scholar
• 3 Michalski C W, Kleeff J, Wente M N et al. Systematic review and metaanalysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer.  Br J Surg. 2007;  94 265-273
  CrossrefPubMedGoogle Scholar
• 4 Tseng J F, Raut C P, Lee J E et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration.  J Gastrointest Surg. 2004;  8 935-949
  CrossrefPubMedGoogle Scholar
• 5 Wanebo H J, Glicksman A S, Vezeridis M P et al. Preoperative chemotherapy, radiotherapy, and surgical resection of locally advanced pancreatic cancer.  Arch Surg. 2000;  135 81-87
  CrossrefPubMedGoogle Scholar
• 6 Andersen J R, Sorensen S M, Kruse A et al. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice.  Gut. 1989;  30 1132-1135
  CrossrefPubMedGoogle Scholar
• 7 Shepherd H A, Royle G, Ross A P et al. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial.  Br J Surg. 1988;  75 1166-1168
  CrossrefPubMedGoogle Scholar
• 8 Smith A C, Dowsett J F, Russell R C et al. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction.  Lancet. 1994;  344 1655-1660
  CrossrefPubMedGoogle Scholar
• 9 Taylor M C, McLeod R S, Langer B. Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a metaanalysis.  Liver Transpl. 2000;  6 302-308
  CrossrefPubMedGoogle Scholar
• 10 Bornman P C, Harries-Jones E P, Tobias R et al. Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for incurable carcinoma of head of pancreas.  Lancet. 1986;  1 69-71
  PubMedGoogle Scholar
• 11 Watanapa P, Williamson R C. Surgical palliation for pancreatic cancer: developments during the past two decades.  Br J Surg. 1992;  79 8-20
  CrossrefPubMedGoogle Scholar
• 12 Lillemoe K D, Pitt H A. Palliation. Surgical and otherwise.  Cancer. 1996;  78 605-614
  CrossrefPubMedGoogle Scholar
• 13 Muller M W, Friess H, Koninger J et al. Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas.  Am J Surg. 2008;  195 221-228
  CrossrefPubMedGoogle Scholar
• 14 Pilepich M V, Miller H H. Preoperative irradiation in carcinoma of the pancreas.  Cancer. 1980;  46 1945-1949
  CrossrefPubMedGoogle Scholar
• 15 Whittington R, Solin L, Mohiuddin M et al. Multimodality therapy of localized unresectable pancreatic adenocarcinoma.  Cancer. 1984;  54 1991-1998
  CrossrefPubMedGoogle Scholar
• 16 Kleeff J, Friess H, Buchler M W. Neoadjuvant therapy for pancreatic cancer.  Br J Surg. 2007;  94 261-262
  CrossrefPubMedGoogle Scholar
• 17 Tempero M, Arnoletti J P, Ben-Josef E et al. Pancreatic adenocarcinoma. Clinical Practice Guidelines in Oncology.  J Natl Compr Canc Netw. 2007;  5 998-1033
  PubMedGoogle Scholar
• 18 Gillen S, Schuster T, Meyer Zum Büschenfelde C et al. Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages.  PLoS Med. 2010;  7 e1000267
  CrossrefPubMedGoogle Scholar
• 19 Neoptolemos J P, Stocken D D, Friess H et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer.  N Engl J Med. 2004;  350 1200-1210
  CrossrefPubMedGoogle Scholar
• 20 Oettle H, Post S, Neuhaus P et al. Adjuvant chemotherapy with gemcitabine vs. observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial.  Jama. 2007;  297 267-277
  CrossrefPubMedGoogle Scholar
• 21 Brunner T B, Grabenbauer G G, Meyer T et al. Primary resection versus neoadjuvant chemoradiation followed by resection for locally resectable or potentially resectable pancreatic carcinoma without distant metastasis. A multi-centre prospectively randomised phase II-study of the Interdisciplinary Working Group Gastrointestinal Tumours (AIO, ARO, and CAO).  BMC Cancer. 2007;  7 41
  CrossrefPubMedGoogle Scholar
• 22 Fiori E, Lamazza A, Volpino P et al. Palliative management of malignant antro-pyloric strictures. Gastroenterostomy vs. endoscopic stenting. A randomized prospective trial.  Anticancer Res. 2004;  24 269-271
  PubMedGoogle Scholar
• 23 Michalski C W, Erkan M, Hüser N et al. Resection of primary pancreatic cancer and liver metastasis: a systematic review.  Dig Surg. 2008;  25 473-480
  CrossrefPubMedGoogle Scholar
• 24 Wong Y T, Brams D M, Munson L et al. Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation.  Surg Endosc. 2002;  16 310-312
  CrossrefPubMedGoogle Scholar
• 25 Maetani I, Tada T, Ukita T et al. Comparison of duodenal stent placement with surgical gastrojejunostomy for palliation in patients with duodenal obstructions caused by pancreaticobiliary malignancies.  Endoscopy. 2004;  36 73-78
  Article in Thieme ConnectPubMedGoogle Scholar
• 26 Dormann A, Meisner S, Verin N et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness.  Endoscopy. 2004;  36 543-550
  Article in Thieme ConnectPubMedGoogle Scholar
• 27 Singh S M, Longmire W P, Reber H A. Surgical palliation for pancreatic cancer. The UCLA experience.  Ann Surg. 1990;  212 132-139
  CrossrefPubMedGoogle Scholar
• 28 Deziel D J, Wilhelmi B, Staren E D et al. Surgical palliation for ductal adenocarcinoma of the pancreas.  Am Surg. 1996;  62 582-588
  PubMedGoogle Scholar
• 29 Nieveen van Dijkum E J, Romijn M G et al. Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma.  Ann Surg. 2003;  237 66-73
  CrossrefPubMedGoogle Scholar
• 30 Brandabur J J, Kozarek R A, Ball T J et al. Nonoperative versus operative treatment of obstructive jaundice in pancreatic cancer: cost and survival analysis.  Am J Gastroenterol. 1988;  83 1132-1139
  PubMedGoogle Scholar
• 31 Sarr M G, Cameron J L. Surgical palliation of unresectable carcinoma of the pancreas.  World J Surg. 1984;  8 906-918
  CrossrefPubMedGoogle Scholar
• 32 van der Schelling G P, van den Bosch R P, Klinkenbij J H et al. Is there a place for gastroenterostomy in patients with advanced cancer of the head of the pancreas?.  World J Surg. 1993;  17 128-132
  CrossrefPubMedGoogle Scholar
• 33 Telford J J, Carr-Locke D L, Baron T H et al. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study.  Gastrointest Endosc. 2004;  60 916-920
  CrossrefPubMedGoogle Scholar
• 34 Sarr M G, Cameron J L. Surgical management of unresectable carcinoma of the pancreas.  Surgery. 1982;  91 123-133
  PubMedGoogle Scholar
• 35 Speer A G, Cotton P B, Russell R C et al. Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice.  Lancet. 1987;  2 57-62
  CrossrefPubMedGoogle Scholar
• 36 Singh S M, Reber H A. Surgical palliation for pancreatic cancer.  Surg Clin North Am. 1989;  69 599-611
  PubMedGoogle Scholar
• 37 Huguier M, Baumel H, Manderscheid J C. Cancer of the exocrine pancreas. A plea for resection.  Hepatogastroenterology. 1996;  43 721-729
  PubMedGoogle Scholar
• 38 Neuberger T J, Wade T P, Swope T J et al. Palliative operations for pancreatic cancer in the hospitals of the U.S. Department of Veterans Affairs from 1987 to 1991.  Am J Surg. 1993;  166 632-636 discussion 636–637
  CrossrefPubMedGoogle Scholar
• 39 Gough I R, Mumme G. Biliary and duodenal bypass for carcinoma of the head of the pancreas.  J Surg Oncol. 1984;  26 282-284
  CrossrefPubMedGoogle Scholar
• 40 Sarr M G, Gladen H E, Beart R W et al. Role of gastroenterostomy in patients with unresectable carcinoma of the pancreas.  Surg Gynecol Obstet. 1981;  152 597-600
  PubMedGoogle Scholar
• 41 Meinke W B, Twomey P L, Guernsey J M et al. Gastric outlet obstruction after palliative surgery for cancer of head of pancreas.  Arch Surg. 1983;  118 550-553
  PubMedGoogle Scholar
• 42 Blievernicht S W, Neifeld J P, Terz J J et al. The role of prophylactic gastrojejunostomy for unresectable periampullary carcinoma.  Surg Gynecol Obstet. 1980;  151 794-796
  PubMedGoogle Scholar
• 43 de Rooij P D, Rogatko A, Brennan M F. Evaluation of palliative surgical procedures in unresectable pancreatic cancer.  Br J Surg. 1991;  78 1053-1058
  CrossrefPubMedGoogle Scholar
• 44 Egrari S, O'Connell T X. Role of prophylactic gastroenterostomy for unresectable pancreatic carcinoma.  Am Surg. 1995;  61 862-864
  PubMedGoogle Scholar
• 45 Lillemoe K D, Cameron J L, Hardacre J M et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial.  Ann Surg. 1999;  230 322-328 discussion 328–330
  CrossrefPubMedGoogle Scholar
• 46 Shyr Y M, Su C H, Wu C W et al. Prospective study of gastric outlet obstruction in unresectable periampullary adenocarcinoma.  World J Surg. 2000;  24 60-64 discussion 64–65
  CrossrefPubMedGoogle Scholar
• 47 Van Heek N T, De Castro S M, van Eijck C H et al. The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life.  Ann Surg. 2003;  238 894-902 discussion 902–905
  CrossrefPubMedGoogle Scholar
• 48 Hüser N, Michalski C W, Schuster T et al. Systematic review and metaanalysis of prophylactic gastroenterostomy for unresectable advanced pancreatic cancer.  Br J Surg. 2009;  96 711-719
  CrossrefPubMedGoogle Scholar

Prof. H. Friess

Klinikum rechts der Isar der TU München · Chirurgische Klinik und Poliklinik

Ismaninger Straße 22

81675 München

Deutschland

Phone: 0 89 / 41 40 21 20

Fax: 0 89 / 41 40 48 70

Email: friess@chir.med.tu-muenchen.de