Aktuelle Diagnostik und Therapie des Ösophaguskarzinoms

Zusammenfassung

Aufgrund einer steten Zunahme beträgt die Inzidenz des Ösophaguskarzinoms in Deutschland derzeit 6 - 10 pro 100 000. Da charakteristische Frühsymptome meist fehlen, wird das Ösophaguskarzinom i. d. R. spät diagnostiziert. Bei nahezu 75 % der Patienten liegt zum Diagnosezeitpunkt ein fortgeschrittenes Tumorstadium UICC III oder IV vor. Der Anteil der Frühkarzinome (T1-Tumoren) liegt leider unter 10 %. Die Diagnostik und das Staging beinhalten die Ösophagoskopie mit histologischer Sicherung, die Endosonographie und die Computertomographie des Thorax und Abdomens. Im Falle eines auf die Mukosa begrenzten T1a-Frühkarzinoms oder einer hochgradigen Dysplasie kann alternativ zur Ösophagektomie die endoskopische Mukosaresektion vorgenommen werden. Die definitive Radiochemotherapie ist die Therapie der Wahl bei Plattenepithelkarzinomen des oberen Ösophagusdrittels. Bei nicht fernmetastasierten Plattenepithelkarzinomen der mittleren und unteren Speiseröhre ist die definitive Radiochemotherapie der alleinigen Ösophagektomie hinsichtlich des Gesamtüberlebens nicht unterlegen und sollte deshalb Patienten mit erhöhtem Operationsrisiko als Therapieverfahren der Wahl angeboten werden. Beim resektablen Adenokarzinom hat bei operablen Patienten die Ösophagektomie ihren festen Stellenwert. Bei primär nicht resektablen Adenokarzinomen wird die neoadjuvante Radiochemotherapie empfohlen. Im Falle der Fernmetastasierung besteht eine Palliativsituation. Bei ausreichend gutem Allgemeinzustand gilt hier die Kombination aus 5-FU und Cisplatin als die Chemotherapie der Wahl. Hinsichtlich der Lebensqualität ist bei stenosierenden, nicht resektablen Tumoren ein Ösophagusstent meist die beste und am schnellsten wirksame Therapie.

Abstract

In Germany the incidence of esophageal cancer is 6 - 10 per 100,000. At the time of diagnosis about 75 % of the patients suffer from UICC stage III or IV esophageal cancer. Less than 10 % of patients are diagnosed with early (T1) cancer. Diagnosis and staging relies on esophagoscopy including biopsies, endoscopic ultrasonography, and computerized tomography of the chest and abdomen. Intramucosal early cancer (T1a) and high-grade dysplasia can be treated either by surgery or by endoscopic mucosal resection. Chemoradiation is the definitive treatment of choice for localized squamous cell cancer of the proximal esophagus. As far as overall survival is concerned definitive chemoradiation is not inferior to esophagectomy even in patients with localized squamous cell cancer of the middle or lower esophagus. In case of high surgical risk chemoradiation should be offered to those patients as the therapy of choice. Esophagectomy should be performed in operable patients suffering from resectable adenocarcinoma of the esophagus. Preoperative chemoradiation is recommended in locally advanced (non-resectable) adenocarcinoma. If staging reveals distant metastases, palliative therapy is indicated. Palliative chemotherapy with 5-fluorouracil and cisplatin should be offered to patients with good performance status. Esophageal intubation (with expandable metal stents) is the palliative treatment of choice for firm stenosing, non-resectable tumors, where rapid relief of dysphagia is required.

Schlüsselwörter

Ösophagektomie - Chemotherapie - Radiochemotherapie

Key words

Esophagectomy - chemotherapy - chemoradiation

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