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Rationales Staging und Follow-up beim kolorektalen Karzinom

Helfen Leitlinien weiter?

Rational staging and follow-up of colorectal cancer

Do guidelines provide further help?

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Zusammenfassung

Klinisches/methodisches Problem

Das kolorektale Karzinom ist eines der häufigsten malignen Tumoren. Die präoperative Bildgebung ist beim Rektumkarzinom entscheidend, da die Patienten nur bei akkuratem Staging einem optimalen Behandlungskonzept zugeführt werden können. Das N‑Staging gestaltet sich oft schwierig und muss als Staging-Parameter infrage gestellt werden.

Radiologische Standardverfahren

Für das lokale Staging eignen sich der endorektale Ultraschall (EUS) und die Magnetresonanztomographie (MRT). Die multiparametrische MRT samt Diffusionsbildgebung ist bei der Tumornachsorge unverzichtbar.

Methodische Innovationen

Mittels hochauflösender MRT gelingt die Beurteilung der Infiltration der mesorektalen Faszie am besten. Als weiterer wichtiger prognostischer Faktor hat sich zudem die extramurale Gefäßinfiltration (EMVI) etabliert. Nach neoadjuvanter Therapie und Restaging des lokal fortgeschrittenen Rektumkarzinoms steht die Identifizierung und Validierung prognostisch relevanter Bildparameter im Vordergrund. Die multiparametrische MRT des Rektums inklusive Diffusionsbildgebung sowie die Anwendung radiologisch-pathologischer Scores (MR-TRG) spielen hier eine bedeutende Rolle.

Bewertung

Für den Radiologen ist es wichtig, sich mit Indikatoren der Resektabilität des Rektumkarzinoms vertraut zu machen und prognostisch relevante Bildparameter in der Tumornachsorge sicher lesen zu können.

Empfehlung für die Praxis

Für die praktische Anwendung ist die Etablierung eines festen MRT-Protokolls unerlässlich. Neben der leitliniengerechten TNM-Klassifizierung muss der Radiologe dem Kliniker auch Informationen über die Infiltration der mesorektalen Faszie und der extramurale Gefäßinfiltration vermitteln. In der Tumornachsorge gewinnen radiologisch-pathologischen Scores (MR-TRG) zunehmend an Bedeutung.

Abstract

Clinical/methodical issue

Colorectal cancer is one of the most common malignant tumors. Preoperative imaging is crucial in rectal cancer as patients can only receive optimal treatment when accurate staging is performed. The N‑staging is often difficult with the available options and must be called into question as a staging parameter.

Standard radiological methods

Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) are particularly suitable for local staging. Multiparametric MRI with diffusion imaging is indispensable for tumor follow-up.

Methodical innovations

The assessment of infiltration of the mesorectal fascia is best accomplished using high-resolution MRI. In addition, extramural vascular infiltration (EMVI) has become established as another important prognostic factor. After neoadjuvant therapy and restaging of locally advanced rectal cancer, the identification and validation of prognostically relevant image parameters are prioritized. Multiparametric MRI of the rectum including diffusion imaging as well as the application of radiological and pathological scores (MR-TRG) are becoming increasingly more important in this context.

Assessment

For the radiologist it is important to become familiar with indicators of the resectability of rectal cancer and to be able to reliably read prognostically relevant imaging parameters in the tumor follow-up.

Practical recommendations

For the practical application, the establishment of a fixed MRI protocol is essential. In addition to a guideline-compliant TNM classification, the radiologist must provide the clinician with information on infiltration of the mesorectal fascia and extramural vascular infiltration. The MR-TRGs are becoming increasingly more important in tumor follow-up.

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Authors and Affiliations

  1. Diagnostische und Interventionelle Radiologie, Klinikum Konstanz, Mainaustr. 35, 78464, Konstanz, Deutschland

    M. S. Juchems

  2. Zentrum für Radiologie, Neuroradiologie und Nuklearmedizin, Clemenshospital Münster, Münster, Deutschland

    J. Wessling

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Correspondence to M. S. Juchems.

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Interessenkonflikt

M.S. Juchems und J. Wessling 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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Juchems, M.S., Wessling, J. Rationales Staging und Follow-up beim kolorektalen Karzinom. Radiologe 59, 820–827 (2019). https://doi.org/10.1007/s00117-019-0578-6

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