Die multimodale Behandlung der Peritonealkarzinose
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1 Die multimodale Behandlung der Peritonealkarzinose Pompiliu Piso Chirurgische Klinik der Universität Regensburg
2 80 Mio Inhabitans new cases CRC/year.
3 Henriettenstiftung Hannover Medizinische Hochschule Hannover Charité, Campus Berlin-Buch 15 Centers, ca. 250 cytos/year 7 centers > 10 HIPEC/year 2 centers > 50 Cytos/year Charité, Campus Mitte Berlin Universitätsklinikum Magdeburg Asklepios Paulinen Klinik Wiesbaden Krankenhaus Hammelburg GmbH Universität Heidelberg Universitätsklinikum Tübingen Klinikum der Universität Regensburg Klinikum der Universität München LMU Kliniken der Universität Witten/Herdecke Universitätsklinikum Freiburg Klinikum Memmingen Uniklinikum Erlangen
4
5 Entities Appendix Non-appendcieal colorectal Ovary Stomach Mesothelioma Small bowel
6 Morbidity and mortality Overall morbidity was 28.7%. Most frequent surgical complications were: enteric fistula (8/80) intestinal obstruction (7/80) pancreatitis (4/80) abdominal abcess (4/80) bile leakage (3/80) Other complications were: renal failure (5/80) pneumonia (3/80) bone marrow toxicity (2/80) pulmonary embolism (2/80) No 30-days mortality, hospital mortality was 1.2% (1/80).
7 Accreditation Minimum of requirements
8
9 Konzept Tumorentitäten Patientenauswahl
10 Konzept Tumorentitäten Patientenauswahl
11 Zirkulation der Peritonealflüssigkeit
12 Therapiekonzept Parietale und viszerale Peritonektomie Multiviszerale Resektion Hypertherme intraperitoneale Chemotherapie
13 Omentektomie
14 Peritonektomie rechter Oberbauch Sugarbaker PH, Surg Oncol Clin N Am 2003
15 Resektion des Omentum majus und minus, Cholezystektomie Sugarbaker PH, Surg Oncol Clin N Am 2003
16 Peritonektomie linker Oberbauch Sugarbaker PH, Surg Oncol Clin N Am 2003
17 Peritonektomie kleines Becken Sugarbaker PH, Surg Oncol Clin N Am 2003
18 Hypertherme Intraperitoneale Chemotherapie Zulauf Wärmeaustauscher Res. Rückfluß Abdomen: offen oder geschlossen (50% vs. 50%) Optimale i. p. Temperatur C Jähne,Piso et al, Langenbecks Arch Chir. 1997;382(1):8-14
19 PubMed peritoneal/hyperthermic/perfusion/chemotherapy Nr. papers
20 Konzept Tumorentitäten Patientenauswahl
21 Tumorentitäten Kolorektales Karzinom Pseudomyxoma peritonei Magenkarzinom Ovarialkarzinom Malignes Mesotheliom
22 Tumorentitäten PMP Kolorektales Karzinom Magenkarzinom Ovarialkarzinom
23 Pseudomyxoma peritonei 2 von Laparotomien* 50 neue Fälle pro Jahr in GB** * Mann et al, Cancer 66, , 1990 ** Bryant et al, Health Technol Assess 8, 1 54, 2004
24 PMP, Serial Debulking, MSKCC
25 PMP, Complete Cyto + Chemo, Washington Cancer Institute
26 Tumorentitäten PMP Kolorektales Karzinom Magenkarzinom Ovarialkarzinom
27 Kolorektales Karzinom Neuerkrankungen/Jahr (Robert-Koch-Institut, 2000) 10-15% 15% Peritonealkarzinose
28 Glehen, O. et al. J Clin Oncol; 22:
29 Kolorektales Karzinom Professor Zoetmulder, Netherlands Cancer Institute 103 Patienten Maximale zytoreduktive Chirurgie + i.v. 5-FU 5 und Leukovorin Limitierte palliative Chirurgie + i.v. 5-FU 5 und Leukovorin Verwaal et al, J Clin Oncol,, 2004
30 National Cancer Institute Amsterdam probability HIPEC 0.2 control control HIPEC months from randomisation Log Rank p = Verwaal et al, J Clin Oncol,, 2004
31 Wichtigster Prognosefaktor: Komplette Zytoreduktion Verwaal et al, Ann Surg Oncol Jan;12(1):65-71
32 Tumorentitäten PMP Kolorektales Karzinom Magenkarzinom Ovarialkarzinom
33 Sugarbaker et al, Semin Surg Oncol 2003, 21: Metaanalyse 8 publizierter Studien
34 Yonemura et al, Br J Surg Mar;92(3): n=29 n=13
35 Tumorentitäten PMP Kolorektales Karzinom Magenkarzinom Ovarialkarzinom
36 Peritoneal disease 75% of patients with POC have peritoneal disease > 60% have a recurrent disease after primary treatment
37 NCI Issues Clinical Announcement for Preferred Method of Treatment for Advanced Ovarian Cancer (January 20, 2006) The National Cancer Institute (NCI) today issued an announcement encouraging treatment with anticancer drugs via two methods which deliver drugs into a vein and directly into the abdomen, extend overall survival for women with advanced ovarian cancer by about a year.
38 Phase II Studies CRS and HIPEC Author Year n OvC Look, Int J Gynecol Cancer P/R Zanon, World J Surg R Ryu, Gynecol Oncol P Reichman, J Surg Oncol P Piso, World J Surg Oncol P/R Gori, Int J Gynecol Cancer P Raspagliesi, Eur J Surg Oncol P/R Rufian, J Surg Oncol P/R Helm, Gynecol Oncol R Glehen, submitted R
39 Malignes peritoneales Mesotheliom Peak für 2020 erwartet Natural history: 6-9 months Prognose nach CC 0 : 50% ÜLR nach 5 Jahre
40
41
42 Konzept Tumorentitäten Patientenauswahl
43 PSOG-Kriterien Primärtumor Keine extraabdominellen Metastasen PCI<20
44 Peritoneal Cancer Index
45 PSOG-Kriterien Primärtumor Keine extraabdominellen Metastasen PCI<20 Guter AZ (WHO1-2) Dünndarm Klasse I/part. II Peritoneal Surface Oncology Group Ann Surg Oncol 2007
46
47 Befall des Mesenteriums und des Dünndarmes I II III
48 Preoperative Diagnosis
49 PSOG-Kriterien Primärtumor Keine extraabdominellen Metastasen PCI<20 Guter AZ (WHO1-2) Dünndarm Klasse I/part. II Nicht mehr als eine Dünndarmstenose Gering befallene Region II Peritoneal Surface Oncology Group Ann Surg Oncol 2007
50 Region II (Epigastrum) Gebiet der A. gastrica sinistra
51 PSOG-Kriterien Primärtumor Keine extraabdominellen Metastasen PCI<20 Guter AZ (WHO1-2) Dünndarm Klasse I/part. II Nicht mehr als eine Dünndarmstenose Gering befallene Region II Operation Komplette Zytoreduktion HIPEC Peritoneal Surface Oncology Group Ann Surg Oncol 2007
52
53
54
55 Resektion der Glisson Kapsel
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