Modernes Management des Pancoast-Tumors

Zusammenfassung

Der Pancoast-Tumor (Sulcus-superior-Tumor) ist eine Sonderform des Lungenkarzinoms mit Infiltration der oberen Thoraxapertur, die durch Schulterschmerz und eventuell Horner-Syndrom klinisch auffällig wird. Die häufig verspätete Diagnose und die komplexe Anatomie der Region stellen eine Herausforderung für die Therapeuten dar. Dieser Beitrag schildert, wie moderne Diagnostik und multimodale Behandlung die Prognose der Erkrankung positiv beeinflussen können.

Abstract

Pancoast or superior pulmonary sulcus tumour is a subset of lung carcinoma that invades the structures of the thoracic inlet – first ribs, distal roots of the brachial plexus, stellate ganglion, vertebrae, and subclavian vessels. The first symptom is usually shoulder pain; consequently, most patients are initially treated for osteoarthritis. Late diagnosis is common. Success of therapy depends on an accurate staging: standard imaging with CT scan of the chest, PET-CT scan, brain MRI are needed to rule out distant metastases, endobronchial ultrasound-guided needle biopsy (EBUS-TBNA) or mediastinoscopy are mandatory for reliable nodal staging. An MRI of the thoracic inlet allows to clearly define the boundaries of local invasion. Modern management of Pancoast tumour includes induction concurrent chemoradiotherapy followed by surgical resection. As compared with historical series treated by preoperative radiation, a trimodally approach did enhance complete resection rates and perhaps long-term survival – from about 30% 5-year survival rate to 60% in R0-resected patients. In patients who have unresectable but non-metastatic Pancoast tumours and appropriate performance status, definitive concurrent chemoradiotherapy and radiotherapy are recommended options.

Kernaussagen

• Der Pancoast-Tumor ist ein Lungenkarzinom mit Infiltration der oberen Thoraxapertur – beteiligt sind die ersten Rippen, die kaudalen Wurzeln des Plexus brachialis, evtl. das Ganglion stellatum, die Wirbelsäule, die Subklaviagefäße.

• Das Leitsymptom ist der Schulterschmerz. Da sich die Ersttherapie gegen eine vermutete Osteoarthropathie richtet, wird die korrekte Diagnose häufig spät gestellt.

• Der Erfolg der onkologischen Behandlung hängt von der genauen Einschätzung der Tumorausbreitung ab: Neben den Standarduntersuchungen (CT-Thorax, PET-CT, MRT-Schädel) sollen eine invasive Untersuchung des Mediastinums und eine MRT der oberen Thoraxapertur angeschlossen werden.

  • Standarduntersuchungen:

    • CT-Thorax

    • PET-CT

    • MRT-Schädel

  • invasive Untersuchung des Mediastinums:

    • EBUS-Bronchoskopie (EBUS = endobronchial ultrasound) mit transbronchialer Nadelaspiration (TBNA)

    • Mediastinoskopie

• Standardbehandlung des potentiell resektablen Pancoast-Tumors ist eine trimodale Therapie mit kombinierter Chemoradiotherapie und erweiterter Chirurgie.

• Bei inoperabler, nicht metastatischer Erkrankung stellt die definitive Chemoradiotherapie die beste palliative Option dar. Falls nicht zumutbar, kommt die alleinige Bestrahlung in Betracht.

Schlüsselwörter

Lungenkarzinom - Chemotherapie - Radiotherapie - Chirurgie

Key words

lung cancer - chemotherapy - radiotherapy - surgery

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