Chirurgische und internistische Diagnostik und Therapie des Ösophaguskarzinoms

Kernaussagen

Ätiologie und Epidemiologie

• Die Hauptrisikofaktoren für Plattenepithelkarzinome des Ösophagus sind Alkohol und Rauchen. Adenokarzinome entwickeln sich fast ausschließlich in einer Zylinderepithelmetaplasie der distalen Speiseröhre, meist als Folge einer chronischen gastroösophagealen Refluxkrankheit.

• Das Barrett-Karzinom ist zurzeit der Tumor mit der höchsten Zuwachsrate aller Malignome, die Inzidenz des Plattenepithelkarzinoms ist gleichbleibend.

Klinik und Diagnostik

• Eine eindeutige Dysphagie - Leitsymptom des Ösophaguskarzinoms - tritt meist erst in einem fortgeschrittenen Tumorstadium auf.

• Der Ausschluss/Nachweis von Fernmetastasen mittels CT von Hals/Thorax und Abdomen ist für die Therapieentscheidung eine der wichtigsten Staginguntersuchung.

• Die genaueste Untersuchung für die Vorhersage der T-Klassifikation ist die Endosonografie, während die Unterscheidung von Mukosa- und Submukosainfiltration am ehesten endoskopisch gelingt.

Therapie

• Bei Mukosakarzinomen umschriebenen Ausmaßes von < 2 cm und Ausschluss von Multifokalität ist bei Erfüllung aller erforderlichen Kriterien die endoskopische Mukosektomie indiziert.

• Funktionell operable Patienten mit Submukosa- oder T2-Karzinom ohne Fernmetastasen werden primär einer radikalen Ösophagektomie zugeführt, wobei in den meisten Fällen die subtotale En-bloc-Ösophagektomie mit 2-Feld-Lymphadenektomie und hoch intrathorakaler Ösophagogastrostomie das Verfahren der Wahl ist.

• Bei funktionell operablen Patienten mit T3- und resektablen T4-Karzinomen wird zur Verbesserung der Ausgangssituation für eine R0-Resektion die neoadjuvante Chemo- (Adenokarzinome) oder Radiochemotherapie (Plattenepithelkarzinome) vorangestellt.

• Funktionell inoperable Patienten sollten einer definitiven Radiochemotherapie zugeführt werden. Bei metastasierter Erkrankung sollte eine Cisplatin-basierte Kombinationschemotherapie erfolgen.

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