Zusammenfassung
Das Bronchialkarzinom ist weltweit der am häufigsten zum Tode führende Tumor. Allein in Deutschland erkranken pro Jahr mehr als 40.000 Menschen, über die Hälfte kann keiner primär kurativen Therapie zugeführt werden. Angesichts dessen ist ein exaktes Staging für Patienten mit nichtkleinzelligem Bronchialkarzinom von entscheidender Wichtigkeit, da sowohl Prognose als auch therapeutische Optionen sich in den verschiedenen Stadien signifikant unterscheiden.
In den letzten Jahren sind zur präoperativen Diagnostik eine Reihe von weiteren Untersuchungen hinzugekommen, deren Ergebnisse Vorbereitung und Therapie des Patienten grundlegend beeinflussen. Heute liefert die CT zwar durch nochmals verfeinerte Auflösung eine optimale anatomische Orientierung, deren Sensitivität zur Vorhersage eines mediastinalen Lymphknotenbefalls hat sich allerdings nicht verbessert und verbleibt mit ca. 50 % schlecht. Die mittlerweile auch in Deutschland in der präoperativen Diagnostik vergütete PET-CT zeitigt einen deutlich verbesserten negativ-prädiktiven Wert, positive Befunde sind jedoch weiterhin generell histologisch oder aber zytologisch zu sichern. Mit der endobronchialen oder aber transösophagealen ultraschallgesteuerten Nadelaspiration haben hier zwei minimalinvasive Methoden Einzug in die Diagnostik gefunden. Diesen Verfahren kann zwar eine hohe Spezifität, jedoch nur ein geringer negativ-prädiktiver Wert attestiert werden. Insofern bedarf es bei negativem Ergebnis der Hinzunahme stärker invasiver Techniken (als Goldstandard die Mediastinoskopie), insofern sich in der PET-CT-Untersuchung ein grenzwertiger oder aber positiver Befund gezeigt hat. Ist hingegen der zytologische Befund per Feinnadelaspiration positiv, so gilt eine N2- oder aber N3-Erkrankung als gesichert und die stadienadaptierte Therapie kann eingeleitet werden.
Dieser Artikel beleuchtet die oben genannten Verfahren und berücksichtigt die 2007 veröffentlichten Empfehlungen der ACCP und der ESTS zum nichtinvasiven respektive Lymphknotenstaging. Hierbei wird insbesondere der Sichtweise unserer Institution Rechnung getragen.
Abstract
Lung cancer is the most common cause of death of cancer worldwide. In Germany there are more than 40,000 new lung cancer cases each year. Unfortunately at the point of diagnosis, more than half of them are at a stage which has no chance of cure. In terms of prognosis and treatment options staging as exact as possible is of special importance. In recent years, some new diagnostic tools, which influence further treatment, have been added to the preoperative workup.
Today the most exact tool for anatomical detail is the CT scan of the thorax. Still the sensitivity to detect mediastinal lymph Mediastinonode involvement is poor (about 50%). PETor PET-CT scan, which is now also reimbursed within Germany, yields a much better negative predictive value whether positive results still have to be cytologically or histologically proved. In terms of nonsurgical microinvasive staging, two new tools have been implemented, the EUS-NA and the EBUS-NA. Both methods have high specificity but have a low negative predictive value. Therefore negative results have to be proved by more invasive techniques as the mediastinoscopy as the reference method, if the initial PET scan showed a borderline or positive result regarding the mediastinal lymph nodes. If the NA result is positive, N2 or N3 disease is confirmed and a stage-adapted therapy can be chosen.
This article places emphasis on the methods mentioned above, especially with regard to the ACCP and ESTS staging guidelines published in 2007. It summarizes the point of view of our institution.
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Dickgreber, N.J., Fischer, S. & Welte, T. Präoperatives Staging bei Patienten mit nichtkleinzelligem Bronchialkarzinom. Z Herz- Thorax- Gefäßchir 22, 56–62 (2008). https://doi.org/10.1007/s00398-008-0607-7
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DOI: https://doi.org/10.1007/s00398-008-0607-7