S3-Leitlinie: Diagnostik und Therapie des hepatozellulären Karzinoms

Wesentliche Neuerungen in der Leitlinie zur Diagnostik und Therapie des hepatozellulären Karzinoms

Die S3-Leitlinie „Diagnostik und Therapie des hepatozellulären Karzinoms und der biliären Karzinome“ umfasst 2 Tumorentitäten. Bisher besteht nur eine Leitlinie zur Diagnostik und Therapie des hepatozellulären Karzinoms (HCC). Daher wird in diesem Kapitel nur auf die Veränderungen der Leitlinie des hepatozellulären Karzinoms eingegangen.

Folgende wesentliche Änderungen ergeben sich zur S3-Leitlinie des hepatozellulären Karzinoms von 2013:

• Histopathologische und molekulare Diagnostik): Die Leberbiopsie wurde als wichtige diagnostische Maßnahme zur Diagnosestellung des hepatozellulären Karzinoms (in der zirrhotischen Leber) gestärkt. In der palliativen Situation sollte eine bioptische Sicherung erfolgen.

• Bildgebende Diagnostik: Bisher wurde in einer zirrhotischen Leber die Diagnose eines hepatozellulären Karzinoms ab 2 cm mittels zweier unabhängiger Bildgebungen (MRT, CT oder Ultraschall) bei typischem Kontrastverhalten gestellt. Die Empfehlung wurde dahingehend geändert, dass die Diagnose eines hepatozellulären Karzinoms in zirrhotischer Leber aufgrund eines typischen Kontrastmittelverhaltens mit arterieller Hypervaskularisation und Auswaschen in der portalvenösen und venösen Phase im kontrastverstärkten MRT diagnostiziert werden soll. Bei unklarem MRT-Befund sollten ein triphasisches CT und/oder ein kontrastverstärkter Ultraschall herangezogen werden.

• Chirurgische Therapieverfahren): Bei geeigneten Patienten mit einem HCC außerhalb der Mailand-Kriterien und innerhalb der UCSF-Kriterien kann eine Lebertransplantation erfolgen, insbesondere dann, wenn ein Downstaging bis innerhalb der Mailand-Kriterien gelingt. Zum Downstaging stehen, ebenso wie beim Bridging, mehrere Therapieverfahren (transarterielle Verfahren, ablative Verfahren und Leberresektion) zur Verfügung.

• Interventionelle Therapieverfahren):

  • Als Standardmethode der lokalablativen Verfahren war bisher nur die Radiofrequenzablation empfohlen. Aufgrund der inzwischen guten Datenlage für die Mikrowellenablation wurde diese als äquivalentes Verfahren aufgenommen.

  • Die transarterielle Chemoembolisation (TACE) sollte mehrfach durchgeführt werden, solange ein Ansprechen hierauf nachweisbar ist und behandelbare hypervaskularisierte Tumoranteile verbleiben.

  • Die Indikation zur Fortführung der TACE soll nach 2 Behandlungszyklen im Tumorboard überprüft werden.

  • Die transarterielle Radioembolisation (TARE) kann nach Beschluss des Tumorboards bei Patienten mit erhaltener Leberfunktion im intermediären HCC-Stadium anstelle einer TACE eingesetzt werden.

  • Eine Hochpräzisionsradiotherapie (Stereotactic Body Radiotherapy, SBRT) kann in Betracht gezogen werden, wenn andere lokale Therapieverfahren nicht möglich sind (z. B. hohe Wahrscheinlichkeit für ein Therapieversagen, eingeschränkte Leberfunktion, technische Hindernisse).

• Systemtherapie: Zum Zeitpunkt der letzten Leitlinie konnte nur Sorafenib evidenzbasiert empfohlen werden. Zwischenzeitlich sind mehrere weitere Substanzen hinzugekommen:

  • Die Kombinationstherapie Atezolizumab und Bevacizumab ist als Erstlinie zugelassen und in der Zulassungsstudie Sorafenib überlegen.

  • Als weitere Erstlinientherapie ist der Tyrosinkinase-Inhibitor Lenvatinib zugelassen.

  • Mehrere Tyrosinkinase-Inhibitoren und der VEGFR-R2-Antikörper Ramucirumab (bei AFP > 400 ng/ml) stehen als weitere zugelassene Therapieoptionen zur Verfügung.

Publication History

Article published online:
18 January 2022

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