Interdisziplinäre Diagnostik und Therapie von Gallengangskarzinomen

Zusammenfassung

Die Diagnose und Therapie von Gallengangskarzinomen sind eine interdisziplinäre Herausforderung. Im diagnostischen und therapeutischen Vorgehen ist zwischen intrahepatischen und extrahepatischen Tumoren zu unterscheiden. Neben der Sonografie haben die endoskopisch retrograde Cholangiografie und Schnittbildverfahren eine zentrale Stellung in der Diagnosesicherung und Therapieplanung. Die einzige kurative Therapie ist die radikale Resektion. Da bei Diagnosestellung bereits viele Tumoren im fortgeschrittenen Stadium sind, kann nur der kleinere Teil der Patienten in kurativer Intention reseziert werden. Die Gefäßinfiltration der Pfortader stellt keine generelle Kontraindikation zur Operation mehr dar. Während eine Lebertransplantation beim intrahepatischen Cholangiokarzinom nicht sinnvoll ist, deuten neueste Daten auf einen möglichen Vorteil der Transplantation bei Klatskin-Tumoren hin. Ein wesentliches Ziel der palliativen Therapie ist die Prophylaxe und Behandlung der obstruktiven Cholangitis. Die Cholangitis ist die Haupttodesursache insbesondere des perihilären Klatskin-Tumors, der häufigsten Manifestation des CC. Ist eine Resektion nicht möglich, können lokal ablative Verfahren zum Einsatz kommen. Dabei ist die photodynamische Therapie das bisher am besten untersuchte Verfahren. Prospektiv kontrollierte Studien zeigten eine Verlängerung des Überlebens. Der Stellenwert radiologisch-interventioneller Verfahren sowie der perkutanen Radio- und Radiochemotherapie ist noch nicht ausreichend durch Studien belegt. Auch die Effizienz systemischer Chemotherapien ist unklar, da bis heute prospektiv evaluierte Chemotherapieregime weitgehend fehlen. Allerdings gibt es Hinweise für einen Vorteil einer Gemcitabin-basierten Chemotherapie. Um Patienten der bestmöglichen Therapie zuzuführen, ist eine enge interdisziplinäre Zusammenarbeit notwendig, und um Fortschritte bei der Therapie des Cholangiokarzinoms zu erzielen, ist die Testung neuer Ansätze in klinischen Studien unbedingt notwendig.

Abstract

The diagnosis of and therapy for cholangiocarcinomas still remains an interdisciplinary challenge. For diagnostic and therapeutic purposes intra- and extrahepatic cholangiocarcinomas need to be distinguished. Multiple imaging tools such as sonography, multidetector computer tomography, magnetic resonance tomography as well as endoscopic ultrasound and endoscopic retrograde cholangiography for the diagnosis and localisation of these tumours are available. To date, surgical resection is the only curative treatment. At the time of diagnosis, most of the tumours are advanced. Therefore, only a small percentage of patients are suitable for curative surgery. Infiltration of the portal vein no longer constitutes a contraindication for surgery. Liver transplantation is not a reasonable option for intrahepatic cholangiocarcinomas but may be of advantage for perihilar Klatskin tumours. Severe cholangitis is the main cause of death of patients with obstructive cholangiocarcinomas. Drainage of the biliary tree system or surgery with construction of a biliary-digestive anastomosis is often necessary. If possible, a photodynamic therapy (PDT) should be performed in addition to biliary drainage. PDT has been shown to facilitate biliary drainage and to improve survival. The value of radiologist-assisted interventional procedures as well as percutaneous ablation and radiochemotherapy is not well established. In addition, so far, there is no standardised chemotherapy in a palliative situation established but there is some evidence for a benefit of gemcitabine-based chemotherapy. For the best care and treatment of patients with cholangiocarcinomas an interdisciplinary approach is required and to achieve progress in the therapy patients should be included in prospective clinical trials to test new approaches.

Schlüsselwörter

cholangiozelluläres Karzinom - Klatskin-Tumor - Gallengangskarzinom

Key words

cholangiocellular carcinoma - Klatskin tumours - bile duct cancer

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