Perioperative Therapie bei nicht kleinzelligem Lungenkarzinom im lokal fortgeschrittenen Stadium: Delphi-Experten-Konsensus der Deutschen Gesellschaft für Thoraxchirurgie

Zusammenfassung

Hintergrund

Durch die Chemoimmuntherapie (CHT/IO) haben sich die multimodalen Therapieoptionen für das operable nicht kleinzellige Lungenkarzinom (NSCLC) in den letzten Jahren nachhaltig verändert. Ziel des Arbeitskreises der Deutschen Gesellschaft für Thoraxchirurgie (DGT) war die Erarbeitung konsentierter praxisnaher Empfehlungen zur perioperativen Therapie des NSCLC im lokal fortgeschrittenen Stadium.

Methoden

Von definierten Arbeitsgruppen wurde ein Fragenkatalog formuliert, der in 2 elektronischen Runden von Deutschlands leitenden Thoraxchirurgen beantwortet wurde. Kontroverse Ergebnisse mit weniger als 75% Übereinstimmung wurden anschließend in einer Expertenkonferenz diskutiert und in einer 3. Fragerunde abgestimmt.

Ergebnisse

Patienten mit gesicherter N1-Metastasierung sollten im perioperativen Regime behandelt werden, ebenso solche mit N2-Lymphknotenbefall. Voraussetzung sind technische und onkologische Operabilität sowie negative Molekularpathologie (obligat EGFR und ALK-Wildtyp). Bei fehlendem radiologischem Progress nach Induktionstherapie ist kein mediastinales invasives Restaging erforderlich. Die Operation soll auch bei gutem radiologischem Ansprechen durchgeführt werden. Inwieweit eine Reduktion des Resektionsausmaßes unter eine Lobektomie onkologisch vertretbar ist, bleibt aufgrund fehlender Evidenz offen. Zur adjuvanten Radiotherapie bestand insofern Konsens, als dass diese bei vollständigem mediastinalem Downstaging keinen Stellenwert hat. Bei ypN2-Situation soll die Bestrahlungsindikation, wie bisher, risikoadaptiert individuell diskutiert werden.

Schlussfolgerung

Zu den diskutierten Themen im Kontext der neuen perioperativen Therapiekonzepte konnte innerhalb der Expertenkonferenz ein weitgehender Konsens erzielt werden, sodass diese den Mitgliedern der DGT zur praxisorientierten Unterstützung dienen können.

Abstract

Background

The recent introduction of chemoimmunotherapy has permanently changed the multimodal therapeutic options for operable non-small cell lung cancer (NSCLC). The aim of the working group of the German Society for Thoracic Surgery (DGT) was to develop consensus-based practical recommendations for the perioperative treatment of locally advanced NSCLC.

Methods

A questionnaire was formulated by defined working groups, which was answered in two electronic rounds by Germany’s leading thoracic surgeons. Controversial results with less than 75% agreement were subsequently discussed in an expert conference and a Delphi survey was conducted.

Results

Patients with confirmed N1 or N2 lymph node metastasis should be treated in a perioperative regimen. Technical and oncological operability are obligate criteria as well as negative molecular status (at least EGFR and ALK wild type). Mediastinal invasive restaging is not required in the absence of radiological progression after induction therapy. Even with a good radiological response, surgery cannot be avoided. Because of a lack of evidence, it cannot be concluded to what extent a reduction in the extent of resection below a lobectomy is oncologically justifiable. The participants agreed that adjuvant radiotherapy has no value in patients with complete mediastinal downstaging. Patients with persistent mediastinal lymph node metastases (ypN2) should be discussed for adjuvant radiotherapy on a risk-adapted individual basis.

Conclusion

A broad consensus was reached at the expert conference on the topics discussed in the context of the new perioperative therapy concepts. These can therefore serve as practice-oriented support for the members of the DGT.

Schlüsselwörter

Lungenkarzinom - perioperative Therapie - Chemoimmuntherapie - Delphi-Konsensus

Keywords

lung cancer - immunochemotherapy - perioperative therapy - Delphi consensus

Publikationsverlauf

Eingereicht: 02. Juni 2025

Angenommen: 10. Juli 2025

Artikel online veröffentlicht:
07. August 2025

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