Pankreaskarzinom: Aktueller Stand der multimodalen Therapie

Zusammenfassung

Nur durch multimodale Therapiekonzepte lässt sich die derzeit weiterhin schlechte Prognose des Pankreaskarzinoms potenziell verbessern. Die Chirurgie hat in Zentren ein hohes Maß an Sicherheit bei sehr niedriger Mortalität erreicht. Infiltrationen der mesenterikoportalen venösen Achse stellen hierbei keine Kontraindikation für die sinnhafte onkologische Chirurgie dar. Nach Resektion eines Pankreaskarzinoms (R0 und R1) sollte eine adjuvante Chemotherapie mit Gemcitabine durchgeführt werden. Derzeit gibt es keinen Hinweis auf die Überlegenheit einer neoadjuvanten Radiochemotherapie bei primär resektablen Pankreaskarzinomen. Die Überlebensraten von primär resektablen Patienten mit neoadjuvanter Vorbehandlung entsprechen denen von Patien­ten mit primärer Resektion und adjuvanter Therapie. Da aufgrund der perioperativen Morbidität einige Patienten der adjuvanten Therapie nicht zugeführt werden können, sollte der Stellenwert der neo­adjuvanten Therapie resektabler Tumore in prospektiv randomisierten Studien überprüft werden. Für Patienten mit primär lokal irresek­tablen Pan­kreaskarzinomen kann in etwa einem Drittel der Fälle nach neoadjuvanter Radio­che­motherapie eine radikale Resektion erfolgen. Für dieses Patientenkollektiv sind randomisierte prospektive Studien dringlich nötig. Die Entscheidung über primäre lokale Resektabilität oder ­Ir­resek­tabilität kann nur durch den in der Pan­kreaschirurgie erfahrenen Chirurgen erfolgen. 

Abstract

Only multimodal treatment concepts may potentially improve the persisting poor prognosis of the carcinoma of the pancreas. In specialized centres surgery has reached a high level of security with a very low level of mortality. Infiltrations of the mesenterico-portal axis are not a contraindication to a curative oncological surgery. R0 and R1 resections should be followed by adjuvant chemotherapy with gemcitabine. Currently there is no evidence of benefit for a neoadjuvant radio-chemotherapy in primary resectable carcinomas of the pancreas. The survival rates of primary resectable carcinoma patients with neoadjuvant pre-treatment correspond to those of primary resectable carcinoma patients with adjuvant therapy. Due to the high perioperative morbidity, some patients do not gain access to the adjuvant therapy within a reasonable time frame. Therefore, the significance of neoadjuvant therapy for resectable tumours should be re-evaluated in prospective randomised trials. In about one third of the patients with primary irresectable carcinomas of the pancreas, a radical resection can be per­formed after neoadjuvant radio-chemotherapy. For this patient group randomised prospective trials are urgently needed. In this context, how­ever, only an experienced pancreatic surgeon can decide about the resectability or irresectability of a pancreatic tumour. 

Schlüsselwörter

Pankreaskarzinom - adjuvante Behandlung - neoadjuvante Behandlung - lokal fortgeschritten - Chemotherapie - Strahlentherapie

Key words

pancreatic carcinoma - adjuvant therapy - neoadjuvant therapy - locally advanced disease - chemotherapy - radiation therapy

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