Gastroenterologie up2date 2010; 6(1): 41-62
DOI: 10.1055/s-0029-1243961
Darm/Anorektum

© Georg Thieme Verlag KG Stuttgart · New York

Medikamentöse Therapie des kolorektalen Karzinoms

Michael  Pohl, Anke  Reinacher-Schick, Wolff  Schmiegel
Further Information

Publication History

Publication Date:
22 March 2010 (online)

Kernaussagen

Adjuvante Therapie

  • Im Stadium II sollten Patienten bei Hochrisikokonstellation eine adjuvante Therapie mit einem Fluoropyrimidin erhalten. Bei Patienten ohne Risikofaktoren kann eine adjuvante Therapie mit einem Fluoropyrimidin erfolgen.

  • Eine FOLFOX-Therapie über 6 Monate ist therapeutischer Standard im Stadium III (mit Lymphknotenbefall).

  • Patienten über 70 Jahre sollten Kombinationstherapien zurückhaltend erhalten.

  • Bei Kontraindikationen für eine Kombinationschemotherapie mit Oxaliplatin sollte Capecitabin gegeben werden.

  • Irinotecan und monoklonale Antikörper haben keinen Stellenwert in der adjuvanten Therapie.

Therapie im Stadium IV

  • Patienten mit Lebermetastasierung (potenziell kurative Therapie) werden nach klinischem Status unterschieden von nicht resektablen Patienten (palliative Therapie).

  • Der k-ras-Mutationsstatus ist ein negativer prädiktiver Faktor für eine Anti-EGFR-Antikörpertherapie. Bei Patienten im Stadium IV mit der Möglichkeit einer Kombinationstherapie sollte der k-ras-Mutationsstatus untersucht werden.

Gruppe 1: Patienten mit primär resektabler Lebermetastasierung:

  • Bei primär resektabler Lebermetastasierung kann eine perioperative Chemotherapie durchgeführt werden (prä- und postoperative oder postoperative Therapie).

Gruppe 2.1: Patienten mit primär nicht resektablen Lebermetastasen, bei denen nach intensiver Kombinationstherapie die Möglichkeit für eine Resektion besteht:

  • Eine intensive Kombinationstherapie aus drei Substanzen sollte eingesetzt werden (Konversionstherapie).

  • Sobald die Erkrankung resektabel erscheint, sollte der Patient operiert werden. Die Hepatotoxizität durch eine präoperative Therapie ist zu berücksichtigen.

Gruppe 2.2: Patienten ohne Möglichkeit einer Resektion mit tumorbedingten Symptomen, Organkomplikationen oder raschem Progress:

  • Bei Erstdiagnose ist eine möglichst intensive Kombinationstherapie indiziert.

  • Eine Kombinationschemotherapie mit monoklonalen Antikörpern verbessert das Überleben, steigert jedoch auch die Kosten und vergrößert den Überlebensvorteil nur moderat.

  • Therapiedeeskalation und Erhaltungstherapien sind bei gleicher Wirksamkeit und verbesserter Lebensqualität durch Reduktion von Toxizitäten möglich.

  • Eine optimale Therapiesequenz gibt es nicht. Entscheidend ist der Einsatz aller wirksamen Substanzen im Erkrankungsverlauf.

Gruppe 3: Patienten mit multiplen Metastasen ohne Option für eine Resektion nach Metastasenrückbildung, ohne tumorbezogene Symptome oder Organkomplikationen und/oder mit schwerer Komorbidität:

  • Eine Monotherapie kann mit 5-FU begonnen werden und ggf. mit Bevacizumab kombiniert werden.

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Prof. Dr. Wolff Schmiegel

Medizinische Universitätsklinik
Knappschaftskrankenhaus Bochum

In der Schornau 23 – 25
44892 Bochum

Email: meduni-kkh@rub.de