Rektumkarzinom: Behandeln wir zu häufig neoadjuvant? Vorschläge zu einer selektiveren, MRT-basierten Indikation

Zusammenfassung

Die moderne optimierte Chirurgie (Konzept der totalen Mesorektumexzision) mit Qualitätssicherung durch standardisierte pathologische Untersuchung, strahlentherapeutische Fortschritte und die Möglichkeiten der hochauflösenden Dünnschicht-MRT erfordern eine neue Abwägung der Indikation zur multimodalen Therapie des Rektumkarzinoms. Danach ist eine neoadjuvante Langzeit-Radiochemotherapie indiziert bei Patienten mit hohem lokoregionärem Rezidivrisiko. Dies sind Patienten mit 1) fixierten fraglich resektablen Tumoren, 2) beweglichen Tumoren, bei denen nach dem MRT-Befund der Tumor die Fascia mesorectalis befällt oder von ihr 1 mm oder weniger entfernt ist, 3) tiefsitzenden Tumoren, die unter den Levatoransatz reichen und jenseits der Muscularis propria infiltrieren. Eine adjuvante Radiochemotherapie ist dann angezeigt, wenn sich ein erhöhtes Lokalrezidivrisiko aufgrund des intraoperativen Verlaufs (Tumorperforation, Schnitt in bzw. durch Tumor) oder der pathologischen Untersuchung des Tumorresektats (inkomplette Mesorektumexzision, Tumor 1 mm oder weniger vom zirkumferentiellen Resektionsrand entfernt) ergibt. Bei Patienten mit Lymphknotenmetastasen, jedoch geringem Lokalrezidivrisiko ist eine postoperative Chemotherapie empfehlenswert.

Abstract

The present-day optimised surgery (concept of total mesorectal excision) with quality assurance by standardized pathologic examination, advances in radiotherapy and the possibilities of high-spatial-resolution MR imaging require reconsideration of pros and contras of neoadjuvant therapy and respective data. According to the resulting new proposal neoadjuvant long-course radiochemotherapy is indicated for patients with 1) fixed questionably R0 resectable tumors, 2) mobile tumors with the MRT finding of tumor involving the mesorectal fascia or 1 mm or less from it, 3) low rectal tumors extending below the levator origin and invading beyond the muscularis propria. If a high risk of local recurrence becomes apparent during surgery (tumor perforation, incision into or through tumor) or after pathologic examination (incomplete mesorectal excision, tumor 1 mm or less from the circumferential resection margin) adjuvant radiochemotherapy is indicated. In case of lymph node metastasis postoperative chemotherapy is given.

Schlüsselwörter

Magnetresonanztomographie - Mesorektumexzision - Multimodale Therapie - Neoadjuvante Langzeit-Radiochemotherapie - Rektumkarzinom

Key words

Magnetic resonance imaging - Mesorectal excision - Multimodal treatment - Neoadjuvant long-course radiochemotherapy - Rectal carcinoma

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