Zusammenfassung
Aufgrund einer steten Zunahme beträgt die Inzidenz des Ösophaguskarzinoms in Deutschland
derzeit 6 - 10 pro 100 000. Da charakteristische Frühsymptome meist fehlen, wird das
Ösophaguskarzinom i. d. R. spät diagnostiziert. Bei nahezu 75 % der Patienten liegt
zum Diagnosezeitpunkt ein fortgeschrittenes Tumorstadium UICC III oder IV vor. Der
Anteil der Frühkarzinome (T1-Tumoren) liegt leider unter 10 %. Die Diagnostik und
das Staging beinhalten die Ösophagoskopie mit histologischer Sicherung, die Endosonographie
und die Computertomographie des Thorax und Abdomens. Im Falle eines auf die Mukosa
begrenzten T1a-Frühkarzinoms oder einer hochgradigen Dysplasie kann alternativ zur
Ösophagektomie die endoskopische Mukosaresektion vorgenommen werden. Die definitive
Radiochemotherapie ist die Therapie der Wahl bei Plattenepithelkarzinomen des oberen
Ösophagusdrittels. Bei nicht fernmetastasierten Plattenepithelkarzinomen der mittleren
und unteren Speiseröhre ist die definitive Radiochemotherapie der alleinigen Ösophagektomie
hinsichtlich des Gesamtüberlebens nicht unterlegen und sollte deshalb Patienten mit
erhöhtem Operationsrisiko als Therapieverfahren der Wahl angeboten werden. Beim resektablen
Adenokarzinom hat bei operablen Patienten die Ösophagektomie ihren festen Stellenwert.
Bei primär nicht resektablen Adenokarzinomen wird die neoadjuvante Radiochemotherapie
empfohlen. Im Falle der Fernmetastasierung besteht eine Palliativsituation. Bei ausreichend
gutem Allgemeinzustand gilt hier die Kombination aus 5-FU und Cisplatin als die Chemotherapie
der Wahl. Hinsichtlich der Lebensqualität ist bei stenosierenden, nicht resektablen
Tumoren ein Ösophagusstent meist die beste und am schnellsten wirksame Therapie.
Abstract
In Germany the incidence of esophageal cancer is 6 - 10 per 100,000. At the time of
diagnosis about 75 % of the patients suffer from UICC stage III or IV esophageal cancer.
Less than 10 % of patients are diagnosed with early (T1) cancer. Diagnosis and staging
relies on esophagoscopy including biopsies, endoscopic ultrasonography, and computerized
tomography of the chest and abdomen. Intramucosal early cancer (T1a) and high-grade
dysplasia can be treated either by surgery or by endoscopic mucosal resection. Chemoradiation
is the definitive treatment of choice for localized squamous cell cancer of the proximal
esophagus. As far as overall survival is concerned definitive chemoradiation is not
inferior to esophagectomy even in patients with localized squamous cell cancer of
the middle or lower esophagus. In case of high surgical risk chemoradiation should
be offered to those patients as the therapy of choice. Esophagectomy should be performed
in operable patients suffering from resectable adenocarcinoma of the esophagus. Preoperative
chemoradiation is recommended in locally advanced (non-resectable) adenocarcinoma.
If staging reveals distant metastases, palliative therapy is indicated. Palliative
chemotherapy with 5-fluorouracil and cisplatin should be offered to patients with
good performance status. Esophageal intubation (with expandable metal stents) is the
palliative treatment of choice for firm stenosing, non-resectable tumors, where rapid
relief of dysphagia is required.
Schlüsselwörter
Ösophagektomie - Chemotherapie - Radiochemotherapie
Key words
Esophagectomy - chemotherapy - chemoradiation
Literaturangaben
- 1
Blot W J, McLaughlin J K.
The changing epidemiology of esophageal cancer.
Sem Oncol.
1999;
26
2-8
- 2
Bareiss D, Stabenow R, Müller R. et al .
Aktuelle Epidemiologie des Ösophaguskarzinoms und des Kardiakarzinoms in Deutschland.
DMW.
2002;
127
1367-1374
- 3
Lagergren J, Bergstrom R, Lindgren A. et al .
The role of tobacco, snuff and alcohol use in the etiology of cancer of the esophagus
and gastric cardia.
Int J Cancer.
2000;
85
340-346
- 4
Scherübl H, von Lampe B, Faiss S. et al .
Screening for esophageal neoplasia in patients with head and neck cancer.
Brit J Cancer.
2002;
86
239-243
- 5
Scherübl H, Scherer H, Hoffmeister B.
Second esophageal cancers in head and neck cancer patients.
N Engl J Med.
2002;
346
1416-1417
- 6
Scherübl H, Sutter A, Zeitz M.
NSAIDs and esophageal cancer.
Gastroenterology.
2003;
125
1914-1915
- 7
Lagergren J, Bergstrom R, Lindgren A. et al .
Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma.
N Engl J Med.
1999;
340
825-831
- 8
Spechler S J.
Barrett's esophagus.
N Engl J Med.
2002;
364
836-842
- 9 Hermaneck P, Sobin L H. TNM classification of malignant tumors. International Union
Against Cancer, 4th ed. Berlin; Springer-Verlag 1987
- 10
Rösch T.
Endosonographic staging of esophageal cancer: A review of literature results.
Gastrointest Endosc Clin North Am.
1995;
5
537-547
- 11
Vazquez-Sequeiros E, Wiersema M, Clain J. et al .
Impact of lymph node staging on therapy of esophageal carcinoma.
Gastroenterology.
2003;
125
1626-1635
- 12
Takashima S, Takeuchi N, Shiozaki H. et al .
Carcinoma of the esophagus: CT vs MR imaging in determing resectability.
Am J Roentgenol.
1991;
156
297-302
- 13
Hulscher J BF, van Sandick J W, de Boer A G. et al .
Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma
of the esophagus.
N Engl J Med.
2002;
347
1662-1669
- 14
Hölscher A H, Bollschweiler E, Schneider P M. et al .
Prognosis of early esophageal cancer.
Cancer.
1995;
76
178-186
- 15
Enzinger P C, Mayer R J.
Esophageal cancer.
N Engl J Med.
2003;
349
2241-2252
- 16
Birkmeyer J, Stukel T, Siewers A. et al .
Surgeon volume and operative mortality in the United States.
N Engl J Med.
2003;
349
2117-2127
- 17
Siewert J R, Stein H J, Feith M. et al .
Histologic tumor type is an independent prognostic parameter in esophageal cancer:
lessons from more than 1000 consecutive resections at a single center in the Western
world.
Ann Surg.
2001;
234
360-369
- 18
De-Ren S .
Ten-year follow-up of esophageal cancer treated by radical radiation therapy.
J Radiat Oncol Biol Phys.
1989;
16
329-334
- 19
Ell C, May A, Pech O. et al .
Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett`s
esophagus.
Gastroenterology.
2000;
118
670-677
- 20
Recht A.
The role of radiation therapy in treating patients with potentially resectable carcinoma
of the esophagus.
Chest.
1995;
107
233S-240S
- 21
Albertson M, Ewers S B, Widmark H. et al .
Evaluation of the palliative effect of radiotherapy for esophageal carcinoma.
Acta Oncol.
1989;
25
267-270
- 22
Ajani J A.
Docetaxel for gastric and esophageal cancer.
Oncology (Huntingt).
2002;
16
89-96
- 23
Ajani J A, Ilson D H, Daugherty K. et al .
Activity of taxol in patients with squamous cell carcinoma and adenocarcinoma of the
esophagus.
J Natl Cancer Inst.
1994;
86
1086-1091
- 24
Mühr-Wilkenshoff F, Hinkelbein W, Ohnesorge I. et al .
A pilot study of irinotecan (CPT- 11) as single-agent therapy in patients with locally
advanced or metastatic esophageal carcinoma.
Int J Colorectal Dis.
2003;
18
330-334
- 25
Stahl M.
Chemotherapy of esophageal carcinoma.
Onkologie.
1999;
22
98-104
- 26
Wadler S, Haynes H, Beitler J J. et al .
Phase II clinical trial with 5-fluorouracil, recombinant interferon-alpha- 2 b, and
cisplatin for patients with metastatic or locally advanced carcinoma of the esophagus.
Cancer.
1996;
78
30-34
- 27
Polee M B, Eskens F A, van der Burg M E. et al .
Phase II study of bi-weekly administration of paclitaxel and cisplatin in patients
with advanced esophageal cancer.
Br J Cancer.
2002;
86
669-673
- 28
Ilson D H, Forastiere A, Arquette M. et al .
A phase II trial of paclitaxel and cisplatin in patients with advanced carcinoma of
the esophagus.
Cancer J.
2000;
6
316-323
- 29
Ilson DH, Ajani J A. et al .
Phase II trial of paclitaxel, fluorouracil, and cisplatin in patients with advanced
carcinoma of the esophagus.
J Clin Oncol.
1998;
16
1826-1834
- 30
Garcia-Alfonso P, Guevara S, Lopez P. et al .
Taxol and cisplatin + 5-fluorouracil sequential in advanced esophageal cancer.
Proc Am Soc Clin Oncol.
1998;
17
260 a
- 31
Ilson D H, Saltz L, Enzinger P. et al .
Phase II trial of weekly irinotecan plus cisplatin in advanced esophageal cancer.
J Clin Oncol.
1999;
17
3270-3275
- 32
Ajani J A, Baker J, Pisters P W. et al .
Irinotecan/cisplatin in advanced, treated gastric or gastroesophageal junction carcinoma.
Oncology (Huntingt).
2002;
16
16-18
- 33
Oettle H, Arnold D, Kern M. et al .
Phase I study of gemcitabine in combination with cisplatin, 5-fluorouracil and folinic
acid in patients with advanced esophageal cancer.
Anticancer Drugs.
2002;
13
833-838
- 34
Livingston R, Edwards J, Gold P.
Phase II trial of irinotecan and mitomycin C in the treatment of metastatic esophageal
cancer.
Proc Am Soc Clin Oncol.
2003;
22
292 (abstr 1171)
- 35
Hoff P, Fuchs C.
The experience with oxaliplatin in the treatment of upper gastrointestinal carcinomas.
Semin Oncol.
2003;
30
54-61
- 36
Yoshioka T, Gamoh M, Shineha R. et al .
A new combination chemotherapy with cis-diammine-glycolatoplatinum (Nedaplatin) and
5-fluorouracil for advanced esophageal cancers.
Intern Med.
1999;
38
844-848
- 37
Wong R, Malthaner R A, Zuraw L. et al .
Combined modality radiotherapy and chemotherapy in nonsurgical management of localized
carcinoma of the esophagus: A practice guideline.
Int J Ratiat Oncol Biol Phys.
2003;
55
930-942
- 38
Herskovic A, Martz K, Al-Sarraf M. et al .
Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients
with cancer of the esophagus.
N Engl J Med.
1992;
326
1593-1598
- 39
Walsh T N, Noonan N, Hollywood D. et al .
A comparison of multimodal therapy and surgery for esophageal adenocarcinoma.
N Engl J Med.
1996;
335
462-467
- 40
Urba S G, Orringer M B, Turrisi A. et al .
Randomized trial of preoperative chemoradiation versus surgery alone in patients with
locoregional esophgeal carcinoma.
J Clin Oncol.
2001;
15
305-313
- 41
Burmeister B H, Smithers B M, Fitzgerald L. et al .
A randomized phase III trial of preoperative chemoradiation followed by surgery (CR-S)
versus surgery alone (S) for localized resectable cancer of the esophagus.
Proc Am Soc Clin Oncol.
2002;
21
130 (abstract)
- 42
Meluch A A, Greco F A, Gray J R. et al .
Preoperative therapy with concurrent paclitaxel/carboplatin/infusional 5-FU and radiotherapy
in locoregional esophageal cancer: final results of a Minnie Pearl Cancer Research
Network phase II trial.
Cancer J.
2003;
9
251-260
- 43
Bedenne L, Michel P, Bouche O. et al .
Randomized phase III trial in locally advanced esophageal cancer: radiochemotherapy
followed by surgery versus radiochemotherapy alone (FFCD 9102).
Proc Am Soc Clin Oncol.
2002;
21
130 (abstract)
- 44
Stahl M, Wilke H, Walz M K. et al .
Randomized phase III trial in locally advanced squamous cell carcinoma (SCC) of the
esophagus: Chemoradiation with and without surgery.
Proc Am Soc Clin Oncol.
2003;
22
250 (abstract)
- 45
Bidoli P, Bajetta E, Stani S C. et al .
Ten year survival with chemotherapy and radiotherapy in patients with squamous cell
carcinoma of the esophagus.
Cancer.
2002;
94
352-361
- 46
Allum W H, Griffin S M, Watson A. et al .
Guidelines for the management of esophageal and gastric cancer.
Gut.
2002;
50 (Suppl V)
v1-v23
- 47
Nihei K, Ishikura A, Ohtsu A. et al .
Long-term survival and toxicity after definitive chemoradiotherapy (CRT) for squamous
cell carcinoma (SCC) of the thoracic esophagus.
J Clin Oncol.
2003;
21
2697-2702
- 48
Burmeister B H, Dickie G, Smithers B M. et al .
Thirty-four patients with carcinoma of the cervical esophagus treated with chemoradiation
therapy.
Arch Otolaryngol Head Neck Surg.
2000;
126
205-208
- 49
Arnott S J, Duncan W, Gignoux M. et al .
Preoperative radiotherapy in esophageal carcinoma: a meta-analysis using individual
patient data (Oesophageal Cancer Collaborative Group).
Int J Radiat Oncol Biol Phys.
1998;
41
579-583
- 50
Fok M, Sham J ST, Choy D. et al .
Postoperative radiotherapy for carcinoma of the esophagus: A prospective, randomized
controlled trial.
Surgery.
1993;
113
138-147
- 51
Kelsen D P, Ginsberg R, Pajak T F. et al .
Chemotherapy followed by surgery compared with surgery alone for localized esophageal
cancer.
N Engl J Med.
1998;
339
1979-1984
- 52
Medical Research Council Oesophageal Cancer Working Group .
Surgical resection with or without preoperative chemotherapy in oesophageal cancer:
a randomised controlled trial.
Lancet.
2002;
359
1727-1733
- 53
Kaklamanos I G, Walker G R, Ferry K. et al .
Neoadjuvant treatment for resectable cancer of the esophagus and gastroesophageal
junction: a meta-analysis of randomized trials.
Ann Surg Oncol.
2003;
10
754-761
- 54
Ando N, Lizuka T, Die H. et al .
A randomized trial of surgery alone vs surgery plus postoperative chemotherapy with
cisplatin and 5-fluorouracil for localized squamous carcinoma of the thoracic esophagus:
The Japan Clinical Oncology Group Study (JCOG 9204).
Proc Am Soc Clin Oncol.
1999;
18
269 a
- 55
Bosset J F, Gignoux M, Triboulet J P. et al .
Chemoradiotherapy followed by surgery compared with surgery alone in squamous cell
cancer of the esophagus.
N Engl J Med.
1997;
337
161-167
- 56
Urschel J, Vasan H.
A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation
and surgery to surgery alone for resectable esophageal cancer.
Am J Surg.
2003;
185
538-543
Prof. Dr. med. Hans Scherübl
Medizinische Klinik I, Gastroenterologie, Infektiologie & Rheumatologie, Charité -
Universitätsmedizin Berlin, Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin, Germany
Email: hans.scheruebl@charite.de