Polypektomie am Kolon – und dann?

Zusammenfassung

Das kolorektale Karzinom (KRK) ist die häufigste Krebserkrankung im menschlichen Gastrointestinaltrakt. Die meisten KRK entstehen aus klassischen Adenomen (= häufigste Polypenform) der Darmschleimhaut im Rahmen einer sog. Adenom-Karzinom-Sequenz im Laufe von etwa 10–15 Jahren. In den letzten Jahren rückten allerdings auch die sogenannten serratierten Polypen in den Fokus zur Entstehung eines KRK. Seit Langem gilt es als gesichert, dass die Vorsorgekoloskopie die krankheitsbezogene Mortalität am KRK senkt. Die komplette Koloskopie ist die empfohlene Methode der Wahl und gilt als Goldstandard ab dem 55. Lebensjahr. Neben den Anforderungen bei Polypektomie an den Endoskopiker gelten ebenso bestimmte Anforderungen an den untersuchenden Pathologen. Nach Polypektomie ist eine Risikostratifizierung anhand der erhobenen endoskopischen bzw. histologischen Befunde notwendig, um ein Regime zur endoskopischen Nachkontrolle festzulegen. Hochrisikopatienten (≥ 3 tubuläre Adenome, ≥ 1 Adenom ≥ 1 cm, tubulovillöse oder villöse Histologie, ≥ 1 Adenom mit hochgradiger IEN [intraepitheliale Neoplasie], ≥ 10 Adenome gleich welcher Größe oder Histologie) sollten eher großzügig (< 3 Jahre), Niedrigrisikopatienten (1–2 Adenome, Größe < 1 cm, tubuläre Histologie) hingegen sollten eher zurückhaltend endoskopisch nachkontrolliert werden (> 5 Jahre). Die 1-Jahres-Koloskopie bedarf der Diskussion und ist Ausnahmesituationen vorbehalten. Der Nutzen chemopräventiver Substanzen zur Sekundärprävention kolorektaler Adenome und Karzinome wird aktuell kontrovers diskutiert.

Abstract

Colorectal cancer (CRC) is the most frequent gastrointestinal tumour. Most CRC appear to arise from adenomas of the colon in a period of 10 or 15 years. The ultimately progression of benign adenomas to malignant CRC is known as the adenoma-carcinoma sequence. In addition, the description of the “serrated pathway” has shifted the focus of interest also towards to sessile serrated adenomas and traditional serrated adenomas in the development of CRC. It has been proven that the screening colonoscopy might prevent CRC by early detection of adenomatous polyps as precursors for colorectal cancer and polypectomy. Thus, disease-associated mortality of CRC could be reduced. Colonoscopy, the gold standard in CRC diagnosis, is recommended to men and women from the age of 55. On the one hand, there are requirements to the endoscopists. On the other hand there are also essential requirements to pathologistsʼ findings. After polypectomy a risk stratification for aftercare based on endoscopic and histological findings is necessary. Endoscopic follow-up of high-risk patients (≥ 3 tubular adenomas, ≥ 1 adenoma ≥ 1 cm, tubulovillous or villous adenoma, ≥ 1 adenoma with high-grade intraepithelial neoplasia, ≥ 10 adenoma no matter what size or histological findings) should be done sooner (< 3 years). In contrast, colonoscopy in low-risk patients (1 or 2 [tubular] adenomas, size < 1 cm) should be performed later rather than sooner (> 5 years). Colonoscopic surveys under 12 months should be done only in exceptional and very serious situations. Pharmaceutical chemoprevention of adenomas or CRC are still part of clinical trails. More data are necessary.

Schlüsselwörter

kolorektales Karzinom - endoskopische Intervention - Follow-up - Screening - Prävention

Key words

colorectal carcinoma - endoscopic intervention - follow-up - screening - prevention

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