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Strahlentherapie nach radikaler Prostatektomie

Indikationen, Ergebnisse und Nebenwirkungen

Radiotherapy following radical prostatectomy. Indications, results and side effects

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Zusammenfassung

Hintergrund

In den letzten Jahren hat die Radiotherapie nach radikaler Prostatektomie bei organüberschreitenden Tumoren mit oder ohne positiven Schnittrand sowohl als adjuvante als auch als Therapie bei PSA-Anstieg unter der Vorstellung eines Lokalrezidivs bzw. eines lokalen Tumorrestes bei einem großen Anteil dieser Patienten zunehmend an Bedeutung gewonnen. Hintergrund hierfür ist die durch den Einsatz des PSA sich durchsetzende Erkenntnis, daß Patienten mit histopathologisch gesicherten pT3/4-Tumoren oder mit Befall der Lymphknoten durch eine alleinige operative oder eine alleinige strahlentherapeutische Therapie bereits nach drei bis fünf Jahren in bis zu 60% systemisch und/oder lokal progredient sind.

Ergebnisse

Eine Vielzahl von allerdings ausschließlich retrospektiven Untersuchungen belegt eine signifikant erhöhte lokale Tumorkontrolle durch die Radiotherapie nach radikaler Prostatektomie. Das gilt sowohl für die adjuvante Therapie bei PSA im „Nullbereich” und bei PSA-Anstieg aus dem „Nullbereich,” wobei berücksichtigt werden muß, daß auch Patienten behandelt werden, bei denen kein lokaler Tumor vorliegt, und dies gilt auch bei histologisch gesichertem Lokalrezidiv. Mehrere Studien zeigen eine signifikante Verlängerung des „freedom from treatment failure”, das heißt des lokalen und systemischen Progresses. Eine Verlängerung des Gesamtüberlebens wurde jedoch bisher nicht nachgewiesen. Bei Anstieg des PSA aus dem „Nullbereich” nach radikaler Prostatektomie oder postoperativ erhöhtem PSA bestehen Hinweise, daß bei Werten oberhalb 2,5 bis 4 ng/ml bereits eine systemische Metastasierung besteht und die Radiotherapie keine kurative Intention mehr besitzt.

Schlußfolgerungen

Durch die lokale adjuvante Radiotherapie nach radikaler Prostatektomie wird sowohl die lokale Kontrolle als auch das „freedom from treatment failure” bei organüberschreitendem Prostatakarzinom mit positivem Schnittrand und wahrscheinlich auch negativem Schnittrand erhöht bzw. verlängert. Eine Verlängerung des Gesamtüberlebens wurde bisher nich bewiesen. Insgesamt drei prospektiv randomisierte Studien werden derzeit durchgeführt. Zur Frage der Strahlentherapie in Verbindung mit einer gleichzeitigen oder auch neoadjuvanten systemischen hormonellen Therapie liegen nur sehr spärliche, allerdings interessante Daten vor.

Abstract

Background

Radiation therapy following radical prostatectomy in locally progressed prostate carcinoma has become increasingly important in the last few years as both adjuvant therapy in patients with pT3-tumors with or without positive margins and treatment for a PSA increase in local recurrence of disease. The background for this is the knowledge gained by using PSA that up to 60% of the patients with histopathologically confirmed pT3/4 tumors or involvement of the lymph nodes are systemically and/or locally progressive after 3 to 5 years if only surgical or radiation therapy was performed.

Results

A number of studies, albeit exclusively retrospective, substantiated a significantly high local tumor control by radiotherapy after radical prostatectomy. This holds true for adjuvant therapy with a PSA in the “zero range” as well as with a PSA increase from the “zero range”, whereby it must be taken into consideration that a certain percentage of treated patients with a PSA in the “zero-range” with or without positive margins actually do not need further therapy. Two retrospective studies demonstrated a significant better lengthening of “freedom from treatment failure” that is local and systemic progression of disease. Lengthening the survival time has, however, not yet been proven. With an increase in the PSA from the “zero range” after radical prostatectomy, there are indications that systemic metastatic spread already occurs with values higher than 2.5 to 4 ng/ml and the radiotherapy no longer has any curative intention.

conclusions

Adjuvant RT following radical prostatectomy gives better local control rates and probably better rates of “freedom from treatment failure” in patients with locally advanced prostate cancer with positive margins and probably in patients with negative margins. However, in retrospective studies no advantage in overall survival was shown.

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Authors and Affiliations

  1. Urologische Klinik des Universitätsklinikums Benjamin Franklin der Freien Universität Berlin, Berlin, Deutschland

    U. Steiner

  2. Abteilung für Strahlentherapie der Universität, Hindenburgdamm 30, D-12203, Berlin

    T. Wiegel & W. Hinkelbein

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Wiegel, T., Steiner, U. & Hinkelbein, W. Strahlentherapie nach radikaler Prostatektomie. Strahlenther. Onkol. 173, 309–315 (1997). https://doi.org/10.1007/BF03038913

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