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Indikationen zur neoadjuvanten und adjuvanten Radio-Chemo-Therapie beim Rektumkarzinom

Indications for neoadjuvant and adjuvant radiochemotherapy of rectal cancer

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Zusammenfassung

Die neoadjuvante Radio-Chemo-Therapie (RCT) hat die postoperative RCT als Standardtherapie bei lokal fortgeschrittenen Rektumkarzinomen (UICC-Stadium II/III) abgelöst. Hauptgründe waren die niedrigere Lokalrezidivrate und die geringere Toxizität. Weiterhin besteht die Indikation zur adjuvanten RCT, wenn postoperativ ein präoperativ nicht erkanntes Stadium UICC-Stadium II/III gefunden wird. Neben der Langzeit-RCT haben randomisierte Studien den Effekt einer Kurzzeitradiotherapie mit 5-mal 5 Gy bestätigt. Vor allem Patienten mit Tumoren im mittleren Drittel des Rektums ohne Lymphknotenbefall oder einem N1-Status dürften davon profitieren. Weiterentwicklungen der Operation und der Diagnostik könnten in den nächsten Jahren zur genaueren Feinabstimmung der Indikation zur RCT führen. Die Bildgebung mittels Magnetresonanztomographie (MRT) könnte dabei eine entscheidende Rolle spielen. Eine mögliche Patientenselektionierung wird evtl. nicht mehr allein durch das klassische TNM-System, sondern eher durch die Identifikation anderer Risikofaktoren, wie etwa des zirkumferenziellen Resektionsrands (CRM), vorgenommen werden. Hauptproblem ist jedoch eine zuverlässige Vorhersage von möglichen Risikofaktoren und eine flächendeckende Qualitätssicherung aller an der Therapie beteiligten Modalitäten. Im vorliegenden Beitrag werden bisherige Ergebnisse, die zu den klassischen Indikationen geführt haben, erläutert und mögliche Faktoren, die die Therapie in Zukunft ändern könnten, kritisch angesprochen.

Abstract

Neoadjuvant radiochemotherapy has replaced postoperative radiochemotherapy as the standard therapy for locally advanced rectal cancer. The main reasons were reduced local recurrence rates and lower toxicity. The indication for adjuvant radiochemotherapy is still valid if UICC stages II and III were not identified preoperatively. Randomized trials have also confirmed the effect of short course preoperative radiotherapy with 5×5 Gy. Mainly patients with tumors in the middle third of the rectum, which have no or only a few perirectal lymph nodes (N1) might benefit. Improvements in surgery and imaging can lead to a more accurate adjustment for the indications of neoadjuvant treatment and magnetic resonance imaging (MRI) could play a decisive role. Patient selection will possibly be performed not only by the established TNM system but also by the identification of other risk factors such as the circumferential resection margin (CRM). The main problem is a reliable prediction of potential risk factors and a comprehensive quality management of all treatment modalities involved. The objective of this review is to present results which have led to the conventional indications and factors which could potentially change the therapy in future will be critically discussed.

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  1. Klinik und Poliklinik für Strahlentherapie, Strahlenklinik des Universitätsklinikums Erlangen, Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Deutschland

    G. Lahmer & R. Fietkau

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  1. G. Lahmer
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Correspondence to G. Lahmer.

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Lahmer, G., Fietkau, R. Indikationen zur neoadjuvanten und adjuvanten Radio-Chemo-Therapie beim Rektumkarzinom. Onkologe 16, 747–756 (2010). https://doi.org/10.1007/s00761-010-1862-2

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  • DOI: https://doi.org/10.1007/s00761-010-1862-2

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