Subscribe to RSS
DOI: 10.1055/s-2008-1027466
© Georg Thieme Verlag KG Stuttgart · New York
Multimodale Therapie des Ösophaguskarzinoms
Multimodal Therapy of Esophageal CancerPublication History
Manuskript eingetroffen: 30.7.2007
Manuskript akzeptiert: 16.4.2008
Publication Date:
20 October 2008 (online)
![](https://www.thieme-connect.de/media/zfg/200810/lookinside/thumbnails/10.1055-s-2008-1027466-1.jpg)
Zusammenfassung
Aufgrund der heutigen Studienlage muss die chirurgische Resektion nach wie vor als das Therapieverfahren der Wahl beim resektablen Ösophaguskarzinom gelten. Ein Überlebensvorteil durch neoadjuvante oder adjuvante Therapiemodalitäten gegenüber der alleinigen Resektion ist jedoch aufgrund der aktuellen Datenlage wahrscheinlich. Hierbei ist die neoadjuvante Radiochemotherapie in Kombination mit der chirurgischen Resektion beim Plattenepithelkarzinom am wirksamsten. Die tendenziell erhöhte perioperative Morbidität und Mortalität nach neoadjuvanter Radiochemotherapie ist durch die Zentrumschirurgie zu minimieren. Beim Adenokarzinom des gastroösophagealen Übergangs zeigte eine neoadjuvante Chemotherapie Vorteile gegenüber der alleinigen Resektion. Für Patienten, bei denen eine radikale Operation mit transthorakaler Tumorresektion ein zu hohes Operationsrisiko darstellt, ist das transhiatale Vorgehen bei distal gelegenen Tumoren zu bevorzugen. Besonders für Hochrisikopatienten mit Plattenepithelkarzinomen des Ösophagus ist zumindest im mittelfristigen Verlauf die alleinige Radiochemotherapie im Vergleich zur Resektion eine mögliche Alternative. Somit sollte heute das Ösophaguskarzinom ein individualisiertes, multimodales Therapiekonzept inklusive Chirurgie, Radiotherapie und Chemotherapie zur Behandlungsgrundlage haben.
Abstract
Surgery is still the treatment of choice in patients with resectable oesophageal cancer. However, recent randomised controlled trials suggest beneficial effects of adjuvant or neoadjuvant treatment modalities on progression-free and overall survival compared to surgery alone. Neoadjuvant chemoradiotherapy in combination with surgery is most effective in squamous cell carcinomas. Increased perioperative morbidity and mortality should be minimised by surgery in a high-volume centre. In adenocarcinomas of the gastro-oesophageal junction neoadjuvant chemotherapy shows beneficial effects compared to surgery alone. A transhiatal resection should be preferred in distal oesophageal cancer compared to a transthoracic oesophageal resection if the patient is in poor condition. In all other cases a transthoracic resection remains the procedure of choice. Chemoradiotherapy alone is an alternative to surgery in high-risk patients with squamous cell carcinomas of the oesophagus. Therefore the treatment of patients with oesophageal cancer should always include an individualised, multimodal approach including surgery, chemotherapy, and radiotherapy.
Schlüsselwörter
Ösophagusresektion - Radiotherapie - Radiochemotherapie - Chemotherapie
Key words
esophageal resection - radiotherapy - chemoradiotherapy - chemotherapy
Literatur
- 1 Bollschweiler E, Wolfgarten E, Gutschow C. et al . Demographic variations in the rising incidence of esophageal adenocarcinoma in white males. Cancer. 2001; 92 549-555
- 2 Hölscher A H, Bollschweiler E, Bumm R. et al . Prognostic factors of resected adenocarcinoma of the esophagus. Surgery. 1995; 118 845-855
- 3 Roder J D, Busch R, Stein H J. et al . Ratio of invaded to removed lymph nodes as a predictor of survival in squamous cell carcinoma of the oesophagus. Br J Surg. 1994; 81 410-413
- 4 Birkmeyer J D, Siewers A E, Finlayson E V. et al . Hospital volume and surgical mortality in the United States. N Engl J Med. 2002; 346 1128-1137
- 5 Birkmeyer J D, Stukel T A, Siewers A E. et al . Surgeon volume and operative mortality in the United States. N Engl J Med. 2003; 349 2117-2127
- 6 Hulscher J B, Van Sandick J W, Boer A G. et al . Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002; 347 1662-1669
- 7 Macadam de R, Sarela A, Wilson J. et al . Bone marrow micrometastases predict early post-operative recurrence following surgical resection of oesophageal and gastric carcinoma. Eur J Surg Oncol. 2003; 29 450-454
- 8 Bosset J F, Gignoux M, Triboulet J P. et al . Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N Engl J Med. 1997; 337 161-167
- 9 Fiorica F, Di Bona D, Schepis F. et al . Preoperative chemoradiotherapy for oesophageal cancer: a systematic review and meta-analysis. Gut. 2004; 53 925-930
- 10 Lee J L, Park S I, Kim S B. et al . A single institutional phase III trial of preoperative chemotherapy with hyperfractionation radiotherapy plus surgery versus surgery alone for resectable esophageal squamous cell carcinoma. Ann Oncol. 2004; 15 947-954
- 11 Malthaner R A, Wong R K, Rumble R B. et al . Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a systematic review and meta-analysis. BMC Med. 2004; 2 35
- 12 Gebski V, Burmeister B, Smithers B M. et al . Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis. Lancet Oncol. 2007; 8 226-234
- 13 Burmeister B H, Smithers B M, Gebski V. et al . Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. Lancet Oncol. 2005; 6 659-668
- 14 Tepper J, Krasna M, Niedzwiecki D. et al . Superiority of trimodality therapy to surgery alone in esophageal cancer: results of CALGB 9781. J Clin Oncol. 2006; 24 (Suppl 18S) 4012 (Abstract)
- 15 Kok T, Lanschot J, Siersema P. et al . Neoadjuvant chemotherapy in operable esophageal squamous cell cancer: final report of a phase III multicenter randomized controlled trial. Proc Am Soc Clin Oncol. 1997; 16 277a (Abstract)
- 16 Walsh T. The role of multimodality therapy in improving survival: a prospective randomized trial. Predicting, defining and improving outcomes for esophageal carcinoma (MD thesis) Dublin; Trinity College, University of Dublin 1995: 124-150
- 17 Malthaner R A, Collin S, Fenlon D. Preoperative chemotherapy for resectable thoracic esophageal cancer. Cochrane Database Syst Rev. 2006; 3 CD001556
- 18 Malthaner R, Fenlon D. Preoperative chemotherapy for resectable thoracic esophageal cancer. Cochrane Database Syst Rev. 2001; 1 CD001556
- 19 Medical Research Council Oesophageal Cancer Working Party . Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet. 2002; 359 1727-1733
- 20 Kelsen D P, Ginsberg R, Pajak T F. et al . Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med. 1998; 339 1979-1984
- 21 Cunningham D, Allum W H, Stenning S P. et al . Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006; 355 11-20
- 22 Ando N, Iizuka T, Kakegawa T. et al . A randomized trial of surgery with and without chemotherapy for localized squamous carcinoma of the thoracic esophagus: the Japan Clinical Oncology Group Study. J Thorac Cardiovasc Surg. 1997; 114 205-209
- 23 Ando N, Iizuka T, Ide H. et al . Surgery Plus Chemotherapy Compared With Surgery Alone for Localized Squamous Cell Carcinoma of the Thoracic Esophagus: A Japan Clinical Oncology Group Study –JCOG9204. J Clin Oncol. 2003; 21 4592-4596
- 24 Arnott S J, Duncan W, Gignoux M. et al . Preoperative radiotherapy for esophageal carcinoma. Cochrane Database Syst Rev. 2005; 19 CD001799
- 25 Xiao Z F, Yang Z Y, Liang J. et al . Value of radiotherapy after radical surgery for esophageal carcinoma: a report of 495 patients. Ann Thorac Surg. 2003; 75 331-336
- 26 Kaklamanos I G, Walker G R, Ferry K. et al . Neoadjuvant treatment for resectable cancer of the esophagus and the gastroesophageal junction: a meta-analysis of randomized clinical trials. Ann Surg Oncol. 2003; 10 754-761
- 27 Urschel J D, Vasan H. A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer. Am J Surg. 2003; 185 538-543
- 28 Kleinberg L, Gibson M K, Forastiere A A. Chemoradiotherapy for localized esophageal cancer: regimen selection and molecular mechanisms of radiosensitization. Nat Clin Pract Oncol. 2007; 4 282-294
- 29 Araujo C M, Souhami L, Gil R A. et al . A randomized trial comparing radiation therapy versus concomitant radiation therapy and chemotherapy in carcinoma of the thoracic esophagus. Cancer. 1991; 67 2258-2261
- 30 Smith T J, Ryan L M, Douglass H OJ. et al . Combined chemoradiotherapy vs. radiotherapy alone for early stage squamous cell carcinoma of the esophagus: a study of the Eastern Cooperative Oncology Group. Int J Radiat Oncol Biol Phys. 1998; 42 269-276
- 31 Slabber C F, Nel J S, Schoeman L. et al . A randomized study of radiotherapy alone versus radiotherapy plus 5-fluorouracil and platinum in patients with inoperable, locally advanced squamous cancer of the esophagus. Am J Clin Oncol. 1998; 21 462-465
- 32 Herskovic A, Martz K, al-Sarraf M. et al . Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med. 1992; 326 1593-1598
- 33 Cooper J S, Guo M D, Herskovic A. et al . Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85 – 01). Radiation Therapy Oncology Group. JAMA. 1999; 281 1623-1627
- 34 Stahl M, Stuschke M, Lehmann N. et al . Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol. 2005; 23 2310-2317
- 35 Bedenne L, Michel P, Bouche O. et al . Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol. 2007; 25 1160-1168
- 36 Luthra R, Wu T T, Luthra M G. et al . Gene expression profiling of localized esophageal carcinomas: association with pathologic response to preoperative chemoradiation. J Clin Oncol. 2006; 24 259-267
- 37 Levine E A, Farmer M R, Clark P. et al . Predictive value of 18-fluoro-deoxy-glucose-positron emission tomography (18F-FDG-PET) in the identification of responders to chemoradiation therapy for the treatment of locally advanced esophageal cancer. Ann Surg. 2006; 243 472-478
- 38 Flamen P, Van Cutsem E, Lerut A. et al . Positron emission tomography for assessment of the response to induction radiochemotherapy in locally advanced oesophageal cancer. Ann Oncol. 2002; 13 361-368
- 39 Lordick F, Ott K, Krause B J. et al . PET to assess early metabolic response and to guide treatment of adenocarcinoma of the oesophagogastric junction: the MUNICON phase II trial. Lancet Oncol. 2007; 8 797-805
Prof. Dr. Jens Werner
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universität Heidelberg
Im Neuenheimer Feld 110
69120 Heidelberg
Phone: ++ 49/62 21/56 51 50
Fax: ++ 49/62 21/56 59 69
Email: jens_werner@med.uni-heidelberg.de