Das Management von Patienten mit Peniskarzinom – Neue Aspekte in der Therapie einer seltenen Tumorentität

Zusammenfassung

Einige Prinzipien der primären Therapie des Peniskarzinoms haben sich in den letzten Jahrzehnten grundlegend verändert: Galt aufgrund der Aggressivität des Tumors bei der Penisteilamputation vor 15 Jahren noch ein tumorfreier Sicherheitsabstand von 2 cm als obligat, so gilt heute, dass weitgehender Organerhalt Priorität hat und minimale tumorfreie Schnittränder ausreichend sind. Es besteht somit der Grundsatz: So viel Organerhalt wie möglich, so viel Radikalität wie nötig. Auch hat sich zunehmend die Erkenntnis durchgesetzt, dass Patienten mit begrenzter regionär-lymphogener Metastasierung heilbar sein können, allerdings nur bei Durchführung einer multimodalen Therapie bestehend aus einer radikalen inguinalen Lymphadenektomie und nachfolgenden adjuvanten Chemotherapie. Bei Patienten mit fixierten inguinalen Lymphknotenmetastasen konnte hingegen die neoadjuvante Chemotherapie etabliert werden.

Trotz der verbesserten Therapieoptionen bleiben die funktionellen und onkologischen Ergebnisse bei der Behandlung des Peniskarzinoms vielfach enttäuschend. Die Möglichkeiten des Organerhalts mittels rekonstruktiver operativer Techniken verbessern zwar die Lebensqualität der Langzeitüberlebenden erheblich, doch weniger als 25 % der Patienten mit Lymphknotenmetastasierung überleben ihre Tumorerkrankung. Von großer Bedeutung ist die chirurgische Lymphknotendiagnostik bei klinisch unauffälligen Lymphknoten ab dem Tumorstadium T1b, da hier eine okkulte Mikrometastasierung in bis zu 25 % der Fälle vorliegen kann. Die minimal-invasive Sentinel-Lymphknoten-Biopsie ist ein durchaus sinnvoller Weg, diese Patienten zu diagnostizieren, ohne gleich die Morbidität einer primär radikalen Lymphadenektomie hervorzurufen. Ein zunehmendes Verständnis der zugrundeliegenden Tumorbiologie, insbesondere Erkenntnisse zum Humanen-Papillomavirus- und Epidermal-Growth-Factor-Receptor-Status, brachten zuletzt erfolgversprechende klinische Studien auf den Weg; zudem wird gegenwärtig die gezielte Immuntherapie mittels Immun-Checkpoint-Inhibitoren bei therapierefraktärem Peniskarzinom geprüft.

In diesem Review werden die aktuellen Aspekte des therapeutischen Managements von Peniskarzinom-Patienten zusammengefasst.

Abstract

Over the past few decades, some principles in the treatment of penile cancer have changed fundamentally. While 15 years ago a negative surgical margin of at least 2 cm was considered mandatory, organ-sparing surgery permitting minimal negative surgical margins has a high priority nowadays. The current treatment principle requires as much organ preservation as possible and as much radicality as necessary. The implementation of organ-sparing and reconstructive surgical techniques has improved the quality of life of surviving patients. However, oncological and functional outcomes are still unsatisfactory.

Alongside with adequate local treatment of the primary tumour, a consistent management of inguinal lymph nodes is of fundamental prognostic significance. In particular, clinically inconspicuous inguinal lymph nodes staged T1b and upwards need a surgical approach. Sentinel node biopsy, minimally-invasive surgical techniques and modified inguinal lymphadenectomy have reduced morbidity compared to conventional inguinal lymph node dissection. Multimodal treatment with surgery and chemotherapy is required in all patients with lymph node-positive disease; neoadjuvant chemotherapy has been established for patients with locally advanced lymph node disease, and adjuvant treatment after radical inguinal lymphadenectomy for lymph node-positive disease.

An increasing understanding of the underlying tumour biology, in particular the role of the human papilloma virus (HPV) and epidermal growth factor receptor (EGFR) status, has led to a new pathological classification and may further enhance treatment options.

This review summarises current aspects in the therapeutic management of penile cancer.

Schlüsselwörter

Organerhalt - Inguinale und pelvine Lymphknotendissektion - Strahlentherapie - HPV - EGFR

Keywords

Organ preservation - inguinal and pelvic lymph node dissection - radiation therapy - HPV - EGFR

^* Geteilte Erstautorenschaft

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