Therapeutische Optionen beim malignen Pleuramesotheliom

Zusammenfassung

Beim malignen Pleuramesotheliom stehen mit Operation, Chemo- und Strahlentherapie verschiedene Therapieoptionen zur Verfügung. Bei der Mehrzahl der Patienten stehen Symptomlinderung und Überlebensverlängerung als palliative Therapieziele im Vordergrund. Eine Heilung ist nur in Ausnahmefällen bei Frühfällen durch eine multimodale Therapie mit radikaler OP, Bestrahlung und Chemotherapie zu erreichen. In dieser Übersicht wird die Rolle der Chirurgie diskutiert mit den Verfahren der radikalen extrapleuralen Pleuropneumonektomie oder der palliativen, wenig invasiven Pleurektomie und Dekortikation. Die Rolle der palliativen Bestrahlung mit dem Problem des Verbringens der notwendigen Dosis an die Pleura in enger Nachbarschaft zu Lunge, Herz, Leber und Nieren wird diskutiert. Die Möglichkeiten der Chemotherapie mit „älteren” Mono- und Kombinationstherapien werden diskutiert. Auch die jüngste große multizentrische Studie, die die Rolle von Cisplatin/Pemetrexed als neuen Therapiestandard beim malignen Pleuramesotheliom begründet, wird dargestellt. Erwähnt werden weitere, experimentelle Verfahren, wie Hyperthermie, Immuntherapie und neue Ansätze der Hemmung von EGFR und VEGF durch „kleine Moleküle” oder Antikörper. Letztlich muss individuell anhand von Tumorausdehnung, Begleitmorbidität, Allgemeinzustand und Patientenwunsch entschieden werden. Für die Mehrzahl der Patienten kommen thorakoskopische Talkumpleurodese und Chemotherapie, evtl. auch die Pleurektomie und Dekortikation, im Verlauf auch mit Bestrahlung von Problemzonen infrage.

Abstract

Malignant pleural mesothelioma may be treated with surgery, radiotherapy and chemotherapy. In most patients, the treatment remains palliative with symptom relief and a moderate survival gain. Only a minority of patients with early stage mesothelioma may be cured by a multimodal approach including radical surgery, chemotherapy, and radiotherapy. We discuss the role of surgery with either radical extrapleural pleuropneumonectomy or less invasive palliative pleurectomy and decortication, and the role of radiotherapy, in which the main problem is how to deliver sufficient doses to the pleural surface, sparing radiosensitive structures such as the lung, heart, liver, and kidneys. Chemotherapeutic options are discussed with ‘older’ mono- and combination regimens and the new promising combination cisplatinum/pemetrexed, now the ‘standard regimen’ for malignant pleural mesothelioma. Experimental approaches such as hyperthermia, interferons or interleukins, and ‘small molecules’ or antibodies inhibiting the EGFR oder VEGF receptor are under clinical evaluation. For the majoritiy of our patients we recommend talcum pleurodesis either by medical thoracoscopy or VATS, followed by chemotherapy with platinum/pemetrexed. Radiotherapy may be applied in case of local tumour growth. The individual therapeutic decision will depend on tumour stage, concomitant diseases, performance status, and on the patient’s preference.

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Bereits publizierte Beiträge zu dieser Serie:

• 1 Bildgebende Diagnostik bei Pleuraerkrankungen.  Pneumologie. 2004;  58 238-254
• 2 Pleura: Pathologie nicht-neoplastischer Erkrankungen.  Pneumologie. 2004;  58 516-524
• 3 Pleuramesotheliom - Pathologie und Pathogenese.  Pneumologie. 2004;  58 670-679
• 4 Diagnostisches Vorgehen beim Pleuraerguss.  Pneumologie. 2004;  58 777-790
• 5 Management der malignen Pleuraergüsse.  Pneumologie. 2005;  59 120-135