Aktuelle Diagnostik und Therapie der Gallengangskarzinome – Update

Kernaussagen

Epidemiologie und Diagnostik

• Gallengangskarzinome werden in Gallenblasenkarzinome, hiläre Gallengangskarzinome (Klatskin-Tumoren), distale extrahepatische Karzinome und intrahepatische Gallengangskarzinome unterteilt.

• Während die Häufigkeit von intrahepatischen Gallengangs- und Papillenkarzinomen zunimmt, nimmt die Inzidenz von extrahepatischen Gallengangs- und Gallenblasenkarzinome dagegen ab.

• Gallensteine stellen den Hauptrisikofaktor für die Entstehung von Gallenblasenkarzinomen dar (ca. 65 – 90 % der Patienten haben Gallensteine). Bei den Gallengangskarzinomen lassen sich dagegen nur in ca. 10 % Risikofaktoren finden.

• Die Umwandlung von normalem in malignes Gallengangsgewebe unterliegt möglicherweise einer Reihe von aufeinanderfolgenden Genmutationen, ähnlich der Adenom-Dysplasie-Karzinom-Sequenz beim Kolonkarzinom.

• Der abdominelle Ultraschall, die nicht invasive kombinierte Magnetresonanzcholangiografie/-tomografie (MRC/MRT), die Multidetektor-Computertomografie (MDCT) und die endoskopische retrograde Cholangiografie (ERC) stellen in der Primärdiagnostik den Goldstandard dar.

• Beim Papillenkarzinom ist die Endosonografie neben der endoskopischen Biopsie diagnostisches Mittel der Wahl.

Therapie

• Eine Heilung ist bei allen Tumorarten nur durch eine radikal-chirurgische Resektion im Gesunden möglich. Durch eine Zunahme der Radikalität konnte in den letzten Jahren eine deutliche Verbesserung der 5-Jahres-Überlebensraten erreicht werden.

• Grundlegende Prinzipien der onkologischen Chirurgie sind die R0-Resektion mit weiten longitudinalen und lateralen Sicherheitsabständen, die Monobloc-Resektion des Tumors und die „No-touch“-Technik, d. h. ohne Manipulation am Tumor.

• Die Frage eines klinischen Benefits für adjuvante Therapiemaßnahmen wird momentan in mehreren Studien untersucht.

• In der Palliation ist die endoskopische und perkutane Drainage der Gallengänge fest etabliert. Der endosonografische Zugang stellt eine neue ergänzende Möglichkeit dar.

• Die fotodynamische Therapie (PDT) ist eine wichtige Ergänzung der Drainage.

• Während eine Radio- bzw. eine Radiochemotherapie in der Palliation nicht etabliert sind, gibt es mittlerweile einen neuen Standard im Bereich der Chemotherapie (Gemcitabin plus Cisplatin).

• Zusätzliche molekulare Therapieziele werden zurzeit untersucht, es fehlen aber noch geeignete Biomarker für eine adäquate Patientenselektion.

• Literatur

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