Zusammenfassung
Hintergrund
Im multimodalen Management des lokal fortgeschrittenen Rektumkarzinoms hat die neoadjuvante Radiochemotherapie (nRCTX) die Lokalrezidivraten weiter senken können, jedoch ohne Überlebensvorteil. Vor dem Hintergrund einer guten lokalen Kontrolle durch die totale mesorektale Exzision (TME), einer prognostisch sehr heterogenen Gruppe von Patienten mit T3-Tumoren, eines limitierten präoperativen Lymphknoten-Stagings sowie der Etablierung des MRT-basierten zirkumferenziellen Resektionsrands (CRM) als wichtigen Prognoseparameter sollte die Indikationsstellung zur nRCTX differenzierter erfolgen.
Material und Methoden
Aktuelle Aspekte zur Indikation der nRCTX beim Rektumkarzinom werden erläutert. Relevante Arbeiten wurden selektioniert und weiterführende Recherchen anhand der Literaturverzeichnisse unternommen.
Ergebnisse
Unter Einhaltung der Qualität der präoperativen MRT-Diagnostik sowie der TME-Chirurgie kann bei Patienten mit cT1/2-Tumoren im mittleren/unteren Rektumdrittel und fraglichem Lymphknotenbefall sowie bei cT3-Tumoren im mittleren Rektumdrittel mit MR-morphologisch negativem CRM (mrCRM >1 mm) und ohne bildgebenden Verdacht auf Lymphknotenmetastasen oder extramuraler Gefäßinvasion (EMVI negativ) als Abweichung eine primäre Resektion ohne nRCTX erfolgen. Für einen mrCRM >1 mm als alleinigen Selektionsparameter für eine primäre Operation ohne nRCTX ist die Evidenz bislang nicht ausreichend.
Schlussfolgerung
Hinsichtlich der vielversprechenden Ergebnisse einer MRT-basierten Indikation zur nRCTX in Abhängigkeit des mrCRM bleiben Ergebnisse kontrolliert-randomisierter Studien abzuwarten. Eine Anwendung dieses alternativen Konzeptes sollte nur unter sorgfältiger Aufklärung des Patienten und Verweis auf den in Leitlinien niedergelegten Behandlungsstandard erfolgen.
Abstract
Background
In the multimodal treatment of locally advanced rectal cancer, neoadjuvant chemoradiotherapy (nRCTX) has further decreased local recurrence rates but without a general survival benefit. In view of good local control by total mesorectal excision (TME), a prognostically very heterogeneous group of patients with T3 tumors, a limited preoperative lymph node staging and the establishment of magnetic resonance imaging (MRI)-based circumferential resection margins (CRM) as an important prognostic parameter, the indications for nRCTX should be more differentiated.
Material and methods
The main aspects of the indications for nRCTX of rectal cancer are discussed. Relevant studies were selected and further research based on the reference lists was undertaken.
Results
With adequate adherence to the quality of preoperative MRI diagnostics and TME surgery, patients with cT1/2 tumors in the middle/lower third of the rectum and questionable lymph node involvement and cT3 tumors in the middle third with MRI-based negative CRM (mrCRM >1 mm) and without any suspicion of lymph node metastases or extramural vascular invasion (EMVI negative), a primary resection without nRCTX can be carried out as an individual variation. The evidence for using mrCRM >1 mm as a sole selection parameter for primary surgery without nRCTX is insufficient.
Conclusion
With respect to the promising results of MRI-based indications for nRCTX depending on mrCRM, the results of controlled randomized trials are to be awaited. Thus, an application of this alternative concept should only be carried out following meticulous patient informed consent and reference to the standard of care laid down in guidelines.
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Holmer, C. Indikation zur Radiochemotherapie beim Rektumkarzinom. coloproctology 41, 250–254 (2019). https://doi.org/10.1007/s00053-019-0361-1
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DOI: https://doi.org/10.1007/s00053-019-0361-1