Neoadjuvante Therapie beim Rektumkarzinom: Auf dem Weg zur individuellen Therapie

Zusammenfassung

Die neoadjuvante Therapie lokal fortgeschrittener Rektumkarzinome ist seit dem Herbst 2004 in die Leitlinien aufgenommen worden. Diese Änderung der Empfehlungen bedeutet einen erheblichen Paradigmenwechsel, da nun die Mehrzahl der behandelten Patienten nicht primär operiert werden sollte. Voraussetzung für eine sinnhafte Therapiestratifizierung ist dabei eine verlässliche Diagnostik. Hier zeichnet sich ab, dass die Kernspintomographie in die Routineabklärung der Patienten mit lokal fortgeschrittenen Rektumkarzinomen aufgenommen wird. Insbesondere die Einschätzung, ob aus einer onkologischen Resektion mit totaler mesorektaler Exzision ein zirkumferenziell tumorfreier Resektionsrand resultiert, gelingt in der MRT zuverlässig und erscheint weniger untersucherabhängig als die Endosonographie. Nicht entschieden ist bisher die Form der neoadjuvanten Therapie. Hier konkurrieren Kurzzeit-Strahlentherapie (5 × 5 Gy) mit Langzeitprotokollen unterschiedlicher Chemotherapiemodifikationen. Letztere werden bei organüberschreitenden Tumoren und distaler Lokalisation eingesetzt, wenn ein Sphinktererhalt ermöglicht werden soll. Chirurgisch-technisch wird eine wissenschaftliche Absicherung der minimalinvasiven Resektion des Rektumkarzinoms erfolgen, der Prämisse eines Sphinktererhaltes um jeden Preis muss eine Auseinandersetzung mit der Sinnhaftigkeit ultratiefer Resektionen folgen. Multimodale Therapien werden aber auch schwierig therapierbare funktionelle Langzeitfolgen nach sich ziehen, die bisher in der Diskussion um eine Verbesserung der onkologischen Ergebnisse unterrepräsentiert sind. Da besonders Patienten von einer Vorbehandlung profitieren, deren Tumoren auch auf eine solche Therapie ansprechen, kommt der Forschung zur Prädiktion der Tumorantwort auf eine neoadjuvante Therapie eine wichtige Rolle zu.

Abstract

Neoadjuvant radiation or chemoradiation followed by oncological resection is the current treatment of choice for locally advanced rectal cancer. Profound diagnostics are mandatory to stratify patients for neoadjuvant treatment or primary surgery. Here, magnetic resonance tomography most probably will become the standard modality due to its ability to predict involvement of the circumferential resection margin during surgery. While the initiation of chemoradiation in T4 rectal cancer and patients with distal tumours potentially undergoing sphincter-preserving surgery is unequivocal, the treatment of choice for the remaining patients is undecided. Here, short-term radiotherapy (5 × 5 Gy) competes with chemoradiation of different intensity. In surgical oncology, minimally invasive surgery of the rectum needs further evidence before it can be accepted as an equivalent. Finally, the increase in multimodality treatment will ultimately increase the incidence of late functional sequelae which, up to now, are underrepresented in most reports due to the priority of oncological results. Since responders to neoadjuvant treatment are the ones who benefit most from these therapies, research related to prediction of treatment response has a fundamental role.

Schlüsselwörter

kolorektales Karzinom - Rektumkarzinom - neoadjuvante Therapie - multimodale Therapie

Key words

colorectal carcinoma - rectal cancer - neoadjuvant treatment - multimodal treatment

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