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Neoadjuvante Radiochemotherapie des Rektumkarzinoms

Neoadjuvant radiochemotherapy for rectal cancer

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Zusammenfassung

Die neoadjuvante Radiochemotherapie ist beim Rektumkarzinom mittlerweile etabliert. Die Indikation stellt sich, wenn primär eine R0-Resektion (wahrscheinlich) nicht zu erreichen ist, das Risiko eines lokoregionären Rezidivs mit alleiniger chirurgischer Therapie erhöht ist und durch eine neoadjuvante Radiochemotherapie der zunächst nicht (sicher) möglich erscheinende Erhalt des analen Sphinkters erreicht werden kann. Die Indikationsstellung für eine Radiochemotherapie im oberen Rektumdrittel wird gegenwärtig noch kontrovers diskutiert. Zur Festlegung der operativen Strategie ist nach einer neoadjuvanten Therapie die Reevaluation der Tumorsituation obligat. Moderne bildgebende Verfahren stoßen hierbei an ihre Grenzen, da zwischen vitalem Tumorgewebe und vernarbten Arealen kaum unterschieden werden kann. Im Zweifelsfall kann dies nur durch die chirurgische Exploration auch unter Inkaufnahme von R1-Resektionen geklärt werden. Insgesamt ist derzeit v. a. die Erfassung von Lymphknotenmetastasen als Indikator erhöhter Lokalrezidive unbefriedigend. Postoperative Komplikationen treten in Abhängigkeit vom operativen Verfahren nach einer neoadjuvanten Radiochemotherapie nicht häufiger auf. Der Effekt der neoadjuvanten Radiochemotherapie auf das Langzeitüberleben und die Fernmetastasierung ist zum jetzigen Zeitpunkt noch unbefriedigend. In laufenden Studien wird durch den Einsatz neuer Chemotherapeutika und modifizierter Behandlungsregiems diesem Zustand Rechnung getragen. Überdies sind das Zeitintervall zwischen Ende der neoadjuvanten Radiochemotherapie und der folgenden chirurgischen Therapie sowie der Umgang mit Patienten nach kompletter Remission bisher nicht abschließend geklärt.

Abstract

Neoadjuvant radiochemotherapy has become established treatment for rectal cancer. It is indicated when primary R0 resection is not an option, in cases of higher risk of locoregional relapse following surgical treatment alone, and when initially impossible conservation of the anal sphincter becomes possible in conjunction with neoadjuvant radiochemotherapy. The indication for radiochemotherapy in the upper third of the rectum is still controversial. Reevaluation of the tumor situation following neoadjuvant treatment is necessary before decisions on operative strategy. Modern imaging techniques are limited in this respect, as they hardly allow differentiation between living tumor tissue and lesions. In case of doubt clarity is possible only through surgical exploration, taking R1 resection into account. Overall the recognition of lymph node metastasis is not a sufficient indicator of local relapse. The frequency of postoperative complications following neoadjuvant radiochemotherapy is independent of the operative method. The effect of neoadjuvant radiochemotherapy on long-term survival and formation of distant metastases is still not clarified. Current studies seek clarification through the use of new chemotherapies and modified treatment regimes. Further, the correct time interval between the end of neoadjuvant radiochemotherapy and the following surgical therapy has yet to be determined. This applies also to the management of patients following complete remission.

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Authors and Affiliations

  1. Chirurgische Klinik, Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Deutschland

    W. Hohenberger, R.S. Croner, S. Merkel & J. Göhl

  2. Strahlenklinik, Universitätsklinikum Erlangen, Erlangen, Deutschland

    G. Lahmer, R. Fietkau & R. Sauer

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  1. W. Hohenberger
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  2. G. Lahmer
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  3. R. Fietkau
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  4. R.S. Croner
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  5. S. Merkel
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  6. J. Göhl
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  7. R. Sauer
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Correspondence to W. Hohenberger.

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Hohenberger, W., Lahmer, G., Fietkau, R. et al. Neoadjuvante Radiochemotherapie des Rektumkarzinoms. Chirurg 80, 294–302 (2009). https://doi.org/10.1007/s00104-009-1707-y

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