Neoadjuvante Therapie des Ösophaguskarzinoms

Zusammenfassung

Die Datenlage zur neoadjuvanten Therapie des Ösophaguskarzinoms ist trotz verschiedener randomisierter Studien uneinheitlich. Es ist deshalb schwierig, Evidenz-basierte Empfehlungen insbesondere auch für das lokal-fortgeschrittene Ösophaguskarzinom zu geben. Die chirurgische Resektion bleibt deshalb nach wie vor die Standardtherapie für das resektable Ösophaguskarzinom. Die neoadjuvante Chemotherapie hat in zwei adäquat gepowerten randomisierten Studien völlig unterschiedliche Ergebnisse hinsichtlich eines möglichen Überlebensvorteils gezeigt. Auch die präoperative Radiochemotherapie wird kontrovers beurteilt, da bis dato nur eine randomisierte Studie einen signifikanten Überlebensvorteil nachweisen konnte. Leider war das Michigan Trial unterpowert, so dass ein Überlebensvorteil von 14 % nach 5 Jahren nicht signifikant zu Buche schlagen konnte. In Anbetracht dieser Ergebnisse und vorsichtiger positiver Trends aus Meta-Analysen, kann Patienten mit lokal-fortgeschrittenen Ösophaguskarzinomen mit akzeptablem Risiko eine neoadjuvante Chemo- oder Radiochemotherapie unter der Voraussetzung angeboten werden, dass die Kontroversen um diese Therapieform angesprochen wurden (informed consent). Größere randomisierte Studien mit adäquater Fallzahlberechnung sind aber notwendig, bevor diese Therapieform als Standardtherapie angesehen werden kann. Prädiktive molekulare Marker für den Response auf die neoadjuvante Therapie wären von größtem Nutzen für die Selektion von Patienten in künftigen neoadjuvanten Therapiestudien.

Abstract

Inconclusive data are currently available from randomized neoadjuvant trials in esophageal cancer and it is very difficult to provide evidence-based guidelines especially for the treatment of patients with locally-advanced disease. Surgery however, remains the standard of care for potentially resectable disease. Preoperative chemotherapy is still controversial with two large randomized trials resulting in two different conclusions regarding the survival benefit. Preoperative chemoradiation is also under discussion since only one randomized trial showed a clear survival benefit. Unfortunately, the Michigan Trial was not powered enough to show a clear survival benefit for patients treated with neoadjuvant chemoradiation although the 14 % improvement of 5-year survival rates suggests this tendency. As a consequence one may consider offering neoadjuvant chemotherapy or neoadjuvant radiochemotherapy to patients with locally-advanced disease under the premise that patients have a good performance status and are informed about the controversies about this therapeutic option. Larger trials with sufficient power to clearly detect survival benefits for patients treated with neoadjuvant chemotherapy or radiochemotherapy are necessary before this therapeutic option will eventually be the standard of care. Predictive molecular markers indicating response or non-response to neoadjuvant treatment would be extremely helpful in selecting patients within future treatment protocols.

Schlüsselwörter

neoadjuvante Therapie - multimodale Therapie - Response - Regression - molekulare Response-Prädiktion

Key words

neoadjuvant therapy - multimodality treatment - response - regression - molecular response prediction

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