Medikamentöse Therapie des kolorektalen Karzinoms

Kernaussagen

Adjuvante Therapie

• Im Stadium II sollten Patienten bei Hochrisikokonstellation eine adjuvante Therapie mit einem Fluoropyrimidin erhalten. Bei Patienten ohne Risikofaktoren kann eine adjuvante Therapie mit einem Fluoropyrimidin erfolgen.

• Eine FOLFOX-Therapie über 6 Monate ist therapeutischer Standard im Stadium III (mit Lymphknotenbefall).

• Patienten über 70 Jahre sollten Kombinationstherapien zurückhaltend erhalten.

• Bei Kontraindikationen für eine Kombinationschemotherapie mit Oxaliplatin sollte Capecitabin gegeben werden.

• Irinotecan und monoklonale Antikörper haben keinen Stellenwert in der adjuvanten Therapie.

Therapie im Stadium IV

• Patienten mit Lebermetastasierung (potenziell kurative Therapie) werden nach klinischem Status unterschieden von nicht resektablen Patienten (palliative Therapie).

• Der k-ras-Mutationsstatus ist ein negativer prädiktiver Faktor für eine Anti-EGFR-Antikörpertherapie. Bei Patienten im Stadium IV mit der Möglichkeit einer Kombinationstherapie sollte der k-ras-Mutationsstatus untersucht werden.

Gruppe 1: Patienten mit primär resektabler Lebermetastasierung:

• Bei primär resektabler Lebermetastasierung kann eine perioperative Chemotherapie durchgeführt werden (prä- und postoperative oder postoperative Therapie).

Gruppe 2.1: Patienten mit primär nicht resektablen Lebermetastasen, bei denen nach intensiver Kombinationstherapie die Möglichkeit für eine Resektion besteht:

• Eine intensive Kombinationstherapie aus drei Substanzen sollte eingesetzt werden (Konversionstherapie).

• Sobald die Erkrankung resektabel erscheint, sollte der Patient operiert werden. Die Hepatotoxizität durch eine präoperative Therapie ist zu berücksichtigen.

Gruppe 2.2: Patienten ohne Möglichkeit einer Resektion mit tumorbedingten Symptomen, Organkomplikationen oder raschem Progress:

• Bei Erstdiagnose ist eine möglichst intensive Kombinationstherapie indiziert.

• Eine Kombinationschemotherapie mit monoklonalen Antikörpern verbessert das Überleben, steigert jedoch auch die Kosten und vergrößert den Überlebensvorteil nur moderat.

• Therapiedeeskalation und Erhaltungstherapien sind bei gleicher Wirksamkeit und verbesserter Lebensqualität durch Reduktion von Toxizitäten möglich.

• Eine optimale Therapiesequenz gibt es nicht. Entscheidend ist der Einsatz aller wirksamen Substanzen im Erkrankungsverlauf.

Gruppe 3: Patienten mit multiplen Metastasen ohne Option für eine Resektion nach Metastasenrückbildung, ohne tumorbezogene Symptome oder Organkomplikationen und/oder mit schwerer Komorbidität:

• Eine Monotherapie kann mit 5-FU begonnen werden und ggf. mit Bevacizumab kombiniert werden.

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