Zusammenfassung
Hintergrund
Die bildgebende Diagnostik stellt einen integralen Bestandteil der Diagnostik, der Verlaufskontrolle sowie der Nachsorge von Patienten mit einem metastasierten Malignom des Urogenitaltrakts dar. Die aktuellen Leitlinien sprechen nur eine selten evidenzbasierte Empfehlung bezüglich der optimalen Modalität und Zeitintervalle der Bildgebung unter medikamentöser Tumortherapie (MTT) aus. Es ist Zielsetzung der vorliegenden Arbeit, den uroonkologisch tätigen Mediziner mit wissenschaftlich belegten Empfehlungen zur bildgebenden Diagnostik unter MTT urogenitaler Malignome auszustatten.
Ergebnisse
Grundlage der Beurteilung des therapeutischen Ansprechens von Weichteilmetastasen unter MTT stellen die RECIST-Kriterien („response evaluation criteria in solid tumors“) dar, das Ansprechen ossärer Metastasen erfolgt mittels Skelettszintigraphie (SZ) und objektiven Algorithmen. Bei Patienten mit metastasierten testikulären Keimzelltumoren (KZT) stellt die Computertomographie (CT) des Thorax, des Abdomens und kleinen Beckens die Bildgebung der Wahl nach abgeschlossener Systemtherapie dar. Lediglich bei seminomatösen KZT mit einem retroperitonealen Residualtumor ≥ 3 cm wird eine Fluordesoxyglukose-Positronenemissionstomographie (FDG-PET)/CT gefordert. Beim metastasierten Nierenzellkarzinom unter molekularer Therapie ist die bildgebende Diagnostik mittels CT in dreimonatlichen Intervallen sinnvoll. Eine FDG-PET/CT kann bereits 8 Wochen nach Therapiebeginn Aussagen über ein therapeutisches Ansprechen zulassen. Beim metastasierten Urothelkarzinom sollte eine Bildgebung nach jedem 2. Zyklus der systemischen Chemotherapie erfolgen. In Abhängigkeit der Metastasenlokalisation stehen CT, SZ oder konventionelles Röntgen zur Verfügung. Beim metastasierten Prostatakarzinom (PCA) unter Androgendeprivation ist eine bildgebende Diagnostik nur bei symptomatischer Progression oder geplanter Therapieänderung erforderlich; ansonsten gilt der PSA-Verlauf (prostataspezifisches Antigen) als valider Surrogatmarker für Ansprechen oder Progression. Bei kastrationsresistentem PCA unter Chemotherapie werden bildgebende Untersuchungen mittels CT oder Magnetresonanztomographie auch nur bei Änderung der Symptomatik oder geplanter Therapieänderung erforderlich. Regelmäßige bildgebende Verlaufskontrollen bei PSA-Ansprechen sind nicht indiziert. Wird das metastasierte kastrationsresistente PCA (KRPCA) mit Lyaseinhibitoren oder Inhibitoren der Androgenrezeptor Signalkaskaden therapiert, sind bildgebende Verlaufskontrollen aufgrund der fehlenden Verlässlichkeit des PSA als Surrogatmarker des Ansprechens in 3-monatlichen Intervallen indiziert.
Schlussfolgerung
Die bildgebenden Untersuchungen zur Beurteilung des therapeutischen Ansprechens urogenitaler Malignome unter MTT sind abhängig von der Tumortherapie, der Art des Karzinoms und den möglichen therapeutischen Konsequenzen individuell zu wählen.
Abstract
Background
Imaging studies are an integral and important diagnostic modality to stage, monitor, and follow-up patients with metastatic urogenital cancer. The currently available guidelines on diagnosis and treatment of urogenital cancer do not provide the clinician with evidence-based recommendations for daily routine. It is the aim of the current manuscript to develop scientifically valid recommendations with regard to the most appropriate imaging technique and the most useful time interval in metastatic urogenital cancer patients undergoing systemic therapy.
Results
Therapeutic response of soft tissue metastases is evaluated with the use of the RECIST criteria. In skeletal metastases, bone scans with validated algorithms must be performed to assess response. In patients with testicular germ cell tumors, computed tomography (CT) of the chest, the retroperitoneum, and the abdomen represents the standard imaging technique of choice usually performed prior to and at the end of systemic chemotherapy. Only in seminomas with residual tumors > 3 cm in diameter should FDG-PET/CT be performed about 6 weeks after chemotherapy. Metastatic renal cell carcinomas treated with molecular targeted therapies are routinely evaluated by CT scans at 3 month intervals. In specific cases, FDG-PET/CT is able to predict responses as early as 8 weeks after initiation of treatment. In patients with metastatic urothelial carcinomas, imaging studies should be performed after every second cycle of cytotoxic therapy. In patients with metastatic prostate cancer, the modality and the frequency of imaging studies depends on the type of the treatment. In men undergoing androgen deprivation therapy, no routine imaging studies are recommended except for patients with new onset symptoms or significant PSA progression prior to change of treatment. In men with metastatic castration-resistant PCA who are treated with cytotoxic regimes, routine imaging studies in the presence of decreasing or stable PSA serum concentrations are not indicated. In men treated with lyase inhibitor or inhibitors of the androgen receptor signaling cascade, imaging studies should be performed at 3 month intervals due to the low correlation of PSA serum concentrations with clinical response.
Conclusions
Imaging studies to assess therapeutic response to systemic treatment in metastatic cancers of the urogenital tract must be chosen depending on the treatment regime, primary organ, and potential consequences of the findings. Routine imaging studies without specific clinical or therapeutic relevance are not justified.
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Interessenkonflikt. A. Heidenreich und S. Krege geben an, dass kein Interessenkonflikt besteht.
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Heidenreich, A., Krege, S. Medikamentöse Tumortherapie urogenitaler Malignome. Urologe 52, 1564–1573 (2013). https://doi.org/10.1007/s00120-013-3253-y
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DOI: https://doi.org/10.1007/s00120-013-3253-y
Schlüsselwörter
- Keimzelltumor
- Positronenemissionstomographie
- Computertomographie
- Skelettszintigraphie
- Kernspintomographie