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Adjuvante und neoadjuvante Therapie des Rektumkarzinoms

Adjuvant and neoadjuvant therapy of rectal cancer: Actual data

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Zusammenfassung

Hintergrund

In einem aktualisierten Konsensus der Deutschen Krebsgesellschaft (CAO/ AIO/ARO, 1. 7. 1998) zur Behandlung des Rektumkarzinoms wurde die eher defensive Haltung bei der Indikationsstellung, zur Adjuvanstherapie aufgegeben und die postoperative Radiochemotherapie bei Tumoren im UICC-Stadium II und III ausdrücklich empfohlen. Grundlage dafür waren die Ergebnisse der jüngsten Studien zur adjuvanten und neoadjuvanten Therapie des Rektumkarzinoms.

Ergebnisse

Die Verhinderung eines Lokalrezidivs ist das vordringliche Therapieziel bei der Primärbehandlung des Rektumkarzinoms. In einzelnen Serien, zum Beispiel den Ergebnissen der Chirurgischen Universitätsklinik Erlangen, besteht dabei ein hochsignifikanter Zusammenhang zwischen lokaler Kontrolle und Überleben. Daten des kürzlich publizierten Swedish Rectal Cancer Trial mit insgesamt 1168 randomisierten Patienten konnten neben einer Reduzierung der Lokalrezidivrate auch einen signifikanten Überlebensgewinn durch eine präoperative Kurzzeitvorbestrahlung zeigen. Die postoperative Kombinationsbehandlung aus Radio-und Chemotherapie ist seit den Studien der Gastrointestinal Tumor Study Group (GITSG) und der North Central Cancer Treatment Group (NCCTG) in den USA und weiten Teilen Europas etabliert. Der durch eine konventionell fraktionierte, adjuvante Bestrahlung und simultane 5-FU-Chemotherapie erreichbare Überlebensvorteil gegenüber einer alleinigen Operation wurde durch eine norwegische Studie erneut bestätigt. Eine weitere Optimierung ist hier durch eine 5-FU-Dauerinfusion zu erwarten. Phase-II-Studien zur präoperativen Radiochemotherapie belegen deren hohe Effektivität mit eindrucksvollen Remissionsraten und begründen die Indikation bei fortgeschrittenen, primär nicht sicher kurativ, (RO) operablen Tumoren. Prospektiv randomisierte Studien untersuchen derzeit die potentiellen Vorteile der neoadjuvanten gegenüber der adjuvanten Radiochemotherapie beim primär operablen Rektumkarzinom.

Schlußfolgerung

Die Radiochemotherapie des Rektumkarzinoms gilt heute als grundsätzlich wirksam und wird außerhalb von Studien als prä- (T4-Tumoren) bzw. postoperative (UICC-Stadium II/III) Adjuvansbehandlung empfohlen. Offene Fragen betreffen vor allem die optimale zeitliche Intergration der einzelnen Modalitäten sowie die Optimierung der Chemotherapie.

Abstract

Background

The Consensus Conference of the German Cancer Society (CAO/AIO/ARO, 1. 7. 1998) has recently updated recommendations for patients with rectal cancer. Instead of a former reservation regarding the indication of adjuvant therapy for rectal cancer the actual version of the consensus particularly emphasizes the role of postoperative radiochemotherapy for stage-II/III tumors. This article reviews the most recent and ongoing trials of adjuvant and neoadjuvant therapy of rectal cancer.

Results

To avoid local recurrence is the most important aspect in the primary treatment of rectal cancer. In some series, e. g. the results of the Surgical Department of the University of Erlangen, a significant correlation between local control and survival was noted. The final results of the Swedish Rectal Cancer Trial with 1168 randomized patients not only confirmed the potential of radiotherapy to reduce local recurrence-rate, but also demonstrated a significant survival advantage for patients receiving short-course preoperative radiation therapy. Postoperative combination therapy is usual in the United States and in most European countries since the publication of two randomized trials of the Gastrointestinal Tumor Study Group (GITSG) and the North Central Cancer Treatment Group (NCCTG). The survival advantage resulting from an adjuvant radiotherapy with conventional doses and concurrent fluorouracil-based chemotherapy as compared to surgery alone was recently confirmed in a Norwegian trial. Protracted venous 5-fluorouracil infusion should further improve, treatment results. Numerous phase-II studies have demonstrated the efficacy of preoperative radiochemotherapy with high rates of pathological response. Thus, neoadjuvant radiochemotherapy is recommended for patients with locally advanced tumor primarily not amenable to curative surgery. Prospective randomized trials are ongoing to clarify the role of preoperative versus postoperative combined treatment for patients with resectable rectal cancer.

Conclusion

Radiochemotherapy for rectal cancer is recommended as standard treatment outside clinical trials for Stage II/III patients after curative treatment and for patients with T4-tumor prior to surgery. The optimal use of chemotherapy and the sequence of treatment modalities remains to be elucidated.

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Authors and Affiliations

  1. Strahlentherapeutische Klinik und Poliklinik der Universität Erlangen-Nürnberg, Universitätsstraße 27, D-91054, Erlangen

    Claus Rödel & Rolf Sauer

  2. Chirurgische Klinik der Universität Erlangen-Nürnberg, Erlangen-Nürnberg, Deutschland

    Werner Hohenberger

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Rödel, C., Hohenberger, W. & Sauer, R. Adjuvante und neoadjuvante Therapie des Rektumkarzinoms. Strahlenther Onkol 174, 497–503 (1998). https://doi.org/10.1007/BF03038981

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