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Cholangiokarzinome – intrahepatisches bis hiläres Gallengangkarzinom

Cholangiocarcinoma—Intrahepatic to hilar bile duct cancer

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Zusammenfassung

Hintergrund

Neben konditionierenden Maßnahmen in der Leberchirurgie gewinnt bei Cholangiokarzinomen (CCA) auch die perioperative antitumorale Therapie zunehmend an Bedeutung.

Ziel der Arbeit

Systematische Übersichtsarbeit zum Stand der multimodalen und insbesondere neoadjuvanten Therapie bei CCA.

Material und Methoden

Literaturübersicht über die aktuellen wissenschaftlichen Original- und Übersichtsarbeiten.

Ergebnisse

Eine Resektion und selten auch eine Lebertransplantation stellen weiterhin die einzigen kurativen Therapieansätze von CCA im nichtfernmetastasierten Stadium dar. Allerdings sind die Langzeitergebnisse z. B. bei nodal positiven Tumoren weiterhin unbefriedigend. Eine adjuvante Chemotherapie gehört heute zum Standard, ist aber bei vielen Patienten nicht umsetzbar. Neoadjuvante Konzepte beinhalten Chemotherapie und lokale/lokoregionäre Verfahren, wie z. B. die Radioembolisation. Beides findet beim intrahepatischen Cholangiokarzinom (iCCA) zunehmend Anwendung, bei perihilären Cholangiokarzinom (pCCA) dagegen nur selten. Erste Daten belegen beim iCCA eine gute Effektivität dieser Verfahren, um in primär inoperablen Fällen eine sekundäre Operabilität zu erreichen. Daneben erscheint aufgrund der aktuelle Datenlage auch bei operablen iCCA und hohem Rezidivrisiko (z. B. Lymphknotenmetastasen) eine neoadjuvante Therapie gerechtfertigt.

Diskussion

Bei CCA besteht ein großes Potenzial für den Einsatz multimodaler Therapien, das sich in den nächsten Jahren durch neue Therapeutika weiter vergrößern könnte. Allerdings können aufgrund fehlender Evidenz noch keine klaren Empfehlungen ausgesprochen werden. Es zeichnet sich jedoch ab, dass eine neoadjuvante Therapie beim iCCA an Bedeutung gewinnt und bei hohem Rezidivrisiko bereits im Rahmen individueller Therapiekonzepte zunehmend eingesetzt wird.

Abstract

Background

In addition to conditioning measures in liver surgery, perioperative anti-tumor therapy is becoming increasingly more important in cholangiocarcinoma (CCA).

Objective

Systematic literature review on the status of multimodal and in particular neoadjuvant therapy for CCA.

Material and methods

Literature overview of the current scientific original and review articles.

Results

Resection and rarely also liver transplantation are still the only curative treatment approaches for CCA in the non-distant metastatic stage; however, long-term results, e.g. in node positive tumors, are still unsatisfactory. Adjuvant chemotherapy is now standard but cannot be used in many patients. Neoadjuvant concepts include chemotherapy and local and locoregional procedures, such as radioembolization. Both are increasingly used in intrahepatic CCA (iCCA) but rarely in perihilar CCA. Initial data show that this is very effective in iCCA to achieve secondary operability in primarily inoperable cases. In addition, based on the current literature, neoadjuvant therapy also seems justified in operable intrahepatic CCA with a high risk of recurrence (e.g. lymph node metastases).

Conclusion

There is a high potential for the use of multimodal therapy in CCA, which could further increase in the near future as a result of new therapeutic agents. Due to the lack of evidence clear recommendations cannot be given; however, it is becoming apparent that neoadjuvant therapy is gaining importance in iCCA and is already increasingly used as part of individual concepts in patients with a high risk of recurrence.

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Abbreviations

ALPPS:

Associating liver partition and portal vein ligation for staged hepatectomy

ASCO:

American Society of Clinical Oncology

ERC:

Endoskopisch-retrograde Cholangiographie

FDG-PET:

Fluordesoxyglukose-Positronen-Emissions-Tomographie

iCCA:

Intrahepatisches Cholangiokarzinom

ITT:

Intention to treat

LTx:

Lebertransplantation

NCCN:

National Comprehensive Cancer Network

pCCA:

Perihiläres Cholangiokarzinom (Klatskin-Tumor)

PRC:

Primär sklerosierende Cholangitis

PTCD:

Perkutane transhepatische Cholangiographie

PVE:

Portalvenöse Embolisation

TACE:

Transarterielle Chemoembolisation

TARE:

Transarterielle Radioembolisation

UICC:

Union for International Cancer Control

5‑JÜR:

5‑Jahres Überlebensrate

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Danksagung

die Autoren bedanken sich bei Herrn Univ.-Prof. Dr. Osama Sabri, Klinik und Poliklinik für Nuklearmedizin und Fr. Dr. Kirsten Papsdorf, Klinik für Strahlentherapie für die Überlassung der Abbildungen zur TARE (Abb. 2) und adjuvanten Radiatio (Abb. 3).

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Authors and Affiliations

  1. Klinik für Viszeral‑, Transplantations- Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland

    Sebastian Rademacher &  Daniel Seehofer

  2. Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland

    Timm Denecke

  3. Medizinische Klinik, Universitätsklinikum Leipzig, Leipzig, Deutschland

    Thomas Berg

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  1. Sebastian Rademacher
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  2. Timm Denecke
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  3. Thomas Berg
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  4. Daniel Seehofer
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Correspondence to Daniel Seehofer.

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Interessenkonflikt

D. Seehofer gibt den Erhalt von Honoraren oder Beratungshonoraren von BTG, Johnson & Johnson, Gubert, Novartis, Olympus und SIRTEX an sowie die Teilnahme an einem von den folgenden Unternehmen gesponserten speaker’s bureau: Abbvie, Astellas, Bayer, BTG, Eisai, Johnson & Johnson, MSD/Merck, Novartis, Olympus. T. Berg gibt Zuschüsse und Forschungsförderung von Abbvie, BMS, Gilead, MSD/Merck, Humedics, Intercept, Merz, Novartis und Sequana Medical an sowie den Erhalt von Honoraren oder Beratungshonoraren von Abbvie, Alexion, Bayer, Gilead, Eisai, Humedics, Intercept, Ipsen, Janssen, MSD/Merck, Novartis, Roche, Sequana Medical, SIRTEX, SOBI und Shionogi, des Weiteren die Teilnahme an einem von den folgenden Unternehmen gesponserten speaker’s bureau: Abbvie, Alexion, Bayer, Gilead, Eisai, Intercept, Ipsen, Janssen, MedUpdate GmbH, MSD/Merck, Novartis, Sequana Medical und SIRTEX. S. Rademacher und T. Denecke 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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Rademacher, S., Denecke, T., Berg, T. et al. Cholangiokarzinome – intrahepatisches bis hiläres Gallengangkarzinom. Chirurgie 93, 644–651 (2022). https://doi.org/10.1007/s00104-022-01660-5

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