Spannungsfeld endoskopische Resektionsverfahren bei GEP-NET // Endoscopic resection for GEP-NET

 

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Zusammenfassung

Neuroendokrine Tumoren des Verdauungstraktes (GEP-NET) sind eine seltene Tumorentität, die häufig als Zufallsbefund diagnostiziert werden. Ein großer Teil dieser Zufallsdiagnosen wird im Rahmen einer endoskopischen Untersuchung gestellt. Während die vollständige Entfernung des Tumors im Sinne einer kurativen chirurgischen Resektion nach onkologischen Kriterien das Standardvorgehen für lokalisierte Tumorerkrankungen ist, kann bei kleinen Tumoren ohne Hinweis und Risiko für eine lymphogene Metastasierung eine endoskopische Abtragung in gleicher Intention erfolgen. Während dies für Magen-, Duodenum- und Rektum-NET der Standard ist, sollten NET des Jejunums und Ileums aufgrund der hohen Metastasierungsrate trotz geringer Tumorgröße regelhaft nicht endoskopisch angegangen werden. Die Grenze für eine endoskopische Resektion ergibt sich sowohl durch die technische Machbarkeit im Sinne des Erreichens einer R0-Resektion, der erwarteten Komplikationen im Sinne von Blutung und Perforationen als auch durch das vermutete Risiko für eine lymphogene Metastasierung. Generell wird eine endoskopische Resektion bei Befunden < 1 cm regelhaft empfohlen, da sowohl die gute technische Machbarkeit als auch das geringe Metastasierungsrisiko für eine endoskopische Resektion sprechen. Bei allen Befunden über 2 cm Größe sind sowohl die technischen Erfolgsaussichten so niedrig als auch das Metastasierungsrisiko so hoch, dass in dieser Situation regelhaft ein chirurgisches Vorgehen erfolgen sollte. Es bleibt somit ein Graubereich bei der Tumorgröße zwischen 1 und 2 cm, wo sowohl endoskopische, aber auch chirurgische Resektionsverfahren sinnvoll eingesetzt werden können. Zunehmend kommen auch gemeinsame Eingriffe im Sinne eines endoskopisch-laparoskopischen Rendezvous-Verfahrens zum Einsatz – insbesondere im Duodenum bieten sich diese Eingriffe an, um eine minimale Resektion mit größtmöglicher R0-Erfolgsrate und niedriger Perforationsrate zu erreichen.

Abstract

Neuroendocrine tumours (NET) are rare tumours of the gastrointestinal tract. Many of these are diagnosed incidentally during routine upper and lower GI endoscopy. Complete surgical resection is the treatment of choice for localised tumours. For small tumours with no associated risk factors for metastases, endoscopic resection can be performed with curative intent. This endoscopic approach is standard of care for gastric, duodenal and rectal NET. In contrast, NET of the jejunum and ileum should not be treated endoscopically, as they exhibit a high rate of metastases independent of tumour size. The feasibility of an endoscopic resection is defined by the technical possibility of achieving an R0 resection, the complication rate of the procedure and the suspected rate of lymph node metastases. In general, endoscopic resection is recommended for tumours less than 1 cm in size, since they can be successfully endoscopically resected without major complications and carry a low risk of metastases. All tumours above 2 cm should be surgically resected, as endoscopic R0 resection is unlikely and risk of lymph node metastases is high. Tumours of between 1 cm and 2 cm could be approached by both surgical or endoscopic resection. A novel approach for these „in between“ tumours is a combined endoscopic-laparoscopic rendezvous to achieve limited organ-sparing resection with maximal safety. This approach is particularly useful for duodenal NET as the risk of perforation is high for endoscopic resection.

Publication History

Received: 03 March 2022

Accepted after revision: 12 April 2022

Article published online:
15 June 2022

© 2022. Thieme. All rights reserved.

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