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Urothelkarzinom des oberen Harntraktes: aktuelle Behandlungsstrategien

Urothelial carcinoma of the upper urinary tract: current treatment strategies

Zusammenfassung

Hintergrund

Das Therapiespektrum des Urothelkarzinoms des oberen Harntraktes ist breit und hängt maßgeblich von der individuellen Risikokonstellation ab. Eine möglichst exakte Diagnosestellung und Ausbreitungsdiagnostik sind unabdingbar für die Einordnung in die Niedrig- bzw. Hochrisikogruppe (low-risk bzw. high-risk).

Ziel

Darstellung der weiterentwickelten Diagnostik- und Therapiemöglichkeiten sowie der differenzierten Behandlungsstrategien des lokal begrenzten Urothelkarzinoms des oberen Harntrakts.

Material und Methoden

Selektive Literaturrecherche in der Datenbank PubMed zu den Themen Urothelkarzinom des oberen Harntrakts, Diagnostik, organerhaltende Therapie, radikale Nephroureterektomie sowie multimodale Therapiekonzepte.

Ergebnisse

Die Fortschritte bei der Bildgebung und den endoskopischen Techniken haben die diagnostische Sicherheit für das Urothelkarzinom des oberen Harntraktes erhöht und das Understaging reduziert. Die möglichst akkurate Einordnung in die Hoch- oder Niedrigrisikogruppe vereinfacht eine Therapieentscheidung. Nierenerhaltende Verfahren, z. B. eine endoskopische lasergestützte Tumorablation oder eine Uretersegmentresektion, können in bestimmten Konstellationen eingesetzt werden. Die radikale Nephroureterektomie ist der Goldstandard bei high-risk Karzinomen aufgrund des hohen Risikos für eine Progression und Metastasierung. Bei einem klinischen Tumorstadium ≥cT3 wird ein offener Zugang gegenüber einer laparoskopischen Vorgehensweise favorisiert. Eine adjuvante platinhaltige Chemotherapie soll nach der radikalen Nephroureterektomie bei einem pathologischen Tumorstadium ≥pT2 und/oder pN+ durchgeführt werden.

Diskussion

Mittlerweile bieten neue Algorithmen die Möglichkeit, therapieinduzierte Morbidität zu reduzieren und das onkologische Outcome zu verbessern, v. a. durch effektivere Multimodalkonzepte.

Abstract

Background

The treatment spectrum of urothelial carcinoma of the upper urinary tract is broad and depends largely on the individual risk constellation. The diagnosis and diagnostics of spreading need to be as accurate as possible for the classification into the low-risk or high-risk group.

Objective

Presentation of new achievements in diagnostics and treatment options as well as the differentiated treatment strategies for localized urothelial carcinoma of the upper urinary tract.

Material and methods

A selective literature search was carried out in PubMed on the topic of urothelial carcinoma of the upper urinary tract, diagnostics, organ-preserving strategies, radical nephroureterectomy and multimodal treatment concepts.

Results

Advances in imaging and endoscopic techniques, in particular, have increased the diagnostic certainty and reduced understaging. An accurate stratification as possible into the low-risk or high-risk group simplifies clinical decision making. Kidney-preserving procedures, such as endoscopic laser-guided tumor ablation or ureteral segmental resection, can be used in certain constellations. Radical nephroureterectomy remains the gold standard for high-risk urothelial carcinoma of the upper urinary tract due to the high risk of progression and metastases. For clinical stage ≥cT3 tumors an open approach is favored over a laparoscopic approach. Adjuvant platinum-based chemotherapy should be performed in a pathological tumor stage ≥pT2 and/or pN+ following radical nephroureterectomy.

Discussion

New algorithms meanwhile provide the possibility to reduce treatment-induced morbidity and to improve the oncological outcome, particularly through more effective multimodal concepts.

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Danksagung

Die Autoren danken herzlich Herrn Dr. de Petriconi für die Bereitstellung der Abb. 2 und 9.

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Correspondence to Christian Bolenz.

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Interessenkonflikt

M. Marx, L.-M. Krabbe, F. Wezel, J.-T. Klein, F. Zengerling und C. Bolenz 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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Marx, M., Krabbe, LM., Wezel, F. et al. Urothelkarzinom des oberen Harntraktes: aktuelle Behandlungsstrategien. Onkologie (2022). https://doi.org/10.1007/s00761-022-01220-w

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  • DOI: https://doi.org/10.1007/s00761-022-01220-w

Schlüsselwörter

  • Nephroureterektomie
  • Übergangszellkarzinom
  • Multimodale Therapie
  • Klinische Entscheidungsfindung
  • Algorithmen

Keywords

  • Nephroureterectomy
  • Carcinoma, transitional cell
  • Combined modality therapy
  • Clinical decision making
  • Algorithms