Adjuvante und palliative Therapie des Pankreaskarzinoms – Update

Kernaussagen

Kurative, adjuvante und additive Therapie

• Eine kurative Therapie bei Patienten mit Pankreaskarzinom ist nur nach radikaler Resektion (meist pyloruserhaltende Whipple-Operation) möglich, wobei ein Langzeitüberleben nur bei ca. 1 – 3 % der Patienten erreicht werden kann.

• Nach potenziell kurativer Resektion sind der Resektionsstatus, das Grading, die Tumorgröße und der Nodalstatus entscheidende Prognoseparameter.

• Eine adjuvante, aber auch eine additive Chemotherapie mit Gemcitabin ist sinnvoll.

Neoadjuvante Therapie

• Eine neoadjuvante Therapie resektabler Patienten sollte außerhalb von Studien nicht erfolgen.

• Eine neoadjuvante Radiochemotherapie mit modernen Bestrahlungsregimen ist noch nicht etabliert. Möglicherweise kann bei einem Teil der Patienten durch eine präoperative Radiochemotherapie die Prognose verbessert werden, wenn durch diese Therapie eine Operabilität zu erreichen ist.

• Eine Induktionschemotherapie hilft eventuell dabei, Patienten zu identifizieren, die von einer neoadjuvanten Radiochemotherapie profitieren.

Palliative Therapie

• Jede Therapie eines lokal fortgeschrittenen oder metastasierten Pankreaskarzinoms erfolgt in palliativer Absicht.

• Neben dem langjährigen Standard Gemcitabin stellt für selektierte Patienten die Kombinationstherapie von Gemcitabin mit nab-Paclitaxel eine Option dar. Alternativ kann bei selektierten Patienten FOLFIRINOX eingesetzt werden. Bei allerdings höherer Toxizität reicht das mediane Überleben bei diesem Protokoll nahe an 1 Jahr heran.

• Durch Addition von „Biologicals“ wie dem EGFR-Inhibitor Erlotinib kann nur bei Auftreten einer signifikanten Hautreaktion eine klinisch relevante Verbesserung des Überlebens erwartet werden.

• Zweitlinientherapien nach Progress unter einer Gemcitabin-Erstlinientherapie sind wahrscheinlich wirksam, hier bieten sich Kombinationen aus Fluoropyrimidinen und Oxaliplatin an. Konzepte zur Zweitlinientherapie beim Pankreaskarzinom sollten weiter in Studien geprüft werden.

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