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Selektionskriterien zur neoadjuvanten Radiochemotherapie beim Rektumkarzinom

Neoadjuvante Therapie auch beim lokal fortgeschrittenen Kolonkarzinom?

Selection criteria for neoadjuvant chemoradiotherapy of rectal cancer

Neoadjuvant therapy even for locally advanced colon cancer?

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Zusammenfassung

In den letzten zwei Jahrzehnten wurde für eine zunehmende Zahl an malignen Tumoren des Gastrointestinaltrakts ein neoadjuvantes Therapiekonzept etabliert. Diese Konzepte unterliegen jedoch weiterhin einem steten Wandel hinsichtlich Indikationsstellung und Art der Therapie. Paradebeispiel hierfür ist das Rektumkarzinom. Durch eine neoadjuvante Therapie wurde vor allem die Rate an Lokalrezidiven signifikant gesenkt, ohne dass bisher jedoch valide eine Verlängerung des Gesamtüberlebens oder des krankheitsfreien Überlebens gezeigt werden konnte. Zu Beginn des Jahrtausends wurde noch empfohlen, jedes Rektumkarzinom im Stadium UICC II und III, unabhängig von der Höhenlokalisation, neoadjuvant zu therapieren. Dies wurde zwischenzeitlich zunehmend relativiert, wobei nur noch für lokal fortgeschrittene Tumoren des mittleren und unteren Rektumdrittels die generelle Empfehlung zur Vorbehandlung gilt, während Rektumkarzinome des oberen Drittels im Wesentlichen einem Kolonkarzinom entsprechend zu behandeln sind. Dabei ist zu erwarten, dass die Indikationsstellung in diesem Zusammenhang in Zukunft, vor allem basierend auf einer präoperativen MRT-Untersuchung, noch differenzierter erfolgen wird. Gleichzeitig zeigen erste Studien für das Kolonkarzinom, dass eine neoadjuvante Chemotherapie Vorteile bringt und eine optimierte CT-Bildgebung ein wertvolles Tool zur prätherapeutischen Patientenstratifizierung sein kann.

Abstract

During the last two decades a neoadjuvant treatment concept has been established for an increasing number of malignant tumors of the gastrointestinal tract; however, these concepts are still subject to a constant change concerning the indications and type of treatment. A prime example for this is rectal cancer. The rate of local recurrence in particular was significantly reduced by neoadjuvant therapy but until now it has not been possible to validly show an improvement in overall or disease-free survival. At the beginning of the millennium it was recommended to treat every rectal carcinoma in UICC stages II and III with neoadjuvant therapy, independent of the height localization. In the meantime this has increasingly been relativized and only locally advanced tumors of the middle and lower thirds of the rectum should be pretreated, whereas tumors of the upper third of the rectum should basically be treated in the same way as colon cancer. It is to be expected that there will be further differentiation concerning the indications in this context in the future mainly based on a preoperative magnetic resonance imaging (MRI) examination. At the same time, initial studies for colon cancer show that neoadjuvant chemotherapy can be beneficial and that an optimized computed tomography (CT) scan can be a worthwhile tool with respect to pretherapeutic stratification of patients.

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Literatur

  1. Maurer CA et al (2011) The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results. Ann Surg Oncol 18(7):1899–1906

    Article  CAS  PubMed  Google Scholar 

  2. Hohenberger W et al (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis 11(4):354–364 (discussion 364–365)

    Article  CAS  PubMed  Google Scholar 

  3. Franke AJ et al (2018) Total neoadjuvant therapy: a shifting paradigm in locally advanced rectal cancer management. Clin Colorectal Cancer 17(1):1–12

    Article  PubMed  Google Scholar 

  4. Glynne-Jones R et al (2017) Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 28(suppl_4):iv22–iv40

    Article  CAS  PubMed  Google Scholar 

  5. D’Souza N et al (2019) Definition of the rectum: an international, expert-based Delphi consensus. Ann Surg 270(6):955–959

    Article  PubMed  Google Scholar 

  6. Clancy C et al (2019) Comparative oncologic outcomes of upper third rectal cancers: a meta-analysis. Clin Colorectal Cancer 18(4):e361–e367

    Article  PubMed  Google Scholar 

  7. Merkel S et al (2014) Prognostic subdivision of ypT3 rectal tumours according to extension beyond the muscularis propria. Br J Surg 101(5):566–572

    Article  CAS  PubMed  Google Scholar 

  8. Siddiqui MRS et al (2018) A meta-analysis assessing the survival implications of subclassifying T3 rectal tumours. Eur J Cancer 104:47–61

    Article  CAS  PubMed  Google Scholar 

  9. Zinicola R et al (2017) The degree of extramural spread of T3 rectal cancer: an appeal to the American Joint Committee on Cancer. Colorectal Dis 19(1):8–15

    Article  CAS  PubMed  Google Scholar 

  10. Wiig JN et al (2008) Preoperative irradiation and surgery for local recurrence of rectal and rectosigmoid cancer. Prognostic factors with regard to survival and further local recurrence. Colorectal Dis 10(1):48–57

    CAS  PubMed  Google Scholar 

  11. Sun W et al (2019) Impact of long-course neoadjuvant radiation on postoperative low anterior resection syndrome and quality of life in rectal cancer: post hoc analysis of a randomized controlled trial. Ann Surg Oncol 26(3):746–755

    Article  PubMed  Google Scholar 

  12. Folkesson J et al (2005) Swedish rectal cancer trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol 23(24):5644–5650

    Article  PubMed  Google Scholar 

  13. Peeters KC et al (2007) The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg 246(5):693–701

    Article  PubMed  Google Scholar 

  14. Sauer R et al (2012) Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol 30(16):1926–1933

    Article  CAS  PubMed  Google Scholar 

  15. MERCURY Study Group (2007) Extramural depth of tumor invasion at thin-section MR in patients with rectal cancer: results of the MERCURY study. Radiology 243(1):132–139

    Article  Google Scholar 

  16. Curvo-Semedo L (2020) Rectal Cancer: Staging. Magn Reson Imaging Clin N Am 28(1):105–115

    Article  PubMed  Google Scholar 

  17. MERCURY Study Group (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 333(7572):779

    Article  PubMed Central  Google Scholar 

  18. Videhult P et al (2007) Magnetic resonance imaging for preoperative staging of rectal cancer in clinical practice: high accuracy in predicting circumferential margin with clinical benefit. Colorectal Dis 9(5):412–419

    Article  CAS  PubMed  Google Scholar 

  19. Kreis ME et al (2016) Use of preoperative magnetic resonance imaging to select patients with rectal cancer for neoadjuvant chemoradiation—interim analysis of the German OCUM trial (NCT01325649). J Gastrointest Surg 20(1):25–32 (discussion 32–33)

    Article  PubMed  Google Scholar 

  20. Ruppert R et al (2018) Oncological outcome after MRI-based selection for neoadjuvant chemoradiotherapy in the OCUM rectal cancer trial. Br J Surg 105(11):1519–1529

    Article  CAS  PubMed  Google Scholar 

  21. Taylor FG et al (2014) Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5‑year follow-up results of the MERCURY study. J Clin Oncol 32(1):34–43

    Article  PubMed  Google Scholar 

  22. Taylor FG et al (2011) Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study. Ann Surg 253(4):711–719

    Article  PubMed  Google Scholar 

  23. Cho MS et al (2018) MRI-based EMVI positivity predicts systemic recurrence in rectal cancer patients with a good tumor response to chemoradiotherapy followed by surgery. J Surg Oncol 117(8):1823–1832

    Article  PubMed  Google Scholar 

  24. Siddiqui MRS et al (2017) A meta-analysis comparing the risk of metastases in patients with rectal cancer and MRI-detected extramural vascular invasion (mrEMVI) vs mrEMVI-negative cases. Br J Cancer 116(12):1513–1519

    Article  PubMed  PubMed Central  Google Scholar 

  25. Dighe S et al (2012) Accuracy of radiological staging in identifying high-risk colon cancer patients suitable for neoadjuvant chemotherapy: a multicentre experience. Colorectal Dis 14(4):438–444

    Article  CAS  PubMed  Google Scholar 

  26. Nerad E et al (2016) Diagnostic accuracy of CT for local staging of colon cancer: a systematic review and meta-analysis. AJR Am J Roentgenol 207(5):984–995

    Article  PubMed  Google Scholar 

  27. Wiegering A et al (2015) Diagnostic value of preoperative CT scan to stratify colon cancer for neoadjuvant therapy. Int J Colorectal Dis 30(8):1067–1073

    Article  PubMed  Google Scholar 

  28. Foxtrot Collaborative Group (2012) Feasibility of preoperative chemotherapy for locally advanced, operable colon cancer: the pilot phase of a randomised controlled trial. Lancet Oncol 13(11):1152–1160

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Zhou Z, Nimeiri HS, Benson AB 3rd (2013) Preoperative chemotherapy for locally advanced resectable colon cancer—a new treatment paradigm in colon cancer? Ann Transl Med 1(2):11

    PubMed  PubMed Central  Google Scholar 

  30. Jestin P et al (2005) Emergency surgery for colonic cancer in a defined population. Br J Surg 92(1):94–100

    Article  CAS  PubMed  Google Scholar 

  31. Arredondo J et al (2017) Mid-term oncologic outcome of a novel approach for locally advanced colon cancer with neoadjuvant chemotherapy and surgery. Clin Transl Oncol 19(3):379–385

    Article  CAS  PubMed  Google Scholar 

  32. de Gooyer JM et al (2019) Neoadjuvant chemotherapy for locally advanced T4 colon cancer: a nationwide propensity-score matched cohort analysis. Dig Surg p:1–10

    Google Scholar 

  33. Jakobsen A et al (2015) Neoadjuvant chemotherapy in locally advanced colon cancer. A phase II trial. Acta Oncol 54(10):1747–1753

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland

    C. Kastner, M. Kim, C.-T. Germer &  A. Wiegering

  2. Institut für Biochemie und molekulare Biologie, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland

    C. Kastner &  A. Wiegering

  3. Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Würzburg, Deutschland

    B. Petritsch

  4. Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland

    C.-T. Germer &  A. Wiegering

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  1. C. Kastner
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Correspondence to A. Wiegering.

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Interessenkonflikt

C. Kastner, B. Petritsch, M. Kim, C.-T. Germer und A. Wiegering geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Kastner, C., Petritsch, B., Kim, M. et al. Selektionskriterien zur neoadjuvanten Radiochemotherapie beim Rektumkarzinom. Chirurg 91, 405–412 (2020). https://doi.org/10.1007/s00104-019-01088-4

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  • DOI: https://doi.org/10.1007/s00104-019-01088-4

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