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Rolle der neoadjuvanten Strahlentherapie beim Rektumkarzinom

Ist die MRT-basierte Selektion ein Zukunftsmodell?

Role of neoadjuvant radiotherapy for rectal cancer

Is MRI-based selection a future model?

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Zusammenfassung

Nach Einführung der totalen mesorektalen Exzision (TME) in der kurativen Behandlung des Rektumkarzinoms hat sich die Rolle der neoadjuvanten Therapie gewandelt. Durch die verbesserte Operationstechnik konnte die Lokalrezidivrate allein durch die Chirurgie nach den TME-Kriterien auf unter 8 % gesenkt werden. Auch wenn die lokale Kontrolle mittels präoperativer Bestrahlung weiter verbessert werden konnte, hat dies nicht zu einem allgemeinen Überlebensvorteil vorbestrahlter Patienten geführt. Leitliniengerecht sollten alle Patienten im UICC-II- und -III-Stadium vorbehandelt werden. Die stadienbasierte Indikationsstellung zur neoadjuvanten Therapie hat jedoch Schwächen. Zum einen stellen die Patienten mit T3-Tumoren eine prognostisch sehr heterogene Gruppe dar, zum anderen ist die präoperative Lymphknotendiagnostik zu ungenau. Im Gegensatz dazu hat sich in den letzten Jahren der zirkumferenzielle Resektionsrand (CRM) als wichtiger prognostischer Parameter etabliert. Patienten, bei denen eine große Nähe/Infiltration der Hüllfaszie (positiver CRM) zum/durch den Tumor besteht, haben eine höhere Lokalrezidivrate und ein schlechteres Überleben. Mit hochauflösender MRT-Untersuchung des Beckens kann bei Patienten mit Rektumkarzinom der präoperative CRM mit einer hohen Sensitivität und Spezifität bestimmt werden. Das mittels MRT verbesserte T‑Staging bzw. die Vorhersage der Resektionsränder können ein wichtiges Kriterium zur Selektion von Patienten für studienbasierte Therapieansätze ohne neoadjuvante Therapie sein.

Abstract

Following the introduction of total mesorectal excision (TME) in the curative treatment of rectal cancer, the role of neoadjuvant therapy has evolved. By improving the surgical technique the local recurrence rate could be reduced by TME surgery alone to below 8 %. Even if local control was further improved by additional preoperative irradiation this did not lead to a general survival benefit. Guidelines advocate that all patients in UICC stage II and III should be pretreated; however, the stage-based indications for neoadjuvant therapy have limitations. This is mainly attributable to the facts that patients with T3 tumors comprise a very heterogeneous prognostic group and preoperative lymph node diagnostics lack accuracy. In contrast, in recent years the circumferential resection margin (CRM) has become an important prognostic parameter. Patients with tumors that are very close to or infiltrate the pelvic fascia (positive CRM) have a higher rate of local recurrence and poorer survival. With high-resolution pelvic magnetic resonance imaging (MRI) examination in patients with rectal cancer, the preoperative CRM can be determined with a high sensitivity and specificity. Improved T staging and better prediction of the resection margins by pelvic MRI potentially facilitate the selection of patients for study-based treatment strategies omitting neoadjuvant radiotherapy.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Deutschland

    Y. Kulu, T. Hackert, M. W. Büchler & A. Ulrich

  2. Klinik für RadioOnkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Deutschland

    J. Debus

  3. Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Deutschland

    M.-A. Weber

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  1. Y. Kulu
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  4. M.-A. Weber
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  5. M. W. Büchler
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  6. A. Ulrich
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Correspondence to A. Ulrich.

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Interessenkonflikt

Y. Kulu, T. Hackert, J. Debus, M.-A. Weber, M. W. Büchler und A. Ulrich geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Kulu, Y., Hackert, T., Debus, J. et al. Rolle der neoadjuvanten Strahlentherapie beim Rektumkarzinom. Chirurg 87, 573–578 (2016). https://doi.org/10.1007/s00104-016-0236-8

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  • DOI: https://doi.org/10.1007/s00104-016-0236-8

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