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Markersysteme beim Hodentumor

The role of tumour markers in diagnosis and management of testicular germ cell tumours

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Zusammenfassung

Alpha-Fetoprotein (AFP), humanes Choriogonadotropin (HCG) und die Laktatdehydrogenase (LDH) stellen die Tumormarker des testikulären Keimzelltumors (KZT) dar, deren Bestimmung im Rahmen der Primärdiagnostik, des primären Stagings, des therapeutischen Monitorings und der Nachsorge entsprechend der aktuellen Leitlinien erfolgen sollte. Der plazentaren alkalischen Phosphatase sowie der neuronenspezifischen Enolase kommt keine Bedeutung zu.

Metastasierte KZT werden entsprechend der Höhe ihrer Serumkonzentration nach der IGCCCG-Klassifikation in Tumoren mit günstiger, intermediärer und ungünstiger Prognose eingeteilt. Die Risikoklassifikation hat therapeutische Bedeutung und bestimmt die Intensität der systemischen Chemotherapie. In seltenen Fällen können AFP und HCG durch andere, nicht testikuläre Ursachen erhöht sein, die im Rahmen der Differentialdiagnostik berücksichtigt werden müssen. Das Ansprechen auf die Chemotherapie wird mit den Markern AFP und HCG kontrolliert, die jeweils am Tag vor Einleitung des nachfolgenden Zyklus bestimmt werden. Ein Anstieg der Tumormarker während oder unmittelbar nach Ende der Systemtherapie macht aufgrund der ungünstigen Prognose die direkte Einleitung einer Salvagetherapie notwendig. Es bleibt zu berücksichtigen, dass nur ca. 40–50% bzw. 30% der Rezidive unter aktiver Surveillance bzw. nach systemischer Chemotherapie mit einem Markeranstieg vergesellschaftet sind. Markeranstiege machen prinzipiell eine bildgebende Diagnostik notwendig; ca. 10% der Patienten sind bildgebend negativ und werden nach Ausschluss falsch-positiver Ursachen der systemischen Rezidivtherapie zugeführt. Residualtumoren werden bei normalisierten oder plateauartig stabilen Markerkonzentrationen der operativen Resektion zugeführt. Eine Residualtumorresektion bei steigenden Markerkonzentrationen im Sinne der „desperation surgery“ ist nur nach Ausschöpfen aller chemotherapeutischen Optionen, kompletter Resektabilität aller Residuen und fehlendem HCG-Anstieg indiziert. Während der Nachsorgeuntersuchungen sollten die Serumkonzentrationen aller 3 Marker bei fortgeschrittenen KZT bestimmt werden, während keine Tumormarkerkontrolle bei Seminomen im klinischen Stadium I indiziert ist.

Abstract

Alpha-fetoprotein (AFP), human choriogonadotropin (hCG) and lactate dehydrogenase (LDH) are established tumour markers of testicular germ cell tumours (TGCT) which are used according to the guidelines for primary diagnosis, staging, monitoring of therapeutic response and follow-up. Placental alkaline phosphatase and neurone-specific enolase play no role at all in the diagnosis and management of TGCT.

Metastasized TGCT are classified according to the IGCCCG classification system into tumours with good, intermediate and poor prognosis depending on their serum concentration. The risk classification has a direct impact on therapy and determines the intensity of chemotherapy. In rare cases AFP and hCG might be elevated due to non-testicular reasons which have to be taken into consideration for the differential diagnosis especially if marker concentration and clinical presentation do not match. Response to chemotherapy is monitored with AFP and hCG which are determined the day before initiation of the next treatment cycle. Marker increases during or shortly after discontinuation of chemotherapy indicate a poor prognosis and make the immediate initiation of salvage treatment regimes necessary. Only 40–50% and 30% of relapses in patients under active surveillance for clinical stage I disease and after systemic chemotherapy are associated with marker increases. The remainder will be diagnosed by imaging studies or clinical symptoms. Marker increases have to be validated by imaging studies. However, about 10% of all relapsing patients have marker increases only without any imaging evidence of metastatic disease. Residual masses of any size and location have to be treated by postchemotherapy resection once the marker concentration is normalized or once it has reached a stable plateau. So-called desperation surgery in the presence of rising tumour markers is only indicated if no curative chemotherapy is available, all residual masses are completely resectable and no hCG elevation are observed. For follow-up, AFP, hCG and LDH should be evaluated for advanced TGCT and clinical stage I nonseminomas, whereas clinical stage I seminomas should be monitored without any markers.

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Authors and Affiliations

  1. Klinik für Urologie, Krankenhaus Maria Hilf, Krefeld, Deutschland

    S. Krege

  2. Klinik für Urologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland

    P. Albers

  3. Klinik für Urologie, Universitätsklinikum Aachen, Pauwelsstraße 30, 5074, Aachen, Deutschland

    A. Heidenreich

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  1. S. Krege
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  2. P. Albers
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  3. A. Heidenreich
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Correspondence to A. Heidenreich.

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Krege, S., Albers, P. & Heidenreich, A. Markersysteme beim Hodentumor. Urologe 50, 313–321 (2011). https://doi.org/10.1007/s00120-010-2414-5

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