Technik der mesorektaler Exzision beim Rektumkarzinom - immer noch ein aktuelles Thema?

Zusammenfassung

Innerhalb der letzten zehn Jahre wurden erhebliche Fortschritte in der Behandlung des Rektumkarzinoms erzielt. Heutzutage werden Adenokarzinome des Rektums auf der Basis eines umfassenden interdisziplinären Stagings UICC-Stadien-abhängig therapiert. Die notwendigen Staginguntersuchungen umfassen die starre Rektoskopie (mit Tumorbiopsie), die rektale Endosonographie, die Kontrastmittel-gestützte Computertomographie und/oder Magnetresonanz-Tomographie der Beckenregion: UICC-I Karzinome können allein durch die Operation geheilt werden, sofern die Prinzipien einer qualitätsgesicherten, onkologischen Resektion unter Anwendung der „No-touch”-Technik, der radikulären Gefäßabsetzung und der totalen mesorektalen Exzision eingehalten werden. Demgegenüber erhalten im unteren und mittleren Rektumdrittel lokalisierte UICC-II/III-Karzinome (T3/T4 o. N+) präoperativ eine Radiochemotherapie (RT/CT) mit 5-FU als Radiosensitizer gemäß den Ergebnissen der CAO/AIO/ARO-94 Studie der German Rectal Cancer Study Group (GRCSG). Für Karzinome im oberen Rektumdrittel (12-16 cm oberhalb der Anokutanlinie) ist die Effektivität der präoperativen RT/CT und TME jedoch umstritten. Die partielle Mesorektumexzision (PME) scheint bei diesen Karzinomen der TME überlegen zu sein, vorausgesetzt ein 4 cm bis 5 cm breiter Sicherheitsabstand kann eingehalten und ein Coning des mesorektalen Gewebes vermieden werden. Zudem gibt es Hinweise, dass Karzinome des oberen Rektumdrittels wie Sigmakarzinome behandelt werden sollten. Vor diesem Hintergrund sind zwei multizentrische Studien aktiviert worden: Die CAO/AIO/ARO-04 Phase-III-Studie der GRCSG prüft die Effektivität einer intensivierten präoperativen RT/CT (5-FU und Oxaliplatin als Radiosensitizer) und adjuvanten Chemotherapie bei UICC-II/III-Rektumkarzinomen der unteren zwei Rektumdrittel gegenüber der allein 5-FU-basierten RT/CT. Die German Advanced Surgical Study Group (GAST) untersucht in ihrer randomisierten Phase-II-Studie den chirurgischen Behandlungserfolg einer qualitätsüberprüften PME gegenüber einer TME bei Karzinomen des oberen Rektumdrittels. Postoperativ erhalten alle Patienten eine adjuvante Standardchemotherapie. Die GAST-05-Studie soll letztlich klären, ob Karzinome des oberen Rektumdrittels als Rektum- oder als Kolonkarzinome klassifiziert und dem entsprechend therapiert werden müssen.

Abstract

During the last decade, considerable progress has been made in the treatment of rectal cancer. Based on improved interdisciplinary staging procedures, rectal cancers today are treated according to their UICC stage. The staging procedures include rigid rectoscopy, rectal ultrasound, computed tomography and/or magnetic resonance tomography of the pelvic region. Carcinomas at UICC stage I can be cured by surgery alone if high-quality resection procedures are applied that are based on radical oncologic principles such as the “no touch” technique, radicular dissection of vessels, and total mesorectal excision (TME). Locally advanced rectal cancers at UICC stages II/III (T3/T4 or N+) that are localized at the lower and middle third of the rectum should receive additional neoadjuvant 5-FU-based chemoradiotherapy (RT/CT) followed by TME, according to the results of the CAO/AIO/ARO-94 trial of the German Rectal Cancer Study Group (GRCSG). For rectal cancer of the upper third of the rectum (12-16 cm above anocutaneous verge) both the efficacy of preoperative RT/CT and TME are still under discussion. Here, partial mesorectal excision (PME) for proximal cancer appears to be superior to TME, provided that a 4 to 5 cm mesorectal margin can be achieved without coning of the tissue. Furthermore, there is evidence that rectal cancer of the upper third should be treated the same way as sigmoid cancer. Two multicentric studies are being carried out that seem to confirm this assumption: The CAO/AIO/ARO-04 phase III trial of the GRCSG is investigating the efficacy of an intensified preoperative RT/CT (5-FU and oxaliplatin) and adjuvant chemotherapy in UICC stage II/III rectal cancers of the lower and middle third of the rectum compared to 5-FU monotherapy-based RT/CT. The German Advanced Surgical Study Group (GAST) is investigating the therapy of rectal cancers of the upper third of the rectum. This randomized phase II trial compares PME- with TME-treatment of UICC stage II/III cancer prior to adjuvant therapy. The study is designed to answer the question whether cancers of the upper third of the rectum should be classified and treated as rectal cancers or rather as colonic cancers.

Totale und partielle mesorektale Exzision - Rektumkarzinom - CAO/AIO/ARO-94-Studie - GAST-05-Studie

total and partial mesorectal excision - rectal cancer - CAO/AIO/ARO-94 study - GAST-05 study

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