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Radiologische Diagnostik des CUP-Syndroms

Radiological diagnostics in CUP syndrome

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Zusammenfassung

Klinisches/methodisches Problem

Im therapeutischen Management des Cancer-of-unknown-primary(CUP)-Syndroms spielt die bildgebende Diagnostik eine zentrale Rolle zur Lokalisation des Primärtumors, zur Identifikation von Tumoren, für die ein dediziertes Behandlungsschema zur Verfügung steht, sowie zur Charakterisierung klinisch-pathologischer Subentitäten, die das weitere diagnostische und therapeutische Procedere bestimmen und eine Einschätzung der Prognose erlauben.

Radiologische Standardverfahren

Zur Verfügung stehende radiologische Modalitäten umfassen die Projektionsradiographie, die Computertomographie (CT), die Magnetresonanztomographie (MRT) und die Sonographie sowie die Hybridverfahren Positronenemissionstomographie(PET)-CT und MR-PET.

Leistungsfähigkeit

In der Ganzkörperbildgebung hat die CT eine hohe Sensitivität für Tumoren, die häufig als metastasierte Tumorerkrankung auftreten. Nach aktueller Literatur ist die CT bei Patienten mit Pankreaskarzinom in 86% der Fälle diagnostisch, bei Patienten mit Kolonkarzinom in 36% und bei Patienten mit Bronchialkarzinom in 74%. Des Weiteren zeigte eine Metaanalyse, dass bei Patienten mit Plattenepithelkarzinom und zervikalen Lymphknotenmetastasen die CT in 22% der Fälle den Primärtumor lokalisieren konnte, im Vergleich zu 36% Detektionsrate der MRT und 28–57% der PET-CT mit 18F-FDG (Fluordesoxyglukose). Der MRT kommt auf Grund des hohen Weichteilkontrasts und der Möglichkeit zur funktionellen Bildgebung besondere Bedeutung bei der Lokalisation primär okkulter Tumoren bei Organuntersuchungen zu, z. B. beim Mamma- oder dem Prostatakarzinom.

Bewertung

Zur Ganzkörperbildgebung steht die CT von Hals, Thorax und Abdomen im klinischen Alltag häufig am Anfang. Je nach Befund folgen organspezifische bildgebende Untersuchungen, um den Primarius zu lokalisieren, z. B. die Mammographie bei Frauen mit axillärer Lymphadenopathie. Zur histologischen und immunhistochemischen Charakterisierung des Tumors dient die Bildgebung auch dazu, eine repräsentative und gut zugängliche Tumormanifestation zu identifizieren und ggf. auch bildgestützt zu biopsieren.

Empfehlung für die Praxis

Am Anfang des diagnostischen Algorithmus bei CUP-Syndrom steht eine Ganzkörperbildgebung zur Primärtumorsuche. Im klinischen Alltag häufig ist die kontrastverstärkte CT von Hals, Thorax und Abdomen, wobei multiple Studien für die 18F-FDG-PET-CT eine verbesserte Sensitivität bei der Detektion von Primärtumoren und metastatischer Tumormanifestationen zeigten.

Abstract

Clinical/methodical issue

Imaging plays an essential role in the therapeutic management of cancer of unknown primary (CUP) patients for localizing the primary tumor, for the identification of tumor entities for which a dedicated therapy regimen is available and for the characterization of clinicopathological subentities that direct the subsequent diagnostic and therapeutic strategy.

Standard radiological methods

Modalities include conventional x-ray, computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound as well as positron emission tomography (PET)-CT and MRI-PET.

Performance

In whole body imaging CT has a high sensitivity for tumor entities which frequently present as a metastasized cancer illness. According to the current literature CT is diagnostic in 86% of patients with pancreatic carcinoma, in 36% of patients with colon carcinoma and in 74% of patients with lung carcinoma. Additionally a meta-analysis showed that for patients with squamous cell carcinoma and cervical lymph node metastases a positive diagnosis was possible in 22% of the cases using CT, in 36% using MRI and in 28-57% using 18F-fluorodeoxyglucose PET-CT (18F-FDG PET-CT). In addition, MRI plays an important role in the localization of primary occult tumors (e.g. breast and prostate) because of its high soft tissue contrast and options for functional imaging.

Achievements

At the beginning of the diagnostic algorithm stands the search for a possible primary tumor and CT of the neck, thorax and abdomen is most frequently used for whole body staging. Subsequent organ-specific imaging examinations follow, e.g. mammography in women with axillary lymphadenopathy. For histological and immunohistochemical characterization of tumor tissue, imaging is also applied to identify the most accessible and representative tumor manifestation for biopsy. Tumor biopsy may be guided by CT, MRI or ultrasound and MRI also plays a central role in the localization of primary occult tumors because of superior soft tissue contrast and options for functional imaging (perfusion, diffusion), e.g. investigation of breast carcinoma or prostate carcinoma.

Practical recommendations

Whole body staging stands at the beginning of the diagnostic algorithm in CUP syndrome to localize a potential primary tumor. Clinically, contrast-enhanced CT of the neck, thorax and abdomen is frequently applied; however, many studies have demonstrated augmented sensitivity of 18F-FDG PET-CT for the detection of primary tumors and metastatic tumor manifestations.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C.C. Cyran weist auf folgende Beziehung hin: Speakers Bureau Bayer Healthcare. P.M. Kazmierczak, K. Nikolaou, A. Rominger, A. Graser, M.F. Reiser geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Correspondence to PD Dr. C.C. Cyran MD.

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Kazmierczak, P., Nikolaou, K., Rominger, A. et al. Radiologische Diagnostik des CUP-Syndroms. Radiologe 54, 117–123 (2014). https://doi.org/10.1007/s00117-013-2547-9

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Schlüsselwörter

  • Bildgebung
  • Tumormanifestationen
  • Staging
  • Therapiemonitoring
  • Prognose

Keywords

  • Imaging
  • Tumor manifestation
  • Staging
  • Therapy monitoring
  • Prognosis