Das Plattenepithelkarzinom des Ösophagus – Stellenwert der Chirurgie im therapeutischen Konzept

Zusammenfassung

Zusammenfassend sind Plattenepithelkarzinome des Ösophagus seitens ihrer Ätiopathogenese, Tumorbiologie, Komorbidität und ihres operativen Risikos sowie der Prognose eine komplett unterschiedliche Entität verglichen mit den Adenokarzinomen. Beim oberflächlichen Plattenepithelkarzinom besteht bereits ab der Mukosainfiltrationstiefe m3 das Risiko einer relevanten Lymphknotenmetastasierung und somit die Indikation zur onkologischen Resektion. Beim lokal fortgeschrittenen Plattenepithelkarzinom ist die neoadjuvante Radiochemotherapie internationaler Standard. Eine Früh-Response-Determinierung sollte angestrebt werden. Nonresponder müssen frühzeitig erkannt und einer Salvage-Operation mit vertretbarem operativen Risiko zugeführt werden. Die definitive Radiochemotherapie ist aufgrund ihrer hohen kompletten Response eine Option insbesondere für hochsitzende Plattenepithelkarzinome und für Patienten mit hohem operativen Risiko, wenngleich die lokale Tumorkontrolle nach operativer Therapie signifikant besser ist. Aufgrund des Erfolgs der definitiven Radiochemotherapie stellt sich zunehmend die Frage, ob zukünftig eine chirurgische Resektion nach neoadjuvanter Radiochemotherapie weiterhin erforderlich ist, oder ob durch die alleinige Radiochemotherapie ähnliche Ergebnisse des rezidivfreien Überlebens und des Gesamtüberlebens erreicht werden können. Die chirurgische Therapie sollte immer in einem Expertenzentrum mit niedriger Morbidität und Mortalität durchgeführt werden. Im Fokus zukünftiger Forschung stehen Prädiktoren der histopathologischen Response, um möglicherweise gezielter die chirurgische Morbidität bei Patienten mit kompletter pathologischer Response nach multimodaler Therapie zu vermeiden.

Abstract

Squamous cell carcinomas of the oesophagus are a completely different entity from adenocarcinomas in regard to their aetiopathology, tumour biology, co-morbidity, operative risk, and prognosis. For superficial squamous cell carcinomas, the risk of a relevant lymph node metastatisation already exists from the mucosal infiltration level m3 onward, and thus oncological resection is indicated. Neoadjuvant radiochemotherapy is the international standard for locally advanced squamous cell carcinoma. The early-response should be determined. Non-responders must be identified early, and a salvage operation with a justifiable operative risk should be carried out. Due to its high complete response rate, definitive radiochemotherapy is an option especially for squamous cell carcinomas of the upper third of the oesophagus and for patients with a high operative risk, even though local tumour control is significantly better after surgical therapy. Due to the success of definitive radiochemotherapy, the question is being asked increasingly, whether surgical resection after neoadjuvant radiochemotherapy will still be necessary in the future or whether radiochemotherapy alone can attain similar results for relapse-free survival and total survival. Surgical therapy should always be carried out in a specialised high volume centre with low morbidity and mortality. Future research will focus on predictors of the histopathological response, in order to possibly more accurately avoid surgical morbidity in patients with complete pathological responses after multimodal therapy.

Plattenepithelkarzinom des Ösophagus - Stellenwert der Chirurgie - therapeutisches Konzept

squamous cell carcinoma of the oesophagus - impact of surgery - therapeutic concept

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